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.     

Acute correction using focal dome osteotomy for deformity about knee joint

Background  Correction of deformities about knee joint may prevent or delay the onset of osteoarthritis or mitigate its effects. Accurate correction of such deformities without production of secondary deformities depends on precise localization and quantification of the deformities. Methods  We corrected deformities around the knee using acute correction with focal dome osteotomy in 21 segments (15 patients). Five segments underwent limb lengthening postoperatively. Results  The mean correction angle was 16.0°. We were able to correct all segments. In the five lengthening cases, the mean external fixation index (EFI) was 70.9 days/cm, which is much higher than the generally reported EFI. There were eight complications, all but one of which occurred in lengthening cases. Conclusions  We believe that acute correction with focal dome osteotomy is very useful for cases of alignment correction, but is not indicated for cases of alignment correction with lengthening, due to a high risk of complications related to poor callus formation.     

Volar ligament release and distal radius dome osteotomy for correction of Madelung's deformity

PURPOSE: Madelung's deformity is usually recognized near the completion of skeletal growth and corrective osteotomy of the radius is frequently performed to treat the deformity and reduce pain. This study reviewed the clinical and radiographic results of a volar approach, ligament release, and dome osteotomy technique for treatment of this deformity. METHODS: Between 1990 and 2000, 26 wrists in 18 patients were treated with a volar ligament release and dome osteotomy of the distal radius. The average age of the patients at the time of surgery was 13 years. All patients were available for review at an average of 23 months after surgery. Radiographs before surgery and at final follow-up evaluation were analyzed for the extent of correction. RESULTS: All patients treated with this corrective osteotomy reported a reduction in pain and improved appearance. Patients showed improvements in forearm supination and wrist extension, with no loss of pronation or flexion. Improvements in the radiographic parameters of radial inclination and lunate subsidence also were observed. Four wrists required concurrent ulnar-sided surgery, and 3 additional wrists required staged ulnar shortening. One patient required a Darrach resection 3 years after the index procedure. CONCLUSIONS: The results of volar dome osteotomy provide improved range of motion, improved appearance, radiographic correction, and pain relief while preserving soft-tissue support for radial rotation around the distal ulna. Long-term follow-up evaluation is ongoing.     

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 supracondylar focal dome osteotomy with plate fixation for acute correction of frontal plane knee deformity

Focal dome osteotomy (FDO) allows deformity correction without secondary translational deformity. The purpose of this study was to evaluate the degree of correction and knee functional outcome after correction of frontal knee deformity using femoral supracondylar FDO fixed with plate and screws. A prospective study included 12 consecutive cases of femoral frontal plane deformity that underwent correction using supracondylar focal osteotomy fixed by plate and screws. Average age was 27 years, while mean follow-up was 2.1 years. Functional assessment was done using the Hospital for Special Surgery (HSS) knee score. The HSS knee score improved from 85 to 96.8 points. Desired correction was achieved in all cases. Postoperative mechanical axis analysis on long film and scanogram showed no secondary deformity. The overall postoperative mechanical axis was at 3.2 mm medially (range 2–5 mm). Autogenous bone graft was not used in any case, and uneventful osteotomy union was achieved at a mean of 13.8 weeks. Minor complications were encountered in two cases. There were no implant failures or reoperations. Supracondylar FDO of the femur with plate fixation is a reproducible technique that can produce full correction of distal femoral frontal plane deformity, while avoiding creating a secondary deformity. Knee function was improved with good patient satisfaction.     

Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children

BACKGROUND: Open reduction, autogenous bone-grafting, and internal fixation for the treatment of established nonunion of the lateral condyle associated with a cubitus valgus deformity has a high rate of complications. As a consequence, we developed a new technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision. METHODS: Eight consecutive patients were treated with the new surgical technique between 1994 and 2000. The mean age at the time of surgery was 8.6 years. The mean interval between the lateral condylar fracture and surgery was 4.9 years. The mean preoperative radiographic humerus-ulna angle was 31 degrees of valgus. The postoperative results were classified with a modification of the scoring system described by Dhillon et al., which assesses pain, weakness, range of motion, the humerus-ulna angle, and prominence of the medial epicondyle on a 12-point scale. RESULTS: All eight lateral condylar nonunions achieved union within three months postoperatively. The mean postoperative humerus-ulna angle was 5.5 degrees of valgus. All of the supracondylar dome osteotomies healed uneventfully, and there was no loss of correction postoperatively. The mean duration of follow-up was 4.5 years. The overall results were excellent in two patients, good in four patients, and fair in two patients. CONCLUSIONS: With better exposure of the lateral condylar nonunion through a posterior approach, we can effectively stabilize the lateral condylar nonunion and avoid postoperative loss of motion and osteonecrosis of the condyle. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. With careful selection of patients, this new technique can be an effective method to treat this clinically challenging problem.     

开放楔形胫骨高位截骨术不同程度矫正内翻畸形的比较

目的研究开放楔形胫骨高位截骨术(OWHTO)后过度矫正内翻畸形的并发症发生情况和临床疗效,并通过放射学指标比较髋关节、髌股关节与踝关节的代偿性变化。 方法回顾性分析2016年1月至2020年5月期间在青岛大学附属医院行OWHTO治疗的63例患者的资料,纳入标准为诊断明确、有症状的膝骨关节炎伴内翻畸形,排除双侧手术、术前有膝关节感染及既往外伤史的患者。根据术后测量承重线比率(WBLR),将所有患者分为正常矫正组52例(50%2＝4.395,P＝0.036)。在OWHTO后,比较两组患者末次HKA和MPTA,差异有统计学意义(t＝6.586、3.709,均为P<0.001),比较末次随访两组患者HAA,差异有统计学意义(t＝-2.309,P＝0.026)。其余影像学指标比较,差异均无统计学意义(均为P>0.05)。两组患者HSS评分、WOMAC评分末次随访比较,两组患者差异无统计学意义。 结论过度矫正内翻畸形(术后WBLR≥67%)不影响OWHTO后早期的临床效果,但增加了术后并发症的发生率,从影像学上,引起髋关节代偿性的内收加剧。     

Barrel stave osteotomy for correction of turribrachycephaly craniosynostosis deformity

The "barrel-stave" osteotomy procedure addresses the characteristic excessive height and reduced anteroposterior projection of the turribrachycephalic skull in one operative procedure. Four quadrant craniectomies are followed by barrel stave-like osteotomies in the parietooccipital region. The parietooccipital bone undergoing osteotomy is displaced posteriorly, thereby opening up the posterior fossa and effectively increasing the potential volume of the cranial vault. This increased capacity allows for notable reduction in skull height and reshaping of the skull along the anteroposterior axis.     

A simple technique for correction of complicated tibial deformity including rotational deformity

Although the simplest way to correct bone deformity is one-stage correction, the problem associated with that method is overstretching of the soft tissues, which limits the correction and leads to complications such as compartment syndrome or peripheral nerve palsy. If an adequate amount of tissue necessary for correction is formed in advance, the deformity can be corrected safely at one stage without overstretching of the tissues. A leg lengthening technique was employed to form the necessary tissues. After leg lengthening with an unilateral external fixator (Hifixator), deformities were corrected manually at one stage without anesthesia, and the corrected positions were again secured with the fixator. To correct rotational deformity, two sets of pins were inserted into the proximal bone fragment of the tibia at the time of the operation, and after lengthening the proximal pin clamp of the fixator was disconnected from one pin set and reconnected to the other set. We applied this method to four tibias of three patients without any complications. The tension of the tissues was monitored using a pressure sensor built into a Hifixator to prevent the tissues from overstretching. During and after the correction, the tension of the tissue was maintained at less than before the correction. Received: 11 February 1997     

胫骨内侧高位楔形截骨治疗膝内翻畸形的临床疗效观察

[目的]探讨胫骨内侧高位楔形截骨治疗膝内翻畸形的疗效.[方法]1998年7月～2007年10月,采用胫骨内侧张开式高位楔形截骨结合植骨钢板内固定术治疗膝内翻畸形共49例72个膝关节.患者术前、术后8周、术后1.5年行患肢全长X线片检查,测量胫股角、胫股内侧关节间距大小.按HSS膝关节功能评定标准评定术前、术后膝关节功能.[结果]72膝术后随访18～128个月,平均58个月;胫股角术前187.5°±5.3°,术后172.6°±3.6°,膝关节功能由(47.2±17.6)分增至(83.2±15.3)分,胫股内侧关节间距由(2.4±1.2)mm增至(4.3±1.2)mm.植骨均愈合满意,无膝内翻复发.术后疼痛缓解及行走功能改善显著.术中出现关节内骨折3例,无神经血管损伤.术后皮肤感染切口延迟愈合2例.[结论]胫骨内侧高位楔形截骨结合植骨钢板内固定术,可作为治疗膝内翻畸形的有效方法之一.     

Double dome osteotomy for the treatment of cubitus varus in children

Purpose

The purpose of this study was to report double dome osteotomy used to correct paediatric cubitus varus and to avoid lateral prominence after correction.

Methods

Eighteen children with cubitus varus underwent double dome osteotomy. Preoperative templating created from radiographs was used to determine the bone cuts. Double dome osteotomy created a proximal and distal cut, then varus deformity and sagittal alignment were corrected. The osteotomies were fixed with K-wires and immobilised in a long-arm cast. Radiographics and clinical histories were evaluated. Ulno-humeral angle pre and postoperative, range of motion and lateral prominent index were evaluated.

Results

The osteotomy was performed in 18 patients, with an average age of 7.5 years. All patients ended up with flexion of 130° or greater with full and symmetrical pronation and supination. The average ulno-humeral angle difference compared to the uninjured side was 3.27°. The mean of the lateral prominent index was −0.91. The mean follow up was 50.3 months (30–115 months). All of the patients had excellent clinical and radiographic alignment. No revisions were made in this series. One transient radial nerve palsy and one superficial infection occurred.

Conclusion

This series demonstrates that double dome osteotomy can provide reliable correction of varus deformity and prevent lateral prominence with a minimal complication rate.     

Mathematically directed single-cut osteotomy for correction of tibial malunion

In 1986 and 1987, four patients with tibial malunion involving both angular and torsional misalignment underwent surgical correction by a single-cut technique based on a mathematical model of long bone deformity. The technique involved a single surgical cut, followed by rotation of the two fragments along the osteotomy plane. The orientation of the osteotomy is based on a computer-assisted design. The deformity is measured on radiographs, computed tomography, and clinical exam and is then plotted on graphs to find the osteotomy orientation. The deformity involved varus and extension in four cases, internal rotation in 2, and external rotation in two. The deformities ranged from 9 to 26 degrees. The cutting angle of the osteotomy ranged from 50 to 66 degrees as measured from the transverse plane. Actual lengthening of 1 cm and functional lengthening over 1.5 cm was obtained without the use of bone graft. As no wedge of bone was removed, all corrected bones were easily suited to rigid internal fixation across the cut surface. In all cases, the desired correction was obtained within measurable error, and union was obtained with minimal immobilization. There were no soft tissue or joint contractures, and no neurovascular complications. In one patient, who had had four prior surgical procedures on the involved limb, an infection developed 6 weeks postoperatively that required debridement and delayed primary closure. As the technique involves only one cut, no wedge of bone is removed, no shortening occurs, and the osteotomy is highly suitable for rigid internal fixation. The described technique is the first to integrate in a precise way the correction of torsion with the correction of angular deformity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Proximal tibial osteotomy for genu varum: Radiological evaluation of deformity correction with a plate vs external fixator

BACKGROUND High tibial osteotomy(HTO) is a well-known procedure for the correction of knee varus. The purpose of this study was to compare the radiological results and accuracy of deformity correction performed using two different techniques: acute opening wedge correction using a plate and gradual correction with a monolateral external fixator.AIM To compare of the radiological results of two different techniques: acute opening wedge correction(a plate and screw) and gradual correction(external fixator).METHODS A total of 43 patients with plates and 36 patients with external fixators were included. All patients had moderate uniplanar varus deformities. We measured radiographic parameters, including the mechanical axis deviation(MAD), medial proximal tibial angle(MPTA), Caton-Deschamps Index(CDI), posterior proximal tibial angle, and joint line obliquity angle(JLOA). The accuracy of MAD correction was calculated based on a correction goal of neutral or overcorrection for medial compartment arthritis.RESULTS Demographics including age, body mass index, sex, and preoperative deformities were similar between the groups. The MAD significantly improved from 23.6 mm medial to the midline(SD = 8.2 mm) to 6.9 mm lateral to the midline(SD = 5.4 mm)(P 0.001). The accuracy of MAD correction did not differ between the groups and was 96.1%(SD = 8.1%) in the plate group and 98.2%(SD = 5.2%) in the external fixator group(P = 0.18). The MPTA significantly improved from 83.9°(SD = 2.9°) to 90.9°(SD = 3.3°)(P 0.001), and the change was similar between the groups. Differences were noted in patella height, with a CDI change of-19.2%(SD = 13.7%) and 3.1%(SD = 8.0%) for the plate and external fixator groups, respectively(P 0.001). The change in JLOA was 1.6 degrees(SD = 1.1 degrees) and 0.9 degrees(SD = 0.9 degrees) for the plate and external fixator groups, respectively(P = 0.04).CONCLUSION Reliable correction of moderate varus alignment was achieved with both the acute opening wedge technique with a plate and the gradual monolateral external fixator technique. The patellar height decreased with the open wedge plate technique. Joint line obliquity decreased to a greater degree with the open wedge plate technique, perhaps as a result of medial collateral ligament release. The appropriate technique should be selected based on surgeon and patient preferences; however, external fixation may be a better choice when the preservation of patellar height is deemed important.     

Late recurrence of varus deformity after proximal tibial osteotomy

One hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus-producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years (mean, 6.3 years). Sixty-four knees (57%) were pain free or had only mild discomfort when walking. The standing femorotibial angle decreased from a postoperative average of 9.3 degrees valgus to 7.8 degrees valgus at the final follow-up examination. The tendency for varus recurrence greater than 5 degrees and for medial- or lateral-compartment arthritic progression was evaluated using the Kaplan-Meier survival method. Varus recurred in 18%, lateral-compartment arthritic progression in 60%, and medial-compartment arthritic progression in 83% by nine years after surgery. The probability of arthritic progression is much higher than the probability of significant varus recurrence in long-term roentgenographic follow-up studies of patients with valgus-producing proximal tibial osteotomies.     

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.     

手指近节指骨骨折后旋转畸形的治疗

目的 探讨手指近节指骨骨折后原位截骨矫正旋转畸形的手术疗效.方法 用钛板螺钉对6例手指近节指骨旋转畸形愈合的患者进行原位截骨矫形后固定,手术均采用背侧入路.结果 术后随访6～22个月,伤口无感染及皮肤坏死,骨愈合时间为6～9周,无延迟愈合、骨不连或畸形愈合.结论 近节指骨骨折处原位截骨不仅可提供更精确的矫形,恢复手指的功能,改善外观,还能解决骨折继发的肌腱粘连,最大限度地减少软组织的损伤.