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Objective: To report long-term outcomes of dogs treated with pantarsal arthrodesis (PTA) with medial plate fixation without external coaptation., Study Design: Retrospective case series., Animals: Client-owned dogs (n = 30)., Methods: Medical records of dogs that had undergone a PTA with a medially applied plate without adjunctive rigid external coaptation were reviewed. Data collected included signalment, complications, and assessment of function at last physical examination. Follow-up information was obtained by phone conversations with owners. Complications were classified as minor, major II, major I, and catastrophic., Results: Thirty-six PTA were performed in 30 dogs. Recorded complications included eight (22.2%) minor complications, 11 (30.6%) major II complications and 11 (30.6%) major I complications. One (2.8%) dog required amputation because of catastrophic complication. Owners provided follow-up for 26 dogs at a median duration of 1215 days (range, 325-3495) after surgery. The outcome was reported as full function in 12 dogs and acceptable function in 14 dogs, with no owners reporting unacceptable function. The owner of the dog in which amputation was required was not contacted. Incorrect contact details prevented owner follow-up in the other three dogs, but all had acceptable function at last veterinary follow up., Conclusion: Dogs treated with PTA by medially applied plate had a high incidence of complications requiring surgical or medical management, although full or acceptable function was achieved in 29 of 30 dogs., Clinical Significance: Pantarsal arthrodesis offers a predictably good medium to long-term outcome in spite of a high risk of complications., (© 2019 The American College of Veterinary Surgeons.)

Objective: This study compares the mechanical stability and surgical usability of 2 locking plate systems (Kyon ALPS-20 and Synthes PIP-LCP system) for arthrodesis of the equine proximal interphalangeal joint (PIJ)., Material and Methods: The experimental ex vivo study included 6 pairs of cadaver distal limbs (n = 12). All specimens were derived from Warmblood horses of various ages that were euthanized for non-orthopedic reasons. Of the 12 limbs collected, 3 left and 3 right distal limb specimens were randomly assigned to each system for implantation. Two abaxial 4.5-mm cortical screws were inserted transarticularly in all cases. Both systems were implanted according to the manufacturer's instructions with the plates placed centrally between the 2 transarticular screws. The ALPS-20 systems were implanted using Kyon B-6.4-mm monocortical locking screws in all positions. The LCP systems were implanted axially using 2 Synthes 5-mm locking screws in the proximal and distal positions, with a standard 4.5-mm cortical screw inserted in the middle position. All constructs underwent CT-scans after implantation and biomechanical testing to detect implant deformation. Uniaxial mechanical loading was applied via a servo-hydraulic test system at a test speed of 50 mm/s, up to a maximum displacement of 80 mm. The resulting load-displacement curves were used to calculate yield point, stiffness, and maximum force for each construct. The measured values were evaluated for statistical significance (p < 0.05) between the 2 plate systems via one-factor ANOVA (Tukey test). The statistical power was verified for yield force, stiffness, and maximum load., Results: No statistically significant differences between the 2 preparation groups were calculated across all of the measured parameters (p > 0.05). The ALPS system implants showed no signs of deformation, either in the plates or the screws. In contrast, the LCP demonstrated visible deformation, which had already occurred at the time of implantation from the tightening of the middle screw, as well as during the subsequent testing of the implants. After biomechanical testing, deformations ranging between 3.1° and 7.0° were measured in 4 LCPs. A total implant failure was observed for 2 LCPs., Conclusion and Clinical Relevance: Both systems demonstrated comparable mechanical properties in the present study's ex vivo test model for equine PIJ arthrodesis. As such, the Kyon ALPS-20 may be a good alternative to the Synthes LCP for equine PIJ arthrodesis., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis., Methods: Studies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included., Results: A total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA., Conclusions: Pooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis.

We prospectively compared subtalar arthroereisis with lateral column calcaneal lengthening for the treatment of painful flatfeet. Twenty-four feet (mean age of patients 12.8 years) were treated. Kinematic motion analysis, pedobarometry, and radiography were performed, and the Oxford Ankle-Foot Questionnaire for Children was administered for each patient before surgery and at the 1-year follow-up. We found statistically significant improvements in both groups, with no difference in their outcomes. Both groups showed significantly improved hindfoot and midfoot motion and positioning. Hindfoot range of motion was preserved. Radiography and pedobarometry also revealed significant improvements. Subtalar arthroereisis is a valid and potentially less-invasive alternative to lateral column lengthening that merits further investigation.

Healing of an arthrodesis occurs optimally when the prepared joint surfaces are held rigidly under compression [1]. We routinely use the "Chisel test" intra-operatively to determine whether we have achieved adequate compression and rigidity after fixation of our foot and ankle fusions. This previously un-reported technique uses tools already on hand when performing an arthrodesis and takes seconds to perform., (Copyright © 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The authors report the results of femoral-tibial fusion with an Ilizarov circular external fixator following septic loosening of knee prosthesis., Materials and Methods: The series included 17 patients with a mean age of 62.9 years, treated from 1990 to 2007 with femoral-tibial fusion. The Cierny-Mader classification was used for clinical and anatomopathological evaluation; the Engh classification was used to assess the bone defect. Surgical treatment differed according to these criteria., Results: Healing was achieved in 13 out of 17 patients at the first surgical attempt in a mean time of 9.3 months. Mean follow-up was 30 months. Of the four complications, two patients had an intolerance to the external fixator that led to its early removal, and the other two had a septic intraarticular nonunion., Conclusions: The Ilizarov circular external fixator is a very reliable fixation system due to its low cost, versatility, stability under load, and low risk of septic dissemination. Nevertheless, an appropriate patient selection and a good surgeon's experience are necessary.

Background: Computer Assisted Surgery (CAS) has shown the potential to increase the accuracy of surgical procedures in different fields of orthopedic surgery. The clinical experiences of 100 cases with CAS guided arthrodeses were evaluated., Materials and Methods: Two navigation systems were used (VectorVision/Navivision, Brainlab). Patients with unilateral foot and/or ankle correction arthrodesis from January 1st, 2005 to March 31st, 2008 were included. The correction was planned on the basis of clinical findings, radiographs and computer tomography. Time spent, accuracy, and problems that occurred with CAS guidance were analyzed. The accuracy was assessed by intraoperative three-dimensional imaging with ISO-C 3D or ARCADIS-3D (Siemens). The deviation from the achieved correction in comparison with the planned correction was analyzed., Results: One hundred patients were included (ankle, n = 19; subtalar, n = 23; ankle and subtalar, n = 12; midfoot/tarsometatarsal (TMT), n = 28, others, n = 18). The average time needed for preparation was 356 seconds (5 minutes, 56 seconds) (range, 4 to 30 minutes), the correction took an average of 28 (range, 12 to 140) seconds. The CAS system encountered malfunctions in 3 procedures (3%). In the remaining cases, all the achieved corrections were within a maximum deviation of 2 degrees/mm when compared to the planned correction (p < 0.05)., Conclusion: With CAS guidance for the correction of deformities of the foot and ankle, a surgeon can achieve a high degree of accuracy with a rapid correction. The high accuracy may lead to improved clinical outcomes.

Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion. In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031). We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.

Flexion-extension radiographs are commonly used to assess lumbar fusion. Recommended criteria for solid fusion have varied from 1 to 5 degrees of angular motion between vertebrae. Notwithstanding this wide variation, the validity of these criteria have never been biomechanically tested. As a preliminary and initial step, it was the authors' purpose to quantify measurable angular motion after simulating solid lumbar fusion in human cadaver spines. Seven cadaveric spines (L1 to L4) were tested in a radiolucent jig fixed to a servohydraulic testing apparatus. Flexion and extension moments of 10 Nm were applied. Fusion was simulated using metallic implants spanning the L2-L3 motion segment. These included transverse process plates, a spinous process plate, pedicle screw construct, or an anterior vertebral body plate to simulate an intertransverse, interspinous process, facet, and interbody fusions, respectively. Angular movements were measured on lateral radiographs and statistically compared using a repeated measures analysis of variance. Simulated intertransverse fusion resulted in 13+/-4 degrees of motion; interspinous fusion, 9+/-4 degrees; posterior facet fusion, 5+/-3 degrees; and interbody fusion with plate, 3+/-2 degrees. Compared with the intact, only posterior facet fusion and interbody fusion with plate had statistically significantly less motion (P=0.006 and 0.0001, respectively). The amount of radiographically detectable flexion-extension motion with simulated fusions varies widely and seems to be influenced by fusion type. This study documents a range of measurable motion on flexion-extension radiographs after several types of simulated lumbar fusion. However, as the degrees of motion seemed to be high, future studies should use a fusion simulation other than metallic implants that more closely resembles bony arthrodesis.

Several techniques have been described for canine pancarpal arthrodesis (PCA) with dorsal plating becoming the most accepted method for ease of placement despite the proposed biomechanical disadvantages. The aim of this study was to compare the biomechanical effects of the addition of crossed K-wires to a standard 2.7/3.5 mm hybrid PCA plate. A 2.7/3.5 mm hybrid PCA plate, alone and combined with crossed K-wires were tested. Six pairs of cadaver forelimbs were collected from medium-sized dogs with an average weight of 24 kg by elbow disarticulation. The limbs were potted and fixed in an Instron load cell (Instron, High Wycombe, UK) and axially loaded to failure. Load displacement data and mode of failure were recorded and stiffness, yield load and ultimate load at failure were calculated. The yield load (kN) of the plate and K-wire construct (1.278+/-0.11) was significantly higher than for the plate construct alone (1.002+/-0.07) (p=0.00056). However, the differences between the two constructs in stiffness and failure loads were not significant.

Objective: To compare failure mode and bending moment of a canine pancarpal arthrodesis construct using either a 2.7 mm/3.5 mm hybrid dynamic compression plate (HDCP) or a 3.5 mm dynamic compression plate (DCP)., Study Design: Paired in vitro biomechanical testing of canine pancarpal arthrodesis constructs stabilized with either a 2.7/3.5 HDCP or 3.5 DCP., Sample Population: Paired cadaveric canine antebrachii (n=5)., Methods: Pancarpal arthrodesis constructs were loaded to failure (point of maximum load) in 4-point bending using a materials-testing machine. Using this point of failure, bending moments were calculated from system variables for each construct and the 2 plating systems compared using a paired t-test. To examine the relationship between metacarpal diameter and screw diameter failure loads, linear regression was used and Pearson' correlation coefficient was calculated. Significance was set at P<.05., Results: HDCP failed at higher loads than DCP for 9 of 10 constructs. The absolute difference in failure rates between the 2 plates was 0.552+/-0.182 N m, P=.0144 (95% confidence interval: -0.58 to 1.68). This is an 8.1% mean difference in bending strength. There was a significant linear correlation r=0.74 (P-slope=.014) and 0.8 (P-slope=.006) between metacarpal diameter and failure loads for the HDCP and 3.5 DCP, respectively., Conclusion: There was a small but significant difference between bending moment at failure between 2.7/3.5 HDCP and 3.5 DCP constructs; however, the difference may not be clinically evident in all patients., Clinical Relevance: The 2.7/3.5 HDCP has physical and mechanical properties making it a more desirable plate for pancarpal arthrodesis.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

Study Design: A biomechanical study to assess the ability of posterior fixation techniques to stabilize a functional spine unit (FSU) after insertion of an anterior load-sharing device., Objective: The objective of this study is to compare various posterior fixation techniques in combination with an anterior load-sharing implant., Summary of Background Data: Pedicle screws and translaminar facet screws have been shown to improve the stiffness of an FSU in combination with an anterior load-sharing device. No published studies, to our knowledge, have compared translaminar facet screw fixation versus bilateral and unilateral pedicle screw fixation used with an anterior load-sharing device., Methods: Ten cadaveric FSUs were potted using methylmethacrylate and attached to a spine simulator mounted to an MTS Mini-Bionix testing machine. The simulator was configured to control compressive loading, axial torque, flexion, extension, and lateral bending. Each specimen was tested in the intact state and following the application of each of four stabilization techniques: custom cage alone, cage plus translaminar facet screw fixation, cage plus unilateral pedicle screw and plate fixation, and cage plus bilateral pedicle screw and rod fixation with transverse coupling. Compressive stiffness and total range of motion (ROM) between +/-8 Nm of torque were extracted from the raw data., Results: Each fixation method decreased ROM in torsion, flexion-extension, and lateral bending compared with the intact state. Unilateral pedicle fixation offered less stability than either of the other posterior fixations in all modes of testing except axial loading, where it was equivalent. Translaminar facet screw fixation was equivalent to bilateral pedicle screws in all modes tested., Conclusions: Using a load-sharing interbody implant, translaminar facet screws are equivalent to bilateral pedicle screws in resisting motion in all three planes. Translaminar facet screws and bilateral pedicle screws offer greater stabilization in all three planes compared with unilateral pedicle screws and a single plate.

Background: First metatarsal phalangeal joint (MTP) arthrodesis is a commonly performed procedure for the treatment of hallux rigidus, severe and recurrent bunion deformities, rheumatoid arthritis and other less common disorders of the joint. There are different techniques of fixation of the joint to promote arthrodesis including oblique lag screw fixation, lag screw and dorsal plate fixation, crossed Kirschner wires, dorsal plate fixation alone and various types of external fixation. Ideally the fixation method should be reproducible, lead to a high rate of fusion, and have a low incidence of complications., Methods: In the present study, we compared the strength of fixation of five commonly utilized techniques of first MTP joint arthrodesis. These were: 1. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical interfragmentary lag screw. 2. Surface excision with machined conical reaming and fixation with crossed 0.062 Kirschner wires. 3. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical lag screw and a four hole dorsal miniplate secured with 3.5 mm cortical screws. 4. Surface excision with machined conical reaming and fixation with a four hole dorsal miniplate secured with 3.5 mm cortical screws and no lag screw. 5. Planar surface excision and fixation with a single oblique 3.5 mm interfragmentary cortical lag screw. Testing was done on an Instron materials testing device loading the first MTP joint in dorsiflexion. Liquid metal strain gauges were placed over the joint and micromotion was detected with varying loads and cycles., Results: The most stable technique was the combination of machined conical reaming and an oblique interfragmentary lag screw and dorsal plate. This was greater than two times stronger than an oblique lag screw alone. Dorsal plate alone and Kirschner wire fixation were the weakest techniques., Conclusions: First MTP fusion is a commonly performed procedure for the treatment of a variety of disorders of the first MTP joint. The most stable technique for obtaining fusion in this study was the combination of an oblique lag screw and a dorsal plate. This should lead to higher rates of arthrodesis.

Proximal intertarsal or tarsometatarsal arthrodesis was performed in four dogs using either 2.0/2.7-mm or 2.7/3.5-mm hybrid dynamic compression plates. Mean radiographic follow-up time was 30.5 weeks (range, 15 to 60 weeks). Mean owner follow-up time was 40.5 weeks (range, 27 to 60 weeks). All cases went on to form stable, healed arthrodeses. Owners reported no noticeable lameness problems long term. Complications occurred in one case and included pressure sores and fracture of the calcaneus. Implant failure did not occur in any case.

The medical records of seven dogs with severe, grade 3, open shearing wounds of the carpus or tarsus that were treated with an immediate arthrodesis were reviewed. Six dogs were managed with a transarticular external skeletal fixator (ESF), and one dog was treated with plate fixation. The soft tissues were managed simultaneously along with the definitive joint stabilization in all cases. Minor complications occurred in four dogs: one dog that required a skin graft, one dog in which a skin graft was recommended but not performed, one dog in which a secondary skin closure was performed, and one dog in which a delayed cancellous bone graft was placed. Major complications occurred in three dogs: two dogs that required restabilization of the arthrodesis and one dog that required implant (i.e., plate) removal due to infection. All dogs healed with acceptable functional and cosmetic results. Further long-term evaluation of five dogs revealed that all but one dog had either excellent or good functional outcomes, and the remaining dog had a fair outcome. Similarly, five dogs had either excellent or good cosmetic outcomes, with the remaining dog having a fair outcome. All owners were very satisfied with the overall results. This clinical study demonstrated that an immediate, definitive management technique, in which bone fusion and wound management are undertaken as simultaneous objectives, is a viable technique of managing severe periarticular shearing injuries. Transarticular stabilization with an ESF is the technique recommended.

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors' institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0-5 degrees of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Objectives: To determine thermal necrosis zone and the maximal temperature achieved with various electrocautery doses applied to the pubic symphysis of immature dogs, and to establish the minimal electrocautery dose needed to affect thermal necrosis of the germinal chondrocytes of the immature canine pubis., Study Design: A randomized, controlled, prospective study., Animals: Twelve puppies, 15 to 17 weeks of age., Methods: Each treated puppy was randomly selected to receive 3 of 33 possible doses of electrical current applied at uniform intervals along the pelvic symphysis. Three treatment sites were sham-operated controls. All treatment zones were biopsied 7 days after application of electrocautery. Confocal laser microscopy with calcein green and ethidium homodimer red stains were used to determine cell type and viability within treatment and control zones. The physeal diameter and thermal necrosis zone were measured. Thermal necrosis zone and dose, and temperature and dose were compared using regression analysis. Prediction equation analysis was used to establish dose recommendations., Results: Doses of 40 W produced a highly significant linear relationship (R(2) =.88, P <.01) with thermal necrosis zone, and a significant linear relationship (R(2) =.76, P <.02) with maximal temperature., Conclusions: The thermal necrosis zone within the pelvic symphysis and maximal temperature achieved can be reliably predicted using electrocautery doses of 40 W. For application of electrocautery to induce pubic symphysiodesis, doses should be chosen based on measured or estimated physeal size. Using prediction equation analysis, the surgeon can plan mean thermal necrosis zone with acceptable variance., Clinical Relevance: Unipolar needle electrocautery can be used to reliably achieve symphyseal necrosis. Prediction equation analysis can be used to determine 40-W doses., (Copyright 2001 by The American College of Veterinary Surgeons)

The modified Lapidus procedure has been used for treatment of hallux abducto valgus for many years, yet only a handful of reports evaluate procedure outcome. The purpose of this investigation was twofold: 1) to provide a retrospective outcome analysis of the modified Lapidus procedure using subjective and objective criteria, and 2) to evaluate procedure outcome in patient populations with differing functional demands: athletes, active patients, and sedentary patients. Thirty-four patients (42 feet) had the modified Lapidus procedure performed by the senior author (R.T.B.) over a 7-year period. Nine patients were lost to follow-up leaving 25 patients (32 feet) for study inclusion. Twenty-three females and two males with average age 44.4 years (range 15-71 years) were evaluated at an average follow-up time of 39 months (range 13-91 months). Evaluation consisted of subjective questionnaire, physical examination, and radiographic assessment. Subjective evaluation revealed that 78% of patients rated surgery "completely" or "very" effective. Athletes demonstrated lower return to preoperative activity levels (30%) than did active patients (86%) and sedentary patients (75%), but this was not statistically significant. Seventy-seven percent of athletes rated surgery "completely" or "very" effective. Postoperative intermetatarsal angle averaged 8.2 degrees (range -2 to 15) and first metatarsophalangeal joint dorsiflexion averaged 62.6 degrees (range 20- 90 degrees). Intermetatarsal angle correction to 10 degrees or less and postoperative first metatarso-phalangeal joint dorsiflexion 45 degrees or greater correlated with improved subjective results. The modified Lapidus procedure is an effective procedure in patients with hypermobility of the first metatarsocuneiform joint. Success is dependent on patient selection, meticulous surgical technique and comprehensive postoperative management.

The proximal interphalangeal joint arthrodesis is frequently performed to correct hammer toe deformities. This study was conducted to compare the inherent stability of the three proximal interphalangeal joint arthrodeses--peg-in-hole, end-to-end, and V constructs--in the sagittal plane by means of load-to-failure testing of 30 fresh-frozen cadaveric specimens fixated with a 0.045 Kirschner wire. The peg-in-hole construct was associated with significantly higher peak loads at failure compared with the other two procedures. Furthermore, the peg-in-hole construct had significantly higher stiffness values as compared with the V procedure. This study thus provides evidence that the peg-in-hole procedure is the most biomechanically stable surgical construct for proximal interphalangeal joint fusions under sagittal plane loading.

Although a number of studies have examined the fate of graft-derived cells during the process of fusion, there remains no consensus regarding their exact contribution to bone formation within the fusion mass. We developed two chimeric mouse isograft fusion models that allowed us to track the fate of graft cells within the host fusion bed. Cortical/cancellous bone graft (1:1 ratio of pelvic to vertebral body bone) from male mice was placed between (a) the tibia and fibula or (b) the coccygeal spine transverse processes of syngeneic female hosts. Both models were characterized histologically and histochemically. Graft-derived cells were then identified by fluorescent in situ hybridization for Y-chromosome sequences present in only the graft (male) cells. When the fusion mass was healing but not yet fused (at 1 and 2 weeks), numerous graft-derived cells were observed throughout the fusion site. The predominant graft-derived cell types included chondrocytes, osteoblasts, and fibroblasts. Chondrocytes arose from precursor cells in the graft de novo. as cartilage was not transplanted during the surgical procedure. By the time a mature fusion mass had formed (at 6 weeks), graft-derived cells persisted as osteocytes within the cortical rim surrounding the fusion mass. These osteocytes likely differentiated from graft-derived precursors that had directly formed bone, because transplanted osteocytes within cortical bone graft fragments were noted to rarely survive even at 1 and 2 weeks. Collectively, our results demonstrate for the first time that bone graft contributes cells that, in conjunction with host cells, directly form bone within the fusion mass during all phases of fusion rather than just the early phases.

Calcaneocuboid distraction arthrodesis can be used to treat stage 2 posterior tibial tendon dysfunction. Nonunion, graft resorption, and implant failure have been reported after this procedure. This study compared two of the most commonly used methods for fixation of calcaneocuboid distraction arthrodesis. Twelve pairs of cadaver feet underwent simulated calcaneocuboid distraction arthrodesis. One specimen in each pair was fixed with two crossed 3.5 mm cortical lag screws. The contralateral specimen was fixed with a cervical H-plate. The calcaneus was fixed and a load was applied to the plantar aspect of the cuboid at a rate of 5 mm/minute until joint separation of 3 mm or fracture occurred. The average applied load to failure at 1.0 mm of joint separation was 30.5 +/- 11.6 N for the crossed screws and 77.7 +/- 36.4 N for the cervical H-plate (p = 0.001). The average stiffness at 1.0 mm of joint separation was 27.5 +/- 10.9 N/mm for the crossed screws and 43 +/- 21.2 N/mm for the cervical H-plate (p = 0.036). The higher stiffness and load to failure may account for the decreased nonunion rate noted anecdotally by some surgeons with H-plate fixation over crossed screw fixation for calcaneocuboid distraction arthrodesis.

Between July 1992 and April 1996, 88 ankle fusions were performed at our institution. Sixty-seven of these had adequate follow-up for evaluation for union of the fusion, including adequate records and/or radiographs. The average age of patients was 43 years. There were 37 men and 24 women. The charts were reviewed to determine what level of trauma had resulted in posttraumatic arthritis (low energy, high energy, or open fracture). Alcohol use, drug abuse, diabetes, peripheral vascular disease, psychiatric history, smoking, or technical problems were also assessed. A chi-square analysis was used to evaluate the statistical significance. Nineteen of sixty-seven ankle fusions progressed to nonunion (28%). Eighty-five percent of the patients had posttraumatic arthritis. Among 17 patients with a history of open trauma, nine patients developed a nonunion (P < 0.03). A trend toward significance was noted for patients who were smokers, drank alcohol, had diabetes, had a psychiatric disorder, or used illegal drugs. Even with current techniques, this study demonstrates that a high risk population in a trauma center is at risk for nonunion after an ankle fusion caused by multiple risk factors, including a history of open trauma, tobacco use, alcohol use, illegal drug use, a history of psychiatric disorders, or diabetes.

A new technique of ankle arthrodesis is described and the results of 12 consecutive procedures are assessed. The method described employs three cannulated transfixion screws and an anterior approach to the ankle. Eleven of the 12 ankles proceeded to solid fusion. One patient developed a painless fibrous non-union. There were no other significant complications. This simple technique provides good compression and adequate resistance to rotatory and angulatory stresses about the ankle fusion site.

One hundred thirty-nine patients underwent 181 arthrodeses of finger distal interphalangeal joints (144) and/or thumb interphalangeal joints (37). Techniques included (1) crossed Kirschner pins (111 joints), (2) interfragmentary wire and longitudinal Kirschner pin (43 joints), and (3) Herbert screw (27 joints). Each technique had a similar nonunion rate. There were 21 nonunions: 13 were pain free, 6 were successfully fused on the second attempt, 1 was painful (but the patient refused further surgery), and 1 was amputated. Inadequate bone stock, inadequate bone resection, premature pin removal, and infection appear to complicate the attainment of bony union. Twenty percent of the fusions had major complications (nonunion, malunion, deep infection, and osteomyelitis). Minor complications (dorsal skin necrosis, cold intolerance, proximal interphalangeal joint stiffness, paresthesias, superficial wound infection, and prominent hardware) occurred in 16% of the joints fused.

Limited arthrodesis of the proximal carpal row to the radius, synovectomy of the extensor tendons and the wrist joint, and a Darrach procedure were carried out in 25 unstable painful rheumatoid wrists that had ulnar shift and/or palmar subluxation of the carpus. The average follow-up period after the operation was 3 years. Satisfactory results were obtained with relief of pain, improved forearm rotation, and increased grip strength. The average degree of extension and flexion was reduced, respectively, 70% and 54% at follow-up compared with the preoperative range. Postoperative x-ray films showed deterioration in the lunocapitate joint in 12 wrists; however, the wrists remained stable and painless.

8 patients with Kienböck's disease and without negative ulnar variance were treated with a modification of Chuinard's capitate-hamate fusion. All patients returned to their normal activities free of pain. The postoperative wrist motion was unchanged, but the grip strength was increased.

Ten resections of the proximal row of carpal bones and 42 partial arthrodese were performed for carpal instability. Whenever possible, the authors prefer the second operation. This choice is often made during the operation and essentially depends on the presence of radio-scaphoid osteoarthritis and the condition of the cartilage of the head of the capitatum.

The results of a series of 36 post-traumatic radio-carpal arthrodeses were compared with those of the series of resection of the first row of carpal bones reported during the round table. The advantages and disadvantages of both procedures were discussed. Arthrodesis results in: 1) loss of grip strength in all cases, averaging 41%; 2) persistent pain in 78% of cases; 3) impairment of function resulting from blocking of the wrist. After the procedure, average time off work is 15 months, level of permanent disability was 30%, and 20% of patients returned to their previous jobs. These figures could be used as arguments against arthrodesis. However, they must be taken in context: final arthrodesis, usually performed on manual workers, is often chosen when resection of the first row of carpal bones would obviously be insufficient, for example, when severe arthritis of the head of the capitate is present.

Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.

The authors after a review of certain elements of the physiology and pathophysiology of the scapho-lunate couple, report a series of 10 patients presenting a post-traumatic scapho-lunate instability stabilized by scapho-lunate bone graft in order to obtain scapho-lunate arthrodesis. The bone fusion was obtained 5 times out of 10, 3 times complete and 2 times by an incomplete bony bridge. In 5 cases, bone fusion was not evident, a fibrous non-union probably occurred which maintained the correction. Nevertheless, the overall results were considered good in 9 out of 10 cases with only one poor result. The outcome with a mean follow-up of 4 years did not show any arthritic changes. The authors consider that scapho-lunate stabilization with an interposed bone graft is a good method which can ensure good stabilization and good clinical results.

The incidence of deep infection after 12,118 primary knee arthroplasties performed in Sweden from October 1, 1975 through 1985 with a median follow-up of 6 years was 1.7 percent for arthrosis and 4.4 percent for rheumatoid arthritis. Risk factors for infection were large prostheses, postoperative wound-healing complications, rheumatoid arthritis, a prior deep infection, and skin infections. We have analyzed the treatment of 357 knee arthroplasties with a deep infection. Systemic antibiotics alone were primarily used in 225 knees, with healing of the infection in 44 knees, 20 of which had a functioning prosthesis at the final follow-up; the treatment did not compromise later revision surgery. Soft-tissue surgery was used in 154 knees--37 healed, 15 of which had a functioning prosthesis. Resection arthroplasty resulted in healing of the infection in 11 of 22 knees. Revision arthroplasty was performed in 107 knees, with eventual healing of the infection in 81 knees, 36 of which had a functioning prosthesis; there were no differences in the outcome of one-stage and two-stage procedures. Arthrodesis was attempted in 135 knees, with eventual healing of the infection in 120 knees and fusion in 105. Twenty-two patients were amputated. Thus, the infection healed in 315 knees (88 percent), but only 71 (20 percent) recovered with a functioning prosthesis, and 8 patients died of the infection. Attention should therefore focus on prophylactic measures directed towards the soft-tissue problems--by avoiding conflicting skin incisions, by gentle handling of the periarticular soft tissues, by avoiding the use of constrained prostheses and oversized compartmental prostheses, by letting wound healing take priority over motion in knees with compromised soft tissues, and by using prophylactic antibiotic treatment for skin ulcers until these have healed.

11 patients with Decoulx stage III Kienböck's disease with rotatory subluxation of the scaphoid were treated with scapho-trapezo-trapezoid arthrodesis. The associated procedures were lunate implant resection arthroplasty in 6 cases, lunate resection in 3 cases, shortening of the radius in 1 case. The average follow-up was 40 months (12 to 84 months). There was no complication of the arthrodesis. Relief of pain is satisfactory in 7 of the 11 patients. The average grip strength is 66% of that observed on the affected side. The range of movement was decreased especially for radial deviation. There was a positive correlation between, the exact scaphoid reduction, a wrist without preoperative degenerative arthritis and the good clinical results. No differences were observed in the results between the associated lunate procedures. STT fusion seems to be a useful procedure in the treatment of stage III Kienböck's disease with carpal malalignment as it removes compressive stress from the diseased lunate and treats, the accompanying rotatory subluxation of the scaphoid.

A study of plantar loading has a place in orthopaedic literature today thanks to the studies conducted by various authors (Stott et al., 1973; Braun et al., 1980, Corvi et al., 1985; Salsano et al., 1986; Pisani, 1987). It is the purpose of this study to report the results obtained by using the baropodometer to study the static and dynamic functions of the foot in patients who were submitted to arthrodesis of the knee 15 or more years ago.

The technique and results of extraarticular subtalar arthrodesis using the dowel method during the 10-year period between 1976 and 1986 were reviewed retrospectively. Fifty feet in 30 children underwent extraarticular subtalar arthrodesis for valgus deformity for diagnoses including meningomyelocele, idiopathic flatfoot, and cerebral palsy. The aims of the procedure were to correct the deformity, obtain a solid arthrodesis, and improve ambulation by reducing bracing requirements and eliminating pain. Results were excellent in 28 cases (56%), satisfactory in 15 (30%), and unsatisfactory in seven (14%). Intraoperative positioning error and simultaneous perineal tendon lengthening in children with cerebral palsy were the major sources of unsatisfactory results.

Luno-triquetral instability dogs not appear to be as rare as one is lead to believe. The clinical features are essentially of progressive discomfort on the medial aspect of the wrist. Plain radiographs are generally of little help, with the diagnosis being made by arthrography with cine-radiography. The authors are reporting a retrospective series of 24 patients which fall into two separate groups: 14 isolated luno-triquetral lesions, 10 associated with a generalized involvement of the proximal carpal row, either as a result of peri lunate dislocation or combined scapho-lunate and luno-triquetral instability without anterior subluxation. The authors have performed 13 luno-triquetral arthrodeses, 6 by pin, 6 by compression screws and one by key graft. For the mixed instabilities the treatment was less specific. The results with a mean follow up of is months have highlighted the problem of non union of the arthrodesis and residual pain various technical aspects of achieving a sound luno-triquetral arthrodesis are discussed.

The instability of atlanto-axial subluxation remains a challenging problem in patients with rheumatoid arthritis. In order to preserve as much function of the cervical spine as possible, inclusion of the occiput into the fusion should exclusively be performed when there is a radiologically or clinically manifest pathological condition of the atlanto-occipital joint or marked upward migration of the dens axis. In order to prevent irreversible damage to the spinal cord, an early indication of surgical stabilization is recommended. This article presents a retrospective analysis of the clinical and radiological results of occipito-cervical fusion in 26 patients with rheumatoid arthritis using a modified Brattström technique. The complications encountered were mainly due to the use of wire fixation, reinforcement using bone cement and insufficient reduction of atlanto-axial subluxation.

Historically, first metatarsocuneiform joint arthrodesis has been advocated for severe metatarsus primus adductus deformity and as a salvage procedure in reconstructive forefoot surgery. At the Podiatry Hospital of Pittsburgh, the authors have expanded the use of this procedure to include elimination of excessive motion at the first metatarsocuneiform joint and to restore functional integrity to the first ray in an otherwise poorly functioning foot. First metatarsocuneiform arthrodesis has had poor acceptance by podiatric surgeons. Common reasons for this poor acceptance are technical difficulty associated with the procedure and often-cited complications such as shortening of the first ray, with symptomatic transfer lesions, as well as nonunion of the arthrodesis site. The authors evaluated 54 procedures. Results of first metatarsocuneiform joint arthrodesis for long-term reduction of the intermetatarsal angle and for limiting abnormal motion at this joint have been very good. Few complications were encountered. Shortening of the first metatarsal with secondary transfer lesions was not found to be a common problem. Several radiographic nonunions occurred, none of which were symptomatic. The surgical procedure, as it is performed at the Podiatry Hospital of Pittsburgh, is described. Results from a 5-year retrospective analysis of first metatarsocuneiform arthrodesis are presented.

Five children, aged 7-15 years, with brachial palsies and flail shoulders, had fusions performed. Four of the five had improved function; however, there was progressive loss of fused abduction position over time.

To evaluate the effect of fusion of the first metatarsophalangeal joint on the first intermetatarsal angle, a series of 62 consecutive first metatarsophalangeal fusions was reviewed. Of these, 47 had sufficient data to be included in this study. The results of this study showed that the change in the first intermetatarsal angle following a first metatarsophalangeal joint arthrodesis is directly proportional to the preoperative first intermetatarsal angle. Therefore, when a first metatarsophalangeal joint arthrodesis is performed on a patient with a wide intermetatarsal angle, a concomitant proximal first metatarsal osteotomy is usually not indicated.