Minor Deformities Research Articles

A Classic Twin Study of External Ear Malformations, Including Microtia

To the Editor: The pathogenesis of microtia, a rare congenital malformation of the external ear, remains elusive. Phenotypes range from minor deformities, such as preauricular tags, to anotia, the ...

Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur

Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. Forty-three of the forty-four fractures united. All reductions were within 5 degrees of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2 degrees and 5 degrees ). There were no complications. Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.

Prevalence of Associated Deformities in Patients with Cam Type Femoroacetabular Impingement (SS-30)

Femoroacetabular impingement (FAI) has recently been described as a cause of hip pain in young adults and a cause of osteoarthritis of the hip. Cam type impingement is due to a non-constant radius of curvature of the femoral head, usually due to a prominence at the anterosuperior head-neck junction. The surgical treatment of FAI may be able to prevent or retard the progression of degeneration within the hip. One critical aspect in the understanding of the natural history of any hip condition is determining the prevalence of bilateral disease. This clinical information can also be very useful for patient counseling, development of treatment strategies as well as patient follow up care. The purpose of this study was to determine the prevalence of bilateral deformity in patients with cam type FAI as well as the presence of associated acetabular abnormalities. All patients less than 56 years of age seen by the senior author for hip pain with at least one antero posterior pelvic radiograph and lateral view were included. All patients with dysplasia and/or arthritis were excluded. One hundred and thirteen patients with symptomatic cam impingement deformity (alpha angle greater than 55.5 degrees) of at least one hip were evaluated. There were 82 males and 31 females with an average age of 37.9 years (range 16-55). Cam type impingement deformity was defined by measuring the a angle of Notzli on the lateral views (either cross-table lateral with leg in 15 degrees of internal rotation or Dunn view). On the AP pelvic radiograph, hips were assessed for signs of pincer type impingement and lateral centre-edge angle of Wiberg. Pincer type impingement was defined as acetabular retroversion, coxa profunda or coxa protrusio. Out of the 113 patients, only 27 patients had bilateral hip symptoms. The average a angle measured was 67.10, sd 10.60, range 39-920. 88 patients had an a angle greater than 55.50 in both hips (77.8%). The average a angle value amongst the cam impinging hips was 69.50, sd 8.50, range 56-920. The average a angle in the female hips was significantly lower than the male hips - 62.10, sd 9.60 versus 69.10, sd 10.40 respectively (p<0.001). 11 out of 31 females (35.5%) and 14 out of 82 (17.1%) males had unilateral impingement. This difference was significant (p=0.03). Patients with unilateral impingement had a significantly lower average a angle on their impingement side than for hips in patients who had bilateral impingement - 63.60, sd 6.70 and 70.40, sd 6.80 respectively, p<0.001. Of patients who complained of unilateral pain, the average a angle of painful hips was 69.90, sd 8.20, whilst that of the non-painful side was 63.1.10, sd 11.70. This difference was statistically significant (p<0.001). Comparing hips with a angles of 610-700 with those less than 600 found an odds ratio of being painful of 2.59 (95% CI: 1.32-5.08, p=0.006). Similarly hips with a angles greater than 710 had an odds ratio of being painful of 2.54 (95% CI: 1.3-4.96, p=0.007). Of these 113 patients, 88 had bilateral cam deformity and 25 unilateral, i.e. 201 of 226 hips had cam type deformity. Ninety-eight hips had pincer impingement, 84 of these occurring in hips with a cam type deformity (42%). 53 hips had retroversion of the acetabulum (21 patients had bilateral retroversion and 11 unilateral). The strong bilateral prevalence and the correlation between the side to side a angles may suggest a predisposition in some patients to an acquired deformity. A post slip deformity is similar in morphology, male predominance and bilateral prevalence. Our study would suggest that patients with alpha angles less than 60 degree are less likely to develop symptoms which can be used when counseling patients with minor deformities with associated labral pathology as well as those with bilateral deformities. In conclusion, most patients with cam type FAI have bilateral deformities and an associated acetabular deformity almost fifty percent of the time, although most will not be symptomatic at the time of presentation. This is important information in terms of better defining the natural history of this deformity as well as devising effective treatment strategies. Physicians should consider getting appropriate x-rays of the contralateral hip when diagnosing a patient with FAI.

Psychological implications in ENT diseases.

We are sometimes faced with psychic derangement or overlay in some of the ENT diseases and the link between patient's psyche and any ENT disease at times becomes signifi cant and troublesome. The conditions in the fi eld between otorhinolaryngology and psychiatry can be classifi ed as psychiatric symptoms resulting from ENT diseases or interventions and those expressing themselves as ENT symptoms due to mental ailment. The former include hearing impairment, dizziness, tinnitus, choked airway, bad oral breath, stuffy nose, traumatic interventions and external nasal deformities. The later include exaggerated and diminished pharyngeal refl ex, globus hystericus, speech disorders, vasomotor rhinitis, nose picking, choked feeling, dizziness and headache. At times diseases originate in the human mind (consciousness), causing negative thoughts like jealousy, anger, and depression due to frustration. p ]A healthy mind in a healthy body generates sound and noble thoughts. Once a healthy body-mind relationship is established, we can be reasonably sure that greater happiness and success is within our reach. Patient seeking help from ENT surgeons to change their physical appearances and or function may not understand that the ultimate goal of surgery is to bring about psychological change by modifying the physical change, which is important aspect in septorhinoplastic surgery. At times patients asking for corrective rhinoplasty for minor external nasal deformities may have underlying psychological disturbance and use even slight external nasal deformity as scapegoat for psychological upset. Males are more diffi cult patients psychologically for any facial cosmetic surgery. These days some patients read about their diseases or treatment on the Internet and get more confused and psychologically disturbed due to rare causes of their illness, rare complications and diversity of treatment available.

Minimally invasive plate osteosynthesis of subtrochanteric femur fractures with a locking plate: a prospective series of 20 fractures

Intramedullary nailing is a mainstay in the treatment of subtrochanteric femoral fractures. But nailing is often unsuitable for difficult fracture patterns with comminution or when the medullary canal is narrow. The purpose of this study was to clarify the efficacy of minimally invasive plate osteosynthesis (MIPO) with locking compression plate in the treatment of subtrochanteric fractures. Twenty patients with subtrochanteric fractures (mean age 49.6 years) were prospectively treated using the MIPO technique using a locking plate. Indications of procedure were fractures with the greater trochanter or medial comminution, and multiple injured patients with a narrow femoral canal. According to the AO/OTA classification, there were three of type A, eight of type B, and nine of type C. All healed without bone graft, at an average of 20.1 weeks (range 16-32). With the exception of two patients with minor internal rotation deformity and one patient with 1 cm of shortening, most achieved acceptable alignment. All patients were able to walk with no or only a slight limp, and median Merle d'Aubigne score was 17.3 (15-18). Four patients complained of a slight pain in the trochanteric area due to plate prominence. The MIPO technique with a locking plate provides an alternative method for fixing subtrochanteric femur fractures, when IM nailing is inappropriate. This technique provides stable fixation, with a high union rate and a minimal complication rate.

Revision Rhinoplasty: An Overview of Deformities and Techniques

This article provides an overview of assessment, planning, and correction of deformities in revision rhinoplasty surgery. Common deformities are described with tips for preventing such postoperative problems, and corrective strategies are suggested. Assessment remains the key to successful rhinoplasty surgery, and its importance in revision operations is emphasized. The external approach is preferred for complex revision surgery due to its unparalleled exposure of the underlying anatomy, but closed approaches are still used for dorsal correction or minor tip deformities. The use of and options for graft material in reconstruction are detailed.

Ear reconstruction following severe complications of otoplasty

Correction of prominent ears is one of the most common operations performed in congenital deformity. Many appropriate corrective techniques have been described. While rare, severe complications destroying ear contours can occur and their correction should follow the established principles of ear reconstruction. A retrospective review of the notes of all patients who presented to Clinique George Bizet (1981-2007) in Paris, for correction of complications after undergoing prominent ear surgery at another facility, was performed. Each patient's age, gender, diagnosis, number of previous operations and final outcome were noted as available. Patients were included in this study if they had undergone one or more operations for prominent ears, leading to severe destructive complications, prior to consultation with the senior author and then underwent surgical repair with either an auricular (conchal) cartilage graft or with autogenous costal cartilage. A total of 49 (25 female, 24 male) patients met the inclusion criteria. The mean age at presentation was 23 years (range of 10-59 years of age). The mean number of previous attempts to correct the ear deformity was 1.3 (1-12) times. Eight patients underwent reconstruction with a conchal cartilage graft and 41 with costal cartilage. While more minor contour deformities are correctable with a contralateral conchal cartilage graft, when more than a quarter of the ear or more than two planes of its complex folds are deformed, costal cartilage is recommended for surgical repair. The principles of ear reconstruction should be well understood prior to attempting a repair of severe complications after otoplasty.

Arthroscopic Ankle Arthrodesis

Arthroscopic arthrodesis has been used mainly for in situ fusion of arthritic ankles without deformity. This paper presents the application of arthroscopic arthrodesis of ankles with marked deformity. The results of 78 consecutive cases of arthroscopic ankle arthrodeses, performed in 74 patients, were retrospectively evaluated. Forty-eight ankles had minor deformity (group A), whereas 30 ankles had a varus or valgus deformity of more than 15 degrees (maximum 45 degrees) (group B). The average hospital stay was 3.8 and 3.4 days in groups A and B, respectively (p = 0.74). Postoperative treatment included ankle immobilization for 3 months. Progressive weightbearing was initiated at 2 weeks. Mean followup was 21.1 months. Fusion occurred in 47 of 48 (97.9%) ankles in group A at an average time of 13.1 +/- 5.8 weeks and in 29 of 30 (96.7%) ankles at 11.6 +/- 2.4 weeks in group B (p = 0.19). Unplanned operative procedures were required in 11 ankles (14.1%). One superficial wound infection occurred. Symptomatic arthritis from the adjacent joints developed in six ankles (7.7%). Postoperative ankle alignment in the frontal plane averaged 0.7 and 0.4 degrees of valgus (p = 0.41), whereas the sagittal plane angle averaged 106 +/- 4 degrees and 104.5 +/- 7 degrees in groups A and B, respectively (p = 0.22). The outcome was graded as very good in 79.2% (38 feet) in group A and 80% (24 feet) in group B, fair in 18.8% (9 feet) in group A and 16.7% (5 feet) in group B and poor in one ankle in each group (p = 0.68). The arthroscopic technique offered high fusion rates and low morbidity. Deformity correction was achieved with good results.

Stainless Steel Flexible Intramedullary Fixation of Unstable Femoral Shaft Fractures in Children

To assess the role of stainless steel flexible intramedullary fixation in unstable pediatric femur fractures, we compared a group of 41 stable (transverse or oblique) fractures with a group of 40 unstable (spiral and/or comminuted) fractures treated with stainless steel (Ender) nails placed through a single lateral insertion. The fractures were followed up until clinical and radiographic union was evident with an average follow-up period of 13 months. All fractures were healed at an average of 1.4 months. No infections or refractures occurred. Although minor radiographic angular deformities and shortening were present in both groups, no patient had a clinically detectable angular deformity. Two patients with stable fracture patterns had 10 to 20 degrees of asymmetry in foot progression angles, and 1 patient with an unstable fracture pattern (Winquist grade IV comminution) had a 3-cm limb length difference at final follow-up. Stainless steel flexible intramedullary fixation is effective for unstable pediatric femur fractures if cortical abutment is present.

Surgical correction for curly toe using open tenotomy of flexor digitorum brevis tendon

Curly toe is a common congenital deformity characterized by flexion and varus deformity of the interphalangeal joints. Because this minor deformity is seldom accompanied with any symptoms, treatment strategy has rarely been discussed in detail in the literature. Eight toes in seven patients with curly toe were treated by open tenotomy of the medial slip of the flexor digitorum brevis tendon. If sufficient correction was not obtained, the collateral ligament and the volar plate of the proximal interphalangeal joint were dissected. The skin defect at the plantar base of the toe was covered using a local flap or a full-thickness skin graft. The median age at operation was 2 years 6 months (ranged from 8 months to 5 years 4 months). In all cases, contracture of the plantar skin at the base of the toe and tight FDB tendon were recognized to a variable degree. Postoperatively, overlapping of the affected toe was corrected in every case at a median follow-up of 2 years 9 months. However, flexion and/or varus deformity tended to remain to some degree in those patients with severe curly toe. Toes with moderate to severe deformity with overlapping beneath the adjacent toe are candidates for surgical correction, because spontaneous correction is unlikely and troublesome symptoms may occur as the child grows older. Surgical correction should be performed until 2-3 years of age. The postoperative result might be poor, if treated in the older age, because skeletal deformity is likely to occur. Open tenotomy of the FDB tendon is easy to perform, and toe function was seldom impaired.

Perichondritis of the auricle and its management

To conduct a study of patients presenting with perichondritis of the auricle and to analyse the possible aetiological factors responsible, the bacteriological agents involved, the treatment modalities and the complications of such infections. Academic department of otolaryngology. A retrospective clinical study of patients treated over a five-year period. Sixty-one patients with clinically proven perichondritis of the auricle, with or without diabetes mellitus (i.e. malignant otitis externa). Based on the severity of the disease, otherwise uncomplicated patients were assigned to group A and divided into three cohorts. Patients with perichondritis secondary to malignant otitis externa were analysed separately as group B. Men formed the majority of the patients and most were young (16-35 years). Trauma was the main cause (46 per cent) and Pseudomonas aeruginosa the most common micro-organism isolated. The condition was managed conservatively with antibiotics alone in 19 patients (31 per cent) and these cases had no residual deformity at follow up (group A, stage one). Incision and drainage was performed in a further 19 patients (31 per cent), resulting in minor residual deformity in one half (group A, stage two). Debridement was performed in 17 patients, and these patients had either gross (29 per cent) or minor residual deformity (71 per cent; group A, stage three). Six patients with perichondritis secondary to malignant otitis externa were managed by wound debridement via a post-auricular approach; all had minor residual deformities. Perichondritis can be divided into two groups, depending on cartilage loss and on the presence or absence of malignant otitis externa. The treatment used and the residual deformity that will ensue are entirely dependent on the stage of disease.

Potential Ecotoxicological Significance of Elevated Concentrations of Strontium in Eggshells of Passerine Birds

Abstract Abstract We investigated the occurrence and potential ecotoxicological significance of elevated concentrations of strontium (Sr) in eggshells of nine passerine birds from four regions in Arizona. Concentrations of Sr in eggshells ranged from 70 to 1360 µg g−1 dry weight (overall mean = 684 ± 345 SD µg g−1 dw) for the four regions. 23% of the eggshells had Sr concentrations greater than 1000 µg g−1 dw. To our knowledge, these are among the highest levels of Sr that have been reported in bird eggshells in North America. Of the nine species, Brown-headed Cowbirds (Molothrus ater) had the greatest concentrations of Sr. There was a significant positive correlation between Sr and calcium (Ca), and between barium (Ba) and Ca. Ca, Sr, and Ba interact with each other and can exert similar chemical and pharmacological effects. Mean (n ≥ 3) eggshell:egg ratios for Sr varied with species and ranged from 6.1:1 to 40.2:1; ratios for individual eggs reached 92.7:1. Mean Sr/Ca values ranged from 1.3 × 10−3 to 3.0 × 10−3 and mean eggshell thickness ranged from 83 ± 6 to 120 ± 9 µm for all species. Eggshell thickness was not significantly correlated with Sr for any species but tended to increase with Sr concentrations. We postulate that high concentrations of Sr in the shell could affect later-stage embryos by possible interference with Ca metabolism and bone growth, resulting in reduced hatching success and potential minor beak deformities.

Management and functional outcomes of combined injuries of flexor tendons, nerves, and vessels at the wrist

A retrospective review of 42 patients with spaghetti wrist lacerations operated on by the author between June 1997 and May 2005 was completed. A total of 31 males and 11 females, average age of 17.1 years (range, 2-40 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (55%), knife wounds (24%), and electrical saw injuries (11%). An average of 9.16 structures was injured, including 6.95 tendons, 1.4 nerves, and 0.8 arteries. The most frequently injured structures were median nerve (83%), flexor digitorum superficialis 2-4 tendons (81%), flexor digitorum profundus 2-4 tendons (66%), ulnar nerve and ulnar artery (57%), and flexor pollicis longus (40%). Combined flexor carpi ulnaris, ulnar nerve, and ulnar artery (ulnar triad) injuries occurred in 31%, while combined median nerve, palmaris longus, and flexor carpi radialis injuries (radial triad) occurred in 43%. Simultaneous injuries of both median and ulnar nerves occurred in 40.5%. Simultaneous injuries of both ulnar and radial arteries occurred in 14%. Neither artery was injured in 30.9%. Follow-up has ranged from 1 to 8 years, with an average of 46 months. Only four patients have been completely lost to follow-up. Range of motion of all involved digits (tendon function) was excellent in 34 patients, good in 3 patients, and poor in only 1 patient. Opposition was excellent in 31 patients, good in 5 patients, and poor in 2 patients. Intrinsic muscle recovery was subjectively reported to be excellent in 29 patients, good in 7, and fair to poor in 2 patients. Minor deformity (partial clawing) was reported in 4 patients and 1 patient has major deformity (total clawing). Sensory recovery was reported, excellent in 32 patients, good in 5 patients, and fair in only 1 patient.

Neglected Irreducible Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.

Sprunggelenkarthrodese und Sprunggelenkprothetik – ein Vergleich

Ankle arthrodesis is performed for the treatment of unstable, arthritic, painful, and deformed ankle joints. A wide variety of surgical options and approaches exist to treat the difficult problem of an ankle arthrodesis. In patients with only minor ankle deformity and minor bone loss arthroscopically assisted fusion is the treatment of choice. The risk for the development of a pseudarthrosis depends on clinical factors like corticoid medication, nicotine, incorrect alignment and improper mobilization. With adequate shoes the patients can remain asymptomatic for long time. Adjacent joints may show radiological degenerative changes in the long-term follow-up; however, they do not need to be clinically symptomatic. Nowadays total ankle replacement is a valid alternative. The surgical technique is demanding. Implants of the 1st and 2nd generation did not show satisfying results. The newer 3rd generation total ankle arthroplasties show promising medium-term and long-term results.

Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing

We report on our 8-year experience of using elastic stable intramedullary nailing for severely displaced proximal humeral fractures in children. Fourteen patients (mean age 13.4 years) with seven epiphyseal and seven metaphyseal fractures underwent intramedullary nailing, using single nail fixation in 12 cases. Clinical and radiological healing was achieved at 2.4 and 3.2 months, respectively. Complications included temporary shoulder and elbow stiffness in one and four cases, respectively, one nail breakage at removal, two cases with minor humeral shortening, and two cases with minor varus deformity. At the final (14.6-month) follow up all patients had a symptom-free full range of motion. Elastic stable intramedullary nailing is a valid method of treating severely displaced proximal humeral fractures in children.

Polycyclic aromatic hydrocarbons affect survival and development of common snapping turtle ( Chelydra serpentina) embryos and hatchlings

Polycyclic aromatic hydrocarbons (PAHs) are toxic compounds found in the John Heinz National Wildlife Refuge in Philadelphia, Pennsylvania. We assessed the impact of PAHs and crude oil on snapping turtle development and behavior by exposing snapping turtle eggs from the Refuge and from three clean reference sites to individual PAHs or a crude oil mixture at stage 9 of embryonic development. Exposure to PAHs had a significant effect on survival rates in embryos from one clean reference site, but not in embryos from the other sites. There was a positive linear relationship between level of exposure to PAHs and severity of deformities in embryos collected from two of the clean reference sites. Neither righting response nor upper temperature tolerance (critical thermal maximum, CTM) of snapping turtle hatchlings with no or minor deformities was significantly affected by exposure to PAHs.

High incidence of deformity in aquatic turtles in the John Heinz National Wildlife Refuge

The John Heinz National Wildlife Refuge is subject to pollution from multiple sources. We studied development of snapping turtle ( Chelydra serpentina) and painted turtle ( Chrysemys picta) embryos from the refuge from 2000 through 2003. Mean annual deformity rate of pooled painted turtle clutches over four years ranged from 45 to 71%, while that of snapping turtle clutches ranged from 13 to 19%. Lethal deformities were more common than minor or moderate deformities in embryos of both species. Adult painted turtles had a higher deformity rate than adult snapping turtles. Snapping turtles at JHNWR had high levels of PAH contamination in their fat. This suggests that PAHs are involved in the high level of deformities. Other contaminants may also play a role. Although the refuge offers many advantages to resident turtle populations, pollution appears to place a developmental burden on the life history of these turtles.

Six-Month Intravascular Ultrasound Follow-up of Coronary Bifurcation Lesions Treated With Rapamycin-Eluting Stents: Technical Considerations

In vitro studies show that stents deform when dilated laterally to access a side branch. This phenomenon may be avoided by use of a kissing balloon at the end of the procedure. However, to date, no in vivo data are available. Our objectives were to investigate the main vessel stent using intravascular ultrasound (IVUS) at six-month follow-up in 55 patients with bifurcation lesions treated using rapamycin-eluting stents and to examine the effect of technical factors. All patients were treated using provisional or T stents. At 6 months, IVUS measurements were made in the main vessel at both proximal and distal ends of the stent, in reference segments, immediately below the side branch ostium, and at the points where the lumen was smallest and where stent expansion was greatest. The lumen area immediately below the side branch ostium was significantly smaller than that at the point of maximum stent expansion (6.7 [1.8] vs 5.1 [1.3] mm2; P<.05). Underexpansion was not influenced by use of a kissing balloon (stent area immediately under the side branch ostium: 5.5 [0.9] vs 5.6 [1.6] mm2; P=NS) and only one patient experienced restenosis at this point. The lumen areas at the proximal and distal edges of the stent were almost identical in patients who did or did not undergo balloon dilation beyond the ends of the stent. Stent underexpansion below the side branch ostium was frequently found following provisional or T stenting of bifurcation lesions. This minor stent deformity was not prevented by use of a kissing balloon nor by any specific side branch treatment and had no significant impact on the restenosis rate.

Giant congenital melanocytic nevi: long-term results of treatment modalities

We present our long-term results of 44 children treated for giant congenital melanocytic nevus (GCMN). Although controversial, their potential malignancy enforces their removal. The choice of the technique is a real challenge but should attempt to remove all of the involved tissue with minor cosmetic deformity. Our present approach favours the use of multimodality therapy, and different surgical procedures being used for each region.