Osteotomy Distraction Research Articles

Distraction Osteotomy Combined With Orthodontics: An Effective Way to Decrease Short-term Recurrence in Treating Child Craniofacial Microsomia.

This study aims to investigate strategies for reducing early relapse following mandibular distraction osteotomy (MDO) in craniofacial microsomia (CFM) patients. Forty CFM patients were divided into 2 groups: 20 underwent MDO alone, while 20 received MDO combined with orthodontic treatment (MDO-O). Preoperative, prefixation, and postfixation CT data in DICOM format were collected and reconstructed using Proplan software. Spatial geometric analysis was conducted to assess the inclination angle of the occlusal plane (OP), and OP deviation was directly measured using the software. Patients in the MDO-O group demonstrated a statistically significant improvement in OP inclination at the end of the fixation period compared with those who underwent MDO alone (P=0.003). Combining MDO with a bite plate and bite glue sticks in CFM patients during the mixed dentition period enhances OP outcomes, effectively reducing short-term recurrence.

Pelvic Symphyseal Distraction Osteotomy with Handmade Cemented Prosthesis to Manage Obstipation Secondary to Pelvic Fracture Malunion in a Young Dog

AbstractA 5-month-old mixed breed dog suffered chronic obstipation secondary to malunion of multiple pelvic fractures. Pelvic symphyseal distraction osteotomy with a handmade cemented prosthesis was performed, resolving pelvic stenosis.

Influence and risk factors of lateral hinge fracture on early effectiveness of supramalleolar osteotomy

To evaluate the influence of lateral hinge fracture (LHF) on the early effectiveness of supramalleolar osteotomy (SMO) and to explore the related risk factors for LHF. A total of 39 patients (39 feet) with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively. There were 10 males and 29 females, aged from 41 to 71 years (mean, 57.7 years). According to Takakura stage, there were 6 feet in stage Ⅱ, 19 feet in stage Ⅲa, and 14 feet in stage Ⅲb. The LHF was recognized by the immediate postoperative X-ray film. The osteotomy healing time and the changes of pain visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and tibiotalar angle (TT) before and after operation were compared between patients with and without LHF. The age, gender, affected side, body mass index, Takakura stage, preoperative VAS score, preoperative AOFAS score, preoperative TAS, preoperative TLS, preoperative TT, SMO correction angle, osteotomy distraction, distance from medial osteotomy to ankle joint line (MD), and distance from lateral osteotomy to ankle joint line (LD) were compared between with and without LHF patients, and further logistic regression analysis was used to screen the risk factors of LHF during SMO. All patients were followed up 12-54 months (mean, 27.1 months). During operation, 13 feet developed LHF (group A) and 26 feet did not develop LHF (group B). X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation; the osteotomy of other patients healed, and there was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, there were significant differences in VAS score, AOFAS score, TAS, TLS, and TT of the two groups when compared with preoperative ones ( P<0.05), but there was no significant difference in the changes of above indicators before and after operation between the two groups ( P>0.05). The differences in SMO correction angle, osteotomy distraction, and LD between with and without LHF patients were significant ( P<0.05), and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO ( P<0.05). Too high or too low lateral hinge position during SMO may lead to LHF, but as long as appropriate treatment and rehabilitation measurements are taken, the early effectiveness is similar to that of patients without LHF.

A finite element model of human hindfoot and its application in supramalleolar osteotomy

BackgroundThe majority of the ankle osteoarthritis cases are posttraumatic and affect younger patients with a longer projected life span. Hence, joint-preserving surgery, such as supramalleolar osteotomy becomes popular among young patients, especially those with asymmetric arthritis due to alignment deformities. However, there is a lack of biomechanical studies on postoperative evaluation of stress at ankle joints. We aimed to construct a verifiable finite element model of the human hindfoot, and to explore the effect of different osteotomy parameters on the treatment of varus ankle arthritis. MethodsThe bones of the hindfoot are reconstructed using normal CT tomography data from healthy volunteers, while the cartilages and ligaments are determined from the literature. The finite element calculation results are compared with the weight-bearing CT (WBCT) data to validate the model. By setting different model parameters, such as the osteotomy height (L) and the osteotomy distraction distance (h), the effects of different surgical parameters on the contact stress of the ankle joint surface are compared. FindingsThe alignment and the deformation of hindfoot bones as determined by the finite element analysis aligns closely with the data obtained from WBCT. The maximum contact stress of the ankle joint surface calculated by this model increases with the increase of the varus angle. The maximum contact stresses as a function of the L and h of the ankle joint surface are determined. InterpretationThe relationship between surgical parameters and stress at the ankle joint in our study could further help guiding the planning of the supramalleolar osteotomy according to the varus/valgus alignment of the patients.

Neurocognitive outcomes and associated clinical factors 5 years after surgery in children with craniosynostosis.

Craniosynostosis involves early closure of one or more sutures, which is known to limit normal cranium growth and interfere with normal brain development. Various surgical methods are used, ranging from minimally invasive strip craniectomy to more extensive whole-vault cranioplasty. This study aimed to evaluate neurocognitive outcomes 5 years after surgical treatment in children with craniosynostosis and to evaluate relevant clinical factors. After exclusion of genetically confirmed syndromic craniosynostosis patients, a retrospective review was conducted on 112 nonsyndromic craniosynostosis patients who underwent surgical treatment and follow-up neurocognitive assessment. Ninety-seven patients underwent strip craniectomy with postoperative orthotic helmet therapy, and 15 received other surgical treatment: 4 with distraction osteotomy and 11 with craniofacial reconstruction. Neurocognitive assessment using the Korean Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (K-WPPSI-IV), was performed 5 years postoperatively. Clinical factors were assessed regarding neurocognitive outcomes. The mean age at surgery was significantly younger in the strip craniectomy group (strip craniectomy 4.6 months vs other surgical treatment 18.6 months, p < 0.01). Patients with 2 or more sutures involved were more likely to receive more extensive surgical treatment (16.5% in the strip craniectomy group vs 53.8% in the other group, p < 0.01). Four (3.5%) patients who showed evidence of increased intracranial pressure (ICP) also underwent more extensive surgical treatment. Multivariable linear regression revealed a significant correlation of age at neurocognitive testing (-3.18, 95% CI -5.95 to -0.40, p = 0.02), increased ICP (-34.73, 95% CI -51.04 to -18.41, p < 0.01), and the level of maternal education (6.11, 95% CI 1.01-11.20, p = 0.02) with the Full-Scale Intelligence Quotient (FSIQ). Age at surgery, involvement of 2 or more sutures, and type of operation demonstrated no correlation with FSIQ. Among the 97 patients who underwent strip craniectomy, the FSIQ ranged from mean ± SD 100.2 ± 10.2 (bicoronal) to 110.1 ± 12.7 (lambdoid), and there was no significant difference between the suture groups (p = 0.41). The 5 index scores were all within average ranges based on their age norms. Age at neurocognitive assessment, increased ICP, and maternal education level showed significant correlations with the neurocognitive function of craniosynostosis patients. Although children with craniosynostosis exhibited favorable 5-year postoperative neurocognitive outcomes across various synostosis sutures, longer follow-up is needed to reveal the incidence of neurocognitive dysfunction in these patients.

Functional Outcomes of Paediatric Missed Monteggia Fractures Managed with Angulation Distraction Osteotomy of Ulna - A Case Series

Functional Outcomes of Paediatric Missed Monteggia Fractures Managed with Angulation Distraction Osteotomy of Ulna - A Case Series

Finite Element Analysis of Protective Measures against Lateral Hinge Fractures in High-Tibial Osteotomy.

Opening wedge high-tibial osteotomy (OWHTO) is widely used for correcting mechanical axis deviations and offloading the medial compartment in unicompartmental osteoarthritis. However, lateral hinge fractures (LHFs) pose a significant complication. This study investigates protective measures to mitigate these fractures, guided by prior observations of mechanical stress impact on LHFs. The study aims to assess the effectiveness of different protective measures, specifically the use of varying sizes of Kirchner wires and drill holes, in reducing the incidence of LHFs during OWHTO. Study Design. The study employs a quantitative, comparative analysis using a finite element method (FEM) based on computed tomography (CT) scans. Using CT-based FEM, the study compares the impact of different sizes of K-wires (1.6 mm, 2.0 mm, and 2.5 mm) and drill holes (3.2 mm and 4.5 mm) on the mechanical stresses around the hinge area in OWHTO. The models were created from a CT scan of a healthy 33-year-old male, focusing on the force required to open the osteotomy gap and the incidence of cracked shell elements. The study found that thicker K-wires increased the force required to open the osteotomy gap, whereas larger apical holes decreased it. The 4.5 mm apical hole model demonstrated significantly fewer cracks compared to the 2.0 mm K-wire model, with no significant difference observed compared to the 2.5 mm K-wire model. Models using a 1.6 mm K-wire or a 3.2 mm drill hole did not significantly reduce cracks compared to the base model. The findings suggest that a 4.5 mm drill hole may be more effective in reducing the risk of LHFs compared to thinner diameter K-wires or smaller apical holes. Both a 2.5 mm K-wire and a 4.5 mm drill hole reduce the number of cracked elements, but the 4.5 mm drill hole also significantly decreases the average and maximum principal stresses as well as the average tensile strength ratio at the hinge area. These findings may be important for surgical planning, particularly in cases requiring increased osteotomy distraction.

Lateral Joint Distraction through Distal Fibula Lengthening Osteotomy for Lateral Compartment Ankle Osteoarthritis

Category: Ankle Arthritis Introduction/Purpose: Lateral compartment ankle OA, commonly due to trauma such as ankle fracture, is not very rare. However there’s no definite established surgical treatment option. In this study, we suggest distal fibula lengthening osteotomy for lateral joint distraction as one of treatment surgical option. We have experienced favorable clinical outcome for 3 cases of post-traumatic lateral compartment ankle OA with joint space narrowing treated with distal fibula distraction osteotomy. We report the case series with the surgical technique and the clinical- radiological outcome. Methods: From April 2016 to August 2021, three ankles which underwent distal fibula distraction osteotomy were included in this study. All three ankles had a history of OR/IF due to fractures in the ankle joint and were diagnosed with lateral compartment OA. We defined lateral compartment OA when clinical symptoms and radiologic findings were consistent. Clinically, the point of pain was characterized as the lateral compartment of the ankle joint, not the syndesmosis or peri fibular area. Radiologically, joint space narrowing is showed in X-ray, and CT arthrography or MRI confirmed cartilage denudation of the lateral compartment. Results: 1) Clinical outcomes Case 1: The AOFAS score improved from 69 preoperatively to 93 postoperatively, and the Pain vas score improved from 7 to 0. According to patient’s subjective expression, daily activity became 'Boxing available' from 'Hard to run'. Case 2: The AOFAS score improved from 73 preoperatively to 91 postoperatively, and the Pain vas score improved from 5 to 0. According to patient’s subjective expression, daily activity became 'No pain on daily activity' from 'Hard to walk'. 2) Radiologic outcomes Lateral joint space, talocrural angle, talar tilt angle and tibia axis-talar dome angle were all changed close to the contralateral ankle index after surgery. Conclusion: Painful ankle OA localized to the lateral compartment in young age is uncommon and there is no definite surgical method. Distal fibula distraction osteotomy is reasonable surgical method that does not burden patients and surgeon. In our study, distal fibula distraction osteotomy showed favorable clinical-radiological outcomes. So, we recommend this method for painful lateral compartment OA in young ages.

Anterior Maxillary Osteotomy Distraction Osteogenesis (Amodo) in the Treatment of Maxillary Hypoplasia in Unilateral Cleft Lip and Palate-A Case Report

Distraction osteogenesis defines a technique of bone generation by distraction of native bony segments. The technique offers a promising treatment alternative for patients with maxillary or midfacial hypolasia. In this case report, the various steps in the treatment of an 18 year old boy with premaxillary hypoplasia and anterior crossbite are described. Patient was treated with a distraction osteogenesis technique and premaxillary advancement was performed using individual tooth - borne distraction device. The surgical procedure involved an anterior segmental maxillary osteotomy respecting the palatal periosteum. Distractor was cemented in the mouth after the surgical procedures. The patient was observed during a seven day latency period after which the device was activated 0.4mm every 12 hours. The anterior crossbite was eliminated and the occlusal correction and settling was achieved with fixed orthodontic appliances.

The best position of bone grafts in the medial open-wedge high tibial osteotomy: A finite element analysis

Background and objectiveThe application of wedge-shaped bone grafts can increase the biomechanical stability of knee during the medial open-wedge high tibial osteotomy (MOWHTO) by reducing the von Mises stress of the medial plate and lateral cortical hinge area. However, the optimal position of bone grafts it remains unclear, so we aimed to determine search for the optimal position of the bone grafts in MOWHTO by using finite element analysis. MethodsIn the finite element analysis, MOWHTO models were established with three different osteotomy distraction heights and assembled into four groups according to different conditions, including the no bone grafts (NBG) group, the anterior bone grafts (ABG) group, the middle bone grafts (MBG) group, and the posterior bone grafts (PBG) group. Based on previous studies, 600 N and 1800 N loads were applied to the knee joint to simulate the static forces during a double and single leg stance to measure the von Mises stress of the medial implant area and lateral hinge area, the maximum displacement of different models, the relative displacement of the osteotomy area and the stress distribution in the bone grafts. ResultsCompared to the NBG and ABG groups, the stress of the lateral cortical hinge area and the medial implate area was significantly lower in the PBG group. For example, under the 600N force load, when the height of the osteotomy area was 10 mm, 15 mm, and 20 mm, the maximum von Mises stress of the medial implate area and lateral cortical hinge area in the NBG group were 140, 141, 172, and 53, 57, 60 MPa, respectively. Compared with the NBG group, the maximum von Mises stress of the medial implate area and lateral cortical hinge area in the PBG group were reduced by 45%, 56%, 63% and 14%, 39%, 68% at distraction height of 10 mm, 15 mm, and 20 mm, respectively. The bone grafts in the posterior parts provide the best stability,with the stress of the middle and posterior bone grafts are mainly concentrated in the edge. ConclusionsThe posterior part of the osteotomy area is the best position for bone graft placement since it provides optimal stability and reduces von Mises stress in the medial plate and lateral cortex hinge area, with the stress of the posterior bone grafts mainly concentrated in the edge. These findings guide bone graft placement sites in clinical surgery and are a basis for future research on bone graft materials and structures in MOWHTO.

Lateral Joint Distraction Through Distal Fibula Lengthening Osteotomy for Lateral Compartment Ankle Osteoarthritis

Category: Ankle; Trauma Introduction/Purpose: Lateral compartment ankle OA, commonly due to trauma such as ankle fracture, is not very rare. However there's no definite established surgical treatment option. In this study, we suggest distal fibula lengthening osteotomy for lateral joint distraction as one of treatment surgical option. We have experienced favorable clinical outcome for 3 cases of post- traumatic lateral compartment ankle OA with joint space narrowing treated with distal fibula distraction osteotomy. We report the case series with the surgical technique and the clinical-radiological outcome. Methods: From April 2016 to August 2021, three ankles which underwent distal fibula distraction osteotomy were included in this study. All three ankles had a history of OR/IF due to fractures in the ankle joint and were diagnosed with lateral compartment OA. We defined lateral compartment OA when clinical symptoms and radiologic findings were consistent. Clinically, the point of pain was characterized as the lateral compartment of the ankle joint, not the syndesmosis or peri fibular area. Radiologically, joint space narrowing is showed in X-ray, and CT arthrography or MRI confirmed cartilage denudation of the lateral compartment. Results: 1) Clinical outcomes (Table 1) Case 1: The AOFAS score improved from 69 preoperatively to 93 postoperatively, and the Pain vas score improved from 7 to 0. According to patient's subjective expression, daily activity became 'Boxing available' from 'Hard to run'. Case 2: The AOFAS score improved from 73 preoperatively to 91 postoperatively, and the Pain vas score improved from 5 to 0. According to patient's subjective expression, daily activity became 'No pain on daily activity' from 'Hard to walk'. Case 3 is not described because there has been no progress for more than 1 year after surgery. 2) Radiologic outcomes (Table 2) Lateral joint space, talocrural angle, talar tilt angle and tibia axis-talar dome angle were all changed close to the contralateral ankle index after surgery. Conclusion: Painful ankle OA localized to the lateral compartment in young age is uncommon and there is no definite surgical method. Distal fibula distraction osteotomy is reasonable surgical method that does not burden patients and surgeon. In our study, distal fibula distraction osteotomy showed favorable clinical-radiological outcomes. So, we recommend this method for painful lateral compartment OA in young ages.

How Low Should We Go? Safety and Craniometric Impact of the Low Occipital Osteotomy in Posterior Vault Remodeling.

A larger volume cranial vault expansion is likely facilitated by a low posterior cranial osteotomy beneath the torcula; however, this may impart an increased risk of venous bleeding. The authors compared the safety of infratorcular versus supratorcular osteotomy in patients undergoing posterior vault reconstruction or posterior vault distraction osteogenesis and analyzed volumetric changes. Patients undergoing initial posterior vault reconstruction or distraction osteogenesis between 2009 and 2021 at the authors' institution were grouped by occipital osteotomy location and analyzed retrospectively. Craniometric analysis was performed if patients had high-resolution computed tomography scans available within 180 days preoperatively and postoperatively. A total of 187 patients were included: 106 (57 percent) who underwent posterior vault distraction osteogenesis and 81 (43 percent) who underwent posterior vault reconstruction. Infratorcular osteotomy was more common in reconstruction [ n = 65 (80 percent)] than in distraction osteogenesis [ n = 61 (58 percent); p < 0.002]. Blood transfused was similar between low and high osteotomy cohorts in the distraction osteogenesis ( p = 0.285) and reconstruction ( p = 0.342) groups. However, median transfused blood volume per kilogram of patient weight was greater in the low versus high osteotomy distraction osteogenesis ( p = 0.010) and reconstruction ( p = 0.041) cohorts. Intraoperative venous sinus injury was rare. In the distraction osteogenesis cohort, there was increased median intracranial volumetric gain in the low (263 ml) compared with the high osteotomy cohort (127 ml; p = 0.043); however, when controlled for distraction distance, only a trend was observed ( p = 0.221). Patients undergoing distraction osteogenesis showed a larger median intracranial volume increase (168 ml) compared with those undergoing reconstruction (73 ml; p < 0.001). Infratorcular osteotomy can be performed safely in most patients undergoing cranial vault remodeling and does not appear to be associated with greater hemodynamic instability or sinus injury. Therapeutic, III.

Double trouble - Airway equipment problem in a difficult airway!

Sir, A 11-year-old boy weighing 29 kg was posted for pelvic supporting osteotomy with limb lengthening and external fixation. He had a history of sepsis in infancy with post-sepsis sequelae and resultant limb length discrepancy. The patient also had surgery six years ago for posttraumatic bilateral temporomandibular ankylosis. Bilateral distraction osteotomy followed by release of ankylosis was performed in a two-stage procedure. On examination, he had micrognathia and retrognathia, with a mouth opening restricted to 2 cm [Figure 1]. He was otherwise healthy, and blood investigations were within normal limits.Figure 1: (a) Patient profile showing significant retrognathia (b) Limited mouth openingWe anticipated a difficult airway and planned to conduct the case under general anaesthesia using supraglottic airway device (SAD), with femoral nerve block for analgesia. Plan B, in case SAD insertion failed, was fibreoptic-guided tracheal intubation. The operating room preparation included difficult airway cart and team briefing about the airway plan. An intravenous line was secured prior to induction. The child was very anxious, so 1 mg midazolam was administered under monitoring. Following administration of glycopyrrolate 4 μg/kg and fentanyl 2 μg/kg, inhalational induction with incremental sevoflurane in 100% oxygen was performed. Once ability to mask ventilate was confirmed, we administered propofol 3 μg/kg. Laryngeal mask airway (LMA) Supreme® size 2.5 was chosen (over our standard preference of i-gel® airway) since it has a rather lean profile which we thought would easily fit into the narrow oral cavity. LMA insertion was easy, and adequate ventilation was achieved with a good seal. Muscle relaxant was avoided and patient was ventilated on pressure support mode with oxygen, air and sevoflurane using low flow anaesthesia. Midway through the procedure, the attending anaesthetist (our fellow in paediatric anaesthesia) noticed that the ventilator bellows had suddenly collapsed and the end-tidal carbon dioxide (EtCO2)value fell from 35 mmHg to 20 mmHg. He immediately took the reservoir bag in hand and started manual ventilation with 100% oxygen. The consultant anaesthetist was called for help and manual ventilation revealed a large leak in the LMA. Functional airway obstruction (laryngospasm, bronchospasm), shifting of the LMA were some of the differentials that came to mind. 1 mg/kg of propofol was administered and decision to change the LMA was taken. The orthopaedic surgeons were informed about the problem and requested to stop surgery. When the tapes securing the LMA were removed and the LMA Supreme® was taken out, we noticed a breach at proximal end at the junction of the bite block, causing the massive leak and loss of ventilation [Figure 2]. Another LMA Supreme® was inserted and the rest of the case proceeded uneventfully. Prompt detection, identification of the problem and timely intervention prevented fall in oxygen saturation. We are a close-knit team of paediatric anaesthetists, fellows and experienced technicians, and the shared understanding of the case ensured efficient crisis management.Figure 2: LMA Supreme® with arrow indicating site of breakage at the junction of shaft with the bite portionWe did a root cause analysis and also conducted a team debriefing after the case. The LMA Supreme® used was a near expiry device, and we believe it may have deteriorated during storage leading to the breakage. On performing a literature search, we found a report of breakage of LMA Supreme® similar to our case.[1] We decided to send this communication for publication to highlight the following points. A visual inspection to confirm the integrity of the airway device and the cuff (in case of cuffed SADs) should be part of the mandatory anaesthesia trolley pre-check. Excessive reuse of reusable SADs can also result in damage.[2] Team briefing is vital prior to every case; especially so for difficult cases. Wherever possible, in DA cases, spontaneous ventilation, avoidance of muscle relaxant and “not to burn bridges” is a sensible, safe approach.[3] Age and weight appropriate “standby” equipment should be immediately available for rescue, such as in our case. Soft skills, for example, team work and communication play an important role in crisis management. Debriefing with the entire team is equally important after critical events to assess and improve team performance and to promote a culture of safety. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Simplifying the Volar Distraction Osteotomy for Distal Radius Malunion Repair.

Background Extra-articular fractures of the distal radius are often treated with a trial of nonoperative management if radiographic parameters are within an acceptable range, especially in the elderly population. Unfortunately, some malunions become symptomatic or become grossly misaligned during nonoperative management which require corrective surgery to restore the normal osseous anatomy and restore function. Description of Technique We describe correction of a distal radius malunion utilizing a distraction-type volar osteotomy, a volar plate specific distraction device, and a novel resorbable calcium phosphate bone cement (Trabexus) designed to withstand compressive loads. Patients and Methods Twelve patients with 13 distal radius fractures were included in this study. The average patient age was 60.9 years and average time from injury to corrective osteotomy was 96.3 days. Radiographic measures (radial inclination, volar tilt, and ulnar variance) and clinical assessment (wrist/forearm range of motion and grip strength) were done pre- and postoperatively and compared. Results The average time from corrective surgical osteotomy to final clinical follow-up was 375.8 days. After surgical intervention, there was a statistically significant improvement in mean volar tilt (-19.8 vs. +0.5 degrees) and mean ulnar variance (+2.8 vs. -0.4 mm). Improvements were also seen in grip strength (1.7 vs. 43.6 lb), wrist flexion (30.5 vs. 48.3 degrees), wrist extension (33.3 vs. 53.8 degrees), forearm pronation (75.0 vs. 88.8 degrees), and forearm supination (53.8 vs. 81.3 degrees). On average, 56.0% of Trabexus bone substitute remained on final clinical radiographs. Conclusion This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients.

Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?

Although lengthening of the lateral column through an osteotomy of the anterior calcaneus is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint after lateral column lengthening (LCL) and determine if Steinmann pin stabilization of the CC joint before distraction maintains a normal relationship. Seven matched pairs of fresh-frozen cadaveric feet underwent preprocedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL by osteotomy through the anterior calcaneus was then performed. One foot of each matched pair had a single smooth Steinmann pin placed centrally across the CC joint before osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12-mm porous titanium wedge. Repeat imaging was obtained and compared with preprocedure studies to quantify sagittal and rotational differences at the CC articulation. Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs. 17.6%, P=0.02) and unpinned (12.5% vs. 16.3%, P=0.04) specimens. No difference in the percentage of subluxation was found between the 2 groups after LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid after LCL in both the pinned (7.6±5.6 degrees, P=0.01) and unpinned (17±12.3 degrees, P=0.01) specimens. The degree of rotation was greater in unpinned specimens after LCL (P=0.043). Both sagittal and rotatory subluxation seem to occur at the CC joint after LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on 3-dimensional imaging are interpreted as dorsal translation when viewed 2 dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with 2 pins during LCL to prevent this rotatory subluxation. Level V-cadaver study.

Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:While lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint following lateral column lengthening (LCL) as well as to determine if Steinman pin stabilization of the CC joint prior to distraction maintains a normal CC relationship.Methods:Seven matched pairs of fresh frozen cadaveric feet underwent pre-procedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL via a calcaneal neck osteotomy was then performed. One foot of each matched pair had a single smooth Steinman pin placed centrally across the CC joint prior to osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12mm porous titanium wedge. Repeat imaging was obtained and compared to pre-procedure studies to quantify sagittal and rotational differences at the CC articulationResults:Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs 17.6%, p=0.02) and unpinned (12.5% vs 16.3%, p=0.04) specimens. No difference in the percentage of subluxation was found between the two groups following LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid following LCL in both the pinned (7.6O +- 5.6O, p=0.01) and unpinned (17O +- 12.3O, p=0.01) specimens. Though a greater degree of rotation was present in the unpinned specimens following LCL, this difference was not statistically significant (p=0.28).Conclusion:Both sagittal and rotatory subluxation seem to occur at the CC joint following LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on three-dimensional imaging are interpreted as dorsal translation when viewed two dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with two pins during LCL to prevent this rotatory subluxation.

Cephalometric Analysis of Hard and Soft Tissue Changes Following Anterior Maxillary Osteotomy Distraction in Cleft Maxillary Hypoplasia.

Nonsyndromic unilateral CLAP patients despite the best surgical efforts present with variable degree of maxillary hypoplasia after cleft palate repair. AMOD is an extension of anterior maxillary osteotomy where the resulting segment anterior to the chosen site of vertical corticotomy cut is distracted with the help of hyrax screw through a tooth-borne appliance. To analyze the hard and soft tissue profile changes following AMOD. To determine the ratio of soft tissue changes to the given extent of hard tissue movements. Study group consisted of 25 patients with cleft maxillary hypoplasia reporting to the Department of OMFS, Coorg Institute of Dental Science. The preoperative and postoperative radiographs were taken followed by prediction tracing. In comparison of pre-op and post-op ceph mean improvement in hard tissue profile was seen at N-A by 2.84mm, N-A-Pg by 2.52, ANS-Gn by 2.28mm, N-ANS by 0.68mm, 1-Nf by 0.32 and at PNS-ANS was 4.2mm signifying improvement in middle third of face. Mean improvement in soft tissue profile at G-Sn-Pg angle by 1.2, G-Sn was 3.92mm, nasolabial angle by 10.92, incisor exposure (Stm-1) by 0.24mm and interlabial gap by 0.56mm. On ratio and correlation of soft tissue changes to given extent of hard tissue change, with movement of point A and U1 resulted significant changes in Sn and Ls. Movement of ANS resulted in significant changes in pronasale and columella. In our study significant improvement was seen in hard and soft tissue facial profile. In conclusion, AMOD is one of the emerging techniques to correct cleft maxillary hypoplasia which will have a defined definitive role to play in future.

Aberrant growth of the anterior cranial base relevant to severe midface hypoplasia of Apert syndrome

BackgroundA 9-year-old male showed severe defects in midface structures, which resulted in maxillary hypoplasia, ocular hypertelorism, relative mandibular prognathism, and syndactyly. He had been diagnosed as having Apert syndrome and received a surgery of frontal calvaria distraction osteotomy to treat the steep forehead at 6 months old, and a surgery of digital separation to treat severe syndactyly of both hands at 6 years old. Nevertheless, he still showed a turribrachycephalic cranial profile with proptosis, a horizontal groove above supraorbital ridge, and a short nose with bulbous tip.MethodsFundamental aberrant growth may be associated with the cranial base structure in radiological observation.ResultsThe Apert syndrome patient had a shorter and thinner nasal septum in panthomogram, PA view, and Waters’ view; shorter zygomatico-maxillary width (83.5 mm) in Waters’ view; shorter length between the sella and nasion (63.7 mm) on cephalogram; and bigger zygomatic axis angle of the cranial base (118.2°) in basal cranial view than a normal 9-year-old male (94.8 mm, 72.5 mm, 98.1°, respectively). On the other hand, the Apert syndrome patient showed interdigitating calcification of coronal suture similar to that of a normal 30-year-old male in a skull PA view.ConclusionTaken together, the Apert syndrome patient, 9 years old, showed retarded growth of the anterior cranial base affecting severe midface hypoplasia, which resulted in a hypoplastic nasal septum axis, retruded zygomatic axes, and retarded growth of the maxilla and palate even after frontal calvaria distraction osteotomy 8 years ago. Therefore, it was suggested that the severe midface hypoplasia and dysostotic facial profile of the present Apert syndrome case are closely relevant to the aberrant growth of the anterior cranial base supporting the whole oro-facial and forebrain development.

In vivo comparison of new biodegradable magnesium‐based implants for bone regeneration

Background A variety of materials have been used for bone augmentation, distraction osteotomy, and in post-cancer patients following tumor removal. However, a temporary metal implant that would resorb after successful treatment is a new concept. Magnesium was suggested as a suitable material for these purposes because it is biocompatible, has better mechanical properties than titanium, and stimulates new bone formation. Aim/Hypothesis To evaluate histological appearance of magnesium-based implants and the surrounding bone. Material and Methods Three magnesium-based biomaterials were tested in a rabbit bone defect model- magnesium hydroxyapatite (Mg-HA), W4 (96% magnesium, 4% yttrium), and pure magnesium (pure Mg). Animals were sacrificed after 6 and 12 weeks and the samples were analyzed histologically and histomorphometrically. Results Mg-HA had the highest mean amount of tartrate-resistant acid phosphatase (TRAP) positive cells at the implantation site of all groups. It had shown the fastest degradation rate already at 6 weeks but the least amount of new bone formation. New bone was seen forming in direct contact to pure Mg and W4. The mean gas volume was highest in W4 compared to pure Mg and Mg-HA but this difference was not statistically significant. W4 had the lowest mean number of TRAP-positive cells of all materials. Conclusions and Clinical Implications Pure Mg and W4 were shown to be the most promising materials in this study in respect to the bone response to the implant material. They could be used for screws and plates in bone augmentation procedures.

Management of Neurologic Deformity of the Ankle and Foot With Concurrent Osteomyelitis With the Ilizarov Method.

The combination of neurologic deformity of the ankle and foot with osteomyelitis is a therapeutic challenge. We investigated the role of Ilizarov with regard to eradication of infection, correction of deformities and improvement of patient function. We retrospectively reviewed 77 patients (77 feet) with neurologic deformity of the ankle and foot with osteomyelitis treated sequentially in 3 stages by Ilizarov method. The 3 stages were (1) active debridement and Ilizarov stabilization, (2) further strengthening of Ilizarov fixator and active osteosynthesis consisting of strategies like arthrodesis, osteotomy distraction, bone transport, or combination thereof, (3) consolidation of fusion/regeneration achieved in second stage. Patients with Charcot arthropathy were not included in the study. There were 43 males and 34 females with mean age of 34.4 (range, 18 to 70) years. All patients had a minimum of 1 year follow-up and 49 patients had 5 years follow-up. Mean duration of external fixation was 179.9 (range, 128 to 413) days. The success of infection eradication was 90.9% and 91.9% at the end of 1 and 5 years, respectively. We achieved plantigrade feet in all cases with no recurrence of deformity. The American Orthopaedic Foot & Ankle Score (AOFAS) improved from a median preoperative value of 74 (interquartile range, 65 to 75.25) to 81 (interquartile range, 77 to 88) ( P < .0001). The improvement of the score was by 7 points only considering the painless nature of the pathology, and the fact that pain contributed to 40% of total score. A total of 39 complications occurred in 30 patients which were managed successfully by alteration of rehabilitation and carefully chosen interventions. Ilizarov external fixation was an effective technique to address problems associated with neurologic foot and ankle deformity with infection. It allowed eradication of infection and achievement of a stable plantigrade foot. It had some disadvantages like lengthy duration of treatment, pin-tract infections, need for operative expertise, and supervised rehabilitation, but we feel these were definitely outweighed by its benefits. Level IV, retrospective case series.