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Introduction: Pedicle subtraction osteotomy (PSO) is a complex surgical procedure that provides correction of moderate sagittal imbalance. Surgical complications have adverse effects on patient outcomes and healthcare costs, making it imperative for clinical researchers to focus on minimizing complications. However, when it comes to risk modeling of PSO surgery, there is currently no consensus on which patient characteristics or measures should be used. This study aimed to describe complications and compare the performance of various sociodemographic characteristics, surgical variables, and established risk indices in predicting postoperative complications, infections, and readmissions after lumbar PSO surgeries., Methods: A review was conducted on 191 patients who underwent PSO surgery at a single institution by a single fellowship-trained orthopaedic spine surgeon between January 1, 2018, and December 31, 2021. Demographic, intraoperative, and postoperative data within 30 days, 1 year, and 2 years of the index procedure were evaluated. Descriptive statistics, t -test, chi-squared analysis, and logistic regression models were used., Results: Intraoperative complications were significantly associated with coronary artery disease (odds ratios [OR] 3.95, P = 0.03) and operating room time (OR 1.01, P = 0.006). 30-day complications were significantly cardiovascular disease (OR 2.68, P = 0.04) and levels fused (OR 1.10, P = 0.04). 2-year complications were significantly associated with cardiovascular disease (OR 2.85, P = 0.02). 30-day readmissions were significantly associated with sex (4.47, 0.04) and length of hospital stay (χ 2 = 0.07, P = 0.04). 2-year readmissions were significantly associated with age (χ 2 = 0.50, P = 0.03), hypertension (χ 2 = 4.64, P = 0.03), revision surgeries (χ 2 = 5.46, P = 0.02), and length of hospital stay (χ 2 = 0.07, P = 0.03)., Discussion: This study found that patients with coronary vascular disease and longer fusions were at higher risk of postoperative complications and patients with notable intraoperative blood loss were at higher risk of postoperative infections. In addition, physicians should closely follow patients with extended postoperative hospital stays, with advanced age, and undergoing revision surgery because these patients were more likely to be readmitted to the hospital., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Objective: The aim of this study was to provide benchmarks for the rates of complications by type of surgery performed., Study Design: Prospective multicenter database., Background: We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment., Materials and Methods: Eight surgical scenarios were defined based on the levels treated, previous fusion status [primary (P) vs. revision (R)], and three-column osteotomy use (3CO): short lumbar fusion, LT-pelvis with 5 to 12 levels treated (P, R, or 3CO), UT-pelvis with 13 levels treated (P, R, or 3CO), and thoracic to lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan-Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile., Results: A total of 1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types ( P <0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however, there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition, or neurological complications (all P >0.5)., Conclusions: This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision-making and more informed patient counseling., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Various fixation devices are available for bunion osteotomy. In this study, we evaluated the radiographic outcomes, postoperative complications, and recurrence rate in a series of hallux valgus deformities treated with various osteotomy procedures using a pin for the fixation of the osteotomy., Methods: Two-hundred forty-seven patients with hallux valgus deformity managed with a Simple, Effective, Rapid and Inexpensive (SERI) osteotomy, distal chevron osteotomy, or proximal crescentic osteotomy and K-wire fixation were included. The mean follow-up of the patients was 53.9 ± 8.9 months. Radiographic evaluations included the assessment of the Hallux valgus angle (HVA), intermetatarsal angle (IMA), and union. Clinical evaluations included the assessment of the range of motion, pain in the first metatarsophalangeal joint, and patient satisfaction., Results: In the last visit, the mean improvement of HVA was 23.9 ± 9.1º (P < 0.001). The mean IMA improvement was 6.1 ± 6º (P < 0.001). The mean metatarsophalangeal flexion and extension were 33 ± 10.7º and 34.6 ± 9.2º, respectively. Postoperative complications included pin tract infection in eight (3.2%) patients, deep infection in five (2%) patients, and early pin complication in four (1.6%) patients. Recurrence was observed in five (2%) patients. Twenty-three (9.3%) patients had slight pain in the last follow-up. The mean surgical time was smaller in the SERI osteotomy (P < 0.001). The mean hospitalization period was longer in the proximal osteotomy group (P = 0.039). The mean metatarsophalangeal flexion and extension were significantly smaller in the distal chevron osteotomy (P = 0.046 and P = 0.037, respectively). 90% of patients were satisfied or very satisfied with the surgical outcomes., Conclusion: K-wire fixation is a safe and effective device for the fixation of bunion osteotomy, and this effectiveness is even higher with SERI and proximal crescentic osteotomy., (© 2024. The Author(s).)

The aim of this study was to describe three dogs with permanent fibular nerve injury following tibial plateau levelling osteotomy (TPLO). Fibular nerve injury following TPLO led to atrophy of the cranial tibial muscle, absent hock flexion and a mild lameness. Fibular nerve injury was confirmed in one case with electrodiagnostics. All three cases had a drill tract in the same location, on the caudal aspect of the tibia, immediately distal to the tibial osteotomy. Permanent fibular nerve injury following TPLO occurred with a more caudally positioned plate and care should be taken when drilling the tibia from medial to lateral in the region described. Careful gait assessment at routine follow-up was required to identify this complication., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS)., Methods: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality., Results: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR., Conclusions: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To report a "critical phase" (between osteotomy completion and correction beginning) that will frequently lead to the reversible intraoperative neurophysiological monitoring (IOM) change during posterior vertebral column resection (PVCR) surgery., Methods: The study sample consisted of 120 patients with severe spine deformity who underwent PVCR and deformity correction surgeries. Those patients were recruited consecutively from 2010 to 2018 January in our spine center. The detailed IOM data (the amplitude of MEP & SEP) and its corresponding surgical points were collected prospectively. Early and long-term postoperative neurologic outcomes were assessed for the following functions: motor, sensory, and pain at immediate postoperative and 1-year post-operation in this cases series., Results: A total of 105 (105/120) patients presented varying degrees of IOM reduction in the critical phase; the mean IOM amplitude retention vs rescue rate was 27% ± 11.2 versus 58% ± 16.9, P < 0.01 (MEP) & 34% ± 8.3 versus 66% ± 12.4 P < 0.01 (SEP). Patients with postoperative spinal deficits often had a significantly longer IOM-alerting duration than the patients without (p < 0.01, Mann-Whitney U-test), and IOM-alerting duration greater than 39.5 min was identified as an independent predictor of the risk of postoperative spinal deficits., Conclusions: The reversible IOM events probably often appear in the critical phase during PVCR surgery. The new postoperative spinal deficits are possible for patients without satisfied IOM recovery or alerting duration greater than 39.5 min. Timely and suitable surgical interventions are useful for rescuing the IOM alerts., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The present study aimed to evaluate the degree of nerve injury on inferior alveolar nerve (IAN) by different implant drills resulting from direct canal intrusion into inferior alveolar canal (IAC). A cadaveric study involving 7 human mandibles was performed to evaluate mechanical injury of canal enclosed IAN resulting from different drills. In group 1, osteotomies were created using different drills with 1 mm of intracanal intrusion, simulating accidental drill intrusion into canal. In group 2, drilling was stopped when the tip has breached into IAC, limited by tactile feedback of operator. The depth and width of nerve defects were assessed using optical coherence tomography. A significant difference in defect depth was found (p < 0.001) in group 1. A sinus lift reamer inflicted the least damage (0.068 ± 0.022 mm). It was also found that the mean defect depth was significantly different when a twist drill was used (p = 0.016). Sinus lift reamer can be used safely for osteotomy preparation in mandible when bone height is limited or when radiographic visualization of canal is poor. Bone corticalization around IAC does not provide adequate protection for IAN in the event of accidental intracanal intrusion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

This systematic review and meta-analysis compare the incidences of complications, reoperations and hardware removal between anterior and dorsal plating after corrective osteotomy for dorsally angulated distal radial malunions. A total of 403 patients were included; 253 patients underwent anterior corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Anterior plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the anterior group. There was no difference in major or minor complications between the groups. Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions.

Background: Modular metaphyseal engaging (MME) femoral components in total hip arthroplasty (THA) allow optimized femoral length, offset, and anteversion and are useful in patients with unusual proximal femoral anatomy. Fretting, corrosion, and stem fractures above the modular sleeve are complications associated with these implants. The purpose of this study was to identify failure mechanisms of retrieved MME femoral components at our institution, identify all broken stem cases, and evaluate how often an extended trochanteric osteotomy (ETO) was required for removal., Methods: All consecutively retrieved MME femoral components from September 2002 to May 2023 were reviewed. Patient demographics, procedure information, component specifications, indications for removal, and requirements for further revision surgery were reviewed. Descriptive statistics were calculated for variables of interest., Results: There were 131 retrieved MME components. The mean age at surgery was 59 years (range, 28 to 75), 49% were women, mean body mass index was 29.4 (range, 20.7 to 33.3), and mean American Society of Anesthesiologists score was 2.4 ± 0.5. There were 102 (78%) stems of 1 design (stem A), and 29 (22%) stems of a different design (stem B). Of 131 components, 10 (7.6%) failed secondary to stem fracture proximal to the modular sleeve. Four of 102 (4%) of stem A and 6 of 29 (21% of stem B) fractured. All broken stems required additional intervention for removal during revision THA, using an ETO (N = 9) or cortical window (N = 1) in which an intraoperative proximal femoral fracture occurred., Conclusions: Broken MME stems present a challenge for orthopaedic surgeons during revision THA. When a stem fracture occurs above the ingrown sleeve, the distal splines may have osseous interdigitation into the clothespin. Thus, when revising a broken MME stem, an ETO should be performed, and the segment should be long enough to allow distal access., (Copyright © 2024. Published by Elsevier Inc.)

Background: The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique., Questions/purposes: (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery?, Methods: Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons., Results: At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years., Conclusion: In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Background: There are few data on the impact of periacetabular osteotomy (PAO) on sagittal spinopelvic alignment. Prior studies have attempted to delineate the relationship by performing measurements on AP radiographs and using mathematical models to determine changes in postoperative pelvic tilt. This information is clinically significant to a surgeon when evaluating acetabular/pelvic position intraoperatively and understanding spinopelvic alignment changes postoperatively; therefore, radiographic changes from PAO should be described in more detail., Questions/purposes: In this study, we asked: (1) Does the performance of PAO result in consistent changes in spinopelvic alignment, as measured on EOS radiographs? (2) Does this differ for unilateral versus bilateral PAOs? (3) Does this differ in the setting of a mobile spine versus an immobile spine? (4) Does this differ based on preoperative pelvic tilt?, Methods: Mean preoperative and at least 1-year postoperative (15 ± 8 months from surgery, minimum 11 months, maximum 65 months) EOS hip-to-ankle standing and sitting radiographs for 55 patients in a prospectively collected registry who underwent PAO with a single surgeon from January 1, 2019, to January 11, 2022, were measured for pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lateral center-edge angle, L1 pelvic angle, and pubic symphysis to the sacroiliac index. Normality was assessed and paired sample t-tests (normally distributed data) or Wilcoxon signed rank tests (not normally distributed data) were utilized to assess if any measurements changed from preoperative to postoperative. Patients were then divided based on whether they had unilateral or bilateral dysplasia and unilateral or bilateral surgery, and these subgroups were analyzed the same way as the entire cohort. Two more subgroups were then formed based on lumbar mobility, defined as a change in sitting-to-standing lumbar lordosis less or greater than 1 SD from the population mean preoperatively, and the subgroups were analyzed the same way as the entire cohort. Finally, two additional subgroups were formed, preoperative standing pelvic tilt less than 10° and more than 20°, and analyzed the same as the entire cohort., Results: For the entire cohort, the median (IQR) standing lateral-center edge angle increased 17°, from a median of 21° (10°) to a median of 38° (8° [95% confidence interval (CI) 16° to 20°; p < 0.001). The median sitting lateral center-edge angle increased 17°, from a median of 18° (8°) to a median of 35° (8° [95% CI 14° to 19°]; p < 0.001). Standing pelvic incidence increased from 50° ± 11° to 52° ± 12° (mean difference 2° [95% CI 1° to 3°]; p = 0.004), but there were no changes for other measured parameters. There were no changes in any of the spinopelvic parameters for patients with unilateral dysplasia receiving a unilateral PAO, but patients with bilateral dysplasia who underwent bilateral PAOs demonstrated an increase in pelvic incidence from 57° (14°) to 60° (16°) (95% CI 1° to 5°; p = 0.02) and a decrease in pubic symphysis to sacroiliac index from 84 mm (24 mm) to 77 mm (23 mm) (95% CI -7° to -2°; p = 0.007). Patients with mobile lumbar spines preoperatively did not exhibit any changes in sagittal spinopelvic alignment, but patients with immobile lumbar spines preoperatively experienced several changes after surgery. Patients with less than 10° of standing pelvic tilt demonstrated a median (IQR) 2° increase in pelvic incidence from median 43° (9°) to 45° (12° [95% CI 0.3° to 4°]; p = 0.03), but they did not experience any other changes in sagittal spinopelvic alignment parameters postoperatively. Patients with preoperative pelvic tilt more than 20° did not experience any change in sagittal spinopelvic parameters., Conclusion: PAO increases pelvic incidence, potentially because of anterior translation of the hip center. There were no changes in other spinopelvic parameters postoperatively except after bilateral PAO. Additionally, patients lacking spine mobility preoperatively, indicated by a minimal change in lumbar lordosis between standing and sitting positions, may experience several changes in spinopelvic alignment, including increased mobility of their spine after PAO. This may be because of decreased compensatory spine splinting after increasing acetabular coverage, but further research including patient-reported outcomes is warranted., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Purpose: Dural tear (DT) is a well-known complication of spinal surgery. We aimed to systematically review the literature from the past decade and determine the incidence and risk factors for DT in the adult spinal deformity (ASD) population to improve both the surgical strategy and counseling of patients undergoing ASD correction., Methods: A systematic review from 2013 to 2023 utilizing PRISMA guidelines was performed. The MEDLINE database was used to collect primary English language articles. The inclusion criterion for patients was degenerative ASD. Pediatric studies, animal studies, review articles, case reports, studies investigating minimally invasive surgery (MIS), studies lacking data on DT incidence, and articles pertaining to infectious, metastatic or neoplastic, traumatic, or posttraumatic etiologies of ASD were excluded., Results: Our results demonstrate that the incidence of DT in ASD surgery ranges from 2.0% to 35.7%, which is a much broader range than the reported incidence for non deformity surgery. Moreover, the average rate of DT during ASD surgery stratified by surgical technique was greater for osteotomy overall (19.5% +/- 7.9%), especially for 3-column osteotomy (3CO), and lower for interbody fusion (14.3% +/- 9.9%). Risk factors for DT in the ASD surgery cohort included older age, revision surgery, chronic severe compression, higher-grade osteotomy, complexity of surgery, rheumatoid arthritis (RA), and higher Anesthesiology Society of America (ASA) grade., Conclusion: To our knowledge, this is the first systematic review discussing the incidence of and risk factors for DT in the ASD population. We found that the risk factors for DT in ASD patients were older age, revision surgery, chronic severe compression, a greater degree of osteotomy, complexity of surgery, RA, and a higher ASA grade. These findings will help guide spine surgeons in patient counseling as well as surgical planning., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Three-column spinal osteotomies (3-CO) are powerful techniques used to correct spinal deformity. These surgeries are associated with an elevated risk of complications. While outcomes have been reported in the literature with 2 years follow-up, longer-term outcomes of three-column osteotomies remain understudied., Objectives: This study aims to examine patient reported outcomes and complications for three-column osteotomies at 5 years., Study Design: Retrospective review of a prospectively collected spinal deformity cases database., Patient Sample: All consecutive adult patients at a single spine surgery center treated with either a pedicle subtraction osteotomy (PSO) or vertebral column resection (VCR) for spinal deformity, and with a minimum 5-year follow-up were included., Outcome Measures: Visual-analog scale (VAS) for back pain score (0 to 10), Oswestry Disability Index (ODI) score (0 to 100), number of complications, revision rate, sagittal balance, lumbar lordosis at preoperative and at 5-year visit., Methods: Data was extracted from a prospectively collected spinal deformity surgery database continuously updated since 2002 with data from operative reports, patients' medical visit notes and patients' self-reported VAS and ODI questionnaires completed at each office visit. Radiographic measurements were performed on standing full-length spine radiographs taken at preop and 5-year visits. Descriptive statistics, comparison of means and proportions among groups, and a logistic regression analysis were conducted using the statistical software package SPSS version 28. Statistical significance was set at p<.05., Results: Of 127 consecutive adult patients with minimum of 5-year follow-up undergoing a 3-CO posterior spinal surgery for spinal deformity were identified and included in the study, 79 (62%) were treated with PSO, and 48 (38%) with VCR. Both PSO and VCR groups demonstrated significant improvements in VAS (PSO preop: 6.7, 5-year: 4.6, p<.001; VCR preop: 7.1, 5-year: 5.2, p<.001), and ODI (PSO preop: 52.9, 5-year: 45.4, p<.001; VCR preop: 57.5, 5-year 43.0, p<.001) that were maintained at 5 years. Major and minor complications occurring within 5 years were not statistically different between the PSO and VCR groups (major: 59.5% vs 56.3%, p=.85; minor: 45.6% vs 37.5%, p=.46). The rate of revision surgery within 5 years was 39.4% overall. Of the fifty patients requiring revision, 37.5% were for nonunion, 27.1% instrumentation failure, 14.6% proximal junctional kyphosis (PJK), 12.5% vertebral fracture, 6.3% motor weakness, and 2.1% infection. Improvements in lumbar lordosis were maintained at 5 years in both the PSO (29.9° vs 47.2°, p<.001) and VCR (34.6° vs 48.5°, p<.001) groups while sagittal balance maintained significant improvement in the VCR group (9.5 cm vs 6.3 cm, p=.008) but not the PSO (11.4 cm vs 9.3 cm, p=.065)., Conclusion: Patients undergoing three-column osteotomies had a major complication rate of 57.5% and a minor complication rate of 42.5% after 5 years. Improvements in lumbar lordosis were maintained at 5-year follow-up, but sagittal balance was only maintained in the VCR group. Despite these radiographic findings, both VCR and PSO groups maintained significant clinical improvements in both VAS and ODI scores at 5-year follow up., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS., Methods: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ 2 test to compare baseline characteristics and postoperative outcomes., Results: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84)., Conclusions: TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: This study investigates the effect of the body mass index (BMI) on the early (2 years) to midterm (5 years) results of medial opening wedge high tibial osteotomy (MOWHTO)., Methods: A prospectively maintained single-centre database of 1138 knee osteotomies, between 2002 and 2022, was retrospectively reviewed. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee osteoarthritis (OA), with varus knee malalignment, having failed conservative management, were included. Patients were categorized into three groups according to their BMI as per the classification from the National Institute for Health and Care Excellence (NICE): the healthy weight (HW) group (BMI of 18.5-24.9 kg/m 2 ), the overweight (OW) (BMI of 25-29.9 kg/m 2 ), and the obesity (OB) group (BMI ≥ 30 kg/m 2 ). Multiple patient-reported outcome measures (n = 6) were recorded preoperatively and at 2 and 5 years postoperatively. Deformity analysis was undertaken preoperatively and postoperatively. The relative risk (RR) of the complications between the HW, OW and OB groups was calculated. The rate of conversion to arthroplasty, and 5 and 10 years survivorship were recorded, as well as the hazard ratio (HR) of BMI on survivorship., Results: A total of 574 cases were included in the study: the HW group (n = 96), the OW group (n = 233) and the OB group (n = 245), with a mean BMI of 23 ± 1.5 kg/m 2 , 27.4 ± 1.4 kg/m 2 and 34.4 ± 3.8 kg/m 2 , respectively. The mean follow-up was 13.3 years (4.8-20.3). The mean mechanical tibiofemoral angle corrections were in the HW group: 7.1 ± 3°, OW group: 6.6 ± 3.5° and OB group: 7.1 ± 3.8°, with no intergroup significant difference (p = n.s.). Clinically, despite lower preoperative scores in the OW and OB groups, no difference was observed postoperatively amongst the three groups. The overall complication rate was 12.5% in the HW group, 6.8% in the OW group, and 9.8% in the OB group. There was no significant difference in the RR of complications between the HW and OW groups (RR = 0.6, 95% confidence interval [CI] = 0.3-1.3) (p = 0.2), and the HW and OB groups (RR = 0.8; 95% CI = 0.3-2.2) (p = 0.7). There was no overall significant difference in survival outcomes based on the BMI between the three groups (p = 0.4). The HR of conversion to arthroplasty between the HW and OW groups was 1.4 [95% CI = 0.6-3.5](p = 0.5) and between the HW and OB groups was 1.8 [95% CI = 0.8-4.4] (p = 0.2)., Conclusion: BMI has no significant effect on either the radiological corrections, clinical outcomes, complications or survivorship of MOWHTO at short- to medium-term follow-up. No specific cutoff point for BMI can be recommended as a contraindication to MOWHTO., Level of Evidence: Level IV, Retrospective cohort study., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Objectives: The purpose of this study was to investigate the relationship between patient demographics and potential intraoperative factors and delayed bone union in opening wedge high tibial osteotomy (OWHTO)., Patients and Methods: A retrospective review of 65 patients (37 females, 28 males; mean age: 60.1±10.1 years; range, 44 to 77 years) who underwent OWHTO using an angle-stable implant with beta-tricalcium phosphate gap filling between September 2016 and October 2019 was conducted. The osteotomy site was divided into five zones from the lateral hinge on anteroposterior radiographs, and we defined the zone in which bone healing was observed. The bone union area was assessed according to this definition at three, six, nine, and 12 months after surgery, and bone union was defined as union at the fourth zone or greater. A generalized estimating equations approach was employed to investigate longitudinal data pertaining to bone union area as a dependent variable. In addition, the association of bone union at six months postoperatively and predictors were evaluated using cross-sectional statistical methods. The categorical predictors included in the models were smoking, diabetes, hinge fracture, and autologous osteophyte grafting. The continuous variables included in the models were age, body mass index, opening gap width, and plate position., Results: Smoking (odds ratio [OR]=0.478, p<0.01), large opening gap width (OR=0.941, p=0.014), and anterior plate placement (OR=0.971, p<0.01) were significantly associated with decreased bone union area. Union rate at six months in smokers was significantly lower compared to nonsmokers (16.6% and 67.8%, respectively; OR=0.10, p=0.023). Area under the curve in the receiver operating characteristic analysis for bone union at six months was 0.60 for gap width and 0.63 for plate placement., Conclusion: Smoking, large opening gap width, and anterior plate placement are risk factors for delayed bone union after OWHTO. Surgeons should avoid anterior placement of the plate and carefully consider other options for smokers and those who require a large correction.

Purpose: Third and fourth-generation minimal invasive osteotomies (MIO) for the treatment of hallux valgus (HV) have become popular procedures worldwide with promising results due to the improvement in the fixation method. The tricortical cannulated screw placement remains a complex procedure that is technically challenging and requires a long skill learning curve with high radiation exposure mainly in the form of intensifier shots (IS) required for the MIO fixation. This study aims to compare the number of X-ray IS required using three different techniques for the cannulated guide placement., Methods: A retrospective cross-sectional observational and comparative study was conducted to assess the number of X-rays IS required for correct cannulated screw guide placement using three different techniques: traditional perforator, the drill and joystick, and K-wire first techniques., Results: A total of 53 MIS procedures from thirty-one patients in two different hospitals were included. IS X-rays were 155.1 ± 29.7 in the traditional technique (n = 14), 143.0 ± 43.2 in the drill and joystick technique (n = 22), and 85 ± 18.7 in the K-wires first technique (n = 17), p =  < 0.001 using one-way ANOVA., Conclusions: The K-wire first technique statistically significantly decreases X-ray IS numbers p ≤ 0.001. There were no statistically significant differences between the traditional (after osteotomy K-wire placement) and the drill and joystick techniques (p = 0.36)., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy., Methods: Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released., Results: The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months., Conclusion: Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research., Level of Evidence: Level II, consensus., (© 2024 The Author(s). Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: Modifications of the pi craniectomy technique are meant to address the occipital bullet deformity of sagittal synostosis, but it is not clear whether they result in persistent improvement. The authors' purpose was to use morphometric analysis to determine whether a low occipital osteotomy with verticalization results in improved occipital shape after a modified pi procedure 2 years after surgery., Method: The authors performed a retrospective cohort study comparing modified pi technique with and without a low occipital osteotomy with verticalization immediately and 2 years after surgery relative to age-matched normal controls. The authors used anthropometric measures and population-level anatomical templates using the multivariate template construction script from advanced normalization tools for comparison between groups. A subgroup analysis was performed for severe occipital bullet deformity at presentation., Results: The authors observed stable improvement in the angle of the inferior occiput with the occipital remodeling modification that persisted 2 years after surgery. This improvement was seen in the entire cohort and was greater in the severe subgroup analysis. Complications and blood transfusion volumes were not different between the 2 techniques. The low occipital osteotomy group demonstrated improved posterior vertical height and cephalic index immediately after surgery, but these did not persist 2 years later., Conclusions: Occipital remodeling improves the bullet deformity but does not affect posterior vertical height 2 years after surgery. The authors recommend direct inferior occipital remodeling when using the pi technique for young patients with acute occipital incline angles and occipital constriction., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Hallux valgus (HV) is the most common forefoot deformity. Surgical correction of HV aims to reduce pain, preserve joints, and re-establish foot function while restoring the hallux valgus angle (HVA) and intermetatarsal angle (IMA). Many surgical procedures have been proposed, including open and minimally invasive (MI) techniques. This study aimed to compare the midterm outcomes of open vs. MI procedures and their impact on the duration of surgery, hospital stay, HVA, and IMA post-operatively., Materials and Methods: One hundred and twenty HV patients operated by open or MI surgery between October 2019 and October 2022 were included. One hundred three patients met the inclusion criteria and consented to the study. Patients were prospectively surveyed for foot functionality, post-operative pain, and complications using the AOFAS score. Radiographic measurements of HV angles, length of hospital stay, and surgery duration were analysed., Results: MI surgery patients had significantly better AOFAS scores (p < 0.001) 12 months post-operatively compared to open surgery. Complication rates were lower in the MI group (3.8% vs. 33.3%, p < 0.001). MI surgery patients also had shorter hospital stays (0.9 ± 0.3 days vs. 2.0 ± 0.0 days) and surgery duration (19.7 ± 2.3 min vs. 80.7 ± 6.8 min). MI surgery was more effective in correcting the IMA but equally effective as open surgery for HVA correction., Conclusion: MI surgery resulted in better patient satisfaction, fewer complications, and more precise correction of IMA values. Moreover, the duration of surgery and hospital stay were significantly lower in patients undergoing MI surgery. Further research is needed to validate these findings in controlled, prospective randomised trials., (© 2024. The Author(s).)

Introduction: One of the most popular containment procedures for Legg-Calvé-Perthes disease (LCPD) is proximal femur varus osteotomy (PFO). While generally successful in achieving containment, PFO can cause limb length discrepancy, abductor weakness, and (of most concern for families) a persistent limp. While many studies have focused on radiographic outcomes following containment surgery, none have analyzed predictors of this persistent limp. The aim of this study was to determine clinical, radiographic, and surgical risk factors for persistent limp 2 years after PFO in children with LCPD., Methods: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 years at disease onset with unilateral early-stage LCPD (Waldenström I) who underwent PFO. Limp status (no, mild, and severe), age, BMI, and pain scores were obtained at initial presentation, 3-month, and 2-year postoperative visits. Preoperative and follow-up radiographs were used to measure traditional morphologic hip metrics including acetabular index (AI), lateral center-edge angle (LCEA), and femoral neck-shaft angle (NSA). Univariate analysis as well as multivariate logistic regression models were used to analyze factors associated with mild and severe limp at the 2-year visit., Results: A total of 95 patients met the inclusion criteria, and of these 50 patients underwent concomitant greater trochanter apophysiodesis (GTA) at the time of PFO. At the 2-year visit, there were 38 patients (40%) with a mild or severe limp. Multivariate logistic regression revealed no significant radiographic factors associated with a persistent limp. However, lower 2-year BMI and undergoing GTA were associated with decreased rates of persistent limp regardless of age ( P <0.05). When stratifying by age of disease onset, apophysiodesis appeared to be protective against any severity of limp in patients aged 6 to 8 years old ( P = 0.03), but not in patients 8 years or older ( P = 0.49)., Conclusions: Persistent limp following PFO is a frustrating problem that was seen in 40% of patients at 2 years. However, lower follow-up BMI and performing a greater trochanter apophysiodesis, particularly in patients younger than 8 years of age, correlated with a lower risk of postoperative limp., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Medical records for dogs treated with tibial plateau leveling osteotomy (TPLO) using Arthrex 3.5 mm self-tapping screws (STS) were evaluated to determine the incidence rate of transcortical tibial fractures (TCTF) and development of complications., Study Design: Retrospective case report., Study Population: A total of 78 dogs., Methods: Dogs that underwent a TPLO performed from March 2022 to August 2023 were reviewed. Postoperative TPLO radiographs were examined for evidence of a TCTF with Arthrex 3.5 mm STS. Records were reviewed for complications up to 14 weeks after surgery., Results: Evidence of a TCTF was found in 42% of cases (33 of 78) and 14% (36 of 250) of STS screws distal to the osteotomy. TCTFs were only identified distal to the osteotomy. Three dogs had radiographic evidence of more than one TCTF. Of the dogs with radiographic TCTF, 6% of patients (2 of 33) developed a major complication that required surgical stabilization of a tibial fracture associated with screw angulation relative to the plate., Conclusion: Use of Arthrex 3.5 mm STS for TPLO is associated with risk of TCTF. TCTF can compromise the structural properties of the tibia and cause complete tibial fracture requiring major revision surgery., Clinical Significance: Development of TCTF after use of STS for TPLO has been recognized, in contrast to use of non-self-tapping screws, and was considered a benign complication. Our findings suggest TCTF associated with Arthrex 3.5 mm STS use in TPLO can contribute to major complications after surgery, including complete tibial fracture, particularly if screws are not placed perpendicular to the plate., (© 2024 The Author(s). Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.)

Purpose: Pelvic support osteotomy (PSO) is regarded to provide pelvic stability and improve abductor function to delay or even avoid total hip arthroplasty (THA) in young patients with high-riding hip dysplasia. However, some of these patients eventually have to undergo THA. Because of the double-angulation deformity of the femur after PSO, subsequent THA is challenging. This study aimed to analyze whether PSO surgery is suitable for high-riding hip dysplasia and summarize orthopaedic strategy during THA for patients with previous PSO., Methods: This case-control study included eight cases of THA for high-riding hip dysplasia patients with previous PSO (study group) and 24 cases of high-riding hip dysplasia patients without any hip surgical therapy (control group) by a 1:3 match (from May 2018 to January 2022). We compared demographics and joint function before and after THA between two groups and recorded all patients' preoperative imaging data, surgical procedures, postoperative imaging data, and complications. The surgical techniques for patients with previous PSO were highlighted., Results: There was no statistical difference between the two groups in demographic (p > 0.05). The study group had worse hip Harris score (HHS), range of motion (ROM), visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (p < 0.05) compared with the control group before THA. All patients had concurrent THA and osteotomy at the proximal femur, but the study group experienced longer operation time (p = 0.047) with more blood loss (p = 0.027) and higher complication rate compared with the control group (p = 0.009). At the last follow-up, the study group's HHS, ROM, VAS, and WOMAC were still worse than those in the control group., Conclusions: PSO did not improve the joint function of high-riding hip dysplasia patients but brought challenges to subsequent THA and affected the surgical outcomes. In short, we suggested that PSO is unsuitable for routine high-riding hip dysplasia patients., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Vertical orbital dystopia (VOD) results in significant facial asymmetry, psychological distress, and poor quality of life in affected patients. The traditional approach (TA) for surgical correction has entailed a standard frontal craniotomy along with circumferential orbital osteotomy, vertical translocation of the orbit, and bone grafting to the lower maxilla. Caution has been expressed regarding its invasive transcranial nature. In this report, the authors describe the limited approach (LA) for simplified surgical correction of VOD, which obviates the need for a standard frontal craniotomy., Methods: A 45-year retrospective review was conducted of all patients who underwent surgical correction of VOD, as performed by a single surgeon. Demographic details, procedural characteristics, and complications were compared between patients who underwent correction by the TA and those who underwent correction by the LA. Complications were defined as cerebrospinal fluid leak, infection of the frontal bone, permanent diplopia, permanent ptosis, sudden-onset vision loss, persistent asymmetry, and surgical revision., Results: Forty patients met inclusion criteria for correction of true VOD, of which 18 underwent the TA and 22 underwent the LA. Mean length of hospital stay was 5.3 ± 2.3 days and 4.0 ± 1.5 days for the TA and LA cohorts, respectively. Mean follow-up time was 4.9 ± 7.5 years for the TA cohort and 2.6 ± 3.3 years for the LA cohort. The only reported complications were persistent asymmetry in 2 patients in the TA cohort, with 1 patient requiring surgical revision because of undercorrection, whereas the LA cohort exhibited no postoperative asymmetry or need for surgical revision., Conclusions: Both the TA and the LA are effective for surgical correction of VOD. The limited craniotomy of the LA reduces exposure of intracranial structures and adequately achieves postoperative symmetry., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non-surgical) interventions treating pain rather than curing deformity are usually first-line treatments. When surgery is indicated, the overall best surgical procedure is an ever-evolving topic of discussion., Objectives: To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non-surgical treatments and other surgical interventions for adults with hallux valgus., Search Methods: We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions., Selection Criteria: We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non-surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events., Data Collection and Analysis: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE., Main Results: We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V-shaped osteotomy) with no treatment and with non-surgical treatment. Fifteen studies compared different surgical techniques, including a V-shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid-shaft Z-shaped osteotomy (Scarf osteotomy). Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases. Surgery versus no treatment Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) -18.00, 95% confidence interval (CI) -26.14 to -9.86; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15-dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI -2.12 to 2.12; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low-certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain. Surgery versus non-surgical treatment Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low-certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low-certainty evidence). Complex versus simple osteotomies Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate-certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low-certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low-certainty evidence) and serious adverse events (12 studies; data not pooled; low-certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low-certainty evidence). No study reported quality of life., Authors' Conclusions: There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non-surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non-surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non-surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non-surgical treatment. Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objective: There were few reports in the literature regarding hidden blood loss following surgery for developmental dysplasia of the hip in children. This study aimed to evaluate the volume of hidden blood loss and its risk factors among children undergoing hip reconstruction for developmental dysplasia of the hip., Methods: A retrospective analysis of clinical data from 42 patients (58 hips), who underwent Pemberton and femoral osteotomies between March 2020 and March 2023, was conducted. Serial complete blood count assays were conducted on the day of admission and four days post-surgery. Preoperative and postoperative hematocrit levels were documented to calculate hidden blood loss utilizing the Gross formula. Pearson and Spearman correlation analyses, along with multivariable linear regression, were employed to ascertain associations between patient characteristics and hidden blood loss., Results: The mean hidden blood loss was recorded as 283.06 ± 271.05 mL, constituting 70.22% of the total blood loss. Multiple linear regression analysis identified weight and surgical duration as independent risk factors contributing to hidden blood loss., Conclusions: A relevant amount of postoperative hidden blood loss occurs after Pemberton osteotomy and femoral osteotomy for developmental dysplasia of the hip. Surgeons should be aware that patients who require blood transfusions and have longer surgical durations are at a higher risk of developing more hidden blood loss. Therefore, attention should be given to hidden blood loss to ensure patient safety during the perioperative period for those undergoing Pemberton and femoral osteotomies., Level of Evidence: IV., (© 2024. The Author(s).)

Ulnar-shortening osteotomy is a reliable solution to treat ulnar impaction syndrome, but it has a significant rate of nonunion as a known complication. Generally nonunion after the procedure is attributed to noninfectious causes. When infections happen, they follow the microbiological trends of nonunions elsewhere in the body. We present a case of ulnar-shortening osteotomy using an oblique-cut osteotomy system that resulted in septic nonunion. At the time of revision surgery, Cutibacterium acnes and Staphylococcus hominis were isolated from the osteotomy site. The patient was successfully treated using intravenous antibiotics and the two-stage Masquelet technique and eventually went on to bony union. As C acnes is rarely encountered in this context, this report highlights the need to consider all possible pathogens in the workup of a potentially septic nonunion. Surgeons should consider bacteria such as C acnes that require prolonged incubation for isolation from cultures, which may not be part of many institutions' usual protocol. [ Orthopedics . 2024;47(4):e211-e213.].

Purpose: Lateral hinge fractures are the main complications in the high tibial osteotomy to treat varus deformities. The aim of present study is to answer the question whether the lateral hinge length (H) has an effect on the type of fracture and required force during the opening in high tibia osteotomy. It was hypothesized in this comparative research that extending the hinge length increased opening force and probability of a type II and type III fractures., Methods: A monoplanar medial open wedge osteotomy with different intact hinge lengths varying from 9 to 32 mm was performed in 20 ostrich bones. A biomechanical experiment using unidirectional tensile testing apparatus was performed to open the wedge, and the required force was increased until a 10 mm opening was reached; then, the presence of fracture in the lateral cortex and its direction were evaluated. Lateral hinge fracture type based on direction was classified as suggested by Takeuchi et al., Results: Fracture that grows along the osteotomy line (type I) was observed in 4 samples with the mean hinge length (H) of 11 ± 1.54 mm. For seven bones with Takeuchi fracture type II, with downward crack propagation, the mean H was 16 ± 3.36 mm. For the mean H of 25 ± 6.53 mm, the crack propagated upward to the cutting path, displaying a Takeuchi type III fracture in seven samples. The statistical analysis showed that the fracture type significantly depends on the hinge length (P value < 0.05). Also, the mean opening force significantly increased with hinge lengthening (P value < 0.05). The peak forces at crack initiation were 41.8 ± 21.9, 115.2 ± 41.5, and 167 ± 135.3 N, respectively, for the fracture types I, II, and III samples., Conclusion: The lateral cortical hinge length was significantly associated with hinge fracture type. The experimental tests indicated that the hinge lengthening increases the risk of type II and III fractures, as classified by Takeuchi., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: This study aimed to investigate the mid- to long-term benefits of high tibial osteotomy in advanced age patients., Methods: This retrospective study was conducted in our hospital from January 2017 to January 2021 with data prospectively collected, 47 patients with knee osteoarthritis who over 65 years old were included, and a 1:1 propensity score (PS) of patients < 65 years were matched according to gender, body mass index, and side. Patient demographics, intraooperative and postoperative variables, and patient self-reported outcomes were compared. A generalized linear model was used to screen possible risk factors., Results: A total of 94 consecutive patients were included; the average age of advanced age group was 69.47 + 4.26 years and 57.87 + 5.51 years in the younger group. There were no statistically difference in K-L grade, smoke, drink, comorbidity, ASA, blood loss, operative duration, length of stay, surgical site infection, hinge fracture, DVT, and preooperative and postoperative aFTA; significantly statistical difference of the eFI was found between two groups (P < 0.05). Two groups had comparable VAS and MOMAC scores at one year postoperatively (P > 0.05), while the younger group had lower VAS and WOMAC scores than the advanced age group at the end of follow-up (P < 0.05). Generalized linear model showed both age and eFI were associated with WOMAC scores; there was a statistically significant difference in the effect of eFI on WOMAC scores at different ages (P > 0.05)., Conclusions: Compared with younger patients, advanced age patients have similar short-term benefits, but less long-term benefits. We recommend that patients proposed for HTO be discriminated by eFI, and patients with higher scores should be cautiously selected., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Study Design: Retrospective comparative study., Objective: To investigate the occurrence of neurological complications in patients undergoing thoracic three-column osteotomy (3CO) utilizing an magnetic resonance imaging (MRI)-based classification that assesses spinal cord shape and the presence of cerebrospinal fluid at the curve apex and evaluate its prognostic capacity for postoperative neurological deficits., Summary of Background Data: Recent advancements in correction techniques have improved outcomes for severe spinal deformity patients undergoing 3CO. A novel MRI-based spinal cord classification system was introduced, but its validation and association with postoperative complications remain unexplored., Materials and Methods: Between September 2012 and September 2018, a retrospective analysis was conducted on 158 adult patients with spinal deformities undergoing 3CO. Radiographic parameters were measured. T2-weighted axial MRI was used to describe spinal cord morphology at the apex. Intraoperative neurophysiological monitoring alerts were recorded, and preoperative and postoperative neurological functions were assessed using the Frankel score. Categorical data were compared using the χ 2 or the Fisher exact test. The paired t test was utilized to assess the mean difference between preoperative and postoperative measurements, while the one-way analysis of variance and independent t test were used for comparative analyses among the different spinal cord types., Results: Patients were categorized into three groups: type 1, type 2, and type 3, consisting of 12, 85, and 61 patients. Patients with type 3 morphology exhibited larger Cobb angles of the main curve ( P <0.001). This disparity persisted both postoperatively and during follow-up ( P <0.05). Intraoperative neurophysiological monitoring alerts were triggered in 32 patients (20.3%), with a distribution of one case in type 1, six cases in type 2, and 22 cases in type 3 morphologies ( P <0.001). New neurological deficits were observed in 15 patients (9.5%), with 1, 3, and 11 cases in type 1, 2, and 3 morphologies, respectively., Conclusions: Patients with type 3 morphology exhibited greater spinal deformity severity, a higher likelihood of preoperative neurological deficits, and an elevated risk of postoperative neurological complications. This underscores the utility of the classification as a tool for predicting postoperative neurological complications in patients undergoing thoracic 3CO., Level of Evidence: 4., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO., Methods: A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes., Results: Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls., Conclusion: A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To validate the safety and clinical results of single-stage bilateral versus unilateral medial opening wedge high tibial osteotomy (HTO)., Methods: A propensity-matched cohort study was performed from March 2020 to March 2021 in our medical center. Data were prospectively collected. Including 34 patients who underwent single-stage bilateral medial opening HTO(SSBHTO), and 68 cases in the unilateral group. Propensity-matched ration was 2:1 based on age, sex, and body mass index using R software. Comparisons of the length of hospital stay, operative time, blood loss, postoperative adverse events, 90-day readmission rate, conversion to TKA rate, self-reported VAS and WOMAC scores were made to investigate the safety and clinical results of bilateral HTO., Results: The mean length of hospital stay was 7.36 ± 2.23 days for SSBHTO and 7 days (IQR, 3 days; range, 4 to 23 days) for the unilateral group (P = 0.219). The mean operative time was 144 ± 47 min for bilateral HTO and 105(37.5) mins for a unilateral OWHTO (P < 0.001). The mean blood loss was 150(100) ml for SSBHTO and 100(50) ml for unilateral OWHTO (P < 0.001). There were no significant difference of the adverse events and 90-day readmission rate between two groups. No failed HTO or conversion to knee arthroplasty were observed at the end of follow-up. VAS, pain, stiffness, and functional scores of the WOMAC scale were essentially comparable of two groups one year after surgery (P > 0.05)., Conclusions: A single-stage bilateral medial opening wedge high tibial osteotomy is advisable for patients with knee osteoarthritis. Patients benefit from avoiding secondary anesthesia, postoperative complications, and substantial cost savings., Level of Evidence: Therapeutic Level III., (© 2024. The Author(s).)

Background: Ulnar impingement syndrome is a prevalent source of ulnar carpal pain; however, there is ongoing debate regarding the specific location of shortening, the method of osteotomy, the extent of shortening, and the resulting biomechanical alterations., Method: To investigate the biomechanical changes in the distal radioulnar joint (DRUJ) resulting from different osteotomy methods, a cadaveric specimen was dissected, and the presence of a stable DRUJ structure was confirmed. Subsequently, three-dimensional data of the specimen were obtained using a CT scan, and finite element analysis was conducted after additional processing., Results: The DRUJ stress did not change significantly at the metaphyseal osteotomy of 2-3 mm but increased significantly when the osteotomy length reached 5 mm. When the osteotomy was performed at the diaphysis, the DRUJ stress increased with the osteotomy length, and the increase was greater than that of metaphyseal osteotomy. Stress on the DRUJ significantly increases when the position is changed to pronation dorsi-extension. Similarly, the increase in stress in diaphyseal osteotomy was greater than that in metaphyseal osteotomy. When the model was subjected to a longitudinal load of 100 N, neither osteotomy showed a significant change in DRUJ stress at the neutral position. However, the 100 N load significantly increased stress on the DRUJ when the position was changed to pronation dorsi-extension, and the diaphyseal osteotomy significantly increased stress on the DRUJ., Conclusions: For patients with distal oblique bundle, metaphyseal osteotomy result in a lower increase in intra-articular pressure in the DRUJ compared to diaphyseal osteotomy. However, it is crucial to note that regardless of the specific type of osteotomy employed, it is advisable to avoid a shortening length exceeding 5 mm., (© 2024. The Author(s).)

Purpose: The purpose of this study was to compare the clinical outcomes of patients with patellofemoral osteoar-thritis (PFOA) treated non-operatively with those treated operatively with an unloading anteromedialization tibial tubercle osteotomy (TTO)., Methods: A retrospective chart review was performed to identify patients with isolated PFOA who were either managed non-operatively or surgically with a TTO and who had a minimum follow-up of 2 years. Patients were surveyed with the visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), Anterior Knee Pain scale (Kujala), and Tegner Activity scale. Statistical analysis included two-sample t-testing, one-way ANOVA, and bivariate analysis., Results: The clinical outcomes of 49 non-operatively managed patients (mean age: 52.7 ± 11.3 years; mean follow-up: 1.7 ± 1.0 years) and 35 operatively managed patients (mean age: 31.8 ± 9.4 years; mean follow-up: 3.5 ± 1.7 years) were assessed. The mean VAS improved sig-nificantly in both groups [6.12 to 4.22 (non-operative), p < 0.0001; 6.94 to 2.45 (TTO); p < 0.0001], with operatively treated patients having significantly lower postoperative pain than non-operatively managed patients at the time of final follow-up [2.45 (TTO) vs. 4.22 (non-operative), p < 0.001]. The mean KOOS-JR score was significantly greater in the operative group at time of final follow-up [78.7 ± 11.6 (TTO) vs. 71.7 ± 17.8 (non-operative), p = 0.035]. There was no significant difference in Kujala or Tegner scores between the treatment groups. Additionally, there was no sig-nificant relationship between the number of intra-articular injections, duration of NSAID use, and number of physical therapy sessions on clinical outcomes in the non-operatively treated group (p > 0.05)., Conclusions: An unloading anteromedialization TTO provides significantly better pain relief and restoration of function compared to non-operative management in the treatment of symptomatic PFOA.

Background: Curved periacetabular osteotomy requires detachment and retraction of the hip flexors. In this study, we evaluated hip flexor muscle status by magnetic resonance imaging (MRI) shortly after curved periacetabular osteotomy., Methods: We retrospectively evaluated 60 hips of 56 patients by MRI 1 week and 3 months after curved periacetabular osteotomy performed from August 2017 to December 2019. We classified the condition of the flexors as follows: Grade 0, normal; Grade I, strain/edema; Grade II, partial tear; and grade III, complete tear., Results: At 1 week after surgery, the iliacus muscle was classified as grades I and II in 12.0 and 88.0% of hips; psoas as grades 0, I and II in 22.0, 72.0, and 6.0%; sartorius muscle as grades 0, I and II in 6.0, 62.0, and 32.0%; and rectus femoris muscle as grades 0 and I in 86.0 and 14.0%, respectively. At 3 months, 82.0, 88.0, and 96.0% of psoas, sartorius, and rectus femoris muscles, respectively, had improved to grade 0, whereas the iliacus was grades I and II in 94.0 and 6.0%, respectively. These changes in the iliacus muscle at 3 months were not significantly associated with patient characteristics, radiographic data, or clinical scores., Conclusions: All the iliacus, 78% of psoas, 94% of sartorius, and 14% of rectus femoris muscles appeared abnormal on MRI 1 week after curved periacetabular osteotomy. However, at 3 months, only 18% of psoas, 12% of sartorius, and 4% of rectus femoris muscles appeared abnormal, whereas all iliacus muscles still appeared abnormal. These abnormalities did not significantly affect clinical scores., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Spinal osteotomies are often essential in the treatment of congenital scoliosis. Risk factors for bleeding in these patients needing extracavitatory approaches, especially hidden blood loss, are sparsely investigated. We aimed to investigate the bleeding characteristics and hidden blood loss in paediatric patients undergoing spinal osteotomies for congenital scoliosis., Methods: A retrospective analysis identified all patients with congenital scoliosis were retrospectively identified from the prospectively collected spine register from 2010 to 2022. Operative technique, perioperative laboratory results and imaging studies were extracted. The primary outcome was total blood loss including intraoperative, drain output and hidden blood loss., Results: Fifty-seven children (32 boys) with a mean age of 8.3 years underwent spinal osteotomy for congenital scoliosis. Posterolateral hemivertebrectomy was sufficient in 34 (59%) patients, while vertebral column resection (VCR) was required in 23 patients. Total bleeding averaged 792 (523) ml accounting for 42% of the estimated blood volume. Hidden blood loss accounted for 40% of total bleeding and 21% of estimated blood volume with a mean of 317 (256) ml. VCR was associated with greater intraoperative and total bleeding than hemivertebrectomies (p = 0.001 and 0.007, respectively). After adjusting for patient weight and fusion levels, hidden blood loss was larger in hemivertebrectomies (4.18 vs. 1.77 ml/kg/fused level, p = 0.049). In multivariable analysis, intraoperative blood loss was inversely correlated with preoperative erythrocyte levels. Younger age was associated with significantly greater drain, hidden and total blood loss., Conclusion: Hidden blood loss constitutes a significant portion (40%) of total bleeding in congenital scoliosis surgery. Younger age is a risk factor for bleeding and the hidden blood loss should be taken into consideration in their perioperative management., (© 2024. The Author(s).)

Objective: Realignment osteotomy performed concomitantly with cartilage restoration typically requires early restricted weightbearing and can add significant morbidity, potentially leading to an increased risk of early perioperative complications. The purpose of this study was to compare the 30-day complication rates after isolated cartilage restoration (ICR) versus concomitant cartilage restoration and osteotomy (CRO) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database., Design: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing ICR (autologous chondrocyte implantation, osteochondral autograft transfer, or osteochondral allograft transplantation) and CRO (with concomitant high tibial osteotomy, distal femoral osteotomy, and/or tibial tubercle osteotomy). Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and respiratory status., Results: A total of 773 ICR and 97 CRO surgical procedures were identified. Mean patient ages were 35.9 years for the ICR group and 31.2 years for the CRO group. Operative time was significantly longer in the CRO group (170.8 min) compared with the ICR group (97.8 min). Multivariate analysis demonstrated no significant differences in rates of PE, VTE, and all-cause readmission between the ICR and CRO groups. No events of wound disruption, SSI and reoperation were found in the CRO group, while the ICR group was characterized by low rates of wound disruption, reoperation, and SSI (<1.1%)., Conclusions: These findings further support concomitant osteotomy with cartilage restoration when appropriate and aid surgeons in the preoperative counseling of patients undergoing cartilage restoration treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There has long been discussion regarding the impact of medial malleolar osteotomies (MMO) as an adjunctive treatment for osteochondral lesions of the talus (OCLT). MMO may improve the visibility and accessibility of the talus, but they also pose a risk of periprocedural morbidity. There is a lack of research about the prevalence and consequences of MMO in the surgical treatment of OCLT., Methods: This study retrospectively evaluated data from the German Cartilage Register (KnorpelRegister DGOU) from its implementation in 2015 to December 2020. The impact of MMO on patient-reported outcome measures (PROMs) was investigated. Wherever possible, subgroups were built and matched using a propensity score which matched a group undergoing OCLT without MMO. Matching included age, sex, weight, localization of the OCLT, the international cartilage repair society (ICRS) grading, surgical procedure and preoperative symptoms using the Foot and Ankle Ability Measure (FAAM) and the Activities of Daily Living Subscale (ADL)., Results: The prevalence of MMO in the operative treatment of OCLT was 15.9%. Most of the osteotomies were performed in OCL of the medial talar dome (76.8%) and in more serious lesions with an ICRS grade of III (29.1%) and IV (61.4%). More than half of the osteotomies (55.6%) were performed during revision surgery. A matched pair analysis of n = 44 patients who underwent AMIC ® via arthrotomy and MMO vs. arthrotomy alone showed no significant differences in patient-reported outcome measures (PROMs, i.e. FAAM-ADL, and FAOS) at 6,12 and 24 months., Conclusions: MMO are mostly used in the treatment of severe (≥ ICRS grade 3) OCL of the medial talar dome and in revision surgery. Functional and patient-reported outcome measures are not significantly affected by MMO compared to arthrotomy alone., Trial Registration: The German Cartilage Register (KnorpelRegister DGOU) was initially registered at the German Clinical Trials Register ( https://www.drks.de , register number DRKS00005617, Date of registration 03.01.2014) and was later expanded by the ankle module., (© 2024. The Author(s).)

The floating toe deformity is classified as a forefoot deformity wherein the distal portion of the toe does not establish touch with the ground, resulting in a suspended or elevated position while the finger is in a relaxed state. At first, it garnered considerable interest as a complication It is worth noting that this condition is particularly common in children under the age of 8, which usually disappears as the individual reaches maturity. Studies have shown that with the aggravation of floating toe deformity, its adverse effects on patients' gait and overall quality of life also increase. Despite the prevalence of floating toe deformity in clinical settings, there is a lack of comprehensive literature investigating its underlying causes and potential preventive strategies. This scope review follows the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) statement guidelines for scope reviews. The literature was obtained from various full-text databases, including China National Knowledge Infrastructure Database (CNKI), Wanfang Database, PubMed, and Web of Science Database. Our search focused on published literature related to floating toes, Weil osteotomy, and distal metatarsal osteotomy, up until March 1, 2023. The literature search and data analysis are conducted by two independent reviewers. If there are any disagreements, a third researcher will participate in the discussion and negotiate a decision. Furthermore, two experienced foot and ankle surgeons conducted a thorough literature analysis for this review. Sixty-two articles were included. Through the clinical analysis of the structural changes of the forefoot before and after operation, the classification of floating toe was described, the causes of pathological floating toe were summarized, and the possible intervention measures for the disease were put forward under the advice of foot and ankle surgery experts. We comprehensively summarize the current knowledge system about the etiology of floating toe and put forward the corresponding intervention strategy. We recommend that future studies will focus on the improvement of surgical procedures, such as the combination of Weil osteotomy, proximal interphalangeal (PIP) arthrodesis and flexor tendon arthrodesis., (© 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Background: Nasal septum osteotomy is used for separating the nasal septum and maxilla during a Le Fort I osteotomy. If this osteotomy is applied too high or is tilted into the nasal cavity, the sphenoid sinus and various adjacent vital structures may be damaged, and serious bleeding, neurological complications, blindness or even death may occur. The aim of this study is to determine the safety margin of the nasal septum osteotomy for sphenoid sinus during the Le Fort I surgery in cleft lip and palate (CLP) patients., Methods: Twenty cleft lip and palate (the CLP group) and 20 healthy individuals (the control group) were included in this study. Three values (two lines and an angle) were measured by cone beam computed tomography (CBCT). The first line is the line passing through the junction of the spina nasalis anterior point and the lower point of the perpendicular lamina of the palatine bone. The undersired line is the line passing through the junction of the spina nasalis anterior point and the lower anterior border of the base of the sphenoid sinus. The osteotomy angle is the angle between these two lines., Results: In the control group; a surgical line of 44.11-61.14 mm (mean 51.91 ± 4.32), an undesired line of 52.48-69.58 mm (mean 59.14 ± 5.08) and an angle of 18.22-27.270 (mean 22.66 ± 2.55) were found, while in the CLP group, a surgical line of 34.53-51.16 mm (mean 43.38 ± 4.79), an undesired line of 46.86-61.35 mm (mean 55.02 ± 3.24) and an angle of 17.60-28.810 (mean 22.60 ± 2.81) were found., Conclusions: Although the angle to the sphenoid sinus was not significantly affected by CLP, careful planning and consideration of these anatomical differences are crucial to prevent complications and ensure the safety of Le Fort I surgery in CLP patients. Further research with larger sample sizes and subgroup analysis of unilateral and bilateral CLP cases is needed to improve our understanding of these anatomical variations and improve surgical approaches to individuals with CLP undergoing orthognathic procedures., (© 2024. The Author(s).)

Background: The disparity in patient-reported outcomes between total knee arthroplasty (TKA) following high tibial osteotomy (HTO) and primary TKA has yet to be fully comprehended. This study aims to compare the patient-reported outcomes, radiological parameters and complication rates between TKA following HTO and primary TKA., Methods: Sixty-five patients who underwent TKA following lateral closing-wedge HTO were compared to a matched group of primary TKA at postoperative 6-months and 1-year. Between-group confounders of age, gender, smoking status, Body Mass index, preoperative Numeric Rating Scale (NRS) pain in rest, Knee injury and Osteoarthritis Outcome Score-Physical function Shortform (KOOS-PS), EuroQol five-dimensional (EQ-5D) overall health score, and Oxford Knee Score (OKS) were balanced by propensity score matching. Patient-reported outcome measures were NRS pain in rest, KOOS-PS, EQ-5D overall health score, and OKS. Radiological parameters were femorotibial angle, medial proximal tibial angle, anatomical lateral distal femoral angle, posterior tibial slope, and patellar height assessed by Insall-Salvati ratio. The complication rates of TKA were compared between the two groups. The HTO survival time, the choice of staple removal before or during TKA in patients who underwent TKA following HTO patients, and the rate of patellar resurfacing were assessed. The p value < 0.0125 indicates statistical significance after Bonferroni correction., Results: After propensity score matching, no significant between-group differences in the patient-reported outcome measures, radiographical parameters and complication rates were found (p > 0.0125). In the TKA following HTO group, with an average HTO survival time of 8.7 years, staples were removed before TKA in 46 patients (71%) and during TKA in 19 patients, and 11 cases (17%) had patella resurfacing. In the primary TKA group, 15 cases (23%) had patella resurfacing., Conclusion: The short-term assessment of TKA following HTO indicates outcomes similar to primary TKA. A previous HTO does not impact the early results of subsequent TKA, suggesting that the previous HTO has minimal influence on TKA outcomes., Level of Evidence: III, cohort study., (© 2024. The Author(s).)

Purpose: We conducted a retrospective analysis of prospectively collected data to evaluate (1) the extent of surgical correction following minimally invasive periacetabular osteotomy, (2) improvements in functional outcomes and any potential predictors for favourable outcome, and (3) complications after minimally invasive periacetabular osteotomy., Methods: A total of 352 minimally invasive periacetabular osteotomy procedures were performed on 312 hip dysplasia patients between 2013 and 2020. Radiological parameters such as lateral centre edge angle, acetabular index, and Tönnis grade of arthritis were calculated. Patients also completed a range of patient reported outcome measures. Wilcoxon signed-rank tests were performed to assess for differences between patient reported outcome measures and radiological outcomes across the follow-up periods. Univariate linear regression and logistic regression were used to assess for predictors of change in functional outcome., Results: Patients had a significant correction in mean lateral centre edge angle from 17.2° to 35.3° (p < 0.001) and mean acetabular index from 13.2° to - 0.82°. At one year follow-up all patient reported outcome measures were significantly greater than their baseline measurements and this improvement was maintained at two years. Changes in patient reported outcome measures were independent of radiological parameters such as change in the lateral centre edge angle and acetabular index, pre-operative Tönnis grade, and patient factors such as age and sex. A total of 5.11% of patients developed post-operative complications, with four requiring posterior column fixation. Four patients (1.12%) needed a total hip replacement., Conclusion: Minimally invasive periacetabular osteotomy is a safe procedure that provides significant functional outcome improvements following surgery at six months which is maintained at two years. More than three-fourths of patients achieved improvement of iHOT-12 score beyond the minimal clinically important difference and more than half of the patients achieved substantial clinical benefit for iHOT-12 score., (© 2024. The Author(s).)

Objective: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP., Methods: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression., Results: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01)., Conclusions: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted., Level of Evidence: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy)., Competing Interests: S.P.W. is a stockholder (within the last 2 years) for Johnson & Johnson. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objective: Medial open wedge high tibial osteotomy (MOW HTO) is associated with moderate to severe postoperative pain. The proximal part of the tibia is innervated by branches from the femoral nerve anteriorly and the sciatic nerve posteriorly. There is a paucity of information regarding the optimal peripheral nerve block for postoperative analgesia with minimal impact on motor function. This study tested the hypothesis that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO in the setting of multimodal analgesia., Design: Randomized controlled single-blind trial., Setting: Operating room, postoperative recovery area and ward, up to 6 postoperative months., Patients: Fifty patients undergoing MOW HTO., Interventions: Interventions were femoral or sciatic nerve block under ultrasound guidance. For each intervention, a total of 100 mg of ropivacaine was injected. Postoperative pain treatment followed a pre-defined protocol with intravenous patient-controlled analgesia of morphine, paracetamol, and ibuprofen., Measurements: The primary outcome was intravenous morphine consumption at 24 h postoperatively. Secondary outcomes included rest and dynamic pain scores (on a numeric rating scale out of 10) at 2, 24 and 48 h postoperatively. Functional outcomes included the Short Form-12, Knee injury and Osteoarthritis Outcome Score, and International Knee Documentation Committee (IKDC) scores measured at 6 months postoperatively., Main Results: Mean [95% confidence interval] i.v. morphine consumption at 24 postoperative hours were 24 mg [15 mg,33 mg] in the femoral nerve block group and 24 mg [16 mg,32 mg] in the sciatic nerve block group (p = 0.98). There were no significant differences in the secondary outcomes between groups., Conclusions: This trial failed to demonstrate that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO under general anesthesia in the setting of multimodal analgesia. There was no significant difference in quality of life and functional outcomes at 6 months postoperatively between groups. Trial registry number:Clinicaltrials.com - NCT05728294; Kofam.ch - SNCTP000003048 | BASEC2018-01774., Competing Interests: Declaration of Competing Interest EA has received grants from the Swiss Academy for Anesthesia Research (SACAR), Lausanne, Switzerland (no grant numbers attributed), from B. Braun Medical AG, Sempach, Switzerland (no grant numbers attributed) and from the Swiss National Science Foundation to support his clinical research. EA has also received an honorarium from B. Braun Medical AG Switzerland, from Sintetica Ltd. UK and MSD AG Switzerland. No conflict of interest declared by the other authors., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: We aim to investigate the associations between lumbar paraspinal muscles and sagittal malalignment in patients undergoing lumbar three-column osteotomy., Methods: Patients undergoing three-column osteotomy between 2016 and 2021 with preoperative lumbar magnetic resonance imaging (MRI) and whole spine radiographs in the standing position were included. Muscle measurements were obtained using a validated custom software for segmentation and muscle evaluation to calculate the functional cross-sectional area (fCSA) and percent fat infiltration (FI) of the m. psoas major (PM) as well as the m. erector spinae (ES) and m. multifidus (MM). Spinopelvic measurements included pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L1-S1 lordosis (LL), T4-12 thoracic kyphosis (TK), spino-sacral angle (SSA), C7-S1 sagittal vertical axis (SVA), T1 pelvic angle (TPA) and PI-LL mismatch (PI - LL). Statistics were performed using multivariable linear regressions adjusted for age, sex, and body mass index (BMI)., Results: A total of 77 patients (n = 40 female, median age 64 years, median BMI 27.9 kg/m 2 ) were analyzed. After adjusting for age, sex and BMI, regression analyses demonstrated that a greater fCSA of the ES was significantly associated with greater SS and SSA. Moreover, our results showed a significant correlation between a greater FI of the ES and a greater kyphosis of TK., Conclusion: This study included a large patient cohort with sagittal alignment undergoing three-column osteotomy and is the first to demonstrate significant associations between the lumbar paraspinal muscle parameters and global sagittal alignment. Our findings emphasize the importance of the lumbar paraspinal muscles in sagittal malalignment., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Aims: Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes., Methods: A total of 40 hips in 40 consecutive patients who underwent PAO between May 2016 and July 2018 were included in the study, as further follow-up of the same patients from a previous study. We prospectively evaluated the incidence, severity, and area of symptoms following LFCN injury. We also recorded the clinical scores at one year and ≥ three years postoperatively using the 36-Item Short Form Health Survey (SF-36) and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) scores., Results: A total of 20 patients (50%) had symptoms of a LFCN injury at one year after PAO. At ≥ three years postoperatively, the symptoms had completely resolved in seven of these patients and 13 (33%) had persistent symptoms. The severity and area of symptoms did not significantly differ between one and ≥ three years postoperatively. The JHEQ showed significant differences in the patient satisfaction and mental scores between those with and those without sypmtoms of LFCN injury at ≥ three years postoperatively, while there was no significant difference in the mean SF-36 scores., Conclusion: The incidence of LFCN injury after PAO using an anterior approach is high. The outcome of PAO, ≥ three years postoperatively, is poorer in patients with persistent symptoms from a perioperative LFCN injury, in that patient satisfaction and mental health scores are adversely affected., Competing Interests: None declared., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Purpose: The primary aim is to assess the efficacy of the surgical callus distraction technique of the metatarsus in paediatric patients. Secondary objectives are to assess complications and treatment duration. We have also described the details of our surgical technique., Materials and Methods: A case series review of paediatric patients who had metatarsal lengthening at our unit between 2014 and 2022. Patient demographics, duration of time in frame, complications and metatarsal length achieved were recorded. The AOFAS Midfoot and the MOXFQ were taken pre-operatively and at final follow-up., Results: Sixteen metatarsals in 8 patients (14 feet) underwent lengthening between 2014 and 2022 using the MiniRail OrthoFix 100 (Orthofix Medical Inc, Lewisville, TX, USA). The mean age was 13.3 (12-17) years. The average duration between surgery and implant removal was 5.2 months. According to Paley's classification, there was one obstacle encountered in a patient who required a revision of their osteotomy and one problem in another patient who had an infected metatarsophalangeal joint stabilising k-wire treated with oral antibiotics. The Mean AOFAS Midfoot score improved from 53.10 to 86.40 (p < 0.0001) and the Mean MOXFQ improved from 32.5000 to 12.1250 (p < 0.05); these were statistically significant., Conclusion: Gradual metatarsal lengthening using the MiniRail external fixator is a safe and effective method to treat brachymetatarsia in paediatric patients. This preliminary report describes and supports metatarsal lengthening in appropriate patients. Holistic care in terms of a pre-operative assessment, psychological support and preparation for the extended rehabilitation period are vital., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses., Patients and Methods: Retrospective analysis of the results of two groups of patients operated upon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of five year follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was five years. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2., Results: The KSS score of group 2 was better in the first six months postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006)., Conclusion: The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments., (© 2024. The Author(s).)

Purpose: This study retrospectively evaluated long-term clinical outcomes and patient-reported outcome measures (PROMs) in patients with osteonecrosis of the femoral head (ONFH) who underwent transtrochanteric rotational osteotomy (TRO), curved varus osteotomy (CVO), and total hip arthroplasty (THA)., Methods: We retrospectively reviewed the 109 hips in 96 patients (46 men, 50 women) who underwent CVO, TRO, or THA for ONFH treatment. The mean follow-up period for the TRO, CVO, and THA groups was 14.8, 11.5, and 13.3 years, respectively., Results: The THA conversion rate of the TRO patients was significantly higher than that of the patients with CVO, and the final clinical scores in the patients with TRO did not improve compared with preoperative scores. Postoperative PROMs showed that the total and pain scores of the patients with THA were significantly higher than those of patients with TRO and CVO, while the PROM score did not change between patients with TRO and CVO. The analysis further showed that the preoperative type C2, stage 3A, or postoperative type C1 and C2 were significant predictors of decreased final PROM scores., Conclusion: This study found that CVO and THA are clinically effective treatments for ONFH, with significant improvements compared with preoperative scores. However, THA was associated with significantly higher PROMs and pain scores than those of CVO and TRO in long-term follow-up. Furthermore, our results suggest that postoperative PROMs depend mainly on the preoperative level of collapse and postoperative transposed intact ratio of the articular surface of the femoral head., (© 2024. The Author(s).)