| Abstract | Objectives: This thesis wanted to compare the outcomes of two common approaches to the Lapidus arthrodesis in symptomatic hallux valgus, the plantar- and the dorsomedial plating systems quantified by radiological analysis of the deformity and patient-reported outcome measures (PROMs). The hypothesis was that the plantar- plating system is superior to the dorsomedial plating system.
Material and methods: This is an observational retrospective study conducted at the alphaMED orthopaedic clinic in Bamberg, Germany, from January 2014 to December 2017. The study included 43 patients treated with the dorsomedial Titanium Lapidus Plating System (AR-8941)® and 34 patients treated with the Plantar Lapidus Plating System® for symptomatic HV deformity. Preoperative measures included clinical and radiological examinations, as well as assessment of HVA and IMA 1-2, AOFAS score, and pain on the VAS. Postoperative measures included clinical and radiological examinations, assessment of the HVA and IMA 1- 2, AOFAS score, pain score on VAS, patient satisfaction, and German school scoring system ranking. Pseudoarthrosis, reoperations and time to full weightbearing were collected.
Results: All variables collected pre- and postoperatively including the HVA, IMA 1-2 and AOFAS score, improved significantly upon surgical treatment (P<0.001). However, no statistically significant difference was found between the plantar- and the dorsomedial plating group, including the HVA, IMA 1-2, AOFAS score, postoperative pain level, overall grade and reoperation wish, although the grade “very good” was awarded with higher frequency and the reoperation wish was bigger in the plantar plating group. Three cases of pseudoarthrosis were observed in the dorsomedial plating group and none in the plantar plating group, showing no statistically significant difference but again a tendency for better outcome in the plantar plating group. The time until full weightbearing of the operated foot was reached however, was significantly shorter (P=0.002) in the plantar plating groups as compared to the medial plating groups.
Conclusion: As hypothesized, the plantar plating system as compared to the dorsomedial plating system in Lapidus arthrodesis surgery is superior in terms of early full weightbearing and rates of pseudoarthrosis which can be translated to better and faster healing tendency. However, bony consolidation was not quantified radiologically in this study and further investigation would be necessary to confirm these findings, changing the study design to a prospective, double- blinded randomized study with clinical surveillance of the postoperative period. Whichever plating system used, the surgical treatment of severe HV deformity remains the gold standard for treatment and significantly improves the deformity as quantified by radiologically and patient-reported outcomes. |
| Abstract (croatian) | Ciljevi: Ova disertacija ima za cilj usporediti ishode dvaju uobičajenih pristupa u Lapidus artrodezi kod simptomatskog hallux valgusa, plantarnog i dorzomedijalnog sustava pločica, kvantificiranih radiološkom analizom deformiteta i mjera ishoda izvješćenih od strane bolesnika. Hipoteza je da je plantarni sustav pločica superiorniji u odnosu na dorsomedijalni sustav pločica.
Materijal i metode: Ovo je opservacijska retrospektivna studija provedena u ortopedskoj klinici alphaMED u Bambergu, Njemačka, od siječnja 2014. do prosinca 2017. godine. U studiju je uključeno 43 bolesnika koji su liječeni dorzomedijalnim Titanijum Lapidus sustavom pločica (AR- 8941)® i 34 bolesnika koji su liječeni Plantarnim Lapidus sustavom pločica® za simptomatski deformitet HV. Preoperativne mjere uključivale su klinički i radiološki pregled, kao i procjenu HVA i IMA 1-2, AOFAS rezultata i boli na VAS-u. Poslijeoperacijske mjere uključivale su klinički i radiološki pregled, procjenu HVA i IMA 1-2, AOFAS rezultata, ocjenu boli na VAS ljestvici, zadovoljstvo bolesnika i ocjenjivanje operacije prema njemačkom školskom sustavu bodovanja (od
1 do 6), pri čemu je 1 najbolji (najviši, vrlo dobro). Prikupljeni su podaci o pseudartrozi, reoperacijama i vremenu do potpunog opterećenja noge.
Rezultati: Sve varijable prikupljene prije i poslije operacije, uključujući HVA, IMA 1-2 i AOFAS rezultate, značajno su se poboljšale nakon kirurškog liječenja (P<0.001). Međutim, nije pronađena statistički značajna razlika između skupina s plantarnim i dorzomedijalnim pristupom, uključujući HVA, IMA 1-2, AOFAS rezultate, razinu boli nakon operacije, ukupnu ocjenu i želju za reoperacijom, iako je ocjena "vrlo dobro" dodijeljena s većom frekvencijom, a želja za reoperacijom bila veća u grupi s plantarnim pristupm. Uočena su tri slučaja pseudartroze u skupini bolesnika s dorzomedijalnim pristupom dok u skupini s plantarnim pristupom ih nije bilo, što pokazuje da nema statistički značajne razlike, ali opet postoji tendencija boljeg ishoda u skupini s plantarnim pristupom. Vrijeme do potpunog opterećenja operirane noge bilo je značajno kraće (P=0.002) u skupini s plantarnim pristupom u usporedbi s dorzomedijalnom skupinom.
Zaključci: Kao što je hipoteza sugerirala, plantarni sustav pločica u usporedbi s dorsomedijalnim sustavom pločica u Lapidus artrodezi je superiorniji u pogledu rane potpune podrške tjelesne težine i stope pseudartroze, što se može prevesti u bolje i brže zacjeljivanje. Međutim, cijeljenje kostiju nije bilo kvantificirano radiološki u ovoj studiji, te bi daljnje istraživanje bilo potrebno kako bi se potvrdili ovi nalazi, mijenjajući dizajn studije u prospektivnu, dvostruko slijepu randomiziranu studiju s kliničkim nadzorom postoperativnog razdoblja. Bez obzira na to koji se sustav pločica koristi, kirurško liječenje teškog HV deformiteta ostaje zlatni standard liječenja i značajno poboljšava deformitet, što je kvantificirano radiološki i od strane samih bolesnika. |
