Box Osteotomy Research Articles

Bone to Soft Tissue Changes Following Box Osteotomy and Facial Bipartition for Surgical Correction of Hypertelorism: A Three-dimensional Analysis

Bone to Soft Tissue Changes Following Box Osteotomy and Facial Bipartition for Surgical Correction of Hypertelorism: A Three-dimensional Analysis

Bone Preservation in Femoral Intercondylar Box Cut - A Comparative Study between Older and Newer Generation Implants.

This study was conducted to compare the quantity of intercondylar bone removed during femoral box osteotomy for implantation of three contemporary newer generation posterior stabilized (PS) total knee arthroplasty designs Attune PS (DePuy), Anthem (Smith and Nephews), and NexGen Legacy (Zimmer) with the older version from the same manufacturers. We compared the maximum volumetric bone resection required for the housing of the PS mechanism of these six designs. Bone removal by each PS box cutting jig was three-dimensionally measured. The differences between the three designs were analyzed by the Kruskal-Wallis test. The Mann-Whitney U-test was used for pairwise comparisons. The level of significance was set at P < 0.05. The newer generation implants save approximately 33% of bone that was resected from the box cut as compared to the older versions. DePuys Attune PS saved 27.1% bone as compared to Sigma PS resecting 6.96 cm3 of bone, and Zimmers Persona saved 40.57% bone as compared to NexGen from the intercondylar box cut resecting 6.18 cm3. Smith and Nephew s Anthem and Genesis have no difference in their box volume with both resecting 7.8 cm3 of bone. Irrespective of implant size, the Attune PS (DePuy) and Nexgen Legacy (Zimmer) cutting jigs always resected significantly less bone than did the jigs of older generations. There was no significant difference in the bone removed during femoral box osteotomy in the newer and older generations of Smith and Nephew.

Saw-box osteotomy versus reamer-box osteotomy in posterior stabilized total knee arthroplasty: a retrospective study of an average fiveyear follow-up.

The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses. Retrospective analysis of the results of two groups of patients operatedupon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of fiveyear follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was fiveyears. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2. The KSS score of group 2 was better in the first sixmonths postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006). The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments.

Surgical Correction of Orbital Malposition: Indications for the Use of the Box Osteotomy and Facial Bipartition

Surgical Correction of Orbital Malposition: Indications for the Use of the Box Osteotomy and Facial Bipartition

Assessment of Soft Tissue Changes Relative to Bone Following Box Osteotomy and Facial Bipartition for Correction of Hypertelorism

Assessment of Soft Tissue Changes Relative to Bone Following Box Osteotomy and Facial Bipartition for Correction of Hypertelorism

Orbital box osteotomy in frontonasal dysplasia with severe hypertelorism: Our first experience

ABSTRACT Frontonasal dysplasia (FND) is a rare craniofacial deformity, including severe hypertelorism. We herein presented the case of a 6-year-old female patient with FND and Grade III hypertelorism who underwent a four-wall-orbital box osteotomy with a bicoronal approach. Orbital wall osteotomy was performed behind the lacrimal fossa. Central resection was done to allow for medial translocation of the orbits. At the last, the newly positioned orbitals were fixated using wire, absorbable plates, and screws. Neurosurgical assistance with the frontal bone flap before orbital osteotomy helps to leave the cribriform plate intact to preserve the olfactory. Finally, excessive median soft tissue was excised. The patient’s hypertelorism improved after surgery. Careful surgical procedures to correct the soft and bony tissue are beneficial treatments for improving the quality of life and general condition of patients with hypertelorism.

Effect of Midface Surgery on Ocular Outcomes in Patients with Orbital and Midface Malformations.

(1) Background: Orbital and midface malformations occur in multiple craniofacial disorders. Depending on the deformity, surgical corrections include orbital box osteotomy (OBO), Le Fort III (LFIII), monobloc (MB), and facial bipartition (FB). The aim of this study was to determine the effect of these procedures on ocular outcomes. (2) Methods: A retrospective analysis was performed. All patients with craniofacial disorders who had previously undergone midface surgery were included. The Wilcoxon signed ranks test was used for statistical analysis. (3) Results: In total, 63 patients were included: two patients were treated by OBO, 20 by LFIII, 26 by MB, and 15 by FB. Pre-operatively, strabismus was present in 39 patients (61.9%), in whom exotropia was most common (n = 27; 42.9%), followed by esotropia (n = 11; 17.5%). Postoperatively, strabismus significantly worsened (p = 0.035) in the overall population (n = 63). Pre-operative binocular vision (n = 33) was absent in nine patients (27.3%), poor in eight (24.2%), moderate in 15 (45.5%), and good in one (3.0%). Postoperatively, binocular vision significantly improved (p < 0.001). Before surgery, the mean visual acuity (VA) in the better eye was 0.16 LogMAR (Logarithm of the Minimum Angle of Resolution), and 0.31 LogMAR in the worse eye. Furthermore, pre-operative astigmatism was present in 46 patients (73.0%) and hypermetropia in 37 patients (58.7%). No statistical difference was found for VA (n = 51; p = 0.058) postoperatively. (4) Conclusions: Midface surgery has a direct and indirect substantial effect on several ocular outcomes. This study emphasizes the importance of appropriate ophthalmological evaluation in patients with craniofacial disorders undergoing midface surgery.

Genioglossus Advancement: Technique Modification for Improved Chin Contour.

Genioglossus advancement plays an important role in the armamentarium of the obstructive sleep apnea surgeon and has gone through many iterations over several decades. A recently described technique involves creating a box osteotomy, which is carried through the inferior border of the mandible in order to increase recruitment of the suprahyoid musculature. Here we introduce a further modification of the technique that uses virtual planning to improve the safety and accuracy of genial tubercle capture. In addition, angulation of the lateral osteotomies enhances bone to bone contact. Before the osteotomy, the surgeon has the opportunity to drill the buccal plate to reduce the chin profile. This approach is particularly valuable in the patient who is prognathic at baseline or who becomes prognathic after simultaneous maxillomandibular advancement. Here we discuss this unique approach, demonstrating how the patient profile may be balanced even as the genial tubercle is advanced.

Reconstructive Operation of Severe Orbital Hypertelorism With Computer-Assisted Precise Virtual Plan.

Orbital hypertelorism correction is still a less precise procedure, with a simple preoperative design and surgical results often depending on the operator's experience. In recent years, computer-assisted technology has been fully utilized in craniofacial surgery. This article aims to explore the clinical results of computer-assisted technology in orbital hypertelorism correction and discuss its advantages and effects on treatment. Four patients with orbital hypertelorism underwent intracranial and extracranial combined box osteotomy correction. Preoperative computed tomography scans were performed, and 3-dimensional 3D digital technology was used to measure the orbital spacing, virtually design the 3D cutting scheme, and guide the intraoperative 3D cutting to improve the accuracy of periorbital osteotomy and reduce the surgical risk. Four patients underwent successful surgery, and the average distance of the medial orbital wall was decreased from 43.6 to 23.4mm. Computer-assisted box osteotomy shortens the operative time and provides better corrective results.

Surgical Management of Hypertelorism: The 3D Animated Technical Note.

The hypertelorism surgery is a complex procedure requiring a long learning curve. Even though the box osteotomy technique is well described in literature, its representation is generally based on texts and illustrations that do not really give a 3-dimensional or a dynamic point of views. The authors present a 3-dimensional animated video, Supplemental Digital Content 1, http://links.lww.com/SCS/E561 showing the craniofacial osteotomies and focusing on the critical points to correct hypertelorism.

Syndromic Synostosis

Frontofacial surgery, encompassing the monobloc with or without facial bipartition and the box osteotomy, can treat the frontal bone and midface simultaneously, providing comprehensive improvement in facial balance. Complex pediatric patients with genetic syndromes and craniosynostosis are most optimized by an interdisciplinary team of surgeons, pediatricians, geneticists, speech pathologists, audiologists, dietitians, pediatric dentists, orthodontists, and psychosocial support staff to manage the myriad of challenges and complications throughout early childhood and beyond. Despite early treatment of the anterior and posterior cranial vault, these patients frequently have resultant frontal and/or midface hypoplasia and orbital abnormalities that are best managed with simultaneous surgical treatment.

Posterior stabilized total knee arthroplasty increases the risk of postoperative periprosthetic fractures

Background The Insall-Burstein posterior-stabilized knee design was first developed in 1978 by adding a central cam mechanism to the articular surface geometry of the total condylar prosthesis to correct its problems being not “rolling back”. Since then, the use of posterior-stabilized (PS) implants in total knee arthroplasty (TKA) is becoming increasingly popular. However, one of the main disadvantages of PS designs is related to the amount of bone removed during femoral box osteotomy to create the housing of the PS mechanism, the clinical value of removing more or less bone during primary TKA remains to be fully established. The objective of this study was to compare the incidence of early postoperative periprosthetic fractures in the cruciate retaining (CR) and posterior stabilized (PS) knee prosthesis. Methods An institutional high volume arthroplasty unit database was reviewed to identify all patients who sustained a postoperative periprosthetic fracture following primary TKA between January 2014 and May 2018. A retrospective chart review was performed to collect clinical, radiographic, and operative report data. A total of 352 patients with 600 primary TKAs were identified. (300 cases of cruciate retaining TKAs from 178 patients and 300 cases of posterior stabilized TKAs from 174 patients) were retrospectively reviewed. Results Eleven patients (1.83%) sustained periprosthetic fractures in the postoperative setting following primary TKA. All of the fractures were located on the femur and were treated surgically. Only one knee (one patient) from the CR group sustained a periprosthetic fracture, while 10 knees (from 10 patients) from the PS group sustained a fracture. The relative risk of sustaining a fracture in the CR group was 0.10 times relative to the PS group (RR = 0.10, 95% CI 0.0129 – 0.776). Conclusion Posterior stabilized total knee arthroplasties (TKAs) significantly increase the risk of periprosthetic fractures in obese Asian patients compared to cruciate retaining TKAs.

ALX-Related Frontonasal Dysplasias: Clinical Characteristics and Surgical Management.

The term frontonasal dysplasia (FND) represents a spectrum of anomalies and its genetics have not been well defined. Recently, the critical role of the aristaless-like homeobox (ALX) gene family on the craniofacial development has been discovered. In the present study, we aimed to propose a systematic surgical treatment plan for the ALX-related FNDs according to the genotypic classification as well as demonstrating their clinical characteristics to help surgeons diagnose the underlying pathology accurately. Single-institution retrospective. Tertiary health care. Eighty-nine FND cases were evaluated. Eight of them had ALX1-related FND3, 3 had ALX3-related FND1, and 2 had ALX4-related FND2. Phenotype characteristics of ALX-related FNDs were evaluated, and relevant surgical interventions were assessed. The ALX1-related FND3 phenotype is striking due to the involvement of the eyes in addition to the presence of hypertelorism, facial clefts, and nasal deformities. A widened philtrum and prominent philtral columns are remarkable features of the ALX3-related FND1, whereas the ALX4-related FND2 has more severe deformities: severe hypertelorism, brachycephaly, large parietal bone defects, broad nasal dorsum, and alopecia. Facial bipartition, box osteotomies, eyelid coloboma repair, cleft lip and palate repair, nasal reconstruction, and fronto-orbital advancement can be performed in ALX-related FNDs based on the characteristics of each subtype. This genetic classification system will help surgeon diagnose patients with FND with unique features and draw a roadmap for their treatment with a better surgical perspective.

Craniofrontonasal dysplasia: hypertelorism correction in late presenting patients.

Craniofrontonasal dysplasia (CFND) is a rare congenital craniofacial syndrome characterized by single suture synostosis, hypertelorism, other clinical facial features, and abnormalities in the upper extremities. There are only a few studies in the applicable literature that address hypertelorism management for CFND patients and outcomes and complication rates. A retrospective study was performed on consecutive late presenting CFND patients referred to our hospital with substantially completed craniofacial skeleton growth, who underwent hypertelorism correction between 2007 and 2019 following intracranial pressure screening, and who received at least 1 year of follow-up care. None of the patients in this study underwent prior craniofacial surgery. Only those patients with a confirmed mutation of the EFNB1 gene were included in this study. All patients in this study underwent hypertelorism correction by facial bipartition or box osteotomy. A total of ten late presenting CFND patients (all female) were treated at our hospital during the study period. None of the patients presented signs of elevated intracranial pressure. The average patient age at hypertelorism correction was 13.4 ± 7.68 years of age. Major complications, defined as complications requiring a return to the operating room, were limited to infection of the frontal bone, which required partial bone removal, and cerebrospinal fluid (CSF) leak, which was completely resolved by insertion of a lumbar shunt for a 7-day period. The absence of elevated intracranial pressure enables hypertelorism correction in late presenting CFND patients via facial bipartition or box osteotomy without the need for additional operations that provide for cranial expansion.

Long-Term Photogrammetric- and Panel Assessment-Based Outcome Study of Staged Reconstructive Approach for Hypertelorism Correction.

The surgical management of hypertelorism is challenging for plastic surgeons, and limited long-term outcome data are available. The purpose of this long-term study was to report a single-surgeon experience with a staged reconstructive protocol for hypertelorism correction. This retrospective study reviewed the records of patients with hypertelorism who were surgically managed by a single surgeon between 1978 and 2000. Bone (orbital box osteotomy and orthognathic surgery) and soft tissue (rhinoplasty and epicanthoplasty) surgeries were performed based on a patient-specific surgical protocol. Included patients were divided into a childhood group and an adolescence or adulthood group according to their age at orbital repositioning (≤12 and >12 years, respectively). Patients were invited for clinical interviews in February 2020 to evaluate whether requests for revision surgery had been made. The photogrammetric analysis-based hypertelorism index was calculated at preoperative and long-term postoperative times. Satisfaction with the long-term outcome was judged by both surgical professionals and laypeople. In total, 14 patients with hypertelorism of different etiologies were included, with no request for revision surgery during an average follow-up of 29 years. The preoperative hypertelorism index was higher than the long-term postoperative evaluation (all, P < 0.05) for both childhood and adolescence or adulthood groups. Intergroup comparison revealed no significant difference for the hypertelorism index and panel assessment-based satisfaction with long-term outcome analysis (all, P > 0.05). Considering the complexity and wide spectrum of clinical presentation of soft tissue and bone deformities in hypertelorism and current outcomes, the surgical approach to these patients should be staged and individualized for achievement of a balanced result between functional (orbital, occlusion, and psychosocial) and aesthetic parameters.

A critical appraisal of surgical outcomes following orbital hypertelorism correction: what is the incidence of true bony relapse versus soft tissue telecanthus?

Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

How Accurate Is Computer-Assisted Orbital Hypertelorism Surgery? Comparison of the Three-Dimensional Surgical Planning with the Postoperative Outcomes.

Importance: Surgery of orbital hypertelorism (ORH) remains an imprecise surgical procedure depending on the experience and habits of the craniofacial surgical teams. Computer-assisted surgery (CAS) has developed dramatically in craniofacial surgery, but there is no current study assessing its accuracy for ORH surgery. Objective: This study aimed to assess the input of CAS and especially the accuracy of the cutting guide-based procedures. The authors presented the computer-assisted box osteotomy or facial bipartition techniques and compared the preoperative surgical planning with the postoperative results. Design, Setting, and Participants: A monocentric retrospective study included the patients who underwent surgical correction of ORH from 2016 to 2019 at the University Hospital Center of Tours, France. All the patients had a computer-assisted orbital hypertelorism surgery (CAOHS) using cutting guides and tailored fixation plates. Of 10 patients included, 7 were treated by box osteotomies and 3 by facial bipartitions. Intervention: Each patient had a preoperative computed tomography (CT) scan enabling a virtual simulation of the reconstruction and the manufacturing of patient-specific cutting guides and customized osteosynthesis plates. The postoperative CT scans were compared with the three-dimensional (3D) virtual simulation using the distances between the sagittal plane and orbital and infraorbital reference points, and from the measurement of the orbital advancement (i.e., 10 reference measurements). Results: All patients had satisfactory clinical and aesthetical outcomes with a mean interorbital distance of 22.8 ± 2.8 mm. The postoperative measurements were significantly higher than for the surgical planning (p < 0.0001). The average absolute differences between the 3D virtual planning and the postoperative CT scans were <1.30, 1.90, and 0.80 mm for the orbital, infraorbital, and orbital advancement measurements, respectively. The overall accuracy of the CAOHS (root mean square deviation) was 1.39 mm. Conclusions: The use of computer-assisted design and computer-aided manufacturing device, such as cutting guides and tailored plates, facilitates the bony surgical correction of ORH using box osteotomy or facial bipartition and allows for valuable, reproducible, and satisfactory clinical outcomes.

Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton

An intracranial approach to the craniomaxillofacial skeleton can be effective for correcting complex craniofacial dystoses such as frontofacial hypoplasia, hypertelorism, and orbital dystopia. However, the significant morbidity resulting from the high complication rates has limited intracranial use. Given the need for intracranial approaches for certain clinical indications, the present study reevaluated intracranial frontofacial procedures to determine their safety and outcomes. A retrospective review was performed of all frontofacial procedures completed between 2007 and 2017 at a single institution. Patients who had undergone monobloc distraction alone or with facial bipartition, facial bipartition alone, or box osteotomy were included in the intracranial cohort. Those who had undergone Le Fort III distraction, advancement, or a combination with Le Fort I were included in the subcranial cohort. The recorded data included demographics, previous craniofacial surgery, and operative events. The complications rates were compared between the 2 cohorts. The present study included 65 patients-35 subcranial and 30 intracranial. The rates of previous craniomaxillofacial (P=.193) and intracranial (P=.340) surgery were equivalent between the 2 cohorts. Of the 30 intracranial and 35 subcranial patients, 26.7% and 34.3% experienced complications (P=.218). The intracranial patients experienced more dural tears (53.3 vs 5.7%; P<.0001); however, no significant differences were observed in cerebrospinal fluid leakage. Reintubations (n=3; 4.5%) occurred exclusively in the subcranial group. No significant differences in the major and minor complication rates were observed between the 2 cohorts. Intracranial and subcranial frontofacial procedures are associated with an equal riskof major and minor complications. Given the lack of an increase in risk, intracranial frontofacial procedures should be considered for the management of complex craniofacial dystoses.

Correction of Complex Neurofibromatosis Orbital and Globe Malposition Using the Orbital Box Segmentation Osteotomy With Patient-Specific Internal Orbit Reconstruction.

Correction of severe orbital and globe malposition from neurofibromatosis remains a significant clinical challenge. Current techniques including zygoma osteotomy, bone grafting, or placement of orbital implants do not adequately address aberrant anatomy, under-correct the deformity, and are prone to relapse. The authors have developed the orbital box segmentation osteotomy to reduce vertical orbital height and translocate the orbit and use patient-specific custom internal orbital titanium implants to close the cranio-orbital communication-reestablishing both the external orbital shape and internal orbital volume. Virtual surgical planning with contralateral mirror imaging was used to design symmetrical repositioning of the external orbit and to determine segmentation required to reduce the vertical excess and inferior rim malposition as well as for manufacturing patient-specific titanium implants. Orbital volume was measured from preoperative, virtual surgical simulation, and postoperative imaging using stereotactic software. Globe position was assessed using pre- and postoperative 3-dimensional photography software (Canfield). All patients (n = 3, mean age 12 years) demonstrated improved globe position and orbital contour with resolution of globe pulsatility. Virtual surgical planning predicted postoperative volumes within 0.8 cm ± 0.5. Mean volume orbital change was 4.5 cm, change in conformation and distribution of orbital volume was present in all patients. Vertical globe position improved from 11.5 mm preoperatively to within 1 mm of the unaffected side postoperatively. One patient had surgical site infection, there is no evidence of relapse at mean 24-months follow-up. Segmental box osteotomy with internal orbital reconstruction redistributes orbital volume safely and accurately addresses globe malposition from neurofibromatosis.

Controversy on the Age of Hypertelorism Correction.

Orbital hypertelorism (HTO) is a challenging craniofacial problem seen in association with some congenital deformities. The age of HTO correction is a matter of debate. to evaluate the outcome of HTO correction and determine the optimal timing for intervention, striving for the earliest possible intervention with the lowest relapse. A standard craniofacial approach with medial bone resection, 4 walls orbital box osteotomy and orbital medialization were done for all patients. Skeletal and soft tissue procedures were done as indicated. there were 10 patients aging 6 to 19 years. Seven were associated with craniofacial clefts, and 3 with craniosynostosis syndromes. HTO was severe in 8 cases and moderate in 2 cases. It was asymmetric in 2 cases. Frontoorbital remodeling was done in 3 cases with craniosynostosis. Failed surgery was reported in 2 cases. A redo surgery was done for one of them with an excellent outcome, while refused by the other. Nine patients had an excellent outcome. The mean level of satisfaction was 93.37%. Three patients had ugly facial scars. No major complications were recorded. The time for surgical treatment of HTO is determined by the severity of the associated deformity. If there is an urgent factor indicating intervention, early correction can be performed exceptionally; otherwise, HTO correction should be performed after the age of 6 years.