Osteotomy Union Research Articles

Curved Periacetabular Osteotomy for Treatment of Dysplastic Hip

The Bernese periacetabular osteotomy has a considerable rate of postoperative complications such as reflex sympathetic dystrophy, motor nerve palsy, heterotopic ossification, and delayed union of the ilium, which are assumed to be caused by extensive exposure or asphericity of the osteotomy surfaces. To address these issues, we developed the curved periacetabular osteotomy, a modification of the Bernese periacetabular osteotomy which limits dissection, prevents the outside of the ilium from being exposed, and produces osteotomy surfaces with the same curvature. Curved periacetabular osteotomies were done on 128 hips in 118 patients whose average age at the time of surgery was 35.2 years (range, 16-59 years). The average followup was 46 months (range, 24-99 months). The average center-edge angles were 4 degrees (range, -15 degrees -5 degrees ) preoperatively and 35 degrees (20 degrees -55 degrees ) postoperatively, and union of the iliac osteotomy was achieved in all hips. We experienced three asymptomatic pubic nonunions. Dysesthesias occurred in 27 patients along the lateral femoral cutaneous nerve and symptoms resolved in 23 patients within 1 year. The average Harris hip score improved from 72 to 93 points. There were no major complications such as sciatic nerve palsy, abductor dysfunction, or heterotopic ossification. Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Femoral shaft osteotomy for malunited femoral fractures presenting with varus OA of the knee

Seven patients presenting between 1992 and 1999 with osteoarthritic knee symptoms in consequence of old malunited femoral shaft fractures, were treated by open femoral shaft osteotomy. The osteotomies were sited at the apex of the deformity and were fixed by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on symptoms and function. The mean age at presentation was 48 years and the mean time from fracture was 28 years. The mean time to osteotomy union was 28 months. Five of the seven patients reported excellent pain relief and functional improvement. These patients presented a difficult management problem at an age that would be worryingly young for total knee replacement. Arthroplasty has been avoided in all but one of this cohort, and is still far from imminent in the remainder, after a mean follow-up period of 5 years.

Total hip arthroplasty in the treatment of neglected congenital dislocation or dysplasia of the hip

Objectives: We evaluated our methods and short-term results of total hip arthroplasty in the treatment of neglected congenital dislocation or dysplasia of the hip. Methods: We performed total hip arthroplasty in 13 hips of 11 female patients (mean age 47.9 years; range 36-65 years) with osteoarthritis secondary to congenital dislocation or dysplasia. Patients with severe acetabular dysplasia required augmentation with bone grafts. In high-riding hips, femoral shortening osteotomy was performed. All patients were evaluated using the Merle d’Aubigne and Harris hip scores. Radiological evaluation was made using preoperative and follow-up anterioposterior and lateral radiographs. The average length of follow-up was 20.9 months. Results: According to Merle d’Aubigne hip scoring, average preoperative and postoperative functional scores were 4.33 and 5.66 for pain, 4.6 and 5.83 for range of motion, and 4.00 and 5.41 for walking ability, respectively. The Harris hip score increased from 60.75 to 91.6 at follow-up. Complications were noted in only two patients, being delayed union of femoral osteotomy and false-route of the stem, respectively. Conclusion: Total hip arthroplasty provides successful outcome in the treatment of neglected congenital dislocation of the hip. Improvement of technical modifications may further increase surgical success

Calcaneal dome osteotomy: a new procedure for revising triple arthrodesis.

A preliminary report of a new calcaneal osteotomy is presented. Five patients ranging in age from 18 to 35 years underwent a calcaneal dome osteotomy. They all had painful and significant foot deformity, recurrent tenosynovitis, callosities, and shoe wear problems. The osteotomy was developed to correct the deformity present in patients that had a previous triple arthrodesis. The crescentic shape of the osteotomy allowed for the correction of various degrees and patterns of deformity with accuracy and provided a broad area of contact resulting in osteotomy union. The results achieved by this new technique showed that deformity was corrected, callosities had disappeared, and all the osteotomies were healed. All patients were satisfied by the procedure.

A redefinition of bilateral sagittal osteotomy (BSO) advancement relapse

M a n y bilateral sagittal osteotomy (BSO) wire osteosynthesis studies have examined relapse and ascribed significance to a number of variables that seemingly cause relapse. 1-11 These studies have generally isolated condylar sag (proximal fragment positional change) as the major source of BSO relapse. The source of condylar sag has not been defined. No study has postulated whether condylar sag occurs because the condyle is not seated into the glenoid fossa at surgery, or some force moves the condyle out of the fossa after placement. Other cited factors associated with relapse have been large advancements, s'7'~2'13 upward and forward (counterclockwise) advancements, 8'1°'14 and high mandibular plane angle. 10,15 It is not clear whether these additional variables are independent of condylar sag or are the cause of condylar sag. The wire osteosynthesis condylar sag relapse model only partially explains early B point relapse (surgery to osteotomy union). It is totally inadequate in explaining late (greater than 9 months) B point relapse, which sometimes occurs. Screw osteosynthesis studies have also examined multiple causes of B point relapse. Magnitude of advancement has had the greatest correlation with relapse associated with this fixation technique. 16 The placement of larger, more numerous and different patterns of screws into the osteotomy site or the use of some form of skeletal suspension have been suggested to stop relapse. 16 The source of screw fixation relapse is not condylar sag, but is assumed to be osteotomy slippage. This accounts for the emphasis on larger screws and greater screw number. Comparison of relapse between rigid and wire osteosynthesis has shown consistently that less relapse occurs with rigid fixation, at least in the short term. 17,18

Healing Patterns of Transverse and Oblique Osteotomies in the Canine Tibia Under External Fixation

Healing patterns were compared between transverse and 60 degrees oblique osteotomies in canine tibiae stabilized under external fixation. Under similar in vitro testing conditions (osteotomy ends in contact), the axial stiffness of the oblique osteotomy under external fixation was 45% of the paired transverse osteotomy. Under torsion and bending, the two sides exhibited similar fixation rigidity. The animals put significantly less weight on the oblique side than on the transverse side in the early phases of bone healing (p less than 0.05 for static and p = 0.024 for dynamic weight bearing). The osteotomy bending stiffness at 60 days (in vivo) and the torsional stiffness of osteotomy union measured after sacrifice at 90 days were significantly higher on the transverse side (p = 0.013 and p = 0.016, respectively). Intracortical new bone formation was significantly higher on the transverse side (p less than 0.01), indicating a difference in the rate of cortical healing and remodeling. The average pin removal torque was significantly lower on the oblique side (p less than 0.05), a sign of increased pin loosening. In the clinical situation, unstable oblique or spiral fractures should be protected from weight bearing even under stable external fixation due to the delayed recovery of bone union stiffness property as well as increased pin tract problems.

Primary and revision total hip replacement without cement and with associated femoral osteotomy.

Nine porous-coated total hip prostheses were implanted without cement in nine patients who had a major proximal femoral deformity. Six patients had revision and three, primary total hip replacement. In all nine patients, as well placed corrective osteotomy was needed to successfully perform the arthroplasty. The average time until union of the proximal femoral osteotomy was fifteen weeks for the patients who had a primary arthroplasty and twenty-seven weeks for the patients who had a revision arthroplasty. The average Harris hip-rating score was 94 points for the patients who had a primary arthroplasty and 84 points (range, 60 to 93 points) for those who had a revision arthroplasty. The length of follow-up averaged forty-seven months.

Ｃｈａｒｎｌｅｙ式股関節全置換術の術後脱臼について

A special review, with the aim of identifying the incidence and the factors of the dislocation of Charnley low-friction arthroplasty, was undertaken. From 1971 to 1986, 304 arthroplasties have been performed at Nagasaki University and followed over 2 years.Dislocation is defined as displacement of the head of the femoral prosthesis out of the prosthetic socket on radiography except the dislocation owing to the loosening of the socket or stem.Dislocation occurred in 8 of 304 hips (2.6%): 2 occurred during 3 weeks, 1 at 3 months, and 5 from 4 months to 180 months. Two of these were traumatic dislocations.In 5 hips, there were inadequate deepening and placement of the acetabular component at operation. In 3 hips, there were varus position of the femoral component, but those varus angles were below 5 degrees. In one hip, there was loss of neck length due to resorption of the femoral calcar. Two dislocations were related to muscle atrophy due to prolonged bedrest and other 2 dislocations were related to scarring from severe trauma or previous surgery.Only one patient showed complete bony union of the trochanteric osteotomy in dislocated cases, whereas 5 of 7 patients showed complete detachment of trochanter.Factors contributing to dislocation were inadequate orientations of prosthetic socket and loss of normal tissue tension as a result of muscle atrophy and defective bony union of trochanteric osteotomy.

Effect of the position of the greater trochanter on the rate of union after trochanteric osteotomy for total hip arthroplasty

The correlation between the position of the greater trochanter and the rate of union of the trochanteric osteotomy was assessed in 85 patients who had unilateral total hip arthroplasty using U-bolt fixation of the trochanter. The position of the trochanter was assessed radiologically immediately after operation and at 3-month intervals for 1 year to ascertain the rate of union of the trochanteric osteotomy. The initial postoperative position of the trochanter was classified as either: group 1, trochanter anatomically reduced; group 2, trochanter reattached with some distal displacement; group 3, superomedial tilt of the trochanter (ie, loss of contact with the femoral shaft distally); or group 4, combination of distal displacement and superomedial tilt of the trochanter. The original reduction of the greater trochanter appears to influence its rate of union to the femoral shaft directly. Anatomic reduction or slight distal overlap of the trochanter resulted in union of the osteotomy within 6 months. Fixation of the trochanter in a tilted position invariably led to a delay in union and in nine cases (10.6%) led to a nonunion.

Correction of combined tibial torsion and valgus deformity of the foot.

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion.

UNION OF INTERTROCHANTERIC OSTEOTOMIES

1. Fibrous union of an osteotomy occurred in only 3 per cent of osteotomies done during a four-year period. 2. Delayed union sometimes gives rise to pain on bearing weight while union is in progress, and non-union is usually associated with disabling pain. 3. The most significant factors predisposing to delayed or fibrous union are inefficient fixation and excessive displacement. A high or very oblique osteotomy may also have an adverse effect upon the rate of bony union.