Osteotomy In Patients Research Articles

Changes of synovial fluid biomarker levels after opening wedge high tibial osteotomy in patients with knee osteoarthritis

The purpose of this study was to evaluate the effects of high tibial osteotomy (HTO) on the biological status of knee osteoarthritis (OA) using joint markers in synovial fluid (SF). Fifty patients with medial compartmental OA of the knee who underwent opening wedge HTO were enrolled. Paired SF samples from the affected knee and arthroscopic evaluation of articular cartilage were collected at the time of HTO surgery and the time of plate removal (postoperative 17±4 months). The concentrations of the following SF biomarkers were measured: interleukin (IL)-1β, IL-6, IL-8, IL-10, tumour necrosis factor-α, matrix metalloproteinase (MMP)-2, MMP-3, MMP-9, MMP-13, vascular endothelial growth factor (VEGF), and cartilage oligomeric matrix protein (COMP). The Knee Society Score (KSS) and hip-knee-ankle (HKA) angle were assessed before and 2 years after HTO. The KSS knee and function scores were significantly improved after HTO (mean changes of 36.4 and 23.7, respectively). The mean HKA angle was altered from mechanical varus (-8.6°) to valgus (5.2°). Concentrations of IL-6, IL-8, MMP-2, MMP-3, MMP-13, VEGF, and COMP in SF were significantly decreased after HTO (mean changes of-49.1%,-30.2%,-31.1%,-26.3%,-30.8%,-42.5%, and-13.7% from preoperative baseline, respectively). The cartilage status was improved in 19 cases (38%) after HTO. However, changes of all biomarkers were not significantly different between subjects with and without an improved cartilage status. SF levels of biochemical markers for cartilage degradation and synovial inflammation were altered after HTO, suggesting an improvement in the OA disease state.

Electromagnetic surgical navigation in patients undergoing mandibular surgery

The purpose of this study was to evaluate the feasibility of electromagnetic (EM) navigation for guidance on osteotomies in patients undergoing oncologic mandibular surgery. Preoperatively, a 3D rendered model of the mandible was constructed from diagnostic computed tomography (CT) images. Cutting guides and patient specific reconstruction plates were designed and printed for intraoperative use. Intraoperative patient registration was performed using a cone beam CT scan (CBCT). The location of the mandible was tracked with an EM sensor fixated to the mandible. The real-time location of both the mandible and a pointer were displayed on the navigation system. Accuracy measurements were performed by pinpointing four anatomical landmarks and four landmarks on the cutting guide using the pointer on the patient and comparing these locations to the corresponding locations on the CBCT. Differences between actual and virtual locations were expressed as target registration error (TRE). The procedure was performed in eleven patients. TREs were 3.2 ± 1.1 mm and 2.6 ± 1.5 mm using anatomical landmarks and landmarks on the cutting guide, respectively. The navigation procedure added on average half an hour to the duration of the surgery. This is the first study that reports on the accuracy of EM navigation in patients undergoing mandibular surgery.

Periacetabular Pelvic Osteotomy in Treatment of Patients with Developmental Dysplasia of the Hip

Background. Pelvic osteotomies are widely used for treatment of young active patients with developmental dysplasia of the hip (DDH) Type I according to the Crowe or type A according to Hartofilakidis classifications and the absence of severe degenerative cartilage lesions. Nowadays, Ganz periacetabular osteotomy (PAO) is the most common choice of surgeons around the world in treatment of such patients.The aim of the study was to evaluate the radiological and functional results of Ganz periacetabular osteotomy in patients with DDH.Material and Methods. A single-center retrospective analysis of 49 Ganz PAO was performed in 43 patients aged 36±9 years. The radiological evaluation criteria were Wiberg (AW), Lequesne (AL), Tonnis (AT) angles, and joint medialization. The results of treatment were evaluated using the Harris scale, iHOT-12, and VAS before treatment and 1 year after, the presence of complications was also monitored.Results. The average follow-up period was 35±15 months (from 1.0 to 6.9 years). Radiological parameters improved after surgery compared to preoperative ones: AW +19.9° (17.1° vs. 37.0°), AT -11.5° (19.9° vs. 8.4°), AL +14.1° (25.1° vs. 39.2°), joint medialization -5.5 mm (14.3 mm vs. 8.8 mm) (p0.001). Functional results and quality of life of patients also improved: the Harris scale +35.6 points (47 vs 83 points), iHOT-12 +40.9 points (44 vs 85 points), pain level -2.8 points (5 vs 2 points) (p0.001). Various complications developed in 20 out of 49 cases (40.8%). Neurological complications were resolved conservatively (22.4%). A direct correlation was evaluated between the surgical treatment of DDH in childhood and the development of neurological complications after PAO (R = 0.76; p0.001). In 9 cases out of 49 (18.4%), revision surgery was required: in 3 — total hip replacement, in 2 — reorientation of the acetabulum, in 4 — arthroscopic fixation of the anterior articular lip. In 93.9% of cases native hip joint surfaces were preserved.Conclusion. Ganz PAO has good reconstructive capabilities and sufficient efficiency. The operation allows to restore the coverage of the femoral head with the acetabulum, delays total hip replacement and provides improved functional results.

A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip

Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach. Patients and Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded. Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively (p = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively (p = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, p < 0.001) and 30.2° (20 to 38°, SD ± 4, p < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (−3 to 13°, SD ± 3.3, p < 0.001) and 3° (−2 to 15°, SD ± 3.3, p < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group. Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach.

Long-term radiographic outcomes and functional evaluation of ulnar shortening osteotomy in patients with ulnar impaction syndrome and reverse oblique sigmoid notch: a retrospective case series study

BackgroundUlnar shortening osteotomy (USO) is an effective treatment for ulnar impaction syndrome. However, there have been reports of osteoarthritis (OA) at the distal radioulnar joint (DRUJ) when USO was performed on patients with a reverse oblique sigmoid notch. This study aimed to evaluate the radiographic and functional outcomes following USO in patients with a reverse oblique sigmoid notch.MethodsWe retrospectively reviewed patients having a reverse oblique sigmoid notch who underwent USO for ulnar impaction syndrome between 2002 and 2013. We evaluated radiographic changes of the DRUJ and functional outcomes of patients.ResultsWe enrolled 22 patients (22 wrists) with an average age of 49.6 years and a mean follow-up of 93.2 (range, 36–179; standard deviation [SD], 38.2) months. We found that there were changes in the inclination angle of the sigmoid notch, from an average reverse oblique of 14.9o (range, 11o–23o; SD, 3.4o) preoperatively to a more parallel 5.1o (range, 0o–11o; SD, 3.2o) at the final follow-up. The functional results at the final follow-up were good, with a mean visual analogue scale for pain of 0.2 (range, 0–1; SD, 0.4) at rest and 1.3 (range, 0–3; SD, 0.9) during activity, QuickDASH of 15.1 (range, 2.3–34.1; SD, 8.8), and modified Mayo Wrist Score of 91.6 (range, 70–100; SD, 6.4). Seven wrists (31.8%) had changes compatible with OA, but the wrists did not exhibit a significantly worse function when compared to wrists without OA changes, except for supination motion and grip strength.ConclusionsFor patients with a reverse oblique sigmoid inclination following USO, we observed that the inclination angle had a tendency to become parallel and some patients developed OA at the DRUJ. However, long-term functional outcomes could still be good. The reverse oblique sigmoid inclination does not seem to be an absolute contraindication for USO.

The Sagittal Parameters and Efficacy of Pedicle Subtraction Osteotomy in Patients with Ankylosing Spondylitis and Kyphosis Under Different Lumbar Sagittal Morphologies.

ObjectiveThis study aimed to compare the changes in sagittal parameters and the efficacy of pedicle subtraction osteotomy (PSO) in patients with ankylosing spondylitis (AS) and kyphosis under different lumbar sagittal morphologies and to explore the effect of sagittal morphology on the selection of PSO levels.MethodsA total of 24 patients with AS and thoracolumbar kyphosis (TK) who were admitted to the First Affiliated Hospital of Xinjiang Medical University between 2008 and 2019 were enrolled in this study. They were divided into two groups: a lumbar lordosis group (n = 14) and a lumbar kyphosis group (n = 10). Changes in sagittal parameters, lumbar Japanese Orthopaedic Association (JOA) scores, and visual analog scale (VAS) scores for lumbar pain before and after operation were compared between the two groups to evaluate postoperative efficacy.ResultsThe preoperative lumbar lordosis (LL) was −29.29 ± 5.40 (lordosis) and 13.50 ± 3.65 (kyphosis) (P < 0.01), and the preoperative sagittal vertical axis (SVA) was 171.35 ± 25.46 (lordosis) and 223.58 ± 21.87 (kyphosis) (P < 0.01). Preoperative global kyphosis (GK) was 75.71 ± 5.26 (lordosis) and 86.30 ± 10.32 (kyphosis) (P < 0.05). All patients in the lordosis group underwent PSO surgery at the twelfth thoracic vertebra (T12) or the first lumbar spinal vertebra (L1), while all patients in the kyphosis group underwent the surgery at the second or third lumbar spinal vertebra (L2 or L3). The differences in postoperative GK, LL, and SVA between the two groups were not significant (P > 0.05). The JOA scores of the two groups increased from 13.00 ± 0.83 (lordosis) and 11.30 ± 0.93 (kyphosis) before surgery to 21.00 ± 0.67 and 19.70 ± 0.60 after surgery (P < 0.05).ConclusionPreoperative lumbar sagittal morphology needs to be considered when selecting the optimal osteotomy plane. An osteotomy can achieve the greatest success in patients with lumbar kyphosis at L2/L3; for patients with lumbar lordosis, it can achieve satisfactory outcomes at T12/L1.

Factors Influencing Outcomes of the Dysplastic Hip in Nonambulatory Children With Cerebral Palsy.

Hip dysplasia in the nonambulatory child with spastic cerebral palsy (CP) is a common condition not always effectively treated with conservative measures even when recognized early. Optimal surgical intervention strategies and timing are not clear from previous studies. Contralateral hips with less severe subluxation in these patients also often undergo surgery and little is known of outcomes of these less severe hips. This study aims to clarify treatment factors related to long term success following hip surgery for subluxation in nonambulatory children with CP. A total of 183 nonambulatory subjects with CP and a minimum of 2-year follow-up were included. All subjects underwent varus rotational osteotomy of the femur; other surgical factors considered were addition of pelvic osteotomy (PO), capsulorrhaphy, and soft tissue releases. Additional factors studied were age at index surgery, sex, and unilateral versus bilateral surgery. Severely subluxated (SS) hips, defined as having >50% migration, were studied separately from contralateral nonsevere hips. Surgeries were deemed successful if final follow-up indicated a migration of <25%; patients with any revision surgeries or >25% migration were categorized as failures. A 60% success rate was found in SS hips and a 68% success rate in nonsevere hips. Age at index surgery did not influence success rates in SS hips. In the nonsevere hips, success was associated with index surgery at older age. The addition of a PO was the only concomitant procedure demonstrated to improve outcomes. In SS hips, those with a successful outcome were 2.5 times more likely to have had a PO. The addition of capsulorrhaphy had a negative effect on the entire group, reducing odds of success to 0.8. No other factors were significant. The findings from this multicenter retrospective study suggest that PO be added to varus rotational osteotomies in patients with severe hip subluxation. Surgery should be undertaken for severe dysplasia without concern for age. The addition of capsulorrhaphy does not improve rate of success. Level III-retrospective comparative study.

Patients with varus knee osteoarthritis undergoing high tibial osteotomy exhibit more femoral varus but similar tibial morphology compared to non-arthritic varus knees.

The aim of this study was to compare alignment parameters between patients undergoing high tibial osteotomy (HTO) for knee osteoarthritis (OA) and non-arthritic controls. Pre-operative computed tomography images from 194 patients undergoing HTO for medial knee OA and 118 non-arthritic controls were utilized. All patients had varus knee alignment (mean age: 57 ± 11years; 45% female). The hip-knee-ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA) and non-weight-bearing joint line convergence angle (nwJLCA) were compared between "control group" and "HTO group". Femoral and tibial phenotypes were also assessed and compared between groups. Variables found on univariate analysis to be different between the groups were entered into a binary logistic regression model. The mean age was lower (Δ = 4 ± 6years, p = 0.024), body mass index (BMI) was higher (Δ = 1.1 ± 2.8kg/m2, p = 0.032) and there were more females (Δ = 14%, p = 0.020) in the HTO group. The HTO group had more overall varus (7° ± 4.7° vs 4.8° ± 1.3°, p < 0.001). There was a significant difference in the mean mLDFA between the two groups with the HTO group having more femoral varus (88.7 ± 3.2° vs 87.3 ± 1.8°, p < 0.001). MPTA was similar between the groups (p = 0.881). Age was found to be a strong determinant for femoral varus (p = 0.03). Patients undergoing HTO for medial knee OA have more femoral varus compared to non-arthritic controls while tibial morphology was similar. This will be an important consideration in pre-operating planning for realignment osteotomy in patients presenting with medial knee OA and warrants further investigation. III, retrospective comparative study.

Mesane Ekstrofisi Tedavisinde Ortopedik Cerrahi Yaklaşımlar

Bladder exstrophy is an embryologic malformation that affects urogenital and skeletal systems. Non-operative treatment of this rare problem is impossible. Urogenital reconstructions can be facilitated by orthopedic procedures. These reconstructions can be performed in a single stage as a complete repair or multi-stage approaches. The goal of the treatment is closure of the bladder and abdominal wall for the achievement of continence, preservation of renal functions, and cosmetic and functional reconstruction of genital organs. Orthopedic procedures are performed to decrease the tension that complicates the bladder and abdominal wall closure by approximating the pubic rami to achieve a secure closure and a low recurrence rate. Surgical interventions consist of the approximation of the pubic rami with different materials such as suture materials and plaque or the application of different osteotomy types such as posterior iliac, anterior pelvic (pubic), diagonal iliac, horizontal iliac and posterior pelvic resection osteotomies. The age of the patient, the amount of pubic diastasis and history of previous operations that the patient has undergone should be considered during the operation planning. Pubic rami can be approximated without performing pelvic osteotomy in patients who are operated within the first 72 hours after birth. But, osteotomy is required in children older than 2 years of age with severe pubic diastasis, concomitant cloacal exstrophy and unsuccessful operation history. The surgical team should have enough knowledge and experience to perform different osteotomy types in case of need to combine anterior and posterior iliac osteotomies. With these multidisciplinary approaches, much more successful outcomes could be achieved.

Preoperative Planning and the Use of Free Available Software for Sagittal Plane Corrective Osteotomies of the Lumbar Spine in Ankylosing Spondylitis.

BackgroundAnkylosing spondylitis (AS) may cause a severe rigid thoracolumbar kyphotic deformity (TLKD) that leads to considerable disturbances of posture and spinal balance. In few patients, a corrective osteotomy of the lumbar spine may be considered. Preoperative planning of a lumbar osteotomy for correction of a severe TLKD due to AS is important to correct patient’s sagittal balance and view angle. There is a need for accurate preoperative planning that can be used easily in daily practice.MethodsThe basic biomechanical and mathematical principles of preoperative planning for correction of a TLKD due to AS are described. A search was performed for free available computer programs that can be used for pre-operative planning of spinal osteotomies in AS. Finally, the use of these computer programs is illustrated and described.ResultsSagittal balance is measured on a standing lateral full-length radiograph of the spine. The assessment of the pelvic parameters (PI, PT, SS) in conjunction with sagittal vertical axis (SVA) and chin-brow-to-vertical angle (CBVA) provides a comprehensive picture of the sagittal spinal alignment and compensatory mechanisms of the patient. The relation between the level of lumbar osteotomy and the amount of correction needed can be calculated with different elementary trigonometric equations. Two free available computer programs, ASKyphoplan and Surgimap, are illustrated and described that can be used for pre-operative planning of spinal osteotomies in AS.ConclusionPreoperative planning of the lumbar osteotomy in AS involves assessment of the combined effect of location of the osteotomy, amount of bone resection, SVA, CBVA, and pelvic parameters. Two free available computer programs, ASKyphoplan and Surgimap, are easy to use in clinical practice to predict postoperative sagittal balance of lumbar osteotomies in patients with severe TLKD due to AS.

Scoliosis Research Society-Schwab Grade 6 Osteotomy for Severe Congenital Angular Kyphoscoliosis: An Analysis of 17 Cases With a Minimum 2-Year Follow-up.

For some patients with severe congenital angular kyphoscoliosis (SCAK), 1-level vertebral column resection is insufficient and the Scoliosis Research Society (SRS)-Schwab Grade 6 osteotomy may be necessary. However, the indications and clinical outcomes of SRS-Schwab Grade 6 osteotomy in patients with SCAK have not been investigated in depth. To investigate the middle-term radiographic and clinical outcomes, and to evaluate the safety of this high technique-demanding procedure. Patients with SCAK undergoing SRS-Schwab Grade 6 osteotomy from 2005 to 2016 followed up at least 2 yr were retrospectively reviewed. The potential indications of SRS-Schwab Grade 6 osteotomy were analyzed. The coronal Cobb angle, segmental kyphosis (SK), deformity angular ratio (DAR), coronal balance, and sagittal vertical axis (SVA) were measured in the preoperative, postoperative, and final follow-up. The intraoperative and postoperative complications were recorded. A total of 17 patients with SCAK (10 M and 7F) were included, and the mean follow-up was 30.8±16.4 mo. The indications of SRS-Schwab Grade 6 osteotomy were as follows: multiple "pushed-out" hemivertebrae (13, 76.5%) and multilevel anterior block (4, 23.5%). Compared with preoperation, the coronal Cobb angle, SK and SVA at postoperation were significantly improved (P<.05 for all). The mean total DAR was 33.4±9.9 at preoperation. Three patients were found to have postoperative neurological deficit. Rod breakage occurred in 3 patients at 15- to 48-mo follow-up, and revision surgeries were performed. At the last follow-up, firm bony fusion was observed in all patients. The technique-demanding SRS-Schwab Grade 6 osteotomy, if well indicated, could provide satisfying correction of the SCAK deformity.

Dislocation Height Performs Well in Predicting the Use of Subtrochanteric Osteotomy in Crowe Type IV Hips.

PurposeThe purpose of this study was to determine whether dislocation height can predict the use of subtrochanteric osteotomy in patients with Crowe type IV hip dysplasia.Patients and MethodsWe retrospectively included 102 patients affected by unilateral Crowe type IV developmental dysplasia who underwent primary total hip arthroplasty with modular cementless stem from April 2008 to May 2019 in our institution. Based on radiographs and operative notes, we found 62 hip arthroplasties were performed with subtrochanteric osteotomy and 40 without subtrochanteric osteotomy, which were named as the (subtrochanteric osteotomy) STO group and non-STO group, respectively. The predictive values of height of greater trochanter, height of femoral head/neck junction, and distalization of greater trochanter were analyzed using receiver operating characteristic (ROC) curves.ResultsThe ROC curves showed that distalization of greater ntrochanter had the highest areas under the ROC curve (AUC), at 0.998. This was followed by height of greater trochanter and height of head/neck junction, which had AUCs of 0.937 and 0.935, respectively. The optimal thresholds of these three indicators were 4.84 cm, 6.05 cm, and 4.26 cm. At the last follow-up, six dislocations occurred (five in the STO group and one in the non-STO group). Four hips were treated by closed reduction and two by open reduction. Three patients (all in STO group) developed femoral nerve palsy with skin numbness on the frontal thigh or tibia and all recovered in a year. At outpatient visit, the limb length was measured. LLD was <1 cm in 83/102, 1–2 cm in 18/102, and >2 cm in 1/102.ConclusionThis study reveals that indicators of dislocation height are useful in predicting the use of subtrochanteric osteotomy during total hip arthroplasty for Crowe type IV hip dysplasia. However, a comprehensive, multivariate analysis may be required to validate these results.

A review of outcomes associated with femoral neck lengthening osteotomy in patients with coxa brevis.

PurposeDouble and triple femoral neck lengthening osteotomies have been described to correct coxa brevis deformity. Only small studies reported the results. Our aim was to provide an overview of the outcomes of double and triple femoral neck lengthening.MethodsAfter an extensive search of different online databases, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsAfter evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported. ConclusionsDouble and triple femoral neck lengthening osteotomies in coxa brevis show good results with few complications in the literature, especially in young patients with non-arthritic hips.Level of evidenceIII

Change in the weight-bearing line ratio of the ankle joint and ankle joint line orientation after knee arthroplasty and high tibial osteotomy in patients with genu varum deformity.

Several studies reported that excessive correction of severe genu varum deformity with total knee arthroplasty or high tibial osteotomy (HTO) could result in ankle joint pain and osteoarthritis progression. However, few studies have evaluated the change in the weight-bearing-line (WBL) ratio of the ankle joint after knee arthroplasty or HTO in patients with genu varum deformities. This study aimed to investigate the change in the WBL ratio of the ankle joint and ankle joint line orientation after knee arthroplasty or HTO in patients with genu varum deformities. We retrospectively evaluated 40 patients (mean age, 69.9 ± 8.0years) with genu varum deformities of > 5° and underwent knee arthroplasty or HTO. Three radiologic parameters, including (1) the hip-knee-ankle (HKA) angle, (2) WBL ratio of the ankle joint, and (3) ankle joint line orientation relative to the ground (AJLO-G), were assessed using pre-operative and post-operative orthoradiographs. A paired t test was used to evaluate post-operative changes in the three parameters. Correlations between the change in HKA angle and that in the WBL ratio of the ankle joint and AJLO-G were analyzed. The mean HKA angle significantly decreased post-operatively (10.6° ± 5.3° to 1.1° ± 3.4°; P< 0.001). The WBL ratio of the ankle joint increased from 35.8% ± 15.2% to 53.0% ± 17.4% (P< 0.001), with a lateral shift of the mechanical axis. The AJLO-G decreased with valgization of ankle orientation (7.8° ± 4.8° to 0.4° ± 3.8°; P< 0.001). The change in the HKA angle was significantly correlated with that in the AJLO-G (correlation coefficient = 0.716; P< 0.001) but not with the change in the WBL ratio of the ankle joint. Knee arthroplasty and HTO corrected the genu varum deformity, which influenced the lateral shift of the WBL of the ankle joint and valgization of the ankle joint line orientation.

OUTCOME OF ARTHROSCOPIC MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION COMBINED WITH TIBIAL TUBEROSITY TRANSFER FOR RECURRENT PATELLAR INSTABILITY

Purpose: This study aimed to assess the outcome of combined medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy in patients who had recurrent patellofemoral instability and a lateralized tibial tubercle.

Inevitable nonunion after ulnar shortening osteotomy in patients with ulnar impaction syndrome and breast cancer under bisphosphonate treatment.

Nonunion after ulnar shortening osteotomy (USO) was observed at a high rate in patients undergoing long-term bisphosphonate (BP) maintenance treatment after breast cancer surgery. Here, we report the unique features of these nonunions. In total, 485 patients who had undergone USO between March 2008 and September 2017 were screened for inclusion based on the following criteria: (1) definitive nonunion after USO; (2) prior history of or ongoing BP therapy after the diagnosis of breast cancer; and (3) no evidence of metastasis in the ulna treated with USO, as determined based on the radiological evaluation. Five patients with histories of breast cancer and subsequent BP treatment were identified; all (100%) of these patients showed definitive nonunion after USO. The mean age was 56.2years, and all ulnae were on the contralateral side to that of the original breast cancer. Intravenous Ibandronate® and Zolendronate® were administrated to one and four patients, respectively. The mean period of administration was 67.8months. Three patients exhibited suspicious lesions impending atypical fracture on their femurs, and the other two patients were treated by intramedullary nailing after the occurrence of atypical fractures. Radiological evaluation revealed no evidence of a metastatic lesion, including in the musculoskeletal system, in any patient. Osteosynthesis was performed with cancellous iliac bone graft and mean of 4.3months after osteosynthesis, union in all cases was achieved. Problems associated with BP treatment are well known. Even in cases in which the agent is essential for preventing bony metastasis of breast cancer, the normal bony physiology, including bone turnover and healing, is likely to be compromised. In addition to atypical fractures of the femur and ulna, procedures such as USO are likely to be affected by BP. Furthermore, not only a primary iliac bone graft but also other method (oblique osteotomy) should be needed to avoid nonunion during plating in USO. IV, Retrospective case series.

Functional Outcome of High Tibial Osteotomy in Patients with Medial Compartment Osteoarthritis Using Dynamic Axial Fixator -a prospective study

IntroductionMedial Compartment Osteoarthritis of the knee is becoming a widespread problem. The surgical options include high tibial osteotomy, unicompartmental knee replacement, and total knee replacement. Replacement surgeries are not advised in the younger age group, so in these patients, high tibial osteotomy is the only option. In this study, we have assessed the functional and radiological outcomes of high tibial osteotomy done by hemicallostasis method. MethodWe report the outcome of 30 patients (30 knees) who underwent hemicallostasis with a dynamic external fixator for medial compartment osteoarthritis of the knee. The radiological assessment was done with the help of Hip Knee Ankle angle. The functional scoring was done via Oxford knee score, IKDC, KOOS, and WOMAC score. ResultsAt a mean follow up of 35 months, the preoperatively mean HKA angle was 172 ± 30. The mean HKA angle postoperatively was 184 ± 10. Appropriate correction of the HKA angle was achieved in 24 of 30 patients (80%). Whereas, there was under correction in 3 patients (10%) and overcorrection in 3 (10%) patients. All the functional scores showed significant improvement in the postoperative scores. There was a positive correlation between the HKA angle and oxford, IKDC, KOOS, and WOMAC Score. Complications like superficial pin tract infection were seen in 3 (10%) patients, deep infection in 1 (3%), and early union of osteotomy in 1 (3%) patient leading to revision of the osteotomy. . ConclusionHTO is effective in improving pain, function, activity of daily living, and quality of life in patients suffering from medial compartment Osteoarthritis of the knee. Hip Knee Ankle Angle is an important parameter to restore for better functional outcomes. The Advantage of using a dynamic axial fixator is the precision in achieving calculated correction without any implant in the bone once the correction is achieved along with good healing rates.

Three-dimensional assessment of nasal changes after maxillary advancement with impaction using stereophotogrammetry.

ObjectiveTo evaluate the changes in the nose in three dimensions after Le Fort I osteotomy in patients with skeletal Class III malocclusion.MethodsThe subjects were 40 adult patients (20 females and 20 males; mean age, 20.3 ± 3.0 years; range, 17.0 to 31.1 years) who underwent one-piece Le Fort I osteotomy with maxillary advancement and impaction treatment for maxillary hypoplasia. The mean maxillary advancement was 4.56 ± 1.34 mm, and the mean maxillary impaction was 2.03 ± 1.04 mm. Stereophotogrammetry was used to acquire three-dimensional images before and at least 6 months after surgery.ResultsAlare (Al) and alare curvature (Ac) points had moved vertically and antero-laterally postoperatively. A significant increase was observed in the nasal ala width and alar base width, and no changes were noted in the columellar length, nasolabial angle, and nasal area. There was a significant relationship between maxillary impaction and nasal ala width and horizontal and sagittal positions of the bilateral Al and Ac. The only relationship found was between maxillary advancement and postoperative sagittal location of the subnasale and pronasale.ConclusionsNasal soft tissues were highly affected by the vertical movement of the maxilla; however, the soft tissue responses were individual-dependent.

Can fusion to S1 maintain favorable surgical outcomes following one-level pedicle subtraction osteotomy in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis?

To compare the surgical outcomes between ankylosing spondylitis (AS)-related thoracolumbar kyphosis patients with the lowest instrumented vertebra (LIV) at S1 or above following one-level pedicle subtraction osteotomy (PSO). One hundred and two AS patients undergoing one-level PSO with a minimum of 2-year follow-up were included. Twenty-two patients were in group S1 (LIV at S1), and eighty were in group non-S1 (LIV above S1). Radiographic parameters including lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI), and sagittal vertical axis (SVA) were measured. Oswestry Disability Index (ODI) and visual analog scale (VAS) were applied for clinical assessment. In both S1 and non-S1 groups, the radiographic parameters and clinical outcomes were significantly improved after surgery (P < 0.05). Patients undergoing distal fusion to S1 had significantly larger preoperative PI-LL mismatch, SVA, and smaller preoperative LL and SS compared to those in group non-S1 (P < 0.05). No significant difference was found between the two groups regarding preoperative and final follow-up ODI and VAS (P > 0.05), as well as the improvement in ODI and VAS (P > 0.05). The incidence of overall complications and each type of complication including the implant failure was similar between group S1 and non-S1 (P > 0.05). Selecting S1 as the LIV without pelvic fixation following one-level PSO in thoracolumbar kyphosis caused by AS could achieve satisfactory surgical outcomes and might not increase the complications. Patients with relatively severe sagittal imbalance, loss of LL, PI-LL mismatch, and small SS might be the potential candidates for distal fusion to S1 following one-level PSO.

Functional and Radiological Outcomes Following Calcaneo-Cuboid-Cuneiform Osteotomy for the Treatment of Planovalgus Feet: A Short-Term Analysis.

Flexible flatfoot refers to the loss of the medial longitudinal arch of the foot on weight bearing and is associated with excessive heel eversion or forefoot abduction. Unless symptomatic, flexible flatfeet are best managed non-operatively. The calcaneo-cuboid-cuneiform osteotomy is a procedure that restores the anatomical shape of the foot without arthrodesis of the joints. Our study aims to evaluate the functional and radiological outcomes of patients treated with calcaneo-cuboid-cuneiform osteotomy in patients with planovalgus feet. A retrospective review of records and radiographs of patients with symptomatic flexible planovalgus feet, who were operated with the calcaneo-cuboid-cuneiform osteotomy by a single senior surgeon in a time period between April 2016 and July 2017 was done. The clinical and radiological outcomes were evaluated in 12 feet in 8 children. A total of 12 feet in 8 children were operated (6 males and 2 females). Average age of patients was 11 ± 1.27years; average follow up was 14.7months ± 2.7months. Two patients had planovalgus feet secondary to spastic diplegia and 6 had idiopathic planovalgus feet. There was a statistically significant improvement in the pain score as well as the radiographic parameters in all the operated patients. The calcaneo-cuboid-cuneiform osteotomy has potential to give good results for symptomatic planovalgus feet with minimal complications.