Programable Active Fixator System for Systematic In Vivo Investigation of Bone Healing Processes

This manuscript introduces a programable active bone fixator system that enables systematic investigation of bone healing processes in a sheep animal model. In contrast to previous systems, this solution combines the ability to precisely control the mechanical conditions acting within a fracture with continuous monitoring of the healing progression and autonomous operation of the system throughout the experiment. The active fixator system was implemented on a double osteotomy model that shields the experimental fracture from the influence of the animal’s functional loading. A force sensor was integrated into the fixator to continuously measure stiffness of the repair tissue as an indicator for healing progression. A dedicated control unit was developed that allows programing of different loading protocols which are later executed autonomously by the active fixator. To verify the feasibility of the system, it was implanted in two sheep with different loading protocols, mimicking immediate and delayed weight-bearing, respectively. The implanted devices operated according to the programmed protocols and delivered seamless data over the whole course of the experiment. The in vivo trial confirmed the feasibility of the system. Hence, it can be applied in further preclinical studies to better understand the influence of mechanical conditions on fracture healing.

Is the One Ray Normal or Are the Rest Shorter?: Brachymetapody—A Case Report

In this case report, we present the case of a 20-year-old male patient who suffered from pain in walking clinically, and in whom an extremely rare type of brachymetatarsia was diagnosed. Although distorted body image is the main reason for consulting a specialist, the patient presented because he was unable to find a proper shoe. The patient had no familial history of brachydactyly, trauma, or a genetic disorder. In this extremely rare case, the decision was made to perform shortening of the normal foot ray with a double osteotomy to the metatarsal and proximal phalanx. At the end of the follow-up period, the patient was walking pain-free and had no limitation in shoe choice.

Intraosseous Sliding Plate Fixation Used in Double Osteotomy Bunionectomy

Background: Distal chevron metatarsal osteotomy bunionectomy is a commonly performed procedure for the treatment of mild to moderate hallux valgus. We continue to use the intraosseous sliding osteotomy plate system for fixation of the distal metatarsal osteotomy. With the addition of the Akin osteotomy, we are able to obtain reliable, reproducible correction with better cosmesis and increased patient satisfaction for more advanced deformities. Methods: We prospectively evaluated 138 (145 feet) consecutive patients who underwent double osteotomy bunionectomy using the intramedullary plate system and 3.2-mm cannulated screw system. The senior author performed all operative procedures. Patients were evaluated preoperatively, postoperatively, and at the final follow-up using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot scoring system. Results: All osteotomy sites of operatively corrected feet healed. There were no hardware failures. A small number of patients complained of stiffness and pain related to the hardware. All patients dramatically improved their AOFAS scores compared with preoperative values. The hallux valgus angle was corrected by a mean of 17.3 degrees (range, 10 to 20 degrees), and the intermetatarsal angle was corrected by a mean of 6.8 degrees (range, 5 to 9 degrees). Conclusion: Chevron osteotomy paired with an Akin osteotomy (double osteotomy bunionectomy) resulted in excellent function and pain relief. We continue to recommend the use of the intramedullary plate system and 3.2-mm cannulated screw system because of its low profile, reliability of fixation, and relative ease of use. Level of Evidence: Level III, retrospective comparative series.

Treatment trends for acquired hallux valgus among orthopedic surgeons and podiatrists

Category: Bunion Introduction/Purpose: Foot and ankle surgery is unique in that both orthopedic surgeons and podiatrists perform many of the same procedures. Very little data exists comparing the two groups for treatment trends and potential complications for acquired hallux valgus deformity. The Truven Health MarketScan® Commercial Claims and Encounters database offers a breadth of information for comparing commercially available health insurance claims. The MarketScan® database was utilized to gain understanding in treatment trends between podiatrists and orthopedic surgeons. Methods: MarketScan® database was used to retrospectively search from 2005-2014 for cases involving a diagnosis of hallux valgus (ICD-9 735.0) that included procedural codes for distal metatarsal osteotomy (CPT 28296), double osteotomy (CPT 28299), and first tarsometatarsal arthrodesis (CPT 28297). The procedures were then divided into the provider groups of podiatry (PO) or orthopedic surgery (OS) to compare the trends in treatment options. Additionally, hospital admission within 3 months, reoperation, and pain medication prescriptions were tracked for the separate groups and for the individual procedures within those groups. Results: From 2005-2014, 206409 patients were identified for comparison. Podiatrists performed 87.5% of hallux valgus corrective procedures with significantly different (p<0.0001) treatment approaches with 78.9% distal metatarsal osteotomy (OS 63.2%), 16.2% double osteotomy (OS 25.3%), and 4.9% first tarsometatarsal arthrodesis (OS 11.5%). Orthopedic surgeons and podiatrists demonstrated similar hospital admission rates 3 months from surgery or reoperation at 1.8% and 1.5% respectively. Amongst all providers, there was significantly more (p<0.001) reoperations and admissions after first tarsometatarsal arthrodesis (2.1%) when compared with distal metatarsal (1.5%) and double (1.6%) osteotomies. 9254 patients were available for prescription drug comparison that demonstrated significantly different prescribing trends with orthopedic surgeons prescribing hydrocodone 2.8% (PO 12.9%), oxycodone 39.4% (PO 10.8%), and tramadol 43.4% (PO 60.0%). Conclusion: A large portion of hallux valgus correction is being performed by podiatrists amongst privately insured patients. Podiatrists were much more likely to perform distal metatarsal osteotomy while orthopedic surgeons were more likely to perform double osteotomies and first tarsometatarsal arthrodesis. Hospital admission within 3 months was similar for the providers. Podiatrists were more likely to prescribe hydrocodone and tramadol while orthopedic surgeons demonstrated greater numbers with oxycodone prescriptions.

Fusion Versus Flexible Reconstruction for Patients with Flexible Flatfoot

Category: Other Introduction/Purpose: When passively correctible, adult acquired flatfoot deformities (AAFD) are often treated with joint-sparing procedures. Questions remain, however, as to the efficacy of such flexible procedures when clinical deformities become more severe. In patients with increasingly severe deformities, a primary fusion may lead to more predictable outcomes, but also risks nonunion. The primary aim of this study was to compare the reoperation rates and complication rates following flexible reconstructions versus fusion procedures in the treatment of flexible AAFD. Methods: All patients, who were diagnosed and treated surgically for a flexible AAFD between January 1, 2001 and January 1, 2016, were identified. Exclusion criteria included incomplete medical records, rigid flatfoot deformities, and prior flatfoot surgery. Procedures defined as flexible reconstructions included medial calcaneal osteotomy (MCO), lateral calcaneal lengthening (LCL), double osteotomy, posterior tibial tendon (PTT) debridement, or PTT augmentation; procedures defined as fusions included subtalar (ST) arthrodesis, talonavicular (TN) arthrodesis, calcaneocuboid (CCJ) arthrodesis (alone or in combination with a LCL), double arthrodesis, or triple arthrodesis. Patient demographics, type of surgical procedure, postoperative complications, and reoperation rates were collected. Bivariate analysis was performed to compare patients who had a flexible reconstruction procedure versus a fusion procedure. Results: Two-hundred-thirty-nine patients (255 feet, mean follow up 62±50 months, range 15-104) were included. Two-hundred-eight (87%) patients underwent a flexible reconstruction, average age 55 (±12.0), while 31 (13%) patients underwent a fusion, average age 58 (±14.4) (p = 0.161). Age, BMI, diabetes and neuropathy rates were similar for both groups. Fifty-four patients (24%) underwent a flexible reconstruction and returned to the OR versus 11 (34%) in the fusion group (p = 0.217). Nonunion occurred more in the fusion group, with 5 (16%) versus 10 (4%) nonunions in the flexible reconstruction (p = 0.027). Symptomatic nonunion rates were similar. Rates of surgical revision for nonunion among patients returning to the OR were similar between flexible (7/54, 3%) and fusion (3/11, 9%) groups (p = 0.117). Conclusion: No significant difference in reoperation rates was found between flexible AAFD patients who were treated with flexible reconstructions versus fusions. As expected, the nonunion rate was significantly higher in the fusion group. Notably, rates of revision surgery for nonunion were similar between groups. Our findings suggest that nonunion should be less of a concern when considering a flexible versus fusion procedure for patients with a severe AAFD, and that other factors such as the degree of deformity should guide decision making.

Peri-talar Osteotomy as Part of Treatment of Talar Osteochondral Defect of Varus Ankle

Category: Ankle Introduction/Purpose: The etiology of osteochondral defect (OCD) of talus is not fully understood. Besides trauma, malalignment of ankle or hindfoot may play a role in the development of OCD. The aim of this study is to assess the efficacy of peri-talar osteotomy in addition to routine treatment of OCD of talus. Methods: This is a retrospective study of 52 cases of varus talar OCD during the period of 2009.9 to 2014.12. Micro-fracture or autograft transplantation were applied for the OCD first according to the dimension of the lesion in all cases. Then peri-talar osteotomy were performed to correct ankle or hindfoot mal-alignment in 26 cases according to the position of varus deformity, including 18 supramalleolar osteotomy, 6 calcaneal osteotomy and 2 combined distal tibial and calcaneal double osteotomy. Pre- and post-operative radiographic parameters of TAS, TTS, TLS angles and MoA were measured on mortise view, lateral view and hindfoot alignment view respectively. AOFAS-AH score, VAS score and SF36 score were performed to assess both subjective and objective outcome. Results: For the osteotomy group, there were statistically changes (P < 0.05) radiographically (TAS, TTS, MoA, TLS) after surgery. While the radiographic parameters didn’t change in the group without corrective osteotomy. AOFAS-AH score and VAS score increased significantly (P < 0.05) in both the osteotomy group and the non-osteotomy group. The SF36 scores score increased significantly (P < 0.05) in the osteotomy group while not significant in the non-osteotomy group. The AOFAS-AH and SF36 scores were statistically higher in the osteotomy group after surgery (p<0.05), and the VAS score were not statistically different in two groups. There were 5 out of 26 revised cases in the non-osteotomy group while 2 out of 26 revised cases in the osteotomy group. Conclusion: Peri-talar osteotomy in addition to routine treatment of OCD of talus results in better radiographic and functional outcome and lower recurrence for patients of varus talar osteochondral defect. Mechanical malalignment may contribute to progression of OCD of talus and thus should be corrected simultaneously.