Incomplete Osteotomies Research Articles

Comparison of Acetabular Morphology Changes After Pediatric Pelvic Osteotomies Using Patient-Specific 3-D Models

Background: Surgical management to improve hip joint morphology in immature patients with acetabular dysplasia includes Pemberton, Dega, San Diego, and Salter acetabular osteotomies. This study evaluates acetabular morphology between these osteotomies using patient-specific 3-D printing technology. Methods: Preoperative computed tomography scans (CTs) from patients with acetabular dysplasia were rendered into 3-D printable formats. Quadruplicate pelvis models for each patient received Pemberton, Dega, San Diego, and Salter osteotomies. CTs were obtained of each model before and after osteotomy. Acetabular volume and regional coverage angles were computed and compared before and after each osteotomy. Results: Fourteen hips (14 patients) were included; 1 male, 13 female; age 5.4±1.3 years (3.9-7.5 years). Acetabular volume decreased following each osteotomy (Pemberton by 14%, Dega by 19%, San Diego by 19%, and Salter by 6%), with smaller volume reduction for Salter than the others (p<0.05). Volume change was similar between Pemberton, Dega, and San Diego (p=0.32). Pemberton increased coverage in Superior and Anterior regions, Dega increased coverage in Superior, Superior-Anterior, and Anterior regions, San Diego increased coverage in Posterior, Superior-Posterior, and Superior regions, and Salter increased coverage in Superior region (p<0.05). Conclusions: Acetabular volume changes found in this study support the convention that redirectional osteotomies such as Salter are more volume neutral than incomplete osteotomies such as Pemberton, Dega, and San Diego. However, even the Salter decreased acetabular volume. This study re-demonstrated that each osteotomy studied changes acetabular coverage in different regions. Based on this, a surgeon’s osteotomy decision should be based on the dysplastic acetabulum morphology.

The impact of associated tenotomies on the outcome of incomplete phalangeal osteotomies for lesser toe deformities

BackgroundPartial or incomplete osteotomy (IO) of the phalanx is recently described in the literature. However, the clinical outcome and the rate of complications when applied to lesser toe deformities (LTD) have been never addressed. This study aims to find out if the association of tenotomies to incomplete or partial phalanx osteotomies has a significant impact on the clinical outcomes, the occurrence of complications, and the recovery time after surgery.MethodsA retrospective review of two cohorts of cases operated in our institution for hallux abductus valgus (HAV) and associated LTD from 2008 to 2014 was carried out. The surgical correction of both HAV and the associated LTD was always performed by minimally invasive techniques. The study included a total of 223 patients (723 IO in 556 toes). In 129 cases, the IO for LTD correction was performed without tenotomies, and in 94, the procedure was combined with flexor and/or extensor tenotomies. Patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire before surgery and at 6- and 12-month follow-up.ResultsThe mean preoperative AOFAS score before surgery was similar in both cohorts. At 12-month follow-up, the cohort without tenotomies showed better recovery (95.7 ± 2.8 versus 92.5 ± 6.8; p < 0.01). AOFAS scores decreased as the number of associated LTD increased (r = − 0.814; p < 0.001). Cases operated on by PO + tenotomy showed a high rate of complications such as delayed union of the osteotomy (p < 0.01), hypertrophic callus (p < 0.01), phalangeal fracture at the osteotomy site (p < 0.01), and lack of correction (p < 0.05). The overall occurrence of adverse events was 38.6% in cases operated by PO + tenotomy and 13.9% in cases receiving PO alone (p < 0.0001). Cases operated on without tenotomy showed a shorter time to complete recovery for daily life activities (37.4 ± 2.3 versus 43.0 ± 1.7 days; p < 0.01).ConclusionThe performance of associated tenotomies to incomplete phalanx osteotomies provides worse clinical outcomes, higher complication rates, and longer recovery time as compared to similar forefoot surgeries without tenotomies.Trial registrationThe study was based on retrospectively registered data starting on May 24, 2008.

A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction

Mandibular reconstruction using computer-aided design/computer-aided manufacturing cutting guides is currently a common procedure. However, inaccurate positioning of the cutting guide onto the fibular bone may result in osteosynthesis difficulties or imprecision in the reconstruction. A novel way to improve the stability of the cutting guides may be to add pillars in order for them to be suspended from the fibula, avoiding soft tissues interactions. We present the case of a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. We designed a customized cutting guide which included a set of 8 pillars allowing a suspension of the cutting guide 8 millimeters above the bone level. The pillars were perpendicular to one another, and allowed the operator to screw the cutting guide to the bone. The orthogonal position of the pillars enabled real stability during the osteotomies. In the operator experience, the length of the pillars was too important, and led to incomplete osteotomies, and the whole device was too bulky. However, with adaptations in the size of the pillars and the size of the whole device, this solution could be useful in cutting guide design to avoid impairments due to the soft tissues surrounding the fibula.

Femur lengthening with monoplanar external fixator associated with locked intramedullary nail

ObjectiveThis study aimed to demonstrate that the lengthening technique of an external fixator associated with locked intramedullary nail is an efficient method that decreases the duration of the external fixation and improves the rehabilitation period. MethodsFrom January of 2005 to May of 2014, 31 patients with mean lower limb discrepancy of 5.31cm were treated. The etiologies of the deformity were femur fracture sequelae, infection, hip development dysplasia, polio, and congenital short femur. ResultsThe mean duration of external fixation was 2.47 months (external fixation index of 16.15 days per cm). The mean time for bone healing was 6.66 months (consolidation index 43 days per cm). Initial mean knee range of motion was −1° to 100°, progressing to 0°–115° at the end of treatment. The complications observed were incomplete osteotomies, hip subluxation, broken fixator, decreased knee range of motion, and need for locking screw removal. ConclusionFemur lengthening with a monoplanar external fixator associated with locked intramedullary nail allowed for a shorter period of external fixation use, better protection for the regenerated bone tissue, and early rehabilitation with possible complications.

Alongamento ósseo femoral com fixador externo monoplanar associado a haste intramedular bloqueada

ObjectiveThis study aimed to demonstrate that the technique of lengthening external fixator associated with locked intramedullary nail is an efficient method that decreases the duration of the external fixation and improves the rehabilitation period. MethodsFrom January of 2005 to May of 2014, 31 patients with mean lower limb discrepancy of 5.31 centimeters were treated. The etiologies of the deformity were femur fracture sequelae, infection, hip development dysplasia, polio, and congenital short femur. ResultsThe mean duration of external fixation was 2.47 months (external fixation index of 16.15 days per cm). The mean time for bone healing was 6,66 months (consolidation index 43 days per cm). Initial mean knee range of motion was ‐1 to 100 degrees, progressing to 0 to 115 degrees at the end of treatment. The complications observed were incomplete osteotomies, hip subluxation, broken fixator, decrease of knee range of motion, and need for locking screw removal. ConclusionFemur lengthening with monoplanar external fixator associated with locked intramedullary nail allowed for a shorter period of external fixation use, better protection for the regenerated bone tissue, and early rehabilitation with possible complications.

Gradual Metatarsal Lengthening by External Fixation: A New Classification of Complications and a Stable Technique to Minimize Severe Complications.

The surgical management of brachymetatarsia remains controversial, and choice is based on potential complications. We report a classification of complications based on severity, and we hypothesized that use of a semicircular external fixator would minimize severe complications in lateral metatarsal lengthening. We retrospectively reviewed 30 patients (10 to 46 years old) with single or multiple brachymetatarsia and performed 54 metatarsal lengthenings with a mean follow-up of 7 months. The mean gain in length was 15 mm (33.7%), and the mean healing index was 67 d/cm. No further procedure was performed. No dislocations or subluxations were reported, but 26 complications (48.1%) occurred, classified as 1 severe (1.8% of the metatarsals), 5 intermediate (9.3%), and 20 benign (37%): 4 incomplete osteotomies, 8 adjacent metatarsal osteotomies, 2 involuntary adjacent metatarsal fixations due to the lack of fluoroscopy use, 6 early consolidations, 2 metatarsal fractures, 2 skin complications, 1 superficial infection, and 1 metatarsophalangeal clinodactyly. A classification of complications based on severity was developed. Gradual lengthening of the lateral metatarsals by semicircular external fixation reduced the risk of severe complications because of stability without donor site morbidity. Thin wires were an advantage in the pediatric population. Level IV, retrospective case series.

Surgical treatment of hip dislocation in Kabuki syndrome: Use of incomplete periacetabular osteotomy for posterior acetabular wall deficiency

Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome. Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7years, with an average of 3.6years. The follow-up postoperative period ranged from 3.2 to 6.3years, with an average of 5.0years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum. Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.

Tension forces in relation to LeFort III osteotomies.

Complications associated with LeFort III osteotomies have led to modifications of the procedure. Attempts to decrease morbidity include performing incomplete osteotomies or eliminating pterygomaxillary dysjunction. The purpose of this study was to determine the amount of tension required for separation of the midface from the pterygoid plates and to observe the fracture patterns. An Instron machine (Instron Corporation, Canton, MA) was used to measure the tension forces in 16 cadaver skulls divided into five groups. The groups varied as to whether the osteotomies were complete and whether pterygomaxillary separation was performed. Specimens with incomplete osteotomies and without pterygomaxillary separation required greater tension forces for separation and exhibited a high percentage (47%) of unfavorable fractures. Because high amounts of tension are required leading to unpredictable separations, we recommend complete osteotomies with pterygomaxillary dysjunction when performing LeFort III osteotomies.