Progressive opening-wedge osteotomy for severe tibia vara in adults

Five patients with tibia vara were treated with progressive opening-wedge osteotomy. The maximum varus deviation of the mechanical axis of the tibia varied from 20 degrees to 12 degrees. The minimum postoperative follow-up was 26 months. Complete correction of the deformity was achieved without any major complications. Progressive opening-wedge osteotomy offers several advantages over conventional osteotomy in adults. First, fibular osteotomy is unnecessary. Second, knee mobility is only slightly restricted immediately following surgery. Third, it is possible to adjust correction postoperatively, and finally, progressive opening-wedge osteotomy does not induce shortening of the lower limb. The most significant disadvantage is the need for prolonged external fixation. This technique should be reserved for patients with severe deformities (minimum of 15 degrees varus) and mild or moderate osteoarthrosis.     

Study on percutaneous rate of P-aminobenzoates using molecular orbital method

The use of a dome osteotomy in the treatment of infantile tibia vara is reportedly associated with insufficient intraoperative assessment of the correction achieved. This article discusses a method to overcome this problem and the long-term advantages of using a dome osteotomy in the treatment of this disease.     

Surgical refinement of the operative procedure for a minor degree of mandibular prognathism

Although sagittal splitting ramus osteotomy is used widely for mandibular prognathism and even for that of a minor degree, a long duration of preoperative and postoperative orthodontic treatment is required. Conversely, mandibular segmental osteotomy has often been used to correct a minor degree of mandibular prognathism without specific orthodontic treatment. Here we describe a surgical refinement accomplishing mandibular segmental osteotomy, reduction genioplasty by double horizontal osteotomies, and decortication of the middle portion of the osteotomies for a minor degree of mandibular prognathism. The amount of setback is limited to 4 to 5 mm, no intermaxillary fixation is required, and no orthodontic treatment, in principle, is needed. This procedure can obtain a rapid aesthetic improvement. We used this procedure in 11 patients (7 females and 4 males) with a minor degree of mandibular prognathism. The amount of setback of the mandibular anterior portion was 4 to 5 mm, and satisfactory results were obtained in all patients.     

Management of late-onset tibia vara in the obese patient by using circular external fixation

Previously published series of surgery for late-onset tibia vara reported a significant number of complications and fair or poor results. Obesity in many of these patients makes surgical intervention an even more daunting prospect. Circular external fixation is applicable to almost any limb size and allows weight bearing as tolerated, with gradual adjustment of alignment. Twenty-five tibiae in 17 patients who exceeded their ideal body weight by > or =50% underwent correction of late-onset tibia vara with the Ilizarov technique. Average age at surgery was 11 years 7 months (range, 7 years 8 months to 15 years 11 months). Mean varus deformity was 27 degrees (range, 10-55 degrees). Treatment time averaged 12 weeks in patients without lengthening and 16.9 weeks in those requiring lengthening (mean, 3.5 cm). All patients achieved alignment within 5 degrees of normal. Complications included one delayed union, premature consolidation in one, and two residual limb-length inequalities. There were no cases of osteomyelitis, compartment syndrome, or nerve palsy. These results are a significant improvement over reports of traditional methods in these difficult patients.     

How to evaluate suspected immunodeficiency

The periacetabular osteotomy is a strategy for the treatment of residual hip dysplasia in young adults with the aim of preventing secondary coxarthrosis. This polygonal, juxta-articular osteotomy respects the vascular blood supply to the acetabular fragment and thus facilitates an extensive acetabular reorientation with improvement of the insufficient coverage of the femoral head, including medial displacement of the fragment. All osteotomies are performed by one approach, the modified Smith-Petersen, which allows an anterior capsulotomy. Inspection of the joint not only provides information on acetabular rim pathologies, but also facilitates the control of impingement-free range of motion after the correction. The posterior column remains partially intact, allowing minimal internal fixation of the acetabular fragment and early mobilization similar to that after an intertrochanteric osteotomy. The dimensions of the true pelvis are unchanged, providing the capacity to have an unimpeded delivery in women. This paper describes the preoperative evaluation, current indications, surgical technique, postoperative care, and the results of this osteotomy.     

Barren female Strongyloides stercoralis from occult chronic infections are rejuvenated by transfer to parasite-naive recipient hosts and give rise to an autoinfective burst

A technique of radius opening-wedge osteotomy, bone graft, and external fixation for the treatment of symptomatic radius malunion is presented. It provides direct rigid fixation to the osteotomy components, thus maintaining the correction while allowing early wrist exercises. This technique has been effective for 7 patients in correcting deformities that averaged--20 degrees palmar tilt with radial shortening of 3.4 mm to a postoperative average palmar tilt of 5.3 degrees and -0.4 mm radial shortening. It is an alternative technique for the hand surgeon treating radius malunion and can be easily combined with adjunctive procedures.     

Bunionette correction by metatarsal osteotomy: preliminary report

A preliminary report is presented of 17 patients who underwent 27 fifth metatarsal osteotomies. Oblique osteotomy without internal fixation was used. Union of the osteotomy without external immobilization occurred in 16 of the patients. Correction was effected in a case of delayed union in one foot because it was symptomatic. Improvement and normal function were the result in 26 of the 27 osteotomies. Delayed union did not seem to mean failure of relief. No painful scars occurred.     

Orthopedic management of osteopetrosis: results of a survey and review of the literature

Osteopetrosis or Albers-Schonberg disease is a rare hereditary disorder of osteoclast function in which resorption of bone is diminished, resulting in abnormally dense bones. The condition is known to occur in at least four recognizable clinical patterns, each of which is variable. The optimal treatment of fractures and of bone deformity in these patients has not previously been made clear. To determine appropriate orthopedic management of the condition, we conducted a survey of the membership of the Pediatric Orthopedic Society of North America. The combined experience of 57 surgeons who treated 79 patients with osteopetrosis was compiled. Four femoral neck fractures treated by closed reduction and internal fixation had a satisfactory result, but three treated nonoperatively developed varus and required osteotomy. A total of 20 hips was treated for coxa vara by various means, none of which was free of complications. Valgus osteotomy, when used as the primary treatment for coxa vara, was the most consistently satisfactory procedure, whereas in situ pinning failed in two of three hips. Fourteen subtrochanteric fractures and 31 other fractures of the femur were treated. Good results were reported with traction or casting or both in the majority of those fractures. Twenty-nine tibia fractures were treated successfully, the majority by nonoperative means. Upper extremity fractures healed well with closed reduction and casting. Vertebral fractures, spondylolysis, and back pain were most frequently treated without surgery.     

The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach

A precise and reproducible lateral osteotomy is a requirement for successful rhinoplasty. Two basic techniques have evolved: the external perforated method and the internal continuous method. The literature supporting the external perforated technique maintains that it contributes to a controlled, stable fracture and produces less nasal airway narrowing, hemorrhage, edema, and ecchymosis; however, the continuous internal method is used by many rhinoplasty surgeons. Our study was designed to compare the two techniques in the fresh cadaver nose using a blinded endoscopic evaluation of the nasal mucosa after the osteotomies were performed by one of these two techniques. Nineteen fresh cadaver heads had an external perforated lateral osteotomy performed on one side and an internal continuous lateral osteotomy performed on the alternate side by an investigator with experience in the use of both osteotomies. In a blinded fashion, four different investigators used nasal endoscopy to detect mucosal perforations and bony irregularities. Eleven percent of the perforated osteotomies resulted in mucosal tearing as opposed to 74 percent of the continuous osteotomies (p < 0.001). This anatomic study confirms our clinical experience that the external perforated osteotomy results in a more controlled fracture with less intranasal trauma and can minimize the associated morbidity (hemorrhage, edema, and ecchymosis) in the rhinoplasty patient.     

The crescentic shelf osteotomy

The authors describe a new surgical technique for the correction of a hallux abducto valgus deformity. The crescentic "shelf" osteotomy combines a dorsal-to-plantar crescentic osteotomy with a medial-to-lateral transverse osteotomy at the first metatarsal base. This technique allows triplanar correction, stable open reduction with internal fixation, and precise intermetatarsal reduction. This article discusses alternate base osteotomies, anatomical considerations of the first metatarsal, and data predicting frontal and sagittal plane motion of the distal fragment. Also included is a procedural guide followed by examples and possible complications. An analysis of 22 procedures are presented. The article briefly introduces the capital crescentic shelf osteotomy with review of the procedure.     

Radiographic course after acetabuloplasty and femoral osteotomy in hip dysplasia

The radiographic course of 101 hips with residual dysplasia treated with roof plasty combined with intertrochanteric varus derotation osteotomy using the osteotomy wedge as a roof graft after Mittelmeier were reviewed. The average followup period was 8.8 years. The acetabular angle was improved by an average of 16 degrees (postoperative mean, 19 degrees; average at followup, 18 degrees). The center edge angle also was improved by 16 degrees and was stable at 25 degrees average at followup. The neck shaft angle, abnormal in 70% of hips preoperatively, was reduced by the varus osteotomies to a mean of 111 degrees and showed a spontaneous postoperative increase to normal values of an average of 129 degrees. There was no correlation of the postoperative of the neck shaft angle to patient age, preoperative valgus extension, correction angle, or length of followup. In nearly all cases, an almost anatomic joint shape was achieved. With a complication rate of only 1%, especially regarding the rate of necroses of the femoral head, the presented surgical technique can be recommended as highly effective, reliable, and safe for the treatment of congenital hip dislocation.     

Hemispheric control of motor function: a whole brain echo planar fMRI study

A sample of 130 patients with vertical maxillary hyperplasia; mandibular hypoplasia with a high mandibular plane angle; narrow, tapered maxillary dental arch form; and anterior vertical open bite were collected from three different institutions to evaluate the stability of transverse maxillary arch dimensions after correction of the open bite. Surgical treatment consisted of Le Fort I or bimaxillary osteotomies. Intermolar, interpremolar, and anterior arch widths were measured three-dimensionally on dental casts using a Reflex microscope, and transverse stability after orthodontic or surgical maxillary expansion was analyzed. Orthodontic expansion followed by a one-piece Le Fort I intrusion osteotomy was performed in 77 patients, and surgical maxillary expansion by a multisegment Le Fort I intrusion osteotomy was performed in 53 patients. The increase of transverse arch width and the relapse after orthodontic or surgical expansion were not significantly different. The transverse arch width in these two groups did not relapse in 20% of the patients after a mean follow-up of 69 months. An additional bilateral sagittal split osteotomy had no detectable effect on stability. Patients who underwent a multisegment Le Fort I osteotomy stabilized with rigid internal fixation showed better transverse stability than those with intraosseous wire fixation and maxillomandibular fixation. Maxillary intermolar and interpremolar arch width relapses were not correlated with tongue interposition or loss of interdigitation. The relapse of these arch widths showed significant correlations with clockwise rotation of the mandible but not with changes of overbite or overjet.     

Inherent stability of proximal first metatarsal osteotomies: a comparative analysis

Proximal first metatarsal osteotomies have been criticized for their instability leading to the dorsal displacement of the first metatarsal head. The purpose of this study was to compare inherent stability of fixated proximal oblique wedge and crescentic first metatarsal osteotomies against simulated vertical ground reactive forces. The authors evaluated four groups of 10 models each with various proximal osteotomy and fixation configurations. Group I was a control group of bone models without osteotomies; group II had oblique closing wedge osteotomies with one 2.7-mm, fully threaded, cortical screw fixation; group III had oblique closing wedge osteotomies with two 2.7-mm, fully threaded, cortical screw fixation; and group IV had proximal crescentic osteotomies with one 4.0-mm, partially threaded, cancellous screw fixation. All 40 bone models were stressed with simulated vertical ground reactive forces. Maximum load to achieve catastrophic failure was higher in the crescentic group (67.7 N, SD 15.1 N, p < or = .005), but the energy required to displace the osteotomy during the stressing sequence was higher in the two-screw oblique closing wedge osteotomy (390.6 N.mm, SD 153.4 N.mm, p < or = .01). The single-screw oblique closing wedge osteotomies showed the least ability to resist simulated vertical ground reactive forces (39.6 N, SD 19.1 N, p < or = .005).     

Type-II external fixation, using new clamps and positive-profile threaded pins, for treatment of fractures of the radius and tibia in dogs

A new external fixation system for repair of fractures of the radius and tibia was developed that uses positive-profile threaded pins. This system allows for addition of a fixation clamp between 2 installed clamps, predrilling of pin holes through a drill sleeve, use of positive-profile threaded pins in all locations, and easier application of full pins. Type-II external fixators were applied, using this system, to fractures in 10 client-owned dogs, and outcome was evaluated. All fractures healed without complications. Duration of surgery, mean time until radiographic evidence of a bridging callus, and mean time until removal of the external fixator were shorter, and frequency of pin loosening were less than with other techniques. Pin loosening was uncommon. This system provides an important improvement in external skeletal fixation.     

Modified Küntscher's nail for the proximal femur fixation after corrective osteotomies in children (author's transl)

The authors describe the development in the design of the modified Küntscher's nail with two fins on its upper part, assigned for the fixation of proximal femur after corrective osteotomies in children. Detailed explanation about the nails construction and its biomechanical characteristics are presented. The fixation of the nail in the proximal and distal femoral part, as well as on the site of osteotomy is particularly analyzed. On the base 423 operated cases, where the modified Küntscher's nail was applied, the authors conclusion is that the nail is very suitable for the correction of proximal femur deformities in children.     

Treatment of condylar hyperplasia of the mandible using unilateral ramus osteotomies

PURPOSE: The long-term outcome of bilateral and unilateral ramus osteotomies used for the treatment of unilateral condylar hyperplasia of the mandible are evaluated and compared. MATERIALS AND METHODS: Thirteen cases of unilateral condylar hyperplasia of the mandible were surgically treated during a 10-year period from 1985 to 1995. Seven of the patients were treated by bilateral ramus osteotomies alone; six were treated by unilateral ramus osteotomies of the affected side. Unilateral ramus osteotomy was combined with a maxillary Le Fort I procedure in two of the six cases. Preoperative analysis of patients, indications for case selection, and postoperative results relating to facial symmetry, temporomandibular joint (TMJ) pain, occlusion, and stability were compared in the two groups. RESULTS: The postoperative findings and long-term results in both groups of patients were favorable. Symmetry, arch coordination, and occlusion remained stable. TMJ pain and dysfunction were invariably cured postoperatively. Unilateral ramus osteotomies alone, or in combination with maxillary surgery when deemed feasible and applicable by preoperative clinical analysis, was sufficient to restore symmetry and occlusion in dentally compensated cases. CONCLUSIONS: This study shows that patients with unilateral condylar hyperplasia of the mandible and deviation can be treated favorably by unilateral ramus osteotomy of the affected side; bilateral ramus osteotomy did not have any advantage in such cases. In addition, this procedure, combined with a Le Fort I osteotomy of the maxilla, was also effective in restoring occlusal canting and facial symmetry in dentally compensated cases. However, bilateral ramus osteotomy was required in prognathic cases and in cases in which a unilateral procedure would cause excessive rotation of the contralateral condyle.     

The "Z" osteotomy versus the Kalish osteotomy for the correction of hallux abducto valgus deformities: a retrospective analysis

A retrospective analysis of hallux abducto valgus surgery performed between 1990 and 1995 where the "Z" osteotomy and Kalish osteotomy were utilized was performed. Objective and subjective data were collected to determine the effectiveness of the Z osteotomy versus the Kalish osteotomy. Twenty cases of hallux abducto valgus where the Z osteotomy was utilized were evaluated on the basis of intermetatarsal angle correction and alleviation of preoperative symptoms. The same evaluation was performed on 21 cases where the Kalish osteotomy was utilized. There did not appear to be an appreciable difference in intermetatarsal angle correction between the two osteotomies; however, the Kalish osteotomy did alleviate preoperative symptoms to a greater degree compared with the Z osteotomy.     

An in vitro evaluation of distractors used for osteogenesis

OBJECTIVE: The objective of this investigation was to evaluate and compare the mechanical behaviors of distractors used for osteogenesis under various conditions by means of common engineering standards. STUDY DESIGN: Five groups of 5 synthetic mandibles were used in this study (N = 25). The first portion of the investigation compared mandibles without intervention (group A [controls]; n = 5), mandibles that had uniform osteotomies stabilized with an external distractor (group B; n = 5), and mandibles that had simulated sagittal osteotomies rigidly fixated with 3 positional screws (group C; n = 5). The second portion of the investigation compared uniform osteotomies (group B; n = 5) and uniform corticotomies (group D; n = 5) that were stabilized with the same external distractor. The last portion of the investigation compared osteotomies stabilized with an external distractor (group B; n = 5) and osteotomies stabilized with an internal distractor (group E; n = 5). Each construct was subjected to vertical loads on a mechanical testing unit. Common engineering standards, including yield load, yield displacement, maximum load, displacement at maximum load, and stiffness, were measured, recorded, and compared by means of a 1-way analysis of variance and a Scheffé multiple comparison test or independent-samples t test. The means between groups were considered significant for P < .05. A polynomial best-fit curve was calculated for the load/displacement data for each group. RESULTS: During the first portion of the investigation, no significant differences were noted between the control, rigidly fixated sagittal osteotomy, and external distractor with osteotomy groups for displacement at maximum load (P = .19). Significant differences were noted between groups for yield displacement (P = .009), yield load (P < .001), maximum load (P < .001), and stiffness (P < .007). Failures occurred in the control and rigidly fixated groups with fractures of the synthetic mandibles. Failures occurred in the external distractor group with permanent deformation or torsion of the pins. During the second portion of the experiment, no statistically significant differences were noted between the corticotomy and osteotomy groups in stiffness (P = .363), maximum load (P = .207), or yield displacement (P = .940). Statistically significant differences were noted between groups for yield load (P = .036) and displacement at maximum load (P = .010). Failures occurred in both groups with permanent deformation or torsion of the pins. During the last portion of the investigation, statistically significant differences were noted between the external distractor and internal distractor groups in yield load (P < .001), yield displacement (P < .001), maximum load (P = .001), and displacement at maximum load (P = .01); no significant differences were noted in stiffness (P = .71). Failures occurred in the external distractor group with permanent deformation or torsion of the pins. Failures occurred in the internal distractor group with fracture of the model or displacement beyond 30.0 mm. CONCLUSIONS: Different patterns of mechanical behavior were found between the control and rigidly fixated sagittal osteotomy groups and the external distractor group, between the corticotomy and osteotomy groups, and between the internal and external distractor groups.     

In vivo treatment with recombinant IL-12 protects C57BL/6J mice against secondary alveolar echinococcosis

A sample of 259 patients with vertical maxillary hyperplasia, mandibular hypoplasia and anterior vertical open bite, collected from three different institutions, was analysed regarding temporomandibular joint (TMJ) sounds, condylar remodelling, and condylar resorption. All patients underwent Le Fort I osteotomies, and bilateral sagittal split advancement osteotomies were performed in 117 patients. Intraosseous wire fixation was used in 149 and rigid internal fixation in 110 patients. Cephalometric and orthopantomographic radiographs were available before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). The number of patients with TMJ sounds decreased from 38% to 31%. At the latest follow up 23.6% of the patients showed condylar remodelling, 7.7% unilateral condylar resorption and 7.7% bilateral condylar resorption. Condylar contours, as assessed on orthopantomographic radiographs, were classified as five different types. Condyles with preexisting radiological signs of osteoarthrosis or having a posterior inclination were at high risk for progressive resorption. Female patients with severe anterior open bite, high mandibular plane angle and a low posterior-to-anterior facial height ratio, who underwent a bimaxillary osteotomy, were prone to condylar resorption. Bone loss was predominantly found at the anterior site of the condyle. The incidence of condylar resorption was significantly higher after bimaxillary osteotomies (23%) than after only Le Fort I intrusion osteotomies (9%). Avoidance of intermaxillary fixation by using rigid internal fixation tended to reduce condylar changes, in particular in patients who underwent only a Le Fort I osteotomy. Rigid internal fixation in bimaxillary osteotomies resulted in condylar remodelling in 30% and progressive condylar resorption in 19% of the patients. Condylar changes were not significantly different after using either miniplate osteosynthesis or positional screws in bilateral sagittal split osteotomy procedures.     

Fixation of osteotomies using bioabsorbable screws in the canine femur

The purpose of this study was to compare the healing properties of femoral osteotomies fixed by bioabsorbable screws (20:80 polyglycolic copolylactic acid copolymer) to standard stainless steel screws of a similar design in a dog femoral model. Two osteotomies were used, the trephine osteotomy (10 mm diameter) in the metaphyseal lateral femoral condyle and in the femoral diaphysis, and a unilateral osteotomy in the lateral femoral condyle. Two months after the trephine osteotomies, the femurs that contained the polymer screws were not significantly different in mechanical strength from the femurs treated with the stainless steel screws, either in the diaphyseal or metaphyseal model. There was no histological difference in bone healing between the metallic and polymer screws for all periods (2, 9, and 17 months). There was no adverse inflammatory response to the polymeric or metallic screws. By month 17, the polymer screws were resorbed completely. All the diaphyseal screw tracks had healed with bone and areas of remodeling were evident in two specimens. For the femoral condyle osteotomy model at 2 months, the polymer screws were present and intact, and all osteotomies healed with no evidence of inflammation. By 9 months, only one specimen had polymeric material left in the screw track. At 15 months, the screw tracks still were present but no evidence of any polymer remained. The tracks were filled with fibrous and adipose connective tissue. All osteotomies stabilized with either bioabsorbable polymer screws or stainless steel screws did heal satisfactorily without any complications, inflammation, or osteolysis. The polyglycolic polylactic acid copolymer may have a clinical role as a bioabsorbable material without the concerns for the osteolysis, foreign body reaction, and sterile abscess formation that have occurred with bioabsorbable fixation methods in the past.