Sen-Yuen Lin

Low tibial osteotomy for moderate ankle arthritis.

Abstract Low tibial osteotomy is one of the significant advances of ankle reconstruction techniques that has been made recently in an effort to halt arthritis in its early stages and leave fusion as the last, not the only, alternative treatment of ankle arthritis. From 1989 to 1995, we performed 18 low tibial osteotomies which included 6 cases of post-traumatic arthritis and 12 cases of degenerative arthritis. The ages of the 7 male and 11 female patients ranged from 18 to 78 years with an average of 41.9 years. The follow-up period lasted a mean of 47.7 months, ranging from 25 to 82 months. The average functional score changed from 49.6 pre-operatively to 88.5 at the last follow up, and showed yearly improvement. Complications included one case of late infection and two cases of implant failure, none of which led to nonunion. The indication for low tibial osteotomy is the intermediate stage of moderate ankle arthritis with a medial joint lesion and intact lateral facet. Using pressure redistribution on the joint surface, this procedure is an alternative treatment for ankle arthritis which may save an arthritic ankle from the fate of fusion or at least postpone fusion surgery.

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus.

BACKGROUND Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeons ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.

Isolated talonavicular arthrodesis for talonavicular arthritis.

We have reviewed a single surgeons experience with isolated talonavicular fusion in 16 patients with talonavicular arthritis. Fixation was either by staples or screws. Fifteen solid unions were achieved in the 16 patients who were followed (mean: 51 months). The average Ankle-Hindfoot Scale improved from 77.2 preoperatively to 92.9 postoperatively (p < 0.001). Subjectively, 15 patients were satisfied and one patient dissatisfied with the results. Further osteoarthritis in the adjacent joints was noted in five patients. We concluded that isolated talonavicular fusion is an effective method of treatment of talonavicular arthritis regarding pain relief and functional improvement. Though osteoarthritis was found in some adjacent joints postoperatively, the results were still satisfactory.

Dome corrective osteotomy for cubitus varus deformity

Between 1994 and 1998, 15 patients had corrective dome-shaped osteotomy of the humerus for posttraumatic cubitus varus deformity. Thirteen patients had surgery before puberty and two patients had surgery after puberty. In the prepuberty group, all the osteotomies were done by a posterior approach with triceps muscle splitting, and cross pins were used to fix the osteotomy. In the postpuberty group, the osteotomies were done by a posterior approach with olecranon osteotomy, and reconstructive plates were used for fixation. The average followup was 2 years and 4 months. Preoperative carrying angle ranged from 19° to 31° varus (average, 26.2° ) and postoperative carrying angle ranged from 7° to 15° valgus (average, 10.7°). No loss of correction was observed and all osteotomies united. The preoperative and postoperative differences of the lateral condylar prominence index ranged from −67% to +6% (average, −30.1%). After reviewing these cases, a dome-shaped osteotomy was found to have the following advantages for correction of cubitus varus deformity: the osteotomy site is more stable than a lateral closing wedge osteotomy for maintaining the correction obtained; the domed osteotomy avoids having the lateral condyle becoming prominent; and the posterior scar is more cosmetically acceptable than the lateral scar in the lateral closing wedge osteotomy.

Subtalar Arthrodesis for Late Sequelae of Calcaneal Fractures: Fusion In Situ Versus Fusion with Sliding Corrective Osteotomy

Primary subtalar arthritis is not common. In most cases, it is the late sequela of intra-articular calcaneal fracture. 7 Subtalar arthrodesis is mostly used for the treatment of traumatic subtalar arthritis in our clinics. We have compared our early cases of in-situ subtalar fusion with our recent cases of fusion with sliding corrective osteotomy in this clinical report. From 1989 to 1992, 15 feet of 13 patients were treated with subtalar arthrodeses for subtalar arthritis caused by malunion of calcaneal fractures. Fusion in situ was done by Olliers approach, and resection of bony protrusion was done if there was lateral entrapment syndrome. From 1992 to 1995, 13 feet of 12 patients also received subtalar arthrodeses to salvage their calcaneal fractures, but the subtalar fusion was done by wide lateral approach, calcaneal sliding corrective osteotomy, and sometimes (11 of 13 feet) with Achilles tendon lengthening to restore the calcaneal height and width. Patients of both groups experienced obvious clinical improvement in subtalar pain relief, but there was no difference with walking distance, running, or jumping. The group undergoing fusion with sliding corrective osteotomy was more satisfied with regard to cosmetic results and shoe wear. The overall satisfactory rate in the group who underwent fusion with sliding corrective osteotomy (92%) was superior to the group who underwent fusion in situ (77%). Though our method of sliding corrective osteotomy does not provide much improvement to the talus declination angle, it is suitable for those patients with a “banana”-shaped calcaneus malunion. If the patient has prominent anterior ankle pain caused by tibiotalar impingement, we believe that a distraction subtalar arthrodesis would be more appropriate.

Indirect reduction and bridge plating of supracondylar fractures of the femur

Between October 1995 and December 1998, 16 patients with A-O type A3, C2 or C3 supracondylar femoral fractures were treated by open reduction and internal fixation using indirect reduction and bridge plating. Seven (44%) patients had open fractures. The patients were followed for a mean of 46 months (range 24-71). All fractures healed. The average time for fracture healing was 18.5 weeks (range 12-28). Four primary bone grafts and three secondary bone grafts were performed. By using the modified Schatzker rating scale, the result of 13 patients (81%) were rated as excellent or good. Complications included two implant failures that were due to full weight bearing before bone healing, and one superficial delayed wound healing. No deep infections were found in this series. The open fracture group needed longer time to heal and had a higher rate of receiving bone grafts. We conclude that indirect reduction and bridge plating with a 95 degrees dynamic condylar screw (DCS) or condylar blade plate can produce favourable results for complex distal femoral fractures. We suggest primary bone grafts or early secondary bone grafts for comminuted open fractures using an indirect reduction technique.

Modified Mitchell osteotomy for hallux valgus.

From 1988 to 1995, 96 patients (161 feet) underwent a modified Mitchell distal metatarsal osteotomy performed for mild-to-moderate hallux valgus. On AP x-rays of the standing foot, the average intermetatarsal angle was corrected from 15° to 9°, and the first metatarsophalangeal angles were corrected from an average of 41° to 15°. Criteria for evaluation of clinical results included relief of pain, appearance of foot, and shoe wear. After an average follow-up of 38 months, the overall satisfaction rate was 92.5%. Complications included 13 pin tract infections, two delayed unions, and two correction losses. The most common late sequela was transfer metatarsalgia of the lesser toes, which occurred in 20 feet (12.4%), leading to some dissatisfaction. The Mitchell osteotomy can be used on cases with less than 20° of intermetatarsal angle, offering a stable construct with easy postoperative care.

Ultrasonographic study of the coexistence of muscular torticollis and dysplasia of the hip.

The consistent relationship between congenital muscular torticollis and dysplasia of the hip is now widely accepted. However, the coexistence rate of these two disorders has been reported with variations from 0 to 20%. To obtain a more accurate coexistence rate, ultrasound scanner was used as the diagnostic tool for both of these disorders. Sixty-three children (30 boys and 33 girls) younger than 6 months who had undergone ultrasound scanning of both bilateral sternocleidomastoid muscle and bilateral hips were included in this study. Forty-seven children were confirmed to have muscular torticollis, and the remaining 16 cases were diagnosed as postural torticollis. Only these 47 cases were included for analysis of the coexistence rate. Eight children were found with dysplasia of the hips associated with muscular torticollis, which included Grafs type IIa for four hips, type IIb for two hips, type IIIa for one hip, and type IIIb for one hip. From the results of the present ultrasonographic study, the coexistence rate of congenital muscular torticollis and dysplasia of the hip was concluded to be 17%. If only those dysplastic hips (type IIb, IIIa, IIIb) that required treatment were included, the coexistence rate would be lowered to 8.5%.

Subtalar Arthrodesis for Subtalar Arthritis

Primary subtalar arthritis is not common except in cases of generalized arthritis such as rheumatoid arthritis. The majority of subtalar arthritis results from intraarticular calcaneal fractures. Arthrodesis seems to be the only way to solve this problem. Thirteen patients (15 feet) were treated with subtalar arthrodesis at KMCH. Preoperative diagnosis included 13 feet with traumatic arthritis secondary to a calcaneal fracture, one foot with rheumatoid arthritis and one foot with primary osteoarthritis. The mean follow up period was 24.9 months. Lateral approach without fibular osteotomy was done with decompression if there was entrapment syndrome and the arthrodesis were accomplished with use of staples for internal fixation. Eleven (85%) of the patients were satisfied with the results. Objectively, the results were excellent after 11 arthrodesis (73%), good or fair after three (20%), and poor after one (7%). There was no nonunion. Complications occurred in 1 patient who developed superficial wound infection, and in 1 patient with staple loosening. Though there was no case of nonunion, the fusion time was rather long. This might have been due to the fixation method because staples can not provide compression force which accelerates union. We believe subtalar arthrodesis is appropriate for isolated subtalar arthritis unless there are associated talonavicular or calcaneocuboid arthritis in which case triple arthrodesis will be more appropriate.

Open Total Talar Dislocation─Report of Two Cases

Total dislocation of talus from all its surrounding joints (tibiotalar, subtalar and talonavicular) is an extremely rare injury. Because of its rarity, only few case reports can be found in the literature. In the review of the literature, infection and AVN are the most commonly encountered complications that affect the outcome of these severe injuries. Herein we report two cases of open total talar dislocation. Immediate debridement, reduction of the talus, and primary skin closure was done followed by cast immobilization. After more than 2 years follow up, neither infection nor AVN was found. We conclude that reimplantation of the talus is preferable if the wound is relatively clean. Talectomy, or combined with tibiocalcaneal fusion should be reserved for later salvage procedure.