Supramalleolar osteotomy for the treatment of symptomatic tibial malunion

Supramalleolar osteotomy was performed on eight patients who were symptomatic from a malunion of the distal two-thirds of the tibia. The patient's subjective reports of pain, limp, appearance, instability, and limitation of activity were evaluated pre- and postoperatively. Objective measurements of range of motion, angular deformity, and radiographic signs of ankle arthritis were also evaluated. All of the patients had varus malunion with a mean angulation of 15 degrees. Three of these patients also had sagittal malalignment. Supramalleolar dome or wedge osteotomies were performed to correct the coronal and sagittal plane deformities. Either internal (three patients) or external (five patients) fixation devices were applied to maintain correction. All osteotomies healed. The final mean angulation was 0 degrees in the coronal plane and 8 degrees of recurvatum. Complications included pin tract infections, wound breakdown, failure to completely correct the deformities, and loss of reduction. Seven of the patients reported symptomatic improvement after the procedure. The one patient who had a loss of reduction became more symptomatic.     

Pivot osteotomy for the correction of malunion of metacarpal neck fractures.

A new configuration of osteotomy has been developed which combines the principles and benefits of opening and closing wedge osteotomies without the degree of shortening associated with the closing wedge osteotomy and the tension imposed on the soft tissues by the opening wedge osteotomy. It is ideally suited to the correction of angular malunions in the long bones of the hands. Ten osteotomies of malunions of the metacarpals have been performed in nine hands giving good correction of the malunion in all cases.     

3D打印截骨导板辅助治疗胫骨骨折畸形愈合

目的探讨3D打印截骨导板在胫骨骨折畸形愈合截骨矫治术中的应用效果。方法回顾性分析2010年1月至2018年1月期间郑州大学第一附属医院骨科收治的30例胫骨骨折畸形愈合患者资料。根据治疗方法不同将患者分为2组:15例患者行3D打印截骨导板辅助截骨术治疗(3D打印组),男9例,女6例;年龄(46.3±8.2)岁;骨折畸形愈合位于胫骨中上段11例,胫骨下段4例;左侧6例,右侧9例;内翻畸形8例,外翻畸形7例;术前骨折畸形角度24.3°±5.5°。15例患者使用传统手术方法治疗(传统手术组),男10例,女5例;年龄(47.1±6.0)岁;骨折位于中上段12例,下段3例;左侧5例,右侧10例;内翻畸形7例,外翻畸形8例;术前骨折畸形愈合角度平均22.5°±5.4°。记录并比较两组患者术前一般资料、手术时间、术中出血量及术后下肢力线恢复情况。结果3D打印组和传统手术组胫骨骨折畸形愈合术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。3D打印组和传统手术组患者术后平均随访12、10个月。3D打印组手术时间较传统手术组明显缩短[(102.2±13.0)vs.(137.9±10.5)min],术中出血量较传统手术组明显减少[(77.3±39.7)vs.(163.3±35.2)mL],术后3D打印组畸形角度较传统手术组显著减小[(1.9°±0.4°)vs.(3.2°±0.9°)],以上项目两组间比较差异均有统计学意义(P<0.05)。末次随访时两组均未见内固定物松动,截骨处均实现愈合,未再次出现畸形,下肢力线恢复良好。结论3D打印截骨导板技术在辅助胫骨骨折畸形愈合的截骨治疗中能精准截骨,减少手术时间及术中出血量,有效纠正下肢力线,术后近期疗效良好,是胫骨骨折畸形愈合有效的辅助技术。     

3D printing-assisted osteotomy treatment for the malunion of lateral tibial plateau fracture

IntroductionOsteotomy and internal fixation are usually the most effective way to treat the malunion of lateral tibial plateau fractures, and the accuracy of the osteotomy is still a challenge for surgeons. This is a report of a series of prospectively study of osteotomy treatment for the malunion of lateral plateau fractures with the aid of 3D printing technology.MethodsA total of 7 patients with malunion of lateral tibial plateau fractures were enrolled in the study between September 2012 to September 2014 and completed follow up. CT image data were used for 3D reconstruction, and individually 3D printed models were used for accurate measurements and detail osteotomy procedures planning. Under the premeditated operation plan, the osteotomy operations were performed. Patients were invited for follow-up examinations at 2 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months or more.ResultsMean age of the patients was 44 years (range 30–52 years), 3 cases were result of fall injuries, 2 were traffic accidents and 2 were sports injuries. Among the cases, one accompanied with craniocerebra trauma, one with pelvic fracture, one accompanied with both. According to the Schatzker Tibial Plateau classification, the original fracture type were 3 type I, 1 type II and 3 type III. The lateral tibial plateau collapse ranges from 4 mm–12 mm, with an average of 9.4 mm. All the operations were successfully completed, the average operation time was 77.1 min (range 70–90 min), the average intraoperative blood loss was 121.4 ml (range 90–180 ml), the mean follow-up time was 14.4 months (range 12–18 months), and the average healing time of the osteotomy fragments was 12 weeks (range 11–13 weeks). The difference between preoperative and postoperative Rasmussen scores were statistically significant (P < 0.05). All the patients were obtained functional recovery, with no complications.Conclusion3D printing technology is helpful to accurately design osteotomy operation, reduce the risk of postoperative deformity, decrease intraoperative blood loss, shorten the operation time, and can effectively improve the treatment effect.     

Sliding osteotomy for deformity correction following malunion of volarly displaced distal radial fractures

OBJECTIVE: To determine the outcome after a sliding osteotomy for deformity correction following malunion of volarly displaced distal radius fractures. DESIGN: Retrospective review of a consecutive patient series. SETTING: A university-affiliated, tertiary-care center. PATIENTS/INTERVENTION: Ten patients with symptomatic distal radius malunion following a volarly displaced distal radial fracture (Smith's fracture) were treated with an oblique sliding osteotomy and plate fixation, through a volar approach, without using an iliac crest bone graft. Five men and five women with an average age of 41.9 years were followed for an average of 2.7 years postoperatively. MAIN OUTCOME MEASUREMENTS: Range of motion, grip strength, Fernandez wrist score, radiographic parameters. RESULTS: At latest follow-up, wrist extension improved from an average of 37 degrees preoperatively to 70 degrees postoperatively (P = 0.002), wrist flexion improved from an average of 40 degrees to 65 degrees (P = 0.012), and supination improved from an average of 31 degrees to 68 degrees (P = 0.002). Postoperative radiographs revealed an average deformity correction of 10.6 degrees of volar tilt, 7.7 degrees of radial inclination, 5.8 mm of ulnar variance, and 10.4 mm of volar translation. Using the Fernandez point score (0-20) system, the average overall score improved from 10.5 preoperatively to 17.6 postoperatively (P = 0.0001). Functional outcome was rated as excellent or good in 9 of 10 patients and fair in 1 patient (who experienced residual problems due to persistent ulnar-sided pain). There were two reoperations (one hardware removal, one distal ulnar hemiresection). CONCLUSIONS: This method reliably restores distal radial anatomy, decreases pain, and improves supination without requiring iliac crest bone grafting.     

Oblique tibial osteotomy in the correction of tibial deformity in children

A new method of oblique tibial metaphyseal osteotomy that uses a single osteotomy cut has been used to allow correction of multiplanar rotational deformities in children. Graphs are used to predict the necessary angle of osteotomy. The osteotomy is performed through a 1-cm incision in the proximal tibial metaphysis, using multiple drill holes and an osteotome. Correction is maintained by casting with or without internal fixation. Fourteen such osteotomies have been followed an average of 27 months without major complications. This osteotomy allows maximal maintenance of length, stability, and metaphyseal contact through a small, cosmetically acceptable incision. Minimal soft-tissue dissection is necessary.     

Corrective osteotomy for symptomatic scaphoid malunion

A prospective study aimed at assessment of the outcome of management of symptomatic scaphoid malunion (hump-back deformity). The work included 13 scaphoid malunions in 13 patients. All patients complained of weak painful hand grip and limitation of wrist function. All cases were subjected to a corrective opening wedge scaphoid osteotomy with insertion of a trapezoid-shaped tricortical iliac bone graft.

At the final assessment, after a mean follow-up period of 42 months, the achieved results were rated excellent in seven cases, good in four and fair in two according to the scoring system used. Objectively, the mean range of wrist motion and hand grip strength improved from 48% and 47% pre-operatively to 82% and 79% at the final assessment. Radiological parameters including height to length ratio, lateral intrascaphoid angle and dorsal cortical angle were also effectively improved. The intra-operative corrected carpal alignment has almost been maintained at the final follow-up. The procedure did not have serious drawbacks such as non-union or avascular necrosis and perhaps might delay the development of degenerative arthritis of the wrist.     

Length changes in tibial osteotomy with angular correction

Twelve boys, aged 11-17 years, who underwent percutaneus proximal tibial osteotomy with acute angular correction and application of external fixator for unilateral Blount's disease were retrospectively reviewed. Preoperative radiographs were compared with radiographs at healing to evaluate changes in tibial length and overall limb length. Angular correction increased overall limb length by a mean of 1.4 cm (range -0.4 cm to 3.2 cm). This increase was a mean 0.7 cm less than was predicted by adding the preoperative tibial and femoral lengths. This failure to achieve the predicted limb length occurs due to shortening in the tibia and should be considered when planning an osteotomy.     

Focal dome osteotomy for the correction of tibial deformity in children

Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.     

Lengthening osteotomy for clavicular malunion with shortening

Objective  Restoration of clavicular length by osteotomy, interposition of an iliac crest autograft, and plate fixation to correct glenohumeral and scapulothoracic dysfunction. Indications  Posttraumatic shortening of clavicle, accompanied by pain and impairment of glenohumeral function, particularly in overhead manual labor or sporting activities. Contraindications  Asymptomatic shortening without functional or neurovascular impairment. Severe osteoporosis. Infection. Surgical Technique  Sagittal approach along Langer’s lines. Osteotomy at fracture site and debridement. Lengthening of clavicle according to preoperative planning and interposition of an iliac crest autograft. Stabilization with 3.5-mm LC-DC plate and screws. Results  Between June 1991 and November 1999, six patients (male/female=4:2, 29±12 years) with symptomatic shortening of the clavicle were treated by a lengthening osteotomy. The mean follow-up was 3.9±3.2 years (range 0.4–9 years). Based on the Constant-Murley score and the UCLA score, all patients but one had an excellent result. The scores averaged 95±8.4 points (Constant-Murley, maximum 100 points) and 32.5±3.8 points (UCLA, maximum 35 points).     

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

IntroductionThere are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.Presentation of caseThe patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.DiscussionThe patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.ConclusionWe reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.     

Femoral shaft bowing influences the correction angle for high tibial osteotomy

Background The optimal femorotibial angle (FTA) after high tibial osteotomy (HTO) is still controversial. Our hypothesis was that FTA itself may not be reliable because FTA cannot represent the accurate alignment of the whole lower extremity. Methods Non-weight-bearing radiographs of the lower extremities were taken in 100 Japanese subjects with medial osteoarthritic knees, and seven anatomic parameters were assessed. The correction angle by FTA was calculated so that the postoperative FTA was set at 166° (14° valgus). Another correction angle was calculated so that the mechanical axis passed through the lateral one-fourth of the tibial articular surface after HTO. After the correlation between two correction angles was assessed, influences of anatomic parameters on the discrepancy between two correction angles were assessed. Results There was a high correlation between two correction angles (R ² = 0.777, P < 0.001). The mechanical axis passed through the lateral one-fourth of the tibial articular surface when the postoperative FTA was set at 166° in 80% of subjects. However, discrepancy between the two correction angles was 3° or larger in 20% of subjects. Femoral shaft bowing and tibial shaft bowing significantly influenced the correction angles. Even though FTA was the same, the femoral head shifted medially in cases with lateral bowing of the femoral shaft, and the correction angle by FTA should be set larger. On the other hand, the correction angle by FTA can be set smaller in knees with medial bowing of the femoral shaft. Tibial shaft bowing also influences the correction angle by FTA. Conclusions The correction angle by FTA for HTO should be calculated taking femoral and/or tibial shaft bowing in the frontal plane into account.     

应用3D打印技术辅助双平面截骨治疗SchatzkerⅣ型胫骨平台骨折畸形愈合

目的探讨采用3D打印技术辅助双平面截骨治疗SchatzkerⅣ型胫骨平台骨折畸形愈合的临床疗效。方法回顾性分析2014年2月至2018年5月河南省焦作市人民医院骨科和郑州市骨科医院足踝外科收治的19例SchatzkerⅣ型胫骨平台骨折畸形愈合患者资料。男11例,女8例;年龄20~55岁,平均37.6岁;受伤至本次手术时间3~8个月;均采用3D打印技术辅助双平面截骨治疗。记录治疗前、治疗后胫股角、胫骨平台内翻角、后倾角及膝关节Lysholm评分情况,并观察并发症情况。结果所有患者术后获12~28个月(平均18.5个月)随访;骨折愈合时间为12~24周(平均15.5周)。末次随访时患者胫股角173.2°±2.0°、胫骨平台内翻角85.6°±1.3°、后倾角11.9°±1.1°,较术前(154.1°±5.0°、76.0°±1.8°、18.9°±1.6°)均有改善,差异均有统计学意义(P<0.05)。末次随访时Lysholm评分(89.8±1.2)分较术前(52.0±4.4)分有显著改善,差异有统计学意义(P<0.05)。1例患者术后6个月出现行走困难,最终行膝关节置换术。结论采用3D打印技术辅助双平面截骨治疗SchatzkerⅣ型胫骨平台骨折畸形愈合可延缓创伤性关节炎的发展,缓解疼痛,恢复膝关节功能。     

Corrective osteotomy for malunion of the distal radius

Positive ulnar variance due to inadequate correction of radial length is a common disorder after radial corrective osteotomy. To avoid this complication we performed a combination of ulnar-shortening osteotomy and radial corrective osteotomy in 6 of 22 radial corrections. The indication for the combined procedure was a relative ulnar length of minimally 6 mm. The functional outcome was fair in 1 and good in 5 cases with combined osteotomy. Overall, the functional results were good in 17 cases, and pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of the ulnar head (Bower's arthroplasty) were performed. It appears that a combination of ulnar shortening and radial osteotomy is a reliable technique, which can reduce symptoms and need for secondary operations on the ulnar side of the wrist.     

Corrective osteotomy for malunion of the distal radius

Forty-five patients were reviewed on average 5.7 years after corrective osteotomy for symptomatic distal radius malunion. Restoration of anatomy and function was assessed compared with the contralateral wrist. It was found that osteotomy of the distal radius alone did not completely restore normal anatomy and relieve symptoms, and in several cases a second operation was needed. Osteoarthritic changes in the radiocarpal and radioulnar joints were common, and they correlated with restriction in range of motion, but not with pain. Range of motion and grip power were reduced compared to the unaffected hand, but only loss of supination and ulnar deviation correlated with an unsatisfactory subjective result. The result was good or satisfactory in 33 of the 45 patients. We conclude that reconstructive procedures in patients with distal radius malunion may not completely restore normal function, and every effort should therefore be made to prevent malunion in the treatment of distal radius fractures.     

Intraarticular osteotomy for malunion of metacarpal head fractures

Three cases of intraarticular osteotomy of malunited intraarticular fractures of the metacarpal head are described. The patients, all young males, had significant improvement in the articular anatomy and function. Rigid internal fixation was used in each case.     

TKA after clamshell osteotomy for femoral diaphyseal malunion

Proper component positioning is essential for successful total knee arthroplasty (TKA). Femoral component positioning presents a technical challenge when significant femoral deformity is present. Most commonly, an intramedullary guide is used to make an accurate distal femoral cut. However, in the presence of a significant femoral deformity, this is not a viable option.The use of clamshell osteotomy to restore anatomic alignment in patients with complex femoral diaphyseal deformity is described in the literature. This article describes a case of a patient who underwent staged TKA after clamshell osteotomy and retrograde femoral nailing to correct femoral diaphyseal malunion. The retrograde intramedullary nail was retained and used as an intramedullary guide, allowing for TKA in a routine manner. Using an intramedullary nail as an alignment guide may be more accurate than using extramedullary alignment and may avoid the increased surgical time and potential pin-site stress risers of navigation. It is a simple, effective way to treat complicated diaphyseal femoral deformities in the face of posttraumatic knee arthritis. Further study of this technique with longer follow-up and multiple surgeons is necessary to validate this treatment algorithm.