Additional Osteotomy Research Articles

In Vitro Comparison of the Sagittal Split Osteotomy With and Without Inferior Border Osteotomy

By adding an osteotomy of the inferior border of the mandibular body to the classic sagittal split osteotomy, the authors expected to prevent unfavorable splits and damage to the inferior alveolar nerve. Thirty-five human mandibles were used to perform 70 sagittal split osteotomies as an in vitro study. Conducted as a split-mouth model, each mandible was split at the midline. One side of the mandible was split using the traditional Obwegeser-Dal Pont technique, and the other side was split in the same manner with an additional osteotomy of the inferior mandible border. The torque used to split the mandible was measured, and the fracture line of the mandible was recorded. The average torque associated with the original technique was 1.38 Nm (standard deviation, 0.60 Nm), with a fracture line along the mandibular canal. The average torque required to split the hemimandible with the modified technique was 1.02 Nm (standard deviation, 0.50 Nm), a significant (P < .001) difference, with a fracture line parallel to the posterior ramus of the mandible. The fracture pattern depended significantly on the technique used (P < .001), but not on the applied torque force. By adding an osteotomy of the inferior mandibular border to the sagittal split osteotomy, less torque was needed to split the mandible. The fracture line was more predictable, even when all the surgical manipulations were performed at a safe distance from the inferior alveolar nerve.

Radiographical Predictors for Postoperative Sagittal Imbalance in Patients With Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis After Lumbar Pedicle Subtraction Osteotomy

A retrospective radiographical study. To identify the radiographical predictors for sagittal imbalance in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis (AS) after 1-level lumbar pedicle subtraction osteotomy (PSO). Few studies had correlated the preoperative sagittal parameters with postoperative sagittal alignments to determine the radiographical predictors for postoperative sagittal imbalance in patients with AS after 1-level lumbar PSO. Thirty-six patients with thoracolumbar kyphosis secondary to AS who underwent 1-level lumbar PSO were recruited with a minimal follow-up of 24 months (mean = 27.4 mo; range, 24-53 mo). Correlation analysis and subsequent stepwise multiple regression analysis were used to evaluate the correlations between preoperative parameters, including global kyphosis, local kyphosis, thoracic kyphosis, thoracolumbar Cobb angle, lumbar lordosis, pelvic incidence (PI), pelvic tilt, sacral slope, and sagittal vertical axis (SVA), as well as SVA at the last follow-up. All these patients were further divided into 2 groups according to the PI value (group A: PI >50°; group B: PI ≤50°). The correction outcomes were compared between these 2 groups. The preoperative SVA was not significantly different between group A and group B (157.6 mm vs. 124.5 mm; P> 0.05), and both groups had similar magnitudes of kyphosis corrections at the last follow-up (global kyphosis: 42.9° vs. 46.1°; local kyphosis: 42.7° vs. 40.5°; lumbar lordosis: 35.7° vs. 43.0°). However, group A patients had significantly larger SVA at the last follow-up (73.2 mm vs. 28.7 mm; P< 0.05) and a higher incidence of postoperative sagittal imbalance (77.8% vs. 25.9%; P< 0.05) than those in group B. The stepwise multiple regression analysis demonstrated that both preoperative SVA and PI were significant independent predictors of postoperative sagittal alignments, which explained 52.0% and 9.7% of the variability of SVA at the last follow-up, respectively. Patients with AS with either larger preoperative SVA or larger PI are more likely to experience failed sagittal realignments after 1-level lumbar PSO. For these patients, additional osteotomies may be recommended for satisfactory correction outcomes. 4.

EComment. Substernal metal support after pectus excavatum open repair

We read with great interest the article by Stefani and colleagues reporting long-term results of the STRATOS system for stabilizing the sternum after severe pectus excavatum (PEx) open repair. This is an important contribution, since there are only 13 cases reported in the literature, although no long-term follow-up is available for them [1]. In severe asymmetric PEx with abnormal curvature of the anterior arc of ribs as shown in figure 1A of the article (chest CT-scan), we use a surgical strategy different from that described by Stefani and colleagues. After complete subperichondrial resection of the elongated/deformed cartilages and transversal wedge osteotomy across the anterior table of the upper sternum, an important step of our procedure is the correction of abnormal curvature of ribs by anterior wedge osteotomy, followed by gentle fracture of the posterior cortex. Then, the running suture of the perichondrial sheaths restores tension to the adjacent intercostal spaces, maintaining the anterior segment of ribs in an adequate position without any complementary rib osteosynthesis. Of 181 patients having undergone a PEx open repair, 15 had severe asymmetric deformity (8%). These 15 patients received additional rib osteotomy as described above, resulting in satisfactory thorax contour [2]. Another feature of our technique is sternum stabilization by means of a large (generally 20 to 22 cm long in the normal adult population) straight metal support bar (WURTZ thorax bar, Medicalex, Bagneux, France), passed substernally after minimal dissection at the level of the sixth perichondrial sheaths. The remaining parts of the bar are extrathoracic, inserted laterally anterior to the ribs and behind the muscles by means of a back and forth movement. The metal bar is then secured to the base of sternum in the midline with an absorbable suture [2]. This support reduces the risk of potential flail chest phenomenon postoperatively, and allows cartilage regeneration with osseous metaplasia in the proper position within 8 weeks. Finally, the bar is easily removed under local anaesthesia as an outpatient procedure, six months after the initial operation. The video description of this technique is currently available on the CTSNet website [3]. The WURTZ thorax bar has numerous advantages in comparison to the STRATOS system: (i) Placement through a significantly smaller incision (mean 13 cm long in adults). (ii) No fixation to the ribs causing pain or rupture as observed by Stefani and colleagues [1] most likely due to constant movements of the rib cage during the respiratory cycle phases. (iii) Excellent mechanical properties as we did not observe any untimely rupture or bending. (iv) Reduced risk for dislocation since the bar is removed at 6 months. Indeed, it has been shown that dangerous intrapericardial dislocation of hard materials used in PEx open repair is related to the time these materials are left in place, or as a consequence of delayed material rupture [4]. (v) No re-entry for material removal with the risk of iterative complications [1]. (vi) In the setting of concomitant cardiopulmonary bypass surgery, the use of our easily removable material inserted at the lower edge of the sternum does not impede a prompt re-entry or potential cardiopulmonary resuscitation manoeuvres if needed [5]. (vii) Significantly lower cost of the WURTZ titanium thorax bar (€810) in comparison with the STRATOS system: €2680 for 1 bar fixed to 2 rib clips, and €5360 when 2 bars are used (priced in 2010). Finally, the STRATOS system was found to be useful for chest wall defect reconstruction [1]. It would be interesting to see more information from large series that would allow the evaluation of the STRATOS materials in the field of PEx repair. Conflict of interest: none declared.

Joint-Preserving Osteotomy for Malunited Intra-articular Calcaneal Fractures

Displaced intra-articular fractures of the calcaneus can lead to severe pain and disability if not treated appropriately. Failure to treat may require fusion of the subtalar joint, supplemented by additional osteotomies. Occasionally, these fractures are seen after the fracture has just healed, and the decision to treat can be a difficult one. Over the course of 10 years, 5 patients were treated with a corrective osteotomy along the primary fracture line, joint realignment, soft tissue balancing, and secondary internal fixation at a mean of 2.9 months after the injury. At a mean of 4.1 years (range, 2-10 years), all patients were satisfied with their result. Two patients underwent implant removal and subtalar arthrolysis 1 year after correction. No secondary fusions were required. The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 19.0 preoperatively to 81.2 at follow-up (P < 0.001). The radiographic parameters (the Böhler angle, talocalcaneal height, and heel width) were substantially corrected. A joint-preserving osteotomy with axial realignment can be a treatment option for malunited intra-articular calcaneal fractures encountered early on, before the development of subtalar arthrosis.

Intraoperative Positioning of the Hindfoot With the Hindfoot Alignment Guide

In a previous study, intraoperative positioning of the hindfoot by visual means resulted in the wrong varus/valgus position by 8 degrees and a relatively large standard deviation of 8 degrees. Thus, new intraoperative means are needed to improve the precision of hindfoot surgery. We therefore sought a hindfoot alignment guide that would be as simple as the alignment guides used in total knee arthroplasty. A novel hindfoot alignment guide (HA guide) has been developed that projects the mechanical axis from the tibia down to the heel. The HA guide enables the positioning of the hindfoot in the desired varus/valgus position and in plantigrade position in the lateral plane. The HA guide was used intraoperatively from May through November 2011 in 11 complex patients with simultaneous correction of the supramalleolar, tibiotalar, and inframalleolar alignment. Pre- and postoperative Saltzman views were taken and the position was measured. The HA guide significantly improved the intraoperative positioning compared with visual means: The accuracy with the HA guide was 4.5 ± 5.1 degrees (mean ± standard deviation) and without the HA guide 9.4 ± 5.5 degrees (P < .05). In 7 of 11 patients, the preoperative plan was changed because of the HA guide (2 avoided osteotomies, 5 additional osteotomies). The HA guide helped to position the hindfoot intraoperatively with greater precision than visual means. The HA guide was especially useful for multilevel corrections in which the need for and the amount of a simultaneous osteotomy had to be evaluated intraoperatively. Level IV, case series.

Cranial distraction osteogenesis for syndromic craniosynostosis: Long-term follow-up and effect on postoperative cranial growth

Although cranial distraction osteogenesis (CDO) is beneficial, few studies have reported on detailed operative procedures and postoperative cranial growth. Herein, we demonstrated the objective effectiveness of CDO in younger infants. The study included infants who underwent primary cranial distraction for craniosynostosis. Infants who had hydrocephalus were excluded and those who underwent additional osteotomy surgeries were analysed before the subsequent procedures. The infants' computed tomography data were analysed using Mimics(®) software (Materialise, Leuven, Belgium) to calculate the cranial volumes and compare them with the Abbott curve for a normal population. We defined cranial growth gap as the difference between the subject data and normal infant data to demonstrate the perioperative effects on cranial growth. CDO was performed in 10 infants. The mean infant age at the time of surgery was 6.4 months (range, 24--61 months) and the mean duration of postoperative follow-up was 38.9 months (range, 24--61 months). Five infants with Crouzon syndrome and five with Apert's syndrome were included. All infants showed postoperative cranial growth, but cranial growth gap showed postoperative declines for a certain period, indicating cranial growth suppression immediately following expansion. At the last follow-up, all cases were within ±2 standard deviation (SD) compared with the normal population. We derived a formula to predict the CDO target volume using the declining cranial growth gap curve. CDO was applicable and suitable for younger infants requiring aggressive cranial expansion.

Therapie des Rezidivklumpfußes und residueller Deformitäten nach kongenitalem Klumpfuß

Relapse and residual deformity after treatment of congenital clubfoot are common problems. Recurrences occur in up to 48 % of cases after successful initial treatment using Ponseti's technique. By casting and anterior tibial tendon transfer as recommended by Ponseti a flexible and well functioning foot can be achieved in most cases. Neglected clubfoot remains a demanding challenge. Depending on the severity of the deformity, the impairment of function and patient age, conservative and/or different operative treatment options can be considered. Manipulation and casting according to Ponseti is also recommended in toddlers with relapses even after peritalar joint release. Thus the need and extent of operative treatment can be reduced. Additional osteotomy may be indicated in more rigid feet and older children. An accurate evaluation of the existing deformity and functional impairment is mandatory for the individual choice of treatment. The number of previous operative procedures reduces the amount of improvement and mobility of the foot. Therefore, the best and most efficient treatment for recurrent clubfoot is prevention in the form of consistent primary treatment, consistently wearing braces and regular follow-up examinations.

Evaluation des sagittalen Profils nach operativer Therapie der thorakalen adoleszenten idiopathischen Skoliose Lenke Typ 1

The principle philosophy of posterior spinal instrumentation and fusion (PSIF) for the treatment of adolescent idiopathic scoliosis (AIS) has changed during recent decades. In the past the treatment of AIS mainly focused on correction of the major curve in the frontal plane while the sagittal profile and balancing were only of inferior interest in treatment planning. Various long-term outcome studies have demonstrated that many AIS patients developed a flatback syndrome (decrease of thoracic kyphosis and lumbar lordosis) associated with pain. It was concluded that treatment of AIS should consider the sagittal profile and balance; however, there are only few studies addressing additional procedures, which include the correction of the sagittal profile. The purpose of this study was to evaluate the effects of different posterior correction techniques on sagittal profile and balance. A total of 36 consecutive patients with thoracic AIS, who were treated with selective thoracic posterior correction were included in this retrospective study. The patients were further assigned to three different subgroups according to different surgical strategies: A: pedicle screws, B: long-head pedicle screws and C: additional Ponte osteotomy. Standardized radiographs in the standing position of the whole spine in two planes were evaluated before and at least 2 years after correction for all patients and a subgroup analysis was done to identify differences between the three groups. A significant correction of the major curve was achieved in all three groups (p < 0.001). There was a significant difference between the groups with groups B and C showing significantly higher levels of major curve correction in comparison to group A (p < 0.001). Concerning the sagittal profile, there was a significant difference in the development of thoracic kyphosis (TK) and lumbar lordosis (LL). While a significant reduction of TK and LL was found in groups A and B after surgery, a significant increase of TK and LL was noted in group C which was associated with a decrease of pelvic tilt and an increase of sacral slope. The 2-year follow-up showed the lowest ODI-% value only in group C which was positively correlated with reduction in pelvic tilt. The results of this study underline that the PSIF technique alone using pedicle screws leads to a satisfactory correction in the frontal plane but is associated with adverse effects on the sagittal profile (flat back syndrome), corroborating previous studies. It was further shown that significant improvements of sagittal parameters were achieved by adding techniques for the lengthening of the dorsal thoracic column. This approach can therefore be recommended for the treatment of AIS Lenke type 1.

Treatment of infantile tibia vara - 18-year follow-up: A case report

Blount disease is developmental disorder of the lower leg, manifested by multiplanar deformity. Surgical treatment includes corrective osteotomy, lateral hemiepiphisyodesis, distraction of the proximal tibial physis, physeal bar resection and elevation of the medial tibial plateau. A case of a 4-year-old girl with bow legs is presented. Condition was recognized as Blount disease, type five. Both lower legs were operated by medial methaphyseal semi-osteotomy of the proximal tibia with the elevation of the medial tibial plateau. Prospectively, bilateral proximal hemiepiphysiodesis was done. Total follow-up period was eighteen years.The patient has no disturbances, clinical and radiographic findings are excellent. Improvement of the femoro-tibial angle is 22 degrees on the right side, and 21 degrees on the left side. Improvement of the varus angle is 7 degrees on the right side, and 27 degrees on the left side. Medial plateau depression is completely bilaterally reduced; improvement on the right side is 46 degrees, and 51 degrees on the left side. It is known today that multiplanar deformity is a part of the disease; varus, antecurvatum and internal rotation of the lower leg. By elevation of the medial plateau varus of the lower and antecurvatum component of deformity can be solved, while internal torsion cannot be solved. This deformity has to be either skillfully neglected, or corrected by an additional osteotomy by the elevation of the medial tibial plateau. Lateral hemiepiphysiodesis serves as extra stabilisator of the achieved result, and it is recommended to be done in combination with surgical elevation of the medial tibial plateau and derotative corrective osteotomy of the tibia.

Tibia Dome-Shaped Osteotomy for a Valgus Deformity in a Ball-andSocket Ankle Joint: A Case Report

We report the case of a 64 year-old man with a painful left ankle valgus instability. The instability was associated with a ball-and-socket ankle joint due to a congenital tarsal coalition. A dome-shaped osteotomy was done of the tibia and an additional osteotomy of the fibula to rebalance the ankle joint complex. At mid-term, the ankle joint remained stable, and the patient was pain free. We demonstrate here that a dome-shaped like osteotomy is a powerful tool to rebalance a severely unstable ball-and-socket ankle joint.

Effects of Different Surgical Techniques on Cephalic Index and Intracranial Volume in Isolated Bilateral Coronal Synostosis Model

Bilateral coronal synostosis (brachycephaly) is the most common single-suture synostosis that may lead to functional deficits such as mental retardation. This increases the importance of volume gain during surgery. This study was designed to understand the differences in volume gain, cranial index (CI), and aesthetic outcomes when additional osteotomies or rotations are applied on the frontoparietal segment. Acrylic brachycephaly models were prepared. Frontoparietal osteotomy was standard in all models. Frontoparietal segment was fixed: to the same position in surgical control model, after 1.2-cm advancement in advancement model, after 180-degree rotation without advancement in rotation model, after 180-degree rotation plus a horizontal osteotomy and 1.2-cm advancement in rotation plus angled advancement model, and after a horizontal osteotomy without rotation and 1.2-cm advancement and in angled advancement model. Intracranial volume changes (in milliliters) and CIs were as follows between groups: control group, 828/94.1; surgical control group, 830/93.8; advancement model, 900/84.5; rotation model, 834/89.1; rotation plus angled advancement model, 897/82.7; angled advancement model, 902/81.8. Advancement of the frontoparietal segment is the keystone of surgery in brachycephaly treatment. Making an additional horizontal osteotomy can angle this segment and may supply additional volume gain. Rotation of the frontoparietal segment does not provide additional volume or CI gain but increase better aesthetic outcomes.

Corrective supramalleolar osteotomy for malunited pronation-external rotation fractures of the ankle

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98). In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15). Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.

Intraoperative Incidence of Hallux Valgus Interphalangeus Following Basilar First Metatarsal Osteotomy and Distal Soft Tissue Realignment

The premise of this study was that after the correction of hallux-metatarsophalangeal pronation, the intraoperative interphalangeal angle (HIA) increases significantly, and that an additional Akin osteotomy (AO) is often needed. Therefore, the purpose of this study was to evaluate whether HIAs in hallux valgus (HV) feet were underestimated, and to assess the need for AO during HV correction. This study was conducted on 54 feet with moderate to severe HV treated from June 2007 to December 2008. HIAs and medial sesamoid subluxations (MSS) were measured initially and intraoperatively after a distal soft tissue procedure (DSTP) and proximal chevron metatarsal osteotomy (PCMO). An intraoperative technique was used to evaluate the incongruency of the metatarsophalangeal joint (MTPJ) to determine the need for additional AO. After performing DSTP and PCMO, HIAs significantly increased from an average of 9 to 13.3 degrees and MSS reduced from average grade 2.5 to 0.5 (p < 0.05). AO was added in 44 (81%) feet. After an average followup of 13.2 months in Akin group, average VAS pain score decreased from 5.7 to 1.2 and average AOFAS score increased from 57.8 to 90.2 (p < 0.05). Final hallux MTPJ dorsiflexion in the Akin group was significantly larger than in the without-Akin group (p < 0.05). Average HIA significantly increased after DSTP and PCMO for moderate to severe HV necessitating additional AO, to achieve ideal HV correction and, to preserve MTPJ motion.

Selective posterior thoracic fusion by means of direct vertebral derotation in adolescent idiopathic scoliosis: effects on the sagittal alignment

The objectives of this retrospective study were to evaluate the effect of direct vertebral derotation on the sagittal alignment of the spine after selective posterior thoracic fusion for Lenke Type I adolescent idiopathic scoliosis (AIS). Preservation of the sagittal alignment has become critical in the management of spinal deformity. Better coronal and rotational corrections in posterior selective thoracic fusion for AIS have been reported with direct vertebral derotation as compared with the simple rod rotation technique. A greater lordogenic effect has been anticipated with direct vertebral derotation; however, data comparing those two techniques in terms of correction in the sagittal plane are still lacking. Standing full-spine PA and standard lateral serial X-rays of a total of 30 consecutive patients with adolescent idiopathic scoliosis treated between 2002 and 2008 at a single institution were evaluated. All the patients had Lenke Type I curves and underwent selective posterior thoracic fusion with pedicle screw instrumentation. Patients who were treated with additional osteotomies and concave or convex thoracoplasty or concomitant anterior releases were excluded. Minimum follow-up period was 24 months. Preoperative and postoperative coronal and sagittal spinal alignments in both the groups were compared. In 13 patients, the correction was achieved by means of a simple rod rotation (SRR). In 17 patients, the technique of direct vertebral derotation (DVD) was used. Scoliosis correction averaged 67 and 69%, respectively, and was similar in both groups (p > 0.05). Thoracic kyphosis and lumbar lordosis remained unchanged in the SRR group (p > 0.1). In the direct vertebral derotation group, a significant decrease of both thoracic kyphosis and lumbar lordosis of 8.1° and 11.8°, respectively, was observed (p < 0.0001). Global sagittal balance remained within normal limits in all the patients at the latest follow-up. Decrease in thoracic kyphosis and lumbar lordosis should be taken into account when using direct vertebral derotation for selective posterior thoracic fusion in AIS. In order to preserve sagittal alignment in these patients, ultra hard rods or maneuvers that pull posteriorly the concave side of the spine, thus avoiding the application of additional flattening forces should be considered.

Modification of the bilateral sagittal split osteotomy (BSSO) in a study using pig mandibles

In a bilateral sagittal split osteotomy (BSSO) mechanical irritation of the inferior alveolar nerve (IAN) (e.g. by chiselling) should be avoided to prevent neural damage. A modification of the Obwegeser-Dal Pont operation technique was studied by splitting 100 pig mandibles ex vivo. An additional osteotomy at the caudal border of the mandible was used to facilitate the sagittal split by means of a locus of minor resistance. The chisel was inserted distal to the second molar and far away from the IAN. The mandible was split by torque. The modified technique reduced the required torque to split the mandible about 30% compared with the original technique (paired t-test, t(69)=-12.89; p<0.05). 75% of all mandibles split by the modified technique were classified as bad splits compared with 100% using the original technique using the same protocol without the additional osteotomy.

Review of "Quantitative Anatomic Study of the Transciliary Supraorbital Approach: Benefits of Additional Orbital Osteotomy?"

Review of "Quantitative Anatomic Study of the Transciliary Supraorbital Approach: Benefits of Additional Orbital Osteotomy?"

Pilot study of modification of the bilateral sagittal split osteotomy (BSSO) in pig mandibles

Objective This study investigated a new technique for the bilateral sagittal split osteotomy (BSSO) by adding a new osteotomy line at the inferior border of the mandible in the Obwegeser–Dal Pont operation. Material and methods For this purpose a test system was designed and 100 pig mandibles were split to assess the test’s reliability, to compare the torque necessary to split the mandible in both techniques and to record the fracture lines. The splitting technique was standardized, avoiding any contact with the inferior alveolar nerve. All outcomes were statistically examined by paired t-tests. Results By using the new technique, we demonstrated a decrease in the torque force required to split the mandible of 29.7% ( t(69) = −12.68; p < 0.05, paired t-test) compared to the Obwegeser–Dal Pont technique. The fracture lines were close to ideal. Conclusion The additional osteotomy facilitates the BSSO technique and it reduces the likelihood of bad splits and damage to the inferior alveolar nerve in pig mandibles.

Application of the Ilizarov Technique to the Correction of Neurologic Equinocavovarus Foot Deformity

The treatment of rigid equinocavovarus foot deformities caused by neurologic disorders is often difficult and relapse is common. We asked whether the Ilizarov technique could be used for correction of neurologic equinocavovarus foot deformities resulting in improved foot and ankle function and patient satisfaction. The neurologic equinocavovarus foot deformities of 26 patients (mean age, 18.7years; 29 feet) were treated using the Ilizarov technique. Nine feet were treated by distraction histiogenesis only with limited soft tissue release, whereas 20 feet needed additional osteotomy and/or tendon transfer/lengthening. Minimum followup was 12months (mean, 72.9months; range, 12-155months). The mean time required for deformity correction was 27.1days (range, 14-47days) and the mean time for stabilization in the apparatus was 23.2days (range, 7-53days). A painless, stable, and plantigrade result was obtained by 22 patients (24 feet). Mild residual foot deformity was observed in the remaining five feet of four patients. Six patients (six feet) experienced postoperative complications. Three patients (four feet) experienced recurrence of the deformity requiring surgical correction. Ilizarov soft tissue distraction with or without callotasis of tarsal bone(s) allows a greater degree of correction of neurologic equinocavovarus foot deformities. However, to reduce the risk of recurrence after fixator removal, it may be necessary to overcorrect the deformity while in the fixator, to use nighttime splinting, and most importantly, to eliminate neuromuscular imbalance, if necessary, by combining arthrodesis with or without tendon transfer. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intraoperative blood loss in bimaxillary orthognathic surgery with multisegmental Le Fort I osteotomies and additional procedures

Autologous blood donation is not currently recommended by most authors for routine bimaxillary osteotomies. There are few data about bimaxillary procedures with multisegmental maxillary osteotomies. Our aim was to investigate the effect of additional osteotomies and iliac crest grafts on operative blood loss. A total of 225 consecutive patients having bimaxillary multisegmental osteotomies during a three-year period (January 2006–January 2009) were examined to see if their haemoglobin concentration and packed cell volume were reduced. The influence of iliac crest grafts, additional osteotomies (genioplasty, malar osteotomy, iliac crest graft, anterior mandibular segmental osteotomy), operating time, age, and sex were assessed. Neither age nor sex influenced blood loss, whereas operating time correlated significantly with reductions in haemoglobin concentration and packed cell volume. Blood loss was significantly higher in the group who had additional procedures ( p 0.001 for haemoglobin concentration and packed cell volume) than in the group who had no additional procedures, whereas there were no significant differences among the three subgroups who had additional procedures (additional osteotomies, iliac crest grafts, or both procedures). Four patients who had additional procedures required transfusion, whereas no blood was given in the group who had no additional procedures. Because the transfusion rate was so low, we could make no general recommendation for preoperative blood donation in such cases.

Osteotomy and primary wound closure in bisphosphonate-associated osteonecrosis of the jaw: a prospective clinical study with 12 months follow-up

This is a prospective clinical study aimed at assessing the success rate of osteotomy and primary wound closure in patients with bisphosphonate-associated osteonecrosis of the jaw (BONJ). Fifty patients who had received bisphosphonates intravenously and subsequently suffered from BONJ were included in the study. All patients underwent osteotomy of the affected jaw bone region and primary wound closure under general anaesthesia. They were followed up bimonthly for a period of 12 months. Macroscopically altered bone could be completely removed in all cases. In two patients with plasmocytoma, major bleeding occurred postoperatively that required monitoring in an intensive care unit. In two cases, recurrence of BONJ was diagnosed during the first 2 months. In three patients, recurrence appeared between the fourth and the sixth month. In these cases, an additional osteotomy had to be performed. Six patients died during the follow-up period. In the remaining 39 patients, no signs of recurrence could be detected during the follow-up of 12 months. The success rate of the surviving patients was 89% after 1 year. Due to the high success rate of osteotomy and primary wound closure, it should be checked for every patient suffering from BONJ if osteotomy is a viable treatment option.