scholarly journals Subtalar Nonunion Following Tibiotalocalcaneal Fusion Using an Intramedullary Nail: A Case Series of Errant Entry Points

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0029
Author(s):  
Anthony Martella ◽  
Ruixian Yue ◽  
Michael Boin ◽  
Jonathan Rogozinski ◽  
Trenden Flanigan ◽  
...  
Keyword(s):  
Intraoperative Imaging ◽  
Case Series ◽  
Valgus Deformity ◽  
Entry Point ◽  
Medial Wall ◽  
Ct Scans ◽  
Patient Demographics ◽  
Entry Points ◽  
Hindfoot Deformity ◽  
Valgus Alignment

Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus. Methods: Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded. Results: Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment. Conclusion: Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.

A radiographic computed tomography–based study to determine the ideal entry point, trajectory, and length for safe fixation using C-2 pars interarticularis screws

2010 ◽  
Vol 12 (6) ◽  
pp. 602-612 ◽  
Author(s):  
Daniel J. Hoh ◽  
Charles Y. Liu ◽  
Michael Y. Wang
Keyword(s):  
Entry Point ◽  
Ct Scans ◽  
Lateral Mass ◽  
Transverse Foramen ◽  
Inferior Aspect ◽  
Significant Difference ◽  
Pars Interarticularis ◽  
Entry Points ◽  
The Mean ◽  
Inferior Edge

Object Effective methods for fixation of the axis include C1–2 transarticular and C-2 pedicle screw placement. Both techniques pose a risk of vertebral artery (VA) injury in patients with narrow pedicles or an enlarged, high-riding VA. Pars screws at C-2 avoid the pedicle, but can cause VA injury with excessively long screws. Therefore, the authors evaluated various entry points and trajectories to determine ideal pars screw lengths that avoid breaching the transverse foramen. Methods Both pars were studied on 50 CT scans (100 total). Various pars lengths were assessed using 2 entry points and 3 trajectories (6 measurements). Entry point A was the superior one-fourth of the lateral mass. Entry point B was 3-mm rostral to the inferior aspect of the lateral mass. Using entry points A and B, Trajectory 1 was the minimum distance to the transverse foramen; Trajectory 2 was the maximum distance to the transverse foramen; and Trajectory 3 was the steepest angle to the pars/C-2 superior facet junction without transverse foramen breach. Results The mean patient age was 46 ± 17 years, and 84% of the CT scans reviewed were obtained in men. There was no significant difference in right or left measurements. Entry point B demonstrated greater pars lengths for each trajectory compared with entry point A (p < 0.0001). For both entry points, Trajectory 3 provided the greatest pars length. Using Trajectory 3 with entry point B, 84, 95, and 99% had a pars length that measured ≥ 18, 16, and 14 mm, respectively. Using Trajectory 3 with Entry point A, only 41, 64, and 87% had a pars length that measured ≥ 18, 16, and 14 mm, respectively. Conclusions Using an entry point 3-mm rostral to the inferior edge of the lateral mass and a trajectory directed toward the superior facet/pars junction, 99% of partes interarticularis in this study would tolerate a 14-mm screw without breach of the transverse foramen.

Revisiting the rules for freehand ventriculostomy: a virtual reality analysis

2018 ◽  
Vol 128 (4) ◽  
pp. 1250-1257 ◽  
Author(s):  
Clemens Raabe ◽  
Jens Fichtner ◽  
Jürgen Beck ◽  
Jan Gralla ◽  
Andreas Raabe
Keyword(s):  
Virtual Reality ◽  
Sagittal Plane ◽  
Three Dimensional ◽  
Anterior Horn ◽  
Entry Point ◽  
Ct Scans ◽  
Medial Canthus ◽  
Hit Rate ◽  
Entry Points ◽  
Ventricular Puncture

OBJECTIVEFrontal ventriculostomy is one of the most frequent and standardized procedures in neurosurgery. However, many first and subsequent punctures miss the target, and suboptimal placement or misplacement of the catheter is common. The authors therefore reexamined the landmarks and rules to determine the entry point and trajectory with the best hit rate (HtR).METHODSThe authors randomly selected CT scans from their institution’s DICOM pool that had been obtained in 50 patients with normal ventricular and skull anatomy and without ventricular puncture. Using a 5 × 5–cm frontal grid with 25 entry points referenced to the bregma, the authors examined trajectories 1) perpendicular to the skull, 2) toward classic facial landmarks in the coronal and sagittal planes, and 3) toward an idealized target in the middle of the ipsilateral anterior horn (ILAH). Three-dimensional virtual reality ventriculostomies were simulated for these entry points; trajectories and the HtRs were recorded, resulting in an investigation of 8000 different virtual procedures.RESULTSThe best HtR for the ILAH was 86% for an ideal trajectory, 84% for a landmark trajectory, and 83% for a 90° trajectory, but only at specific entry points. The highest HtRs were found for entry points 3 or 4 cm lateral to the midline, but only in combination with a trajectory toward the contralateral canthus; and 1 or 2 cm lateral to the midline, but only paired with a trajectory toward the nasion. The same “pairing” exists for entry points and trajectories in the sagittal plane. For perpendicular (90°) trajectories, the best entry points were at 3–5 cm lateral to the midline and 3 cm anterior to the bregma, or 4 cm lateral to the midline and 2 cm anterior to the bregma.CONCLUSIONSOnly a few entry points offer a chance of a greater than 80% rate of hitting the ILAH, and then only in combination with a specific trajectory. This “pairing” between entry point and trajectory was found both for landmark targeting and for perpendicular trajectories, with very limited variability. Surprisingly, the ipsilateral medial canthus, a commonly reported landmark, had low HtRs, and should not be recommended as a trajectory target.

scholarly journals 63 Chronic Femoral Osteomyelitis Case Series: Outcomes and Economic Impact at A United Kingdom Based Tertiary Centre

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
E Lau ◽  
Z Arshad ◽  
A Aslam ◽  
A Thahir ◽  
M Krkovic
Keyword(s):  
Economic Impact ◽  
Treatment Protocol ◽  
Case Series ◽  
Consecutive Series ◽  
Financial Loss ◽  
Patient Demographics ◽  
Tertiary Centre ◽  
The Mean ◽  
Eq Vas

Abstract Introduction Osteomyelitis refers to an inflammatory process affecting bone and bone marrow. This study reviews chronic femoral osteomyelitis treatment and outcomes, including economic impact. Method We retrospectively collected data from a consecutive series of 14 chronic femoral osteomyelitis patients treated between January 2013 and January 2020. Data collected include patient demographics, comorbidities, pathogens, complications, treatment protocol and costs. Functional outcome was assessed using EuroQOL five-dimensional interview administration questionnaire (EQ-5D-5L™) and EuroQOL Visual Analogue Scale (EQ-VAS™). Results Of these, 92.9% had one or more osteomyelitis risk factor, including smoking and diabetes. Samples from 78.6% grew at least one pathogen. Only 42.9% achieved remission after initial treatment, but 85.7% were in remission at final follow-up, with no signs of recurrence throughout the follow-up period (mean: 21.4 months). The average treatment cost was £39,249.50 with a net mean loss of £19,080.10 when funding was considered. The mean-derived EQ-5D score was 0.360 and the mean EQ-VAS score was 61.7, lower than their values for United Kingdom’s general population, p = 0.0018 and p = 0.013 respectively. Conclusions Chronic femoral osteomyelitis treatment is difficult, resulting in significant economic burden. With previous studies showing cheaper osteomyelitis treatment at specialist centres, our net financial loss incurred suggests the need for management at specialised centres.

scholarly journals Radiographic Outcomes, Union Rates, and Complications Associated With Plantar Implant Positioning for Midfoot Arthrodesis

2021 ◽  
Vol 6 (3) ◽  
pp. 247301142110271
Author(s):  
Tyler W. Fraser ◽  
Daniel T. Miles ◽  
Neal Huang ◽  
Franklin B. Davis ◽  
Burton D. Dunlap ◽  
...  
Keyword(s):  
Hallux Valgus ◽  
Skin Irritation ◽  
Case Series ◽  
Deformity Correction ◽  
Valgus Deformity ◽  
Union Rate ◽  
Radiographic Outcomes ◽  
Hallux Valgus Deformity ◽  
Metatarsal Angle ◽  
Radiographic Union

Background: Midfoot arthrodesis has long been successfully included in the treatment paradigm for a variety of pathologic foot conditions. A concern with midfoot arthrodesis is the rate of nonunion, which historically has been reported between 5% and 10%. Plantar plating has also been noted to be more biomechanically stable when compared to traditional dorsal plating in previous studies. Practical advantages of plantar plating include less dorsal skin irritation and the ability to correct flatfoot deformity from the same medial incision. The purpose of this study is to report the arthrodesis rate, the success of deformity correction, and the complications associated with plantar-based implant placement for arthrodesis of the medial column. Methods: A retrospective review was undertaken of all consecutive patients between 2012 and 2019 that underwent midfoot arthrodesis with plantar-positioned implants. Radiographic outcomes and complications are reported on 62 patients who underwent midfoot arthrodesis as part of a correction for hallux valgus deformity, flatfoot deformity, degenerative arthritis, Lisfranc injury, or Charcot neuroarthropathy correction. Results: Statistically significant improvement was seen in the lateral talus–first metatarsal angle (Meary angle) and medial arch sag angle for patients treated for flatfoot deformity correction. In patients treated for hallux valgus deformity, there was a reduction in the intermetatarsal angle from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The rate of nonunion was higher at the NC joint compared to the TMT joint and with compression claw plates. One symptomatic nonunion required revision surgery (1.7%). There were no nonunions when excluding neuroarthropathy patients and smokers. The odds ratio (OR) for nonunion in patients with neuroarthropathy was 6.05 ( P < .05), and in active smokers the OR was 2.33 ( P < .05). Conclusion: Plates placed on the plantar bone surface for midfoot arthrodesis achieved and maintained deformity correction with rare instances of symptomatic hardware for a variety of orthopedic conditions. An overall clinical and radiographic union rate of 94% was achieved. The radiographic union rate improved to 100% when excluding both neuroarthropathy patients and smokers. The incidence of nonunion was higher in smokers, neuroarthropathy patients, naviculocuneiform joint fusions, use of compression claw plates, and when attempting to fuse multiple joints. Incisional healing complications were rarely seen other than in active smokers. Level of Evidence: Level IV, case series.

Difficult Cases in Robotic Arm-Assisted Total Knee Arthroplasty: A Case Series

2017 ◽  
Vol 31 (01) ◽  
pp. 027-037 ◽  
Author(s):  
Robert Marchand ◽  
Anton Khlopas ◽  
Nipun Sodhi ◽  
Caitlin Condrey ◽  
Nicolas Piuzzi ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Case Series ◽  
Valgus Deformity ◽  
Robotic Assisted ◽  
Surgical Technology ◽  
Flexion Contractures ◽  
Total Knee ◽  
Robotic Devices ◽  
Sagittal Deformity

AbstractSagittal deformity of the knee is commonly corrected to neutral biomechanical axis (±3 degrees) during total knee arthroplasty (TKA), which is a widely accepted goal. Recent advances in surgical technology have made it possible to accurately plan and fulfill these goals. One of these is robotic-assisted TKA, which has been noted to help increase accuracy and precision of restoring a neutral mechanical axis. While there are data confirming the ability of robotic devices to better correct knee alignment than the manual technique, there is a lack of data concerning the use of the robotic devices in more complex cases, such as those in patients with severe varus or valgus deformity, as well as in flexion contractures. Therefore, the purpose of this case study is to present three cases in which the robotic-assisted TKA device was used to correct a severe varus and severe valgus deformities. Based on this case series, it should be noted that the robotic device can also help correct severe varus/valgus deformities and flexion contractures.

scholarly journals Femoral malalignment after gamma nail insertion in the lateral decubitus position

SICOT-J ◽  
2018 ◽  
Vol 4 ◽  
pp. 34
Author(s):  
Hossam M.A. Abubeih ◽  
Osama Farouk ◽  
Mohammad Kamal Abdelnasser ◽  
Amr Atef Eisa ◽  
Galal Zaki Said ◽  
...  
Keyword(s):  
Case Series ◽  
Gamma Nail ◽  
Lateral Decubitus Position ◽  
Entry Point ◽  
Age Group ◽  
Rotational Malalignment ◽  
Implant Positioning ◽  
High Incidence ◽  
Nail Insertion ◽  
Lateral Decubitus

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position. Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides. Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019). Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

scholarly journals Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO)

2018 ◽  
Vol 3 (3) ◽  
pp. 247301141879007 ◽  
Author(s):  
Pablo Wagner ◽  
Emilio Wagner
Keyword(s):  
Hallux Valgus ◽  
Case Series ◽  
Valgus Deformity ◽  
Metatarsal Osteotomy ◽  
Level Of Evidence ◽  
Reliable Technique ◽  
Intermetatarsal Angle ◽  
Hallux Valgus Deformity ◽  
The Mean ◽  
Prospective Case Series

Background: Hallux valgus deformity consists of a lateral deviation of the great toe, metatarsus varus, and pronation of the first metatarsal. Most osteotomies only correct varus, but not the pronation of the metatarsal. Persistent postoperative pronation has been shown to increase deformity recurrence and have worse functional outcomes. The proximal rotational metatarsal osteotomy (PROMO) technique reliably corrects pronation and varus through a stable osteotomy, avoiding fusing any healthy joints. The objective of this research is to show a prospective series of the PROMO technique. Methods: Twenty-five patients (30 feet) were operated with the PROMO technique. The sample included 22 women and 3 men, average age 46 years (range 22-59), for a mean prospective follow-up of 1 year (range 9-14 months). Inclusion criteria included symptomatic hallux valgus deformities, absence of severe joint arthritis, or inflammatory arthropathies, with a metatarsal malrotation of 10 degrees or more, with no tarsometatarsal subluxation or arthritis on the anteroposterior or lateral foot radiograph views. The mean preoperative and postoperative Lower Extremity Functional Scale (LEFS) score, metatarsophalangeal angle, intermetatarsal angle, metatarsal malrotation, complications, satisfaction, and recurrence were recorded. Results: The mean preoperative and postoperative LEFS scores were 56 and 73. The median pre-/postoperative metatarsophalangeal angle was 32.5/4 degrees and the intermetatarsal angle 15.5/5 degrees. The metatarsal rotation was satisfactorily corrected in 24 of 25 patients. An Akin osteotomy was needed in 27 of 30 feet. All patients were satisfied with the surgery, and no recurrence or complications were found. Conclusions: PROMO is a reliable technique, with good short-term results in terms of angular correction, satisfaction, and recurrence. Long-term studies are needed to determine if a lower hallux recurrence rate occurs with the correction of metatarsal rotation in comparison with conventional osteotomies. Level of evidence: IV, prospective case series.

Kingella kingae septic arthritis

2021 ◽  
Vol 103-B (3) ◽  
pp. 584-588
Author(s):  
Mohammed Khattak ◽  
Sujith Vellathussery Chakkalakumbil ◽  
Robert A. Stevenson ◽  
David J. Bryson ◽  
Michael J. Reidy ◽  
...  
Keyword(s):  
Septic Arthritis ◽  
Young Patients ◽  
Case Series ◽  
Blood Parameters ◽  
Pcr Analysis ◽  
Kingella Kingae ◽  
Patient Demographics ◽  
The Mean ◽  
Polymerase Chain ◽  
Prospective Case Series

Aims The aim of this study was to determine the extent to which patient demographics, clinical presentation, and blood parameters vary in Kingella kingae septic arthritis when compared with those of other organisms, and whether this difference needs to be considered when assessing children in whom a diagnosis of septic arthritis is suspected. Methods A prospective case series was undertaken at a single UK paediatric institution between October 2012 and November 2018 of all patients referred with suspected septic arthritis. We recorded the clinical, biochemical, and microbiological findings in all patients. Results A total of 160 patients underwent arthrotomy for a presumed septic arthritis. Of these, no organism was identified in 61 and only 25 of these were both culture- and polymerase chain reaction (PCR)-negative. A total of 36 patients did not undergo PCR analysis. Of the remaining 99 culture- and PCR-positive patients, K. kingae was the most commonly isolated organism (42%, n = 42). The knee (n = 21), shoulder (n = 9), and hip (n = 5) were the three most commonly affected joints. A total of 28 cases (66%) of K. kingae infection were detected only on PCR. The mean age of K. kingae-positive cases (16.1 months) was significantly lower than that of those whose septic arthitis was due to other organisms (49.4 months; p < 0.001). The mean CRP was significantly lower in the K. kingae group than in the other organism group (p < 0.001). The mean ESR/CRP ratio was significantly higher in K. kingae (2.84) than in other infections (1.55; p < 0.008). The mean ESR and ESR/CRP were not significantly different from those in the 'no organism identified' group. Conclusion K. kingae was the most commonly isolated organism from paediatric culture- and/or PCR-positive confirmed septic arthritis, with only one third of cases detected on routine cultures. It is important to develop and maintain a clinical suspicion for K. kingae infection in young patients presenting atypically. Routine PCR testing is recommended in these patients. Cite this article: Bone Joint J 2021;103-B(3):584–588.

Drug Discovery and Development: The Road from an Idea to Promoting Human Health

2014 ◽  
Author(s):  
Eugene H. Cordes
Keyword(s):  
Drug Discovery ◽  
Two Dimensions ◽  
Human Medicine ◽  
Entry Point ◽  
Actual Process ◽  
Drug Discovery And Development ◽  
The Road ◽  
Medical Need ◽  
Entry Points ◽  
Long Time

We are almost where we need to be to grasp the tales of drug discovery that make up the final seven chapters of this book. The three previous chapters have laid the necessary scientific foundation. Here is my take on what you still need to know to understand drug discovery and development: the process of getting from an idea to a product that meets a medical need—from the laboratory to the bedside. We begin with a look at the process from 35,000 feet. Realize one thing at the outset: there is more than one way of getting from an idea to approval of a new drug for use in human medicine. The process described in this chapter captures the essential features of getting this done. However, each drug discovery effort poses specific problems, and getting around them may have an effect on the actual process followed. Nonetheless, what is described here is well worth understanding. Imagine running a maze that may have more than two dimensions, a huge number of entry points, and a very small number of exits or perhaps no exit at all, depending on your entry point. Have a look at Figure 5.1 to get the idea. You can see the external features but have no clue what awaits you inside. You can wander in this maze for a long time without getting very far. This pretty well symbolizes what happens during a lot of drug discovery projects. In target-based drug discovery, described in the next section, each entry point in the maze corresponds to a molecule chosen as a starting place to begin work. Most of these entry points are dead ends. No matter what you do or how hard you try, the only exit from the maze is the place you entered—nothing gained. The journey may be long, there may be encouraging signs along the way, but at the end of the day, you are back where you started.

Surgical Outcomes and Predictive Factors of Medial Toe Excision for Polysyndactyly of the Fifth Toe

2020 ◽  
pp. 107110072097128
Author(s):  
Kyung Rae Ko ◽  
Jong Sup Shim ◽  
Jiwon Kang ◽  
Jaesung Park
Keyword(s):  
Surgical Outcomes ◽  
Proximal Phalanx ◽  
Case Series ◽  
Valgus Deformity ◽  
Retrospective Case ◽  
Functional Disturbance ◽  
Thickness Skin ◽  
Fifth Toe ◽  
The Mean

Background: We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. Methods: We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. Results: At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. Conclusion: The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. Levels of Evidence: Level IV, retrospective case series.

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