Orthopedic Correction Research Articles

The management of skeletal dysplasia

Skeletal dysplasia (SD) is disorders of bone and cartilage development caused by genetic defects. It comprises more than 300 specific disorders[1]. Causative genes responsible for SD include those encoding the bone and cartilage matrix proteins, receptors and intracellular molecules involved in signal pathway of chondrocyte and osteoblast, specific transcription factors, enzymes involved in bone and cartilage metabolism, cell surface ion channels, and so on. Recently, many novel causative genes have been discovered with the help of whole exome sequencing, whose protein function has not been well elucidated. SD had been classified according to their clinical and radiologic phenotype, however with discovery of causative genes, nosology and classification has evolved over the last several decades based more on the genotype. Correct diagnosis is the starting point of optimal management of SD, but it can be very difficult in some cases. One should not hesitate to consult to SD specialists in order to make correct diagnosis. Common clinical problems in the skeletal system that interfere with patients’ daily life include short stature, limb deformity, spine deformity, C1-2 instability, and precocious osteoarthritis. Only few medical treatments effective for SD have been established. Bisphosphonate for osteogenesis imperfecta was the most successful medical treatment so far. Hence, the management of SD is still largely surgical intervention and rehabilitation. Orthopedic correction of the limb deformity can improve not only cosmesis, but also patients’ locomotive function. Distraction osteogenesis by Ilizarov principle makes complex deformity correction possible, and asymmetrical physeal suppression enables minimally invasive correction of the deformity. Bilateral limb lengthening for height became popular since 80’s, but considering its high rate of complication, surgical indication should be narrowed and the surgery should be discussed thoroughly with the patient and parents preoperatively. Many SDs provoke hip problems and various surgical interventions have been applied, but most of them are anecdotal cases with varying outcomes. Atlantoaxial instability may result in a serious outcome, either acutely or chronically. Great attention should be paid to this condition. Surgical intervention of SD is one of the most challenging areas in orthopedic field, and will evolve with advance of orthopedic technology.

Correction of class III malocclusion using modified tandem appliance-two case reports

Skeletal discrepancies in growing children can have great physical and psychological impact on their appearance. These deformities require orthopedic correction at an appropriate age to avoid future extensive management. Managing a midfacial deficiency or true mandibular prognathism is perhaps the most challenging situation for the clinician. Many orthopedic appliances like chin cup, facemask, and so on have been advocated to correct class III malocclusion. The major problems with these appliances are physical appearance, skin irritation from the anchorage pads and hence, less patient compliance. We present management of class III malocclusion in two children with modified tandem appliance (MTA), which is an intraoral appliance, with no extraoral anchorage, and has better patient compliance and cooperation.

Inflammatory bone loss

Inflammatory bone loss

Result of Orthopedic Correction for Femur Nonunion and Shortening

Result of Orthopedic Correction for Femur Nonunion and Shortening

Use of intermaxillary forces in early treatment of maxillary deficient Class III patients: Results of a case series

IntroductionThe early treatment of Class III malocclusion with a protraction facemask can produce forward movement of the maxilla but is generally associated with posterior rotation of the mandible and dentoalveolar compensations. This article shows the dental and skeletal effects of intermaxillary elastics applied to temporary anchorage devices in the treatment of maxillary deficient Class III patients. Materials and methodsA total of 6 patients with skeletal Class III malocclusion were treated with intermaxillary elastics only. This traction was applied between modified miniplates placed in the maxilla and a modified lower acrylic resin plate bonded on mandibular tooth surfaces. To evaluate the orthodontic changes, lateral cephalograms were taken at the start of the treatment (T1), at the end of the orthopaedic treatment (T2) and at the follow-up (T3). ResultsAll patients showed orthopaedic correction of the skeletal Class III relationship with reduction of facial concavity. No dentoalveolar compensations or changes in mandibular position were observed. ConclusionThe treatment of maxillary deficiency with orthopaedic forces from skeletal anchorage directed to the hooks of a modified lower acrylic resin plate bonded on the mandibular tooth surfaces, seems to be a promising technique.

Evidence on early correction of class III malocclusion

The presence of high quality evidence on the dentofacial orthopaedic correction of Class III malocclusion is scarce. Long-term follow-up of growth modification has reported mixed results. The aim of this article is to review the literature on the early correction of Class III malocclusion and to provide some clarification on the following important issues: definite types of treatment modalities for treatment of Class III malocclusion; case selection; short-term and long-term effects of different treatment modalities; timing of treatment; success rate and skeletal and dental effect of different treatment modalities. Clinical Relevance: Early treatment of Class III patients with maxillary deficiency using appliances such as protraction facemasks can be used to maximize maxillary growth potential in appropriate cases. However, correct diagnosis and understanding of the individual growth pattern is imperative in determining the success of early Class III treatment.

Skeletal Anchorage for Orthopedic Correction of Growing Class III Patients

Maxillary protraction headgear in conjunction with expansion appliances have been widely used in the treatment of Class III malocclusion with maxillary deficiency. However, there are problems associated with protracting the maxilla with conventional tooth-borne anchorage. These include the loss of dental anchorage, which is of concern, especially in situations in which preservation of arch length is necessary. In addition, tooth borne anchorage alone does not allow the application of orthopedic force directly to the maxillary sutures. The latter effects can be eliminated or minimized by the use of absolute intraoral anchorage devices, such as miniplates. Several reports have been published in the literature on the use of miniplates for maxillary protraction. However, the skeletal and dental changes in response to maxillary protraction using miniplates as anchorage have not been reported. The purpose of the present study was to quantify and compare the effects of maxillary protraction when using a facemask in conjunction with a rapid maxillary expansion appliance (RME) with a second group treated with a facemask together with a surgical miniplate as anchorage. Maxillary protraction headgear in conjunction with expansion appliances have been widely used in the treatment of Class III malocclusion with maxillary deficiency. However, there are problems associated with protracting the maxilla with conventional tooth-borne anchorage. These include the loss of dental anchorage, which is of concern, especially in situations in which preservation of arch length is necessary. In addition, tooth borne anchorage alone does not allow the application of orthopedic force directly to the maxillary sutures. The latter effects can be eliminated or minimized by the use of absolute intraoral anchorage devices, such as miniplates. Several reports have been published in the literature on the use of miniplates for maxillary protraction. However, the skeletal and dental changes in response to maxillary protraction using miniplates as anchorage have not been reported. The purpose of the present study was to quantify and compare the effects of maxillary protraction when using a facemask in conjunction with a rapid maxillary expansion appliance (RME) with a second group treated with a facemask together with a surgical miniplate as anchorage.

Sindrome dell’ostruzione respiratoria e unità rino-faringo-tubarica

Objectives To evaluate the effects of airway obstruction on craniofacial morphology with emphasis on the oral and nasal cavities and the middle ear. Materials and methods Obstructed breathing can alter the anatomy of the upper maxilla and the middle third of the face, producing functional and morphological changes in structures close to the oral cavity, such as the nose and ear. Results Mouth-breathing children present underdevelopment of the maxilla, progressive atrophy of the nasal cavity, and Eustachian tube dysfunction that can lead to otitis media and conductive hearing loss. Orthopedic correction of the altered dental and skeletal morphology with rapid upper maxillary expansion can also solve problems involving the nose and ear. Conclusions Mouth breathing alters the anatomy of the nasal cavity and maxilla and the function of the middle ear. Rapid maxillary expansion increases the transverse dimensions of the maxilla, enlarges the nasal cavity, and improves Eustachian tube function. The result is improved breathing and the reduction of conductive hearing loss.

Complex rehabilitation in patients with complete absence of teeth

The paper deals with recovery of function, including surgical and orthopedic correction, in patients with complete absence of teeth. The proportion of patients with complete or partial absence of teeth is rather high. In this connection, the role of rehabilitation increases in this patient group.

Clinical outcomes for patients finished with the SureSmile™ method compared with conventional fixed orthodontic therapy

Utilize American Board of Orthodontics (ABO) cast/radiographic evaluation (CRE) to compare a series of 63 consecutive patients, finished with manual wire bending (conventional) treatment, vs a subsequent series of 69 consecutive patients, finished by the same orthodontist using the SureSmile™ (SS) method. Records of 132 nonextraction patients were scored by a calibrated examiner blinded to treatment mode. Age and discrepancy index (DI) between groups were compared by t-tests. A chi-square test was used to compare for differences in sex and whether the patient was treated using braces only (no orthopedic correction). Analysis of covariance tested for differences in CRE outcomes and treatment times, with sex and DI included as covariates. A logarithmic transformation of CRE outcomes and treatment times was used because their distributions were skewed. Significance was defined as P < .05. Compared with conventional finishing, SS patients had significantly lower DI scores, less treatment time (∼7 months), and better CRE scores for first-order alignment-rotation and interproximal space closure; however, second-order root angulation (RA) was inferior. SS patients were treated in less time to better CRE scores for first-order rotation (AR) and interproximal space closure (IC) but on the average, malocclusions were less complex and second order root alignment was inferior, compared with patients finished with manual wire bending.

Diagnosis and Treatmentof Diastematomyelia in Children

Objective. To analyze neurological status of patients, radiological presentation of disease, and an incidence rate of diasematomyelia’s association with skin and musculoskeletal disorders. Material and Methods. The study included 20 patients with diastematomyelia aged from 1 to 18 years. Diagnosis was based on a case history, clinical examinations, spine radiography in coronal and sagittal planes, CT (20 cases), CT myelography (1 case), MRI (20 cases), and neurophysiological study (electroneuromyography of lower extremities). Septum resection was indicated in 17 children. Results. All patients had cutaneous changes along the midline of the back such as hypertrichosis, hemangiomas, and dermal sinuses. Neurological symptoms were noted in 17 patients: lower paraparesis in 11, urinary incontinence in 2, monoparesis in 4, and pyramidal insufficiency in 2 patients. Three patients did not show any neurological deficit. Orthopedic examination revealed spinal deformities of various degrees of severity. Conclusion. Resection of the septum in patients with diastematomyelia should be the first stage of surgical scoliosis correction and precede orthopedic correction of low extremity deformity. Patients having neither neurological deficit no orthopedic deterioration should be followed up, and in case of pathological symptoms augmenting or elecroneuromiography changing a question of surgical treatment should be regarded.

Impact of genioplasty on mandibular growth during puberty

Genioplasty has been validated for the correction of mandibular vertical excess and is generally performed at the end of the growth period, either alone or in association with other forms of osteotomy. Our aim was to assess whether genioplasty performed at an earlier age can impact mandibular growth. This comparative prospective study included 25 high-angle, mouth-breathing adolescents following orthodontic and ENT treatment. Subjects were divided into two groups according to their stage of puberty, either early (group 1: Tanner's stage 3, n=12) or late stage (group 2: Tanner stage 4-5, n=13). Genioplasty was performed in both groups. Cephalometric comparison was made on the overall population and for each group, before and after genioplasty (at 1, 6, 12 and 18months). In the immediate postoperative period, significant variation of all the cephalometric measures was observed within each group showing reduction of the vertical dimension and sagittal augmentation. Eighteen months post-surgery, only group 1 exhibited a significant increase in SNPog. Augmentation of the SNB and anterior mandibular rotation were also significantly greater in group 1. The difference in the direction of growth of the mandible before genioplasty (18months of orthodontics) and postgenioplasty (18months of postoperative monitoring) was also significant. Early genioplasty permits redirection of mandibular growth conducive to orthopedic correction of high angle Class II.

Long-Term Results of Microsurgical Selective Tibial Neurotomy for Spastic Foot : Comparison of Adult and Child

Selective neurotomy is generally a safe, effective, and long-lasting treatment for patients with spastic equinovarus foot deformity. We retrospectively analyzed the results of microsurgical selective tibial neurotomy (STN) for spastic feet in adults and children. A neurosurgeon selected 32 patients with 45 spastic feet (adults : 13, children : 32) to undergo microsurgical STN between October 1998 and September 2007. A physician of rehabilitation assessed spasticity pre- and postoperatively, that was based on the Ashworth scale, ankle clonus, and the amplitude of ankle dorsiflexion. The mean postoperative follow-up period was 36.7 months in adults and 42.5 months in children. Spastic components of the feet were corrected immediately after surgery in both the adult and child groups. The mean Ashworth's grade changed from 3.6 +/- 0.40 to 1.6 +/- 0.70 in adults and from 3.7 +/- 0.69 to 1.4 +/- 0.49 in children. Mean ankle clonus decreased markedly, from 1.6 +/- 0.79 to 0.3 +/- 0.42 in adults and from 1.7 +/- 0.65 to 0.3 +/- 0.56 in children. The mean amplitude of ankle dorsiflexion was improved, but eight (adults: 4, children: 4) contracted feet needed complementary orthopedic correction for acceptable results. STN can be effective in the long-term for improving lower limb function and reduction of equinovarus deformity. Our results demonstrate that STN might be an effective procedure for treating localized harmful spastic feet in adults and children.

Complex Treatment of Patients with Spine Osteomyelitis

Objective. To assess the efficacy of regional lymphotropic antibacterial therapy and anterior stabilization of the involved segment in the treatment of patients with spinal osteomyelitis. Material and Methods. Regional lymphotropic therapy and surgical intervention including resection of the osteomyelitis locus, replacement of the cavity with autograft, and anterior stabilization of the spine were performed in 12 patients. Dynamics of the process was controlled radiographically. Results. Regional lymphotropic antibacterial therapy proved to facilitate decrease in erythrocyte sedimentation rate, leucocytosis, and pain syndrome. Spinal fixation provided conditions for the graft implantation, and allowed early loading. Inflammatory process was arrested and spinal fusion was achieved in all patients. Conclusion. Suggested multimodal treatment of patients with hematogenous osteomyelitis provides orthopaedic correction of kyphotic deformity if present, and rigid fixation of the operated segment, creates favorable conditions for fusion and remodeling of autografts without resorption, and prevents possible inflammatory complications in postoperative period.

Clinical Significance of Cervical Vertebral Flexion and Extension Spatial Alignment Changes

Radiographic review. To study changes in alignment and curvature of the cervical vertebral column in the sagittal plane, and to provide references for the orthopedic treatment of cervical kyphosis. There are few reports analyzing changes of the vertebral body itself or changes in their relationships between separate vertebrae. To understand cervical vertebrae and curvature dynamic variation patterns in the sagittal plane and provide a theoretical reference for orthopedic correction of cervical kyphosis, we measured spatial position and alignment of the cervical vertebrae on sagittal plane films of various postures. Blind repeated measures design analysis of sagittal view standard lateral, hyper flexion, and hyper extension cervical spine of 60 healthy subjects measuring spatial alignment angle of C2 to C7 vertebral bodies in the sagittal plain ( angleA), C2 to C7 inferior terminal lamina tilt angle of ( angleB), and segmental intervertebral space angles C2/3 to C6/7 ( angleC) calculating flexion and extension amplitude changes in angleA, angleB, and angleC. Cervical curve apex was determined using Borden's method to compare change and distribution characteristics. RESULTS.: Segmental angleA is a positive mean value that increases from C2 to C7 when in the upright position. In hyper extension, mean angleA value decreases with gradual amplitude decrease from C2 to C7; however, a gradual overall increasing pattern is observed for mean angleA from C2 to C7. In hyper flexion, segmental angleA mean value increases with gradual amplitude decrease from C2 to C7, whereas with decreasing angular measurements from C2 to C7. angleB follows similar change regularities as angleA with a larger mean value than angleA. During maximum extension and maximum flexion, angleD is equal to angleE. For example: C2 angleD = C2 variable angleA; C2 angleE angle(C3 variable angleA + C2/3 variable angleC); and C2 angleD = C2 angleE. Cervical spine curve apex is mainly distributed between C4 and C5 on standard, hyper extension and hyper flexion lateral view. Dynamic cervical curvature changes based on a central apex, stems from vertebral rotation and displacement in the sagittal plane. Our study reveals variation patterns of dynamic cervical spine sagittal alignment and curvature, providing vertebral spatial alignment value as reference for orthopedic cervical kyphosis corrective surgery.

Neurosurgical Treatment for Cerebral Palsy Spasticity

The spasticity of cerebral palsy is usually a useful substitute for deficiency of motor strength. However not infrequently, it may become harmful leading to an aggravation of motor disability. When excessive spasticity is not sufficiently controlled by physical therapy and pharmacological treatment, patients can have recourse to neurosurgery: neurostimulation, intrathecal baclofen or selective ablative procedures. Because excessive hypertonia has to be reduced without suppression of the useful muscular tone or impairment in the residual motor and sensory functions, neuroablative procedures must be as selective as possible. These selective lesions can be performed at the level of peripheral nerves, spinal roots, or the dorsal root entry zone(DREZotomy). The new neurological status brought about by the neurosurgical operation will reach its optimal level only if intensive, prolonged, comprehensive treatment is provided by an expert multidisciplinary team including rehabilitation medicine. The neurosurgical treatment must take place before the onset of irreversible articular disturbances and musculotendinous retractions, which require complementary orthopedic corrections.

Avaliação cefalométrica dos efeitos do aparelho Herbst no tratamento da deficiência mandibular na dentadura permanente

OBJETIVO: o objetivo do presente estudo cefalométrico retrospectivo consistiu em investigar os efeitos induzidos pelo aparelho Herbst, complementados pela mecânica ortodôntica com aparelho Straight wire e elásticos de Classe II, na correção da má oclusão Classe II, divisão 1, Padrão II, com deficiência mandibular, na dentadura permanente. METODOLOGIA: foram traçadas telerradiografias iniciais (idade média de 12 anos e 10 meses) e finais (idade média de 14 anos e 8 meses) de 18 pacientes, 12 meninos e 6 meninas, para quantificar o comportamento de 12 grandezas cefalométricas representativas da posição sagital das bases apicais, convexidade facial, rotação mandibular e posição sagital dos incisivos superiores e inferiores. O tempo médio de tratamento foi de 22,5 meses, sendo 9,8 meses com o aparelho Herbst e 13 meses com a mecânica ortodôntica subseqüente. RESULTADOS E CONCLUSÕES: os resultados registraram: 1) ausência de influência no comportamento da maxila; 2) avanço mandibular; 3) redução na convexidade facial; 4) preservação da inclinação do plano mandibular e 5) presença de compensação dentária, sobretudo nos incisivos inferiores (vestibularização). Reitera-se, portanto, o fato de que, mesmo com aparelho ortopédico fixo, é mais previsível e mais fácil obter compensação dentária do que remodelação esquelética na correção ortopédica da deficiência mandibular.

Bisphosphonates in Osteogenesis Imperfecta

Osteogenesis Imperfecta (OI) is a rare heritable condition characterized by bone fragility and reduced bone mass. Most affected individuals carry a mutation that compromises the synthesis and/or the structural organization of type I collagen. Histologically there is a picture of osteoporosis with increased remodeling rate. On that basis, bisphosphonate treatment was introduced, and definite benefits, in terms of pain control, fracture incidence and degree of ambulation, became rapidly evident. Cyclical intravenous pamidronate is now the standard of care for moderate/severe OI in combination with appropriate orthopedic corrections and rehabilitation programs. While it is amply demonstrated that the use of bisphosphonates in OI is effective and safe for the short term (4–5 years), their long term effects are still under investigation.

Assessment of Cleft Lip and Palate Patients Treated With Presurgical Orthopedic Correction and Either Primary Bone Grafts, Gingivoperiosteoplasty, or Without Alveolar Grafting Procedures

The effects of alveolar grafting on the development of the craniofacial complex have been reported by numerous investigators. The reported results vary in the literature from significant to very little impediment of maxillary growth. The present work evaluates and compares facial form at age six years in complete unilateral cleft lip and palate patients treated with presurgical orthopedic correction and primary reconstruction with (1) primary bone grafts (n = 14), (2) gingivoperiosteoplasty (n = II), or (3) without alveolar grafting procedures at the time of lip repair (n = 13). The cohort groups were analyzed with a one-way analysis of variance (ANOV A). Statistical analysis revealed significant differences between the three groups for only one of the 12 parameters analyzed. The primary bone grafted group demonstrated less vertical descent-of the anterior maxilla compared to the gingivoperiosteoplasty and non-grafted groups (P = .0027).

ORTHOPAEDIC ASPECTS OF SURGICAL TREATMENT OF PATIENTS WITH DEGENERATIVE-DYSTROPHIC DAMAGE OF THE LUMBOSACRAL SPINE

Objective. On the basis of clinical and anatomico-functional results of surgical treatment of patients with degenerativedystrophic disease of the lumbosacral spine to develop and introduce into clinical practice orthopaedic surgical approaches aimed mainly to the correction and stabilization of the spine. Materials and Methods. The results of surgical treatment of 340 patients operated on for degeneconventionally and by the technique proposed by authors with the account for orthopaedic factors rative-dystrophic disease of the lumbosacral spine were analyzed. Results. The treatment outcome was mainly influenced by the following factors: spinal stenosis, instability and lumbosacral shape (balance) disturbance. The pattern of preopreative planning was developed on the basis of the introduced comprehensive methods of diagnosis. The suggested approach to surgical treatment has gone through clinical approbation resulted in recommendations for its application in practice. The paper presents the advantages of use of modern neuroorthopaedic technologies for various forms of spinal stenosis, and orthopaedic correction techniques in patients with discogenic radiculopathy associated with instability and deformity of the lumbosacral spine. Conclusion. The modern level of neuroorthopaedic care suggests new approaches to diagnosis and surgical management of patients with degenerative-dystrophic disease of the lumbosacral spine.