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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: 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: 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.)

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.)

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.)

Objective: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP., Methods: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression., Results: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01)., Conclusions: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted., Level of Evidence: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy)., Competing Interests: S.P.W. is a stockholder (within the last 2 years) for Johnson & Johnson. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Periorbital edema and ecchymosis that may occur after surgery in septorhinoplasty patients who have undergone lateral osteotomy are common morbidities and are seen as the main limiting factors for the recovery process of the patients. There are many different studies in the literature about the causes of periorbital edema and ecchymosis. In this study, the authors aimed to investigate the possible relationships between the bone density and bone thickness measured in the frontal process of the maxillary bone, and postoperative periorbital edema and ecchymosis, which are suitable for the osteotomy lines that they will detect in computerized tomography., Methods: Between January 1, 2019 and November 11, 2020, 59 patients whose nasal pathologies were determined by paranasal sinus computed tomography examination due to nasal deformity and nasal deformity and who underwent septorhinoplasty operation were included in this study. Bone density and thickness measurements were performed on the frontal process of the maxillary bone in accordance with the lateral osteotomy lines on the lateral nasal wall in each patient, right and left side. According to the bone density values measured at the point determined on the lateral osteotomy line, 2 groups were formed as "very dense" and "less dense." According to the bone thickness values of the patients, 2 groups were determined as "thick" and "thin." Thus, the authors investigated the relationship between periorbital edema and ecchymosis on the postoperative first, third, and seventh days obtained from the examination files of the patients., Findings: When bone density subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "very dense" and "less dense" group categories decreased from the first day to the seventh postoperative day. The degrees of periorbital edema on the third postoperative day were statistically higher in the "less dense" group than in the "very dense" group. In the authors' study, no correlation was found between the degrees of postoperative periorbital edema and ecchymosis and bone density subgroups on other days. While an increase was observed in the periorbital ecchymosis grades of the patients in the "less dense" subgroup category from the first day to the third postoperative day, the periorbital ecchymosis grades of the patients in the "very dense" subgroup category decreased from the first day to the third day. In both subgroups, the lowest periorbital ecchymosis levels were observed on the postoperative seventh day.When bone thickness subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "thick" and "thin" group categories decreases from the first day to the seventh day postoperatively. When the bone thickness subgroups were examined, the periorbital ecchymosis degrees of the patients in the "thick" and "thin" group categories increased on the third postoperative day, while it reached the lowest level on the postoperative seventh day. There was no significant difference between the first, third, and seventh-day periorbital edema and ecchymosis conditions in the "thick" and "thin" groups., Conclusion: The authors observed that periorbital edema and ecchymosis that may occur after septorhinoplasty can be affected by the variable features of the lateral nasal wall bone structure. The authors conclude that the changes in the healing process can be affected by different bone density values in particular., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: The authors aimed to compare the effects of total maxillary setback osteotomy (TMSO) and anterior maxillary segmental osteotomy (AMSO) on nasolabial morphology., Methods: This retrospective clinical trial enrolled 130 patients undergoing maxillary surgery using TMSO or AMSO. Ten nasolabial-related parameters and nasal airway volume were measured preoperatively and postoperatively. The soft-tissue digital model was reconstructed using Geomagic Studio and Dolphin image 11.0. Statistical analysis was performed using IBM SPSS Version 27.0., Results: A total of 75 patients underwent TMSO, and 55 underwent AMSO. Both techniques achieved optimal repositioning of the maxilla. Except for the dorsal nasal length, the dorsal nasal height, the length of the nasal columella, and the upper lip thickness, the remaining parameters were significantly different in the TMSO group. In the AMSO group, only the nasolabial angle, the alar base width, and the greatest alar width showed significant differences. There was a significant difference in the nasal airway volume for the TMSO group. The results of matching maps are consistent with the statistical results., Conclusions: TMSO has a more significant impact on both nose and upper lip soft tissues, whereas AMSO has a more significant impact on the upper lip and less on the nasal soft tissue. There is a significant decrease in nasal airway volume after TMSO, whereas AMSO showed less decrease. This retrospective study is helpful for clinicians and patients to understand the different changes in nasolabial morphology caused by the two interventions, which is essential for effective intervention and physician-patient communication., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Prupose: To analyze the incidence and risk factors of intraoperative neurophysiological monitoring (IONM) alerts in patients undergoing three-column osteotomy., Methods: A total of 551 patients (340 males and 211 females) with an average age of 31.9 years undergoing posterior 3-column osteotomy were retrospectively reviewed. The coronal Cobb angle of main curve and sagittal global kyphosis were measured on preoperative standing whole spinal x-rays. The Frankel scores at preoperation, postoperation, and the last follow-up were recorded and applied for assessment of neurologic status. Surgical procedures and other factors associated with IONM alerts were analyzed., Results: A total of 98 (17.8%) IONM alerts were reported during surgery, including 82 somatosensory evoked potential alerts and 91 motor evoked potential alerts. Positive wake-up test was revealed in 57 patients (10.3%) even after prompt managements, and new neurologic deficits were observed in 50 patients (9.1%) at immediate postoperation. Of the 50 patients with new neurologic deficits at postoperation, the Frankel scores were A in 5 patients, B in 4, C in 9, and D in 32. The χ 2 test showed that patients with congenital deformities, global kyphosis >90°, vertebral column resection procedure, cervicothoracic/thoracic osteotomy, blood loss >3,000 mL, and preoperative neurologic deficit were at a higher risk of IONM alerts., Conclusions: The incidence of IONM alerts in patients undergoing 3-column osteotomy was 17.8%. Congenital deformities, global kyphosis >90°, vertebral column resection, cervicothoracic/thoracic osteotomy, blood loss >3,000 mL, and preoperative neurologic deficit indicated high risk of IONM alerts., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 by the American Clinical Neurophysiology Society.)

Background: Wrist pain on the ulnar side is often caused by ulnar impaction syndrome (UIS). Idiopathic UIS requires surgical treatment when conservative treatment fails. The 2 main surgical procedures used are the wafer procedure and ulnar shortening osteotomy (USO) of the metaphysis or diaphysis. This review aimed to analyze comparative studies of the 2 procedures in UIS to determine clinical outcomes and complications., Methods: One prospective and 5 retrospective comparison trials were retrieved from the PubMed, Embase, and Cochrane Library databases. The primary outcomes were treatment effectiveness; pain visual analog scale (VAS), disabilities of the arm, shoulder, and hand (DASH) score, Mayo wrist, and Darrow scores. The incidence of postoperative complications formed the secondary outcome., Results: The selected studies included 107 patients who underwent the wafer procedure (G1) and 117 patients who underwent USO (G2). The wafer procedure had the benefits of less postoperative immobilization and an early return to work. However, there were no significant differences in the postoperative pain improvement and functional scores. All 6 studies reported high total complication rates and reoperation with USO. The most frequent complication was implant-related discomfort or irritation; subsequent plate removal was the most common reason for a secondary operation., Conclusions: There was no difference in pain improvement or the postoperative functional score between the groups. Nevertheless, postoperative complications were the major pitfalls of USO. As the specialized shortening system advances further, a high-level study will be necessary to determine the surgical option in UIS., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Distal tubercle biplanar open-wedge high tibial osteotomy (DT-BOWHTO) is a method frequently applied in the treatment of knee joint medial osteoarthritis. The aim of this study was to evaluate the radiological, clinical, and functional results of patients at 5 years after DT-BOWHTO surgery. The study included a total of 41 patients who underwent DT-BOWHTO, comprising 19 (46.3%) males and 22 (53.7%) females with a mean age of 55.54 ± 4.17 (45-63) years and mean follow-up of 66.76 ± 6.29 (60-81) months. Statistical comparisons were made of the preoperative and postoperative body mass index (BMI), modified Insall-Salvati index, Blackburn-Peel index, Kelgren-Lawrence classification (KLC), tibial slope angle, American Knee Society Functional Score (AKSFS), Clinical American Knee Society Score (CAKSS), visual analog scale (VAS) pain score, Tegner Functional Activity Score (TFAS), total corrected angular measurements (TCA), and the tibio-femoral varus angle. Compared to the preoperative values, no statistically significant difference was determined in the postoperative modified Insall-Salvati index, Blackburn-Peel index, and tibial slope angle values (P > .05), and a statistically significant difference was determined in the BMI, AKSFS, CAKSS, VAS, KLC, tibio-femoral varus angle, and TFAS values (P ≤ .001). When the preoperative and postoperative BMI values were compared in 3 groups of normal, overweight, and obese, there was found to be a statistically significant difference (P = .014). No significant correlation was determined between the BMI values and the VAS and KLC values (P > .05). No significant correlation was determined between the total corrected angular and the preoperative and postoperative pain, and clinical and functional knee scores (VAS, AKSFS, CAKSS, TFAS) (P > .05). DT-BOWHTO was seen to provide extremely good 5-year results in the knee clinical findings, pain severity, and functional results. As the patella height and tibial slope angle were not changed, this did not cause the development of osteoarthritis in the patellofemoral and tibiofemoral joints. Grafting and fixation of the tibial tubercle with additional screws in the application of DT-BOWHTO were not seen to make any additional contribution to the healing of the osteotomy line. There was no relationship between increased BMI, reduced pain, and increase in knee functions in patients who underwent DT-BOWHTO., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

This study aimed to critically reanalyze systematic reviews of patients suffering from condylar resorption (CR) and summarize the current scientific pieces of evidence with a focus on a possible relationship between CR and orthognathic surgery (OS). The work followed the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol" guidelines and was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42020168660). The search strategy produced 143 articles. After reading the abstracts, 113 articles were excluded, and the full-text articles in English of the remaining 30 studies were separately examined for eligibility by 2 authors, with 20 of them being excluded because they did not meet the inclusion criteria. Finally, 10 systematic reviews were processed for critical evaluation. Young female patients with a high mandibular plane angle, diminished posterior facial height, posteriorly inclined condylar neck, and a counter-clockwise jaw rotation, are more likely to develop CR after OS. The most common procedure associated with CR in the included systematic reviews was the bimaxillary OS followed by bilateral sagittal split osteotomy. Hence, extreme caution and surgical modification should be used in these high-risk conditions. There is still a need for more evidence on the risks of OS or iatrogenic factors during the fixation of various osteosynthesis devices because it is still inconclusive and requires further justification., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Study Design: Retrospective comparative study., Objective: To assess the relationship of fusion mass bone density on computed tomography (CT) and the development of rod fractures (RFs) and proximal junctional kyphosis (PJK)., Summary of Background Data: Few studies have evaluated the relationship of fusion mass bone density to mechanical complications., Materials and Methods: A retrospective review of adult spinal deformity patients who underwent thoracolumbar three-column osteotomy from 2007 to 2017 was performed. All patients underwent routine 1-year CT imaging and had at least 24 months follow-up. Posterior fusion mass bone density was evaluated by measuring hounsfield unit (HU) on CT in three different regions [upper instrumented vertebra (UIV), lower instrumented vertebra, and osteotomy site], and were compared between patients with and without mechanical complications., Results: A total of 165 patients (63.2 years, 33.5% male) were included. Overall PJK rate was 18.8%, and 35.5% of these underwent PJK revision. There was significantly lower density of posterior fusion mass at the UIV in patients who experienced PJK compared with patients without PJK (431.5HU vs. 537.4HU, P =0.026). Overall RF rate was 34.5% and 61.4% of these underwent revision for RFs. Among 57 patients with RFs, 71.9% had pseudarthrosis. Fusion mass density did not differ between patients with or without RFs. However, in RF patients with pseudarthrosis, there was significantly higher bone mass density near the osteotomy compared with those without pseudarthrosis (515.7HU vs. 354.2HU, P =0.012). There were no differences in radiographic sagittal measures between the patients with and without RF or PJK., Conclusions: Patients with PJK tend to have less dense posterior fusion mass at the UIV. Fusion mass density does not correlate with RF, but greater bone density near the osteotomy was correlated with accompanying pseudarthrosis in patients with RFs. Assessing density of posterior fusion mass on CT may be helpful in assessing risk for PJK and provide insight as to the causes of RFs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: A retrospective cohort study., Objective: To evaluate the outcomes of vertebral body sliding osteotomy (VBSO) with a minimum follow-up of five years and compare the results with those of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF)., Summary of Background Data: VBSO reportedly results in fewer complications, better lordosis restoration, and faster bone union than corpectomy. Although previous studies demonstrate the outcomes of VBSO with follow-up of two years or longer, results in longer term surveillance remain unknown., Methods: This study included 128 patients who underwent VBSO (n=38), ACDF (n=62), or ACCF (n=28) as a treatment for cervical myelopathy and was followed up for five years or more. Fusion, subsidence, C0-2 lordosis, C2-7 lordosis, segmental lordosis, C2-7 sagittal vertical axis, surgical complications, and neck pain visual analog scale, Neck Disability Index, and Japanese Orthopedic Association (JOA) scores were assessed. Comparisons between continuous variables in each group were made using independent sample t tests. For nominal variables, the Fisher exact test or the χ 2 test was used. Paired t test was used to analyze the changes in postoperative values compared with preoperative values., Results: The reoperation rate (0.0%) after VBSO was significantly lower than that after ACCF (14.3%; P =0.028). VBSO had a higher fusion rate at six-month and one-year follow-up, but the fusion rate at five years (97.4%) was not significantly different from that of ACDF (85.5%; P =0.054) and ACCF (85.7%; P =0.077). Segmental lordosis at the five-year follow-up was significantly higher in the VBSO group (16.1°) than in the ACDF (11.9°; P =0.002) and ACCF (6.5°; P <0.001) groups. C2-7 lordosis at five-year follow-up was significantly higher in the VBSO group than in the ACCF group ( P =0.017). Neck pain visual analog scale, Neck Disability Index, and JOA scores and the JOA recovery rate did not show significant intergroup differences during the five-year study period., Conclusions: VBSO showed promising long-term results in terms of low revision rate, fast solid union, and effective segmental lordosis restoration when compared with other anterior reconstruction techniques., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This study aimed to gather existing evidence regarding the incidence, clinical presentation, and management of pseudoaneurysms (PA) after orthognathic surgery, identify the common blood vessels involved in PA, and propose a treatment algorithm based on current evidence. The protocol for this study was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols and was registered at the International Prospective Register of Systematic Reviews under the registration number CRD42020205479. Although these are rare, oral and maxillofacial surgeons should consider PA as a possible diagnosis, specifically in the maxillary artery of patients with epistaxis, severe facial edema, and swelling following LeFort I osteotomy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Rationale: Tethered cord syndrome (TCS) represents a spectrum of neurological symptoms that are caused by constant or intermittent axial traction of the terminal cone of the spinal cord due to abnormal positioning. It is uncommon for abnormal structures of TCS to be accompanied by split cord malformation, thoracic spinal stenosis, and other spinal cord diseases., Patient Concerns: A 45-year-old male patient visited our hospital due to severe lower back pain, extensive left lower limb muscle weakness, and intermittent claudication., Diagnoses: TCS combined with stenosis of the thoracic canal, split cord malformation, and kyphosis deformity., Interventions: The patient underwent Dekyphosis operation combined with limited osteotomy symptoms., Outcomes: The patient felt the right lower limb improved after surgery. At 4-month follow-up, a radiological examination showed adequate decompression of the spinal cord and a good internal fixation position. Overall, the patient's clinical symptoms significantly improved., Conclusion: This is a rare case of TCS combined with thoracic disc herniation and bony mediastinum. A more conservative invasive surgical approach was elected and markedly improved the patient's symptoms. Additional clinical cases are needed to confirm the stability and feasibility of this surgical approach., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Study Design: Retrospective cohort study., Objective: Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time., Summary of Background Data: As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown., Materials and Methods: Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time., Results: A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03)., Conclusion: Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques., Competing Interests: International Spine Study Group reports conflicts of interest from NuVasive, and SI Bone. Past conflicts include DePuy Synthes, K2M, Stryker, Biomet, Allosource, and Orthofix. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A larger volume cranial vault expansion is likely facilitated by a low posterior cranial osteotomy beneath the torcula; however, this may impart an increased risk of venous bleeding. The authors compared the safety of infratorcular versus supratorcular osteotomy in patients undergoing posterior vault reconstruction or posterior vault distraction osteogenesis and analyzed volumetric changes., Methods: Patients undergoing initial posterior vault reconstruction or distraction osteogenesis between 2009 and 2021 at the authors' institution were grouped by occipital osteotomy location and analyzed retrospectively. Craniometric analysis was performed if patients had high-resolution computed tomography scans available within 180 days preoperatively and postoperatively., Results: A total of 187 patients were included: 106 (57 percent) who underwent posterior vault distraction osteogenesis and 81 (43 percent) who underwent posterior vault reconstruction. Infratorcular osteotomy was more common in reconstruction [ n = 65 (80 percent)] than in distraction osteogenesis [ n = 61 (58 percent); p < 0.002]. Blood transfused was similar between low and high osteotomy cohorts in the distraction osteogenesis ( p = 0.285) and reconstruction ( p = 0.342) groups. However, median transfused blood volume per kilogram of patient weight was greater in the low versus high osteotomy distraction osteogenesis ( p = 0.010) and reconstruction ( p = 0.041) cohorts. Intraoperative venous sinus injury was rare. In the distraction osteogenesis cohort, there was increased median intracranial volumetric gain in the low (263 ml) compared with the high osteotomy cohort (127 ml; p = 0.043); however, when controlled for distraction distance, only a trend was observed ( p = 0.221). Patients undergoing distraction osteogenesis showed a larger median intracranial volume increase (168 ml) compared with those undergoing reconstruction (73 ml; p < 0.001)., Conclusion: Infratorcular osteotomy can be performed safely in most patients undergoing cranial vault remodeling and does not appear to be associated with greater hemodynamic instability or sinus injury., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Hip containment surgeries in multiple epiphyseal and spondyloepiphyseal dysplasia (MED/SED) patients aim to improve the mechanical environment of the hip joint. The purpose of this study was to determine if surgical intervention to improve femoral head coverage improved radiographic and clinical outcomes. A retrospective study identified patients with MED/SED seen in clinic between May 2000 and September 2017, with a minimum of 2-year follow-up. Patient charts/radiographs were reviewed for radiographic hip measurements, pain, and gait. Sixty-nine hips in 35 patients were identified. Forty-four hips were treated nonoperatively and 25 were treated surgically. The mean age at diagnosis was 6.2 years. The mean follow-up was 7.7 years for the surgical group and 7.1 years for the nonsurgical group. The mean postoperative follow-up was 5.4 years. Acetabular index decreased from initial to final visit by 9.0° in the surgical group and 1.6° in the nonsurgical group. Tonnis angle decreased by 13.5° in the surgical group and 1.5° in the nonsurgical group. Center edge angle increased by 19.0° in the surgical group and 7.1° in the nonsurgical group. Hips in the surgical group were 6.1 times more likely to experience an improvement in pain compared with hips in the nonsurgical group. Gait at the final follow-up was similar among the two groups. In this study cohort, containment surgery provided increased femoral head coverage; however, there was equal femoral head deformation despite intervention. Hips treated surgically were more likely to experience an improvement in pain; however, gait alterations did not improve., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the orbital anatomy and completely understand the important components relevant to surgical correction of enophthalmos, including oculo-orbito relations. 2. Understand the pathophysiology and predictive factors for posttraumatic enophthalmos and identify the challenges associated with correction of enophthalmos in the late setting. 3. Develop a surgical plan for late enophthalmos repair and understand the value and utility of osteotomies, intraoperative navigation, and patient-specific implants. 4. Discuss the expected outcomes, possible complications, and adjunctive surgery as related to late enophthalmos repair., Summary: This article addresses the current management of late posttraumatic enophthalmos. In this article, the authors describe surgically relevant orbital anatomy and oculo-orbital relations, the pathophysiology of enophthalmos, clinical and radiologic findings, decision-making in management, and surgical treatment. The authors attempt to cover some of the main challenges and recent advances in the management of late posttraumatic enophthalmos, including intraoperative navigation and patient-specific implants., Competing Interests: Disclosure:The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information contained in this article. No sources of funding were used for the creation of this article., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are widely used for the treatment of medial unicompartmental knee osteoarthritis (OA). However, the best approach remains controversial. This study aimed to present a systematic review and a meta-analysis to directly compare the clinical outcomes between HTO and UKA. We hypothesized that the clinical outcomes after UKA and HTO would be similar., Methods: Electronic databases (Web of Science, PubMed, Embase, CENTRAL, and Biosis Preview) were searched for related studies published before November 30, 2021. Retrospective and prospective studies that directly compared the postoperative outcomes between UKA and HTO were included. Odds ratio (ORs) and 95% confidence interval (CIs) for complications, revision to total knee arthroplasty (TKA), and weighted mean difference (MD) and 95% CIs in range of motion (ROM), pain, walking speed and function score were evaluated. Two reviewers independently assessed the quality of the studies. Subgroup and sensitivity analyses were performed to explore the heterogeneity., Results: Twenty-three retrospective and 6 prospective studies were included. A total of 3004 patients (3084 knees) were evaluated for comparison. Complications (OR, 4.88, 95% CI: 2.92-6.86) were significantly greater in the HTO group than in the UKA group. Postoperative function scores including Lysholm score (MD, -2.78, 95% CI: -5.37 to -0.18) and Hospital for Special Surgery (HSS) score (MD, -2.80, 95% CI: -5.39 to -0.20) were significantly lower in the HTO group than the UKA group. The postoperative ROM was similar between HTO and mobile-bearing UKA (MD, -3.78, 95% CI: -15.78 to 8.22). However, no significant differences were observed between the HTO and UKA group in terms of postoperative pain, walking speed, and revision to TKA., Conclusions: UKA is superior to HTO in minimizing complications and enhancing postoperative function scores. Mobile-bearing UKA has a similar ROM compared with HTO. Both HTO and UKA provide satisfactory clinical outcomes in terms of walking speed, relieving pain, and revision to TKA. UKA appears to be more suitable for the elderly, and both mobile-bearing UKA and HTO are viable surgical options for younger active individuals., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Traditionally graft displacement following Pemberton and Dega acetabuloplasties involves internal fixation for treatment of developmental dysplasia of hip (DDH). This study was performed to assess the acetabular remodeling by conservative management of graft displacement among patients with DDH. This was a retrospective study of 20 patients 17 (85%) women and 3 (15%) men; mean age 22.90 ± 6.96 months with DDH who underwent Pemberton and Dega acetabuloplasties at King Khalid University Hospital, Riyadh between January 2013 and January 2018. All patients after losing acetabular correction during immediate postoperative period were treated by conservative management. The management involved application of Spica cast for 6 weeks that was trimmed to broomstick cast for an extended period of time and finally replaced by nocturnal abduction brace until normal acetabular index (AI) was achieved. The patients were followed up for a mean period of 44.60 ± 12.36 months. Out of the total, 18 (90%) patients with DDH were successfully treated by conservative management. The mean preoperative AI of 43.70° ± 5.91° improved to 21.35o ± 6.32o at the final follow-up (P < 0.001) which was no different when compared to the mean of unaffected hips (19.70o ± 2.96o; P < 0.44). The mean preoperative CEA of all the patients was negative that improved during the conservative treatment to 29.20° ± 10.0° which was no different when compared with the mean of unaffected (31.70° ± 4.64o; P = 0.32) hips at the final follow-up. doption of less aggressive approach for management of displaced, rotated or impacted autograft following acetabuloplasties among children with DDH was not only a useful conservative approach for remodeling of hips but also obviated the need for additional surgical intervention., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The objective of this study was to evaluate the incidence of avascular necrosis (AVN) of the femoral head in children less than 3 years of age with developmental dysplasia of the hip (DDH) treated with closed reduction, open reduction alone and open reduction combined with osteotomy. We reviewed clinical trials from the PubMed, EMBASE and Cochrane Library databases (up to November 2020) that were related to closed reduction, open reduction alone and open reduction combined with osteotomy for the treatment of children under 3 years of age with DDH. The screening and quality evaluation of the literature were performed independently by two researchers. In case of disagreement, a third researcher resolved the discourse. Finally, the data were extracted, and the R software and GeMTC program package were used to conduct a network meta-analysis (NMA). The evaluation index was the incidence of AVN. Fourteen articles were included. The NMA showed that in terms of the incidence of AVN, cases treated with open reduction alone were higher than those with closed reduction, and the difference was statistically significant. Open reduction alone had the highest probability (94.4%) of having the highest incidence of AVN, followed by open reduction combined with osteotomy (5.5%) and closed reduction (0.1%). In the treatment of children with DDH who are younger than 3 years old, open reduction alone is most likely to be the treatment with the highest incidence of AVN, followed by open reduction combined with osteotomy. The closed reduction had the smallest probability of AVN., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: We aimed to investigate the rate of loss of correction and the factors thereof in pediatric patients undergoing osteotomy for treatment of cubitus varus deformity.Between July 2008 and July 2017, we treated 30 patients who underwent osteotomy for cubital varus. We compared the preoperative and postoperative clinical and imaging findings, including the H-Cobb and Baumman angles, in all patients. Postoperative evaluation was performed by telephonic interviews.Our patients consisted of 17 males and 13 females. The mean age was 75 months. At the first follow-up, approximately 80% of patients had experienced a loss of correction of the humerus-cobb angle (H-Cobb angle); at the second follow-up, the incidence was 83%. Meanwhile, 57% and 43% of patients experienced a loss of correction of the Baumman angle at the first and second follow-ups, respectively. The average interval between the first and second follow-ups was 24 days, and the mean loss in the H-Cobb angle was 2.4°. There was a significant difference between the H-Cobb angles as measured before and after surgery (P < .05). There was no significant difference between the H-Cobb angles of the affected side and the contralateral healthy elbow at the third postoperative follow-up; however, there was a significant difference between the Baumman angle between before and after surgery (P < .05). The Baumman angles as measured at the second and third postoperative follow-ups differed significantly from those of the contralateral healthy elbow joint. According to the survival curve analysis, the median survival times of the H-Cobb and Baumman angles were 27 and 34 months, respectively.The postoperative loss of the 2 angles occurred mainly during the first and second follow-up periods. Therefore, patient follow-up is particularly important in the period directly following the operation. Additional measures may be necessary to avoid rapid angle loss., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory., Methods: Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders., Results: Seven patients (21 percent) experienced nonunion after initial corrective osteotomy. Risk factors associated with nonunion included correction length of osteotomy of 5 mm or greater and prior treatment with open reduction and internal fixation. Autograft use was protective against nonunion. History of osteoporosis showed a trend toward increased risk. Angle of osteotomy correction, nutritional deficit, age, diabetes, smoking status, and obesity were not identified as risk factors by the multivariate model., Conclusions: Distraction length at the osteotomy site, graft selection, and prior internal fixation were significant risk factors for distal radius osteotomy nonunion, but other factors traditionally associated with nonunion did not appear to impact risk. The authors recommend using autograft bone augmentation, particularly when distracting the osteotomy beyond 5 mm or after prior internal fixation., Clinical Question/level of Evidence: Risk, III., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: The scapular flap is the most versatile composite flap used for mandibular reconstruction. The purpose of this study was to review and summarize findings of cases of mandibular reconstruction with a scapular flap and describe associated outcomes and complications., Methods: A total of 208 microvascular scapular free flaps were performed for mandibular reconstruction in a total of 205 patients from 2003 to 2018. This study involved a retrospective review of all eligible patients' medical records., Results: There were seven cases (3.4 percent) of microvascular thrombosis. Postoperative bone union was achieved by 201 patients, except for five with total flap necrosis and two with partial flap necrosis. There were four cases (1.9 percent) of mandibular condyle dislocation. Two major types of complications were observed at the donor site, including four cases of infection and six cases of scapular body fracture. Postoperative denture prosthesis was introduced to 97 patients (47.3 percent). Implant treatment was performed in 10 patients (4.9 percent). Functional and aesthetic outcomes were good to excellent., Conclusions: The scapular composite free flap for mandibular reconstruction was associated with favorable outcomes and demonstrated satisfactory results. Although scapular bone fracture is rare, patients who have undergone mandibular reconstruction using a scapular flap should be monitored for its presence. ., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Narrowing genioplasty is commonly performed among East Asian populations, as a broad and/or square chin can be aesthetically unappealing. This study was aimed to introduce the home plate-shaped sliding osteotomy technique for narrowing genioplasty and to evaluate the results of this technique., Methods: A retrospective chart review of 117 patients who underwent home plate-shaped sliding osteotomy alone between 2011 and 2019 was performed. The angles of oblique osteotomy lines and measurements of caudal repositioning, which significantly affect the postoperative chin shape, were evaluated., Results: The home plate-shaped sliding osteotomy technique was successfully accomplished for narrowing genioplasty as an isolated procedure. The mean distance of caudal repositioning was 3.9 ± 0.8 mm, and the mean angles of oblique osteotomy lines were 23.3 ± 4.8 degrees on the right and 21.8 ± 3.5 degrees on the left. This produced an aesthetically pleasing rounded and proportionately narrow chin. The incidence of minor complications was 6.0 percent. There were no major complications. In particular, the risk of inferior alveolar nerve injury was obviated, as an additional mandibular border osteotomy was not typically used with this technique., Conclusions: This new surgical procedure for narrowing genioplasty provides improved aesthetic results by altering the chin shape, rather than reducing the transverse width of the chin. The versatility of this procedure allows the chin shape to be adjusted with respect to narrowing, vertical lengthening, anterior advancement, and asymmetric or cleft chin correction. The present study suggests that home plate-shaped sliding genioplasty may be an excellent alternative for correcting broad and/or square chins and more complex chin deformities., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Introduction: Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening., Discussion: Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm., Conclusion: If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: Traditionally, surgical access for extirpation and reconstruction of midfacial tumors requires external incisions that can cause a myriad of complications, especially in irradiated patients. The modern midfacial degloving approach involves hidden, sublabial and intranasal incisions that provide reliable access for free flap reconstruction of nasal and maxillofacial tumors. Seven patients with a history of radiation therapy underwent free flap reconstruction of the midface. Five patients underwent the technique in a delayed manner, and the remaining two underwent reconstruction immediately at the time of resection. Five patients underwent free radial forearm fasciocutaneous free flaps and two underwent reconstruction with anterolateral thigh perforator flaps. Bone and/or rib cartilage grafting was used in all patients. All patients underwent successful free flap reconstruction of the midface without external incisions. The most common complication was postoperative infection requiring oral or intravenous antibiotics. No patients sustained loss of their grafts or hardware in the postoperative period. The midfacial degloving technique provides satisfactory exposure to the nasal cavity, midface, orbits, and skull base for free flap reconstruction, without disrupting the external soft tissue. The authors describe a novel use of the midfacial degloving technique to provide safe and reliable results with improved cosmetic outcome., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Current risks and practices in medical prophylaxis of venous thromboembolism (VTE) after major elective lower extremity surgeries such as pelvic osteotomies have not been well-defined in the pediatric population. The purpose of this study was to (1) evaluate population rates of VTE in adolescents undergoing pelvic osteotomies, and (2) characterize current practices on types of VTE prophylaxis being utilized after pelvic osteotomies., Methods: The study evaluated the Pediatric Health Information System database between October 1, 2015 and January 1, 2020 for patients between 10 and 18 years of age meeting selected ICD-10 procedure and diagnosis codes relating to pelvic osteotomies. The rate of VTE was calculated within 90 days of index procedure. Types of pharmacologic prophylaxis were characterized. Continuous variables were compared with 2-sample t tests; proportions and categorical variables were compared with Fisher exact or χ2 tests, all with 2-tailed significance <0.05., Results: Of 1480 included patients, 9 were diagnosed with VTE within 90 days of surgery (VTE rate: 0.61%). Four of 9 (44.4%) had received pharmacologic prophylaxis postoperatively. There were no differences in baseline demographics or length of stay between patients that did or did not develop VTE (P>0.05). Overall, 52.0% received at least one form of pharmacologic prophylaxis postoperatively. The most common pharmacologic prophylaxis used was aspirin (47.6%), of which 64.4% received 81 mg dosing. There was no difference in VTE rates in those with or without prophylaxis (0.52% vs. 0.70%, P=0.75). However, those prescribed prophylaxis were significantly older (15.2±2.3 vs. 13.6±2.4 y, P<0.0001) and had a higher proportion of females (71.8% vs. 54.6%, P<0.01)., Conclusions: The overall rate of VTE in pediatric patients after pelvic osteotomies is non-negligible. There is heterogeneity in the type of anticoagulant utilized; however, VTE prophylaxis is most commonly prescribed in older adolescents and female patients. Guidelines for medical prevention of deep venous thrombosis and pulmonary embolism in the pediatric population are warranted after hip preservation surgery., Level of Evidence: Level IV, case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: International, multicenter, prospective, longitudinal observational cohort., Objective: To assess how new motor deficits affect patient reported quality of life scores after adult deformity surgery., Summary of Background Data: Adult spinal deformity surgery is associated with high morbidity, including risk of new postoperative motor deficit. It is unclear what effect new motor deficit has on Health-related Quality of Life scores (HRQOL) scores., Methods: Adult spinal deformity patients were enrolled prospectively at 15 sites worldwide. Other inclusion criteria included major Cobb more than 80°, C7-L2 curve apex, and any patient undergoing three column osteotomy. American Spinal Injury Association (ASIA) scores and standard HRQOL scores were recorded pre-op, 6 weeks, 6 months, and 2 years., Results: Two hundred seventy two complex adult spinal deformity (ASD) patients enrolled. HRQOL scores were worse for patients with lower extremity motor score (LEMS). Mean HRQOL changes at 6 weeks and 2 years compared with pre-op for patients with motor worsening were: ODI (+12.4 at 6 weeks and -4.7 at 2 years), SF-36v2 physical (-4.5 at 6 weeks and +2.3 at 2 years), SRS-22r (0.0 at 6 weeks and +0.4 at 2 years). Mean HRQOL changes for motor-neutral patients were: ODI (+0.6 at 6 weeks and -12.1 at 2 years), SF-36v2 physical (-1.6 at 6 weeks and +5.9 at 2 years), and SRS-22r (+0.4 at 6 weeks and +0.7 at 2 years). For patients with LEMS improvement, mean HRQOL changes were: ODI (-0.6 at 6 weeks and -16.3 at 2 years), SF-36v2 physical (+1.0 at 6 weeks and +7.0 at 2 years), and SRS-22r (+0.5 at 6 weeks and +0.9 at 2 years)., Conclusion: In the subgroup of deformity patients who developed a new motor deficit, total HRQOLs and HRQOL changes were negatively impacted. Patients with more than 2 points of LEMS worsening had the worst changes, but still showed overall HRQOL improvement at 6 months and 2 years compared with pre-op baseline.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to analyze the long-term results of humeral lengthening in achondroplastic patients and make suggestions on the most appropriate surgical technique to improve patient outcomes., Methods: Fifty-four humeral lengthening procedures performed in 27 achondroplastic patients were reviewed. Elongations were performed by means of callotasis with unilateral external fixation. Inclusion criteria were: achondroplastic patients under 17 years without prior arm operations and minimum follow-up of 36 months., Results: Fifty humeri in 25 patients (13 men and 12 women), aged between 9 and 17 years, met the inclusion criteria. Mean humeral lengthening was 8.82 cm (range: 5 to 10.5 cm), which represented an elongation of 54.80% (range: 46% to 63%) of the original length. The healing index was 0.91 months (range: 0.72 to 1.4 mo) per centimeter gained. Shoulder and elbow range of motion and stability were preserved in 47 limbs. Noncomplicated cases consistently experienced a significant functional improvement in the performance of activities of daily living such as putting on footwear and personal hygiene. Short-term complications included 11 pin-tract infections, 1 radial nerve neuropraxia, and 1 failure of the regenerated bone formation. None of these complications prevented from completion of treatment. Long-term complications included 2 cases of nonunion, 3 elbow flexion contractures, and 2 cases of psychological dissatisfaction, all of them in 4 patients. Factors associated with long-term complications were intraoperative fragment displacement and distal humeral osteotomy. No fractures of the regenerated bone were identified in the long term., Conclusions: Callotasis with unilateral external fixation is a reliable and well-tolerated procedure for humeral lengthening in achondroplastic patients, with an acceptable complication rate. Guided fixator placement and a proximal humeral osteotomy are strongly recommended technical tips as they may help prevent complications and improve outcomes., Level of Evidence: Level IV-case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Although lengthening of the lateral column through an osteotomy of the anterior calcaneus is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint after lateral column lengthening (LCL) and determine if Steinmann pin stabilization of the CC joint before distraction maintains a normal relationship., Methods: Seven matched pairs of fresh-frozen cadaveric feet underwent preprocedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL by osteotomy through the anterior calcaneus was then performed. One foot of each matched pair had a single smooth Steinmann pin placed centrally across the CC joint before osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12-mm porous titanium wedge. Repeat imaging was obtained and compared with preprocedure studies to quantify sagittal and rotational differences at the CC articulation., Results: Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs. 17.6%, P=0.02) and unpinned (12.5% vs. 16.3%, P=0.04) specimens. No difference in the percentage of subluxation was found between the 2 groups after LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid after LCL in both the pinned (7.6±5.6 degrees, P=0.01) and unpinned (17±12.3 degrees, P=0.01) specimens. The degree of rotation was greater in unpinned specimens after LCL (P=0.043)., Conclusions: Both sagittal and rotatory subluxation seem to occur at the CC joint after LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on 3-dimensional imaging are interpreted as dorsal translation when viewed 2 dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with 2 pins during LCL to prevent this rotatory subluxation., Level of Evidence: Level V-cadaver study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Rhinoplasty is the cosmetic procedure that is most difficult to master. Anatomical preservation should represent the main goal of rhinoplasty. One emerging tool appears to be erbium:yttrium-aluminum-garnet laser bone and cartilage reshaping. The authors developed a new small laser hand probe to perform what we called laser-assisted rhinoplasty. The authors evaluate the feasibility of the laser-assisted rhinoplasty and the aesthetic and functional result of laser-assisted rhinoplasty compared to classic rhinoplasty., Methods: A total of 50 patients were enrolled and randomized into two cohorts: the first cohort of patients was submitted to classic rhinoplasty, and the second cohort to laser-assisted rhinoplasty. The laser beam was used to perform both the resection of the crura and the resection of the nasal hump and osteotomies., Results: Laser-assisted rhinoplasty is a safe and reproducible technique. At a clinical assessment, lateral crura reshaping showed a visible step or excessive skin retraction in 12 percent of the classic rhinoplasty population with thick cartilage and/or thin skin, and this was not present in the laser-assisted rhinoplasty population at 12-month follow-up. The patient satisfaction rate was higher in the laser-assisted rhinoplasty population compared with standard open rhinoplasty. The authors also clinically noted a reduction in edema in the immediate postoperative period in the laser-assisted rhinoplasty population and a more rapid complete resolution of the swelling., Conclusion: The laser-assisted rhinoplasty technique is feasible and safe and has no major complication, and the aesthetic and functional results can be superimposed onto classic rhinoplasty but with a higher degree of intraoperative precision, higher patient satisfaction, a cleaner field, and less bleeding., Competing Interests: Disclosure:The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background and Purpose: Medial compartment femoro-tibial osteoarthritis (OA) is a common disease and opening-wedge high tibial osteotomy (OWHTO) is the common surgical procedure carried out for these patients. While most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the pain control effect of femoral nerve block (FNB) for OWHTO patients., Methods: In this prospective, single-center, randomized controlled trial (RCT) study, 41 patients were operated on by OWHTO for OA during 2017 to 2018. Twenty of them (group A) accepted epidural anesthesia with FNB and 21 patients (group B) only had their single epidural anesthesia. All blocks were successful and all the 41 patients recruited were included in the analysis and there was no loss to follow-up or withdrawal. Systematic records of visual analog scores (VAS), quadriceps strength, mean number of times of patient-controlled intravenous analgesia (PCIA), using of additional opioids or nonsteroidal anti-inflammatory drugs (NSAIDs), and complications were done after hospitalization. The Student t test and Chi-Squared test was used and all P values ≤.05 were considered statistically significant., Results: VAS scores at rest (3.48 ± 1.0 vs 4.68 ± 1.1) and on movemment (4.51 ± 0.6 vs 4.97 ± 0.8) decreased more in group A than group B with significance at follow-up of 12 hours. The quadriceps strength, consumption of additional opioids or NSAID injections and mean number of times that the patients pushed the PCIA button didnot differ significantly within each group., Conclusion: This RCT study shows that FNB in patients undergoing OWHTO for unicompartmental osteoarthritis of the knee could result in significant reduction in VAS scores at 12 hours postoperatively.Research registry, Researchregistry4792. Registered April 7, 2019 - Retrospectively registered, http://www.researchregistry.com., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: There is no consensus in regard to grafts used after pelvic osteotomy in developmental dysplasia of the hip in the literature. The aim of this study was to compare iliac and femoral autografts used after Pemberton pelvic osteotomy (PPO)., Methods: In this prospective, randomized study, 60 hips with dysplasia of the hip were included. All patients underwent open reduction, PPO, and femoral shortening osteotomy. Iliac autograft (group I; n=30 hips; mean age, 39.07; range, 18 to 72 mo) and femoral autograft (group II; n=30 hips; mean age, 42.53; range, 19 to 70 mo) were used to fill the iliac osteotomy. The height and width of the iliac and femoral autografts were measured intraoperatively. Anteroposterior pelvic radiographs were obtained on the 45th day, and in the 2nd, 3rd, 6th, and 12th months postoperatively. Acetabular index angle, height of the graft, loss of graft position, graft resorption, operative time, blood loss, and union time were compared between the groups., Results: There was a significant difference in each group in terms of loss of graft height between the intraoperative measurement and the postoperative measurement at the 6th week and 3rd month. The intraoperative width of the grafts was significantly greater, loss of graft height was significantly less, and the amount of bleeding was significantly lower in group II (P<0.001 for all 3). However, time to union was significantly shorter in group I (P<0.001). There was no significant difference between the groups in terms of acetabular index angle at the last controls. There were loss of graft position in 2 cases and graft resorption in 1 case for group I, but no such cases occurred for group II., Conclusions: Graft height and position loss, donor site morbidity, and graft resorption were less in the femoral autografts group compared with the iliac autografts group in the treatment PPO with femoral shortening osteotomy., Level of Evidence: Level II.

Background: Apert syndrome is a rare condition characterized by a craniosynostosis associated with complex bilateral malformations of the hands and feet. Although correction of syndactyly of the extremities is largely described, just a few authors have focused their attention on the gradual subluxation of the second metatarsal head during child growth, with hyper pressure, hyperkeratosis on the plantar surface and acute pain leading to walking impairment. The aim of this study is to describe our experience with the Helal metatarsal osteotomy technique on this group of patients. An oblique osteotomy performed dorsal to plantar, proximal to distal on the subluxed metatarsal bone is carried out. No internal bone fixation is needed, but a fundamental hypercorrective bandage is placed under the plantar surface. Immediate full weight-bearing, 24 hours after surgery, is highly recommended., Methods: Seventeen feet of 12 patients were treated between 2003 and 2018. Corrective osteotomy was performed on a single bone in 13 patients, on 2 bones in 3 patients, and on 3 bones on 1 patient. The mean follow-up was 5 years, with a physical examination once a year., Results: No complication such as infection or delayed wound healing was registered. X-rays taken 3 weeks after surgery showed complete bone consolidation and a correction of the previous plantarflexed position of the metatarsal with consistent reduction of pressure and pain for every patient who was able to wear normal shoes again after surgery., Conclusion: The Helal metatarsal osteotomy is a safe, reproducible, and feasible technique that should be considered in cases of painful metatarsal head plantar subluxation in Apert feet., Level of Evidence: Level IV.

Background: Treatment of symptomatic hip dysplasia in skeletally mature patients with spastic cerebral palsy (CP) can be challenging. This study examines our technical experience with the Bernese periacetabular osteotomy (PAO) in combination with adjunctive procedures in the treatment of this complex hip deformity., Methods: Sixteen consecutive patients (18 hips) with symptomatic CP hip dysplasia were treated with a PAO and variable adjunctive procedures and retrospectively reviewed. Two patient (2 hips) were excluded due to insufficient follow-up. The average age at the time of surgery was 17.7 years (range: 13 to 28 y). We compared the preoperative to postoperative changes in radiographic parameters as well as early outcomes as measured by patient assessment of hip pain and function using the modified Harris Hip Score (mHHS)., Results: The average time of follow-up was 3.3 years (range: 2.0 to 6.3 y). Tönnis angles decreased from a median of 30 degrees (range: 18 to 45 degrees) preoperatively to a median of 6 degrees (range: -9 to 21 degrees) postoperatively. Lateral center-edge angles increased from a median of -8 degrees (range: -28 to 15 degrees) to a median of 32 degrees (range: 19 to 38 degrees). Anterior center-edge angles increased from a median of 2 degrees (range: -22 to 39 degrees) to a median of 35 degrees (range: 22 to 47 degrees). The extrusion index decreased from a median of 57% preoperatively (range: 35% to 73%) to a median of 21% (range: 11% to 36%) postoperatively.The median mHHS was 62 (range: 37 to 81) preoperatively and 85 (range: 65 to 100) postoperatively. Notably, the pain component of the mHHS improved from 20 (range: 0 to 44) to 42 (range: 30 to 44). Tönnis osteoarthritis grade preoperatively was either 0 (11 hips) or 1 (5 hips) and remained unchanged in 11 hips and increased by 1 grade in 5 hips., Conclusions: It has been our experience that the Bernese PAO in combination with appropriate adjunctive treatments has provided a very satisfactory surgical approach in the treatment of CP hip dysplasia. In the adolescent and young adult with spastic CP, utilizing the Bernese PAO technique makes it possible to obtain redirection of often a very severe acetabular dysplasia. Adjunctive soft tissue procedures and a proximal femoral osteotomy are frequently necessary to maintain postoperative stability. A notable improvement in the quality of life and function directly attributable to our surgical treatment of their pre-existing problematic hip dysplasia has been consistently noted in early follow-up for our patients., Level of Evidence: Level IV-therapeutic.

Background: Delta triphalangeal thumbs (DTPT) and irregular epiphysis thumbs (IET) had different anatomic deformities. Our primary purpose was to evaluate the clinical and radiographic outcomes of surgical treatment in DTPT and IET., Methods: In total, 43 ulnar-deviated thumbs were included and categorized into 2 types according to x-ray and exploration during surgery, DTPT and IET. Surgical excision of the delta phalanx in DTPT and intraepiphysis osteotomy in IET was conducted., Results: In total, 23 ulnar-deviated thumbs were classified as DTPT and 20 as IET. Ten thumbs that could not be classified initially were followed-up until they could be categorized at the mean age of 24 months. The preoperative mean degrees of ulnar deviation at the interphalangeal joints were 40 and 33 degrees, in DTPT and IET, respectively. The mean degrees were 2 and 5 degrees in final follow-up, showing significant improvement (DTPT, P<0.05; IET, P<0.05). Complications during the study included residual ulnar deviation, overcorrection, and nonunion. The stability and range of movement at the interphalangeal joint were good overall. According to the Japanese Society for Surgery of the Hand scoring system, results were excellent in 29 cases, good in 13, and fair in 1., Conclusions: Ulnar clinodactyly of the thumb occurs because of different anatomic features such as DTPT or IET. We recommend surgical treatment be postponed until the anatomic abnormality can be ascertained. Furthermore, almost all patients with ulnar-deviated thumbs had significant improvement in clinical and radiographic outcomes after surgery.

Study Design: A retrospective study., Objective: The aim of this study is to investigate the changes in sleep quality in patients surgically treated for kyphosis due to ankylosing spondylitis (AS) and the correlation between these changes and spinal sagittal realignment., Summary of Background Data: Sleep problems are prevalent in AS patients. However, little attention has been paid to the sleep quality in patients with AS kyphosis and the effect of surgical intervention on sleep quality., Methods: We have retrospectively reviewed 62 patients with AS-induced thoracolumbar kyphosis who underwent surgically treatment from October 2012 to November 2016. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Preoperative and postoperative radiological characteristics and supine function were documented. We compared the above-mentioned parameters pre- and 24 months postoperatively and analyzed the correlation of the changes in the PSQI with the changes in radiological characteristics., Results: Fifity-one patients (82%) classified as poor sleepers preoperatively. In addition to use of sleeping medication, each domain of the PSQI and the total PSQI were increased postoperatively. Improved sleep quality was correlated with changes in spinal sagittal characteristics, among which the lumbar lordosis (LL) and the chin-brow vertical angle (CBVA) were the independent correlation factors. The number of patients with supine dysfunction decreased from 89% to 15% after surgery. Significant differences were identified in the PSQI scores between the patients with and without supine dysfunction either pre- or postoperatively., Conclusion: Surgical correction of spinal deformity may improve sleep quality and supine function in patients with AS. Spinal sagittal realignment may be correlated with the improvement of sleep quality., Level of Evidence: 4.

Hip subluxation in ambulant children with cerebral palsy may lead to limited walking and pain. This study aimed to introduce the indications and methods of femoral varus osteotomy combined with Pemberton osteotomy in treating spastic hip subluxation to evaluate the interim clinical result and outcome and to discuss its corrective mechanism and orthopedic effect. A total of 23 children with spastic hip subluxation, who underwent femoral varus osteotomy combined with Pemberton osteotomy were selected. The clinical effects were evaluated according to the migration percentage, acetabular index, proximal femur neck shaft angle (NSA), and Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The median migration percentage was 55 (50, 75) before operation, 20 (0, 30) at postoperative 1 year, and 22 (5, 32) at last follow-up. The median acetabular index was 30° (25°, 40°) before operation, 20°(15°, 26°) at postoperative 1 year, and 20° (15°, 25°) at last follow-up. The median NSA was 145 (138, 153) before operation, 117 (107, 126) at postoperative 1 year, and 118 (110, 125) at last follow-up. The MCPHCS grade 4 counts 23 (100%) before operation, grade 3 counts 20 (87.0%), grade 2 counts 2 (8.7%) and grade 1 counts 1 (4.3%) at postoperative 1 year, and grade 4 counts 1 (4.3%), grade 3 counts 21 (91.3%) and grade 1 counts 1 (4.3%) at last follow-up. Femoral varus osteotomy combined with Pemberton osteotomy is a good surgical treatment for children with Gross Motor Function Classification System levels I and II and migration percentage greater than 50%.

Background: Since its original description, the triple pelvic osteotomy has undergone several modifications and refinements most often utilizing 3 or 2 incisions. Recently, a single-incision extraperiosteal technique has been described; however, little data exist on the outcomes of this procedure., Methods: All patients undergoing single-incision triple osteotomy from 2 centers were retrospectively reviewed. Demographic data, underlying diagnosis, and preoperative radiographic data were recorded. Intraoperative details including estimated blood loss and type of postoperative immobilization were noted. Over the follow-up period, complications were recorded as were radiographic outcomes including lateral center edge angle, acetabular index, migration percentage, continuity of Shenton's line, and time to union., Results: Twenty-eight hips (in 24 patients) underwent surgery at a mean age of 9.3 years (range, 6.5 to 13.8 y). Diagnoses included Trisomy 21 (9), developmental dysplasia of the hip (5), Charcot-Marie-Tooth (3), and neuromuscular disease (9) among others. The mean estimated blood loss was 135 mL (±98 mL) and most patients were immobilized in an abduction brace or single-leg spica cast for an average of 7.6±2.2 weeks after surgery before weight-bearing was advanced. At a mean follow-up of 3.0±2.2 years, the lateral center edge angle improved from an average of 1±14 degrees preoperatively to 35±7 degrees, the acetabular index from 27±11 degrees to 2±5 degrees, and the migration percentage from 44%±21% to 3%±5%. Fourteen hips had frank instability before surgery and 20 had a break in Shenton's line >5 mm. At most recent follow-up, all but 1 hip was stable (93%) and all had restoration of Shenton's line (100%). Radiographic union occurred at a mean of 14 weeks (±11 wk). One patient developed an ischial nonunion that underwent further surgery, 1 had premature closure of the triradiate cartilage, and 1 patient with transverse myelitis developed Charcot arthropathy. There were no other complications in this series., Conclusions: In this dual-center retrospective series, the single-incision triple innominate osteotomy was extremely effective for improving acetabular coverage and stabilizing unstable hips in a variety of underlying diagnoses with an acceptably low rate of complications., Level of Evidence: Level IV-case series.

Background: Bilateral hip reconstructions with osteotomies are commonly required in patients with severe cerebral palsy (CP) and dysplasia. These procedures can be performed by staging each hip surgery, separated by weeks to months, or by addressing both hips in a single-event surgery. The optimal timing of such surgery is yet to be determined. The purpose of this study was to retrospectively compare major complications between the staged and single-event approaches., Methods: Medical records of patients who underwent bilateral hip osteotomies, with at least one side including a pelvic osteotomy, were retrospectively reviewed. Subjects were identified who had a diagnosis of nonambulatory CP (defined by Gross Motor and Functional Classification System level IV or V), and at least 1 year of clinical follow-up. All hips were treated by 1 of 7 surgeons: 2 surgeons who always performing single-event surgery and 5 who always perform staged surgeries. Complications were stratified by the Modified Clavien-Dindo Classification (grades 1 to 5). The primary outcome was major complications (grade ≥3), while minor complications, readmissions, reoperations, and resource utilization outcomes were investigated secondarily., Results: Sixty-five patients met our inclusion criteria: 35 received single-event surgery and 30 received staged surgery. The staged group had a higher rate of major complications per patient (0.30 vs. 0; P=0.013). Unplanned readmissions and reoperations were likewise increased in the staged group. Minor complication rates were high in both groups, with no differences observed between staged and single-event approaches (3.27 per patient vs. 2.91; P=0.952). There were no complications causing permanent disability or death. The total length of stay (6.2 vs. 4.0 d; P<0.001) and mean nonsurgical operating room time (65.7 vs. 45.6 min; P<0.001) were increased in the staged group versus the single-event group., Conclusions: The staged approach to bilateral hip reconstructions in the nonambulatory CP population was associated with a higher rate of major complications compared with a single-event approach. Minor complications were similar for both approaches. Both approaches can have an acceptable safety profile with no observed grade 4 or 5 complications., Level of Evidence: Level III.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.

Hip preserving procedures are still a challenge in late-stage osteonecrosis of femoral head (ONFH) patients. We aimed to compare the clinical outcomes of surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy for treatment of ONFH in Association Research Circulation Osseous (ARCO) stage III patients.We retrospectively reviewed 30 ARCO stage III patients (33 hips) who had surgical dislocation and impaction bone graft or surgical dislocation and rotational osteotomy in our center from June 2012 to December 2017. Baseline characteristics, clinical evaluation using Harris score and radiologic evaluation up to 12 months after surgery were recorded and compared.Fifteen patients (17 hips) were in the surgical dislocation and impaction bone graft group and 15 patients (16 hips) were in the surgical dislocation and rotational osteotomy group. No significant differences in age, gender, etiology, ARCO stage, duration of illness, operation time, and length of hospitalization were observed between the 2 groups. Compared to preoperation Harris score, the Harris score of 6 months postoperation and 12 months postoperation significantly improved. At 12 months postoperation, the excellent and good rate was 76.5% in the impaction bone graft group and 87.5% in the rotational osteotomy group. No significant difference in Harris scores was detected in the 2 groups.Surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy had satisfactory 1-year efficacy for ARCO III ONFH patients. Surgical dislocation and rotational osteotomy had better short-term efficacy than surgical dislocation and impaction bone graft.

Background: Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone., Methods: The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall., Results: One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03)., Conclusions: Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications., Clinical Question/level of Evidence: Risk, II.

Background: Deformity of the tibia, including shortening and angulation, may accompany severe forms of postaxial hypoplasia (fibular deficiency). The current literature reflects varying opinions on the appropriate management for tibial deformity in the setting of fibular deficiency., Methods: We performed a retrospective review to determine outcomes of tibial deformity correction in patients with a primary diagnosis of fibular deficiency. Clinical and radiographic outcomes of patients treated with foot ablation were reviewed to establish indications for tibial deformity correction, identify occurrence of additional surgical procedures related to limb alignment or deformity, and characterize difficulties with prosthetic wear potentially related to residual or recurrent tibial deformity., Results: From 1989 to 2016, 51 patients (57 extremities) with fibular deficiency were managed with a foot ablation procedure. Twenty-five (44%) had simultaneous correction of the tibial deformity. The initial tibial deformity measured 42.5 degrees, was corrected to 5.6 degrees intraoperatively, and measured 18.6 degrees at follow-up, suggesting recurrent deformity. In follow-up, approximately half of the patients complained of redness and one third complained of a continued prominence along the anterior tibia. Thirty-two extremities had an isolated foot ablation procedure without tibial osteotomy. Radiographic review demonstrated mild tibial bowing at the time of amputation with a mean angular deformity of 15.4 degrees and remained unchanged during the follow-up period (mean, 12.7 degrees). Similar to the osteotomy group, approximately half of the patients complained of redness and erythema over the anterior bow, with one fourth noting prominence, and only 2 reporting significant pain., Conclusions: Tibial osteotomies in patients with more significant degrees of angular deformity can be safely performed at the same setting as foot ablative procedures for fibular deficiency. Recurrent deformity with growth may occur. Patients and their caregivers should be aware that rebound deformity may occur, but typically can be managed with prosthetic adjustment and without significant disruption to the child's daily activities., Level of Evidence: Level IV (case series).

Background: Madelung deformity arises from a partial distal radial growth disturbance in combination with an abnormal hypertrophic ligament spanning the volar radius and carpus, termed, the Vickers ligament. The purpose of this study is to report long-term clinical and radiographic outcomes following Vickers ligament release and distal radial physiolysis in a population of skeletally immature patients with symptomatic Madelung deformity., Methods: Medical records were retrospectively reviewed of patients with Madelung deformity surgically treated between 1994 and 2005. All eligible patients who underwent a Vickers ligament release and distal radial physiolysis were contacted and invited to return to the clinic for follow-up., Results: Six patients (8 wrists) with Madelung deformity underwent Vickers ligament release and distal radial physiolysis. All were white females with a mean age at initial presentation of 11.4 years (10 to 12.8 y). Mean age at the time of initial surgery was 12.0 years (10.0 to 14.5 y). The median follow-up time was 10.6 years (5.8 to 21.9 y) and the average age at last follow-up was 23.1 years (17.5 to 32.2 y). Pain alone or in combination with concerns for deformity was the chief complaint in 6 of 8 of the wrists. At 1 year of clinical follow-up, 7 of 8 wrists were reported to be pain-free, and 6 of the 8 were noted to be completely pain-free at last follow-up. Motion in flexion, extension, pronation, supination, radial, or ulnar deviation was similar between the preoperative status and long-term follow-up. The average preoperative ulnar tilt was 35.1 degrees (SD: 8.5 degrees), average preoperative lunate subsidence was 1.9 degrees (SD: 1.8 degrees), and average preoperative palmar carpal displacement was 21.9 degrees (SD: 2.9 degrees). At the final follow-up, there was a large progression in lunate subsidence, but minimal change in ulnar tilt and palmar carpal displacement. At last clinical follow-up, 2 of the 6 patients had undergone a subsequent procedure including 1 radial dome osteotomy and 1 ulnar shortening osteotomy., Conclusion: In the skeletally immature patient population with Madelung deformity with growth potential remaining, distal radial physiolysis and Vickers ligament release is associated with relief of pain, preservation of motion, and, a reasonable rate of reoperation., Type of Study: This was a therapeutic study., Level of Evidence: Level II.