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Background: Total knee arthroplasty (TKA) remains challenging in severe varus knees. We evaluated the impact of hip-knee-ankle varus deformity and osteophyte size on achieving restricted kinematic alignment (rKA) in robotic-arm-assisted TKA. Methods: This retrospective study included 244 knees (194 patients) that underwent robotic-arm-assisted TKA for varus primary knee osteoarthritis at an academic institution. Intraoperative hip-knee-ankle angle (HKA) and soft tissue balance were monitored to assess the success of rKA with osteophyte resection alone. For those that failed, medial collateral ligament needle pie-crusting was performed. Results: Mean age was 65.3 years (range, 48-83). Mean preoperative HKA was 11.9° varus (range, 1.0°-32.0°), and HKA after osteophyte resection was 5.1° varus (range, 0°-19.0°). Mean HKA correction was 6.8° (range, 0°-18.0°). rKA was achieved in 36.9% at a boundary of ≤3° varus and up to 72.1% at ≤6° varus. Preoperative varus HKA was lower in successful cases across all target alignments (P < .05). Medial tibial osteophyte size was 6.1% ± 2.9% and was smaller in all groups that achieved rKA (P < .05). Both were positively correlated with degree of deformity correction, r = 0.718 (P < .01) and r = 0.281 (P < .01), respectively. Conclusions: This study highlighted the importance of varus deformity and medial tibial osteophytes when adopting rKA. They were associated with increased failure to achieve rKA. rKA was reliably achieved in minimal varus deformities (HKA ≤ 5°), we recommend an expanded protocol of HKA ≤ 6° varus for mild deformities (HKA 6°-10°), and consider medial soft tissue release for moderate (HKA 11°-15°) and severe deformities (HKA ≥ 16°).

Background: Four-dimensional computerized tomographies (4D-CTs) or motion CTs in elbow disorders have several potential advantages over conventional static imaging such as a reduction of misdiagnoses, a more targeted surgical approach, better patient understanding of their condition and potentially faster operative times. However, the radiation dose is higher than conventional static CT scans so this should be used judiciously. Our study reviews the current literature for 4D-CTs in dynamic elbow disorders and provides a technical note describing radiation-reduced targeted elbow 4D-CTs (te4D-CT) with two exemplar cases alongside our recommendations for when te4D-CTs are indicated. Methods: te4D-CTs are performed in a lateral decubitus elbow above head position. Preliminary static source axial cut CT obtained with subsequent sagittal and axial planes reconstruction and 3D reconstruction obtained, followed by scan performed in motion and reconstructed to 4D Component. te4D-CTs are taken for either flexion and extension (FE) or pronation and supination (PS) motions depending on the clinical pathology suspected following thorough clinical examination. Results: te4D-CT for PS and FE protocol scans had an effective radiation exposure dose of 0.53 and 0.95mSv, respectively, compared to 1.13-1.83 mSv in conventional elbow 4D-CTs. In addition, te4D-CTs have good diagnostic accuracy provided that the FE or PS pathology is identified carefully by the ordering physician. Conclusion: te4D-CT using isolated pronation and supination, or flexion and extension protocols does come with a significantly reduced radiation dose and can be of equal clinical yield compared with 4D-CTs.

Background:. The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb. Methods:. Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation. Results:. In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5). Conclusions:. Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.

A 51-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with pain and a typical history of Morton's neuroma. Examination revealed a palpable swelling over the right foot in the third intermetatarsal space. Following failed conservative management, the patient underwent excision of the neuroma. Histology revealed of necrotizing granulomas with peripheral palisading and no evidence of features specific to a neuroma. This has rarely been described previously and supports the concept of rheumatoid synovitis and nodules producing symptoms mimicking Morton's neuroma/metatarsalgia.Level of clinical evidence: 4

One of the contraindications to patella resurfacing in total knee arthroplasty is a thin and severely eroded ‘deficient’ patella. However, such patients often present with severe patellofemoral joint arthritis, patellar lateral subluxation, and patella maltracking, which can only be treated effectively with resurfacing. While various treatments have been proposed, options remain limited.Here we introduce a method of patella reconstruction using four 2.7-mm titanium cortical screws crossing each other into the inner shell of the patella. This provides a scaffold onto which bone cement and any standard polyethylene patellar component can be fixed. Postoperatively, the patient had no anterior knee pain, no patella maltracking, and no component loosening.Advantages of this technique include minimization of extensor disruption, low costs, easy accessibility, reproducibility, and improved mechanical strength.

Objective: We report the unorthodox injury of the subclavian vessels by the malposition of a chest drain, for the treatment of a pneumothorax in the presence of a lateral third open fracture of the left clavicle. This case presents the first report of a ruptured subclavian vein and cephalic vein after the insertion of a chest drain for a pneumothorax. A systematic search performed in MEDLINE, EMBASE, Cochrane Library, and Web of Science found no similar cases documented in the literature. Methods: A Chest tube was inserted into the second intercostal space mid-clavicular line. Immediately postinsertion the left-hand digits were cyanosed with an absent radial pulse. An intraoperative haematoma was noted surrounding the chest drain insertion point. Vascular surgeons provided assistance and detected ruptured cephalic and subclavian veins and a punctured subclavian artery. The subclavian artery was repaired and both veins tied. The chest drain was re-inserted as per the ATLS protocol into the 4th intercostal space mid-axillary line. Upon healing of vascular repair of the subclavian artery injury the clavicle fracture was treated by use of a hook plate. Results: The patient made a good recovery, follow-up radiographs showed signs of fracture healing with complete resolution of pneumothorax and the patient was discharge from the department of orthopedic care. Conclusion: We believe that strict adherence to ATLS principles is vital as fractures of the lateral third of the left clavicle can distort anatomical landmarks. This can increase the incidence of injury to subclavian vessels due to malposition of the chest drain. Insertion of the chest drain in the fourth intercostal space mid-axillary line provides sound decompression of a pneumothorax as per ATLS protocol and reduces iatrogenic risk.

Objective: We report the unorthodox use of a retrograde intramedullary nail via antegrade technique for the treatment of a subtrochanteric pathological femur fracture in the presence of significant coxa vara. No similar use has been documented previously in literature. Methods: A standard approach to the proximal right femur was performed and standard antegrade technique used to introduce a guide wire into the proximal femur after which the femoral shaft was reamed. A 38-cm long 10 mm diameter retrograde nail was attached to the retrograde insertion and targeting device as if to perform a left sided retrograde femoral nailing. The nail was then inserted antegrade into the proximal right femur and locked. Results: The patient made a good recovery without complications and was followed up regularly at the clinic until complete healing of the fracture. Conclusion: We believe that a retrograde intramedullary nail inserted antegrade, enabling proximal locking with screws passing into the femoral head, provides a mechanically sound fixation of a subtrochanteric fracture, where a reduced neck-shaft angle precludes the use of a standard cephalo-medullary nail.

Introduction The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery. Aims To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction. Methods 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score. Results At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 ( P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups. Conclusions Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients’ satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction.

Suture-based vascular closure devices are used in percutaneous endovascular procedures. However, failures are not uncommon. We have described our initial experience with two adjunct techniques to reinforce the suture-based vascular closure device (ProGlide; Abbot Vascular, Santa Clara, Calif) after percutaneous endovascular aneurysm repair. The threads of the ProGlide device (Abbot Vascular) were passed through a pledget with the help of a needle, which was secured to the puncture site to allow for traction compression. The use of the techniques can be helpful if the suture-based vascular closure devices fail to achieve immediate and complete hemostasis. The use of these adjuncts could reduce the incidence of closure-related complications after percutaneous endovascular procedures.

From our monogenic diabetes registry set-up at a secondary-care diabetes center, we identified a nontrivial subpopulation (~15%) of maturity-onset diabetes of the young (MODY) among people with young-onset diabetes. In this report, we describe the diagnostic caveats, clinical features and long-term renal-trajectory of people with HNF1B mutations (HNF1B-MODY). Between 2013 and 2020, we received 267 referrals to evaluate MODY from endocrinologists in both public and private practice. Every participant was subjected to a previously reported structured evaluation process, high-throughput nucleotide sequencing and gene-dosage analysis. Out of 40 individuals with confirmed MODY, 4 (10%) had HNF1B-MODY (harboring either a HNF1B whole-gene deletion or duplication). Postsequencing follow-up biochemical and radiological evaluations revealed the known HNF1B-MODY associated systemic-features, such as transaminitis and structural renal-lesions. These anomalies could have been missed without prior knowledge of the nucleotide-sequencing results. Interestingly, preliminary longitudinal observation (up to 15 years) suggested possibly 2 distinct patterns of renal-deterioration (albuminuric vs. nonalbuminuric chronic kidney disease). Monogenic diabetes like HNF1B-MODY may be missed among young-onset diabetes in a resource-limited routine-care clinic. Collaboration with a MODY-evaluation center may fill the care-gap. The long-term renal-trajectories of HNF1B-MODY will require further studies by dedicated registries and international consortium.

Category: Bunion; Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Pes planus is associated with hallux valgus development. Increased forefoot abduction and pressure through the hallux during the heel-rise phase of the gait in a pes planus foot is believed to contribute to hallux valgus formation. These abnormal forces through the hallux may result in poorer healing and more residual pain after surgical correction. We investigated if patients with increasing severity of pes planus presented with more severe hallux valgus deformity and whether these patients had more residual pain and poorer function following hallux valgus surgery. Methods: We evaluated 191 consecutive cases of hallux valgus surgery with Scarf osteotomy as the primary procedure. American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, visual analog scale (VAS), Short Form-36 physical component summary (SF-36 PCS), mental component summary (SF-36 MCS) and a satisfaction questionnaire were assessed at baseline, 6 months and 24 months postoperatively. Pes planus angles measured were the talonavicular coverage angle (TNCA), lateral talus-first metatarsal angle (Meary's angle) and lateral talocalcaneal angle (LTCA). The cohort was stratified into controls (0°-4.0°), mild (4.1°-14.9°), moderate (15.0°-30.0°) and severe (>30.0°) pes planus groups according to Meary's angle. Clinical outcomes were compared among the groups. Multiple regression was used to determine association between pes planus angles and outcomes. Results: There were 78 controls, 95 mild, 18 moderate and no severe cases of pes planus. Meary's angle was independently associated with preoperative HVA (beta 0.408, 95% CI 0.104-0.712, P =.009). Patients with mild and moderate pes planus had significantly greater preoperative HVA (P

Abstract:. On February 8, 2020, Singapore raised its Disease Outbreak Response System Condition (DORSCON) level to Orange, indicating that coronavirus 2019 (COVID-19) was a severe disease with high human transmissibility. Using lessons learned from the severe acute respiratory syndrome (SARS) outbreak in 2003, the orthopaedic surgery department at Singapore General Hospital, a tertiary-level referral center, was prepared to handle this pandemic through business-continuity planning. The business that we are referring to is the “business” of orthopaedic surgery, encompassing clinical care, education, research, and administration. There is a lack of literature detailing business-continuity plans of surgical departments during pandemics, with new guidelines being developed. A large proportion of orthopaedic work, such as cases of fracture and infection, cannot be postponed. Even elective surgeries cannot be postponed indefinitely as it could result in detriment to the quality of life of patients. The aim of this article is to detail the business-continuity plans at our institution that allowed the delivery of essential musculoskeletal care through personnel segregation measures during the COVID-19 pandemic. Strategies to ensure the provision of timely medical intelligence, the reduction of nonessential ambulatory visits and surgical procedures, ensuring the safety and morale of staff, and continuing education and research efforts were paramount. As the COVID-19 pandemic unfolds, our posture needs to constantly evolve to meet new challenges that may come our way. Our existing business-continuity plan is not perfect and may not be applicable to smaller hospitals. There is conflict between envisioned normalcy, remaining economically viable as an orthopaedic department, and fulfilling training requirements, and educating the next generation of orthopaedic surgeons on the one hand and the need for segregation, workload reduction, virtual education, and social distancing on the other. Orthopaedic surgeons need to strike a balance between business continuity and adopting sustainable precautions against COVID-19. We hope that our experience will aid other orthopaedic surgery departments in adapting to this new norm, protecting their staff and patients, managing staff morale, and allowing the continuation of musculoskeletal care during the COVID-19 pandemic.

Background:. The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI). Methods:. Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded. Results:. All patients’ mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis. Conclusions:. All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient’s death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:. The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures. Methods:. A prospective study of patients who presented to the accident and emergency department of the authors’ institution was performed. The duration of the study was 4 years. All patients ≥18 years of age with an isolated open fracture of the tibia were included in the study. Open fractures were graded using the Gustilo-Anderson (GA) classification. The study participants were divided into 3 groups based on the timing of the surgery. Infection and nonunion rates were compared using chi-square analysis. P < 0.05 was considered significant. Results:. A total of 1,896 patients were included in the study. There was no significant difference between the results of surgery performed before 48 hours and those of surgery performed after 48 hours with regard to the infection rates associated with GA type-I (p = 0.48), type-II (p = 0.70), or type-III (p = 0.87) fractures or the nonunion rates associated with type-I (p = 0.6338), type-II (p = 0.4030), or type-III (p = 0.4808) fractures. A higher GA classification was associated with higher rates of infection and nonunion independent of the timing of the surgery (95% confidence interval [CI] = 1.24 to 1.89, p < 0.01). Conclusions:. Our study indicates that the risks of infection and nonunion remain acceptable despite delays in the management of open tibial fractures within a 24 to 96-hour window. A delay in the initial time to debridement is acceptable only when early care cannot be provided. Prompt initial debridement remains the best possible treatment for open tibial fractures. Level of Evidence:. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The current coronavirus disease 2019 (COVID-19) pandemic has not only caused global social disruptions but has also put tremendous strain on healthcare systems worldwide. With all attention and significant effort diverted to containing and managing the COVID-19 outbreak (and understandably so), essential medical services such as transplant services are likely to be affected. Closure of transplant programs in an outbreak caused by a highly transmissible novel pathogen may be inevitable owing to patient safety. Yet program closure is not without harm; patients on the transplant waitlist may die before the program reopens. By adopting a tiered approach based on outbreak disease alert levels, and having hospital guidelines based on the best available evidence, life-saving transplants can still be safely performed. We performed a lung transplant and a liver transplant successfully during the COVID-19 era. We present our guidelines and experience on managing the transplant service as well as the selection and management of donors and recipients. We also discuss clinical dilemmas in the management COVID-19 in the posttransplant recipient.