دانلود رایگان مقاله بازبینی لاپیدوس آرترودز توسط آندوسکوپی استخوان

Abstract

Revision arthrodesis is indicated in symptomatic nonunion of the first tarsometatarsal joint. Revision by first tarsometatarsal arthroscopy cannot deal with the dilated screw tract and associated bone cysts. Revision by bone endoscopy is indicated in symptomatic nonunion of the first tarsometatarsal joint, which is previously fixed by transarticular screw along with loosening of the screw and bone cyst formation. The screw tract makes up the portal tract, with the proximal and distal ends of the tract corresponding to the proximal and distal portals, respectively. In this technical note, we describe zonal debridement and bone grafting of the bone cysts, nonunion site, and the screw tract via the bone endoscopy. This can resolve all the co-pathologies of nonunion of the first tarsometatarsal fusion.

Discussion

There are several potential complications of Lapidus arthrodesis, including first metatarsal shortening, metatarsal elevatus, and nonunion.17 Classically, the symptomatic first metatarsocuneiform nonunion is revised through an open approach. In case of stable fixation and good initial positioning of the first metatarsal, the nonunion can be revised by first tarsometatarsal athroscopy.11 As an arthroscopic procedure, advantages associated with this technique include better cosmesis, better visualization, limited bone resection and less soft-tissue dissection (Table 2).7,8,11 However, the working space of the nonunion site is limited and the arthroscopic approach was technically difficult. Moreover, in case of screw loosening, there would be dilatation of the screw tract and associated bone cyst formation. This cannot be dealt with by first tarsometatarsal arthroscopy alone. The indication for the reported bone endoscopy technique is symptomatic nonunion of the first tarsometatarsal joint, which has been previously addressed through a transarticular screw as well as loosening of the screw and bone cyst formation. Smoking should be considered a relative contraindication to this revision surgery.18 This approach is technically not difficult as the working area (screw tract) is more spacious and well defined. It can be divided into 3 zones: screw tract itself, nonunion site and the associated bone cysts. This classification allows systemic debridement and bone grafting of the different zones. The dorsal and plantar portals are coaxial portals and interchangeable as viewing and instrumentation portals. However, insertion of the arthroscopic awl through the plantar portal should be avoided as its sharp tip can put the neurovascular structures and tendons of the sole at risk. The angled awl can serve as a dissector to break down the adhesions of the nonunion site. It can also microfracture the wall of the cysts and screw tract and crack the sclerotic bone plate of the nonunion site to facilitate the subsequent fusion. However, the area of fusion surface preparation of the nonunion site is limited and centered at the screw tract. This can be supplemented by percutaneous drilling of the nonunion site by a K wire.