Quality and Readability Analysis of Online Information on First Metatarsophalangeal Joint Fusion

Patients frequently turn to the internet to learn about their orthopedic procedures. This study evaluates the readability and quality of first metatarsophalangeal (MTP) joint fusion information found online. We evaluated websites based on classification, search term, readability, HON code, DISCERN score, Journal of the American Medical Association benchmark criteria, and an author-created MTP fusion index (MFI). The average readability of websites was 8.48 ± 1.99, above the recommended sixth- or eighth-grade reading level. Almost half of all websites (48.98%) provided "poor" information. Keywords had no significant impact on the readability or quality of information. Academic/governmental websites had the highest quality of information, with the highest DISCERN and second highest MFI. Most websites (52.04%) were commercial and were the easiest to read, but had the second lowest DISCERN and MFI scores. Our results suggest that inappropriate information on the MTP joint fusion procedure is abundant online. Academic/governmental websites have the highest quality of information, but may be difficult for patients to comprehend. Many websites do have readable and relevant information. We recommend that physicians create a list of websites with accurate, relevant information for patients to circumvent the misinformation they may find while navigating and reading online.

Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.

Severe Hallux Valgus Angle Attended With High Incidence of Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Follow-Up Study

The incidence of nonunion after first metatarsophalangeal joint (MTP-1) arthrodesis was found to be high in our clinic. By raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers, and promoting solely the use of hand instruments to prepare the joint for arthrodesis, we tried to decrease the numbers of nonunion. This prospective cohort study included all patients who underwent MTP-1 fusion between January 2018 and March 2019. Patients were treated according to a standardized protocol, using hand instruments to prepare the joint for fusion. Anthropometric and therapy-related data were collected and compared with an earlier 2015-2016 cohort that was retrospectively assessed. Furthermore, the frequency of nonunion between convex-concave reamers and hand instruments was compared. A total of 53 patients underwent MTP-1 fusion surgery. The incidence of nonunion was 3.8%, significantly lower than the 24.1% in 2015 to 2016 (p = .002). Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019 (95% confidence interval [CI] 1.55 to 32.55) (p = .012). Furthermore, an increase of 10° in HVA showed a 1.52 risk of occurrence of nonunion (95% CI 1.07 to 2.17) (p = .021). The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion (95% CI 1.14 to 11.43) (p = .029); however, after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion (p = .108). Patients suffering from severe hallux valgus had nonunion in 32.1% of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation. Severe hallux valgus is prone to nonunion, and more research into this indication for MTP-1 fusion and outcome is needed.

Identification of the third FGF9 variant in a girl with multiple synostosis-comparison of the genotype:phenotype of FGF9 variants in humans and mice

Multiple synostosis syndrome (SYNS) is a heterogeneous group of genetic disorders mainly characterized by multiple joint synostosis due to variants in either NOG, GDF5, FGF9 or GDF6. To date, only two FGF9 variants have been associated with SYNS, characterized with hand and feet joint synostosis and fusion of the elbow and vertebral lumbar joints. Craniosynostosis was also observed in one family. Here, we report the clinical and radiological description of a young girl with a third heterozygous FGF9 variant, NM_002010.2:c.427A>T;p.(Asn143Tyr), which interestingly, is located at the same amino acid as the well characterized spontaneous Eks mouse variant. We also compare the genotype: phenotypes observed between humans and mice with SYNS.

Mini-plate versus Kirschner wire internal fixation for treatment of metacarpal and phalangeal fractures

OBJECTIVE

To conduct a meta-analysis to show the associations of perioperative and postoperative outcomes of mini-plate internal fixation (MPIF) versus Kirschner wire internal fixation (KWIF) for treating metacarpal and phalangeal fractures.

METHODS

A literature search was performed in PubMed, Web of Science, Cochrane Library, and Embase from the earliest date of data collection to April 2018. Studies that compared perioperative and postoperative outcomes of MPIF with those of KWIF in patients with metacarpal and phalangeal fractures were included.

RESULTS

Twenty-six articles met the inclusion and exclusion criteria (n = 2029 patients; 1042 with MPIF and 987 with KWIF). MPIF was related to a greater increase in length of surgery, hospital days, excellent and good rate of outcome, short-form health survey-36 score, and flexion and extension range compared with KWIF. MPIF was related to a greater decrease in intraoperative blood loss, finger visual analog scale score, functional exercise time, fracture healing time, incidence of complications, and postoperative infection rate compared with KWIF.

CONCLUSIONS

Patients with MPIF have sufficient pressure and strength, and MPIF promotes successful joint fusion and reduces complications of the operation. MPIF is ideal for reduction and stability of patients with metacarpal and phalangeal fractures.

The proximal interphalangeal joint: arthritis and deformity

Finger joints are of the most common site of osteoarthritis and include the DIP, PIP and the thumb saddle joint.

Joint arthroplasty provides the best functional outcome for painful destroyed PIP joints, including the index finger.

Adequate bone stock and functional tendons are required for a successful PIP joint replacement

Fixed swan-neck and boutonnière deformity are better served with PIP arthrodesis rather than arthroplasty.

Silicone implants are the gold standard in terms of implant choice. Newer two-component joints may have potential to correct lateral deformities and improve lateral stability.

Different surgical approaches are used for PIP joint implant arthroplasty according to the needs and the experience of the surgeon.

Post-operative rehabilitation is as critical as the surgical procedure. Early protected motion is a treatment goal.

Revision and exchange PIP arthroplasty may successfully be used to treat chronic pain, but will not correct deformity.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180042

Arthrodesis for Treatment of Intra-Articular Synovial Cysts of the Hallux Interphalangeal Joint

Synovial cysts are benign tissue masses that develop near joints and tendons as a result of fluid leakage. They can be difficult to eradicate, and adjacent tendon and joint surfaces can complicate their treatment. We retrospectively analyzed the data from 4 consecutive patients who had undergone hallux interphalangeal fusion from January 2009 to December 2010. Of the 4 patients, 3 were male and 1 was female, with a mean age of 55 ± 22 (range 26 to 79) years. These 4 patients had developed painful interphalangeal arthritis with radiographic cystic changes of 1 to 4 years' duration. All patients were treated at a single facility, with surgical fixation of the joint performed by insertion of a single 4.3-mm headless lag screw across the interphalangeal joint. A final postoperative follow-up examination was performed at 22 ± 7 (range 14 to 30) months postoperatively. The mean American Orthopaedic Foot and Ankle Society hallux functional scores increased significantly from 70.8 ± 6.1 preoperatively to 90.5 ± 5.2 postoperatively (p < .01). No complications were observed, and complete interphalangeal joint fusion was observed at a mean of 9.2 ± 1.2 weeks. In conclusion, these preliminary data suggest that arthrodesis is an alternative effective treatment of symptomatic synovial cyst formation localized to the hallux interphalangeal joint.

Orthopaedic procedures in haemophilia

Haemophilia may nowadays be considered an "ortho paedic" disease given due to the involvement of musculoskeletal system in almost all haemophilic subjects. The modern haematological prophylaxis has dramatically improved the quality of life reducing bleedings and life-threatening complications; however, joint bleedings, progressive and irreversible arthropathy and osteoporosis are still now common challenging issues to be faced. One of the tissues involved by Haemophilia is the bone, particularly in the periarticular zone: poor bone quality and decrease of bone stock are typical patterns, and the worse is the arthropathy, the greater the bone loss. The orthopaedic management of such condition is now mandatory and characterized by several surgical techniques. The purpose of this work is to provide an overview of these options derived from our experience in managing haemophilic patients.

Ilizarov External Fixator Versus Retrograde Intramedullary Nailing for Ankle Joint Arthrodesis in Diabetic Charcot Neuroarthropathy

Charcot neuroarthropathy of the ankle joint is a destructive process that leads to instability and significant morbidity that can end with amputation. Surgical arthrodesis in Charcot neuroarthropathy has a high failure rate. The aim of the present prospective study was to compare the outcomes of an Ilizarov external fixator and retrograde intramedullary nailing (IMN) for tibiotalar arthrodesis in Charcot neuroarthropathy. From February 2010 to October 2013, 27 patients (16 males and 11 females) with Charcot neuropathy of the ankle joint were treated in our department. Their ages ranged from 32 to 75 (average 54) years. Of the 27 patients, 14 received an Ilizarov external fixator and 13 underwent IMN. A preoperative clinical and radiologic assessment of all patients was performed. The outcomes were measured for bone union, development of complications, and clinical follow-up. The mean score of modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale was 80 ± 2.7 points in the Ilizarov group and 75 ± 1.9 points in the IMN group. In the Ilizarov group, 12 of 14 patients achieved union, and in the IMN group, 10 of 13 patients achieved union. The complication rate was significantly greater in the external fixator group than in the IMN group. The complications in the Ilizarov group included nonunion in 2 patients (14%), pin tract infection in 8 (57%), pin tract loosening in 3 (21%), surgical wound infection in 3 (21%), and wound breakdown in 1 patient (7%). In the IMN group, nonunion occurred in 3 patients (23.1%), back-out of a distal locking bolt in 2 (15.4 %), and a superficial wound infection that resolved with antibiotics in 1 patient (7.7%). In conclusion, retrograde IMN and the Ilizarov external fixator both yielded better union for tibiotalar arthrodesis in Charcot neuroarthropathy. The Ilizarov external fixator resulted in a greater union rate than IMN but the complications with external fixation were significantly greater than those with IMN.

Pollicization of the index finger requiring secondary fusion of the new metacarpophalangeal joint

In children with absent thumbs, some authors have stated that 'relative' contraindications of pollicization include severe fixed flexion contracture and instability of the proximal interphalangeal joint of the index finger. The current author does not consider severe proximal interphalangeal joint deformities of the index finger as a contraindication to pollicization; and hence these children are offered the procedure. A literature review did not reveal any study that specifically documents the outcome of pollicization in these cases. The current series included five children: four with severe (over 80°) fixed flexion contracture of the proximal interphalangeal joint of the index finger and one with instability of the proximal interphalangeal joint. All children were initially assessed during infancy at their local hospitals and the parents were informed that a pollicization procedure would yield a poor outcome. Presentation to the author was relatively late at a mean of 9.3 years (range 2.5-12). All children underwent two surgical procedures: a pollicization followed by fusion of the new metacarpophalangeal joint. The overall early functional outcome was good and all children/parents were satisfied with the procedure. These encouraging results warrant a prospective long term study on various conditions that are considered as 'relative' contraindications to the pollicization procedure.Level evidence: IV Therapeutic (case series).

Elbow arthrodesis for post-traumatic sequelae: surgical tactics using the Ilizarov frame

BACKGROUND

Surgical arthrodesis of the elbow joint is frequently unsuccessful and rarely performed. It is the purpose of this article to evaluate tactics and different constructs to achieve elbow arthrodesis (EA) using the Ilizarov apparatus in patients with post-traumatic nonreconstructable elbow sequelae.

METHODS

A consecutive series of 4 patients were treated between 2009 and 2013 (3 men and 1 woman; mean age, 46.7 [35-75] years). Two patients had late complications in total elbow replacement and developed nonunion after condylar fractures of the distal humerus. There were 3 ulnohumeral arthrodeses and 1 radiohumeral arthrodesis. The hybrid advanced Ilizarov technique was used in all cases.

RESULTS

Complete union was obtained in 3 EAs (75%) without additional surgery at an average of 23 weeks. Fusion angles ranged from 90° to 120°. One patient required amputation above the elbow because of persistent infection and chronic pain after attempted reconstruction with distraction osteogenesis for infected total elbow replacement with humeral bone loss. The average length of follow-up after EA was 33 months (range, 18-60 months). At final follow-up, the median score of the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire was 42.4 (27.3-52.2). Three patients returned to their working activities.

CONCLUSIONS

EA is not a common orthopedic procedure. Despite its difficulties and need of specific training, the Ilizarov technique provides a reproducible and reliable way of achieving solid fusion with the desired angle. Advantages include infection control, early mobilization, accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Arthroscopic Arthrodesis of the Distal Tibiofibular Syndesmosis

Chronic syndesmosis disruption can occur if an acute lesion is missed or inadequately managed. This can result in significant functional deficit and development of post-traumatic ankle arthritis. Anatomic reduction of the syndesmosis and maintenance of the reduction by syndesmotic screw fixation alone, ligamentous reconstruction, or fusion of the syndesmosis are recommended. A technique of arthroscopic distal tibiofibular syndesmosis arthrodesis is described.

Tibiocalcaneal arthrodesis in the high-risk foot

The present case series outlines the history and surgical treatment of 6 patients who underwent tibiocalcaneal arthrodesis from April 2002 to May 2012, all with external fixation as the primary or secondary fixation. Surgical intervention was performed by the same surgeon at the same facility. The indication for surgery was a nonbraceable Charcot deformity in 5 (83.3%) patients and bone and soft tissue infection complicating previous intramedullary hindfoot fusion in 1 (16.7%) patient. Talectomy was performed in 2 (33.3%) patients secondary to widespread osteomyelitis of the talus and in 4 (66.7%) patients secondary to avascular necrosis and/or disintegration and fragmentation of the remaining talus. The postoperative complications have been discussed in detail and their management outlined. At the most recent follow-up visit, all patients were independently ambulating on a braceable limb with or without the use of an assistive device. In conclusion, tibiocalcaneal arthrodesis is a reasonable option for limb salvage to produce community ambulators in the high-risk population. We emphasize that although multiple fixation options are available for tibiocalcaneal arthrodesis, a combination of internal and external fixation is vital to its success.

Arthrodesis for failed total elbow arthroplasty with deep infection

BACKGROUND

Elbow arthrodesis is typically reserved as a salvage procedure. Current literature suggests that satisfactory outcomes can be expected if fusion occurs. There is a paucity of literature on outcomes of elbow arthrodesis after failed elbow arthroplasty with deep infection.

METHODS

Five elbow arthrodeses were performed after a failed elbow arthroplasty due to deep infection. Clinical data were retrospectively reviewed for all surviving patients. Fusion angle, complications, and time to fusion or resection arthroplasty were recorded. The procedure was considered a failure if resection arthroplasty was required or there was a failure of bone union after 1 year.

RESULTS

The average age at arthrodesis was 49 years (range, 35-69 years). One patient died 3 months after arthrodesis and was excluded from analysis. No patients had confirmed union at final follow-up. Two developed a fibrous union and were not symptomatic. All patients required at least 1 reoperation; 6 reoperations were required in total for the entire group. Three patients required revision arthrodesis after hardware failure. Two patients ultimately underwent a resection arthroplasty. One patient required débridement and hardware removal after wound dehiscence. Other complications included 2 patients with transient ulnar neuritis.

CONCLUSION

Elbow arthrodesis is not recommended as a salvage procedure for failed total elbow arthroplasty after infection because of a high reoperation rate and difficulty in achieving solid fusion.

Early results of sacro-iliac joint fixation following long fusion to the sacrum in adult spine deformity

BACKGROUND

The sacro-iliac joint (SIJ) is the largest joint in the human body. When the lumbar spine is fused to the sacrum, motion across the SIJ is increased, leading to increased degeneration of the SIJ. Degeneration can become symptomatic in up to 75% of the cases when a long lumbar fusion ends with a sacral fixation. If medical treatments fail, patients can undergo surgical fixation of the SIJ.

QUESTIONS/PURPOSES

This study reports the results of short-term complications, length of stay, and clinical as well as radiographic outcomes of patients undergoing percutaneous SIJ fixation for SIJ pain following long fusions to the sacrum for adult scoliosis.

METHODS

A retrospective review of all the patients who underwent a percutaneous fixation of the SIJ after corrective scoliosis surgery was performed in a single specialized scoliosis center between the years 2011-2013. Ten SIJ fusions were performed in six patients who failed conservative care for SIJ arthritis. Average age was 50 (range 25-60 years). The patients were 15.3 years in average after the original surgical procedure (range 4-25 years). Average post-operative follow-up was 10.25 months (range 15-4 months). The medical charts of the patients were reviewed for hospital stay, complications, pre- and post-operative pain, quality of life, and satisfaction with surgery using the visual analogues score (VAS), Scoliosis Research Society (SRS)22 and Oswestry Disability Index (ODI) questionnaires. Images were reviewed for fixation of the SIJ, fusion, and deviation of the implants from the SIJ.

RESULTS

There were no complications in surgery or post-operatively. Discharge was on post-operative day 2 (range 1-4 days). Leg VAS score improved from 6.5 to 2.0 (P < 0.005; minimal clinically important difference (MCID) 1.6). Back VAS score decreased from 7.83 to 2.67 mm (P < 0.005; MCID 1.2). ODI scores dropped from 22.2 to 10.5 (P = 0.0005; MCID 12.4). SRS22 scores increased from 2.93 to 3.65 (P = 0.035; MCID 0.2) with the largest increases in the pain, function, and satisfaction domains of the questionnaires.

CONCLUSION

Fixation of the SIJ in patients that fail conservative care for SIJ arthritis after long fusions ending in the sacrum provides a reduction in back pain and improved quality of life in the short and medium range follow-up period.