Osteotomies around the knee

The concept of osteotomy has been around for thousands of years. Whilst the principles have not changed, practice has definitely evolved. Osteotomies around the knee have traditionally been used to treat unicompartmental osteoarthritis but they are now playing an important role in managing joint instability and are also being utilized in combination with cartilage regenerative procedures. To understand how this is possible, this article will outline and summarize the required mechanical principles for the different types of osteotomy around the knee. It will also provide a précis of both standard and novel operative techniques which are facilitating the revival of this procedure, allowing for an increased repertoire of indications and ultimately better patient outcomes.     

Complications in knee surgery

This is a comprehensive review of complications that can occur with common knee surgical procedures. Procedures have been grouped into arthroscopic & soft-tissue knee surgery, articular cartilage restoration procedures, osteotomy, and arthroplasty. As newer implants and procedures are developed it is anticipated that new complications may arise. However, the overall trend will be towards a generalized reduction. At the same time, patient expectations are increasing in tandem with improvements in health and longevity. It is important to counsel patients regarding any risks of potential complications associated with any intervention as part of the informed consent process.     

Intra-articular osteotomy for ankle arthritis

Ankle arthritis is a condition affecting a wide age range of patients. There are a variety of surgical treatment options available when non-operative treatments are not providing adequate symptom control. These are broadly classified into joint-preserving or joint-sacrificing surgery with arthroplasty or arthrodesis. The joint-preserving operations include soft tissue and bone debridement, osteochondral defect surgery, distraction arthroplasty and realignment osteotomies. For the younger patients with high activity and work demands the development of realignment osteotomies as a measure to delay joint sacrificing procedures is appealing. The realignment surgery aims to alter the mechanical axis and alter the joint contact pressures. Depending on the arthritis pattern, the osteotomy can be intra-articular or extra-articular or a combination of osteotomies. The focus of this article is an in-depth review of the biomechanics, surgical techniques and results of intra-articular osteotomies performed for ankle arthritis.     

Cartilage grafting in the knee: where are we now?

Focal cartilage defects in the knee are a common and debilitating pathology. High arthroplasty revision rates in the <55-year-old population continue to make arthroplasty a limited primary surgical option. Advancements in surgical techniques and more robust long-term data on cartilage procedures have increased greatly in the last few years. Results vary and are dependent on matching suitable procedures to lesion and patient type. In this difficult-to-manage group, offering the right procedure to the right patient at the first instance has an important impact on outcomes. In this paper we review the evidence and new guidelines in the management of focal cartilage lesions of the knee.     

Osteoarthritis of the ankle

Ankle arthritis is a debilitating condition. Primary ankle joint osteoarthritis is much rarer than hip or knee arthritis. The majority of cases are post-traumatic secondary to previous articular trauma or ligamentous instability. Treatment methods available are guided by disease severity and the patient's functional demands. Weight loss, activity modification, the wearing of an ankle brace or high-topped lace-up boots and orthoses should be the first line of treatment. Joint-sparing procedures such as arthroscopic debridement, supramalleolar osteotomy and distraction arthroplasty have been trialled with low levels of supporting evidence. The demand for joint preservation has led to the development of total ankle allografting procedures, but these have fallen out of favour. Despite advancements, the gold standard for end-stage arthritis remains arthrodesis, although evidence for total ankle arthroplasty in certain groups of patients is increasing. The current third-generation implants have improved survivorship although their results remain inferior to arthroplasty of the hip and knee. There is currently a UK randomized control trial of ankle replacement versus arthrodesis under way as well as several national joint registries, which will hopefully better define those patients who will gain most benefit from replacement as opposed to fusion.     

The stability of facial osteotomies. Part 6. Chin setback

Isolated horizontal osteotomy of the anterior mandible (genioplasty) to move the chin posteriorly can be used to improve facial profile. There has been an increasing tendency in practice to carry out this procedure in combination with maxillary and/or mandibular surgery. This is most appropriately undertaken when pre-operative prediction techniques indicate that chin prominence will remain excessive following maxillary and/or mandibular advancement surgery.
This paper reviews surgical techniques applicable to posterior movement of the chin ('the setback genioplasty') and illustrates the clinical results achieved with its use.     

下颌发育过度外科矫治术式的选择

下颌发育过度是临床常见的一种牙颌面畸形,下颌支垂直骨切开术和下颌支矢状骨劈开术是用来矫治这种骨性Ⅲ类错(牙合)的常用术式。本文对这两种手术方法的优缺点进行比较与讨论,从而为下颌前突外科矫正术式的合理选择提供参考。     

(i) Investigation of the painful knee arthroplasty

Both total and unicompartmental knee arthroplasty are effective operations for the treatment of gonarthrosis. However, up to 20% of patients will return with pain and a suboptimal functional outcome. The investigation of such a patient is critical in determining an accurate diagnosis and establishing an effective management plan. Causes of pain can be broadly classified into extrinsic and intrinsic. The commonest intrinsic causes of pain are infection, component loosening, component mal-orientation and soft tissue impingement. Extrinsic causes, including hip and spinal pathology, may be responsible for the patient’s symptoms and must be considered. Accurate evaluation uses a four-step procedure involving a detailed history, thorough clinical examination and microbiological plus imaging analysis. This review article will focus on each of these key steps and highlight some of the latest modes of investigating the painful knee arthroplasty.     

Focal knee resurfacing

A significant number of patients suffer from focal articular damage that is neither appropriate for traditional arthroplasty, nor for biological repair. Since 2005, contoured focal resurfacing systems for the femoral condyle have been available that can cater for this specific subgroup of patients. Independent long-term data on these implants have previously been lacking, but are now becoming available. This review will look at: the basic biology of cartilage, the natural progression of focal cartilage disease in the knee, the surgical and non-surgical options available, the indications for focal resurfacing, surgical techniques, which implants are currently available, and the current clinical data with respect to these.     

Peri- and postoperative complications in Le Fort I osteotomies

This retrospective study was performed to report the peri- and postoperative complications encountered by patients who underwent Le Fort I osteotomy, as well as predictor variables affecting the risk of complications.Patients who underwent only Le Fort I osteotomy were included in the study. Information on peri- and postoperative complications were collected from the patient data records. The effects of certain predictor variables on complication rates were also studied.Twenty-four per cent of the patients suffered from complications, six (6.1%) of whom were reoperated. Most of the complications were minor and transient. Compared with one-piece osteotomy, segmental osteotomy was a significant risk factor predisposing patients to postoperative complications (p = 0.04619). Additionally, the use of patient-specific implants seemed to increase the risk of both perioperative and postoperative complications (p = 0.0248).Currently, the conventional plate fixation method is the primary method in Le Fort I osteotomies. Careful patient selection, surgical planning, and selection of surgical technique seem to be the most important factors in reducing the complication risk. Special attention should be paid with segmental osteotomy surgery.     

A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis

This meta-analysis aims to provide evidence-based data to assist surgeons to make an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were 'cleft', 'distraction', 'maxilla', 'maxillary', 'advancement', 'osteotomy', and 'orthognathic surgery'. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intra-operative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. Both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics.     

Bone healing with electric current: a histological assessment

Skeletal relapse is a major concern after correction of retrognathism with surgical mandibular advancement. It was hypothesized that the stimulation from a direct electric current can accelerate the osseous repair through the enhancement of the maturation of fibrocartilage. Furthermore, this stimulation may enhance the mechanical properties of the facial osteotomy site and reduce the skeletal relapse. The purpose of the present study was to examine the osteotomy site histologically and determine the effect of post‐surgical electrical stimulation on the healing of a facial osteotomy site in a rat model. Three groups of adult male Sprague–Dawley rats, 15 in each group (direct electric current, electric sham, and control), were used to generate data. Electrodes were placed in both the direct electric current and the electric sham groups. A 20‐μA direct current was delivered to the osteotomy site only in the direct electric current group.
Histological slides of the osteotomy site for each animal were prepared and interpreted to characterize the healing process of the osteotomy site for each animal. The results showed no statistically significant difference among the three groups of animals (p>0.005). An examination with histology earlier in the healing process and the utilization of an experimental animal with a larger jaw are suggested for any further investigation that involves electrical stimulation and osseous healing in a facial osteotomy site.     

Reprint of “Hip arthroplasty”

Total hip arthroplasty is a cost-effective surgical procedure undertaken to relieve pain and restore function to the arthritic hip joint. More than 1 million arthroplasties are done every year worldwide, and this number is projected to double within the next two decades. Symptomatic osteoarthritis is the indication for surgery in more than 90% of patients, and its incidence is increasing because of an ageing population and the obesity epidemic. Excellent functional outcomes are reported; however, careful patient selection is needed to achieve best possible results. The present economic situation in many developed countries will place increased pressure on containment of costs. Future demand for hip arthroplasty, especially in patients younger than 65 years, emphasises the need for objective outcome measures and joint registries that can track lifetime implant survivorship. New generations of bearing surfaces such as metal-on-metal, ceramic-on-ceramic, and metal-on-ceramic, and techniques such as resurfacing arthroplasty have the potential to improve outcomes and survivorship, but findings from prospective trials are needed to show efficacy. With the recall of some metal-on-metal bearings, new bearing surfaces have to be monitored carefully before they can be assumed to be better than traditional bearings.     

Experiencing your own orthognathic surgery: A personal case report

There has been much research on minimizing the side effects of orthognathic surgery. However, there are very few doctors and researchers who themselves have undergone this surgery. This case report describes the findings of a maxillofacial surgeon who underwent combined orthodontic and orthognathic treatment for correction of Class II malocclusion. In March 2012, the surgeon was referred to an orthodontist, and an orthodontic examination revealed a Class II, division 2, malocclusion with a traumatic palatal bite and attrition of the lower front teeth. The patient underwent alignment of the upper and lower arches, followed by a bilateral sagittal split osteotomy. During this treatment, he made many interesting observations and learned much as a patient, which can have implications in improving the outcomes and quality of care for patients receiving such treatment. Thus, this case report aims to provide a critical perspective of the surgical procedure and treatment from the viewpoint of a maxillofacial surgeon who himself experienced the surgery as a patient.     

Le-fort I access osteotomy to nasopharyngeal tumor – A case-report

Removal of extensive central skull base and paranasal sinus tumors is a significant challenge that is often hampered by limited access and exposure. The safety and efficacy of the Le Fort I osteotomy approach to the skull base have been well established. The purpose of this article is to describe the use of Le fort-1I osteotomy as an access procedure to reach tumors in the nasopharyngeal region in a young patient. The large mass which he presented within the nasopharyngeal region, later diagnosed to be juvenile nasopharyngeal angiofibroma, posed a challenge for surgical access.     

Evaluation of facial aesthetics by laypersons in patients undergoing intraoral quadrangular Le Fort II osteotomy compared with conventional Le Fort I osteotomy

In this study we compared the aesthetic outcome of (1) Le Fort I (LFI) osteotomy and (2) intraoral quadrangular Le Fort II (IQLFII) osteotomy for surgical correction of skeletal class III dysgnathia involving midfacial deficiency. The aim was to investigate whether laypersons see differences in facial changes that occur due to variations of the osteotomy cuts. The patient collectives consisted of 23 patients in each group. Pre- and postoperative photographs were presented in a random sequence to 40 layperson raters. The rating procedure was conducted with a four-point Likert scale. Assessed characteristics were ‘attractiveness’ (‘Attraktivität’), ‘likeability’ (‘Sympathie’), ‘intelligence’ (‘Intelligenz’), ‘aggressiveness’ (‘Aggressivität’) and ‘dominance’ (‘Dominanz’). For preoperative photographs we found a significant difference for ‘likeability’ with lower ratings for the IQLFII group; all other criteria were rated similarly. For the IQLFII group we found a significantly larger shift from lower to higher ratings for ‘attractiveness’ and ‘likeability’ and a significantly larger shift from higher to lower ratings for ‘aggressiveness’ and ‘dominance’ than for the LF I group. Our study shows that lay raters detect significant differences between the two surgical groups. Thus, IQLFII osteotomy, when indicated, represents a favourable alternative to conventional LFI osteotomy, if patients desire the expectable change in recognition by their social circle.     

颧骨颧弓肥大整形现状与思考

东亚人崇尚以纤瘦的卵圆脸型为美,因此近几十年来,颧骨颧弓缩小术在东方国家非常流行。颧骨颧弓缩小术根据截骨位置可以分为四个类型：前方截骨、后方截骨、两侧截骨及中间截骨。本文回顾了20世纪以来颧骨颧弓肥大整形的相关文献,从颧骨解剖、手术适应证、手术方法及常见并发症等方面进行讨论。     

Osteochondral allograft transplantation of the knee: a review of indications,techniques, outcome and how to promote biology

Articular cartilage lesions of the knee in young and active patients can result in significant disability. Osteochondral allografts (OCAs) can be used to treat challenging articular lesions of the knee ≥2 cm², either as a primary or revision procedure. They have the advantage of restoring the articular surface with mature hyaline cartilage without any size limitations or donor site morbidity. Chondrocyte viability above 70% at the time of implantation is thought to be desirable, and consequently OCA implantation within the 28-day graft expiration date can result in logistical challenges. No randomized trials exist; however, excellent clinical outcomes have been reported, along with good long-term survivorship up to 20 years. Several factors can influence the outcome after OCA use, including patient selection, anatomical location, associated pathologies and several biological considerations. The purpose of this article is to review the latest evidence on treatment indications, graft storage and surgical techniques, biological considerations, patient outcomes and rehabilitation after surgery.     

Evaluation of Post-operative Complication Rate of Le Fort I Osteotomy: A Retrospective and Prospective Study

Le Fort I osteotomy has become a routine procedure in elective orthognathic surgery. This procedure is often associated with significant but rare post-operative complications. The study was conducted to evaluate the rate of post-operative complications following conventional Le Fort I osteotomy. Twenty-five healthy adult patients who had to undergo Le Fort I osteotomy without segmentalization of maxilla were included in the study based on indications of surgery. All the patients were followed up for a period of 6 months post-operatively to assess the rate of various post-operative complications such as neurosensory deficit, pulpal sensibility, maxillary sinusitis, vascular complications, aseptic necrosis, unfavourable fractures, ophthalmic complications and instability or non-union of maxilla, etc. The results of our study showed a post-operative complications rate of 4 %. Neurosensory deficit and loss of tooth sensibility were the most common findings during patient evaluation at varying follow-up periods while one patient presented with signs and symptoms of maxillary sinusitis post-operatively. Neurosensory as well as sinusitis recovery took place in almost all the patients within 6 months. It was concluded that thorough understanding of pathophysiological aspects of various complications, careful assessment, treatment planning and the use of proper surgical technique as well as instrumentation may help in further reducing the complication rate.     

口内路径下颌骨升枝矢状劈开截骨术治疗下颌前突畸形

下颌骨升枝矢状劈开术是目前世界上使用最普遍的矫正下颌骨畸形的手术方法之一。作者采用口内入路下颌骨畸形的手术方法之一。作者采用口内入路下颌骨升枝矢状劈开截骨术治疗下颌骨前突１８２例，其中真性下颌前突１４３例，假性下颌前突３９例。年龄在１５～５８岁之间，平均２４岁。随访６个月～９年。除９例术后畸形复发需再次矫正以外均获满意效果。本文介绍了口内入路下颌骨升枝矢状截骨术的手术过程及注意事项，并着重讨论了其优缺点，可能出现的并发症及处理方法