Management of fingernail deformities after thermal injury

Fingernail deformities after thermal injury can be very disfiguring and troublesome. The fingernails may be discoloured, cleft or vertically deviated. From the pathophysiology of the nail growth in general, the specific features of the nail deformities after deep burn can be deduced, as can guidelines for the treatment. Over a two-year period, 153 patients with burned hands were treated in the Groningen Burn Centre. Seven of these patients developed abnormal quality and growth pattern of the fingernails. In two patients an effort was made to correct the deformity by incising the dorsal skin at the base of the nail fold, reflecting the nail fold and covering the acquired defect with a full thickness skin graft. Although the patients were satisfied with the results achieved, one year after the operation little or no improvement in the nail growth was found. A cautious policy should be followed in correcting these deformities, since dislocation of the eponychium together with damage to the nail matrix and the nail bed play a complex role in the process of deformation.     

Management of residual cranial vault deformities.

The aims of calvarial reconstruction are to restore anesthetic contour and to provide protection for the underlying central nervous system structures. The authors present their algorithm of reconstructive options. Important considerations are the anatomic location of the defect and the duration since the original injury.     

Management of fixed deformities in total knee arthroplasty

Total knee arthroplasty (TKA) has developed significantly since the early 1970s. The basic principles have not changed over the past 30 years; however, the techniques and prostheses have improved a great deal. The TKA must correct deformity while balancing the ligaments and equalizing the flexion and extension gaps. Deformity can be a result of bone angulation or ligament imbalance. Bone deformity must be isolated out to the diaphysis, metaphysis, or articular surface of the knee. The latter two areas can be managed at the same time as the arthroplasty. Diaphyseal changes that are greater than 20 degrees of angulation most often require a separate operative procedure. Ligament imbalance can be managed with either lengthening of the tightened ligament or tightening of the lax ligament. While lengthening is the easier of the two approaches, both techniques are acceptable when performed correctly. Deformity of the knee can be a challenging problem, but with proper planning, the results are very acceptable and rewarding both for the patient and the operating surgeon.     

Management of knee deformities in children with arthrogryposis

Arthrogryposis includes heterogeneous disorders, characterized by congenital contractures of multiple joints. Knee involvement is very common (38?C90?% of patients with amyoplasia) ranging from soft-tissue contractures (in flexion or hyperextension) to subluxation and dislocation. Flexion contractures are more common and disabling and show significant resistance to treatment and rate of recurrence. Surgical procedures vary with severity of contracture and patient age and include soft-tissue release, femoral shortening-extension osteotomy, gradual correction with Ilizarov, and femoral anterior epiphysiodesis. The presence of pterygium greatly complicates treatment, given the high rate of complications reported. Hyperextension deformities (recurvatum, anterior subluxation, and dislocation) have better prognosis for walking ability. Surgical options include percutaneous (or mini-open) quadriceps tenotomy, open quadricepsplasty, and femoral shortening osteotomy with limited arthrotomy. Knee dislocations usually require surgery and should be reduced early.     

Management of pectus chest deformities in female patients

Background

There is sparse published information regarding surgical management of females with pectus excavatum (PE) or carinatum (PC) deformities.

Methods

During the past 33 years 104 females with PE, and 21 with PC underwent surgical repair using extensive modifications of the Ravitch technique. Seven had previous right breast implants, 3 had prostheses placed in the PE deformity. Nine PE patients underwent successful pregnancy before repair, but had severe third trimester dyspnea.

Results

Very good to excellent results were reported by 96% (mean follow-up, 6 years). Increased endurance, decreased dyspnea, reduced chest discomfort, and less tachycardia occurred in all within 6 months. No patients had significant breast asymmetry after repair. Complications included mildly hypertrophic scar (8), transient pleural effusion (3), bar displacement (1), and mild recurrence (3).

Conclusions

Females with symptomatic PE or PC, can be repaired with low morbidity, mild pain, low cost, and improvement in body image and symptoms. Prostheses are not beneficial in the treatment of physiologic symptoms caused by pectus deformities.     

Management of ankle deformities in multiple hereditary osteochondromata

Nine patients with multiple hereditary osteochondromata underwent ankle surgery for valgus deformity. The indications for operation included pain from trauma of the prominent masses, pain in the ankle joint associated with the deformity, limited ankle motion, and undesirable cosmesis. The procedures included excision of osteochondromata, fibular lengthening, and medial tibial hemiepiphyseal retardation by inserting staples. Excision of osteochondromata as an isolated procedure relieved pain and improved cosmesis but did not alter the tibiofibular length discrepancy or the ankle valgus. Lengthening of the fibula and medial tibial hemiepiphyseal stapling, alone or in combination, corrected the valgus deformity of the ankle. At final follow-up (mean 43 months), no patient had pain or functional impairment.     

Management of neuromuscular spinal deformities with Luque segmental instrumentation

Forty-six patients who had a neuromuscular spinal deformity were treated with arthrodesis and Luque segmental spinal instrumentation and were followed for an average of three years. Twenty-two patients had cerebral palsy and twenty-four had another neuromuscular disease. In thirty-nine patients, the arthrodesis was extended to the sacrum. Eleven patients who had severe scoliosis as well as pelvic obliquity and decompensation of the torso had a combined anterior and posterior arthrodesis; the other thirty-five patients had a one-stage posterior procedure. Preoperatively, the average scoliosis was 74 degrees; this was corrected to 39 degrees at follow-up. Final corrections were similar for scoliosis and were better for pelvic obliquity and decompensation of the torso in patients who had combined anterior and posterior arthrodesis. The results for scoliosis and pelvic obliquity in patients who had a spastic deformity were similar to the results in patients who had a flaccid deformity. Correction of decompensation of the torso was better in patients who had a spastic deformity. Postoperatively, a brace was used in half of the patients in each group; this did not appear to affect the amount of correction in either group, although the result may have been influenced by the selection process. The rate of complications was 48 per cent. Pseudarthrosis occurred in three patients (6.5 per cent). There were no major neurological deficits related to the correction or to the use of sublaminar wires. Three patients died, one in the immediate postoperative period and the other two at eighteen months and four years after the original procedure, due to causes unrelated to the operation.     

Management of deformities of the forearm in multiple hereditary osteochondromas

A patient with multiple hereditary osteochondromas may have any of several severe deformities of the forearm, the most common of which are ulnar deviation of the wrist associated with relative shortening of the ulna, bowing of either or both of the bones of the forearm, shortening of the forearm, and late dislocation of the radial head. The natural history of these deformities is progression, with variable weakness, functional impairment, and cosmetic deformity of the extremity. We describe the results, after a follow-up of at least two years, in eighteen patients who underwent major surgical procedures: excision of the osteochondromas (ten patients), ulnar lengthening with excision of the osteochondromas (three patients), and ulnar lengthening with radial hemiepiphyseal stapling (seven forearms of five patients). Early excision of the osteochondromas alone did not slow the progression of the deformity. Ulnar lengthening did, on occasion, correct the ulnar drift at the wrist, but the relative shortening of the ulna recurred. Distal radial hemiepiphyseal stapling should accompany ulnar lengthening if radiocarpal angulation or subluxation of the lunate occurs with ulnar shortening. Deformities of the forearm should be treated early and aggressively to prevent disability.     

Management of the neuromuscular foot deformities with the Ilizarov method

Nine feet of eight patients with neurologic foot deformities caused from poliomyelitis, Charcot-Marie-Tooth disease, and traumatic nerve injury were treated with V-osteotomy and the Ilizarov method. A painless and plantigrade foot was obtained in all but one patient. A residual deformity occurred in this case because of the soft-tissue problems during the correction period. No major complication had been encountered by the latest follow-up at a mean of 42 months. The results of the current study indicate that the V-osteotomy and the Ilizarov method, while technically difficult, is an effective method for correcting neurologic foot deformities and obtaining a stable, plantigrade, painless foot, especially when complicated with other lower leg problems (i.e., leg length discrepancy, joint contractures).     

Management of rachitic deformities in children with chronic renal failure

Five children with chronic renal failure and severe rachitic deformities of the lower limbs were treated with 1 alpha-hydroxyvitamin D (1 alpha-OHD3) for 16 to 53 months. There was symptomatic, biochemical and radiological improvement in all five children and operative correction of their deformities was not needed. We recommend a trial of treatment with 1 alpha-OHD3 for this condition before surgical procedures.     

单侧唇裂术后继发唇鼻畸形的矫治

目的：探讨单倒唇裂术后继发唇鼻畸形部分手术方法的改进。方法：基于对唇裂术后唇算畸形病理解剖的认识。唇裂继发唇鼻畸形的二期修复包括上唇瘢痕的切除与松解，以及对上唇短曲外翻或过长，唇红、唇弓、唇珠畸形、鼻小柱、鼻中隔偏斜或短曲、鼻头低垂及鼻孔过大或偏小，鼻翼塌陷、卷曲等不同程度的畸形通过局部组织移位或填充等综合娇治的手术方法，使畸形得以纠正，使以上组织恢复正常的解剖形态。结果：自2003年1月以来，经过58例的，临床实践，术后鼻底丰满，上唇人中嵴，人中凹显现，通过二期综合矫治，皆获得了满意效果。结论：通过对某些术式进行改进．提高了手术疗效，减少了畸形复发。     

双侧唇裂继发鼻唇畸形的综合整复治疗

目的　评价和探讨双侧唇裂术后继发鼻唇畸形的综合整复矫治方法。方法　 2 0 0 0年1月～ 2 0 0 3年 6月我们为 4 0例双侧唇裂术后继发鼻唇畸形患者进行了综合治疗。其中术前施行牙槽突裂髂骨松质骨植骨修复 2 8例 ,牙正畸治疗 2 2例 ;前牙义齿修复 2 0例 ,正颌外科手术或上颌骨牵引成骨手术 2 0例。完成上述治疗程序后行鼻唇二期整复手术。手术方法采用自上唇中央唇红、瘢痕缘、鼻小柱旁至双侧鼻孔内侧缘连续切口 双侧鼻翼沟及鼻孔底切口入路 ,行鼻小柱延长、鼻翼鼻孔轮廓成形、人中嵴、人中凹及唇峰唇珠重建术。结果　患者鼻唇外形均获得较前明显的改善 ,随访 3个月～ 3.5年 ,满意率达 95 %。结论　对双侧唇裂术后鼻唇继发畸形采用综合序列治疗 ,强调二期手术前牙 -颌基础框架的搭建 ,再采用本手术方法矫治鼻唇软组织畸形 ,效果自然稳定。     

双侧唇裂术后继发唇鼻畸形的治疗

目的:评价和探讨双侧唇裂术后继发唇鼻畸形的整复矫治方法。方法:将23例患者按唇畸形、鼻畸形的不同,分别采用三种不同的术式治疗。对上唇及鼻畸形较轻者,采用上唇瘢痕切除,口轮匝肌重建,V-Y成形、Z成形术或双侧肌蒂红唇肌粘膜瓣向中间推进矫正红唇口哨畸形;对唇鼻畸形较严重但上唇组织较多者,采用鼻底叉形瓣延长鼻小柱进行矫治;对唇鼻畸形严重并有上唇过紧者,采用前唇组织瓣延长鼻小柱,下唇带蒂组织瓣(Abbé瓣)旋转修复上唇正中缺损。结果:23例患者中,17例效果满意,5例患者有明显改进,1例不满意。结论:本文介绍的三种术式适用于不同类型双侧唇裂术后唇鼻畸形的患者。     

Management of upper limb deformities. Treatment concepts through the years

The provision of aids and prostheses for patients with upper limb deficiencies has to be based on comprehensive knowledge in the field of orthopaedic technology. Taking into account the patient's complete background, evaluation of the possible functional benefit is mandatory in order to achieve good acceptance of a prosthesis in the long term. The extent of extremity "loss" and the remaining function of the deficient limb have an impact on the success of prosthetic fitting. Furthermore, there is a trend towards myoelectric prostheses, which seem to improve prosthetic acceptance. Bilateral congenital deficiency of the upper limbs cannot be equated with amputations. Most people affected do not push for a prosthesis, but should be provided with one, if the need arises. Decades of overuse of the deficient limbs often take their toll in terms of decreasing function as degenerative changes occur. As a consequence, artificial upper limbs may be obligatory to prevent loss of independence.     

小儿脊髓纵裂及其合并畸形的治疗

[目的]探讨小儿脊髓纵裂及其合并畸形的治疗方法。[方法]回顾性分析近10a获随访经手术治疗的脊髓纵裂患儿48例，男29例，女19例；年龄7d-14岁。均因腰背部异常、双下肢和（或）二便功能障碍做全脊柱x线、MRI、CT等检查。手术先切断终丝松解栓系，再打开硬膜直视下切除纤维束或骨软骨嵴，合并先天性脊柱侧弯者一期或二期半脊椎后路切除矫形。[结果]48例患儿均有脊髓低位，伴发脊髓栓系综合征34例，脊柱侧弯及后凸26例，脊髓脊膜膨出14例，脊髓空洞15例，椎管内脂肪瘤12例。依照脊髓纵裂Pang分型：Ⅰ型27例，Ⅱ型18例，混合型3例。位于颈段1例，胸段6例，胸腰段1例，腰段38例，骶段2例。术后改善28例，恢复正常3例，无效3例。后路半脊椎切除术矫治先天性脊柱侧弯效果满意。[结论]脊髓纵裂极易合并脊髓栓系及先天性脊柱侧弯，患儿应常规行脊柱x线、MRI、CT等检查，以提高脊髓纵裂、脊髓栓系及其他脊柱畸形的诊断率。早期切断终丝松解栓系，直视下切除纤维性、骨或软骨性间隔是治疗脊髓纵裂的必要手段。同时一期或二期后路半脊椎切除是早期治疗先天性脊柱侧弯的有效方法。     

Maxillary deformities

The management of congenital maxillary anomalies can be managed with ease by the well trained facial plastic surgeon. An understanding of dental anatomy, occlusion, and the rudiments of cephalometric analysis are important prerequisites for this type of work. A background in the management of facial trauma prepares the surgeon for the surgery involved. A sense of aesthetics is required to adequately anticipate what the final cosmetic and functional outcome should be in these cases. The Le Fort III osteotomy is particularly difficult, especially if there is associated hypertelorism that requires craniotomy. Significant experience in the less demanding operations of the maxilla coupled with experience in skull base surgery is essential before tackling this demanding procedure.