Deformity Patients Research Articles

Treatment of an anterior cervicothoracic myelomeningocele together with spine deformity correction in a child: illustrative case.

Anterior cervicothoracic myelomeningoceles are a rare pathology. In reported cases, treatment has included shunting, isolated resection and repair without deformity correction, or isolated deformity correction without meningocele repair. The authors describe a pediatric patient with an anterior cervicothoracic myelomeningocele presenting with progressive neurological decline, who underwent simultaneous treatment of the myelomeningocele to detether the spinal cord and achieve major correction of the scoliotic deformity. A 15-year-old girl was born with C7-T1-T2 hemivertebrae and anterior cervical myelomeningocele at C7-T1. She developed progressive cervical thoracic scoliosis, left hemiparesis initially, and additional right hemiparesis eventually. She underwent surgical repair via C7, T1, and T2 corpectomies with intradural detethering of the spinal cord. The scoliosis was treated with C7-T2 Ponte osteotomies and C2-T5 posterior fixation, followed by anterior reconstruction with a titanium cage and anterior plate from C6 to T3. The myelomeningocele was adequately treated with good correction of the patient's deformity. The patient had postoperative improvement in her strength and solid arthrodesis on postoperative imaging. The authors describe the successful treatment of an anterior cervicothoracic myelomeningocele and associated scoliosis in a child. This is a unique report of a combined strategy to achieve both deformity correction and detethering of the spinal cord.

THREE-COLUMN OSTEOTOMY WITH COMBINATION OF COMPRESSION HOOK AND PEDICLE SCREW FIXATION FOR ADULT SPINAL DEFORMITY IN PATIENTS WITH PARKINSON’S DISEASE

Purpose: Surgical treatment for adult spinal deformity (ASD) in patients with Parkinson’s disease (PD) is challenging and is associated with a significant risk of postoperative mechanical complications, such as rod breakage, pseudoarthrosis and proximal junctional failure. We herein report the surgical results of three-column osteotomy with pedicle screw fixation combined with compression hook for ASD associated with PD. Methods: We retrospectively investigated four patients with ASD due to PD who underwent three-column osteotomy with posterior instrumentation. The compression hook system placed on the laminae was used for closure of the osteotomy site during surgery and reinforcement of pedicle screw fixation. Surgical outcomes and radiographical parameters were analyzed. Results: Lumbar lordosis was improved from −25[Formula: see text]± 18[Formula: see text] preoperatively to 51[Formula: see text]± 7[Formula: see text] postoperatively, and 48[Formula: see text]± 5[Formula: see text] at the final follow-up examination. The sagittal vertical axis was restored from 297 ± 104 mm preoperatively to 41 ± 13 mm postoperatively, and 72 ± 23 mm at the final follow-up examination. The preoperative VAS (88 ± 14 mm) for low back pain was significantly improved at the final follow-up examination (14 ± 28 mm). Walking disturbance due to low back pain was improved in all patients. No patients had mechanical failure (e.g. rod fracture, pseudarthrosis, or junctional failure) after surgery. Conclusion: The use of compression hooks to supplement pedicle screw fixation is beneficial for performing safe osteotomy closure during surgery and preventing postoperative mechanical failures, and may be a useful option when performing three-column osteotomy for ASD associated with PD.

Intramedullary Beaming Superconstructs for the Treatment of Midfoot Deformity in Patients with Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Charcot arthropathy is a debilitating condition often accompanied by rocker-bottom deformity and plantar ulcerations. Patients with this condition historically experienced poor results, with varying rates of postoperative wound complications, infection, and amputation. Intramedullary beaming in midfoot reconstructions has been previously identified as a viable treatment option for these patients. However, these studies have been limited to small case series. The purpose of this study was to report our experience with realignment and extended fusion with the use of intramedullary beaming superconstructs in patients with Charcot arthropathy and resultant midfoot deformity. Methods: We retrospectively reviewed patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct between January 2017 to January 2021. Bone resection and/or osteotomy were required to reduce the deformity. Intramedullary screws were placed, either antegrade or retrograde, across the arthrodesis sites. Additional hindfoot and/or tibio- talar arthrodesis was performed as indicated by the patient's deformity. Supplemental plate fixation was performed at the discretion of the treating surgeon. All patients were followed for a minimum of three months. Postoperative imaging was assessed to determine fusion at the arthrodesis site. Patient demographics and comorbidities were recorded to assess for risk factors. Patient deformities were classified according to the Brodsky classification. Postoperative rates of infection, limb salvage, reoperation, hardware fatigue, and return to walking were also recorded. Descriptive statistics, Fisher's exact test, Students T- test, and logistic regression were used to analyze outcomes. Results: Thirty-six patients were included. Limb salvage occurred in 35 (97%) patients, while one patient underwent below knee amputation. Fusion was achieved in 30 (83%) patients at an average time of 5.4+-1.3 months. A stable pseudarthrosis allowing ambulation was achieved in 5 (14%) patients. Thirty-three (92%) patients returned to ambulation. Seven patients (19%) required revision surgery (3 for recurrent ulcer, 4 for deep infection). Four (11%) patients experienced hardware fatigue, but all returned to ambulation. Five (14%) patients required assistive devices and seven (19%) required bracing. No patient characteristics were associated with non-union. Absence of supplemental plate fixation was associated with nonunion (P=0.04) and confirmed as an independent risk factor with regression analysis (P=0.03). Additional subtalar and/or hindfoot fixation was not associated with increased fusion rates. Conclusion: Open reduction and arthrodesis using an intramedullary beaming superconstruct for the surgical correction of midfoot collapse in patients with Charcot arthropathy provides a stable and reliable construct with high rates of limb salvage, fusion, and return to ambulation while minimizing complications. Supplemental plate fixation may provide increased construct stability and higher rates of union. However, this clinical importance of this is unknown.

Flexibility of sagittal imbalance based off preoperative imaging

Correction of sagittal imbalance is a major goal of spinal deformity surgery. Sagittal imbalance is broadly categorized as flexible or rigid/fixed, but distinguishing between flexible and rigid can be difficult. Flexibility is important because rigid deformities often require osteotomies to achieve the desired correction. The authors present a review of current literature on the topic of flexibility of sagittal imbalance based on preoperative imaging, to help surgeons better understand what surgical techniques may be required to correct the patient's deformity and thus better prepare themselves and their patients for surgery.

Representative dynamic ranges of spinal alignment during gait in patients with mild and severe adult spinal deformities

Surgical correction strategies for adult spinal deformity (ASD) relies heavily on radiographic alignment goals, however, there is often debate regarding degree of correction and how static alignment translates to physical ability in daily life. Kinematic analysis has the potential to improve the concept of ideal spinal alignment by providing clinically meaningful estimates of dynamic changes in spinal alignment during activities of daily life. Estimate representative dynamic ranges of spinal alignment during gait among ASD patients using 3D motion tracking; compare dynamic alignment between mild and severe deformity patients and to healthy adults. Retrospective review at a single institution. Fifty-two ASD patients and 46 healthy adults. Radiographic alignment, kinematic spine motion, spatiotemporal gait measures, patient reported outcomes (VAS pain, ODI, SRS-22r). Spinal alignment was assessed radiographically and during standing and overground walking tests. Dynamic alignment was initialized by linking radiographic alignment to kinematic alignment during standing and at initial heel contact during gait. Dynamic changes in maximums and minimums during gait were made relative to initial heel contact for each gait cycle. Total range-of-motion (RoM) was measured for both ASD and healthy subjects. Dynamic alignment measures included coronal and sagittal vertical axes (CVA, SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), and pelvic tilt (PT). ASD patient's deformities were classified as either Mild or Severe based on the SRS-Schwab ASD classification. Severe ASD patients had significantly larger dynamic maximum and minimums for SVA, TPA, LL, and PT (all p<.05) compared with Mild ASD patients. ASD patients exhibited little difference in dynamic alignment compared with healthy subjects. Only PT had a significant difference in dynamic RoM compared with healthy (p<.001). Mild and Severe ASD patients exhibited similar global dynamic alignment measures during gait and had comparable RoM to healthy subjects except with greater PT and reduced spatiotemporal performance which may be key compensatory mechanisms for dynamic stabilization.

Surface topography assessment of body shape after surgical correction in adolescent idiopathic scoliosis.

Body surface topography (ST) improvements are associated with surgical correction in adolescent idiopathic scoliosis (AIS) and correlate with radiographic imaging. Prospective observational study. Patients undergoing correction of AIS are most affected by body image. Radiographs have been the standard assessment tool but do not assess body shape features. ST, a validated, radiation-free assessment tool, directly represents the patient's deformity. We set out to assess ST improvements associated with surgical correction in AIS. Twenty-three consecutive operative AIS patients were enrolled and had radiographs and posterior ST obtained pre- and postoperatively (PO). ST changes were compared using paired t test, and correlations of ST with radiograph measurements were evaluated by linear regression. Mean age at surgery was 15.0 ± 2years, 82.6% female with mean follow-up of 1.0year. Major Cobb angle improved from 56.91° ± 15.57° to 13.70° ± 4.89°. ST scoliosis angle corrected from 41.43° ± 11.52° to 11.78° ± 7.84° (p < .0001). Trunk length increased from 401.22 ± 32.43 to 422.30 ± 25.77mm (Δ21.08mm; p = .0004). Pelvic obliquity (waist asymmetry) trended toward improvement (6.0 ± 4.3 vs. 5.3 ± 7.1mm; p = .06). Surface rotation was corrected from 17.35 ± 6.73 to 11.8 ± 4.12mm (p < .0001), highly correlated with clinical trunk rotation (T p = .002 and TL p = .02). ST highly correlated with radiographic parameters. Sagittal balance correlated with improved function (p = .02). ST, a radiation-free body shape assessment tool, improved with surgical correction of AIS and was highly correlated with radiographic outcomes.

Stomach Deformities Recognition Using Rank-Based Deep Features Selection.

Doctor utilizes various kinds of clinical technologies like MRI, endoscopy, CT scan, etc., to identify patient's deformity during the review time. Among set of clinical technologies, wireless capsule endoscopy (WCE) is an advanced procedures used for digestive track malformation. During this complete process, more than 57,000 frames are captured and doctors need to examine a complete video frame by frame which is a tedious task even for an experienced gastrologist. In this article, a novel computerized automated method is proposed for the classification of abdominal infections of gastrointestinal track from WCE images. Three core steps of the suggested system belong to the category of segmentation, deep features extraction and fusion followed by robust features selection. The ulcer abnormalities from WCE videos are initially extracted through a proposed color features based low level and high-level saliency (CFbLHS) estimation method. Later, DenseNet CNN model is utilized and through transfer learning (TL) features are computed prior to feature optimization using Kapur's entropy. A parallel fusion methodology is opted for the selection of maximum feature value (PMFV). For feature selection, Tsallis entropy is calculated later sorted into descending order. Finally, top 50% high ranked features are selected for classification using multilayered feedforward neural network classifier for recognition. Simulation is performed on collected WCE dataset and achieved maximum accuracy of 99.5% in 21.15s.

Evaluating cervical deformity corrective surgery outcomes at 1-year using current patient-derived and functional measures: are they adequate?

Current health-related quality of life (HRQL) metrics used to assess patient outcomes following surgical correction of cervical deformity (CD) are not deformity-specific and thus cannot capture all aspects of a patient's deformity and outcomes. The purpose of this study is to evaluate the sensitivity of different HRQL outcome measures in assessing CD patients' outcomes 1-year post-operatively. Retrospective review of prospective multi-center database. Inclusion criteria: CD patients ≥18 yrs with pre- and 1-year post-operative radiographs and HRQLs [modified Japanese Orthopaedic Association (mJOA), EuroQol five-dimensions (EQ-5D), neck disability index (NDI)]. Associations between changes in EQ5D and NDI with improvement at 1-year in mJOA scores were assessed by whether or not the patient met the minimum clinically important difference (MCID) as well as whether or not they improved by one or more categories (i.e., change from moderate to mild). Odds ratios reported with 95% confidence intervals. Sixty-three CD patients were included (mean 62 y, 55.6% F). Average baseline NDI scores were 46.75, mJOA was 13.68, and EQ-5D 0.74. Overall baseline myelopathy breakdown: none-9.5%, mild-30.2%, moderate-42.9%, high-17.5%. At 1-year, 46% of patients improved in mJOA, 71.4% NDI, and 65.1% EQ-5D. 19% of patients met mJOA MCID, 44.4% NDI MCID, 19% EQ-5D MCID. One-point improvement in NDI increased the odds of mJOA improvement and reaching mJOA MCID (improvement: OR, 1.06, CI: 1.01-1.10, P=0.01; MCID: OR, 1.06, CI: 1.02-1.11, P=0.006). Improvement in EQ-5D by 0.1 increased the odds of improving in mJOA and reaching mJOA MCID at 1-year (improvement: OR, 3.85, CI: 1.51-9.76, P=0.005; MCID: OR, 3.88, CI: 1.52-9.88, P=0.005). While correlations exist between outcome measures, when modeling these outcomes while controlling for confounders including cSVA change, surgical invasiveness, age and CCI, these HRQLs were not strongly correlated. Improvements in functional outcomes, as defined by mJOA score, were correlated with changes in neck based disability and general health state, defined by NDI and EQ-5D respectively. In an adjusted model, however, these direct relationships were not maintained. A CD-specific HRQL might be more useful for surgeons in assessing patient outcomes using a single metric.

Surgical Management of Stage 2 Adult and Pediatric Acquired Flatfoot Without Tendon Transfer or Arthrodesis: A Retrospective Study

Posterior tibial tendon dysfunction (PTTD) is a common pathology of the foot and ankle. Numerous techniques are available to reconstruct the flatfoot. Fusions and tendon transfers are popular methods; however, a wide range of complications have been associated with these procedures. The objective of the present study was to demonstrate the outcomes of reconstructive surgery for flatfoot correction without tendon transfer or arthrodesis. We performed a retrospective study of 43 patients and 56 feet who had undergone flatfoot reconstructive surgery from November 2011 to June 2016, with a mean follow-up period of 60 weeks (range 12 to 60 months). Each patient demonstrated a stage 2 flatfoot deformity classified using the Johnson and Strom classification. Depending on the patient's deformity, the procedures consisted of different variations of gastrocnemius recession, medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy. Six different preoperative and postoperative angles were radiographically measured on each foot studied. In all cases, the differences in the preoperative versus postoperative measurements were statistically significant (p < .003). We believe the foot and ankle surgeon can correct flatfoot deformity with the use of extraarticular procedures and create a plantigrade functional foot without fusion or tendon transfer.

Treatment of severe pediatric spinal deformities.

The management of severe pediatric spinal deformities continues to evolve as advances in spinal instrumentation, surgical techniques, and neuromonitoring occur. The techniques of spinal osteotomies have been refined to allow surgeons to perform better corrections with less operative time, more safely, and through a posterior approach alone, making multiple patient positioning changes during surgery a less common occurrence. With these techniques comes a learning curve for the entire surgical team, wherein communication and planning can help minimize major complications and morbidity. This overview will review various techniques used in the correction of severe spinal deformities. Topics reviewed include the role of anterior release, traction, posterior releases, and osteotomies. Indications, techniques, and pitfalls will be reviewed. A clear understanding of the patient's deformity, normal sagittal parameters, spinal anatomy, and the principles of neuromonitoring will help improve surgical planning and patient outcome.

An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome

BackgroundThe genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.MethodsA retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps: Complete proximal to distal surgical decompression of the peroneal nerveRadical release and mobilization of the severe quadriceps contracture and iliotibial band contractureDistal lateral hamstring lengthening/tenotomy and lateral collateral ligament releaseProximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocationProximal tibial varus osteotomy with partial fibulectomy and anterior compartment releaseOccasionally, distal femoral osteotomyResultsIn all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.ConclusionThe operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.Level of evidenceIV.

The result of ankle arthrodesis in hind foot deformity inpatients with rheumatoid arthritis using intramedullary nail with fin

The result of ankle arthrodesis in hind foot deformity inpatients with rheumatoid arthritis using intramedullary nail with fin

Progressive severe kyphosis as a complication of multilevel cervical percutaneous facet neurotomy: a case report

Percutaneous facet neurotomy is a procedure commonly used for the treatment of pain thought to originate from zygoapophyseal joint dysfunction. Some practitioners have also used this technique to treat cervicogenic headache. Previously reported complications for this procedure have been minimal and have included dysthesias and local pain. Case report. Bilateral multilevel cervical percutaneous facet neurotomies were used to treat a patient suffering from a chronic headache and neck pain that had failed to respond to extensive medical management. Within days of completing the bilateral facet neurotomies, the patient developed head drop. Subsequent electromyography revealed denervation of the patient's paraspinous muscles. Initially the patient was managed conservatively in a cervical collar with the hope that he would recover some function. After few years, the patient developed fixed kyphotic deformity. Correction of the patient's deformity required multilevel anterior cervical discectomy and fusion followed by posterior instrumented fusion. When performing multilevel percutaneous cervical facet neurotomies, there is a risk of paraspinous muscle denervation, and subsequent kyphotic deformity may occur. The likelihood of this rare and previously unreported complication can probably be reduced by proper needle positioning and by minimizing the number of levels at which the procedure is performed.

Current concepts of leg lengthening.

Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1mm/day) at a 4×0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.

Mandibular Ramus/Coronoid Process Grafts in Maxillofacial Reconstructive Surgery

To evaluate the utility of autogenous extended mandibular ramus and coronoid process bone grafts for maxillofacial reconstructive surgery. Twelve patients aged 23 to 76 years (mean, 52) who underwent extended ramus/coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or iatrogenic nasal deformity. All patients had either unilateral or bilateral combined coronoid process-mandibular ramus bone grafts for their reconstruction. There was 1 nasal reconstruction, 2 unilateral mandibles, 1 bilateral mandible, 4 unilateral maxillas, 1 unilateral maxilla and mandible combined, and 1 bilateral maxilla and mandible combined. The procedure was considered a success when the patient's deformities were reconstructed ad integrum and when there were no failures of the dental implants placed in the augmented areas as of the longest follow-up. All patients were successfully reconstructed. There was 1 infection at a donor site that resolved with local care and oral antibiotics. All but 1 of the maxillary and mandibular alveolar augmentations underwent endosteal implant placement approximately 4 to 6 months following grafting. The nasal reconstruction restored normal function and symmetry. Using both the coronoid process of the mandible and the mandibular ramus as a source for autogenous bone graft can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions.

Vomer Bone Graft to Augment the Deficient Cleft Maxilla

Patients with clefts of the lip and palate commonly develop maxillary hypoplasia. In addition to orthognathic surgery, augmentation of the anterior maxilla may be necessary in these patients to restore symmetry to the nasomaxillary complex. Bone graft may be obtained from numerous sites. All require a separate incision at the donor site and may result in additional morbidity.The authors describe a 16-year-old with a complete right unilateral cleft of the lip and palate who underwent maxillary advancement at the Le Fort I level. Pronounced sagittal deficiency of the maxilla necessitated osseous augmentation. The patient's deformity resulted in deviation of the superior vomer bone. This bone was of adequate quality to be used as an onlay graft for the maxilla. This is the first report documenting the use of vomer as a bone graft for maxillary augmentation.

Operative Correction and Follow-Up of Craniofacial Duplication

Anterior craniofacial duplication (diprosopus) is an extremely rare form of conjoined twins. The children share a single trunk with normal extremities and varying degrees of facial malformation. Duplication of specific structures, such as the nose (diprosopus dirrhinus), eyes (diprosopus tetraophthalmus), and ears, is possible. The authors present a case of partial facial duplication (diprosopus dirrhinus) in a male infant. The clinical and radiographic findings and the surgical correction and follow-up are described. In a single surgical session, the authors were able to achieve not only a functionally but also an aesthetically acceptable result. In the postoperative course, the child showed nearly normal growth and satisfactory psychosocial and motor development. However, 40 months postoperatively, we noticed a tendency of the orbitae to diverge (i.e., toward hypertelorism). The surgical management of complex craniofacial malformations such as diprosopus needs a precise morphologic analysis of the patient's deformity followed by a clear treatment plan. A staged reconstructive approach is carried out to coincide with facial growth patterns and brain and eye function. If the interorbital distance in our patient increases progressively, a second operation for reduction of the interorbital distance may be necessary.

Preoperative Ilizarov Frame Construction for Correction of Ankle and Foot Deformities

The Ilizarov method is being used increasingly to correct many orthopedic deformities. The frames required for ankle and foot deformity correction are among the most difficult to construct owing to the complexity of the deformities which must be corrected. A technique using a rubberized material (Pedilen) to create an exact replica of a preoperative ankle and foot deformity is described. This exact model, both in size and shape, may then be used on a workbench to preconstruct an Ilizarov frame that resembles the patient's deformity exactly in three dimensions with respect to size and shape. This allows thoughtful frame construction before operation reducing operating time and minimizing frustrations that may arise with complex deformities.

Scoliosis Evaluation

The office evaluation of the patient with suspected or confirmed scoliosis is directed toward establishing the etiology (if a known one exists), defining the configuration and magnitude of the deformity, making an estimate of the likely outcome for the patient based on existing knowledge of the natural history of the patient's deformity, and selecting management options. The evaluation tools needed are the patient interview, physical examination, frequently diagnostic radiology, and sometimes other laboratory studies.