Precision of orthognathic digital plan transfer using patient-specific cutting guides and osteosynthesis versus mixed analogue–digitally planned surgery: a randomized controlled clinical trial

Over the last decade, the accuracy of three-dimensional computer-assisted orthognathic surgery has been investigated extensively. The absence of high-quality controlled trials, limited number of studies overall, and methodological flaws have hindered its use in general clinical practice. The aim of this study was to assess the accuracy of computer-assisted orthognathic surgery compared to the classic occlusal wafers. Eighteen patients were randomly allocated to two groups: CAD/CAM splints and patient-specific osteosynthesis were used for maxillary positioning in group 1; occlusal wafers fabricated on a semi-adjustable articulator were used in group 2. Patients were assessed for linear and angular deviations of maxillary position from the virtual plan using cone beam computed tomography scans. The CAD/CAM group showed mean deviations of 0.26 mm vertically, 0.17 mm anteroposteriorly, and 0.07 mm mediolaterally, while the classic wafer group showed mean deviations of 1.45 mm vertically, 1.31 mm anteroposteriorly, and 0.71 mm mediolaterally. Statistical analysis showed that the proposed workflow provided a significantly more accurate plan transfer compared to classic occlusal wafers. Despite the statistical significance, the clinical significance was less appreciated. However, this new technology facilitated cases with skeletal asymmetry, reduced operating times, and allowed a trainee surgeon to perform the procedure with great accuracy and minimal time. The main limitation was the high cost.     

Solutions for failed osteosynthesis of the acetabulum

Osteosynthesis of the acetabulum is complex and requires very careful planning and preoperative preparation. The goal is to achieve anatomical reduction without steps or gaps in the articular surface. If it has not been possible to achieve an optimal reconstruction, one has to consider whether it makes sense to carry out reosteosynthesis or revise the fixation. The risk of infection, heterotopic ossification, avascular necrosis of the femur and cartilage damage is much higher than with the primary procedure. Often, especially in older patients, it may make more sense to achieve fracture union and to implant a total hip prosthesis in due course. In younger patients, every attempt should be made to achieve optimum anatomical reduction and this may mean consideration of reosteosynthesis after careful planning and counselling of the patient. If reosteosynthesis is considered adequate imaging including a postoperative CT is essential as part of the planning. This article looks at the possible solutions for failed osteosynthesis of the acetabulum.     

First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment

PurposeTo evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.Materials and methodsThirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.ResultsThe 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94).ConclusionPVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.     

Reconstruction of parodontal tissue with chitosan

Chitosan ascorbate, obtained by mixing chitosan with ascorbic acid and sodium ascorbate, was produced in a gel form suitable for the treatment of periodontitis according to current dental surgery. While chitosan ascorbate underwent degradation in vitro, especially in the presence of atmospheric oxygen and at pH 6.0, the protection from oxygen offered by the surgical cements and the physiological pH value permitted chitosan ascorbate to play an important biological role in vivo, where it kept a honeycomb structure, as indicated by SEM on biopsies taken on 10 patients. The proliferation and organization of the cells were thus favoured with a subsequent enhanced capability of reconstructing a histoarchitectural tissue. Chitosan was progressively reabsorbed by the host, with very satisfactory clinical recoveries of the 52 defects treated, for which tooth mobility and pocket depths were significantly reduced.     

Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision

BackgroundIt is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem.MethodsAll patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results.ResultsA total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes.ConclusionCompared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option.Evidence LevelHistorical cohorts. Level III.     

Staged minimally invasive plate osteosynthesis of proximal tibial fractures with acute compartment syndrome

PurposeHigh-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome.MethodsTwenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9–158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out.ResultsTwenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the occurrence of infection.ConclusionsStaged MIPO for proximal tibial fractures with acute compartment syndrome may achieve satisfactory bony union and functional results, while decreasing deep infections and soft tissue complications.     

Effectiveness of sonography assisted minimal invasive plate osteosynthesis (MIPO) compare with fluoroscope assisted in femoral shaft fracture: A cadaveric study

IntroductionA minimal invasive plate osteosynthesis (MIPO) has an advantage of biological soft tissue preservation that consists of preserving bony blood supply, fracture hematoma and less soft tissue damage which leads to decreasing of infection rate and rapid bone healing. However, the radiation exposure is still a disadvantage of this technique. A sonography that provides dynamic real time imaging may be used as an alternative technique for assisting MIPO. The aim of this study was to compare the effectiveness of MIPO in femoral shaft fracture between the sonography assisted and the fluoroscopy assisted.MethodsTwenty-eight cadaveric limbs were subjected to create femoral shaft fracture. Then, sonography assisted reduction with temporary external fixation and MIPO were performed. Images of the sonography and the fluoroscopy were recorded including before reduction, after reduction and after MIPO in order to identify fracture displacements in anteroposterior and mediolateral directions. Moreover, the anterior and posterior distances from edge of the bone to the plate were measured to confirm plate position. The effectiveness of this technique was defined as the proper plate position and acceptable alignment after fixation. All distances from the sonography and the fluoroscopy were also analyzed and compared using Pearson correlation and Bland-Altman method to assess the agreements between two tests.ResultAll of the subjects were met the criteria for acceptable alignment. We found only three femoral shaft fracture (11%) operated with MIPO by sonography assisted that showed slipped plate off femoral bones. According to Pearson correlation, there were good to excellent agreements in term of measuring fracture displacement before (Pearson Correlation >0.7) and after reduction (Pearson Correlation >0.7) between these two tests. There was moderate agreement regarding to evaluation of plate position (Pearson Correlation 03.–0.7). When we compared two methods of measurement using Bland-Altman plot, there were no statistical significant difference (P < 0.05).ConclusionImages from the sonography could provide visualization of the fracture during reduction and MIPO as accurately as the radiography. Thus, the sonography assisted MIPO in femoral shaft fracture can be done effectively comparing with radiographic assisted.