BackgroundThe purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patien...

Hallux valgus: demographics, etiology, and radiographic assessment.

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review.

Nonunion is a common complication following long-bone fracture, with a prevalence that ranges from 2.5-46%, depending on the location and severity of the injury to the bone, soft tissue, and vascular structures. The treatment of nonunions involves addressing the biology of fracture repair and the mechanical stability of fracture fixation, which are interrelated. Nonunion treatment has traditionally included the addition of autograft from the iliac crest to enhance healing. However, there an associated morbidity with the harvesting of the graft, and alternatives such as bone marrow aspirate, platelet-rich plasma, allograft, and ceramics have also been studied. In addition, new advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors, such as bone morphogenetic proteins, to accelerate bone healing. This article reviews the benefits of iliac crest bone graft relative to those of other modalities in the treatment of nonunions.

Autologous iliac crest bone graft: Should it still be the gold standard for treating nonunions?

Autogenous cancellous bone graft provides an osteoconductive, osteoinductive, and osteogenic substrate for filling bone voids and augmenting fracture-healing.The iliac crest remains the most frequently used site for bone-graft harvest, but the proximal part of the tibia, distal end of the radius, distal aspect of the tibia, and greater trochanter are alternative donor sites that are particularly useful for bone-grafting in the ipsilateral extremity.The most common complication associated with the harvest of autogenous bone graft is pain at the donor site, with less frequent complications including nerve injury, hematoma, infection, and fracture at the donor site.Induced membranes is a method that uses a temporary polymethylmethacrylate cement spacer to create a bone-graft-friendly environment to facilitate graft incorporation, even in large segmental defects.

Autogenous Bone Graft: Donor Sites and Techniques

Background:There have been few long-term studies documenting the outcome of surgical treatment of hallux rigidus. The purposes of this report were to evaluate the long-term results of the operative treatment of hallux rigidus over a nineteen-year period in one surgeon's practice and to assess a clin

Hallux rigidus. Grading and long-term results of operative treatment.

Purpose: The purpose of this study was to show that magnetic resonance imaging (MRI) can accurately and noninvasively evaluate the articular cartilage overlying osteochondral lesions of the talus, using arthroscopy as the standard, and provide information about lesion stability. A classification system applicable to both MRI and arthroscopy is proposed. Type of Study: Retrospective review with MRI and arthroscopy correlation. Methods: A retrospective analysis involving 26 men and 28 women who underwent MRI of the ankle and in whom arthroscopy had been performed. The talar dome cartilage was evaluated using the following grading system: 0, normal cartilage; 1, abnormal signal but intact; 2, fibrillation or fissures not extending to bone; 3, flap present or bone exposed; 4, loose undisplaced fragment; 5, displaced fragment. There was a history of trauma in 80% of cases. Results: At surgery, 14 ankle joints had intact cartilage and 40 showed osteochondral lesions. MRI correctly identified all 40 osteochondral lesions and all 14 normal ankles. MRI correctly graded 33 of 40 (83%) of the osteochondral lesions using the described 5-point scale. Of the remaining 7 lesions, all were identified within 1 grade. Collapsing all grades into disease-negative status (grades 0 and 1) and disease-positive status (grades 2, 3, 4, and 5) yielded sensitivity of 95%, specificity of 100%, negative predictive value of 88%, and positive predictive value of 100%. Conclusions: This study shows that MRI can be used to evaluate the articular cartilage covering osteochondral lesions of the talus with a high degree of accuracy and thus may aid in identifying patients who would benefit from definitive arthroscopic treatment. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp 353–359

Osteochondral lesions of the talus: A new magnetic resonance grading system with arthroscopic correlation

Thirty patients (37 feet) with severe hallux rigidus underwent resection arthroplasty of the first metatarsophalangeal joint with our modification (reattachment of the extensor hood and extensor brevis to the flexor hallucis brevis as a capsular interposition arthroplasty, with minimal bone resection). Pain and function were significantly improved. Transfer metatarsalgia was not seen. All patients had at least 4/5 plantarflexion strength and averaged 50 degrees of dorsiflexion. In patients with severe hallux rigidus and nearly equal length of first and second metatarsals, capsular interposition arthroplasty offers a surgical option that relieves pain without sacrificing motion or strength.

Capsular Interposition Arthroplasty for Severe Hallux Rigidus

Background: Although ankle arthrodesis remains a standard operative procedure for disabling ankle arthritis, it has potential long-term problems. Total ankle arthroplasty offers preserved joint mot...

Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation.

Background: In recent years ankle distraction arthroplasty has gained popularity in the treatment of ankle arthritis as a means of both maintaining range of motion and avoiding fusion. We present a retrospective review of 25 patients who have undergone ankle distraction from 1999 to 2006. Materials and Methods: The mean age was 43 years; 16 were male, and 7 were female. Followup was 30 months after frame removal (range, 12 to 60 months). We were able to obtain followup on 23 of 25 patients. Adjuvant procedures were performed in some cases including Achilles tendon lengthening (5), ankle arthroscopy (4), open arthrotomy (1), and supramalleolar tibial and distal fibular osteotomy to correct distal tibial deformity (6). Results: Twenty-one patients (91%) reported improved pain with those furthest post-op experiencing the best results. The average preoperative AOFAS score was 55 (range, 29 to 82), and the average postoperative score was 74 (range, 47 to 96). The difference between pre- and postoperative scores was significant (p = 0.005). SF-36 scores showed modest improvement in all components. Only two of the patients in the study underwent fusion after ankle distraction. Total ankle motion was maintained in all patients with improvement in the functional arc of motion in five patients who started with mild equinus contractures. Conclusion: We feel that ankle distraction offers a promising solution for many people with ankle arthritis.

/pdf/joint-preservation-of-the-osteoarthritic-ankle-using-21lvar3q9z.pdf

Joint Preservation of the Osteoarthritic Ankle Using Distraction Arthroplasty

Background
Many procedures have been developed to correct hallux valgus deformity using distal soft tissue realignment, metatarsal osteotomy, and periodically, a proximal phalanx osteotomy (Akin). The ideal metatarsal osteotomy allows for varying degrees of correction with reliable improvement in deformity and patient satisfaction.

/pdf/outcomes-after-scarf-osteotomy-for-treatment-of-adult-hallux-k883pyr0u0.pdf

Martin J. O’Malley

Papers

Osteochondral lesions of the talus: A new magnetic resonance grading system with arthroscopic correlation

Capsular Interposition Arthroplasty for Severe Hallux Rigidus

Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation.

Joint Preservation of the Osteoarthritic Ankle Using Distraction Arthroplasty

Outcomes after Scarf Osteotomy for Treatment of Adult Hallux Valgus Deformity