Gender-Affirming Facial Surgery: Lower Third of the Face

This article is intended to give the reader an overview of facial gender-affirming procedures applicable to the lower face and neck. A review of facial analysis in the context of masculine versus feminine facial features and the contributions of both soft tissue and bone to this anatomy is provided. The use of systematic facial evaluation and patient-driven concerns as a guide for presurgical planning is reviewed. Detailed descriptions of the unique surgical interventions to feminize the soft tissues and the skeletal framework of the lower face and neck are provided.

Proximal Redundant Fibula Bone Template for Flap Osteotomies in Mandibular Reconstruction: A Novel Technique

Background

Free fibula flap has been the workhouse of reconstruction for segmental mandibular defects. The use of computer aided design helps in achieving the desired aesthetic and functional outcome. It has its advantages but it comes with an extensive financial burden.

Purpose

We propose the use of redundant proximal fibula bone segment as a template and a cutting guide for flap osteotomies in mandibular reconstruction.

Methods

We have used this surgical technique in a case of T4 oral cancer that required segmental mandibulectomy.

Result

Average ischaemia time was 1 hour and 30 minutes. Based on histopathology report, both the patients required adjuvant radiotherapy. Oral competence was maintained in both the patients. Post-operatively, the contour and the orientation of the mandibular reconstruction were comparable both clinically and radiologically to the previously planned 3D cases.

Conclusion

This surgical technique provides an accurate guide for end angle osteotomy. In addition, it does not require any extra surgical step and does not increase the ischemia time of the flap with no additional extra cost.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01567-4.

Charcot-Marie-Tooth Disease: A Surgical Algorithm

In Charcot-Marie-Tooth (CMT) cavovarus surgery, a regimented approach is critical to create a plantigrade foot, restore hindfoot stability, and generate active ankle dorsiflexion. The preoperative motor examination is fundamental to the algorithm, as it is not only guides the initial surgical planning but is key in the decision making that occurs throughout the operation. Surgeons need to be comfortable with multiple techniques to achieve each surgical goal. There is no one operation that works for all patients with CMT. A plantigrade foot is the most important of the surgical goals as hindfoot stability and ankle dorsiflexion can be augmented with bracing.

Hallux valgus; An observational study on patient characteristics, surgical treatment and pre-operative HRQoL from the Swedish foot and ankle register (Swefoot)

INTRODUCTION

Hallux valgus (HV) is a common condition with impact on pain, function and HrQoL. International consensus does not exist on operative treatment of HV and population-level data regarding surgical treatment of HV is lacking. In this study we aimed to present base-line data from surgically treated HV patients reported to the Swedish register for foot and ankle surgery (Swefoot) during the period 2014-2021.

MATERIAL AND METHODS

In total, 7543 feet in 6770 patients were analyzed regarding patient characteristics, grading of HV, surgical procedures and pre-operative PROMs Euroqol-5 Dimension-3 L (EQ-5D-3 L) and Self-reported Foot and Ankle Score (SEFAS).

RESULTS

Median age was 55 years (range 15-91) and 87% were women. The surgeon classified 63% of the cases as moderate HV, 15% as mild and 22% as severe. The Chevron osteotomy was the preferred surgical method and was used in 74% of all cases. Out of these, 58% were fixated with a screw. The Offset-V osteotomy was the most performed shaft osteotomy. Proximal osteotomies and lateral releases were less common. The pre-operative mean EQ-5D-3 L index and SEFAS summary score were low and HV patients with overweight and rheumatoid arthritis had significantly lower scores.

CONCLUSION

This is the first report from Swefoot describing surgeon- and patient reported pre-operative data in patients with surgical treated HV.

Flatfoot over the centuries: the background of current conservative and operative treatments

PURPOSE

Although flatfoot is a widespread human condition, historical medical texts and ancient illustrations on this deformity are extremely rare. Nowadays, doubts regarding its management remain unsolved. This historical review aims to identify the presence of pes planus since the prehistoric era and examine the treatments proposed over the centuries up to the present.

METHOD

For this propose, we performed an extensive electronic search of the relevant literature, complemented by a manual search of additional sources from archaeological to artistic, literary, historical, and scientific accounts, describing flatfoot and its treatment in different eras.

RESULTS

Flatfoot accompanied the evolutionary timeline of human species: from Lucy Australopithecus to Homo Sapiens. It was described among various diseases suffered by Tutankhamun (1343-1324 B.C.), while the first anatomical description dates to Emperor Trajan (53-117 A.D.) and the medical studies of Galen (129-201 A.D.). It was also represented in the anatomical drawings of Leonardo da Vinci (1452-1519) and Girolamo Fabrici d'Acquapendente (1533-1619). Historically, the conservative treatment by insoles was the only one proposed until the nineteenth century. Since then, the most popular surgical procedures performed for correction have been osteotomies, arthrodesis, arthrorisis, and tendon lengthening and transfer.

CONCLUSION

During the centuries, conservative therapeutic strategies have not radically changed in their substance, while operative ones have become the protagonists during the twentieth century up to the present. Nevertheless, after more than 2000 years of history, there is no consensus regarding the best indication for the flatfoot and if it really needs to be treated.

Gender-Affirming Surgery of the Mandible: Lower Jaw Feminization and Masculinization

For patients with gender dysphoria, gender-affirming surgery of the face has been shown to vastly improve quality of life. The mandible is one area of the face that has distinct feminine and masculine presentations. This article will review gender-affirming surgery of the lower jaw, both for feminization and masculinization. Techniques for bony contouring and soft tissue manipulation will be discussed.

No benefits of knee osteotomy patient's specific instrumentation in experienced surgeon hands

PURPOSE

To compare the clinical and radiological outcomes of patient-specific instrumentation (PSI) with the conventional free hand (FH) technique in performing coronal plane corrective knee osteotomies in terms of limb alignment and functional scores. The hypothesis is that conventional FH technique in experienced hands with proper pre-operative planning is as precise as PSI.

METHODS

Patients who underwent coronal plane corrective knee osteotomies with either PSI or FH technique between 2017 and 2019 by the same senior surgeon and have a minimum of 2 years follow-up period were included in this study. A total of 91 knees (84 patients) with mean age of 42.9 ± 12.5 years who had a pre- and post-operative complete weight-bearing radiographic work-up (50 of them were performed with the FH technique and 41 by means of PSI) were included for comparison. The data were retrospectively reviewed both radiologically and clinically using the Knee Injury and Osteoarthritis Outcome Score (KOOS) sub-scores. All cases in both groups were evaluated for the following measurements: hip-knee-ankle (HKA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), and joint line convergence angle (JLCA) both preoperatively and postoperatively. In addition, FH and PSI osteotomy cases were also compared for their precision in achieving the target correction that was planned preoperatively. All cases were also evaluated clinically preoperatively and at 2-year follow-up using KOOS sub-scores and the two groups were compared.

RESULTS

The mean HKA precision was 1.5 ± 0.9 in FH group and 1.3 ± 0.7 in PSI (P value = n.s.), the mean MPTA precision was 1.6 ± 1.6 in FH group and 2.1 ± 1.2 in PSI (P value = n.s.), the mean m-LDFA precision was 1.9 ± 1.7 in FH group and 1.4 ± 1.3 in PSI (P value = n.s.), and the mean JLCA precision in the FH group was 1.5 ± 1.2 and 1.7 ± 1.2 in PSI (P value = n.s.). For all the radiographic parameters, there were no statistically significant differences between the target correction and the obtained correction in both groups. Moreover, PSI and FH techniques were comparable in terms of clinical outcomes and no significant difference was found between the two groups in any of the 2-year follow-up KOOS sub-scores.

CONCLUSION

Conventional FH method in the hands of experienced surgeons is as precise as PSI in reliably achieving the planned correction in different coronal plane knee corrective osteotomies. Moreover, there was also no difference between both methods in the 2-year clinical outcome scores.

Access to Pterygopalatine and Infratemporal Fossa Region by Newer Maxillary Suprastracture Swing Technique: A Report of Two Cases

Surgical access to pterygopalatine and infratemporal fossa has always been important for head and neck surgeons to deal with various benign and malignant tumours. Technical advancements leading to advent of microdebrider, coblation instruments and endoscopes, have proved helpful in gaining access to these complex anatomical areas, by way of endoscopic endonasal approaches but availability of instruments and learning curve remains a limiting factor. Thus older open surgical techniques like maxillary swing, Le Fort osteotomies and midfacial degloving still holds their importance in providing direct open access to these areas. We share our experience of the newer maxillary suprastracture swing technique in gaining direct open surgical access to these anatomical regions for two different cases i.e. neurofibroma located in infratemporal fossa and JNA involving both pterygopalatine and infratemporal fossa.

Rhinogavel™: A Precise and Perfect Hammer for Rhinoplasty

Nose is very important in standards of beauty because of its central location on face, making any slightest alteration in its appearance vulnerable to appreciation as well as criticism. Osteotomy is one of main steps of rhinoplasty which brings appreciably drastic change in the appearance of the individual after appropriate correction. Many approaches and instruments have since been used for proper correction of width of nasal bridge. Sometimes wrong use of force can even result in comminuted fracture of nasal bones leading to undesired surgical outcome. We have designed a hammer (gavel) made of hylam or bakelite for its precision role and use in rhinoplasty.

The incidence and risk factors for stress fracture following periacetabular osteotomy

AIMS

The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union.

METHODS

We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union.

RESULTS

A total of 331 patients underwent PAO during the study period with 56 (15.4%) stress fractures: 46 fractures of the retroacetabular posterior column, five cases of ischiopubic stress fracture, and five cases of concurrent ischiopubic and retroacetabular stress fractures. Overall, 86% (48/56) healed without intervention. Univariate analysis revealed that stress fractures occurred more frequently in females (p = 0.040), older patients (mean age 27.6 years (SD 8.4) vs 23.8 (SD 9.0); p = 0.003), and most often with the use of the broad Mast chisel (28.5%; p < 0.001). Multivariable analysis revealed that increasing age (odds ratio (OR) 1.04; 95% CI 1.01 to 1.07; p = 0.028) and use of the broad Mast chisel (OR 5.1 (95% CI 1.3 to 19.0) compared to narrow Ganz chisel; p = 0.038) and surgeon (p = 0.043) were associated with increased risk of stress fracture. Patients with stress fractures were less likely to have healed osteotomies after one-year follow-up (76% vs 96%; p < 0.001).

CONCLUSION

Stress fracture of the posterior column may be an under-recognized complication following PAO, and the rate may be influenced by surgical technique. Consideration should be given to using a narrow chisel during the ischial cut to reduce the risk of stress propagation through the posterior column.Cite this article: Bone Joint J 2022;104-B(9):1017-1024.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

A Comparative Study of Isolated Osteotomies Versus Osteotomies with Spreader Graft Placement to Correct Primary Deviated Nose

BACKGROUND

It is a complete objective and subjective comparative study between two techniques of septorhinoplasty in patients undergoing primary rhinoplasty for crooked nose deformity.

METHODS

Forty patients having crooked nose deformity were randomly divided into 2 groups exhibiting two different techniques of correction. Patients were randomly divided into 2 group: Group 1: 20 patients underwent correction of crooked nose by performing bilateral triple osteotomies + Septoplasty Group 2: 20 patients underwent correction of crooked nose by performing bilateral triple osteotomies as well as placement of spreader grafts + Septoplasty Objective and subjective assessment of patients in preoperative and postoperative period was done by various scales and scores.

RESULTS

Both the groups showed improvement in facial angles, ROE score, nasal airflow, and NOSE score. But, group 2 patients were more satisfied than group 1 patients in terms of both aesthetic appearance of nose and breathing function.

CONCLUSION

It is very well known to the authors that aesthetic result of rhinoplasty is not just dependant on one technique. Keeping this in mind, we conclude that as group 2 patients were more satisfied with their overall results, the additional step of spreader graft placement helped these patients with the complaints associated with crooked nose deformity. However, we also emphasize that additional studies on larger numbers of patients should be performed to compare and know other intricacies of each technique that may play minor or major roles in deciding the success of each technique.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patella Alta: When to Correct and Impact on Other Anatomic Risk Factors for Patellofemoral Instability

Patella alta is described as abnormally high-riding patella in relation to the femur, the trochlear groove, or the tibia with decreased bony stability. Patella alta represents an important predisposing factor for patellofemoral instability. Different measurement methods are used to define patella alta. Despite the clinical importance of patella alta, there is only limited consensus on cutoff values, indications for treatment, and ideal correction. In addition, the impact of patella alta on other risk factors for lateral patellar instability is significant. This must be considered when assessing clinical complaints and choosing the best individual treatment. Combined surgical interventions may be necessary.

Osteotomies around the knee lead to corresponding frontal realignment of the ankle

Introduction

Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation.

Materials and methods

Long-leg standing radiographs of 154 consecutive patients undergoing valgisation or varisation osteotomy around the knee in 2017 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip knee ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), the mechanical medial proximal tibia angle (mMPTA) and five angles around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test.

Results

One hundred fifty-four patients (96 males, 58 females) underwent osteotomies around the knee for coronal realignment. The mean age was 51 ± 11 years. Correction osteotomies consisted of 73 HTO, 54 DFOs, and 27 double level osteotomies. Of all osteotomies, 118 were for valgisation and 36 for varisation. For valgisation osteotomies, the mean HKA changed from 5.8° ± 2.9° preoperatively to − 0.9° ± 2.5° postoperatively, whereas the mMPTA changed from 85.9° ± 2.7° to 90.7° ± 3.1° and the malleolar-horizontal-orientation-angle (MHA) changed from 16.4° ± 4.2° to 10.9° ± 4.2°. For varisation osteotomies, the mean HKA changed from − 4.3° ± 3.7° to 1.1° ± 2.2° postoperatively, whereas the mLDFA changed from 85.7° ± 2.2° to 89.3° ± 2.3° and the MHA changed from 8.8° ± 5.1° to 11.2° ± 3.2°.

Conclusion

Osteotomies around the knee for correction of coronal limb alignment not only lead to lateralization or medialization of the weight-bearing line at the knee but also lead to a coronal reorientation of the ankle. This can be measured at the ankle using the MHA. When planning an osteotomy around the knee for correction of genu varum or valgum, the ankle should also be appreciated—especially in patients with preexisting deformities, ligament instabilities, or joint degeneration around the ankle.

Orthognathic surgery in COVID-19 times, is it safe?

COVID-19 has impacted the provision of orthognathic surgery globally. Uncertainty around its effects and transmission in aerosol generating procedures (AGP’s) has led to disagreement within maxillofacial surgeons into the safety of orthognathic surgery during the pandemic. We present a local case series of orthognathic surgery undertaken during the COVID-19 pandemic. To our knowledge no such similar study has been reported worldwide. Data was collected from the 1^st June to 30^th November 2020 for all patients undergoing orthognathic surgery by a single consultant. All procedures and inpatient stays were performed ‘off site’ at the local Spire Healthcare Group plc© facility. A strict preoperative two-week self-isolation period and negative COVID-19 testing was mandatory. All procedures were classified as AGP’s and personal protective equipment (PPE) was worn in line with local guidelines. The primary outcome was 30-day COVID-19 infection among patients, with day 0 the date of surgery. Secondary outcome measures included duration of stay, return to theatre and complications. A total of 59 patients were identified. 42/59 had bimaxillary procedures and 17/59 single jaw. 9/17 had maxillary and 8/17 had mandibular procedures. A total of 3/59 had simultaneous genioplasty. Median duration of stay was one night (range 1-3). Immediate and late complications were seen in 3% (2/59) and 3% (2/59) respectively. Only 1% (1/59) returned to theatre. Zero patients tested positive in the 30-day postoperative period. No staff members tested positive for the duration of the study. Adopting strict safety protocols, orthognathic surgery can be safely delivered during the pandemic without detriment to the patient or staff.

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome

BACKGROUND

Varus deformities of the knee are frequently corrected by osteotomies, which should be performed at the level of origin. But in contrast to high tibial osteotomies (HTO), little data exists for distal femoral osteotomies (DFO). This study evaluates radiological and clinical outcomes after valgisation osteotomies in the proximal tibia and distal femur.

METHODS

We used an observational cohort study design and prospectively performed preoperative long standing radiographs (LSR), lateral x-rays and clinical questionnaires (SF-36, Lysholm score, VAS). Postoperative LSR and lateral x-rays were obtained on average 18 months postoperative and postoperative clinical questionnaires at final visit (mean follow up 46 months). A subgroup analysis of the different surgical techniques (oHTO vs. cDFO) was performed, with regards to radiological and clinical outcomes.

RESULTS

Finally 28 osteotomies with medial tibial opening (oHTO) or lateral femoral closing (cDFO) wedge osteotomies in 25 consecutive patients (mean age 40 years) were identified. There were 17 tibal and 11 femoral procedures. All osteotomies were performed at the origin of deformity, which was of different etiology. The average deviation of the final HKA compared to the preoperative planning was 2.4° ± 0.4°. Overall, there was a significant improvement in all clinical scores (SF-36: 61.8 to 79.4, p < 0.001; Lysholm-score: 72.7 to 90.4, p < 0.001; VAS: 3 to 1, p < 0.001). There was no significant correlation between surgical accuracy and outcome scores.

CONCLUSION

Valgisation osteotomies lead to a significant improvement in all clinical scores with the demonstrated treatment protocol. An appreciable proportion of varus deformities are of femoral origin. Since cDFO provides comparable radiological and clinical results as oHTO, this is an important treatment option for varus deformities of femoral origin.

Freiberg's Infraction: Surgical Options

Freiberg's infraction is an uncommon condition of the lesser metatarsophalangeal joints. Onset is usually between the 11th and 17th year of age. It is the only osteochondrosis that dominantly affects females with a reported female-to-male ratio of 5.1. The second metatarsal is most frequently involved (68%) followed by the third metatarsal (27%), and the fourth (3%). Surgical treatment options can be categorized in joint destructive and joint preserving procedures. Studies reveal complete resolution of pain and full return to activities in 70% after joint destructive procedure and more than 90% after joint preserving procedures.

Lateral osteotomy plus hump resection vs hump re-modeling without lateral osteotomy: impact on frontal nasal view

This article reviews the personal experience and evolution of osteotomy approach in the last years of practice to obtain a natural appearance of the nasal pyramid in the frontal view. The aim is to analyse the long-term results after rhinoplasty on nasal width in two different cohorts of patients subjected to lateral osteotomy plus hump resection vs. hump re-modeling without lateral osteotomy considering the impact on frontal nasal view and how this relates to changes observed over time in the nasal width and contour. The study was carried out between January 2010 and December 2013, considering 42 patients undergoing primary rhinoplasty. Comparisons were made between the change in the dorsal width of the nasal pyramid at the level of the medial canthi, at the level of the inferior margin of the orbital rim, of ventral width of the nasal pyramid at the level of the medial canthi and at the level of the inferior margin of the orbital rim. In the first group, we found significant postoperative mean widening of the intercanthal dorsal width and narrowing of the ventral, while in the second group there was significant postoperative mean narrowing of the dorsal width both at level of the medial canthi and the anterior junction of the nasal bones. Our analysis seems to point out that dorsal grafting is useful for re-shaping the nasal profile with a persistent and harmonious correction of the dorsal frontal dimension of the nose. Simple hump removal/repositioning may be considered in selected instances to avoid lateral osteotomies. It also seems of paramount importance to tailor osteotomies according to nasal bone anatomy: large, strong and curved bones deserve aggressive narrowing by lateral and medial continuous osteotomies without periosteal elevation, although this approach may be insufficient to narrow the upper dorsal aspect of the nose.

Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique

Maxillary alveolar ridge expansion performed by intercortical bone splitting is a seducing alternative surgical procedure for alveolar bone widening. The aim of this technique is to gain enough bone width to be able to place a dental implant simultaneously. This technique avoids a second surgical site for bone graft harvesting. However there are risks of surgical failure caused by unintended bone fracture during expansion and implant placement, or by insufficient bone widening for implant insertion. To limit these risks, we have published expansion techniques using various corticotomies. These corticotomies are achieved according to bone anatomy, most of them remote from implant position. Bone fractures are guided during the bone expansion and the implant placement, avoiding cortical bursting. Wider and safer bone movements can be achieved allowing to place the forecasted implant with adequate dimensions, axis, and cervical position on the bone ridge. Our technique increases the success rate of both the bone volume expansion and the dental implant placement, and improve the functional and aesthetic result of implant and prosthesis restoration. Four main types of bone expansion movement using corticotomies have been described: expansion with apical cortical hinge, cortical translation, bi-cortical osteotomy, and frame-shaped corticotomy. Our subject is the alveolar bone width augmentation with the frame- shaped corticotomy expansion technique, which allows to place an implant in a narrow and concave alveolar bone, with a straightened axis, without modifying its cervical position on the bone ridge arch. A series of 10cases with a 1 to 5year surgical follow-up is studied. Implants were all placed in the same stage and their supported prosthesis successfully made. Peculiarities and interest of this technique are discussed.

The Use of Navigation in Osteotomies Around the Knee

Osteotomies around the knee for treating osteoarthritis or knee instability are currently well-established procedures. Success of these realignment procedures is based on the accuracy and the reliability of correction angles in the coronal and sagittal alignment. In this context of improving precision and adapting the correction to each patient, navigation is currently being widely used. The rationale for its use is based on understanding the advantages and limitations, technical principles, and potential pitfalls. This article describes these areas and the overall clinical outcomes of this system for knee osteotomies.

Lower Jaw Recontouring in Facial Gender-Affirming Surgery

Facial gender-affirming surgery can have significant impact on patient quality of life for some gender-dysphoric patients. Lower jaw contouring can be used to harmonize the face during facial gender-affirming surgery through masculinization or feminization. During feminization, the mandibular angle and body and chin are reduced in width and size. During masculinization, augmentation of the mandibular angle and body and chin are completed with alloplastic implants, fat, or bone. Complications are minimal. Further research is needed on outcomes of these procedures.

Cervical Spine Deformity-Part 3: Posterior Techniques, Clinical Outcome, and Complications

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications. Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

Cervical Spine Deformity-Part 2: Management Algorithm and Anterior Techniques

A sound operative plan based on solid understanding of the pathology and biomechanics is the most important part of cervical deformity correction. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In Part 2 of this three-part review series, we discuss the pre-operative planning, management algorithm, and anterior surgical techniques for cervical deformity correction.

Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification

Cervical spine deformities can have a significant negative impact on the quality of life by causing pain, myelopathy, radiculopathy, sensorimotor deficits, as well as inability to maintain horizontal gaze in severe cases. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and is often controversial. We aim to provide an overview of cervical spine deformity in a 3-part series covering topics including the biomechanics, radiographic parameters, classification, treatment algorithms, surgical techniques, clinical outcome, and complication avoidance with a review of pertinent literature.

Intermediate osteotomies in rhinoplasty: a new perspective

The nasal dorsum framework plays a major role in nasal and facial harmony. This study presents a new approach to an already known technique, intermediate osteotomies, which can be used routinely in patients with cosmetically unpleasant changes in eyebrow-tip line features, allowing the acquisition of a natural, aesthetically agreeable and harmonious dorsum contour, while preserving nasal function. The approach was evaluated retrospectively in 50 consecutive patients at a tertiary referral hospital. Patients were asked to complete a survey to rate their satisfaction with the cosmetic outcome on a 5-point visual analog scale (VAS) and to compare the impact of nasal obstruction on their quality of life, pre- and postoperatively, by completing the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Satisfaction was scored as excellent (satisfaction level VAS average score, 4.4), with more than 50% of the patients completely satisfied with the aesthetic result, while NOSE scale scores demonstrated preservation of nasal function postoperatively. Typical complications of the upper third of the nose following osteotomies were not observed.

Predictors of Health-Related Quality-of-Life After Complex Adult Spinal Deformity Surgery: A Scoli-RISK-1 Secondary Analysis

STUDY DESIGN

Longitudinal cohort.

OBJECTIVES

To identify variables that predict 2-year Short Form-36 Physical Composite Summary Score (SF-36PCS) and the Scoliosis Research Society-22R (SRS22-R) Total score after surgery for complex adult spinal deformity.

SUMMARY OF BACKGROUND DATA

Increasingly, treatment effectiveness is assessed by the extent to which the procedure improves a patient's health-related quality of life (HRQOL). This is especially true in patients with complex adult spinal deformity.

METHODS

The data set from the Scoli-Risk-1 study was queried for patients with complete 2-year SF-36 and SRS-22R. Regression analysis was performed to determine predictors of 2-year SF-36PCS and SRS-22R Total scores. Factors included were sex, age, smoking status, body mass index, American Society of Anesthesiologists (ASA) grade, Lower Extremity Motor Score improvement, indication for surgery, preoperative and 2-year maximum coronal Cobb angles, number of prior spine surgeries, number of three-column osteotomies, number of surgical levels, number of surgical stages, lowest instrumented level, presence and type of neurologic complication, and number of reported serious adverse events.

RESULTS

Of 272 cases enrolled, 206 (76%) cases were included in this analysis, 143 (69%) females, and mean age of 57.69 years. Factors that were significantly associated with of 2-year SF-36PCS were age (p < .001), ASA grade (p < .001), maximum preoperative Cobb angle (p = .007), number of three-column osteotomies (p = .049) and type of neurologic complication (p = .068). Factors predictive of 2-year SRS-22R Total scores were maximum preoperative Cobb angle (p = .001) and the number of serious adverse events (p = .071).

CONCLUSIONS

Factors predictive of lower 2-year HRQOLs after surgery for complex adult spinal deformity were older age, higher ASA grade, larger preoperative Cobb angle, larger numbers of three-column osteotomies, and the occurrence of both neurologic and nonneurologic complications. Most of these factors are beyond the control of surgeons. Still, surgeons should medically optimize a patient prior to surgery to minimize the risk of complications and offer the best chance of improving a patient's quality of life.

LEVEL OF EVIDENCE

Level II. Prospective cohort.

Neurological complications in adult spinal deformity surgery

The number of surgeries performed for adult spinal deformity (ASD) has been increasing due to an aging population, longer life expectancy, and studies supporting an improvement in health-related quality of life scores after operative intervention. However, medical and surgical complication rates remain high, and neurological complications such as spinal cord injury and motor deficits can be especially debilitating to patients. Several independent factors potentially influence the likelihood of neurological complications including surgical approach (anterior, lateral, or posterior), use of osteotomies, thoracic hyperkyphosis, spinal region, patient characteristics, and revision surgery status. The majority of ASD surgeries are performed by a posterior approach to the thoracic and/or lumbar spine, but anterior and lateral approaches are commonly performed and are associated with unique neural complications such as femoral nerve palsy and lumbar plexus injuries. Spinal morphology, such as that of hyperkyphosis, has been reported to be a risk factor for complications in addition to three-column osteotomies, which are often utilized to correct large deformities. Additionally, revision surgeries are common in ASD and these patients are at an increased risk of procedure-related complications and nervous system injury. Patient selection, surgical technique, and use of intraoperative neuromonitoring may reduce the incidence of complications and optimize outcomes.

Surgical Treatment of the Twisted Nose

The twisted nose is a challenging procedure in rhinoplasty. The goal of surgery is to realign the nasal skeleton to create symmetry in the face and restore nasal patency. Key in the surgical procedure is that all structures of the nasal skeleton be dissected free, mobilized, repositioned, and stabilized. Important surgical steps are intermediate osteotomies on the contralateral side of the deviation for the upper nasal third; for the mid nasal third, a unilateral spreader graft or splint on the nondeviated side, and for the lower nasal third, fixation of the caudal septum to the anterior nasal spine.

Orthopedic aspects of separation

In the management of conjoined twins the orthopedic surgeon may be involved directly, as part of the surgical team at operation or indirectly, in dealing with associated anomalies or the sequelae of surgery. The overwhelming indication for orthopedic involvement is ischiopagus, either tripus or tetrapus. The main role of the orthopedic surgeon is to facilitate midline closure through the use of pelvic osteotomies, which allow the symphysis pubis to be approximated.

Surgical assistance for rapid orthodontic treatment and temporary skeletal anchorage

In surgically-assisted osteogenic orthodontics, multiple modalities are combined to shorten treatment time and to accomplish results that cannot be achieved with orthodontics alone. There is a significant reduction in cost to the patient, especially when there is a lack of insurance coverage for orthognathic techniques. Surgeons are able to work in the comfortable environment of their own offices. Decreased cost, recovery time, and treatment time, and an in-office environment all increase patient acceptance and allow surgeons to provide treatment to patients who might otherwise have no options.

[Twisted noses]

Correction of a twisted or crooked nose can be very complex and require the use of a broad range of surgical techniques. Patient needs are often mixed--aesthetic and functional--particularly in post-trauma cases. The quality of postoperative breathing is therefore as important as correction of the nasal deviation. Extracorporeal septoplasty or spreader grafts are very effective not only in correction of the nasal pyramid deformation, but also in resolution of functional respiratory issues. Reconstruction and proper support of the septum are necessary components for a straight nose. Aesthetic deformation can be difficult to correct owing to the memory of the bone and cartilage. Although minor deformations can be corrected with simple techniques, a more aggressive procedure is often necessary in the most complex cases. Despite attempts to correct deformation thanks to the various techniques described here, a postoperative deviation can persist. Preoperative discussion is very important and enables the surgeon to explain to the patient that it is very difficult to obtain a perfectly straight nose.

Persistent vesicocutaneous fistula after repair of classic bladder exstrophy: a sign of failure?

OBJECTIVE

To describe the potential predisposing clinical characteristics at initial closure, the treatments of and outcomes associated with vesicocutaneous fistula (VCF) after primary bladder closure.

MATERIALS AND METHODS

Eighteen patients were referred for VCF after primary bladder exstrophy closure. Aspects from the primary closure such as gender, timing of diagnosis and repair, osteotomies, pelvic immobilization, layers of closure, use of tissue adjuncts, and complications in addition to details from their required treatment of VCF were retrospectively extracted from the medical record.

RESULTS

A diagnosis of failed closure was made at the time of evaluation in 13 of 18 patients who presented with VCF. All 13 patients underwent delayed single-layer closures and had a widened pubic diastasis. Five patients with secure closures who underwent successful simple fistula repairs were all closed early in life, had multi-layered closures with pelvic osteotomies, and had minimal change in pubic diastasis.

CONCLUSION

VCF may represent a failed bladder closure. Factors which may suggest failure are a fistula tract in the lower abdominal midline between the pubic rami, a pubic diastasis increased from pre-closure measurement, and cystoscopic evidence of an anteriorly positioned bladder.

VALGUSING INTERTROCHANTERIC OSTEOTOMY FOR THE TREATMENT OF FEMORAL NECK NON-UNIONS: REPORT OF 32 CASES

The purpose of the present study was to review the results of femoral neck non-unions treatment with valgusing intertrochanteric osteotomy.

METHODS

Between 1988 and 2003 we treaded thirty two femoral neck non-unions with valgusing osteotomy and fixation. The mean follow-up time was 9.8 years and the mean age was 41.7 years.

RESULTS

Twenty eight (87.4%) of the thirty two valgusing osteotomies evolved to femoral neck union, while four cases (12.6%) evolved to total hip arthroplasty. Eight cases evolved to partial osteonecrosis.

CONCLUSIONS

The valgusing intertrochanteric osteotomy for treating femoral neck non-unions achieved consolidation in 87.4% (28/32). However, only 56.2% (18/32) achieved full recovery of hip function.