Two-stage Surgical Procedure Research Articles

Artificial Membrane Induced by Novel Biodegradable Nanofibers in the Masquelet Procedure for Treatment of Segmental Bone Defects

The Masquelet induced-membrane technique for the treatment of segmental bone defects includes a two-stage surgical procedure, and polymethylmethacrylate (PMMA) plays a major role in the treatment. However, the PMMA spacer must be surgically removed. Here, we investigated the potential of poly(lactic-co-glycolic acid) (PLGA) nanofibers, a biodegradable material to replace the PMMA spacer, allowing the bioactive membrane to be induced and the spacer to degrade without the additional surgery on a rabbit femoral segmental bone defect model. PLGA nanofibers were shown to degrade completely six weeks after implantation in the investigated animals, and a thick membrane was found to circumferentially fold around the segmental bone defects. Results from image studies demonstrated that, in the group without the bone graft, all studied femurs exhibited either nonunion or considerable malunion. In contrast, the femurs in the bone graft group had a high union rate without considerable deformities. Histological examinations suggested that the membranous tissue in this group was rich in small blood vessels and the expression of BMP2 and VEGF increased. Our results demonstrate that the biodegradable PLGA nanofibers may be useful for replacing the PMMA spacer as the bioactive-membrane inducer, facilitating the process of healing and removing the need for repeated surgeries.

Role of associating liver partition and portal vein ligation in staged hepatectomy (ALPPS)-strategy for colorectal liver metastases.

Colorectal carcinoma (CRC) is the third leading cause of cancer-related death in the United States. The liver is the most frequent site of metastasis and a key determinant of survival in patients with isolated colorectal liver metastasis (CRLM). Surgical resection remains the only hope for prolonged survival in patients with CRLM. However, most patients are deemed to be unresectable at presentation due to a small future liver remnant (FLR) and fear of post-hepatectomy liver failure. Procedures such as portal vein ligation or embolization (PVL/PVE) followed by hepatectomy have been established as standard methods to increase FLR volume, but have limitations dependent upon extent of disease and patient's ability to grow the liver remnant. Recently, associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) has been introduced as a technique to induce liver hypertrophy over a shorter time period. Being a complex two-stage surgical procedure, initial reports of higher ALPPS-associated complications and mortality limited its worldwide adoption by hepatobiliary surgeons. However, recent studies have showed ALPPS superiority over conventional procedures in terms of feasibility and inducing liver hypertrophy, with comparable morbidity and mortality. We herein review the role of ALPPS in management of patients with CRLM.

Peripheral denervation participates in heterotopic ossification in a spinal cord injury model

We previously reported the development of a new acquired neurogenic HO (NHO) mouse model, combining spinal cord transection (SCI) and chemical muscle injury. Pathological mechanisms responsible for ectopic osteogenesis after central neurological damage are still to be elucidated. In this study, we first hypothesized that peripheral nervous system (PNS) might convey pathological signals from injured spinal cord to muscles. Secondly, we sought to determine whether SCI could lead to intramuscular modifications of BMP2 signalling pathways. Twenty-one C57Bl6 mice were included in this protocol. Bilateral cardiotoxin (CTX) injection in hamstring muscles was associated with a two-stage surgical procedure, combining thoracic SCI with unilateral peripheral denervation. Volumes of HO (bone volume, BV) were measured 28 days after surgery using micro-computed tomography imaging techniques and histological analyses were made to confirm intramuscular osteogenesis. Volume comparisons were conducted between right and left hind limb of each animal, using a Wilcoxon signed rank test. Quantitative polymerase chain reaction (qPCR) was performed to explore intra muscular expression of BMP2, Alk3 and Id1. Nineteen mice survive the complete SCI and peripheral denervation procedure. When CTX injections were done right after surgery ( n = 7), bilateral HO were detected in all animals after 28 days. Micro-CT measurements showed significantly increased BV in denervated paws (1.47 mm 3 ± 0.5) compared to contralateral sides (0.56 mm 3 ± 0.4), P = 0.03. When peripheral denervation and CTX injections were performed after sham SCI surgery ( n = 6), bilateral HO were present in three mice at day 28. qPCR analyses showed no changes in intra muscular BMP2 expression after SCI as compared to control mice. Peripheral denervation can be reliably added to spinal cord transection in NHO mouse model. This new experimental design confirms that neuro-inflammatory mechanisms induced by central or peripheral nervous system injury plays a key role in triggering ectopic osteogenesis.

Results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection

BackgroundThe objective of this study is to present the results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection and to determine the rate of positive cultures in the second-stage surgery in shoulder arthroplasty and its meaning.MethodsTwenty-one patients (22 cement spacers) treated with two-stage surgery because of a shoulder arthroplasty infection were included. In the second stage, the cement spacer was sent for sonication and at least four tissue cultures were obtained. Epidemiological data, comorbidities, sensitivity of the microorganisms to the antibiotic loaded in the cement spacer in the first revision surgery, time elapsed since an antibiotic was last administered until second revision procedure, functional shoulder status at last follow-up, and any complication were recorded.ResultsThree out of the 22 cases (13.6%) presented positive cultures at the second-stage surgery. Periprosthetic tissue culturing detected the three positive culture cases in the second stage while the cement spacer sonication detected two and missed one. Considering periprosthetic tissue culturing as the standard procedure, the cement spacer sonication showed sensitivity at 66.6%. Recurrent infection over time was considered present in 3 patients; two of them had been previously diagnosed with a positive culture at the second stage (66.6%).ConclusionsA good number of patients (13.6%) present a positive culture at the second stage of the two-stage surgical procedure for infected shoulder arthroplasty, and those patients seem to be at high risk for recurrent infection. Periprosthetic tissue cultures have a higher sensitivity to detecting a positive culture at the second stage than cement spacer sonication.

Superior calvarial bone regeneration using pentenoate-functionalized hyaluronic acid hydrogels with devitalized tendon particles

Traumatic brain injury (TBI) is a life-threatening condition defined by internal brain herniation. Severe TBI is commonly treated by a two-stage surgical intervention, where decompressive craniectomy is first conducted to remove a large portion of calvarial bone and allow unimpeded brain swelling. In the second surgery, spaced weeks to months after the first, cranioplasty is performed to restore the cranial bone. Hydrogels with paste-like precursor solutions for surgical placement may potentially revolutionize TBI treatment by permitting a single-stage surgical intervention, capable of being implanted with the initial surgery, remaining pliable during brain swelling, and tuned to regenerate calvarial bone after brain swelling has subsided. The current study evaluated the use of photocrosslinkable pentenoate-functionalized hyaluronic acid (PHA) and non-crosslinking hyaluronic acid (HA) hydrogels encapsulating naturally derived tissue particles of demineralized bone matrix (DBM), devitalized cartilage (DVC), devitalized meniscus (DVM), or devitalized tendon (DVT) for bone regeneration in critical-size rat calvarial defects. All hydrogel precursors exhibited a yield stress for placement and addition of particles increased the average material compressive modulus. The HA-DBM (4–30%), PHA (4%), and PHA-DVT (4–30%) groups had 5 (p < 0.0001), 3.1, and 3.2 (p < 0.05) times greater regenerated bone volume compared to the sham (untreated defect) group, respectively. In vitro cell studies suggested that the PHA-DVT (4–10%) group would have the most desirable performance. Overall, hydrogels containing DVT particles outperformed other materials in terms of bone regeneration in vivo and calcium deposition in vitro. Hydrogels containing DVT will be further evaluated in future rat TBI studies. Statement of SignificanceTraumatic brain injury (TBI) is a life-threatening condition characterized by severe brain swelling and is currently treated by a two-stage surgical procedure. Complications associated with the two-stage surgical intervention include the occurrence of the condition termed syndrome of the trephined; however, the condition is completely reversible once the secondary surgery is performed. A desirable TBI treatment would include a single surgical intervention to avoid syndrome of the trephined altogether. The first hurdle in reaching the overall goal is to develop a pliable hydrogel material that can regenerate the patient’s bone. The development of a pliable hydrogel technology would greatly impact the field of bone regeneration for TBI application and other areas of bone regeneration.

A successful outcome of treatment in a patient with a spleen artery aneurysm complicated by bleeding in pseudocyst of the pancreas

A pseudoaneurysm is a rare and potentially dangerous vascular complication of acute pancreatitis, with a mortality of 20–43% in untreated patients. Its treatment includes embolization or surgical resection. A clinical case of a 39-year-old patient, with a history of chronic pancreatitis, pseudocyst of the tail of the pancreas, as well as a false aneurysm of the splenic artery detected by means of computed tomography of abdominal organs with contrast is presented. A two-stage surgical procedure was performed. The patient was discharged in a satisfactory condition. This case shows a successful use of diagnostic techniques, as well as a stage-by-stage approach to surgical treatment of this pathology.Received 20 April 2017. Accepted 7 June 2017.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsConception and study design: I.V. HalturinData collection and analysis: I.V. HalturinDrafting the article: I.V. HalturinResources: I.V. Halturin, S.A. Sergeev, R.G. Achmetzyanov Critical revision of the article: S.A. Sergeev, R.G. AchmetzyanovFinal approval of the version to be published: I.V. Halturin, S.A. Sergeev, R.G. Achmetzyanov

Peripheral denervation participates in heterotopic ossification in a spinal cord injury model.

We previously reported the development of a new acquired neurogenic HO (NHO) mouse model, combining spinal cord transection (SCI) and chemical muscle injury. Pathological mechanisms responsible for ectopic osteogenesis after central neurological damage are still to be elucidated. In this study, we first hypothesized that peripheral nervous system (PNS) might convey pathological signals from injured spinal cord to muscles in NHO mouse model. Secondly, we sought to determine whether SCI could lead to intramuscular modifications of BMP2 signaling pathways. Twenty one C57Bl6 mice were included in this protocol. Bilateral cardiotoxin (CTX) injection in hamstring muscles was associated with a two-stage surgical procedure, combining thoracic SCI with unilateral peripheral denervation. Volumes of HO (Bone Volume, BV) were measured 28 days after surgery using micro-computed tomography imaging techniques and histological analyses were made to confirm intramuscular osteogenesis. Volume comparisons were conducted between right and left hind limb of each animal, using a Wilcoxon signed rank test. Quantitative polymerase chain reaction (qPCR) was performed to explore intra muscular expression of BMP2, Alk3 and Id1. Nineteen mice survive the complete SCI and peripheral denervation procedure. When CTX injections were done right after surgery (n = 7), bilateral HO were detected in all animals after 28 days. Micro-CT measurements showed significantly increased BV in denervated paws (1.47 mm3 +/- 0.5) compared to contralateral sides (0.56 mm3 +/-0.4), p = 0.03. When peripheral denervation and CTX injections were performed after sham SCI surgery (n = 6), bilateral HO were present in three mice at day 28. Quantitative PCR analyses showed no changes in intra muscular BMP2 expression after SCI as compared to control mice (shamSCI). Peripheral denervation can be reliably added to spinal cord transection in NHO mouse model. This new experimental design confirms that neuro inflammatory mechanisms induced by central or peripheral nervous system injury plays a key role in triggering ectopic osteogenesis.

Associations of alveolar bone loss and interleukin-1β levels in one- and two-stage surgical procedures: a randomized prospective trial

Objective: Dental implants have been widely and successfully used in recent years as an alternative treatment for removable and fixed dental prostheses. The aim of this randomized prospective study was to determine the alveolar bone loss rate (ABLR) and IL-1β levels in one- and two-stage surgical procedures.Materials and methods: This study included 40 patients with a single missing tooth in the posterior mandible; dental implants were inserted using a one-stage surgical procedure (Group I) or a two-stage surgical procedure (Group II). All clinical periodontal parameters were recorded; peri-implant crevicular fluid (PICF) samples were collected before loading (T0) and during the third (T1) and sixth (T2) months after loading. ABLR values were evaluated at T0 and T2 by using dental tomography. PICF was analysed after T2 samples were collected. The study was registered through clinicaltrials.gov; identifier NCT03045458.Results: This study found that, the probing pocket depth was found to be significantly higher in Group I than Group II at both T1 and T2 (p < .05). There was no significant difference in other clinical parameters between the groups (p > .05). There was a significant difference between Group I ABLR values at T0 and T2 (p < .05). The PICF IL-1β levels were not significantly different between groups (p > .05).Conclusions: Within the limitations of the short observational period and small sample size of this study, two-stage implant placement shows comparable clinical outcomes to implants placed using a one-stage placement protocol.

Similarities between induced membrane and amniotic membrane: Novelty for bone repair

Previous clinical studies have shown the efficacy of a two-stage surgical procedure – the induced membrane (IM) technique – for reconstruction of large bone defects or bone non-union. The first stage involves radical debridement and insertion of a cement spacer into the bone defect. The second stage, performed weeks to months later, consists of removing the spacer while leaving the foreign body membrane induced by the cement in place, and then filling the cavity with bone autograft. The IM has been shown to (1) act as a protective physical barrier by preventing bone autograft resorption and (2) act as a bioreactor by promoting healing through revascularisation and growth factor secretion, and by concentrating mesenchymal stem cells (MSC) with osteogenic properties. New solutions to reduce this surgical procedure to a single step are being explored, for example by using an IM-like bioactive and protective barrier inserted into the bone defect at the same time as bone graft.

Partial quadriceps tendon transfer for revision medial patellofemoral ligament reconstruction: A new surgical technique

Medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability is a common procedure. Although MPFL reconstruction is a successful procedure in terms of return to normal life or sports, revision cases are challenging due to previous holes into the patella or implants placed in the anatomical femoral insertion site. In this technical note, the use of a partial quadriceps tendon transfer to the adductor magnus tendon is presented as a good solution for revision cases to avoid the use of implants, bone drilling, use of allografts, or two-stage surgical procedures. In addition, this procedure could be also used as a primary procedure in skeletally immature patients.

Two-stage surgical treatment for septic non-union of the forearm.

AIMTo investigate the effectiveness of a two-stage surgical procedure for the treatment of septic forearm non-union.METHODSSeptic non-unions are rare complications of forearm fractures. When they occur, they modify the relationship between forearm bones leading to a severe functional impairment. Treatment is challenging and surgery and antibiotic therapy are required to achieve infection resolution. It is even harder to obtain non-union healing with good functional results. The aim of this study is to present a two stages surgical treatment for septic forearm non-union with revision and temporary stabilization of the non-union until infection has cleared and subsequently perform a new synthesis with plate, opposite bone graft strut and intercalary graft. We retrospectively reviewed 18 patients with a mean age at the time of primary injury of 34.5 years (19-57 years) and a mean follow-up of 6 years (2-10 years). All patients presented an atrophic non-union with a mean length of the bone defect of 1.8 cm (1.2-4 cm). Complications and clinical results after surgical treatment were recorded.RESULTSMean time to resolution of the infectious process was 8.2 wk (range 4-20 wk) after the first surgery and specific antibiotic therapy. All the non-union healed with an average time of 5 mo (range 2-10 mo) after the second step surgery. Cultures on intraoperative samples were positive in all cases. No major intraoperative complications occurred. Two patients developed minor complications and one needed a second surgical debridement for infection resolution. At the last follow-up functional results were excellent in 5 (27.8%) patients, satisfactory in 10 (55.5%) and unsatisfactory in 3 (16.7%) patients. No activities of daily living (ADLs) limitations were reported by 12 (66.6%) patients, slight by 3 (16.6%) and severe limitation by 3 (16.6%) patients. Mean visual analog scale at the last follow-up was 1 (0-3).CONCLUSIONThe two-step technique has proven to be effective to achieve resolution of the infectious process and union with good functional results and low rate of complications.

Implants for elderly patients.

In the developed world, the large birth cohorts of the so-called baby boomer generation have arrived in medical and dental practices. Often, elderly patients are 'young-old' baby boomers in whom partial edentulism is the predominant indication for implant therapy. However, the generation 85+years of age represents a new challenge for the dental profession, as their lives are frequently dominated by dependency, multimorbidity and frailty. In geriatric implant dentistry, treatment planning is highly individualized, as interindividual differences become more pronounced with age. Nevertheless, there are four typical indications for implant therapy: (i) avoidance of removable partial prostheses; (ii) preservation of existing removable partial prostheses; (iii) stabilization of Kennedy Class I removable partial prostheses; and (iv) stabilization of complete prostheses. From a surgical point of view, two very important aspects must be considered when planning implant surgery in elderly patients: first, the consistent strive to minimize morbidity; and, second, the fact that coexisting medical risk factors are significantly more common in elderly patients. Modern three-dimensional cone beam computed tomography imaging is often indicated in order to plan minimally invasive implant surgery. Computer-assisted implant surgery might allow flapless implant surgery, which offers a low level of postoperative morbidity and a minimal risk of postsurgical bleeding. Short and reduced-diameter implants are now utilized much more often than a decade ago. Two-stage surgical procedures should be avoided in elderly patients. Implant restorations for elderly patients should be designed so that they can be modified to become low-maintenance prostheses, or even be removed, as a strategy to facilitate oral hygiene and comfort in the final stage of life.

A novel single-step surgical technique for vestibular deepening using laser in conjunction with periodontal flap surgery

Moderate-to-severe chronic periodontitis results in clinical loss of attachment, reduced width of attached gingiva (AG), periodontal pockets beyond mucogingival junction (MGJ), gingival recession, loss of alveolar bone, and decreased vestibular depth (VD). The encroachment of frenal and muscle attachments on marginal gingiva increases the rate of progression of periodontal pockets, prevents healing, and causes their recurrence after therapy. Loss of VD and AG associated with continuous progression of pocket formation and bone loss requires two-stage surgical procedures. In this article, one-stage surgical procedure is being described for the first time, to treat the periodontal pockets extending beyond the MGJ by periodontal flap surgery along with vestibular deepening with diode laser to increase the AG. One-step surgical technique is illustrated whereby pocket therapy with reconstruction of lost periodontal tissues can be done along with gingival augmentation by vestibular deepening.

Negative pressure wound therapy limits downgrowth in percutaneous devices.

Maintenance of a soft tissue seal around percutaneous devices is challenged by the downgrowth of periprosthetic tissues-a gateway to potential infection. As negative pressure wound therapy (NPWT) is used clinically to facilitate healing of complex soft tissue pathologies, it was hypothesized that NPWT could limit downgrowth of periprosthetic tissues. To test this hypothesis, 20 hairless guinea pigs were randomly assigned into four groups (n = 5/group). Using a One-Stage (Groups 1 and 3) or a Two-Stage (Groups 2 and 4) surgical procedure, each animal was implanted with a titanium-alloy subdermal device porous-coated with commercially pure, medical grade titanium. Each subdermal device had a smooth titanium-alloy percutaneous post. The One-Stage procedure encompassed insertion of a fully assembled device during a single surgery. The Two-Stage procedure involved the implantation of a subdermal device during the first surgery, and then three weeks later, insertion of a percutaneous post. Groups 1 and 2 served as untreated controls and Groups 3 and 4 received NPWT. Four weeks postimplantation of the post, the devices and surrounding tissues were harvested, and histologically evaluated for downgrowth. Within the untreated control groups, the Two-Stage surgical procedure significantly decreased downgrowth (p = 0.027) when compared with the One-Stage procedure. Independent of the surgical procedures performed, NPWT significantly limited downgrowth (p ≤ 0.05) when compared with the untreated controls.

PWE-234 Management and outcomes of intestinal failure in a district general hospital setting: Abstract PWE-234 Table 1

Introduction Centralisation of intestinal failure (IF) services is being considered. It will not be possible to manage all patients with type 2 IF in national centres and many patients will need to be managed regionally. We have audited our practice of type 2 and 3 IF with respect to aetiology, management and outcomes in a DGH setting. Method Retrospective analysis of consecutive patients admitted with type 2/3 IF requiring parenteral nutrition (PN) for > 28 days between 01/09/2009–31/07/2014 was done from prospectively maintained database and cross-referenced with case notes (electronic and paper). Data are represented as median (range). Results There were 84 patients (45 women) admitted during the study period. The median age was 68 (20–90) years. Aetiology PN details Patients were managed on PN for a median of 65 (29–728) days while being an in-patient. The catheter related infection rate was 0.16 CRBI /1000 catheter-days. PN was administered by peripherally inserted central catheters by a nurse led service. Outcome Nutritional autonomy was achieved following conservative management in 17 (20%) patients. 46 (55%) underwent one-stage (n = 24) or two-stage (n = 22) surgical procedures and achieved nutritional autonomy. 8(10%) required home parenteral nutrition of which 6 were palliative patients who were discharged to hospice and 2 were referred to national IF centres. 12(14%) with type 2 IF and 1 (1%) with type 3 IF died in hospital. At a median follow-up of 479 (19–1885) days, 18 (21%) with type 2 IF and 6 (7%) with type 3 IF died. Conclusion Sepsis management and safe PN administration is the key to managing patients with IF and can be done in regional units. Disclosure of interest None Declared.

Early peri-implant bone loss: a prospective cohort study

The aim of this study was to measure the early peri-implant bone level changes before the completion of an implant–abutment connection and to evaluate the influence of demographic, biologically relevant, anatomical, and implant-specific variables on these changes. A prospective cohort study design was used. STROBE guidelines were followed. The sample comprised 493 implants placed using a two-stage surgical procedure. Random allocation was used to determine the implant placement depth. Peri-apical radiographs taken at implant insertion and at the second surgery 2 months later were matched. Kappa statistics were used to compute intra- and inter-examiner reliability. The statistical analysis was performed at the implant level. Two-way analysis of variance (ANOVA) with the Bonferroni adjusted post hoc test was used to evaluate the influence of variables. One-way ANOVA with Tukey's range test and unpaired Student t-tests were used to analyze significant variables. Early marginal bone remodelling was −0.86mm. The timing of implant placement (P=0.00) and the depth of implant placement (P≤0.05) significantly influenced early bone remodelling. Relevant radiographic early bone loss was found, but implants initially positioned below the alveolar crest and inserted ≥3 months after tooth extraction showed statistically significant higher marginal bone loss during the healing phase.

Preservation Technique of Autologous Bone in Scoliosis Surgery

Study Design This is a retrospective study. Objective This study aims to describe surgical technique of locally wound autologous bone conservation when primary surgery becomes mandatory to be staged, described as well the evolution and technique complications. Introduction One of the goals of scoliosis surgery is to halt the progression of curves achieving solid fusion. The contribution of additional bone graft in particular cases is critical. There are different types of bone grafts or bone substitutes, with different costs, and technical complications; it has become increasingly important the way to obtain and preserve a good amount of autologous bone. Patients and Methods A total of 12 patients, who required two-staged surgical procedures, were operated from June 2012 to April 2014 in our Spine Department. A subfascial pocket was performed in paraspinal muscles at the distal end of the surgical field where we added 1 g of vancomycin every 50 mL of bone graft. Surgical procedure, surgical correction, and complications with a full detailed analysis of infectious complications were assessed and recorded. Results Overall, 12 patients were operated in our hospital Spine Department with a two-staged surgical procedure plan. Patients mean age at surgery was 14 years. The etiology of deformity consisted in five idiopathic scoliosis, three congenital scoliosis, one associated with high-grade spondylolisthesis, two neuropathic scoliosis, and one myopathic scoliosis. In five cases (41.6%), surgery was initially staged in two different surgical days according to surgeon criteria and spinal severity deformity, in the other seven cases (58.4 degrees), the surgeon in charge, resolved to reschedule the surgical procedure in two different stages because of some intraoperative urgent event. The mean preoperative scoliosis angular value was 92.8 degrees. The mean postoperative scoliosis angular value was 42.4 degrees. We found that every patient in this study group required three surgical procedures to solved spinal deformity. Five patients developed superficial or deep infection (41.6%). Conclusion The local conservation of autologous bone graft in severe scoliosis surgery that has to be rescheduled or was already staged in 2 different days can be performed by storing the local bone graft in a subaponeurotic or subfascial pocket, with proper bone fusion imaging recordings, without incurring in an increasing risk of infection diminishing health costs.

Post-Odontoma autotransplantation of an impacted tooth: A case report

After years of relegation by dental implants, autotransplantation has recently become more popular because of a better understanding of its science. The prognosis of autotransplantation primarily depends upon the presence of an intact alveolar bone at the transplant site and the regeneration of a functional periodontal ligament of the transplant. Replacement of an unsalvaged or a missing tooth by a natural tooth with normal periodontium within a short duration of treatment is the ultimate challenge of autotransplantation. Meanwhile, Platelet Rich Fibrin (PRF) is popular as a biomaterial which helps in the regeneration of bone and periodontal tissues. To improve the prognosis, and also shorten the treatment time in a rare case of autotransplantation of an impacted tooth in a post-odontoma site, we did a two-stage surgical procedure aided by synthetic bone granules (Biograft) and PRF. The clinical and radiological findings at 6 months follow-up showed good result and promise.

Two-Stage Surgical Treatment of Complex Femoral Deformities with Severe Coxa Vara in Polyostotic Fibrous Dysplasia

In patients with polyostotic fibrous dysplasia with extensive femoral involvement, severe coxa vara may cause complex femoral deformities that are difficult to treat with a single-stage surgical procedure. We evaluated the results of treatment of such patients with a two-stage procedure. Eleven patients with polyostotic fibrous dysplasia and severe coxa vara (including one who required bilateral treatment and one who required repeat treatment) were treated surgically at a mean age of fourteen years and four months. A two-stage surgical procedure was planned to correct the deformity. The first stage involved correction of the coxa vara and fixation with a hip plate. The second stage involved correction of a shepherd's crook deformity if present and definitive fixation with an interlocking cervicodiaphyseal nail. All patients were evaluated clinically and radiographically at a mean of four years and seven months after the second-stage procedure. The femoral neck-shaft angle averaged 83° before surgery and was corrected to a mean of 130° after the first-stage procedure. In two patients, cutout of the hip screw-plate caused acute postoperative loss of correction (by 40° in one patient and 20° in the other). After the second-stage procedure, the neck-shaft angle was either fully corrected or improved and the shepherd's crook deformity was fully corrected in all patients. At the time of the latest follow-up, the mean neck-shaft angle was 124°, with a mean loss of correction of 5° relative to the angle measured at the end of the second-stage procedure. The mean estimated blood loss was 625 mL in the first stage and 979 mL in the second. The two-stage surgical procedure designed to treat patients with polyostotic fibrous dysplasia with complex femoral deformity and severe coxa vara restored a nearly normal femoral alignment that was maintained at a mean of four years and seven months of follow-up. The clinical benefits were pain relief in all of the patients and gait normalization or improvement in most. The estimated blood loss was substantial in both stages. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

重度の骨格性下顎前突症患者に対して二段階の顎矯正手術を施行した1例

In cases of jaw deformity, bimaxillary surgery combining Le Fort I osteotomy and sagittal split ramus osteotomy (SSRO) is one of the standard operations. However, this operation can be difficult to use in cases of severe mandibular prognathism because of the large amount of setback. We report herein a case of severe mandibular prognathism treated with a two-stage surgical procedure. At the first stage, we performed mandibular body ostectomy, followed at the second stage by maxillary advancement by Le Fort I osteotomy and mandibular set-back by sagittal split ramus osteotomy. This unique two-stage surgical treatment improved and kept the patient's overall facial aesthetics and occlusion for one year postoperatively.