Keithals6221

DOI 10.1302/2058-5241.6.210018.The full-length standing radiograph in an anteroposterior projection is the primary tool for defining and measuring limb alignment with definition of the physiological axes and mechanical and anatomic angles of the lower limb.We define the deformities of the lower limb and the importance of correct surgical planning and execution.For patients with torsional malalignment of the lower limb, computerized tomography scan evaluation is the gold standard for preoperative assessment. Cite this article EFORT Open Rev 2021;6487-494. DOI 10.1302/2058-5241.6.210015.Preoperative evaluation of the pathomorphology is crucial for surgical planning, including radiographs as the basic modality and magnetic resonance imaging (MRI) and case-based additional imaging (e.g. 3D-CT, abduction views).Hip arthroscopy (HAS) has undergone tremendous technical advances, an immense increase in use and the indications are getting wider. The most common indications for revision arthroscopy are labral tears and residual femoroacetabular impingement (FAI).Treatment of borderline developmental dysplastic hip is currently a subject of controversy. It is paramount to understand the underlining problem of the individual hip and distinguish instability (dysplasia) from FAI, as the appropriate treatment for unstable hips is periacetabular osteotomy (PAO) and for FAI arthroscopic impingement surgery.PAO with a concomitant cam resection is associated with a higher survival rate compared to PAO alone for the treatment of hip dysplasia. Further, the challenge for the surgeon is the balance between over- and undercorrection.Femoral torsion abnormalities should be evaluated and evaluation of femoral rotational osteotomy for these patients should be incorporated to the treatment plan. Cite this article EFORT Open Rev 2021;6472-486. DOI 10.1302/2058-5241.6.210019.Pelvic discontinuity (PD) has been a considerable challenge for the hip revision arthroplasty surgeon. However, not all PDs are the same. Some occur during primary cup insertion, resembling a fresh periprosthetic fracture that separates the superior and inferior portions of the pelvis, while others are chronic as a result of gradual acetabular bone loss due to osteolysis and/or acetabular implant loosening.In the past, ORIF, various types of cages, bone grafts and bone cement were utilized with little success. Today, the biomechanics and biology of PD as well as new diagnostic tools and especially a variety of new implants and techniques are available to hip revision surgeons. Ultraporous cups and augments, cup-cage constructs and custom triflange components have revolutionized the treatment of PD when used in various combinations with ORIF and bone grafts. For chronic PD the cup-cage construct is the most popular method of reconstruction with good medium-term results.Dislocation continues to be the leading cause of failure in all situations, followed by infection. Ultimately, surgeons today have a big enough armamentarium to select the best treatment approach. Case individualization, personal experience and improvisation are the best assets to drive treatment decisions and strategies. Cite this article EFORT Open Rev 2021;6459-471. DOI 10.1302/2058-5241.6.210022.Most meta-diaphyseal femoral fractures that are treated with intramedullary nailing can be reduced satisfactorily by skeletal traction without 'opening' the fracture site and therefore, complications such as nonunion, infection and wound healing problems are reduced.In cases where adequate fracture reduction cannot be achieved by skeletal traction, 'reduction aids' have been used during the operative procedure in order to avoid the exposure of the fracture site.The 'blocking' screw, as a reduction tool, was proposed initially for the 'difficult' metaphyseal fractures of the tibia. Subsequently, surgeons have tried to implement the 'blocking' screw technique in 'difficult' distal femoral fractures.This article presents the 'blocking' screw technique as an adjunctive process in the management of fractures of the proximal and distal femur which are found to be non-reducible by skeletal traction alone. The minimal invasiveness of the technique contributes greatly to the preservation of both the soft tissue integrity and the fracture haematoma and thus reduces the major complications that can occur by exposing the fracture site. Cite this article EFORT Open Rev 2021;6451-458. DOI 10.1302/2058-5241.6.210024.Routine outcome measurements as a critical prerequisite of value-based healthcare have received considerable attention recently. There has been less attention for the last step in value-based healthcare where measurement of outcomes also leads to improvement in the quality of care. This is probably not without reason, since the last part of the learning cycle 'Closing the loop', seems the hardest to implement.The journey from measuring outcomes to changing daily care can be troublesome. As early adopters of value-based healthcare, we would like to share our 10 years of experience in this journey.Examples of feedback loops are shown based on outcome measurements implemented to improve our daily care process as a focused hand surgery and hand therapy clinic.Feedback loops can be used to improve shared decision making, to monitor or predict treatment progression over time, for extreme value detection, improve journal clubs, and surgeon evaluation.Our goal as surgeons to improve treatment should not stop at the act of implementing routine outcome measurements.We should implement routine analysis and routine feedback loops, because real-time performance feedback can accelerate our learning cycle. Cite this article EFORT Open Rev 2021;6439-450. DOI 10.1302/2058-5241.6.210012.There is some confusion in the terminology used when referring to MIS (Minimal invasive surgery) or percutaneous surgery. The correct term to describe these procedures should be percutaneous (made through the skin) and MIS should be reserved for procedures whose extent is between percutaneous and open surgery (e.g. osteosynthesis). Minimal incision surgery may be distinguished in first, second and third generation minimal incision surgery techniques.First generation MIS hallux valgus surgery is mainly connected with the Isham procedure; an intraarticular oblique and incomplete osteotomy of the head of the first metatarsal without fixation.The Bösch osteotomy and the SERI are classified as second generation MIS hallux surgery. They are both transverse subcapital osteotomies fixed with a percutaneous medial K-wire inserted into the medullary canal. For all these procedures, intraoperative fluoroscopic control is necessary.Open hallux valgus surgery can be divided into proximal, diaphyseal and distal osteotomies of the first metatarsal. click here Reviewing the available literature suggests minimally invasive and percutaneous hallux valgus correction leads to similar clinical and radiological results to those for open chevron or SCARF osteotomies. First generation minimally invasive techniques are primarily recommended for minor deformities. In second generation minimally invasive hallux valgus surgery, up to 61% malunion of the metatarsal head is reported. Once surgeons are past the learning curve, third generation minimally invasive chevron osteotomies can present similar clinical and radiological outcomes to open surgeries. Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques. Cite this article EFORT Open Rev 2021;6432-438. DOI 10.1302/2058-5241.6.210029.Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article EFORT Open Rev 2021;6420-431. DOI 10.1302/2058-5241.6.210017.The histopathological examination of the periprosthetic soft tissue and bone has contributed to the identification and description of the morphological features of adverse local tissue reactions (ALTR)/adverse reactions to metallic debris (ARMD). The need of a uniform vocabulary for all disciplines involved in the diagnosis and management of ALTR/ARMD and of clarification of the parameters used in the semi-quantitative scoring systems for their classification has been considered a pre-requisite for a meaningful interdisciplinary evaluation.This review of key terms used for ALTR/ARMD has resulted in the following outcomes (a) pseudotumor is a descriptive term for ALTR/ARMD, classifiable in two main types according to its cellular composition defining its clinical course; (b) the substitution of the term metallosis with presence of metallic wear debris, since it cannot be used as a category of implant failure or histological diagnosis; (c) the term aseptic lymphocytic-dominated vasculitis- associated lesion (ALketing surveillance, and implant registries.The review of key terms used for the description and histopathological classification of ALTR/ARMD has resulted in a comprehensive, new standard for all disciplines involved in their diagnosis, clinical management, and long-term clinical follow-up. Cite this article EFORT Open Rev 2021;6399-419. DOI 10.1302/2058-5241.6.210013.Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory.