Posttraumatic Deformity Research Articles

Guidelines for Orbital Defect Assessment and Patient-Specific Implant Design: Introducing OA2 (Orbital Assessment Algorithm).

This study presents a review of the evolutionary development in reconstructive orbital surgery over the past 3 decades. Additionally, it proposes the Orbital Assessment Algorithm (OA2) to enhance decision-making for intraorbital reconstruction of post-traumatic orbital deformities. The objective of this paper is to provide insights into modern post-traumatic orbital reconstruction from a surgeon's perspective, with a specific focus on adult patients. It aims to highlight the advancements in computer-aided design and manufacturing techniques, particularly in the field of reconstructive orbital surgery, and to introduce the OA2 as a tool for improved decision-making in this context. The study conducts a comprehensive review of the evolution of reconstructive orbital surgery, focusing on the integration of 3D technology into surgical practices. It also outlines the development and rationale behind the proposed OA2, emphasizing its potential to enhance the accuracy and efficacy of intraorbital reconstruction procedures for post-traumatic deformities. The review demonstrates the significant progress made in reconstructive orbital surgery, particularly in leveraging 3D technology for virtual modeling, navigation, and the design and manufacturing of patient-specific implants. The introduction of the OA2 provides a structured approach to assessing and addressing post-traumatic orbital deformities, offering potential benefits in decision-making and surgical outcomes. In conclusion, this paper underscores the pivotal role of computer-aided design and manufacturing in advancing reconstructive orbital surgery. It highlights the importance of integrating innovative design concepts into implant manufacturing processes and emphasizes the potential of the OA2 to guide surgeons in the management of post-traumatic orbital deformities, ultimately contributing to improved patient outcomes.

Validation of a software-based torsional measurement method of the lower limb: A retrospective study.

The aim of this study was to evaluate a software-based measurement tool of computed tomography imaging to assess torsional alignment of the lower limb-usually used for patients with posttraumatic deformities and patellofemoral issues-and compare these measurements with manual measurements of two experienced raters. This study was a retrospective analysis of 58 lower limbs (47 patients, 20 men and 27 women) aged between 19 and 97 years. Inclusion criteria were the clinical indication for torsion measurement of the lower limb. Legs with incomplete imaging and age less than 18 years were excluded. Femoral and tibial torsion were measured separately. Torsional alignment was assessed software-based at two time points by two raters. Rater one additionally assessed manual-based measurement at two time points. The software used was mediCAD 3D Knee Version 2.5.33 (Hectec). Subsequently, intra- and inter-rater reliability was calculated using the intraclass correlation coefficient (ICC). Validity testing was performed by means of precision, concordance correlation coefficient according to Lin (ccc) and Pearson correlation coefficient. High intra-rater reliability for software-based as well as manual-based evaluation of torsional alignment was found for the tibia as well as the femur (ICC ranging between 0.870 and 0.993). Inter-rater reliability also showed highly significant results of both manual and software-based measurements (ICC ranging between 0.851 and 0.993). For almost all comparisons (except the tibia left), software-based measurements showed higher ICC scores above 0.9, and, therefore, classified as 'excellent reliability'. For validity testing, correlation coefficients and precision showed very good correspondence of the measurements (all values > 0.9), without systematic deviations. Software-based measurement of torsional alignment according to the measurement method developed by H.-A. Waidelich proved to be a reliable and valid technique. Especially for inexperienced surgeons, software-based measurement, therefore, might improve confidence in reliable medical decisions in diagnostics and treatment. Level III.

Medial Tibial Condylar Valgus Osteotomy improve clinical outcomes and effectively corrects significant Tibial varus deformities without compromising joint line obliquity or patellar heigh

BackgroundTibial condylar valgus osteotomy (TCVO), or Chiba osteotomy, is a recognized procedure for treating advanced knee osteoarthritis in middle-aged individuals. Although its effectiveness is established, limited literature exists on its outcomes for specific conditions such as post-traumatic deformities, Blount disease (BD), and Pagoda-like proximal tibia varus deformities. HypothesisWe hypothesized that TCVO could improve both clinical and radiographic outcomes in patients with severe varus deformities, correcting lower-limb variances while preserving joint line obliquity (JLO) and patellar height in substantial varus deformities. Patients and methodsThis study included 33 patients who underwent TCVO, with etiologies including post-traumatic (26 patients, 78.8%), Blount disease (4 patients, 12.1%), and Pagoda deformities (3 patients, 9.1%). The average age was 32.5 years (standard deviation = 12.8 years). Techniques for deformity correction varied, including Patient Specific Instrumentation (PSI) for 10 patients (30.3%) and locking plate fixation for 13 patients (39.4%). We assessed several radiological parameters such as hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), Caton-Deschamps index (CDI), and proximal posterior tibial angle (PPTA). Patient-reported outcomes, including the Knee injury and Osteoarthritis Outcome Score (KOOS) and simple knee value (SKV), were recorded both pre-operatively and two years post-operatively. ResultsStatistically significant improvements were observed in clinical scores and alignment changes two years post-operatively, including increases in HKA (from 166.1 to 178.4, p < .0001) and MPTA (from 72.4 to 85.1, p < .0001), and a decrease in JLO (from 9.8 to 3.2, p < .0001). No significant changes were noted in JLCA, PPTA, and CDI, with the patellar height remaining stable post-operatively. The achieved corrections closely matched the pre-operative plans. ConclusionTCVO offers significant improvements in radiological and clinical parameters for patients with substantial tibial varus deformities, effectively maintaining JLO and patellar height. Optimal outcomes from TCVO are dependent on careful patient selection and precise execution of surgical techniques. Level of evidenceIII.

Re-establishing Facial Aesthetics - Patient-specific Orbital Implant for Post-traumatic Deformity

Abstract Rationale: Complex fractures of the maxillofacial region can require staged interventions to achieve optimal outcomes. A significant example of this are complex fractures of the orbital floor, which may be difficult to restore during primary treatment. The secondary correction is often required which can be using stock- or customised implants. Patient Concerns: A previously operated case of panfacial trauma presented with an aesthetic concern regarding the asymmetrical appearance of his eyes. Diagnosis: On clinical and radiological evaluation, the patient was diagnosed with enophthalmos of the left eye secondary to orbital floor fracture. Treatment: A patient-specific implant (PSI) was fabricated and placed for orbital floor reconstruction. Outcomes: Postoperatively, aesthetic and functional outcomes were satisfactory. Take-away Lessons: This case report highlights the use of PSIs in orbital floor reconstruction, made possible due to the advent of virtual surgical planning and three-dimensional printing in the field of oral and maxillofacial surgery.

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Optimizing Management and Minimizing Risk of Osteoporotic Vertebral Fractures - Perspectives of the AO Spine KF Trauma and Infection Group Key Opinion Leaders.

Literature review with clinical recommendations. To highlight important studies about osteoporotic spinal fractures (OF) that may be integrated into clinical practice based on the assessment of the AO Spine KF Trauma and Infection group key opinion leaders. 4 important studies about OF that may affect current clinical practice of spinal surgeons were selected and reviewed with the aim of providing clinical recommendations to streamline the journey of research into clinical practice. Recommendations were graded as strong or conditional following the GRADE methodology. 4 studies were selected. Article 1: a validation of the Osteoporotic Fracture (OF)-score to treat OF fractures. Conditional recommendation to incorporate the OF score in the management of fractures to improve clinical results. Article 2: a randomized multicenter study comparing romosozumab/alendronate vs alendronate to decrease the incidence of new vertebral fractures. Strong recommendation that the group receiving romosozumab/alendronate had a decreased risk of new OF when compared with the alendronate only group only. Article 3: a systematic literature review of spinal orthoses in the management of. Conditional recommendation to prescribe a spinal orthosis to decrease pain and improve quality of life. Article 4: post-traumatic deformity after OF. A conditional recommendation that middle column injury and pre-injury use of steroids may lead to high risk of post-traumatic deformity after OF. Management of patients with OF is still complex and challenging. This review provides some recommendations that may help surgeons to better manage these patients and improve their clinical practice.

How Strong Is the Ligamentum Teres of the Hip? A Biomechanical Analysis.

Intraarticular hip pain represents a substantial clinical challenge, with recent studies implicating lesions in the ligamentum teres as potential contributors. Even more so, damage to the ligamentum teres is particularly prevalent among young patients undergoing joint-preserving interventions. Although several studies have investigated the biomechanical attributes of the ligamentum teres, inconsistencies in reported findings and reliance on cadaveric or animal models have raised concerns regarding the extrapolation of results to clinical practice. Furthermore, there is a lack of research examining ligamentum teres biomechanics specifically within the relevant patient cohort-individuals who benefit from joint-preserving surgical interventions. We sought (1) to determine the biomechanical properties (ultimate load to failure, tensile strength, stiffness, and elastic modulus) of fresh-frozen ligaments from patients undergoing surgical hip dislocation, and (2) to identify patient-specific factors that are associated with them. This was an institutional review board-approved study on intraoperatively harvested ligamentum teres from 74 consecutive patients undergoing surgical hip dislocation for joint preservation (August 2021 to September 2022). After the exclusion of patients with previous surgery, posttraumatic deformities, avascular necrosis, slipped capital femoral epiphysis, and Perthes disease, 31 ligaments from 31 patients were analyzed. The mean age of the study group was 27 ± 8 years, and 61% (19) of participants were male. The main indication for surgery was femoroacetabular impingement. Standardized AP pelvic and axial radiographs and CT scans were performed in all patients for better radiological description of the population and to identify associated radiological factors. The ligament was thoroughly transected at its origin on the fossa acetabuli and at the insertion area on the fovea capitis and stored at -20°C until utilization. Specimens were mounted to a materials testing machine via custom clamps that minimized slippage and the likelihood of failure at the clamp. Force-displacement and stress-strain curves were generated. Ultimate failure load (N), tensile strength (MPa), stiffness (N/mm), and elastic modulus (MPa) were determined. Using a multivariate regression analysis and a subgroup analysis, we tested demographic, degenerative, and radiographic factors as potential associated factors. The ligamentum teres demonstrated an ultimate load to failure of 126 ± 92 N, and the tensile strength was 1 ± 1 MPa. The ligaments exhibited a stiffness of 24 ± 15 N/mm and an elastic modulus of 7 ± 5 MPa. After controlling for potential confounding variables like age, fossa/fovea degeneration, and acetabular/femoral morphologies, we found that female sex was an independent factor for higher tensile strength, stiffness, and elastic modulus. Excessive femoral version was independently associated with lower load to failure (HR 122 [95% CI 47 to 197]) and stiffness (HR 15 [95% CI 2 to 27]). Damage to the acetabular fossa was associated with reduced load to failure (HR -93 [95% CI -159 to -27]). Overall, the ligamentum teres is a relatively weak ligament. Sex, degeneration, and excessive femoral version are influencing factors on strength of the ligamentum teres. The ligamentum teres exhibits lower strength compared with other joint-stabilizing ligaments, which calls into question its overall contribution to hip stability. Young patients undergoing hip-preserving surgery are the population at risk for ligamentum teres lesions. Baseline values for load to failure, tensile strength, elastic modulus, and stiffness are needed to better understand those lesions in this cohort of interest.

Incorrectly healed supracondylar humerus fracture : That will grow out later on?!

The supracondylar humerus fracture is the most frequent fracture of the elbow region during the growth period. The peak age is around 5years. Extension fractures predominate. The clinical diagnostics are supplemented by X‑ray images in two projections. Growth-associated spontaneous corrections of posttraumatic deformities rarely occur. The goal of treatment is therefore the active transformation of every displaced fracture into a nondisplaced stably fixed fracture.If this is not successful, the consequences of healing in amalalignment can be, e.g., restriction of elbow flexion due to remaining antecurvation or cubitus varus. Combinations are often present. The causes include technical problems with reduction and retention but also misjudgement of the X‑ray findings, ignorance of the growth prognosis or inadequate verification of whether the treatment goal has been achieved.Unsatisfactory treatment results should be corrected as early as possible. This can be done primarily before bony healing is completed or secondarily as acorrective osteotomy at any later point in time. The earlier the correction of the malalignment is performed, the greater the chances of a complete restoration to the original condition. Depending on the type and extent of the deformity various techniques for corrective osteotomy are suggested in the literature.

Retrospective analysis of surgical treatment of adult patients with trauma and posttraumatic deformities of the middle zone of the facial skeleton

The issues of diagnosis, planning, timing and tactics of surgical treatment, possible risks of postoperative complications in patients with trauma of the middle zone of the facial skeleton have remained relevant for many years. Due to the prevalence and complexity of solving a number of problems facing specialists arising from post-traumatic deformities (PTD) in this area, the problem of treating this category of patients is not only medical, but also socio-economic. Purpose. To carry out a retrospective analysis of the data of medical documentation of adult patients with trauma and PTD of the middle zone of the facial skeleton. Material and methods. We analyzed statistical data on the provision of specialized medical care to patients with trauma and PTD of the middle zone of the facial skeleton in institutions subordinate to the Moscow Department of Health for 2021 and 2022. A sample of 32 495 medical records of patients who were hospitalized at the State Budgetary Healthcare Institution of the Department of Healthcare of the Moscow “Maxillofacial Hospital for War Veterans” was conducted from March 2015 to December 2023. Statistical processing of the obtained data from the study group of patients was carried out. Results. Information is presented on the specialized care provided to adult patients with trauma and PTD of the middle zone of the facial skeleton in institutions subordinate to the Moscow Department of Health for 2021 and 2022. Our study included 233 patients with trauma and PTD of the midfacial skeleton who underwent surgical treatment. Of these, 84.12% (n=196) were men and 15.88% (n=37) women. The average age of the patients was 35.74±11.11 years. The study group was divided into two subgroups: the 1st – patients with injuries to the bones of the midface (n=157, 67.38%), the 2nd – with PTD of the bones of the midface (n=76, 32.62%). The article presents the main characteristics of these patients. The methods of their examination at the prehospital stage are analyzed in detail; the time from the moment of injury to the moment of seeking specialized medical care; channels of hospitalization; causes of injuries; aesthetic and functional disorders as a result of injuries; types of injuries; applied methods and tactics of surgical treatment. Conclusions. The results of the study present a modern characterization of adult patients with trauma and PD of the middle zone of the facial skeleton. Recommendations are given on the use of four main fixation points during operations of metallosteosynthesis of the bones of the zygomatic complex, the need to reduce the time from the moment of injury to the moment of specialized medical care, the need for an integrated approach and treatment of patients with injuries and PTD of the bones of the middle zone of the face in specialized centers of maxillofacial-facial surgery.

The aspects of implementation of digital technologies under rendering of services in health care: The publications review

The article presents review summarizing contemporary National and foreign experience of implementing digital technologies under provision of services in health care. The systematic analysis of data from Scopus, eLibrary, PubMed and others electronic databases permitted to select 30 sources in Russian and English for 2016-2023. Modern digitization trends affect collaborations of companies where vectors of modernization become development of unified digital framework based on common state information system of health care; common educational platform for medical knowledge enriching by AI capabilities, through development of organizational activities and workflows based on digital technologies and services utilizing digital transformation. The deficiency of tools evaluating efficiency of reading software products and scalability of health digitization processes become problematic issues. As of today, diagnostic technologies using AI systems, technologies of lung cancer screening, examination methods of patients with post-traumatic deformations of cheekbone-orbital complex, monitoring of readings of devices with digital registration, further office consulting of various levels and application of AI in neurosurgery were described already. The article also considers issues of telemedicine consultations and development of modernized care models. The authors expect that digital ecosystem in development addressing issues of legal concept of management, financing and system of patient legal protection will do everything necessary to mitigate cyber incidents.

General Surgeon’s Challenge: Primary Reconstruction of High-Velocity Facial Trauma

Background: Facial wounds are often seen in the emergency department. Whether isolated or associated with cranial injuries or poly-trauma, they can have a significant impact on the patient’s facial aesthetics and consequently, their eminent psychological states.Case presentation: A 63-year-old man was referred to our emergency department with an extensive facial injury, which occurred when a grinder disc for working with metal broke, while he was working at home and hit him with high velocity in the face. The patient was hemodynamically stable with a disfiguring, profusely bleeding wound of the maxilla and mandible. One tooth in the lower jaw had been broken and one was missing. The wound was closed with synthetic, resorbable, interrupted sutures in two layers (the inner layer was buccal mucosa, and the other layer was only the skin).Discussion and conclusion: The extent of damage to soft tissue depends on the type and velocity of the object. Proper wound treatment is necessary, including thorough irrigation, removal of foreign bodies, tension-free closure, reconstruction of anatomical landmarks and correct follow-up. Wound healing starts shortly after the initial tissue trauma, and can take up to several months to complete. Disorder in hemostasis and uncontrolled inflammation can lead to an unfavorable outcome. Facial injuries are treated by general surgeons in only 0.5% of cases, with plastic surgeons, oral and maxillofacial surgeons, and otolaryngologists/head and neck surgeons being the most common specialties. Anatomic, diagnostic, and handling considerations should be analyzed to achieve the best results and minimize late post traumatic deformities. Complex facial reconstruction is possible when treated by an experienced general surgeon.

RECOVERY OF STABILIZING MUSCLES THAT PROVIDE A VERTICAL POSITION OF THE TRUNK IN PATIENTS WITH POST-TRAUMATIC DEFORMITIES OF THE LONG BONES OF THE LOWER LIMBS IN THE DISTANT PERIOD

Rehabilitation treatment in the case of posttraumatic deformities of long bones of lower extremities (PDLBLE) in the distant period after trauma is aimed at the restoration of support ability of lower extremity while walking and standing. Objective. To work out the set of the exercises targeted on the restoration of muscle-stabilizer function in patients with (PDLBLE) Methods. Research group — 40 patients who received closed injuries of the long bones of the lower limbs, initial trauma occured 6–12 months ago. Among them were 21 women. (52.5 % of persons; age 27–73 years) and 19 men (47.5 % of people, age 29–77 years). The comparison group included 40 healthy volunteers, among which there were 12 women (30 % of persons; age 24–50 years) and 28 men (70 % of people, age 31–49 years). The assessment was carried out before and after rehabilitation for 2 weeks. Parameters evaluated: pain scores on VAS, the results of restoring the support ability using the scale of Tyazhelov O. A. Results. The results of observations are given, where in addition to descriptive statistics (minimum, maximum, average meanings), parameters of support ability and VAS, in patients and volunteers before and after treatment, cumulative group indicators (CG) were calculated for each group at the beginning (CG0) and 2 weeks after rehabilitation (CG1); the «rehabilitation» coefficient as a ratio of group indicators before and after treatment was calculated as well. Cumulative group indicator after rehabilitation (CG1) increased to 2 995 points, which indicates an increase in support ability. Cumulative group VAS score after rehabilitation (CG1) decreased to 116 points from 200 points before rehabilitation — reduction of pain in patients. After rehabilitation, volunteers showed a slight increase in the cumulatory group indicator (CG1) to 3 917 points. Conclusions. The system of rehabilitation of patients with PDLBLE in the remote period after injuries proved its effectiveness in restoring muscle-stabilizers vertical position of the trunk, pelvis, lower limbs and pain reduction.

Treatment of patients with posttraumatic deformities of the thoracolumbar spine using Schwab 5 osteotomy through combined and posterior approaches

Objective. To analyze the results of surgical treatment of patients with rigid posttraumatic deformities of the thoracolumbar spine operated on using Schwab 5 osteotomy through combined and posterior approaches.Material and Methods. A retrospective cohort study was conducted. Study group included 60 patients (m/f = 25/35). Median age was 48 (26–58) years, median time since injury was 11 (9–14) months, and minimum follow-up period was 2 years. A two-stage intervention with resection of the vertebral body, correction of the deformity, and placement of an interbody implant through the anterior approach followed by final fixation through the posterior approach (VCRa+p group) was performed in 29 cases. Vertebral body resection through the posterior approach with correction of the deformity, installation of an interbody implant, and rigid transpedicular fixation (VCRp group) was performed in 31 cases. In all patients, the magnitude of correction was assessed, as well as the following parameters: frontal balance, sagittal balance, thoracic kyphosis, lumbar lordosis, pelvic incidence, sacral slope and pelvic tilt. The results of treatment were evaluated in dynamics by the level of pain syndrome (VAS) and quality of life (ODI), as well as based on the analysis of postoperative complications.Results. The groups were comparable in terms of gender, age, magnitude of the kyphotic component of the deformity, level of pain syndrome and degree of initial neurological deficit (p &gt; 0.05). Correction of the deformity kyphotic component was significantly better in patients in the VCRp group compared to those in the VCRa+p group (p = 0.036). Both groups showed a significant decrease in the level of pain syndrome 3 months after surgery. However, further follow-up showed a tendency for back pain to increase on average one year after surgery in the VCRa+p group. A total of 67 complications were revealed in 40 (66.7 %) patients. Herewith, in the early postoperative period there were 55 complications in 31 patients, and in the late period there were 12 complications in 9 patients. Analysis of early complications showed a higher incidence of anemia (p = 0.002) and liquorrhea (p = 0.017) in the VCRp group compared to those in the VCRa+p group. The incidence of long-term complications did not differ significantly between groups (p = 0.866). An increase in back pain in the long-term period was observed in 12 (41.4 %) patients of the VCRa+p group and in 4 (12.9 %) patients of the VCRp group. Analysis of risk factors for this condition showed a tendency for back pain to increase in the long-term period in patients with residual local deformity against the background of low pelvic index values.Conclusion. Correction of the kyphotic component of deformity was significantly better in patients of the VCRp group, which was accompanied by greater surgical trauma and incidence of early postoperative complications. The tendency of patients’ quality of life to deteriorate in the long-term follow-up period seems to be related to the occurrence of pain syndrome in the lumbar spine in patients with residual kyphotic deformity against the background of initially low compensatory capabilities.

Retracted: Clinical Features and Surgical Strategies of Distal Radius Posttraumatic Deformity

Retracted: Clinical Features and Surgical Strategies of Distal Radius Posttraumatic Deformity

Five-Segment Mandibular Osteotomy: A Novel Approach to the Correction of Complex Post-Traumatic Mandibular Deformities.

Post-traumatic mandibular malocclusion is a complex condition that poses a significant challenge to reconstructive surgeons. The malocclusion that ensues from bilateral condylar and parasymphseal fractures presents a particular challenge as it leads to bilateral posterior shortening and lingual tilting of dental arch leading to a combination of open anterior bite, crossbite, overbite, underbite, and/or facial asymmetry. The complexity of such malocclusion requires intricate freedom of movement of the mandibular arch that can be achieved by performing a 5-segment mandibular osteotomy. This is a case series of 9 adult patients with significant post-traumatic mandibular malocclusion who were treated with 5-segment mandibular osteotomy technique. This article details the demographics, surgical technique and outcomes in this cohort of patients. All 9 patients in this series had condylar fracture as part of the index mandibular trauma. They have a common post-traumatic deformity of the mandibular arch due to shortening of the vertical mandibular height in the fracture site and variable degrees of lingual tilting leading to crossbite. The 5-segment mandibular osteotomy provided an adequate correction of dental and facial deformities in all 9 patients. One patient had a relapse of the dental malocclusion that required postoperative rescue orthodontics. Furthermore, one patient had a significant postoperative hemorrhage that required a facial artery ligation. Post-traumatic mandibular malocclusion is a complex deformity that poses a great challenge to practicing surgeons. Five-segment mandibular osteotomy is a technique that provides ample degrees of movement of mandibular segments that is necessary to correct such deformity.

Corrective Osteotomies in Severe Non-Idiopathic Lower Limb Alignment Disorders in the Aspect of Future Joint Endoprosthesis-A Perspective Study.

The aim of this study was to retrospectively evaluate the effectiveness of corrective osteotomies in lower limb axis disorders at different levels of non-idiopathic (post traumatic, developmental, post-septic) etiology. A total of 50 patients were divided into three groups: A-thigh segment alignment disorder (24 patients); B-tibia segment alignment disorder (18 patients); C-thigh and tibia segment alignment disorder (8 patients). Radiological evaluation of digital lower limb postural X-ray was performed laterally and for AP, and included mLPFA, mLDFA, MAD, CORA coronal and sagittal plane parameters for the femur segment and mMPTA, mLDTA, MAD, CORA coronal and sagittal plane for the tibia segment. Clinical assessment was based on the LLFI. The mean follow-up was 55.8 months (12-86). Improvements in the radiological parameters and statistical significance were achieved for all measurements in all groups (p < 0.05). The most common plane of deformation was the coronal plane (varus/valgus), followed by the transverse (rotational) and sagittal planes (procurvatum/recurvatum). In this study, we examined 29 post-traumatic deformities and 21 other etiologies. Improvements in the LLFI score performance after corrective osteotomies were observed in all three groups. Corrective osteotomies are a safe and useful but challenging method of preserving joints in cases of post-traumatic, developmental or post-septic lower limb alignment disorders.

Tibiotalocalcaneal Arthrodesis with Hybrid Nail-Plate Constructs: A Novel Technique for Treatment of Unstable Ankle &amp; Hindfoot Deformities

Category: Ankle; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the hindfoot and ankle. Traditional fixation options include intramedullary nailing or plate-screw constructs. In certain patients, for example when bone quality or post-operative compliance are of concern, more robust fixation may be desired. Charcot neuroarthropathy (CN) patients in particular often have complex deformities, poor bone quality, and impaired sensation. New trauma literature shows hybrid nail-plate constructs (NPCs) may permit early weight bearing in osteoporotic distal femur fractures. We report early results of TTC arthrodesis using NPCs in patients with complex deformities of the ankle and hindfoot. Methods: Patients undergoing TTC arthrodesis via intramedullary nail fixation plus plating by a single surgeon from September 2020 to December 2022 were included in our study. Indications included CN, post-traumatic deformities, and advanced arthritis. Age, comorbidities, Hemoglobin A1c, presence of an ulcer, implants, bone graft used, and postoperative complications were retrospectively recorded. Results: Fifteen patients met inclusion criteria. Six patients had CN; eight patients had post-traumatic complications; and one patient had an arthritic cavovarus deformity. Average age was 55 years (range 31-72). Eleven patients were treated with a lateral TTC locking plate; three were treated with an anterior tibiotalar arthrodesis plate; and one was treated with a 3.5mm reconstruction plate. All patients were treated with a TTC arthrodesis nail. In all cases, cellular bone matrix was used; in fourteen cases, autograft was also used. Average follow-up was 35 weeks (min. 12). Three patients underwent below-knee amputation, two for infection and the other for hardware failure. Two others required postoperative debridements but subsequently cleared their infections. Twelve patients have a stable, non-infected, ulcer free foot at latest follow-up. Conclusion: TTC arthrodesis can be used for a variety of indications, and many of these patients present complex challenges. Patients with CN in particular often have severe deformities and poor bone quality. Hybrid fixation methods provide added stability in complex cases, possibly allowing for more powerful deformity correction and earlier weight-bearing. We report a 80% favorable outcome rate in our case series, with major complications confined to patients with significant medical comorbidities (poorly controlled diabetes, peripheral vascular disease). We believe that TTC arthrodesis with hybrid nail-plate constructs represents an attractive solution to complex ankle and hindfoot deformities.

Secondary correction of the post-traumatic deformity: A clinical study

The current manuscript explores the outcome of treatment for post-traumatic secondary deformities using the re-fracture of segments by osteotomies of the bone either at the fractured site or by the orthognathic osteotomies with repositioning to its premorbid place followed by internal fixation. A total of 14 patients were reported with post-traumatic secondary deformities of the craniofacial region to the Department of Facio-maxillary surgery from January 2019 - July 2022. All patients had varied clinical features including deranged occlusion, anterior open bite, difficulty in mastication, deviated nose, and depressed frontal bone. The radiological findings were mal-union, non-union, malocclusion, and failed implants. All patients were treated with osteotomies and internal fixation with titanium implants. The age range of patients with post-traumatic secondary deformity was from 17-45 years. The reasons for the secondary deformities that we experienced in our institute were excessive delay in initial treatment due to neurosurgical issues, financial issues and SARS-COVID-19, secondary infections due to the immunocompromised status of the patient, and failure of implants leading to non-union. At the end of 3 months follow-up, all patients had satisfactory results. The treatment for post-traumatic secondary deformities by re-osteotomising at the existing previous fracture site and doing reduction with internal fixation and orthognathic osteotomies for chronic malocclusion yields sufficient aesthetic and functional outcomes when there is no loss of hard or soft tissue.

Use of patient-specific guides and 3D model in scapula osteotomy for symptomatic malunion

BackgroundScapular osteotomy for malunion can lead to resolution of pain and functional improvement in scapula fracture sequelae. Understanding three-dimensional bone morphology and analysing post-traumatic deformity is the main step of planning and the key to success of the procedure. 3D models and patient-specific guides are a growing technology to enhance accuracy of planning and to assist during surgery.Case presentationWe report the case of a 50 years old male, complaining of pain and limited function after a malunited scapular body fracture. Clinical assessment showed a severe impairment of shoulder function with active and passive forward flexion limited to 80°, absent external rotation, and internal rotation limited to the buttock. X-rays and CT scan showed an excessive lateral border offset of 53 mm and complete displacement of the glenoid segment anteriorly and medially to the scapular body, with impingement between the lateral most prominent scapular bone spur and humeral shaft. Glenopolar angle was 19°, scapular body angulation on the sagittal plane was 12°. Corrective osteotomy was planned on a virtual interactive rendering and on 3D printed models. Patient-specific guides were developed to perform a body-spine osteotomy with removal of a bone wedge, and a glenoid-spine osteotomy; a patient-specific wedge spacer was used to hold the reduction during plate fixation. Follow-up up to 12 months after surgery demonstrated improvement in scapula anatomy, shoulder girdle function, and patient-reported outcomes.ConclusionsFor the first time in scapula malunion surgery, patient-specific osteotomy guides were succesfully used during surgery to perform osteotomies and to assist in reduction maneuvers.

Secondary Reconstruction of Late Deformities of the Orbitozygomaticomaxillary Complex using a Halo Device.

Reconstructing late deformities of the orbitozygomaticomaxillary complex after inadequate treatment of facial fractures requires zygomatic osteotomy to reposition the bony fragments to their anatomical position. However, confirming the position of the bone fragments can be challenging due to the loss of anatomic landmarks caused by bone remodeling, and swelling resulting from surgery, which might hinder locating the bone from the body surface. Here, the authors describe fixation of the halo of the Blue Device multi-vector distraction system to the patient's ear canal, with alignment of the position of the zygoma by measuring the distances between the halo and zygoma using several reference points. This technique allows for measurement not only from the body surface using a K-wire but also directly to the bone using a needle. The authors applied this technique in 2 cases of post-traumatic deformities after complex zygomatic fractures. Both cases achieved an almost symmetrical appearance of the infraorbital region.

Reconstruction of posttraumatic deformities and defects

The reconstruction of posttraumatic defects of bone and soft tissue, as well as residual deformities of the bone is often alengthy and complicated procedure. Multiple surgical interventions are necessary to reconstruct the affected extremity and restore its functionality. To achieve an optimal result it often takes months or years and requires great patience and compliance of the patient. This treatment should be carried out in centers with the appropriate instrumental and human resources. Since the pathologies are often complex with bony deformities or loss of bone, as well as infections and soft tissue defects, the treatment should be carried out by very experienced surgeons to successfully manage these complex reconstructions. This often requires interdisciplinary cooperation, especially with experienced plastic surgeons. Asoft tissue reconstruction for better blood circulation in the exposed bony structures, as well as the bony defects themselves, can be reconstructed at the same time.