Combined Osteotomy Research Articles

TRUE FEMORAL NECK LENGTHENING OSTEOTOMY WITH PERIACETABULAR OSTEOTOMY FOR COXA BREVA THROUGH SURGICAL HIP DISLOCATION

Sequelae of Legg-Calve -Perthes disease (LCPD) and treatment of developmental dysplasia of the hip (DDH) can present a coxa breva or coxa magna deformity, sometimes associated with coxa vara. This unique deformity decreases the efficiency of the abductor mechanism, causing a Trendelenburg gait and hip pain, leg length discrepancy and leads to intra- and extra-articular impingement, and eventually osteoarthritis. Several surgical techniques have been advocated to treat this kind deformity, such as great trochanter transfer, relative femoral neck lengthening. We evaluated primary results of true femoral neck-lengthening osteotomy (TFNLO) in combination with periacetabular osteotomy (PAO) for treatment of Coxa Breva through surgical hip dislocation (SHD).Fourteen patients with Coxa Breva received true femoral neck lengthening osteotomy in combination of PAO through SHD between March 2020 and October 2023. Ten patients with minimum 1 year followed-up were retrospectively reviewed clinically and radiographically. Eight patients had Perthes disease, 2 had DDH received closed reduction and fixation during childhood. The mean age at surgery was 16 years (range, 12 to 31 years). Clinical findings, radiographic analyses including the change in horizontal femoral offset and the leg length discrepancy as well as complications were assessed.Horizontal femoral offset improved 19.5mm(6–28mm). Limb length increase 16.8mm(11–30mm). Mean HHS increased from 80.6(66–91) to 91.8(88–96). Complication: screw broken in 1(no need operation). Asymptomatic fibrous union of the great trochanter was found in 1. No infection and joint space narrow as well as nerve palsy happened.TFNLO combined with PAO can be effective for the treatment of patients with Coxa breva. But long term follow up is warranted.

Combined Distal Metatarsal and Akin Osteotomies for Concomitant Metatarsophalangeal and Interphalangeal Hallux Valgus: Clinical and Radiological Outcomes

Combined metatarsal and Akin-type proximal phalanx osteotomies represent a surgical solution for concomitant metatarso-phalangeal and inter-phalangeal hallux valgus. This retrospective observational study aimed to evaluate clinical and radiographic outcomes following combined distal linear metatarsal and Akin osteotomies. The study included 42 feet from 37 patients, with a mean follow-up of 27.1 (range 24-37) months. Mean surgical time was 16.54 ± 4.17 minutes. Pre- and postoperative clinical scores and radiological parameters were collected. Positive outcomes with a low recurrence and complications rates were reported. A statistically significant improvement in the Manchester–Oxford foot questionnaire, the EuroQol 5D-5L dimensions instrument, the visual analogue scale, the intermetatarsal angle, the hallux valgus angle, the distal metatarsal articular angle, and the interphalangeal angle correction was observed. Despite the results reported, further prospective studies are needed to identify the most suitable patients for this combined osteotomy approach.

COMPARATIVE ANALYSIS OF THE EFFICIENCY OF DIFFERENT METHODS OF OSTEOTOMY WHEN PERFORMING CLOSED RHINOPLASTY

The aim. Increasing the effectiveness of treatment of patients with primary deformity of the nasal skeleton with a pronounced violation of the function of nasal breathing, by improving existing and developing new methods of reconstructive surgery of the nose.
 Materials and methods. 38 patients participated in the study. They were divided into two groups of 19 patients each. The gender and age distribution in both groups was approximately the same. The control group had rhinoplasty performed using a traditional osteotomy. Endonasal continuous osteotomy was performed using a 4 mm chisel. The research group underwent a combination of piezoelectric surgery and combined transcutaneous access, during rhinoplasty. At the same time, a 3 mm chisel was used for lateral and transverse lateral osteotomies, and a piezotome was used to remove the hump, medial and transverse dorsal osteotomies. All patients of both groups underwent only primary rhinoplasty in a closed manner.
 Results. Postoperative symptoms and complications were studied in both groups: perforation of the mucous membrane, narrowing of the nasal airways, bony irregularities, eyelid swelling, periorbital ecchymoses, as well as overall patient satisfaction. Symptoms were evaluated on the first day after surgery, 3 days after surgery, and 1 week after treatment. When comparing the obtained data, a statistically significant decrease in intra- and post-operative complications was found when performing rhinoplasty using piezoelectric surgery in combination with transcutaneous access. Also, piezotome osteotomy in combination with transcutaneous access has a number of advantages over classic osteotomy, which consist in reducing traumatic complications, obtaining more stable bone structures during surgery, which gives a better predicted result of rhinoplasty, and therefore, greater patient satisfaction.
 Conclusions. Performing a combination of piezotome osteotomy with a transcutaneous approach improves the postoperative period for patients and contributes to a better rhinoplasty result due to fewer complications.

Do facial soft tissue thicknesses change after surgeries correcting dental malocclusions? An intra- and inter-patient statistical analysis on soft-tissue thicknesses in BSSO + LFI surgeries.

The aim of this study was to analyse changes in facial soft tissue thickness (FSTT) after corrective surgeries for dental malocclusion. The correlation between body mass index (BMI) and sex of patients and their FSTT before undergoing surgery was analysed. Cone beam computed tomography of seventeen patients that underwent Le Fort I osteotomy in combination with bilateral sagittal split osteotomy were collected. Hard and soft tissue landmarks were selected basing on the interventions. FSTT were computed, and measurements from pre- to post-operative were compared. The relationship between FSTT, sex, and BMI was investigated. Considering the comparison between pre- and post-operative measurements, any significant difference emerged (p > .05). The Pearson's correlation coefficient computed between BMI and the FSTT (pre-operative) showed a correlation in normal-weight patients; the region-specific analysis highlighted a stronger correlation for specific landmarks. Higher median values emerged for women than for men; the subset-based analysis showed that women presented higher values in the malar region, while men presented higher values in the nasal region. The considered surgeries did not affect the FSTT of the patients; differences related to BMI and sex were found. A collection of FSTT mean values was provided for twenty landmarks of pre- and post-operative of female and male subjects. This exploratory analysis gave insights on the behaviour of STT after maxillofacial surgeries that can be applied in the development of predictive methodologies for soft tissue displacements and to study modifications in the facial aspect of the patients.

8. The Versatile Role of Fat Injection during Various Genioplasties

PURPOSE: Fat injection is increasingly common in aesthetic surgery due to autogenous volume augmentation, anti-inflammatory properties of adipocyte stem cells, regenerative potential, and restoration of youthful aesthetics. However, there is sparsity in the literature to the chin and corresponding complications. We report our experience with fat injection during chin surgery. METHODS: Data from our institution was collected from 2016-2022 for patients who underwent chin fat grafts and genioplasty alone. Patients with chin fat injection were divided into isolated chin fat injection (CFI), combined facial and chin fat injection (FFCFI) and those who underwent genioplasty or osteotomy in combination with chin fat injection (CFIO). Patient demographics and surgical details were compiled for each patient. Complications and reoperations were compared using Fischer’s exact test compared to genioplasty alone. RESULTS: A total of 181 patients were included in the final analysis, with 14 CFI patients, 130 FFCFI patients, 24 CFIO patients, and 13 patients who underwent genioplasty alone. Additional fat injections were required in 17 (9.4%) patients overall, which included 14 FFCFI patients (10.8%) and three CFIO patients (12.5%) (p=0.73). No patients who underwent genioplasty alone or CFI required reoperation. There were no significant differences in complications between the genioplasty-alone (0%) in comparison to the CFI (7.1%; p=1.00), FFCFI (8.3%; p=0.53), or CFIO cohorts (7.7%; p=1.00). CONCLUSION: Fat injection provides options for augmentation on patients as either an isolated procedure or in combination with osteotomies for enhanced aesthetic outcomes, and has low complication rates.

Using multivariate nonlinear mixed-effects model to investigate factors influencing symptom improvement after high tibial osteotomy in combination with bone marrow concentrate injection for medial compartment knee osteoarthritis: a prospective, open-label study

PurposeTo investigate the effects of various demographic, structural, radiographic, and clinical factors on the prognosis of patients with medial compartmental knee osteoarthritis with varus deformity undergoing medial opening wedge high tibial osteotomy (HTO) in combination with bone marrow concentrate (BMC) injection.MethodsIn this prospective study, 20 patients underwent medial opening wedge HTO in combination with BMC injection with 12 months of follow-up. The structural and radiographic outcomes were evaluated by femorotibial angle and posterior tibial slope angle. The clinical outcomes were evaluated by visual analogue scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and The Knee injury and Osteoarthritis Outcome Score (KOOS). Multivariate nonlinear mixed-effects models with asymptotic regressions were used to model the trajectory of symptom improvement.ResultsMedial opening wedge HTO in combination with BMC corrected the malalignment of the knee and led to significant symptom relief. The improvement of clinical symptoms reached a plateau 6 months after the surgery. Greater symptom severity at baseline and lower Kellgren-Lawrance (KL) grades were correlated with better post-operative clinical outcomes. Body-Mass-Index (BMI), femorotibial angle, age, and sex may also play a role in influencing the extent of symptom relief.ConclusionSymptom severity at baseline is important for prognosis prediction. In clinical practice, we suggest that the evaluation of clinical features and functional status of the patients be more emphasised.

Trapezoidal Osteotomy for Treatment of Long-Standing Nonunion of Lateral Humeral Condyle Fracture With Cubitus Valgus Deformity

Long-term nonunion of the lateral humerus condyle fracture may lead to progressive cubitus valgus, elbow pain and instability, and secondary ulnar neuritis. A number of techniques of osteotomy are available for correction, but each has its disadvantages. The aim of this study was to present a technique of medial trapezoidal osteotomy for correcting nonunion of the lateral humeral condyle with an elbow valgus deformity >20°. Eight patients (mean age, 7.5 years) with cubitus valgus, after neglected nonunion of a lateral humeral condyle fracture of greater than 2 years duration, were treated with trapezoidal combined osteotomy. The mean interval from the lateral condylar fracture to surgery was 3.1 years. The osteotomy lines were marked on the bone with a template made before surgery. The lateral condyle and osteotomy site were fixed with K-wires, and the elbow joint was immobilized in a plaster brace. Pre- and postoperative carrying angles, range of motion, elbow function, and ulnar nerve neuropathy were analyzed. The mean follow-up was 5.9 years. Union of the lateral condyle was achieved in all patients; 3 healed at 8 weeks, 2 healed at 9 weeks, 2 healed at 10 weeks, and 1 healed at 12 weeks. The mean carrying angle decreased from 30.1° before surgery to 5.8° after surgery. The surgery did not reduce the range of motion at the elbow. According to the Mayo Elbow Performance Score, 6 patients had excellent elbow function, and 2 had good elbow function at the last follow-up. All preoperative ulnar nerve symptoms resolved. One patient had a mild surgical site infection. No other complications occurred. Medial trapezoidal osteotomy appears to be an effective method for treating nonunion of lateral humeral epicondyle fracture with cubitus valgus deformity. Therapeutic V.

Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty.

Symptomatic proximal humeral fracture sequelae (PHFS) represent a surgical challenge due to the altered bone and soft tissue morphology. The purpose of this study was to report the outcome of Multiplanar Corrective Humeral Osteotomies (MCHOs) in combination with reverse total shoulder arthroplasty (rTSA) performed following a three-dimensional (3D) preoperative planning and using a 3D-printed patient-specific surgical instrumentation (PSI) in type 1C, 1D, and 4 PHFS. In this prospective monocentric study, we enrolled patients affected by symptomatic PHFS type 1C, 1D, or 4 of Boileau's classification, treated between 2018 and 2019 with rTSA associated to MCHO and followed-up at 12 and 24 mo. The preoperative and postoperative Constant Score (CS), visual analog scale, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded. All patients underwent a preoperative computed tomography, then a dedicated software was used to run a segmentation algorithm on computed tomography images. Metaphyseal bone cuts were virtually performed before surgery in all patients, and a 3D-printed PSI was used to reproduce the planned osteotomies invivo. Twenty patients completed a 2-y follow-up. The mean (± standard deviation) CS, visual analog scale, and DASH values improve from 24.3 (± 8.8), 6.5 (± 1.3), 60.7 (± 9.6) preoperatively, to 67.7 (± 11.4), 1.6 (± 0.8), 24.1 (± 13.1) points after surgery, respectively. The minimally clinical important difference for CS and DASH score was achieved in 95% of patients. No major complication was observed. One patient showed an unexplained worsening of clinical scores between the 12 and the 24-mo follow-up, while in one patient bone resorption of the greater tuberosity was observed on radiographs at 2 y, with no clinical impact. The combination of preoperative 3D planning and intraoperative use of 3D-printed PSI to perform MCHO as concurrent procedure in the context of rTSA in the treatment of Boileau type 1C, 1D, and 4 PHFS may lead to a satisfactory clinical outcome at 2 y of follow-up.

Short graft anterior cruciate ligament reconstruction: Current concepts

Short graft anterior cruciate igament reconstruction is increasing in popularity for performing a primary ACLR. The short graft coupled with the all-inside technique using closed sockets and suspensory fixation at both femoral and tibial ends are its defining features. The outcomes of this technique have been comparable to well established transportal ACLR techniques. It has the benefits of preserved hamstring strength and less pain attributed to transtibial drilling. However, there is a learning curve involved and will require time before mastery of the technique. Furthermore, in combined osteotomy or multiligament surgery, the use of short graft anterior cruciate ligament reconstruction with sockets preserve bone stock and the single tendon harvest spares the other tendons for use in other ligament reconstruction.

Computer-assisted design model to evaluate the outcome of combined osteotomies in Legg-Calvé-Perthes disease

ObjectiveThe current study aims to conduct a quantitative dynamic analysis of hip morphology using a computer-assisted design (CAD) model to evaluate the combined pelvic and femoral osteotomies in the treatment of Legg-Calvé-Perthes disease (LCPD).Materials and methodsCAD models of patients with unilateral LCPD treated by combined pelvic and proximal femoral osteotomies were established based on the data of CT scan, on which morphological parameters were measured. Shape difference analysis of normal hips was adopted to locate the most apparent displacement and the main strain on the surface of the proximal femur.ResultsFifteen patients were included, and the mean age of receiving operation was 6.63 years old. There were 10 hips rated as Herring type C, and the rest were type B. Compared with the normal side, the affected hip joints have a longer distance between femoral head and acetabular sphere. The difference of coverage area of the femoral head surface and femoral head volume between the affected and normal sides was bigger compared with the preoperative model, respectively. The changes in the acetabular radius and the area of the surface were not apparent, pre-, and post-operatively. The displacement was mainly on superior and lateral superior portions of the femoral head where the stresses were concentrated.ConclusionCombined pelvic and femoral osteotomies could effectively improve the superior and superior–posterior area of acetabulum containment with increased femoral head volume. CAD model and shape difference analysis can provide a better understanding of deformations of LCPD and more information for surgical planning and evaluation of treatment outcomes.

Mid-Long-Term Outcomes of Surgical Treatment of Legg-Calvè-Perthes Disease: A Systematic Review.

Background: Legg–Calvè–Perthes disease (LCPD) is a common childhood disease that usually occurs in 4- to 12-year-old children. Surgical treatment consists of femoral, pelvic, or combined osteotomies. This comprehensive review aimed to investigate the mid- and long-term outcome of the surgical treatment. Methods: A systematic review of PubMed, Science Direct, and MEDLINE databases was performed by two independent authors, using the keywords “outcome”, “surgical treatment”, “pelvic osteotomy”, “femoral osteotomy”, and “Legg–Calvè–Perthes disease” to evaluate studies of any level of evidence that reported the surgical outcome of LCPD. The result of every stage was reviewed and approved by two senior investigators. Results: A total of 2153 articles were found. At the end of the screening, we selected 23 articles eligible for full-text reading according to the inclusion and exclusion criteria. Our analysis showed that the main prognostic factors for surgical outcome in patients with LCPD are the age at onset and the degree of initial disease severity. Conclusions: Surgical treatment in patients older than 6 years has excellent results in Herring B and B/C hips and poor results in Herring C hips, with a slight advantage for patients between 6 and 8 years old.

Pelvic osteotomy in cloacal exstrophy: A changing perspective

BackgroundThe type of osteotomy and pelvic fixation in the management of primary cloacal exstrophy (CE) closure is variable. The purpose of this study was to evaluate primary CE closure outcomes with osteotomy, immobilization, and multi-staging procedure trends over time. MethodsAn institutional database was retrospectively reviewed for patients who underwent primary CE closure from 1960 to 2020. Demographics, osteotomy, fixation, and outcomes were noted. Subanalyses by location of primary closure (AH=author's hospital; OH=outside hospital). ResultsOut of 122 patients, multi-stage became more common than single-stage procedures (p = 0.019), with multi-stage associated with higher success rates (77.4% v 45.7%; p = 0.001). The use of any osteotomy increased over time (p = 0.007), with a posterior approach falling out of favor and increasing prevalence of a combined osteotomy (p<0.001). The use of any osteotomy compared to no osteotomy was associated with successful closure (77.6% v 41.7%; p = 0.007). The combined, posterior, and anterior approaches were associated with 90%, 76.2%, and 60.9% successful primary closure rates, respectively (p<0.001). Fixation modalities changed over time as Buck's traction (p<0.001) and external fixation (p<0.001) became more prevalent. Spica casting has become less common (p = 0.0002). Immobilization type was associated with success rates with Buck's (92.1%; p<0.001) and external fixation (86.0%; p<0.001) performing best. ConclusionsThe use of osteotomy and fixation in the CE spectrum has changed markedly. In this cohort, a staged approach with combination osteotomy was associated with better outcomes when using a multidisciplinary team approach. Level of EvidenceThis is a retrospective comparative study (Type of Study: Treatment; Evidence Level: III)

Extended pedicle subtraction osteotomy in combination with novel four-rod technique in an ankylosing spondylitis patient with neglected thoracolumbar fracture: a case report

Introduction: Ankylosing spondylitis is an autoimune disorder that affects mainly the enthesis of the spinal ligaments and capsules and causes a progressive fusing of the vertebra bodies. The ankylosed spine will lose the ability of absorbing and dissipating the axial loading force and therefore becomes vulnerable with injuries. Case report: We report a 27-year-old male patient with past history of ankylosing spondylitis who suffered from a neglected thoracolumbar fracture after a traffic accident one year before admission. He noticed an ongoing kyphotic deformity over time to the point that he could not have a horizontal gaze at present. The full spine Xray depicted a severe kyphosis at L1/2 (80o ) due to a nonunion L1/2 flexion-distraction fracture. There were no neurological deficits at admission. Surgical treatment and outcome: The patient underwent an extended L2 pedicle subtraction osteotomy and long instrumentation from T10 to L5. The clinical and radiological outcome were satisfactory as the global kyphosis was reduced from 80o to 20o and patient could regain his normal upright posture, even better than before the accident. Conclusion: Kyphotic deformity in ankylosing spondylitis patients, especially with traumatic causes is always a challenge for spinal surgeons as corrective surgeries involve potential neurological complications. Conventional pedicle subtraction osteotomy remains a procedure of choice. The downside of this technique is the relatively high risk of non-union and implant failure which can be improved by reinforcing two additional short rods to the whole configuration.

A Case of Patellar Instability and Lateral Facet Cartilage Defect

Background: Concomitant cartilage injury is commonly associated with patellofemoral instability. While nonoperative treatment remains the gold standard for first time dislocators, there has been an increased trend toward addressing patellar instability when symptomatic cartilage disease is present. Indications: A healthy active 29-year-old woman &gt;2 years of patellar instability and pain symptoms in the right knee. Imaging revealed tibial tubercle to trochlear groove (TT-TG) distance of 19.8 mm, and a Caton Deschamps Ratio of 1.54. Initial staging arthroscopy demonstrated a near full thickness cartilage defect of the lateral patellar facet measuring 2x2 cm. Technique Description: In the index procedure, a staging diagnostic arthroscopy is performed to evaluate the extent of the cartilage defect. Given the size of the lesion, a matrix-induced autologous chondrocyte implantation (MACI) biopsy is performed for later implantation. At the second stage procedure, a midline approach to the patella and tibial tubercle is performed. A 45° osteotomy is initiated with a cutting jig. The osteotomy is detached distally to allow for both anteromedialization and distalization to offload the cartilage defect and improve patellar articulation. The lateral patellar facet cartilage defect is prepared, and a combination of fibrin sealant and digital pressure is used to implant the pre-shaped MACI transplant. The osteotomy is then secured with 2 bicortical screws. A semitendinosus allograft is secured to the upper half of the medial border of the patellar and secured to its anatomometric point on the femur to reconstruct the medial patellofemoral ligament (MPFL). Results: Patient successfully returned to running and is currently working on return to other sports with no anterior knee pain or instability. Recent studies have demonstrated overall good clinical outcomes following MACI for patellofemoral lesions. Addressing underlying bony deformity and offloading patellofemoral cartilage lesions with tibial tubercle osteotomy in combination with MPFL reconstruction has improved patellar stability and good patient satisfaction. Discussion/Conclusion: Combined tibial tubercle osteotomy, MPFL reconstruction, and MACI in a comprehensive approach can successfully address symptomatic patellofemoral cartilage disease in the setting of patellar instability with underlying bony abnormalities.

Surgical Management of Pre-Chiasmatic Intraorbital Optic Nerve Gliomas in Children after Loss of Visual Function-Resection from Bulbus to Chiasm.

Optic pathway gliomas in children carry significant morbidity and therapeutic challenges. For the subgroup of pre-chiasmatic gliomas, intraorbital and intradural resection is a curative option after blindness. We present a two-center cohort using different surgical approaches. A retrospective analysis was performed, including 10 children. Mean age at surgery was 6.8 years. Interval between diagnosis and surgery was 1–74 (mean 24 ± 5.5, median 10) months. Indications for surgery were exophthalmos, pain, tumor progression, or a combination. Eight patients underwent an extradural trans-orbital-roof approach to resect the intra-orbital tumor, including the optic canal part plus intradural pre-chiasmatic resection. Gross total resection was achieved in 7/8, and none had a recurrence. One residual behind the bulbus showed progression, treated by chemotherapy. In two patients, a combined supra-orbital mini-craniotomy plus orbital frame osteotomy was used for intraorbital tumor resection + intradural pre-chiasmatic dissection. In these two patients, remnants of the optic nerve within the optic canal remained stable. No patient had a chiasmatic functional affection nor permanent oculomotor deficits. In selected patients, a surgical resection from bulb to chiasm ± removal of optic canal tumor was safe without long-term sequela and with an excellent cosmetic result. Surgery normalizes exophthalmos and provides an effective tumor control.

Melolabial interpolated island flap for reconstruction of an anterior oronasal fistula after horseshoe Le Fort I osteotomy with iliac bone grafts interposition - A case report.

IntroductionHorseshoe Le Fort I osteotomy (HLFO) in combination with iliac bone grafts interposition is an established and very effective procedure for reconstructing the severely atrophic maxilla. However potential complications connected to this method, such as oronasal fistula (ONF), have not been described in the literature to date.Case presentationWe report the case of a female patient with severe atrophy of the edentulous maxillary alveolar ridge with type 2 diabetes (T2D). Initially, a sinus floor augmentation was performed, followed by a failed placement of dental implants. Afterwards, HLFO with simultaneous interposition of iliac bone grafts was conducted. Subsequently, an oronasal communication occurred in the antral maxilla. As several local flaps had not achieved sufficient results, a melolabial interpolated island flap was carried out, yielding satisfactory results.DiscussionFailed implant treatment or bone augmentation procedures in combination with T2D may have resulted in significant tissue irritation and subsequent wound healing complications in the antral maxilla, leading to an ONF.ConclusionIn this case, an ONF occurring after HLFO was described for the first time. The melolabial interpolated island flap proved to be an outstanding long-term solution for the management of an anterior ONF occurring after HLFO over a period of 10 years. Less invasive treatment options including zygomatic implants should be taken into consideration for the treatment of such patients.

Comparative effectiveness of treatment modalities in severe Legg‑Calvé‑Perthes disease: Systematic review and network meta‑analysis of observational studies.

There are several treatment modalities for Legg-Calvé-Perthes disease (LCPD), self-limiting, avascular osteonecrosis of the femoral head in children. Most treatments focus on containment of the weakened femoral head, but there is no consensus on the best modality for severe LCPD. Therefore, we compared the effectiveness of all treatment modalities for severe LCPD. We searched the PubMed, Embase, and Scopus up until July 2021 for studies that investigated LCPD treatment effectiveness. A network meta-analysis was performed to examine the comparative effectiveness in terms of the ability to achieve radiographic spherical congruity of the hip joint after skeletal maturity. The risk ratio (RR) and 95% confidence interval (CI) of each treatment modality were estimated from both direct and indirect evidence. Treatment ranking was based on Surface Under the Cumulative Ranking curve (SUCRA). A total of 857 studies were identified and 34 comparative studies with 3718 affected hips comparing seven different LCPD treatment modalities were included. Compared with symptomatic treatment, combined osteotomy was the most effective modality (RR = 1.47, 95% CI 0.90 to 2.42, SUCRA = 0.8), followed by femoral varus osteotomy (RR = 1.31, 95% CI 1.06 to 1.60, SUCRA = 0.7), and Salter innominate osteotomy (RR = 1.25, 95% CI 0.95 to 1.65, SUCRA = 0.6). Combined osteotomy is the most effective procedure in terms of improving the spherical congruity of the hip joint in severe LCPD patients. However, the superiority of operative treatments seems to be limited to patients older than eightyears old.

When it is necessary to perform an additional akin osteotomy with a scarf osteotomy for mild and moderate deformities of hallux valgus?

SummaryIntroduction. Scarf osteotomy is a common method of treating acquired hallux valgus deformity today. At the same time, as a result of scarf osteotomy, the pathological hallux valgus interphalangeal angle (HVIPA) is not elimi-nated. In order to correct the latter, it is possible to per-form an osteotomy of the base of the main phalanx of the 1st finger (Akin osteotomy). There is a limited amount of objective data comparing the radiological and functional results of treatment of patients with mild and moderate HV deformity who underwent solely either scarf osteo-tomy or scarf osteotomy in combination with additional Akin osteotomy. The aim of the study was to compare the clinical and radiological results of isolated scarf osteo-tomy and a double scarf and Akin osteotomy in patients with mild and moderate HV forefoot deformity. Materials and methods. The study included 187 patients (187 feet) with HV anterior deformity of mild and moderate severi-ty, who were divided into 2 groups. The first group, where Akin surgery was performed in addition to scarf osteoto-my, consisted of 86 patients (86 feet). 101 patients (101 feet) were included in the second group, where only scarf osteotomy was performed. According to all indicators, the patients of the groups were comparable and had no significant differences. The exception was the hallux val-gus interphalangeal angle (HVIPA), which was significant-ly larger in the first group A, since the threshold value for performing an additional Akin osteotomy was the HVIPA value of 9° or more. All patients underwent clinical exam-ination, X-ray control and questionnaires of AOFAS, VAS and MOXFQ scales before surgery, as well as on the 12thand 24th months after surgery. An objective assessment of the quality of hallux valgus deformation elimination was carried out according to three angular indicators: hallux valgus interphalangeal angle (interphalageal an-gle — HVIPA), hallux valgus angle (hallux valgus angle — HVA), the first interplatarsal angle (1–2 intermaetatarsal angle — 1–2 IMA). Results. There was no statistically sig-nificant difference in anatomical and functional results of treatment of patients of the studied groups. In addition, there were no significant changes in the studied indica-tors at 12 and 24 months after surgery, both within each group and in comparison of the groups with each other. Conclusion. To achieve good results when correcting the hallux valgus of the first toe, the anatomy of the phalan-ges of the first toe should be taken into account. Liter-ature data, as well as the results of our studies indicate that correction of valgus deformity of the interphalangeal joint with an HVIPA of 9° or more is recommended to pre-vent loss of correction after osteotomy of the first meta-tarsal. Despite the increase in the traumatic nature of the intervention, Akin osteotomy performed in addition to scarf osteotomy according to appropriate indications does not require correction of the postoperative rehabili-tation program, does not adversely affect the anatomical and functional outcome of treatment, does not lead to an increase in the proportion of complications.

Deep Digital Flexor Contracture following Combined Tibial Plateau Levelling Osteotomy and Cranial Closing Wedge Ostectomy: A Case Report in a Dog

AbstractThis case report describes the use of a Z-plasty tenotomy and anastomosis to surgically lengthen the deep digital flexor (DDF) tendons of digits 2 to 5 of the pelvic limb in a 6-year-old male castrated Greyhound. The procedure was used to treat contracture of this tendon complex which developed after a series of complications secondary to proximal osteotomies utilized for the treatment of cranial cruciate ligament rupture. The dog was evaluated for lameness associated with left cranial cruciate ligament rupture and excessive tibial plateau slope; accordingly, a combined tibial plateau levelling osteotomy and cranial closing wedge ostectomy was performed. Postoperatively, the dog developed substantial DDF tendon contracture that led to severe digital hyperflexion and contributed to a non-weight bearing lameness. The dog received intensive rehabilitation therapy but failed to substantially improve; therefore, all of the weight-bearing left hindlimb DDF tendons were lengthened with a Z-plasty tenotomy and anastomosis followed by further rehabilitation. Follow-up evaluation 44 months postoperatively documented mild, intermittent left hindlimb lameness on gait observation and confirmed success of the Z-plasty procedure via ultrasonographic evaluation. Conservative treatment alone was unsuccessful in managing DDF tendon contracture in this dog. Z-plasty tenotomy and anastomosis of the DDF tendon allowed for return-to-acceptable function in this case.

Surgically assisted rapid palatal expansion for transverse maxillary discrepancy in adults - Case report.

Introduction and importanceTransverse maxillary deficiency is one of the most detrimental problems to midfacial growth and the integrated dentoalveolar structures. Early diagnosis and proper treatment of such cases is most important to maintain the balance between the basal bones and stable occlusion.Case presentationIn our case, a 17-year-old male had irregular upper front teeth with an unpleasant smile. Detail examination revealed a symmetrical face with an orthognathic profile, mild malar deficiency, competent lips, asymmetrical arches, Class I molar and canine relationships bilaterally. Crowding was present in the upper anterior arch with 2 mm of anterior open bite and posterior cross bite present in the premolar region and molar region bilaterally. Lefort-1 osteotomy, midpalatal split, pterygomandibular disjunction without down fracture was done. The HYRAX appliance was cemented. Distraction started after four days of surgery. One mm distraction per day was done for 10 days. The patient was transferred to fixed orthodontic treatment to relive the anterior crowding. Records were taken after 1 year of follow up and analyzed. Skeletal relationships were in harmony. Dental crowding, anterior open bite and posterior crossbite were corrected.Clinical discussionThe zygomatic buttress and the pterygomaxillary junction are considered as the critical areas of resistance for maxillary expansion. Literature claims lefort-1 osteotomy in combination with palatal distraction results in more displacement and less stress in the maxilla.ConclusionSARPE has proved to be clinically effective and stable for the correction of transversely deficient maxilla after cessation of growth in adult patients.