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Introduction: Medial opening wedge high tibial osteotomy (MOWHTO) is a surgical option for medial femorotibial osteoarthritis, which preserves articular cartilage by correcting the extra-articular deformities of the lower limbs that cause osteoarthritis. This is an increasingly popular treatment in a population with high functional demand, such as the French military population. The aim of this study was to evaluate the rate of return to work and military activities at 6 months postsurgery and at last follow-up in this military population following MOWHTO.The hypothesis of this study was that MOWHTO enabled a majority of service members to return to the same level of activity within 6 months of surgery., Materials and Methods: This was a retrospective, multicenter study including all French military personnel operated on for MOWHTO alone for osteoarthritis of medial compartment between 2008 and 2018 in different Military Teaching Hospitals. We excluded civilian patients. For each patient, a questionnaire was used to collect epidemiological, professional, sports, and functional data. The primary endpoint was the rate of return to work at 6 months postsurgery. We also studied the recovery of sports activities and functional results at a 6.6-year follow-up by standardized questionnaires (Tegner activity scale, Lysholm, IKDC subjective (International Knee Documentation Commitee))., Results: Twenty-four MOWHTOs were performed during this period in a cohort of 22 French military personnel. Return to work at 6 months was possible in 20/24 cases (83.3%). Of the four patients who did not return to work at 6 months, two changed their activities, while the other two returned to their jobs after 6 months. The rate of resumption of sporting activities at an equal or higher level was 50% (11/22). There was no difference between pre- and postoperative Tegner Activity Scale scores at the longest follow-up (P = .08). The mean postoperative Lysholm scores were 73.5 (standard deviation 17.8) and IKDC 59 (standard deviation 8.7). No intraoperative complications were found, and one case of postoperative infection was found., Conclusions: A total of 83% of the operated soldiers were able to return to their professional activities in less than 6 months. We observed a functional improvement at the last follow-up. Comparing these results with data from civilian populations, the rate of occupational recovery is comparable. However, the return to sport is much better in the series of nonmilitary patients with approximately 90% return to work and sport in the year following surgery. MOWHTO improves the functional results of the knee, enabling a return to work and sport in most cases in young, active populations such as the French military., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Objective: To systematically review the clinical efficacy and safety of high tibial osteotomy (HTO) combined with platelet-rich plasma (PRP) for treating knee osteoarthritis (KOA) and to provide evidence of the effectiveness of evidence-based medicine for treating this disease., Methods: Clinical studies on the use of HTO combined with PRP for the treatment of KOA before September 2024 were identified. The literature that met the inclusion criteria was strictly screened out, the literature information was extracted, and the data were input into RevMan5.4 for analysis., Results: Ten studies (12 controls) with 625 patients were included. Overall, the visual analog scale (VAS) score (mean difference (MD) = -0.53, 95% confidence interval (CI) (-0.76, -0.31), P < 0.00001), range of motion (ROM) (MD = 7.24, 95% CI (2.79, 11.69), P = 0.001), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = -6.91, 95% CI (-9.47, -4.34), P < 0.00001), cartilage recovery (cartilage thickness: MD = 0.43, 95% CI (0.35, 0.51), P < 0.00001; cartilage regeneration: relative risk (RR) = 1.81, 95% CI (1.40, 2.33), P < 0.00001; and the International Cartilage Repair Society (ICRS) grade: RR = 1.96, 95% CI (1.44, 2.66), P < 0.0001), and the Lysholm score (MD = 6.51, 95% CI (4.97, 8.04), P < 0.00001) after HTO-PRP treatment had certain advantages compared to the control group. After treatment, there was no statistically significant difference in the knee joint mechanical axis angle between the HTO-PRP group and the control group (femoral tibial angle (FTA): MD = -0.29, 95% CI (-1.07, 0.49), P = 0.47; medial proximal tibial angle (MPTA): MD = 0.19, 95% CI (-0.49, 0.88), P = 0.58; posterior tibial slope (PTS): MD = -0.12, 95% CI (-0.49, 0.25), P = 0.53; knee varus angle (KVA): MD = -0.30, 95% CI (-1.77, 1.17), P = 0.69; weight-bearing line (WBL): MD = 1.10, 95% CI (-0.89, 3.09), P = 0.28)., Conclusion: The results showed that in the treatment of KOA, the HTO-PRP group had better efficacy than the control groups did and had certain safety reliability., (© 2024. The Author(s).)

Background: Medial open-wedge high tibial osteotomy (OWHTO) is performed for isolated medial compartment osteoarthritis or osteonecrosis of the knee and correction of varus deformity of the full lower extremity. OWHTO may induce sagittal parameter changes, including these in the tibial posterior slope (TPS), patellar height (PH), and patellofemoral joint problems. This study aimed to identify radiographic parameters associated with patellofemoral cartilage damage after OWHTO., Hypothesis: The patellofemoral joint cartilage worsens after OWHTO and is adversely affected by PH changes., Patients and Methods: Twenty patients (25 knees) who underwent primary OWHTO and subsequent implant removal surgery, including second-look arthroscopy for evaluation of the patellofemoral cartilage condition were enrolled. The patients were received 12 to 35 months of postoperative follow-up, and categorized into two groups according to whether patellofemoral cartilage damage worsened. TPS and PH parameters, including the Insall-Salvati, Blackburne-Peel, Caton-Deschamps, and modified Blumensaat (MBI) indices, were measured on lateral knee radiographs. The hip-knee-ankle and medial proximal tibial angles were measured using an anteroposterior radiograph of the full lower extremity. The extent of change from preoperative to postoperative (Δ) was calculated for all indices., Results: Eleven knees (44%) had worsening cartilage conditions in the femoral trochlear groove, with>1-degree of deterioration in the International Cartilage Repair Society grade. The radiographic measure for predicting patellofemoral cartilage deterioration was ΔMBI (95% confidence interval [CI]: 3.53×10 -14 -0.812, p=0.047). PF cartilage damage tended to progress in ΔMBI<-0.145. The postoperative TPS and HKAA in patients with deterioration in patellofemoral cartilage damage was greater than that in patients without deterioration in patellofemoral cartilage damage (p=0.037 and 0.038, respectively)., Discussion: The patellofemoral cartilage damage tends to progress after OWHTO. ΔMBI is a factor for predicting worsening patellofemoral cartilage condition. However, attention should be paid to the excessive posterior slope as high TPS and valgus alignment as valgus HKAA because intraoperative control of MBI is impossible., Level of Evidence: IV, retrospective study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Surgical intervention, such as the Broström-Gould procedure, is typically indicated for patients with chronic lateral ankle instability. In this study, we are comparing the safety and efficacy of the Broström-Gould procedure with peroneal tendon debridement, a sliding lateralizing calcaneal osteotomy, and adjuvant procedures performed with a single- versus double-incision approach. Our retrospective analysis included patients who underwent the procedure of interest between 2011 and 2020. Patients were divided into 2 groups: undergoing either a 1-incision (n = 53) or a 2-incision approach (n = 47), both with a lateralizing calcaneal osteotomy. A significant difference in skin bridge breakdown was observed between the 2-incision (n = 6 [13%]) and 1-incision groups (n = 0 [0%]). There were no significant differences in infection, deep wound dehiscence, nerve palsy, or neuroma between patients in the 2 groups. Furthermore, no statistically significant differences in mean PROMIS scores existed between the cohorts. The described Broström-Gould procedure shows promise for treating chronic ankle instability. While patients in both single- and double-incision groups had similar rates of postoperative complications, the decreased incidence of skin bridge breakdown in the 1incision group highlights the approach's safety and potential benefits in reducing wound-related complications., (Copyright © 2024. Published by Elsevier Inc.)

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a 9-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the 3 years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR] = 3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR = 2.33; CI: 1.08, 5.00) and third point of fixation (OR = 2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients., (Copyright © 2024 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Venous thoracic outlet syndrome (vTOS) is caused by compression of the subclavian vein at the costoclavicular space, which may lead to vein thrombosis. Current treatment includes thoracic outlet decompression with or without venolysis. However, given its relatively low prevalence, the existing literature is limited. Here, we report our single-institution experience in the treatment of vTOS., Methods: We performed a retrospective review of all patients who underwent rib resection for vTOS at our institution from 2007 to 2022. Demographic, procedural details, and perioperative and long-term outcomes were reviewed., Results: A total of 76 patients were identified. The mean age was 36 years. Swelling was the most common symptom (93%), followed by pain (6.6%). Ninety percent of patients had associated deep vein thrombosis, with 99% of these patients starting anticoagulation preoperatively. A total of 91% of patients underwent rib resection via the infraclavicular approach, 2% via the paraclavicular approach (due to a neurogenic component), and 7% via the transaxillary approach. Eighty-three percent of patients had endovascular intervention before or at the time of the rib resection, with catheter-directed thrombolysis (87%), followed by angioplasty (71%) and rheolytic thrombectomy (57%) being the most common interventions. The median time from endovascular intervention to rib resection was 14 days, with 25% at the same admission. The median postoperative stay was 3 days (2-5 days). There was no perioperative mortality or nerve injury. Fourteen percent of patients had postoperative complications, with bleeding complications (12%) being the most common. Waiting more than 30 days between initial endovascular intervention and rib resection was not associated with decreased risk of bleeding complications. Patients were seen postoperatively at 1-month (physical examination) and 6-month (duplex) intervals or for any new or recurrent symptoms. Twenty-two percent of our overall patient population underwent reintervention, most commonly angioplasty (21%). At last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free., Conclusions: Over the last decade, we have transitioned to an infraclavicular approach for isolated vTOS, with low perioperative morbidity and good patency rates. These results support the adoption of the infraclavicular approach with adjunct endovascular techniques as a safe and efficacious treatment of vTOS., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Understanding the implications of either nonoperative or operative treatment of developmental dysplasia of the hip (DDH) performed before periacetabular osteotomy (PAO) is critical to counseling patients and their families. There are limited studies, however, on PAO for the treatment of residual DDH after surgical intervention during childhood, and even less information about PAO after prior nonoperative treatment., Questions/purposes: We analyzed patients who had undergone PAO for DDH and asked: Did patients with prior childhood treatment (either operative or nonoperative) (1) improve less in modified Harris hip score (mHHS), 12-item International Hip Outcome Tool (iHOT-12) score, or WOMAC score; (2) demonstrate more severe preoperative deformities; and (3) receive less complete radiographic correction and have more frequent complications than did patients whose hips had not undergone prior treatment? We also asked: (4) Were there subgroup differences among patients with DDH treated nonoperatively versus operatively before PAO in these same functional and radiographic parameters?, Methods: Between January 2011 and December 2020, a total of 90 PAOs were performed in 82 patients who had prior surgical or nonsurgical treatment. Of those, 3 patients (3 hips) with neuromuscular diseases were excluded, 4 patients (5 hips) were excluded for having received treatment after childhood, 7 hips that had undergone bilateral PAOs were excluded, and another 4 patients (4 hips) were lost to follow-up before the minimum study period of 2 years, leaving 71 patients (71 hips) for analysis (the previous treatment group). Among these, 32 patients had a history of previous surgery (the previous surgery group), and 39 patients had prior nonsurgical treatment (such as a Pavlik harness, closed reduction, spica casting) (the previous nonoperative group). During the same period, 1109 PAOs were performed in 956 patients who had no history of previous hip treatment. Following a 1:2 ratio, 142 patients (142 hips) were selected as the control group by matching for age (within 2 years difference), year of surgery (same year), and follow-up time (within 1-year difference). The patient characteristics for both the previous treatment group and the control group exhibited comparability, with mean ± SD follow-up durations of 49 ± 23 months and 48 ± 19 months, respectively. Within the previous 5 years, 3 patients (8%) in the previous nonoperative group, 4 patients (13%) in the previous surgery group, and 15 patients (11%) in the control group had not attended follow-up visits. We compared hip function and radiographic results between the two groups and performed a subgroup analysis between the previous surgery group and the previous nonoperative group. Hip function was assessed using the mHHS questionnaire, the WOMAC, and the iHOT-12 with attention to the minimum clinically important differences of these tools. The threshold values for clinically important improvement were 9.6 points, 13 points, and 16.1 points for the mHHS, iHOT-12, and WOMAC, respectively. Radiographic measurements included the lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), Tönnis angle, acetabulum-head index, and acetabular wall index. We also evaluated Tönnis osteoarthritis grade and femoral head deformity. Occurrences of adverse radiographic events such as posterior column fracture, nonunion, stress fractures, insufficient coverage or overcoverage, acetabular protrusion, and progression of osteoarthritis were recorded., Results: We found no clinically important differences in magnitude of improvement between the previous treatment group and the control group in terms of mHHS (mean ± SD 10 ± 12 versus 12 ± 12; p = 0.36), iHOT-12 (25 ± 18 versus 26 ± 19; p = 0.51), or WOMAC score (12 ± 12 versus 15 ± 19; p = 0.17). Preoperative deformity in the previous treatment group was more severe than in the control group (mean ± SD LCEA -1° ± 9° versus 5° ± 8°; ACEA -8° ± 18° versus 1° ± 14°; Tönnis angle 31° ± 7° versus 27° ± 7°; acetabulum-head index 56% ± 13% versus 61% ± 8%; all p < 0.001). In the previous treatment group, a higher percentage of patients exhibited flattening or irregularity of the femoral head compared with the control group (52% versus 9%; p < 0.001), and there was also a higher proportion of patients with Tönnis grade 1 or above (51% versus 42%; p < 0.001). Although there were still differences in LCEA, ACEA, and Tönnis angle between the two groups at the last follow-up, the differences were small, and the mean values were within the normal range. The previous treatment group had a higher risk of intraoperative posterior column fracture (14% and 5%; p = 0.02), insufficient acetabular coverage (20% and 8%; p = 0.01), and progression of osteoarthritis (17% and 8%; p = 0.04) compared with the control group. Subgroup analysis revealed no clinically important differences in magnitude of improvement between the previous surgery group and the previous nonoperative group in terms of mHHS (10 ± 14 versus 10 ± 11; p = 0.91), iHOT-12 (22 ± 21 versus 27 ± 14; p = 0.26), or WOMAC score (12 ± 14 versus 12 ± 11; p = 0.94). Apart from a higher proportion of patients who presented with arthritis (72% versus 34%; p = 0.01) and a smaller anterior wall index (11% ± 11% versus 20% ± 12%; p = 0.01) in the previous surgery group, all other preoperative radiographic parameters were consistent between the two groups. Additionally, the previous surgery group had a higher frequency of arthritis progression (28% versus 8%; p = 0.02), while the frequencies of other complications were similar between the two groups. Specifically, the frequencies of pubic ramus nonunion (22% versus 21%; p = 0.89), intraoperative posterior column fracture (19% versus 10%; p = 0.50), and insufficient acetabular coverage (25% versus 15%; p = 0.31) were high in both groups., Conclusion: We found no clinically important difference in the magnitude of improvement between patients who had childhood treatment and those who did not, but patients who had prior childhood treatment were more likely to experience serious complications, and radiographic correction in those patients was less complete. As in the case of patients who have had prior operative treatments, it is crucial not to overlook the unexpectedly severe deformity of residual DDH after previous nonoperative treatment and complications following PAO. Surgeons and patients alike should be aware of the potential for worse radiographic outcomes or an increased risk of complications when prior operative or nonoperative treatment has preceded PAO. Future studies might investigate optimal management strategies for this specific group of patients to improve outcomes and reduce complications., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Objective: Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair., Methods: A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized., Results: In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications., Conclusions: Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon., Competing Interests: Conflict of Interest Statement Dr Jaroszewski discloses consulting and IP/royalties through Mayo Clinic Ventures with Zimmer Biomet Inc. All other authors reported no conflict of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: One procedure that has gained popularity in the surgical management of hallux valgus is the minimally invasive Chevron and Akin osteotomy (MICA). The purpose of this systematic review was to evaluate the learning curve associated with this technically demanding procedure., Methods: A search of the EMBASE and PubMed databases was performed to identify all clinical studies that assessed the learning curve associated with the MICA procedure. Studies where patients were not diagnosed with hallux valgus, did not undergo MICA, or did not report data on operation time, fluoroscopy exposure, or complications were excluded. A risk of bias assessment was conducted to assess the validity of the studies., Results: The initial literature search yielded 287 studies, and seven studies were included in the final analysis. A quantitative comparative analysis could not be performed as the included studies used different statistical methods to quantify the learning curve. Lewis et al. determined that after 38 operations, there was a decrease in operation time and fluoroscopy exposure (p < .001). Merc et al. found that it took 29 and 30 operations to reach a plateau for operation time and fluoroscopy exposure, respectively (p < .001). Palmanovich et al. found that it took 20 and 26 operations to reach a plateau for operation time and fluoroscopy exposure, respectively (p < .001). Toepfer and Strässle found there was a significant decrease in operation time and fluoroscopy exposure after the first 19 procedures in their series (p < .001). With respect to complications, one study found a significant difference after the 42nd operation (p = .007). However, the remaining studies found that complication rates did not significantly change with increased technical proficiency. All seven studies were deemed to have a moderate risk of bias., Conclusions: Surgeons can expect a learning curve of 20 to 40 operations before reaching technical proficiency with the MICA procedure. After the learning curve is achieved, surgeons can expect to see a significant decrease in both operation times and fluoroscopy exposure. No consistent significant difference was found in complications as one becomes more technically proficient with the procedure., (© 2024. The Author(s).)

The present study aimed to evaluate the effect of Piezosurgery on histopathologic features of the inferior alveolar nerve (IAN) damage after osteotomy of the buccal cortex of the mandible using piezoelectric devices in Hamdani sheep. A total of ten healthy mature female sheep were included. Each side of the mandible underwent two different experiments: the first experiment operated directly on the mental nerve by touching and activating the piezo tip on the nerve for ten seconds for the left side and thirty seconds for the right side. In the second experiment, the inferior alveolar nerve was touched by an activated piezo tip inside the mandibular canal for ten seconds on the left side and thirty seconds on the right side. All the nerve samples underwent histopathological evaluation, and the scoring system was performed to assess the nerve structures. Mental nerves exposed to piezo tip for 10 seconds showed mild abnormality including disruption of the perineurium with the endoneurium remaining intact. Mental nerves exposed for 30 seconds showed moderate injury with destruction of the perineurium and moderate degeneration of nerve fibers, nevertheless, the endoneurium remained continuous with normal node of Ranvier. Severe damage of the inferior alveolar nerve was seen after exposure to piezo tip for 10 seconds, which showed sloughing of the perineurium and severe vacuolar degeneration of nerve fibers, partial disruption of the endoneurium; however, the axons were still intact. Inferior alveolar nerves exposed for 30 seconds revealed destruction of the perineurium, marked vacuolar degeneration of nerve fibers, focal damage of axon and loss of endoneurium (axonotmesis). Piezosurgery devices have the potential to cause severe nerve damage during surgery and should be used very carefully.

Background: Developmental dysplasia of the hip (DDH) is one of the principal causes of secondary hip osteoarthritis, giving rise to considerable pain, impaired mobility, and a reduced quality of life. The optimal approach to managing individuals who have Crowe type IV DDH remains controversial. This study aimed to review the existing literature on the application of total hip arthroplasty (THA) as a treatment modality for Crowe type IV DDH, assessing its efficacy in addressing this severe hip deformity., Methods: A comprehensive search across the PubMed, Scopus, and Web of Science databases identified relevant studies. Inclusion criteria encompassed investigations reporting outcomes of THA in Crowe type IV DDH patients. Data extraction and quality assessment were performed independently by 2 reviewers. Utilizing R software, the prevalence of THA complications was analyzed through proportion analysis, employing the inverse variance method., Results: In this systematic review, a total of 74 studies were included, comprising a collective sample size of 2,829 patients (3,356 hips) diagnosed with Crowe type IV DDH. The posterior or posterolateral approach was the most commonly utilized surgical approach, followed by the lateral Hardinge and direct lateral approaches. The majority of studies have employed subtrochanteric osteotomies. Notably, post-THA, leg length discrepancy decreased, Trendelenburg sign resolved, and back pain was reduced. Patient-reported outcome measures like the Harris Hip Score improved significantly. The pooled prevalence rates of major postoperative complications were also assessed, including dislocation (7.2%), revision (8.7%), intraoperative fractures (10.5%), loosening (5.7%), nerve paralysis (5.6%), deep vein thrombosis (3.6%), infection (3.8%), heterotopic ossification grade 2 and above (6.1%), and a complicated patient rate of 11.0%., Conclusions: Synthesizing diverse study data, an overview of THAs performance emerges, demonstrating significant enhancements in function, pain reduction, quality of life, and the correction of substantial leg length discrepancy. While THA has shown positive outcomes, instances of complications have been reported. The decision to undergo THA should involve a collaborative assessment between the surgeon and the patient, considering potential benefits and complications., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This systematic review and meta-analysis assesses the clinical outcomes of implants inserted during or following transcrestal sinus lifts. The study protocol was prospectively registered on PROSPERO (CRD42024504513). PubMed, Web of Science, Embase, and Scopus databases were searched up to 21 February 2024, and randomised clinical trials utilising transcrestal sinus lifts were included. Qualitative and quantitative syntheses were conducted. A random effects model was used to pool the survival rate of implants placed with transcrestal sinus lifts using hand osteotomes without grafting, along with meta-regression and subgroup analyses. Funnel plots and Egger's linear regression were used to explore possible publication bias. Probabilities of less than 0.05 were considered significant. A total of 1807 records were identified after the initial search. Seventeen studies were included with 10 of them considered for meta-analysis. Studies used hand osteotomes, a combination of piezoelectric and hand osteotomes, drills, and smart lifts for sinus elevation. Only studies that used hand osteotomes reported subsequent vertigo and dizziness in patients. The meta-analysis showed a 100% (95% CI: 99% to 100%) survival rate for both grafted and non-grafted transcrestal sinus lifts using hand osteotomes. Meta-regression showed that follow-up time did not significantly affect the implants' survival. Subgroup analyses showed no significant difference between bone-level and tissue-level implants and one-stage or two-stage implants. On considering the limitations of this study it can be concluded that closed maxillary sinus elevation can be considered a relatively safe technique that is associated with a high survival rate. However, caution should be taken when using hand osteotomes because of a higher rate of sinus lining perforation and reported patient vertigo., (Copyright © 2024 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with micrognathia undergoing mandibular distraction osteogenesis (MDO) for functional and aesthetic improvement are at significant risk for dental complications. The authors investigated the association of 2 osteotomy patterns-oblique and inverted-L-with risk to developing dentition., Methods: A senior orthodontist (H.D.N.) performed a retrospective review of dental radiographs of patients undergoing MDO with confirmed oblique or inverted-L osteotomies between 2012 and 2022. Images were assessed for evidence of missing, damaged, or displaced teeth, and proportion of affected hemimandibles by injury type and median number of affected teeth per hemimandible were compared between groups using appropriate statistical methodology., Results: Analysis included 44 patients (23 oblique, 21 inverted-L) and 85 hemimandibles (45 oblique, 40 inverted-L). Mean age at surgery was 3.1 ± 4.6 years, and mean time to imaging was 4.9 ± 4.1 years; there was no difference between groups ( P = 0.23, P = 0.34, respectively). Oblique osteotomy was associated with greater odds of missing teeth (odds ratio [OR], 13.3, P < 0.001), damaged teeth (OR, 3.2; P = 0.02), and any dental injury (OR, 39.9; P < 0.001) compared with inverted-L, as well as greater number of missing teeth (β = 0.6; P < 0.01), damaged teeth (β = 0.3; P = 0.02), and total number of affected teeth (β = 0.9; P < 0.001). There was no difference in incidence ( P = 0.5) or number ( P = 0.4) of displaced teeth between groups., Conclusions: Inverted-L osteotomies were associated with fewer dental complications compared with oblique osteotomy at all ages studied. Although longer-term follow-up and prospective data are needed before definitive recommendations can be made, these data are helpful to surgeons as they plan MDO., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Rhinoplasty is one of the most common plastic surgeries and is commonly associated with postoperative edema, ecchymosis, and pain which play a role in patients' dissatisfaction. In this randomized comparative study, we discuss the effect of cannula drainage in the reduction of postoperative periorbital edema, ecchymosis, pain, and nasal obstruction after open structural septorhinoplasty. The study was conducted at a tertiary referral center from April to November 2022. We performed internal lateral osteotomy on all patients using the lateral saw and aided by lateral osteotome. At the end of the procedure, a cannula drain is prepared and inserted in the subperiosteal tunnel on the left side only. Patients were examined on the 1st, 3rd, 7th, 14th, and 21st days for periorbital edema, ecchymosis, pain, and nasal obstruction, and each side is scored separately. A total of 40 patients (80 sides in total) were recruited, 22 females (55%) and 18 males (45%), all of whom were adults (18-44 years old; mean age 29 years). The most frequent age group is those younger than 20 years representing 35% of the sample and the males forming 33.3%. The reduction in edema and pain was statistically significant in the drained sides ( p  = 0.000) during all the postoperative days. On the other hand, ecchymosis was lower on the drained side but statistically insignificant ( p  = > 0.29). Nasal obstruction was reduced significantly only on the seventh postoperative day ( p  = 0.000). The postoperative morbidities associated with rhinoplasty could have important functional and psychological effects on patients. This study demonstrates that inserting a cannula in the subperiosteal tunnel for drainage in rhinoplasty yields a significant clinical and statistical decrease in postoperative periorbital edema and pain with little effect on ecchymosis and nasal obstruction., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: Pedicle subtraction osteotomy (PSO) is a complex surgical procedure that provides correction of moderate sagittal imbalance. Surgical complications have adverse effects on patient outcomes and healthcare costs, making it imperative for clinical researchers to focus on minimizing complications. However, when it comes to risk modeling of PSO surgery, there is currently no consensus on which patient characteristics or measures should be used. This study aimed to describe complications and compare the performance of various sociodemographic characteristics, surgical variables, and established risk indices in predicting postoperative complications, infections, and readmissions after lumbar PSO surgeries., Methods: A review was conducted on 191 patients who underwent PSO surgery at a single institution by a single fellowship-trained orthopaedic spine surgeon between January 1, 2018, and December 31, 2021. Demographic, intraoperative, and postoperative data within 30 days, 1 year, and 2 years of the index procedure were evaluated. Descriptive statistics, t -test, chi-squared analysis, and logistic regression models were used., Results: Intraoperative complications were significantly associated with coronary artery disease (odds ratios [OR] 3.95, P = 0.03) and operating room time (OR 1.01, P = 0.006). 30-day complications were significantly cardiovascular disease (OR 2.68, P = 0.04) and levels fused (OR 1.10, P = 0.04). 2-year complications were significantly associated with cardiovascular disease (OR 2.85, P = 0.02). 30-day readmissions were significantly associated with sex (4.47, 0.04) and length of hospital stay (χ 2 = 0.07, P = 0.04). 2-year readmissions were significantly associated with age (χ 2 = 0.50, P = 0.03), hypertension (χ 2 = 4.64, P = 0.03), revision surgeries (χ 2 = 5.46, P = 0.02), and length of hospital stay (χ 2 = 0.07, P = 0.03)., Discussion: This study found that patients with coronary vascular disease and longer fusions were at higher risk of postoperative complications and patients with notable intraoperative blood loss were at higher risk of postoperative infections. In addition, physicians should closely follow patients with extended postoperative hospital stays, with advanced age, and undergoing revision surgery because these patients were more likely to be readmitted to the hospital., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Objective: The aim of this study was to provide benchmarks for the rates of complications by type of surgery performed., Study Design: Prospective multicenter database., Background: We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment., Materials and Methods: Eight surgical scenarios were defined based on the levels treated, previous fusion status [primary (P) vs. revision (R)], and three-column osteotomy use (3CO): short lumbar fusion, LT-pelvis with 5 to 12 levels treated (P, R, or 3CO), UT-pelvis with 13 levels treated (P, R, or 3CO), and thoracic to lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan-Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile., Results: A total of 1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types ( P <0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however, there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition, or neurological complications (all P >0.5)., Conclusions: This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision-making and more informed patient counseling., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This systematic review and meta-analysis aimed to investigate the differences in hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopedic Foot and Ankle Society (AOFAS) scores, and complication rates between chevron osteotomy and scarf osteotomy for correcting hallux valgus., Methods: Two investigators independently searched for randomized controlled trials (RCTs) published from 2007 to 2018 on PubMed, Web of Science, and Cochrane Library databases. Next, chevron and scarf osteotomies were compared for their postoperative outcomes using HVA, IMA, and AOFAS scores and their complication rates. Meta-analysis was performed using Review Manager (version 5.3)., Results: Six RCTs-comprising 507 feet, of which 261 and 246 underwent chevron and scarf osteotomies, respectively-were included. The meta-analysis revealed that chevron osteotomy led to significantly smaller postoperative HVAs than scarf osteotomy (weighted mean difference [WMD] = -1.94, 95% CI = - 2.65 to - 1.29, P < .00001). However, the differences in postoperative IMA (WMD = - 0.44, 95% CI = - 1.10 to 0.22, P = .19), postoperative AOFAS scores (WMD = 0.75; 95% CI = - 5.32 to 6.82; P = .81), and complication rates (risk ratio = 1.22, 95% CI = 0.65-2.27, P = .53) between feet that underwent chevron and scarf osteotomies were nonsignificant., Conclusions: Compared with scarf osteotomy, chevron osteotomy had significantly more favorable postoperative outcomes in terms of HVA correction, but not in terms of IMA, AOFAS scores, or complication rates., Level of Evidence: Level I, systemic review and meta-analysis., (© 2024. The Author(s).)

Background: Various fixation devices are available for bunion osteotomy. In this study, we evaluated the radiographic outcomes, postoperative complications, and recurrence rate in a series of hallux valgus deformities treated with various osteotomy procedures using a pin for the fixation of the osteotomy., Methods: Two-hundred forty-seven patients with hallux valgus deformity managed with a Simple, Effective, Rapid and Inexpensive (SERI) osteotomy, distal chevron osteotomy, or proximal crescentic osteotomy and K-wire fixation were included. The mean follow-up of the patients was 53.9 ± 8.9 months. Radiographic evaluations included the assessment of the Hallux valgus angle (HVA), intermetatarsal angle (IMA), and union. Clinical evaluations included the assessment of the range of motion, pain in the first metatarsophalangeal joint, and patient satisfaction., Results: In the last visit, the mean improvement of HVA was 23.9 ± 9.1º (P < 0.001). The mean IMA improvement was 6.1 ± 6º (P < 0.001). The mean metatarsophalangeal flexion and extension were 33 ± 10.7º and 34.6 ± 9.2º, respectively. Postoperative complications included pin tract infection in eight (3.2%) patients, deep infection in five (2%) patients, and early pin complication in four (1.6%) patients. Recurrence was observed in five (2%) patients. Twenty-three (9.3%) patients had slight pain in the last follow-up. The mean surgical time was smaller in the SERI osteotomy (P < 0.001). The mean hospitalization period was longer in the proximal osteotomy group (P = 0.039). The mean metatarsophalangeal flexion and extension were significantly smaller in the distal chevron osteotomy (P = 0.046 and P = 0.037, respectively). 90% of patients were satisfied or very satisfied with the surgical outcomes., Conclusion: K-wire fixation is a safe and effective device for the fixation of bunion osteotomy, and this effectiveness is even higher with SERI and proximal crescentic osteotomy., (© 2024. The Author(s).)

The aim of this study was to describe three dogs with permanent fibular nerve injury following tibial plateau levelling osteotomy (TPLO). Fibular nerve injury following TPLO led to atrophy of the cranial tibial muscle, absent hock flexion and a mild lameness. Fibular nerve injury was confirmed in one case with electrodiagnostics. All three cases had a drill tract in the same location, on the caudal aspect of the tibia, immediately distal to the tibial osteotomy. Permanent fibular nerve injury following TPLO occurred with a more caudally positioned plate and care should be taken when drilling the tibia from medial to lateral in the region described. Careful gait assessment at routine follow-up was required to identify this complication., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS)., Methods: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality., Results: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR., Conclusions: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To report a "critical phase" (between osteotomy completion and correction beginning) that will frequently lead to the reversible intraoperative neurophysiological monitoring (IOM) change during posterior vertebral column resection (PVCR) surgery., Methods: The study sample consisted of 120 patients with severe spine deformity who underwent PVCR and deformity correction surgeries. Those patients were recruited consecutively from 2010 to 2018 January in our spine center. The detailed IOM data (the amplitude of MEP & SEP) and its corresponding surgical points were collected prospectively. Early and long-term postoperative neurologic outcomes were assessed for the following functions: motor, sensory, and pain at immediate postoperative and 1-year post-operation in this cases series., Results: A total of 105 (105/120) patients presented varying degrees of IOM reduction in the critical phase; the mean IOM amplitude retention vs rescue rate was 27% ± 11.2 versus 58% ± 16.9, P < 0.01 (MEP) & 34% ± 8.3 versus 66% ± 12.4 P < 0.01 (SEP). Patients with postoperative spinal deficits often had a significantly longer IOM-alerting duration than the patients without (p < 0.01, Mann-Whitney U-test), and IOM-alerting duration greater than 39.5 min was identified as an independent predictor of the risk of postoperative spinal deficits., Conclusions: The reversible IOM events probably often appear in the critical phase during PVCR surgery. The new postoperative spinal deficits are possible for patients without satisfied IOM recovery or alerting duration greater than 39.5 min. Timely and suitable surgical interventions are useful for rescuing the IOM alerts., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The present study aimed to evaluate the degree of nerve injury on inferior alveolar nerve (IAN) by different implant drills resulting from direct canal intrusion into inferior alveolar canal (IAC). A cadaveric study involving 7 human mandibles was performed to evaluate mechanical injury of canal enclosed IAN resulting from different drills. In group 1, osteotomies were created using different drills with 1 mm of intracanal intrusion, simulating accidental drill intrusion into canal. In group 2, drilling was stopped when the tip has breached into IAC, limited by tactile feedback of operator. The depth and width of nerve defects were assessed using optical coherence tomography. A significant difference in defect depth was found (p < 0.001) in group 1. A sinus lift reamer inflicted the least damage (0.068 ± 0.022 mm). It was also found that the mean defect depth was significantly different when a twist drill was used (p = 0.016). Sinus lift reamer can be used safely for osteotomy preparation in mandible when bone height is limited or when radiographic visualization of canal is poor. Bone corticalization around IAC does not provide adequate protection for IAN in the event of accidental intracanal intrusion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

This systematic review and meta-analysis compare the incidences of complications, reoperations and hardware removal between anterior and dorsal plating after corrective osteotomy for dorsally angulated distal radial malunions. A total of 403 patients were included; 253 patients underwent anterior corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Anterior plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the anterior group. There was no difference in major or minor complications between the groups. Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions.

Background: Modular metaphyseal engaging (MME) femoral components in total hip arthroplasty (THA) allow optimized femoral length, offset, and anteversion and are useful in patients with unusual proximal femoral anatomy. Fretting, corrosion, and stem fractures above the modular sleeve are complications associated with these implants. The purpose of this study was to identify failure mechanisms of retrieved MME femoral components at our institution, identify all broken stem cases, and evaluate how often an extended trochanteric osteotomy (ETO) was required for removal., Methods: All consecutively retrieved MME femoral components from September 2002 to May 2023 were reviewed. Patient demographics, procedure information, component specifications, indications for removal, and requirements for further revision surgery were reviewed. Descriptive statistics were calculated for variables of interest., Results: There were 131 retrieved MME components. The mean age at surgery was 59 years (range, 28 to 75), 49% were women, mean body mass index was 29.4 (range, 20.7 to 33.3), and mean American Society of Anesthesiologists score was 2.4 ± 0.5. There were 102 (78%) stems of 1 design (stem A), and 29 (22%) stems of a different design (stem B). Of 131 components, 10 (7.6%) failed secondary to stem fracture proximal to the modular sleeve. Four of 102 (4%) of stem A and 6 of 29 (21% of stem B) fractured. All broken stems required additional intervention for removal during revision THA, using an ETO (N = 9) or cortical window (N = 1) in which an intraoperative proximal femoral fracture occurred., Conclusions: Broken MME stems present a challenge for orthopaedic surgeons during revision THA. When a stem fracture occurs above the ingrown sleeve, the distal splines may have osseous interdigitation into the clothespin. Thus, when revising a broken MME stem, an ETO should be performed, and the segment should be long enough to allow distal access., (Copyright © 2024. Published by Elsevier Inc.)

Background: The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique., Questions/purposes: (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery?, Methods: Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons., Results: At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years., Conclusion: In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Background: There are few data on the impact of periacetabular osteotomy (PAO) on sagittal spinopelvic alignment. Prior studies have attempted to delineate the relationship by performing measurements on AP radiographs and using mathematical models to determine changes in postoperative pelvic tilt. This information is clinically significant to a surgeon when evaluating acetabular/pelvic position intraoperatively and understanding spinopelvic alignment changes postoperatively; therefore, radiographic changes from PAO should be described in more detail., Questions/purposes: In this study, we asked: (1) Does the performance of PAO result in consistent changes in spinopelvic alignment, as measured on EOS radiographs? (2) Does this differ for unilateral versus bilateral PAOs? (3) Does this differ in the setting of a mobile spine versus an immobile spine? (4) Does this differ based on preoperative pelvic tilt?, Methods: Mean preoperative and at least 1-year postoperative (15 ± 8 months from surgery, minimum 11 months, maximum 65 months) EOS hip-to-ankle standing and sitting radiographs for 55 patients in a prospectively collected registry who underwent PAO with a single surgeon from January 1, 2019, to January 11, 2022, were measured for pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lateral center-edge angle, L1 pelvic angle, and pubic symphysis to the sacroiliac index. Normality was assessed and paired sample t-tests (normally distributed data) or Wilcoxon signed rank tests (not normally distributed data) were utilized to assess if any measurements changed from preoperative to postoperative. Patients were then divided based on whether they had unilateral or bilateral dysplasia and unilateral or bilateral surgery, and these subgroups were analyzed the same way as the entire cohort. Two more subgroups were then formed based on lumbar mobility, defined as a change in sitting-to-standing lumbar lordosis less or greater than 1 SD from the population mean preoperatively, and the subgroups were analyzed the same way as the entire cohort. Finally, two additional subgroups were formed, preoperative standing pelvic tilt less than 10° and more than 20°, and analyzed the same as the entire cohort., Results: For the entire cohort, the median (IQR) standing lateral-center edge angle increased 17°, from a median of 21° (10°) to a median of 38° (8° [95% confidence interval (CI) 16° to 20°; p < 0.001). The median sitting lateral center-edge angle increased 17°, from a median of 18° (8°) to a median of 35° (8° [95% CI 14° to 19°]; p < 0.001). Standing pelvic incidence increased from 50° ± 11° to 52° ± 12° (mean difference 2° [95% CI 1° to 3°]; p = 0.004), but there were no changes for other measured parameters. There were no changes in any of the spinopelvic parameters for patients with unilateral dysplasia receiving a unilateral PAO, but patients with bilateral dysplasia who underwent bilateral PAOs demonstrated an increase in pelvic incidence from 57° (14°) to 60° (16°) (95% CI 1° to 5°; p = 0.02) and a decrease in pubic symphysis to sacroiliac index from 84 mm (24 mm) to 77 mm (23 mm) (95% CI -7° to -2°; p = 0.007). Patients with mobile lumbar spines preoperatively did not exhibit any changes in sagittal spinopelvic alignment, but patients with immobile lumbar spines preoperatively experienced several changes after surgery. Patients with less than 10° of standing pelvic tilt demonstrated a median (IQR) 2° increase in pelvic incidence from median 43° (9°) to 45° (12° [95% CI 0.3° to 4°]; p = 0.03), but they did not experience any other changes in sagittal spinopelvic alignment parameters postoperatively. Patients with preoperative pelvic tilt more than 20° did not experience any change in sagittal spinopelvic parameters., Conclusion: PAO increases pelvic incidence, potentially because of anterior translation of the hip center. There were no changes in other spinopelvic parameters postoperatively except after bilateral PAO. Additionally, patients lacking spine mobility preoperatively, indicated by a minimal change in lumbar lordosis between standing and sitting positions, may experience several changes in spinopelvic alignment, including increased mobility of their spine after PAO. This may be because of decreased compensatory spine splinting after increasing acetabular coverage, but further research including patient-reported outcomes is warranted., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Purpose: Dural tear (DT) is a well-known complication of spinal surgery. We aimed to systematically review the literature from the past decade and determine the incidence and risk factors for DT in the adult spinal deformity (ASD) population to improve both the surgical strategy and counseling of patients undergoing ASD correction., Methods: A systematic review from 2013 to 2023 utilizing PRISMA guidelines was performed. The MEDLINE database was used to collect primary English language articles. The inclusion criterion for patients was degenerative ASD. Pediatric studies, animal studies, review articles, case reports, studies investigating minimally invasive surgery (MIS), studies lacking data on DT incidence, and articles pertaining to infectious, metastatic or neoplastic, traumatic, or posttraumatic etiologies of ASD were excluded., Results: Our results demonstrate that the incidence of DT in ASD surgery ranges from 2.0% to 35.7%, which is a much broader range than the reported incidence for non deformity surgery. Moreover, the average rate of DT during ASD surgery stratified by surgical technique was greater for osteotomy overall (19.5% +/- 7.9%), especially for 3-column osteotomy (3CO), and lower for interbody fusion (14.3% +/- 9.9%). Risk factors for DT in the ASD surgery cohort included older age, revision surgery, chronic severe compression, higher-grade osteotomy, complexity of surgery, rheumatoid arthritis (RA), and higher Anesthesiology Society of America (ASA) grade., Conclusion: To our knowledge, this is the first systematic review discussing the incidence of and risk factors for DT in the ASD population. We found that the risk factors for DT in ASD patients were older age, revision surgery, chronic severe compression, a greater degree of osteotomy, complexity of surgery, RA, and a higher ASA grade. These findings will help guide spine surgeons in patient counseling as well as surgical planning., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Three-column spinal osteotomies (3-CO) are powerful techniques used to correct spinal deformity. These surgeries are associated with an elevated risk of complications. While outcomes have been reported in the literature with 2 years follow-up, longer-term outcomes of three-column osteotomies remain understudied., Objectives: This study aims to examine patient reported outcomes and complications for three-column osteotomies at 5 years., Study Design: Retrospective review of a prospectively collected spinal deformity cases database., Patient Sample: All consecutive adult patients at a single spine surgery center treated with either a pedicle subtraction osteotomy (PSO) or vertebral column resection (VCR) for spinal deformity, and with a minimum 5-year follow-up were included., Outcome Measures: Visual-analog scale (VAS) for back pain score (0 to 10), Oswestry Disability Index (ODI) score (0 to 100), number of complications, revision rate, sagittal balance, lumbar lordosis at preoperative and at 5-year visit., Methods: Data was extracted from a prospectively collected spinal deformity surgery database continuously updated since 2002 with data from operative reports, patients' medical visit notes and patients' self-reported VAS and ODI questionnaires completed at each office visit. Radiographic measurements were performed on standing full-length spine radiographs taken at preop and 5-year visits. Descriptive statistics, comparison of means and proportions among groups, and a logistic regression analysis were conducted using the statistical software package SPSS version 28. Statistical significance was set at p<.05., Results: Of 127 consecutive adult patients with minimum of 5-year follow-up undergoing a 3-CO posterior spinal surgery for spinal deformity were identified and included in the study, 79 (62%) were treated with PSO, and 48 (38%) with VCR. Both PSO and VCR groups demonstrated significant improvements in VAS (PSO preop: 6.7, 5-year: 4.6, p<.001; VCR preop: 7.1, 5-year: 5.2, p<.001), and ODI (PSO preop: 52.9, 5-year: 45.4, p<.001; VCR preop: 57.5, 5-year 43.0, p<.001) that were maintained at 5 years. Major and minor complications occurring within 5 years were not statistically different between the PSO and VCR groups (major: 59.5% vs 56.3%, p=.85; minor: 45.6% vs 37.5%, p=.46). The rate of revision surgery within 5 years was 39.4% overall. Of the fifty patients requiring revision, 37.5% were for nonunion, 27.1% instrumentation failure, 14.6% proximal junctional kyphosis (PJK), 12.5% vertebral fracture, 6.3% motor weakness, and 2.1% infection. Improvements in lumbar lordosis were maintained at 5 years in both the PSO (29.9° vs 47.2°, p<.001) and VCR (34.6° vs 48.5°, p<.001) groups while sagittal balance maintained significant improvement in the VCR group (9.5 cm vs 6.3 cm, p=.008) but not the PSO (11.4 cm vs 9.3 cm, p=.065)., Conclusion: Patients undergoing three-column osteotomies had a major complication rate of 57.5% and a minor complication rate of 42.5% after 5 years. Improvements in lumbar lordosis were maintained at 5-year follow-up, but sagittal balance was only maintained in the VCR group. Despite these radiographic findings, both VCR and PSO groups maintained significant clinical improvements in both VAS and ODI scores at 5-year follow up., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS., Methods: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ 2 test to compare baseline characteristics and postoperative outcomes., Results: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84)., Conclusions: TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: This study investigates the effect of the body mass index (BMI) on the early (2 years) to midterm (5 years) results of medial opening wedge high tibial osteotomy (MOWHTO)., Methods: A prospectively maintained single-centre database of 1138 knee osteotomies, between 2002 and 2022, was retrospectively reviewed. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee osteoarthritis (OA), with varus knee malalignment, having failed conservative management, were included. Patients were categorized into three groups according to their BMI as per the classification from the National Institute for Health and Care Excellence (NICE): the healthy weight (HW) group (BMI of 18.5-24.9 kg/m 2 ), the overweight (OW) (BMI of 25-29.9 kg/m 2 ), and the obesity (OB) group (BMI ≥ 30 kg/m 2 ). Multiple patient-reported outcome measures (n = 6) were recorded preoperatively and at 2 and 5 years postoperatively. Deformity analysis was undertaken preoperatively and postoperatively. The relative risk (RR) of the complications between the HW, OW and OB groups was calculated. The rate of conversion to arthroplasty, and 5 and 10 years survivorship were recorded, as well as the hazard ratio (HR) of BMI on survivorship., Results: A total of 574 cases were included in the study: the HW group (n = 96), the OW group (n = 233) and the OB group (n = 245), with a mean BMI of 23 ± 1.5 kg/m 2 , 27.4 ± 1.4 kg/m 2 and 34.4 ± 3.8 kg/m 2 , respectively. The mean follow-up was 13.3 years (4.8-20.3). The mean mechanical tibiofemoral angle corrections were in the HW group: 7.1 ± 3°, OW group: 6.6 ± 3.5° and OB group: 7.1 ± 3.8°, with no intergroup significant difference (p = n.s.). Clinically, despite lower preoperative scores in the OW and OB groups, no difference was observed postoperatively amongst the three groups. The overall complication rate was 12.5% in the HW group, 6.8% in the OW group, and 9.8% in the OB group. There was no significant difference in the RR of complications between the HW and OW groups (RR = 0.6, 95% confidence interval [CI] = 0.3-1.3) (p = 0.2), and the HW and OB groups (RR = 0.8; 95% CI = 0.3-2.2) (p = 0.7). There was no overall significant difference in survival outcomes based on the BMI between the three groups (p = 0.4). The HR of conversion to arthroplasty between the HW and OW groups was 1.4 [95% CI = 0.6-3.5](p = 0.5) and between the HW and OB groups was 1.8 [95% CI = 0.8-4.4] (p = 0.2)., Conclusion: BMI has no significant effect on either the radiological corrections, clinical outcomes, complications or survivorship of MOWHTO at short- to medium-term follow-up. No specific cutoff point for BMI can be recommended as a contraindication to MOWHTO., Level of Evidence: Level IV, Retrospective cohort study., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: The periacetabular osteotomy (PAO) was developed to treat acetabular dysplasia and avoid the progression of osteoarthritis. Prior research has correlated demographic and radiographic variables with postoperative patient outcomes but with limited focus on patient expectations and correlation with satisfaction. The purpose of this study was to determine whether any such associations exist with the PAO., Methods: An anonymous, de-identified satisfaction survey was applied to patients undergoing a PAO between April 2017 and April 2019. Forty patients (26 females) who underwent PAOs were included in the final analysis. The average age of the cohort was 22.0 ± 5.1 years of age. All patients had a minimum of 12 months of follow-up from the date of surgery. Patient demographics, diagnosis, and complications were recorded. Radiographs were then analyzed to determine pre- and postoperative lateral center edge angle (LCEA) and Tönnis roof angle, and correlations between satisfaction and radiographic analyses were performed. Statistical analysis included non-parametric Spearman's correlation and receiver operator characteristic. Statistical significance was set at p < 0.05., Results: Thirty (75%) patients were satisfied with their outcome. There were no statistically significant associations between patient age or sex and postoperative satisfaction (p > 0.05). The average LCEA was 10.9° ± 6.9° preoperatively and 26.0° ± 4.2° postoperatively with an average change of 15.1° ± 5.6°. The average Tönnis angle was 18.8° ± 3.3° preoperatively, decreasing to 11.6° ± 3.2° postoperatively with an average change of -7.2° ± 3.2°. Interobserver reliability was high, ranging from r = 0.782, p < 0.001 for postoperative Tönnis angle to r = 0.958, p < 0.001 for preoperative LCEA. Preoperative LCEA correlated positively with satisfaction, r = 0.351, p = 0.027. Logistic regression demonstrated that for every increasing degree of preoperative LCEA, odds of postoperative satisfaction increased by 1.13 (95% CI: 1.01 to 1.27), p = 0.034., Conclusion: This study suggests that postoperative patient satisfaction after PAO may be associated with preoperative patient demographics such as LCEA. It also suggests that more dysplastic hips may have lower rates of postoperative satisfaction than patients with less severe deformity. These associations warrant further study, which may yield prognostic value for future surgery.

Background: An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient reported outcomes., Methods: A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, sex, and follow-up time. Recurrent instability (including re-dislocation and subluxation), visual analog scale (VAS) for pain score, Kujala score, and satisfaction were evaluated., Results: There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311), or revision surgeries (10.2% vs. 10.2%) between groups., Conclusion: There was a low complication rate, excellent patient reported outcomes, and a low rate of recurrent patellar instability following TTO and MPFLR with allograft.

Objectives: The purpose of this study was to investigate the relationship between patient demographics and potential intraoperative factors and delayed bone union in opening wedge high tibial osteotomy (OWHTO)., Patients and Methods: A retrospective review of 65 patients (37 females, 28 males; mean age: 60.1±10.1 years; range, 44 to 77 years) who underwent OWHTO using an angle-stable implant with beta-tricalcium phosphate gap filling between September 2016 and October 2019 was conducted. The osteotomy site was divided into five zones from the lateral hinge on anteroposterior radiographs, and we defined the zone in which bone healing was observed. The bone union area was assessed according to this definition at three, six, nine, and 12 months after surgery, and bone union was defined as union at the fourth zone or greater. A generalized estimating equations approach was employed to investigate longitudinal data pertaining to bone union area as a dependent variable. In addition, the association of bone union at six months postoperatively and predictors were evaluated using cross-sectional statistical methods. The categorical predictors included in the models were smoking, diabetes, hinge fracture, and autologous osteophyte grafting. The continuous variables included in the models were age, body mass index, opening gap width, and plate position., Results: Smoking (odds ratio [OR]=0.478, p<0.01), large opening gap width (OR=0.941, p=0.014), and anterior plate placement (OR=0.971, p<0.01) were significantly associated with decreased bone union area. Union rate at six months in smokers was significantly lower compared to nonsmokers (16.6% and 67.8%, respectively; OR=0.10, p=0.023). Area under the curve in the receiver operating characteristic analysis for bone union at six months was 0.60 for gap width and 0.63 for plate placement., Conclusion: Smoking, large opening gap width, and anterior plate placement are risk factors for delayed bone union after OWHTO. Surgeons should avoid anterior placement of the plate and carefully consider other options for smokers and those who require a large correction.

Purpose: Third and fourth-generation minimal invasive osteotomies (MIO) for the treatment of hallux valgus (HV) have become popular procedures worldwide with promising results due to the improvement in the fixation method. The tricortical cannulated screw placement remains a complex procedure that is technically challenging and requires a long skill learning curve with high radiation exposure mainly in the form of intensifier shots (IS) required for the MIO fixation. This study aims to compare the number of X-ray IS required using three different techniques for the cannulated guide placement., Methods: A retrospective cross-sectional observational and comparative study was conducted to assess the number of X-rays IS required for correct cannulated screw guide placement using three different techniques: traditional perforator, the drill and joystick, and K-wire first techniques., Results: A total of 53 MIS procedures from thirty-one patients in two different hospitals were included. IS X-rays were 155.1 ± 29.7 in the traditional technique (n = 14), 143.0 ± 43.2 in the drill and joystick technique (n = 22), and 85 ± 18.7 in the K-wires first technique (n = 17), p =  < 0.001 using one-way ANOVA., Conclusions: The K-wire first technique statistically significantly decreases X-ray IS numbers p ≤ 0.001. There were no statistically significant differences between the traditional (after osteotomy K-wire placement) and the drill and joystick techniques (p = 0.36)., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy., Methods: Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released., Results: The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months., Conclusion: Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research., Level of Evidence: Level II, consensus., (© 2024 The Author(s). Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: Modifications of the pi craniectomy technique are meant to address the occipital bullet deformity of sagittal synostosis, but it is not clear whether they result in persistent improvement. The authors' purpose was to use morphometric analysis to determine whether a low occipital osteotomy with verticalization results in improved occipital shape after a modified pi procedure 2 years after surgery., Method: The authors performed a retrospective cohort study comparing modified pi technique with and without a low occipital osteotomy with verticalization immediately and 2 years after surgery relative to age-matched normal controls. The authors used anthropometric measures and population-level anatomical templates using the multivariate template construction script from advanced normalization tools for comparison between groups. A subgroup analysis was performed for severe occipital bullet deformity at presentation., Results: The authors observed stable improvement in the angle of the inferior occiput with the occipital remodeling modification that persisted 2 years after surgery. This improvement was seen in the entire cohort and was greater in the severe subgroup analysis. Complications and blood transfusion volumes were not different between the 2 techniques. The low occipital osteotomy group demonstrated improved posterior vertical height and cephalic index immediately after surgery, but these did not persist 2 years later., Conclusions: Occipital remodeling improves the bullet deformity but does not affect posterior vertical height 2 years after surgery. The authors recommend direct inferior occipital remodeling when using the pi technique for young patients with acute occipital incline angles and occipital constriction., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Hallux valgus (HV) is the most common forefoot deformity. Surgical correction of HV aims to reduce pain, preserve joints, and re-establish foot function while restoring the hallux valgus angle (HVA) and intermetatarsal angle (IMA). Many surgical procedures have been proposed, including open and minimally invasive (MI) techniques. This study aimed to compare the midterm outcomes of open vs. MI procedures and their impact on the duration of surgery, hospital stay, HVA, and IMA post-operatively., Materials and Methods: One hundred and twenty HV patients operated by open or MI surgery between October 2019 and October 2022 were included. One hundred three patients met the inclusion criteria and consented to the study. Patients were prospectively surveyed for foot functionality, post-operative pain, and complications using the AOFAS score. Radiographic measurements of HV angles, length of hospital stay, and surgery duration were analysed., Results: MI surgery patients had significantly better AOFAS scores (p < 0.001) 12 months post-operatively compared to open surgery. Complication rates were lower in the MI group (3.8% vs. 33.3%, p < 0.001). MI surgery patients also had shorter hospital stays (0.9 ± 0.3 days vs. 2.0 ± 0.0 days) and surgery duration (19.7 ± 2.3 min vs. 80.7 ± 6.8 min). MI surgery was more effective in correcting the IMA but equally effective as open surgery for HVA correction., Conclusion: MI surgery resulted in better patient satisfaction, fewer complications, and more precise correction of IMA values. Moreover, the duration of surgery and hospital stay were significantly lower in patients undergoing MI surgery. Further research is needed to validate these findings in controlled, prospective randomised trials., (© 2024. The Author(s).)

Introduction: One of the most popular containment procedures for Legg-Calvé-Perthes disease (LCPD) is proximal femur varus osteotomy (PFO). While generally successful in achieving containment, PFO can cause limb length discrepancy, abductor weakness, and (of most concern for families) a persistent limp. While many studies have focused on radiographic outcomes following containment surgery, none have analyzed predictors of this persistent limp. The aim of this study was to determine clinical, radiographic, and surgical risk factors for persistent limp 2 years after PFO in children with LCPD., Methods: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 years at disease onset with unilateral early-stage LCPD (Waldenström I) who underwent PFO. Limp status (no, mild, and severe), age, BMI, and pain scores were obtained at initial presentation, 3-month, and 2-year postoperative visits. Preoperative and follow-up radiographs were used to measure traditional morphologic hip metrics including acetabular index (AI), lateral center-edge angle (LCEA), and femoral neck-shaft angle (NSA). Univariate analysis as well as multivariate logistic regression models were used to analyze factors associated with mild and severe limp at the 2-year visit., Results: A total of 95 patients met the inclusion criteria, and of these 50 patients underwent concomitant greater trochanter apophysiodesis (GTA) at the time of PFO. At the 2-year visit, there were 38 patients (40%) with a mild or severe limp. Multivariate logistic regression revealed no significant radiographic factors associated with a persistent limp. However, lower 2-year BMI and undergoing GTA were associated with decreased rates of persistent limp regardless of age ( P <0.05). When stratifying by age of disease onset, apophysiodesis appeared to be protective against any severity of limp in patients aged 6 to 8 years old ( P = 0.03), but not in patients 8 years or older ( P = 0.49)., Conclusions: Persistent limp following PFO is a frustrating problem that was seen in 40% of patients at 2 years. However, lower follow-up BMI and performing a greater trochanter apophysiodesis, particularly in patients younger than 8 years of age, correlated with a lower risk of postoperative limp., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Medical records for dogs treated with tibial plateau leveling osteotomy (TPLO) using Arthrex 3.5 mm self-tapping screws (STS) were evaluated to determine the incidence rate of transcortical tibial fractures (TCTF) and development of complications., Study Design: Retrospective case report., Study Population: A total of 78 dogs., Methods: Dogs that underwent a TPLO performed from March 2022 to August 2023 were reviewed. Postoperative TPLO radiographs were examined for evidence of a TCTF with Arthrex 3.5 mm STS. Records were reviewed for complications up to 14 weeks after surgery., Results: Evidence of a TCTF was found in 42% of cases (33 of 78) and 14% (36 of 250) of STS screws distal to the osteotomy. TCTFs were only identified distal to the osteotomy. Three dogs had radiographic evidence of more than one TCTF. Of the dogs with radiographic TCTF, 6% of patients (2 of 33) developed a major complication that required surgical stabilization of a tibial fracture associated with screw angulation relative to the plate., Conclusion: Use of Arthrex 3.5 mm STS for TPLO is associated with risk of TCTF. TCTF can compromise the structural properties of the tibia and cause complete tibial fracture requiring major revision surgery., Clinical Significance: Development of TCTF after use of STS for TPLO has been recognized, in contrast to use of non-self-tapping screws, and was considered a benign complication. Our findings suggest TCTF associated with Arthrex 3.5 mm STS use in TPLO can contribute to major complications after surgery, including complete tibial fracture, particularly if screws are not placed perpendicular to the plate., (© 2024 The Author(s). Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.)

Purpose: Pelvic support osteotomy (PSO) is regarded to provide pelvic stability and improve abductor function to delay or even avoid total hip arthroplasty (THA) in young patients with high-riding hip dysplasia. However, some of these patients eventually have to undergo THA. Because of the double-angulation deformity of the femur after PSO, subsequent THA is challenging. This study aimed to analyze whether PSO surgery is suitable for high-riding hip dysplasia and summarize orthopaedic strategy during THA for patients with previous PSO., Methods: This case-control study included eight cases of THA for high-riding hip dysplasia patients with previous PSO (study group) and 24 cases of high-riding hip dysplasia patients without any hip surgical therapy (control group) by a 1:3 match (from May 2018 to January 2022). We compared demographics and joint function before and after THA between two groups and recorded all patients' preoperative imaging data, surgical procedures, postoperative imaging data, and complications. The surgical techniques for patients with previous PSO were highlighted., Results: There was no statistical difference between the two groups in demographic (p > 0.05). The study group had worse hip Harris score (HHS), range of motion (ROM), visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (p < 0.05) compared with the control group before THA. All patients had concurrent THA and osteotomy at the proximal femur, but the study group experienced longer operation time (p = 0.047) with more blood loss (p = 0.027) and higher complication rate compared with the control group (p = 0.009). At the last follow-up, the study group's HHS, ROM, VAS, and WOMAC were still worse than those in the control group., Conclusions: PSO did not improve the joint function of high-riding hip dysplasia patients but brought challenges to subsequent THA and affected the surgical outcomes. In short, we suggested that PSO is unsuitable for routine high-riding hip dysplasia patients., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Vertical orbital dystopia (VOD) results in significant facial asymmetry, psychological distress, and poor quality of life in affected patients. The traditional approach (TA) for surgical correction has entailed a standard frontal craniotomy along with circumferential orbital osteotomy, vertical translocation of the orbit, and bone grafting to the lower maxilla. Caution has been expressed regarding its invasive transcranial nature. In this report, the authors describe the limited approach (LA) for simplified surgical correction of VOD, which obviates the need for a standard frontal craniotomy., Methods: A 45-year retrospective review was conducted of all patients who underwent surgical correction of VOD, as performed by a single surgeon. Demographic details, procedural characteristics, and complications were compared between patients who underwent correction by the TA and those who underwent correction by the LA. Complications were defined as cerebrospinal fluid leak, infection of the frontal bone, permanent diplopia, permanent ptosis, sudden-onset vision loss, persistent asymmetry, and surgical revision., Results: Forty patients met inclusion criteria for correction of true VOD, of which 18 underwent the TA and 22 underwent the LA. Mean length of hospital stay was 5.3 ± 2.3 days and 4.0 ± 1.5 days for the TA and LA cohorts, respectively. Mean follow-up time was 4.9 ± 7.5 years for the TA cohort and 2.6 ± 3.3 years for the LA cohort. The only reported complications were persistent asymmetry in 2 patients in the TA cohort, with 1 patient requiring surgical revision because of undercorrection, whereas the LA cohort exhibited no postoperative asymmetry or need for surgical revision., Conclusions: Both the TA and the LA are effective for surgical correction of VOD. The limited craniotomy of the LA reduces exposure of intracranial structures and adequately achieves postoperative symmetry., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non-surgical) interventions treating pain rather than curing deformity are usually first-line treatments. When surgery is indicated, the overall best surgical procedure is an ever-evolving topic of discussion., Objectives: To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non-surgical treatments and other surgical interventions for adults with hallux valgus., Search Methods: We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions., Selection Criteria: We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non-surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events., Data Collection and Analysis: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE., Main Results: We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V-shaped osteotomy) with no treatment and with non-surgical treatment. Fifteen studies compared different surgical techniques, including a V-shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid-shaft Z-shaped osteotomy (Scarf osteotomy). Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases. Surgery versus no treatment Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) -18.00, 95% confidence interval (CI) -26.14 to -9.86; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15-dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI -2.12 to 2.12; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low-certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain. Surgery versus non-surgical treatment Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low-certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low-certainty evidence). Complex versus simple osteotomies Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate-certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low-certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low-certainty evidence) and serious adverse events (12 studies; data not pooled; low-certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low-certainty evidence). No study reported quality of life., Authors' Conclusions: There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non-surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non-surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non-surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non-surgical treatment. Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objective: There were few reports in the literature regarding hidden blood loss following surgery for developmental dysplasia of the hip in children. This study aimed to evaluate the volume of hidden blood loss and its risk factors among children undergoing hip reconstruction for developmental dysplasia of the hip., Methods: A retrospective analysis of clinical data from 42 patients (58 hips), who underwent Pemberton and femoral osteotomies between March 2020 and March 2023, was conducted. Serial complete blood count assays were conducted on the day of admission and four days post-surgery. Preoperative and postoperative hematocrit levels were documented to calculate hidden blood loss utilizing the Gross formula. Pearson and Spearman correlation analyses, along with multivariable linear regression, were employed to ascertain associations between patient characteristics and hidden blood loss., Results: The mean hidden blood loss was recorded as 283.06 ± 271.05 mL, constituting 70.22% of the total blood loss. Multiple linear regression analysis identified weight and surgical duration as independent risk factors contributing to hidden blood loss., Conclusions: A relevant amount of postoperative hidden blood loss occurs after Pemberton osteotomy and femoral osteotomy for developmental dysplasia of the hip. Surgeons should be aware that patients who require blood transfusions and have longer surgical durations are at a higher risk of developing more hidden blood loss. Therefore, attention should be given to hidden blood loss to ensure patient safety during the perioperative period for those undergoing Pemberton and femoral osteotomies., Level of Evidence: IV., (© 2024. The Author(s).)

Ulnar-shortening osteotomy is a reliable solution to treat ulnar impaction syndrome, but it has a significant rate of nonunion as a known complication. Generally nonunion after the procedure is attributed to noninfectious causes. When infections happen, they follow the microbiological trends of nonunions elsewhere in the body. We present a case of ulnar-shortening osteotomy using an oblique-cut osteotomy system that resulted in septic nonunion. At the time of revision surgery, Cutibacterium acnes and Staphylococcus hominis were isolated from the osteotomy site. The patient was successfully treated using intravenous antibiotics and the two-stage Masquelet technique and eventually went on to bony union. As C acnes is rarely encountered in this context, this report highlights the need to consider all possible pathogens in the workup of a potentially septic nonunion. Surgeons should consider bacteria such as C acnes that require prolonged incubation for isolation from cultures, which may not be part of many institutions' usual protocol. [ Orthopedics . 2024;47(4):e211-e213.].

Purpose: Lateral hinge fractures are the main complications in the high tibial osteotomy to treat varus deformities. The aim of present study is to answer the question whether the lateral hinge length (H) has an effect on the type of fracture and required force during the opening in high tibia osteotomy. It was hypothesized in this comparative research that extending the hinge length increased opening force and probability of a type II and type III fractures., Methods: A monoplanar medial open wedge osteotomy with different intact hinge lengths varying from 9 to 32 mm was performed in 20 ostrich bones. A biomechanical experiment using unidirectional tensile testing apparatus was performed to open the wedge, and the required force was increased until a 10 mm opening was reached; then, the presence of fracture in the lateral cortex and its direction were evaluated. Lateral hinge fracture type based on direction was classified as suggested by Takeuchi et al., Results: Fracture that grows along the osteotomy line (type I) was observed in 4 samples with the mean hinge length (H) of 11 ± 1.54 mm. For seven bones with Takeuchi fracture type II, with downward crack propagation, the mean H was 16 ± 3.36 mm. For the mean H of 25 ± 6.53 mm, the crack propagated upward to the cutting path, displaying a Takeuchi type III fracture in seven samples. The statistical analysis showed that the fracture type significantly depends on the hinge length (P value < 0.05). Also, the mean opening force significantly increased with hinge lengthening (P value < 0.05). The peak forces at crack initiation were 41.8 ± 21.9, 115.2 ± 41.5, and 167 ± 135.3 N, respectively, for the fracture types I, II, and III samples., Conclusion: The lateral cortical hinge length was significantly associated with hinge fracture type. The experimental tests indicated that the hinge lengthening increases the risk of type II and III fractures, as classified by Takeuchi., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: This study aimed to investigate the mid- to long-term benefits of high tibial osteotomy in advanced age patients., Methods: This retrospective study was conducted in our hospital from January 2017 to January 2021 with data prospectively collected, 47 patients with knee osteoarthritis who over 65 years old were included, and a 1:1 propensity score (PS) of patients < 65 years were matched according to gender, body mass index, and side. Patient demographics, intraooperative and postoperative variables, and patient self-reported outcomes were compared. A generalized linear model was used to screen possible risk factors., Results: A total of 94 consecutive patients were included; the average age of advanced age group was 69.47 + 4.26 years and 57.87 + 5.51 years in the younger group. There were no statistically difference in K-L grade, smoke, drink, comorbidity, ASA, blood loss, operative duration, length of stay, surgical site infection, hinge fracture, DVT, and preooperative and postoperative aFTA; significantly statistical difference of the eFI was found between two groups (P < 0.05). Two groups had comparable VAS and MOMAC scores at one year postoperatively (P > 0.05), while the younger group had lower VAS and WOMAC scores than the advanced age group at the end of follow-up (P < 0.05). Generalized linear model showed both age and eFI were associated with WOMAC scores; there was a statistically significant difference in the effect of eFI on WOMAC scores at different ages (P > 0.05)., Conclusions: Compared with younger patients, advanced age patients have similar short-term benefits, but less long-term benefits. We recommend that patients proposed for HTO be discriminated by eFI, and patients with higher scores should be cautiously selected., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Study Design: Retrospective comparative study., Objective: To investigate the occurrence of neurological complications in patients undergoing thoracic three-column osteotomy (3CO) utilizing an magnetic resonance imaging (MRI)-based classification that assesses spinal cord shape and the presence of cerebrospinal fluid at the curve apex and evaluate its prognostic capacity for postoperative neurological deficits., Summary of Background Data: Recent advancements in correction techniques have improved outcomes for severe spinal deformity patients undergoing 3CO. A novel MRI-based spinal cord classification system was introduced, but its validation and association with postoperative complications remain unexplored., Materials and Methods: Between September 2012 and September 2018, a retrospective analysis was conducted on 158 adult patients with spinal deformities undergoing 3CO. Radiographic parameters were measured. T2-weighted axial MRI was used to describe spinal cord morphology at the apex. Intraoperative neurophysiological monitoring alerts were recorded, and preoperative and postoperative neurological functions were assessed using the Frankel score. Categorical data were compared using the χ 2 or the Fisher exact test. The paired t test was utilized to assess the mean difference between preoperative and postoperative measurements, while the one-way analysis of variance and independent t test were used for comparative analyses among the different spinal cord types., Results: Patients were categorized into three groups: type 1, type 2, and type 3, consisting of 12, 85, and 61 patients. Patients with type 3 morphology exhibited larger Cobb angles of the main curve ( P <0.001). This disparity persisted both postoperatively and during follow-up ( P <0.05). Intraoperative neurophysiological monitoring alerts were triggered in 32 patients (20.3%), with a distribution of one case in type 1, six cases in type 2, and 22 cases in type 3 morphologies ( P <0.001). New neurological deficits were observed in 15 patients (9.5%), with 1, 3, and 11 cases in type 1, 2, and 3 morphologies, respectively., Conclusions: Patients with type 3 morphology exhibited greater spinal deformity severity, a higher likelihood of preoperative neurological deficits, and an elevated risk of postoperative neurological complications. This underscores the utility of the classification as a tool for predicting postoperative neurological complications in patients undergoing thoracic 3CO., Level of Evidence: 4., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO., Methods: A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes., Results: Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls., Conclusion: A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To validate the safety and clinical results of single-stage bilateral versus unilateral medial opening wedge high tibial osteotomy (HTO)., Methods: A propensity-matched cohort study was performed from March 2020 to March 2021 in our medical center. Data were prospectively collected. Including 34 patients who underwent single-stage bilateral medial opening HTO(SSBHTO), and 68 cases in the unilateral group. Propensity-matched ration was 2:1 based on age, sex, and body mass index using R software. Comparisons of the length of hospital stay, operative time, blood loss, postoperative adverse events, 90-day readmission rate, conversion to TKA rate, self-reported VAS and WOMAC scores were made to investigate the safety and clinical results of bilateral HTO., Results: The mean length of hospital stay was 7.36 ± 2.23 days for SSBHTO and 7 days (IQR, 3 days; range, 4 to 23 days) for the unilateral group (P = 0.219). The mean operative time was 144 ± 47 min for bilateral HTO and 105(37.5) mins for a unilateral OWHTO (P < 0.001). The mean blood loss was 150(100) ml for SSBHTO and 100(50) ml for unilateral OWHTO (P < 0.001). There were no significant difference of the adverse events and 90-day readmission rate between two groups. No failed HTO or conversion to knee arthroplasty were observed at the end of follow-up. VAS, pain, stiffness, and functional scores of the WOMAC scale were essentially comparable of two groups one year after surgery (P > 0.05)., Conclusions: A single-stage bilateral medial opening wedge high tibial osteotomy is advisable for patients with knee osteoarthritis. Patients benefit from avoiding secondary anesthesia, postoperative complications, and substantial cost savings., Level of Evidence: Therapeutic Level III., (© 2024. The Author(s).)

Background: Ulnar impingement syndrome is a prevalent source of ulnar carpal pain; however, there is ongoing debate regarding the specific location of shortening, the method of osteotomy, the extent of shortening, and the resulting biomechanical alterations., Method: To investigate the biomechanical changes in the distal radioulnar joint (DRUJ) resulting from different osteotomy methods, a cadaveric specimen was dissected, and the presence of a stable DRUJ structure was confirmed. Subsequently, three-dimensional data of the specimen were obtained using a CT scan, and finite element analysis was conducted after additional processing., Results: The DRUJ stress did not change significantly at the metaphyseal osteotomy of 2-3 mm but increased significantly when the osteotomy length reached 5 mm. When the osteotomy was performed at the diaphysis, the DRUJ stress increased with the osteotomy length, and the increase was greater than that of metaphyseal osteotomy. Stress on the DRUJ significantly increases when the position is changed to pronation dorsi-extension. Similarly, the increase in stress in diaphyseal osteotomy was greater than that in metaphyseal osteotomy. When the model was subjected to a longitudinal load of 100 N, neither osteotomy showed a significant change in DRUJ stress at the neutral position. However, the 100 N load significantly increased stress on the DRUJ when the position was changed to pronation dorsi-extension, and the diaphyseal osteotomy significantly increased stress on the DRUJ., Conclusions: For patients with distal oblique bundle, metaphyseal osteotomy result in a lower increase in intra-articular pressure in the DRUJ compared to diaphyseal osteotomy. However, it is crucial to note that regardless of the specific type of osteotomy employed, it is advisable to avoid a shortening length exceeding 5 mm., (© 2024. The Author(s).)