Medial Osteotomy Research Articles

Variations in the Origin and Number of Medial Calcaneal Nerve

Variations of nerve are of anatomical, embryological and clinical importance. There adequate knowledge will help in increasing surgical precision and decreasing morbidity. In present study, the variation in the origin and number of medial calcaneal nerve (MCN) was studied. The material for present study comprised of 60 lower extremities belonging to 30 adult human cadavers obtained from department of Anatomy, GMC Amritsar. In the present study, number of MCN is highly variable. 1 MCN innervated 35%, 2 MCN innervated 40%, 3 MCN innervated 15%, 4 MCN innervated 8.3%, 5 MCN innervated 1.67%. There were total 121 medial calcaneal nerves found in the present study. MCN originated from tibial nerve in 57 instances (47.10%), from bifurcation of tibial nerve in 30 (24.79%), from lateral plantar nerve in 32 (26.44%) and from medial plantar nerve in 2 instances (1.65%). Description of variation of origin of medial calcaneal nerve in medial aspect of calcaneus is required to establish an anatomical guide for diagnosis and therapy of some tarsal region diseases including tarsal tunnel syndrome, fixation of fracture with external nailing, medial displacement osteotomy and nerve block in podiatric medicine.

Medial cortex fracture patterns after sagittal split osteotomy using short versus long medial cuts: can we obviate bad splits?

The aim of the present study was to evaluate the lingual fracture patterns after sagittal split osteotomy (SSO) using short and long medial osteotomy cuts, via three-dimensional (3D) cone beam computed tomography (CBCT). Forty-six subjects participated in this prospective study. Two types of medial osteotomy line were made: for type I, the medial osteotomy line was finished just before the lingula; for type II, the medial osteotomy line was extended 3–4mm beyond the lingula. Three fracture patterns were observed after SSOs. There were no significant differences in the medial fracture patterns between the two medial osteotomy types (P=0.16). The buccolingual thickness of the ramus was lower in fractures with pattern 3 (bad split) than in the two other fracture patterns. The length of the medial osteotomy line – short or long – did not alter the prevalence of a bad split. The bone thickness of the ramus may affect the type of fracture pattern on the medial side of the ramus.

Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant club foot deformity (the bean-shaped foot).

I read with interest the article “Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant club foot deformity (the bean-shaped foot) by Elgeidi and Abulsaad [1]. I would, however, like to draw attention to some errors in their description of the double osteotomy technique. In their article the authors mention that the procedure described by Jawish [2] in his 1994 article was the sole opening wedge osteotomy of the first cuneiform technique. This is not correct, and in fact in this article the author describes a single medial osteotomy for the foot with primus varus, as well as a double osteotomy for feet with resistant metatarsus adductus observed in the clubfoot and Z-shaped-foot. To quote part of the abstract of Jawish’s [2] article: “in resistant metatarsus adductus, closed wedge osteotomy of the cuboid has been added to correct the varus deformity of the fore foot, it allows lateral swing of the fore foot: the bone excised from the cuboid is use to stabilize medial osteotomy”. In the same paragraph of the article of Elgeidi and Abulsaad [1], the authors report that McHale and Lenhart [3] were the first to describe, in 1991, the double osteotomy (opening of the cuneiform and closing of the cuboid). Again, this is incorrect: the double osteotomy technique was first performed by Jawish and colleagues in Paris (Hopital Enfants-Malades), and their description of the technique was published in Chirurgie Orthopedique (a French-language journal) in 1990 [4]. The double osteotomy technique described by Jawish and colleagues in 1990 was performed to correct the resistant adduction of the forefoot in the Z-shaped foot and was performed exactly as cited in 1991 by McHale and Lenhart for forefoot adduction in club foot. The technique is mentioned in the abstract of the 1990 article [4], and illustrations of the double osteotomy are provided in the article itself, with follow-up (Fig. 1). Fig. 1 (Boy DEL...Stephane) a At 12 years old, the patient had a Z-shaped foot grade 4 with no initial treatment. He has metatarsus adductus and lateral deviation of the anterior tarse, with deformities of the first cuneiform and the cuboid. ... To summarize, the double osteotomy of the cuneiform and the cuboid is a technique reported in 1990 by Jawish et al. [4], developed by these authors in the Department of Pediatric Orthopaedics of Hopital Enfants-Malades (Paris) to treat resistant adduction of forefoot. The article published in 1994 by the first author reported the application of the same technique in a series of children with multiple causes of forefoot deformities.

Arthroscopically assisted treatment of a malunited tibia plateau fracture: A case report

Arthroscopy is playing an increasing role in the management of tibia plateau fractures. We present its use in a Nigerian patient with malunited tibia plateau fracture. A 37-yearold male teacher with a 4-month-old left tibia plateau fracture presented with pain, instability, and deformity. He had arthroscopic evaluation followed by medial opening wedge corrective osteotomy. At 4 months follow-up, he was pain free and had a stable knee. Arthroscopy can be successfully used and is beneficial in the treatment of a malunited tibia plateau fracture. This case highlights the possible benefits of arthroscopy in case of this very complex injury. As the practice of arthroscopy and other minimally invasive surgeries becomes more widespread in Nigeria, we hope that more surgeons will incorporate this in their practice.

A guiding oblique osteotomy cut to prevent bad split in sagittal split ramus osteotomy: a technical note

Aim: To present a simple technical modification of a medial osteotomy cut which prevents its misdirection and overcomes various anatomical variations as well as technical problems. Methods: The medial osteotomy cut is modified in the posterior half at an angle of 15°-20° following novel landmarks. Results: The proposed cut exclusively directs the splitting forces downwards to create a favorable lingual fracture, preventing the possibility of an upwards split which would cause a coronoid or condylar fracture. Conclusion: This modification has proven to be successful to date without encountering the complications of a bad split or nerve damage.

Radiostereometric analysis of early anatomical changes following medial opening wedge high tibial osteotomy.

The objective of this study was to use radiostereometric analysis (RSA) to evaluate the anatomical changes that occur in the tibia immediately after surgical correction with medial opening wedge high tibial osteotomy (HTO), and the changes that occur over the course of the first twelveweeks of osseous union. Patients included nine males and one female, with a mean age of 49.0 ± 5.5 years and mean BMI of 28.4 ± 3.8 kg/m(2). The patients underwent HTO using a non-locking plate. RSA marker beads were inserted in the tibia, femur, and patella. RSA exams were first obtained intra-operatively prior to the osteotomy, and subsequently at one, two, four, six, and twelveweeks postoperatively. Patients were corrected from a mean alignment preoperatively of 8.6 ± 2.5° to 0.3 ± 1.9° postoperatively, with a mean osteotomy of 12.5 ± 3.6mm. Immediate tibia changes surrounding the osteotomy site included 9.2 ± 2.4° of valgus rotation and 6.2 ± 2.0mm of distal translation. Secondary motions included 2.5 ± 2.4° of internal rotation of the distal tibia, 1.8 ± 1.4mm of posterior movement of the femur, and 8.5 ± 3.4mm of patella baja. Micromotion between the proximal and distal tibial segments decreased over time. The results suggest that subtle changes to the anatomy occur, beyond what is intended with the procedure, but partial corrections of these phenomena occurred over the twelveweeks. Micromotion surrounding the osteotomy site decreased with osseous union.

CBCT Evaluation of Bony Nasal Pyramid Dimensions in Iranian Population: A Comparative Study with Ethnic Groups.

Background. The aim of the present study was to have normative data of nasal bone thickness for use before reconstructive surgery and nasal augmentation through radiography analysis. Methods and Materials. In this descriptive-analytical study, 74 patients were selected from people referred to Radiology Department of Isfahan University for CBCT examination in 2012. Patients with a history of nasal surgery or facial trauma and known congenital anomaly were excluded from the study. Height of nasal bone and width of pyriform aperture and nasal bone thickness in lateral and medial osteotomy line were measured. All these measurements were repeated by two radiologists; finally one sample t-test was performed. Results. The mean thickness of nasal bone on the lateral osteotomy line was 1.92 ± 0.29 mm in females and 1.73 ± 0.32 mm in males (P value = 0.39). The mean thickness of medial osteotomy line was 1.63 ± 0.47 mm in females and 1.94 ± 0.19 mm in males (P value = 0.31). The mean length of nasal bone was 23.5 ± 3.34 mm in females and 25.7 ± 2.96 mm in males (P value = 0.11). The mean width of pyriform aperture was 23.77 ± 2.58 mm in females and 25.67 ± 1.79 mm in males (P value = 0.25). Conclusions. The dimensions of nasal pyramid are known to be significant in choosing suitable osteotome size for reducing surgery side effect. Our results can be used for preoperative estimation of nasal bone dimension of people undergoing reconstructive surgery and augmentation.

Facial Plastic Surgery in Pediatric Otolaryngology: Outcomes and Satisfaction

Objectives: Highlight the role of facial plastic and reconstructive surgery in the surgical management of pediatric head and neck lesions and assess cosmetic outcomes. Methods: Retrospective case series of 13 pediatric head and neck lesions managed at a tertiary care children’s hospital. The charts of all patients were reviewed for clinical presentation, radiologic findings, surgical technique used for excision and reconstruction, preoperative and postoperative photography, pathology and cosmetic outcomes. Results: A total of 13 pediatric patients with ages ranging from 18 months to 12 years had adequate documentation for review. There were 4 naso-frontal dermoids, 4 head and neck skin lesions, 3 midface/orbital bony lesions, and 2 parotid/facial soft tissue lesions. Six patients were managed by soft tissue advancement flaps, 2 required complex linear closure and 2 had a surgical exposure achieved with cosmetically placed incisions. Two patients needed a midface degloving approach for exposure, one required medial osteotomies and bone pate for reconstruction and 2 were managed with calvarial bone grafts. At last follow-up cosmetically acceptable outcomes were photographically documented in all 13 patients. This was confirmed by parental satisfaction. Conclusions: The involvement of facial plastic and reconstructive surgery is an important adjunct in the management of pediatric head and neck lesions. It leads to better cosmetic outcomes that can be documented and confirmed by parental satisfaction.

Biomechanical effects of plate area and locking screw on medial open tibial osteotomy

Medial open high tibial osteotomy (HTO) has been used to treat osteoarthritis of the medial compartment of the knee. However, weaker plate strength, unstable plate/screw junction and improper surgery technique are highly related to the HTO outcomes. Two π-shape plates were designed and eight variations (two supporting area × four locking stiffness) were compared by finite-element method. The computed tomography-based tibia was reconstructed and both wedge micromotion and implant stresses were chosen as the comparison indices. The construct was subjected to surgical and physiological loads. The medial-posterior region is the most loaded region and the load through the posterior leg is about four times that through the anterior leg. This indicates that the two-leg design can form a force-couple mechanism to effectively reduce the implant stresses. The use of locking screws significantly decrease the screw and hole stresses. However, the extending plate reduces the stresses of screws and holes above the wedge but makes the distal screws and holes much stressed. Wedge micromotion is affected by extending plate rather than locking screw. Three factors contribute to effective stabilisation of unstable HTO wedge: (1) intimate tibia–plate contact at medial-posterior regions, (2) sufficient rigidity at plate-screw junctions and (3) effective moment-balancing design at distal tibia–plate interfaces.

Cervical Subcutaneous Emphysema and Pneumomediastinum After Septorhinoplasty

Cervical and facial subcutaneous emphysema is mainly caused by maxillofacial trauma or head and neck surgery. There are only 2 cases of subcutaneous emphysema after septorhinoplasty in the English literature. We report a case of subcutaneous emphysema and pneumomediastinum after a septorhinoplasty.A healthy 35-year-old man with nasal obstruction and dissatisfaction with the shape of his nose was referred to our outpatient clinic. The patient had a septorhinoplasty including bilateral medial and lateral osteotomy under general anesthesia. On the fifth day after the surgery, the patient visited the emergency department with swelling and pain in the right submandibular area and cheek. On computed tomographic (CT) scans, air was observed in the right temporal space, masticator space, submandibular space, and superior mediastinal space. He was immediately hospitalized for administration of intravenous antibiotics and bed rest.On the fifth day after the hospitalization, follow-up CT scans were performed. Subcutaneous emphysema and pneumomediastinum were markedly decreased. The patient was discharged on the fifth day.

Valgus deformity caused by dysplasia epiphysealis hemimelica in the knee

A rare case of dysplasia epiphysealis hemimelica in the left knee which caused valgus deformity and dysfunction of the limb is presented in this article. Subtotal excision of the lesion, distal femoral medial wedge osteotomy, and reconstruction of the medial collateral ligament were performed for treatment. Cannulated screws and plaster casts were used to stabilize the ligament and distal femur. Two years after removal and reconstruction, the knee was symptom free. The left knee laxity was restored and the mechanical axis of the distal femur was realigned.

The Effect of Fracture Pattern Stability on Implant Loading in OTA Type 31-A2 Proximal Femur Fractures

Internal fixation of OTA type 31-A2 proximal femoral fractures can be performed with either a sliding hip screw and side plate (SHS-P) or a sliding hip screw and intramedullary nail (SHS-IMN). Controversy exists as to which is the best implant for these types of fractures. The primary aim of this study was to investigate the stability of 31-A2 fractures as a function of loss of medial cortical buttress. The secondary aim was to assess the influence of fracture stability on the different internal fixation constructs. Simulated simple intertrochanteric fractures were made in 12 cadaver proximal femurs. Six fractures were fixed with an SHS-P and 6 with an SHS-IMN. Both implants were instrumented with a strain gauge at the lag screw-nail/plate interface to allow assessment of implant load bearing (ILB). A primary fracture line, in accordance with the 31-A2 OTA classification, was created after which 3 subsequent horizontal osteotomies in 1-cm increments were made across the medial cortex. Compressive loading up to 1050 N was performed after each osteotomy. ILB was presented as percentage of maximal ILB. SHS-P constructs increased their load bearing gradually. For SHS-P constructs, ILB was 8.1% ± 1.8% in the intact state, increasing to 49.6% ± 14.0% after the initial intertrochanteric osteotomy (P = 0.0002), 68.7% ± 15.9% after the first medial osteotomy (P = 0.028), and 80.0% ± 15.9% after the second medial osteotomy (P = 0.15). After the first-level medial osteotomy, SHS-IMN constructs reached a plateau in which the implant carried the entire load. Type 31-A2 fractures become increasingly unstable with increased medial comminution (or fragment size). SHS-P constructs were more load sharing than SHS-IMN constructs. These findings may help guide the surgeon in choice of implant for a 31-A2 intertrochanteric fracture, leaning toward SHS-IMN for the more unstable fracture patterns.

Beta-tricalcium phosphate shows superior absorption rate and osteoconductivity compared to hydroxyapatite in open-wedge high tibial osteotomy

The purpose of this study was to clinically and radiologically compare the utility, osteoconductivity, and absorbability of hydroxyapatite (HAp) and beta-tricalcium phosphate (TCP) spacers in medial open-wedge high tibial osteotomy (HTO). Thirty-eight patients underwent medial open-wedge HTO with a locking plate. In the first 19 knees, a HAp spacer was implanted in the opening space (HAp group). In the remaining 19 knees, a TCP spacer was implanted in the same manner (TCP group). All patients underwent clinical and radiological examinations before surgery and at 18 months after surgery. Concerning the background factors, there were no statistical differences between the two groups. Post-operatively, the knee score significantly improved in each group. Concerning the post-operative knee alignment and clinical outcome, there was no statistical difference in each parameter between the two groups. Regarding the osteoconductivity, the modified van Hemert's score of the TCP group was significantly higher (p = 0.0009) than that of the HAp group in the most medial osteotomy zone. The absorption rate was significantly greater in the TCP group than in the HAp group (p = 0.00039). The present study demonstrated that a TCP spacer was significantly superior to a HAp spacer concerning osteoconductivity and absorbability at 18 months after medial open-wedge HTO. Retrospective comparative study, Level III.

Exposure of the Medial Talar Dome

Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.

Use of Simple Algorithms to Predict Screw Length Facilitates Navigation-controlled Medial Opening-wedge Osteotomy Using the TomoFix HTO System

This study was performed to establish simple algorithms to predict proper screw lengths for the 4 proximal holes of TomoFix plates (Synthes GmbH; Solothurn, Switzerland) based on radiographic mediolateral (ML) and anteroposterior (AP) dimensions of the proximal tibia and to determine how well these algorithms function for navigation-controlled medial opening-wedge high tibial osteotomy (HTO) using TomoFix. Experimental HTO surgery was performed in proximal tibial models manufactured for 30 patients undergoing HTO to determine the longest screw lengths for the 4 proximal holes of TomoFix plates. Eight algorithms were created for the 4 proximal screws by investigating the relationships between measured screw lengths and radiographic dimensions and were used for 30 navigation-controlled medial opening-wedge HTOs. The algorithms used to predict screw length were: screw A=ML width-20 mm and AP length+5 mm; screw B=ML width-25 mm and AP length; screw C=ML width-35 mm and AP length-10 mm; and screw D=ML width-40 mm and AP length-15 mm. All 30 surgeries were performed with no perioperative adverse events. Mean operative time was 47.1 minutes, and no far cortex perforation of more than 3 mm was observed for any of the 4 proximal screws. Mean mechanical tibiofemoral angle and weight load line coordinate at the knee joint were valgus 3.7° and 62.9%, respectively. Targeted alignment was achieved in 28 (93%) knees for a mechanical tibiofemoral angle between valgus 2° and 6°, and in 25 (83%) knees for a weight load line coordinate between 55% and 70%. The authors propose the use of the developed algorithms to select proper screw lengths for medial opening wedge HTO using the TomoFix HTO system.

Paper 126: Early Changes in Biomechanical and Self-Reported Measures of Knee Function After Medial Opening Wedge High Tibial Osteotomy

Paper 126: Early Changes in Biomechanical and Self-Reported Measures of Knee Function After Medial Opening Wedge High Tibial Osteotomy

A retrospective analysis of medial opening wedge high tibial osteotomy for varus osteoarthritic knee

Background:Medial opening wedge high tibial osteotomy (MOWHTO) has proven to be an effective treatment for varus osteoarthritic knees. Various methods of fixation with different implant types and using either bone grafts or bone substitutes have been reported. We performed non-locking T-buttress plate fixation with autologous iliac bone graft augmentation, which is defined here as the traditional method, and locking compression plate fixation without any bone graft or bone substitute. We aimed to compare bone union and complications of these two MOWHTO techniques.Materials and Methods:Between June 2005 and December 2007, 50 patients who underwent MOWHTO (a total of 60 knees) were retrospectively reviewed and classified into two groups: group A, which consisted of 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft augmentation and group B, which consisted of 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation. Demographic characteristics and radiographic outcomes, including union rate, time to union, medial osteotomy defects, and complications, were collected and compared between the two groups. The progress of all patients was followed for at least 2 years.Results:All osteotomies united within 12 weeks after surgery. Group B had slightly longer time to union than group A (10.3 weeks and 9.5 weeks, respectively; P = 0.125). A significantly higher incidence of medial defects after osteotomy was reported in the locking compression plate group (P = 0.001). A total of 5 (8.3%) knees had complications. In group A, one knee had a superficial wound infection and another knee had a lateral tibial plateau fracture without significant loss of correction. In group B, one knee had screw penetration into the knee joint and two knees had local irritation that required the removal of the hardware.Conclusion:Locking compression plate fixation without the use of bone grafts or bone substitutes provides a satisfactory union rate and an acceptable complication rate when compared to the traditional MOWHTO technique. Thus, we recommend using this technique for treating unicompartmental medial knee osteoarthritis.

Ostéotomie de recentrage dans le traitement de la luxation postérieure de l’épaule de la paralysie obstétricale

Summary Background The main objective of this study is to describe a new surgical technique that, through a gleno-humeral approach, reduces the incongruent joint while a humeral head centering osteotomy achieves shoulder stabilization. A humeral medial derotational osteotomy is performed associated with the articular reduction. Patients and methods Fourteen patients with obstetrical palsy presenting a posterior humeral head dislocation were submitted to a centering osteotomy procedure. Our study included patients with: (1) more than 1.5 year postoperative follow-up, (2) presence of humeral head posterior dislocation. The exclusion criteria were the following: (1) patients with total flaccid paralysis, (2) low paralysis and (3) any kind of active infection at the time of the procedure. Results Before treatment, in all patients, the shoulder joint was posteriorly dislocated and in internal rotation. All patients went on to have successful healing at the osteotomy site. In all cases an improvement in the functional Mallet scale was observed. In all patients, except one, the posterior dislocation was corrected. In two cases a second surgery (external derotation osteotomy) was performed to improve the upper extremity's position. Conclusions Articular congruency, after posterior dislocations of the humeral head, is achieved by humeral head centering osteotomy in patients with obstetrical palsy late deformities and also improves function. Level of evidence Level IV case series.

Extended Osteocartilaginous Spreader Graft for Reconstruction of Deviated Nose

Correction of a deviated nose is a challenging problem for which different approaches may be considered. This study was designed to introduce a new technique for correction of a deviated nose with a high success rate. The study was a prospective follow-up of 59 patients with deviated nose who had undergone corrective surgery. An extended osteocartilaginous spreader graft was harvested from the quadrangular septum and the perpendicular plate of the ethmoid. After a medial osteotomy that was performed on the concave side, the nasal bone was lateralized and an extended osteocartilaginous spreader graft was inserted between the nasal bone and the septum to prevent further retraction of the concave side due to fibrotic scar tissue. On the contralateral side, a low lateral osteotomy was done as routine. The operation was done on the 59 cases with deviated nose. The subjects were followed up during a period of 8 months to 4 years. According to physical examination, postoperative photography, and patients' satisfaction, the final results were categorized as excellent, fair, or poor. Forty-eight patients (81.3%) were categorized as having excellent results. Eight patients (13.6%) showed fair improvement, while the results of surgery in only 3 patients (5.1%) were classified as poor. An extended osteocartilaginous spreader graft, with medial osteotomy and lateralization of the nasal bone on the concave side, is a new technique with a high success rate for correction of deviated nose.

Finite Element Analysis of Acetabular Medial Wall Displacement Osteotomy in Adult Acetabular Dysplasia

Objective To look for a suitable displacement range of acetabular medial wall following osteotomy by computer-aided design finite element analysis. Methods SolidWorks 2008 software was used to establish three-dimensional models of acetabular dysplasia pelvis. Acetabular medial wall displacement osteotomy was simulated to make acetabular medial wall bone displace from 2 mm bone contact to 7 mm bone contact in the pelvic cavity. One experimental group was set at 1 mm intervals, totally 10 experimental groups. The acetabulum in each group was split into four quadrants. The prosthesis acetabulum-bone interface in each group was analyzed by computer simulation contrast mechanics experiment. The Mises stress and shear stress values were measured between acetabular prosthesis and bone interface. Results In groups 1, 5, 6, 9 and 10, the Mises stress was unevenly distributed in posterior inferior, anterior superior and anterior inferior quadrants. In groups 2, 3, 4, 7 and 8, the Mises stress was evenly distributed in posterior inferior, anterior superior and anterior inferior quadrants. Of them, the stress was most even in the group 4. In groups 2, 3, 4, 7 and 8, the shear stress was evenly distributed in the above-mentioned three quadrants. The shear stress was lowest in the groups 7 and 8. These indicate that joint force in the acetabulum mainly focused in the posterior superior quadrant. With the displacement of acetabular cup, the contact area of acetabular cup and bone would gradually increase, which finally increased the Mises stress in the contact surface. However, shear stress decreased with displacement of acetabular medial wall. Conclusion the suitable displacement range of acetabular medial wall osteotomy is 1 mm away from the pelvic cavity and 1 mm complete embolism in the pelvic cavity. The optimal position was 1 mm complete embolism in the pelvic cavity.