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INTRODUCTION: The aim of this study was to compare the clinical, radiological and functional outcomes between cannulated compression screw with cable construct (CS) and tension band wiring (TBW) in transverse patella fractures. MATERIALS AND METHODS: A retrospective study was conducted on patients surgically treated for AO/OTA 34C1 or 34C2 transverse patella fractures with CS or TBW technique between January 2019 and January 2023. Clinical outcomes included complications related to the implant, wound and fracture at 6 months and 1 year, time to achieving full weight bearing status and early perioperative clinical outcomes. Radiological outcomes included the time to fracture heals and delayed union. Functional outcome measures using the Oxford Knee Scale, 36-short form questionnaire and the Bartlett Anterior Knee Score were assessed. RESULTS: 73 patients were treated with CS (n = 33) or TBW (n = 40). TBW had higher complication rates: 25.0% (n = 10) required implant removal, 12.5% (n = 5) had wire breakage, 12.5% (n = 5) experienced fracture displacement while 52.5% (n = 21) experienced implant migration. In contrast, no CS patients had implant removals, wire breakage or fracture displacement and 3.0% (n = 1) experienced implant migration. At 1 day post-operatively, 87.9% (n = 29) CS group patients were able to ambulate as compared to the 55.0% (n = 22) of TBW patients. Furthermore, CS patients ambulated further distances at 11.8 ± 10.6 m than the TBW group (6.4 ± 7.4 m). The CS group (25.9 ± 24.6 days) also achieved full weight bearing status faster than the TBW group (43.6 ± 39.4 days). The time taken for the fracture to heal and functional outcomes were comparable among the two groups. CONCLUSIONS: The CS technique demonstrated lower complications, in particular, no CS patient had implant removals, wire migration or fracture displacement. Additionally, CS technique showed a faster return to ambulation and time to achieving full weight bearing status.

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INTRODUCTION: Knowledge of femoral and tibial morphology is important for patient-specific surgery in both joint reconstruction and preservation procedures. Studies evaluating morphological variance in femoral and tibial alignments in Asian populations are scarce. This is the first descriptive study evaluating the femoral and tibial phenotypes of varus alignment in a Southeast Asian population. METHODS: Long-leg coronal standing radiographs of 2021 limbs were obtained, and the hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle and joint line convergence angle were measured. Joint line obliquity was calculated, and the knees were classified according to the Coronal Plane Alignment of Knee (CPAK) classification. Descriptive analyses on alignment parameters and demographic data (age, gender, ethnicity and body mass index [BMI]) were performed and entered into a linear regression model. RESULTS: The highest frequency of limb alignment in the population was found to be CPAK type I (52.71%, n = 1003). Tibial varus was the largest contributor of varus malignment. Of the varus knees (n = 1247), varus deformity was found solely in the tibia (68.60%), solely in the femur (2.07%) and was contributed by both the femur and the tibia (4.97%). In the linear regression model, BMI was found to be a strong determinant for femoral varus (P = 0.004) and joint line incongruence (P < 0.001). CONCLUSION: The findings of this study will be important to surgeons during planning for joint preservation procedures (such as corrective osteotomies) and joint arthroplasties to restore alignment.

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Introduction: Acute shoulder pain is among the most common presenting complaints in the clinic. Clinicians may find it challenging with the myriad of potential etiologies to explain for the presenting complaint. We present a unique case, where a herpes zoster infection in the C6 dermatome mimicked the presentation of rotator cuff pathology and was admitted to the care of orthopedics. We have also included a detailed literature review on the topic in our study. Case Report: The patient was a 38-year-old Chinese female who presented with acute atraumatic right-sided shoulder pain and weakness which was potentially confounded by an attempt of traditional Chinese medicine. Clinical examination revealed that the range of motion was globally reduced and painful in all directions with equivocal impingement testing. Examination of the skin revealed the presence of polymorphous eruption of erythematous papules and vesicles in the right shoulder and C6 region. In this paper, we discuss a possible algorithm to aid clinicians in an acute shoulder pain history with accompanying red flags to look out for. This is accompanied by a detailed literature review on the topic which demonstrates the rarity of this presentation which eventually confounded the initial management of the patient. Conclusion: A thorough history and physical examination must remain the cornerstone of a clinician's diagnostic algorithm. Zoster neuropathy at the level of the cervical spine is a rare entity. This case report also emphasizes the need for cognizance of local traditional remedies practiced and their interactions with clinical diagnosis and treatment.

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Background: Hip fractures are a common and debilitating condition posing not only a huge health care but also socioeconomic burden. Surgical management for a neck of femur fracture is typically with arthroplasty in the form of total hip arthroplasty or hip hemiarthroplasty. Serial radiographs are typically performed routinely as part of follow-up to look for complications, although their clinical utility in asymptomatic patients is yet to be validated. Our paper therefore aims to review the utility and necessity of radiographic follow-up following arthroplasty for NOF fractures. Materials and Methods: Patients who underwent operative management for acute fragility neck of femur fractures in the year from 1st January 2018 to 31st December 2018 at the author's institution were identified. All patients who underwent surgery, and had at least one pre and one post-operative plain film radiograph of the affected hip were included in this study. Exclusion criteria included patients who had undergone surgery for chronic fractures, avascular necrosis of the femoral head, mortality within 1 year, peri-prosthetic fractures, pathological fractures from metastases, had concomitant injuries, or had inaccessible or incomplete records. Clinical records were assessed for the number of visits, an abnormal presenting history or clinical examination, as well as changes in management of the patient. The number and type of radiographs were also assessed, and each radiograph analyzed for abnormal findings. Results: A total of 157 patients were included in our study with a mean age of 79.5 at the time of surgery, and a mean follow up of 17.3 months. Data was collected from 626 clinical visits and a total of 973 radiographs. The 3 abnormal radiographic series identified with a corresponding normal consult did not result in a change of management for the patient. A negative change in management was only observed in 1 patient with an abnormal consult and a corresponding normal radiograph. Conclusion: Post-operative complications following arthroplasty for NOF fractures are likely to result in a symptomatic presentation of the patient. Routine radiographic follow-up provides limited utility in asymptomatic patients and should only be performed if clinically indicated.

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Background & aims: Knee osteoarthritis (KOA) is a progressive degenerative disease of chronic nature. The mainstay of surgical management for KOA would be total knee arthroplasty. Joint preserving options like High Tibial Osteotomy (HTO) and Proximal Fibular Osteotomy (PFO) have been offered as an inexpensive option by knee preservation surgeons. Current literature on PFO outcomes lack of clarity for specific indications for offering PFO based on degree of severity of KOA. Therefore, this systematic review aims to critically evaluate clinical and radiological outcomes of PFO stratified by severity of KOA. Methods: PubMed, Scopus, CINAHL and Google Scholar databases were searched. Eligible studies included those published up till August 2023, with 271 studies obtained. After duplicate removal, title-abstract screening, and a full text screen based on inclusion and exclusion criteria, 11 papers were included. 46 papers were further identified from snowballing of 7 existing systematic reviews, with 2 additional papers subsequently included. Results: 13 included articles analysed 788 knees. Our study found that indications based on KL grading of KOA do not seem to differ in terms of post-operative clinical outcomes (VAS score) and radiological measures also found that hip knee alignment was improved regardless of KL grading of KOA. Additionally, the most common post-operative complication reported was deep peroneal nerve palsy. Conclusion: PFO is a viable knee joint preserving surgery for medial compartment KOA, however given the high risk for complications reported in the literature, surgeons should pay close attention to the neuroanatomical landmarks and techniques to avoid neurovascular injury.

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OBJECTIVES: The development of the Popeye's deformity is a known complication of long head of the biceps tendon (LHBT) tenotomy. Incidence of developing Popeye's deformity after LHBT tenotomy ranges between 13% and 70%. While this complication is well tolerated, it can be avoided with proper patient selection. We aim to study patient and clinical factors resulting in the development of the Popeye's deformity after LHBT tenotomy so as to better identify suitable surgical candidates. METHODS: 91 patients underwent unilateral rotator cuff repairs and concomitant LHBT tenotomy between March 2013 and March 2017. Assessment of patient factors contributing to Popeye's deformity included patient demographics, and physical attributes were analyzed and correlated. Patients also completed a questionnaire regarding their overall postoperative satisfaction. Prospectively collated Visual Analog Pain Scale (VAS), Constant-Murley shoulder score (CSS), University of California, Los Angeles Shoulder Score (UCLA), and Oxford Shoulder Score (OSS) were compared at 6 and 24 months post operation between patients who developed Popeye's deformity and those who did not. RESULTS: The incidence of post-tenotomy Popeye's sign was 58.9%. Majority of patients were satisfied with their procedure, postoperative function, and cosmesis. Patients who developed Popeye's sign had a statistically significant lower body mass index (BMI) (24.9 â€‹± â€‹4.2 â€‹kg/m2 versus 27.3 â€‹± â€‹4.3 â€‹kg/m2, p â€‹= â€‹0.048) (rpb â€‹= â€‹- 0.210, p â€‹> â€‹0.05) and had a greater biceps-circumference-(in flexion)-to-wrist-circumference ratio (1.91 â€‹± â€‹0.16 versus 1.83 â€‹± â€‹0.13, p â€‹= â€‹0.012) (rpb â€‹= â€‹0.319, p â€‹< â€‹0.05) than those who did not. Nevertheless, the development of Popeye's sign did not affect clinical outcomes (VAS, CSS, UCLA, and OSS; p â€‹> â€‹0.05) at 24 months. CONCLUSIONS: The incidence of Popeye's deformity is high post LHBT tenotomy. There was a greater incidence in patients with lower BMI and greater biceps brachii muscle bulk. However, this complication is well tolerated. By better selecting our patients, we can achieve better outcomes and minimize potential complications. LEVEL OF EVIDENCE: Level-III evidence. TYPE OF STUDY: Retrospective comparative study.

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BACKGROUND: Isolated knee medial compartmental osteoarthritis(MOA) can be treated with High Tibial Osteotomy (HTO) or Unicompartmental Knee Arthroplasty (UKA). This study aims to describe and compare outcomes of HTO and UKA in patients with isolated severe MOA. The authors hypothesized that similar outcomes can be achieved. METHODS: Data was collected prospectively of HTOs and UKAs performed between January-2016 and April-2021 by a knee surgeon. Oxford Knee Score (OKS), Knee Society Knee Score (KSKS) and Function Score (KSFS) were collected pre-operatively, six-months and two-years post-surgery. OA severity was graded on pre-operative radiograph. Medial Proximal Tibia Angle (MPTA), Lateral Distal Femoral Angle (LDFA), Joint Line Convergence Angle (JLCA) and Hip-Knee-Ankle Angle (HKAA), were measured on full-length radiograph. 47 HTO and 74 UKA were included. Propensity score matching was performed, accounting for preoperative scores, age, gender and body mass index (BMI), before statistical analysis. Level of significance was set at 0.05. RESULTS: Both groups were similar in age(56.42 vs 58.57, p = 0.067), BMI(29.82 vs 29.09, p = 0.484), gender distribution (p = 0.663) and laterality (p = 0.836). Pre-operatively, both groups were similar in clinical scores and lower limb alignment. On follow-up, both groups achieved similar improvements in clinical scores. However, the HTO group reported poorer extension at 6-months (7.91° vs 4.80°, p = 0.013) and 2-years (5.57° vs 3.24°, p = 0.018). Three cases of hinge fracture and six cases of implant removal occurred in the HTO group. One case of tibial fracture occurred in the UKA group. CONCLUSIONS: In severe MOA, similar outcomes were achieved with HTO and UKA at two years.

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Introduction The calcaneus is the most commonly fractured tarsal bone, accounting for up to 60% of tarsal bone fractures and 2% of all fractures in the body. With the calcaneus playing an important role in maintaining a stable and efficient bipedal gait, the sequelae of these injuries have also been associated with potential long-term disability or discomfort, especially if improperly managed. Incorrectly sized implants similarly cause their own set of complications, such as poor fixation, impingement, or implant prominence. This potentially increases the need for revision surgery or implant removal, with increased morbidity for the patient. As such, a thorough understanding of calcaneal morphology is vital to ensure optimal conservative and surgical management of calcaneal pathology. CT imaging has become an indispensable tool in the evaluation of such a complex three-dimensional structure and allows us to accurately map out calcaneal morphology. This study aims to evaluate calcaneal morphology in the Southeast Asian population using CT imaging and to determine if morphological differences exist between male and female patients. Methods Calcaneus measurements were taken from CT scans of 100 patients with intact calcanei, consisting of 34 female and 66 male patients. Patients who have had fractures or previous calcaneus surgery were excluded. IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, NY, USA) was used for statistical calculations. Mean values were calculated, and t-tests were performed to establish any significant differences between measurements taken from male and female patients. Results were deemed to have a significant difference if the p-value was less than 0.05. Results Males had larger calcanei measurements than females in all parameters included. Calcaneal length in females measured on CT axial views was 66.2 mm, compared to 75.2 mm in males (p < 0.001). Calcaneal height, measured at the medial wall, was 28.2 mm in females and 33.9 mm in males (p < 0.001). Calcaneal height measured at the lateral wall was 33.3 mm and 38.1 mm in females and males, respectively (p > 0.001). Calcaneal width was 33.0 mm in females and 36.9 mm in males (p < 0.001). The mean dimensions measured in the total sample were an axial length of 72.1 mm, a medial wall height of 32.0 mm, a lateral wall height of 36.4 mm, and a width of 35.6 mm. Conclusion There is a significant difference in calcaneal morphology on CT imaging between male and female patients in the Southeast Asian population, which is an important consideration for surgical planning and the selection of appropriately sized implants.

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OBJECTIVE: The use of synthetic bone substitute material (BSM) as osteotomy gap fillers have been reported to improve outcomes in medial opening wedge high tibial osteotomy (MOWHTO). This study aims to evaluate the early radiological outcomes (bone union) and complication rates of the novel patient-specific 3D-printed honeycomb-structured polycaprolactone and tricalcium phosphate (PCL-TCP) synthetic graft compared to allogeneic bone grafts as an osteotomy gap filler in MOWHTO. METHODS: A retrospective matched-pair analysis of patients who underwent MOWHTO with either PCL-TCP synthetic graft or allogenic femoral head allograft as osteotomy gap filler was performed. The osteotomy gap was split into equal zones (Zone 1-5), and bone union was evaluated on anteroposterior radiographs based on the van Hemert classification at 1, 3, 6, and 12 months postoperatively. Postoperative complications including infection, lateral hinge fractures, and persistent pain was measured. The study and control group were matched for age, smoking status, diabetes mellitus, and osteotomy gap size. RESULTS: Significantly greater bone union progression was observed in the PCL-TCP group than in the allograft group at 1 month (Zones 1-3), 3 months (Zones 1-4), 6 months (Zones 1-2, 4), and 12 months (Zones 2-3, 5) postoperatively (P < 0.05). No significant difference in complications rates was noted between the two groups at 1 year. CONCLUSIONS: Bone union rates observed in patients who underwent MOWHTO with the PCL-TCP synthetic graft osteotomy gap filler were superior to those in the allograft group at 1 year postoperatively, with no significant difference in complication rates (postoperative infection, lateral hinge fractures, and persistent pain).

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Introduction Hallux rigidus (HR) refers to osteoarthritis of the first metatarsal phalangeal joint, resulting in stiffness, pain, and limitation in daily function. Surgery of HR is indicated in those who have failed a trial of non-operative management and is typically divided into joint-preserving (JP) and joint-sacrificing procedures. Cheilectomy is the most commonly practiced JP procedure, often done in conjunction with associated procedures for HR. Our paper aims to report the clinical outcomes after cheilectomy and cheilectomy done with subchondroplasty (SCP) performed for HR. Methods All patients who underwent cheilectomy for HR between 2017 and 2022 were identified and had their outcomes evaluated at the time of this review. The patients had their pre-operative radiographs and clinical and operative notes analyzed for the grading of HR. Functional outcomes were assessed with the use of the visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, as well as comparing the pre-operative and post-operative degree of dorsiflexion of the affected first metatarsophalangeal joint. This study was approved by the SingHealth Institutional Review Board (IRB) Institution with approval number 2021/2629. Results A total of 19 patients and 20 feet were included in our study at a mean follow-up of 29.8 months. There was an increase in dorsiflexion of the first MTP joint by 27.2 degrees (p-value = <0.0001). Patients who underwent cheilectomy alone (Group 1) had a mean improvement in VAS scores of 5.46 (p-value = <0.0001). Patients who underwent SCP of the first metatarsal head along with cheilectomy (Group 2) had an improvement in VAS scores by 5.78 (p-value = 0.0007). There was a mean improvement in AOFAS scores of 25.6 (p-value = <0.0001) for patients in Group 1. Patients in Group 2 had a mean improvement in AOFAS scores of 31.0 (p-value = 0.0003). Conclusion Both cheilectomy and cheilectomy performed with SCP for HR show good outcomes at short-term follow-up (mean 29.8 months). Cheilectomy is a viable alternative to arthrodesis for the surgical treatment of HR even in patients with higher grades. The use of SCP should be further explored as an adjunct in the surgical treatment of HR.

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PURPOSE: This study aims to assess the significance of post-operative change in limb length in medial opening wedge high tibial osteotomy (MOWHTO), and evaluate the correlation between correction angles and changes in limb length. We hypothesize that opening wedge height and correction angles directly correlate to changes in limb length. METHODS: The medical records and radiographs of 91 MOWHTO patients were retrospectively evaluated for relevant radiographical parameters both pre- and post-operatively. The exclusion criteria are: (i) concurrent distal femur osteotomy in the same setting, (ii) other previous unilateral lower limb surgeries prior to MOWHTO and (iii) failure to follow-up with post-operative radiographs. A linear regression model was performed and a line of best fit, Pearson's correlation coefficient (r) and coefficient of determination (R2) were computed. Chi-squared test was also performed, and results with P < 0.05 were considered statistically significant. RESULTS: There is a statistically significant increase in post-MOWHTO limb length (Absolute Δ = 4.3 ± 2.86 mm, % Δ = 0.652% ± 0.434%, p < 0.001). There was no significant difference in the limb length change between patients with larger (> 8 mm) and smaller (< 8 mm) opening widths. There was a weakly positive correlation between limb length change versus actual (R2 = 0.140, 95%CI [-0.068, 0.336]) and planned correction angles (R2 = 0.196, 95%CI [-0.012, 0.387]). CONCLUSION: In conclusion, post-MOWHTO change in limb length is statistically significant, but the clinical significance is minimal. Further studies are required to assess other factors. Development of a reliable mathematical model that predicts post-MOWHTO limb length change would be useful in predicting the anatomical outcomes. LEVEL OF EVIDENCE: Level III. Retrospective Cohort Study.

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Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan done or had ankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDs found in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

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Introduction Chronic lateral ankle instability (CLAI) is a known complication of ankle sprains, most commonly involving injury to the anterior talofibular ligament (ATFL). Growing evidence has shown an association between anteromedial (AM) impingement and CLAI. The purpose of this paper is to compare magnetic resonance imaging (MRI) with arthroscopic findings for the incidence of AM impingement in CLAI. Methods A retrospective study was performed by analyzing the radiological and operative reports of all patients who underwent an arthroscopic Broström-Gould procedure for CLAI between 2021 and 2022 at Changi General Hospital, Singapore. All patients who had a pre-operative MRI ankle scan performed and mention of the presence or absence of AM impingement in the operative notes were included in this study. Patients with concomitant fractures or systemic conditions affecting the same ankle were excluded. Results Ninety-seven patients were included in this study, 65 males and 32 females; 6.2% (6 of 97) of patients had a suggestion of AM impingement based on MRI findings, and 77.3% (75 of 97) of patients were noted to have AM impingement based on arthroscopic findings. Conclusion There is a high incidence of AM impingement associated with CLAI. AM impingement is often missed based on MRI findings. Arthroscopic Broström should be considered to address both issues of AM impingement and CLAI in the same setting.

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Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.

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Introduction Hallux rigidus (HR) is a degenerative condition affecting the first metatarsal phalangeal joint, causing stiffness and pain. Surgery is indicated for those who have failed a trial of conservative management. The purpose of this paper is to evaluate the functional outcomes at short and medium term after surgery for HR. Methods All patients who underwent surgical treatment for HR between 2017 and 2022 at the time of this study were identified and invited to return for a follow-up evaluation. Outcomes were assessed by comparison of pre-operative and post-operative visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Results A total of 26 patients were included in our study with a mean follow-up of 31 months. There was a mean improvement in VAS score by 5.6 (p-value < 0.0001) and 5.7 (p-value = 0.0012) in patients who underwent joint-preserving (JP) and joint-sacrificing (JS) surgery, respectively. Patients who underwent JP surgery had a mean increase of 28.1 points (p-value < 0.0001) in the AOFAS Hallux score, while patients who underwent JS surgery had a mean increase of 27.29 points (p-value = 0.0066). Conclusion Functional outcomes after surgical management for HR are good at short- and medium-term follow-up. Good outcomes are seen with both JP and JS procedures. JP procedures should be considered as a first-line surgical option for HR as it allows revision procedures if required.

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Osteochondral allograft (OCA) transplantation has been used to treat a wide spectrum of cartilage deficiencies in the knee, including spontaneous necrosis of the knee. Studies reporting outcomes after OCA transplantation have shown reliable improvement in pain and return to activities of daily living. We describe a single-plug, press-fit technique for OCA transplantation with concomitant high tibial osteotomy to treat femoral condyle chondral defects in a varus knee. Pearls and pitfalls of this technique are presented; attention should be paid to correction of concomitant joint pathology and malalignment to facilitate osseointegration and survivorship of the allograft plug into host bone. Appropriate surgical timing and prompt allograft implantation help to maximize chondrocyte viability.

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BACKGROUND: The incidence of lateral hinge fractures (LHFs) during medial opening wedge high tibial osteotomy (MOW-HTO) is unacceptably high, especially with distractions >10 mm. LHFs result in malunion, loss of correction, and recurrence of symptoms adversely affecting clinical outcomes. PURPOSE: (1) To investigate the incidence of LHF when a protective guide wire is utilized during MOW-HTO in small and large corrections and (2) to study the effect of correction size on early clinical outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was performed of 96 knees that underwent MOW-HTO between 2019 and 2020. A protective wire applied intraoperatively across the lateral hinge point before opening wedge distraction was performed for all patients. Patients were divided into 2 groups based on opening wedge sizes: group A (opening distraction <10 mm) and group B (opening distraction ≥10 mm). LHF and wound complications were recorded. Prospective Knee Score and Function Score (Knee Society), Oxford Knee Score, and Physical and Mental Component Summaries of the 36-Item Short Form Health Survey questionnaire were recorded preoperatively and at 6 months and 2 years after surgery. RESULTS: Incidence of LHF was low in group A (n = 2; 6.1%) and group B (n = 3; 9.1%). A single case of intraoperative LHF was noted in each group, with each case resulting in a type 1 fracture. The incidence of postoperative fractures was comparable between groups (groups A vs B, n = 1 vs 2). At 6 months, clinical outcomes in group A were superior to those of group B (Knee Score, 85.7 ± 14.7 vs 73.1 ± 20.3, P = 0.028; Function Score, 73.5 ± 16.5 vs 63.1 ± 19.5, P = 0.047; Oxford Knee Score, 20.2 ± 4.7 vs 25.6 ± 8.5, P = 0.008; Physical Component Summary, 46.8 ± 8.1 vs 40.2 ± 10.9, P = 0.018). However, clinical outcomes were comparable at 2 years (P > .05). CONCLUSION: A protective wire was associated with a low incidence of LHF, even in larger MOW-HTO corrections. Large corrections had poorer clinical outcomes as compared with small corrections at 6 months. However, clinical outcomes between groups were comparable at 2 years.

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PURPOSE: Closing wedge distal femoral osteotomies (CWDFO) are attractive treatment options for unicompartmental knee osteoarthritis with coronal plane deformity. However, it has been traditionally associated with high rates of hinge fracture that can adversely impact recovery and patient outcomes. Appropriate siting of hinge point can be an effective method of reducing the incidence of hinge fractures. This study aims to illustrate a case series of CWDFO with low rates of hinge fracture utilising our preferred hinge point site. METHODS: A retrospective study of a cohort of 39 CWDFO was performed between May 2019 and May 2022. Both medial and lateral CWDFO were included. The hinge point in all cases was placed at the level of the inferior margin of the metaphyseal flare, and inferior to the gastrocnemius origin, with a hinge thickness of 10 mm. Post-operative radiographs were obtained at 2, 4 and 8 weeks after surgery to assess for hinge fracture and union. RESULTS: Thirty-nine cases of CWDFO were performed, consisting of eighteen cases of valgus malalignment that underwent medial CWDFO and twenty-one cases of varus malalignment that underwent lateral CWDFO. At surgery, the mean age was 47.6 (± 13.9) years and mean BMI was 29.4 (± 4.9). There were 23 men and 16 women. Three cases of hinge fractures occurred intraoperatively, translating into a hinge fracture rate of 7.69%. However, union was achieved in all three cases and all patients in this case series were able to progress to weight bear as tolerated at 2 months post-osteotomy. CONCLUSION: Distal placement of the hinge at the level of the inferior metaphyseal flare margin with the use of a hinge wire can greatly reduce the rates of hinge fracture in CWDFO. LEVEL OF EVIDENCE: Level III.

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INTRODUCTION: The influence of prior high tibial osteotomy (HTO) on total knee arthroplasty (TKA) functional outcomes remains widely debated. Alignment of failed HTO can pose technical challenges with subsequent TKA. The primary aim of this study was to evaluate the influence of HTO alignment on the clinical outcomes of subsequent TKA. The secondary aim was to compare the time to TKA for each HTO alignment type. METHODS: Patients who underwent TKA post lateral closing-wedge HTO for symptomatic medial compartment osteoarthritis between 2001 and 2014 were prospectively followed up for 2 years. A total of 159 patients were assigned to three groups based on their pre-TKA femora tibia angles using long lower limb radiographs: varus alignment (VrA) ≤ 3o valgus, neutral alignment (NA) 3-9o valgus alignment, valgus alignment (VlA) ≥ 9o valgus. Functional outcomes were quantified using Knee Society Function Score and Knee Scores (KSFS and KSKS respectively), modified Oxford Knee Score (OKS), Short Form 36 Physical Component Score (SF-36 PCS), and SF-36 Mental Component Score (SF-36 MCS). Pre-operative and post-operative knee range of motion were also measured. RESULTS: Mean pre-TKA KSKS in VrA patients (35 ± 18) was significantly lower than both NA (51 ± 19) and VlA (40 ± 21) patients (p < .05). Otherwise, there was no significant difference in functional outcome scores (KSFS, KSKS, OKS, SF-36 PCS and SF-36 MCS) or range of motion at 6 months and 2 years post-TKA. The mean duration from HTO to TKA was 12 ± 7 years with no significant differences between VrA, NA, and VlA HTO to TKA (13 ± 7 years, 13 ± 6 years and12 ± 8 years respectively, p > .05). CONCLUSION: HTO alignment did not influence time to subsequent TKA. HTO alignment did not influence early outcomes as well as radiological outcomes of subsequent TKA. LEVEL OF EVIDENCE: III.

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STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: To compare early postoperative radiological and clinical outcomes between 2-level minimally invasive (MIS) trans-psoas lateral lumbar interbody fusion (LLIF) and MIS transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spinal stenosis. METHODS: Fifty three consecutive patients undergoing 2-level lumbar interbody fusion from L3-L5 for degenerative lumbar spinal stenosis were enrolled. Twenty four patients underwent LLIF and 29 underwent TLIF. RESULTS: Operative time and length of stay were similar between LLIF and TLIF (272.8 ± 82.4 vs 256.1 ± 59.4 minutes; 5.5 ± 2.8 vs 4.7 ± 3.3 days, P > .05), whereas blood loss was lower for LLIF (229.0 ± 125.6 vs 302.4 ± 97.1mls, P = .026). Neurological deficits were more common in LLIF (9 vs 3, P = .025), whereas persistent deficits were rare for both (1 vs 1, P = 1). For both groups, all patient reported outcomes visual analogue scale (VAS back pain, VAS leg pain, ODI, SF-36 physical) improved from preoperative to 2-years postoperative (P < .05), with both groups showing no significant differences in extent of improvement for any outcome. Lateral lumbar interbody fusion demonstrated superior restoration of disc height (L3-L4: 4.1 ± 2.4 vs 1.2 ± 1.9 mm, P < .001; L4-L5: 4.6 ± 2.4 vs .8 ± 2.8 mm, P < .001), foraminal height (FH) (L3-L4: 3.5 ± 3.6 vs 1.0 ± 3.6 mm, P = .014; L4-L5: 3.0 ± 3.5 vs -.1 ± 4.4 mm, P = .0080), segmental lordosis (4.1 ± 6.4 vs -2.1 ± 8.1°, P = .005), lumbar lordosis (LL) (4.1 ± 7.0 vs -2.3 ± 12.6°, P = .026) and pelvic incidence-lumbar lordosis (PI-LL) mismatch (-4.1 ± 7.0 vs 2.3 ± 12.6°, P = .019) at 2-years follow-up. CONCLUSION: The superior radiological outcomes demonstrated by 2-level trans-psoas LLIF did not translate into difference in clinical outcomes compared to 2-level TLIF at the 2-years follow-up, suggesting both approaches are reasonable for 2-level lumbar interbody fusion in degenerative lumbar spinal stenosis.