Conceptos actuales en osteotomías en doble nivel alrededor de la rodilla / Current concepts in double-level osteotomies around the knee

Con la osteotomía en un solo nivel, se puede lograr la corrección del eje de la extremidad en pacientes con deformidades combinadas femoral y tibial, pero de forma simultánea generará una alteración patológica de oblicuidad de la interlínea articular, lo que conducirá a elongación ligamentaria, inestabilidad, degeneración condral y, en última instancia, comprometerá su sobrevida y los resultados funcionales. En virtud del análisis de la literatura más reciente, podemos concluir que existe un número significativo de pacientes que requieren de un procedimiento combinado para lograr un objetivo biomecánico óptimo. La finalidad de una osteotomía en doble nivel alrededor de la rodilla consiste en restablecer la anatomía normal, descargar el compartimiento afectado, normalizar los ángulos mecánicos y la orientación de la interlínea articular. Los ejes fisiológicos pueden restablecerse a través de un análisis preoperatorio exhaustivo, respetando principios biomecánicos y fijación estable con placas bloqueadas. Es un procedimiento demandante y con indicaciones en evolución, que progresivamente se ha instaurado como una alternativa de tratamiento justificada en estudios clínicos y biomecánicos para el manejo de deformidades severas alrededor de la rodilla.

With single-level osteotomy, correction of the limb axis in patients with combined femoral and tibial deformities can be achieved. This correction, however, will generate a pathological alteration in the joint line oblicuity, leading to ligament elongation, instability, joint degeneration and, ultimately, it will compromise the longevity and functional results of the correction. By analyzing the most recent literature, we can conclude that there is a significant number of patients who require a combined procedure to achieve an optimal biomechanical goal. The purpose of a double-level osteotomy around the knee is to restore normal anatomy, unload the affected compartment, normalize the mechanical angles and the orientation of the joint line. Physiological axes can be reestablished by means of a thorough preoperative analysis, observing the biomechanical principles and stable fixation with locked plates. It is a demanding procedure with increasing indications, which has progressively been established in clinical and biomechanical studies as a justified treatment alternative for the management of severe deformities around the knee.

Hip Screening in Infants Presenting with Asymmetricity of Lower Extremity / 대한정형외과학회잡지

PURPOSE: This study aimed to investigate the clinical features of congenital postural deformities and lower extremity asymmetry with respect to the presence of developmental dysplasia of the hip (DDH) in infants with a discrepancy of the limb length referred for suspected DDH. MATERIALS AND METHODS: We retrospectively reviewed the medical records and radiographs of 150 infants who visited Korea University Anam Hospital Orthopedic Clinic for suspected DDH between March 2013 and March 2015. RESULTS: There were greater numbers of infants with a shorter lower extremity on the left side (n=86, 57.3%) than the right. Plagiocephaly was present in 62 infants and trunk curvature in 124 infants (82.7%). Pelvic tilting—indirectly assessed by a skewed direction of the external genitalia in female infants—was present in 62 infants (63.3%). None of the 139 infants with normal physical examination of the hip were diagnosed with DDH. Of those 11 infants with abnormal findings from the hip physical examination, a total of 6 infants were diagnosed with DDH. CONCLUSION: Regardless of the associated findings of congenital postural deformation, all infants diagnosed with DDH had abnormal findings from the physical examination of the hip joint. Thus, we conclude that the hip examination is important as the primary clinical screening in aiding the diagnosis of DDH.

Obliquity of the Stapes in Otosclerosis: A New Radiological Sign

Abstract Introduction Observing the obliquity of stapes by closely scrutinizing the HRCT temporal bone in otosclerosis revealed a reliable and consistent finding. This finding can add to the existing radiological criteria in diagnosis of otosclerosis. Objective The objective of this study is to establish the obliquity of stapes in otosclerosis by radiological measurements using HRCT temporal bone by comparing: (a) the distance between the horizontal (tympanic) segment of facial nerve and stapes head in otosclerotic ears (study group) with non-otosclerotic ears (control group); and (b) the angle subtended by stapes with promontory in the study and control groups. Methods This is a prospective study performed after the institutional Ethics Committee clearance (IEC 3/2013). Results An increased mean distance between the horizontal segment of facial nerve and stapes head in otosclerotic patients (i.e., 2.49mm +/ 0.24mm SD), when compared with the non-otosclerotic patients (i.e., 1.46mm +/ 0.16mm SD) is noted. There is a change in angle (i.e., 64.550 +/ 7.190 SD) subtended by the stapes toward the promontory in otosclerotic ears when compared with that of controls (i.e., 99.700 +/ 40 SD). We applied the Mann-Whitney U non-parametric test and considered p value of < 0.0001 highly significant. Conclusions Obliquity of stapes in otosclerosis referred to as a "Pisa" sign by the senior author has diagnostic value as a new radiological sign in imaging of otosclerosis. This obliquity explains the torsional effect of otosclerosis on the ossicular chain. The findings correlate with late complications and failures in stapes surgery.

The Character of Reverse Obliquity Intertrochanteric Fractures in Elderly Patients

PURPOSE: To discriminate the characteristics between reverse obliquity fractures in the elderly and that of young adults using three-dimensional computed tomography (3D CT). MATERIALS AND METHODS: Eighteen patients who had reverse obliquity intertrochanteric fractures were enrolled from January 2007 to March 2012. The fracture pattern was analyzed using the 3D CT. The area showing low density (bone defect) of trochanter and femoral neck region was measured. Patients were divided into two groups: Group I, less than 65 years old and Group 2, 65 years and over. RESULTS: In all 9 cases of group 1, the proximal fragment had a 'V' shape with an average of 5.6 cm below the vastus ridge; however, the fracture of 8 cases (88.97%) in group 2 had a 'Lambda' shape of the distal fragment at the level of vastus ridge and an additional fracture line extending to the greater trochanter tip. The bone defect volume of the trochanter and femoral neck region was larger significantly in group 2 than in group 1. CONCLUSION: Reverse obliquity intertrochanteric fracture in the elderly demonstrated a pattern of bursting fracture with 4 parts, which had different patterns from that of young patients. We believe that the larger volume of bone defects resulted in the difference of fracture patterns between the two groups.

A Comparison of Intramedullary and Extramedullary Fixations for the Treatment of Reverse Oblique or Transverse Intertrochanteric Femoral Fractures / 대한고관절학회지

PURPOSE: This study was designed to compare the clinical and radiological results of intramedullary fixation to those of extramedullary fixation in patients with reverse oblique or transverse intertrochanteric femoral fractures. MATERIALS AND METHODS: We retrospectively reviewed 39 cases of reverse oblique or transverse intertrochanteric femoral fractures between September 2001 and December 2010. There were 20 cases treated with intramedullary fixation (Group I) and 19 cases treated with extramedullary fixation (Group II). The operative time, intraoperative blood loss, amount of blood transfused, hospital day, and time to bone union were compared between the two groups. Radiologically, the position and sliding length of the lag screw or blade, change of femoral neck-shaft angle, and medialization of distal fragment were compared. Also, complications were assessed. RESULTS: The mean operative time was 87.8 minutes with Group I and 153.8 minutes with Group II. The mean intraoperative blood loss was 375.0 ml with Group I and 1,015.8 ml with Group II. The mean amount of transfusion was 555.5 ml with Group I and 801.6 ml with Group II. The mean time to bone union was 12.1 weeks with Group I and 18.1 weeks with Group II. There were no statistical differences in other parameters between the two groups. CONCLUSION: The intramedullary fixation group revealed better results in the aspects of invasiveness and time to bone union in comparison with the extramedullary fixation group for the treatment of reverse oblique or transverse intertrochanteric femoral fractures.

Attenuation of Spinal Curvature and Pelvic Obliquity by Body Shape Molded Inner System in Cerebral Palsy with Non-Fixed Scoliosis

OBJECTIVE: To investigate the effect of the body shape molded inner system on attenuation of spinal curvature and pelvic obliquity in cerebral palsy (CP) with scoliosis. METHOD: Fifteen patients with CP who had fixed or non-fixed scoliosis were recruited. By radiographic studies, Cobb's angle and pelvic obliquity were measured with or without sitting in the body shape molded inner system. RESULTS: Spinal curvature assessed by Cobb's angle was significantly reduced when CP patients were seated in the body shape molded inner system rather than in conventional seats. Although pelvic obliquity was not improved in patients with fixed scoliosis, it was significantly ameliorated in patients with non-fixed scoliosis when seated in the body shape molded inner system. CONCLUSION: The body shape molded inner system attenuated spinal curvature and pelvic obliquity in CP patients with non-fixed scoliosis which had a flexible spinal curve.

Semi-Automatic Measurement of the Airway Dimension by Computed Tomography Using the Full-With-Half-Maximum Method: a Study of the Measurement Accuracy according to the Orientation of an Artificial Airway

OBJECTIVE: To develop an algorithm to measure the dimensions of an airway oriented obliquely on a volumetric CT, as well as assess the effect of the imaging parameters on the correct measurement of the airway dimension. MATERIALS AND METHODS: An airway phantom with 11 poly-acryl tubes of various lumen diameters and wall thicknesses was scanned using a 16-MDCT (multidetector CT) at various tilt angles (0, 30, 45, and 60degree). The CT images were reconstructed at various reconstruction kernels and thicknesses. The axis of each airway was determined using the 3D thinning algorithm, with images perpendicular to the axis being reconstructed. The luminal radius and wall thickness was measured by the full-width-half-maximum method. The influence of the CT parameters (the size of the airways, obliquity on the radius and wall thickness) was assessed by comparing the actual dimension of each tube with the estimated values. RESULTS: The 3D thinning algorithm correctly determined the axis of the oblique airway in all tubes (mean error: 0.91 +/- 0.82degree). A sharper reconstruction kernel, thicker image thickness and larger tilt angle of the airway axis resulted in a significant decrease of the measured wall thickness and an increase of the measured luminal radius. Use of a standard kernel and a 0.75-mm slice thickness resulted in the most accurate measurement of airway dimension, which was independent of obliquity. CONCLUSION: The airway obliquity and imaging parameters have a strong influence on the accuracy of the airway wall measurement. For the accurate measurement of airway thickness, the CT images should be reconstructed with a standard kernel and a 0.75 mm slice thickness.

The Effect of Shoe Lift on Lumbar Scoliosis Associated with Pelvic Obliquity / 대한척추외과학회지

STUDY DESIGN: A retrospective study designed to evaluate the effect of a shoe lift on the lumbar scoliosis associated with pelvic obliquity. OBJECTIVES: To analyze the changes in pelvic height, Cobb angle and clinical manifestations after application of a shoe lift. SUMMARY OF LITERATURE REVIEW: The most common form of scoliosis in adolescence is idiopathic (85% of scoliosis), which is a form of structural scoliosis. Some non-structural scoliosis may be assessed as an idiopathic form, which can result in an unnecessary treatment, such as bracing. Pelvic obliquity may be a cause of non-structural scoliosis, and a shoe lift may be used for its correction. MATERIALS AND METHODS: Twelve cases of lumbar scoliosis associated with pelvic obliquity, between April, 1998 and October, 2002, were investigated for the changes in the pelvic height and Cobb angle. Standing T-L AP and standing pelvic AP for measuring the Cobb angle and pelvic obliquity, respectively, were checked before and after application of a shoe lift. The Bell-Thompson method was used for measuring the limb length discrepancy. The shoe lift was composed of a compact cork pad and soft sponge tissue. The extent of a shoe lift was determined with the use of the most comfortable wood block height on stand-ing still. The radiological and clinical outcomes of the shoe lift were investigated. RESULTS: After the introduction of the shoe lift, 9 cases (75%) achieved a leveled pelvis (height difference less than 0.3cm) 1 week post-shoe lift. The mean Cobb angle before treatment was 16degrees ranging from 9 to 26degrees which was reduced to 6.7degrees ranging from 0 to 23degrees due to the shoe lift 1 week post-shoe lift. The mean correction of the Cobb angle after the introduction of a shoe lift was 73.9%. Clinically, 2 cases with low back pain achieved an improvement in the pain, and most patients expressed that walk-ing and standing had become more comfortable. CONCLUSION: A shoe lift seems to be significantly effective in correcting the Cobb angle and pelvic height in lumbar scoliosis associated with pelvic obliquity.

Classification and Management of Fixed Paralytic Pelvic Obliquity / 대한정형외과학회잡지

In order to group the pelvic obliquity into clinically useful classification and to develop appropriate guidelines for treatment, we evaluated 55 patients who had been treated between 1985 and 1993 for pelvic obliquity after poliomyelitis. Age at surgery ranged from 15 years to 49 years (average 27 years). Fixed pelvic obliquity after poliomyelitis was classified into two major types according to the level of the pelvis relative to the short limb and into four subtypes in each type according to the direction and severity of scoliosis. Forty-six patients had obliquity with the pelvis down (type I), and nine patients had the pelvis up (type II) on the short limb side. Subtype A: straight spine with localized lower lumbar compensatory angulation, mainly at the L4-5 intervertebral space. Subtype B: mild scoliosis with convexity to the short limb side, Subtype C: mild scoliosis with convexity opposite to the short limb side. Subtype D: moderate to severe paralytic scoliosis, which has a convexity to the short limb side in type I and opposite to the short limb side in type II. In the pelvis of type I-A, I-B and I-C deformities, abduction contracture of the hip was released on the side of affected short limb, and lumbodorsal fasciotomy was performed on the contralateral side of short limb, where iliolumbar angle converged and the pelvis was elevated, if necessary. In most cases, hip instability existed on the side of short limb and it was treated with triple innominate osteotomy, which also contributed to leg length equalization by lengthening. In type II-A, II-B and II-C deformities, it was necessary to perform a triple innominate osteotomy on the side of affected short limb with adducted unstable hip in most cases. Lumbodorsal fasciotomy was performed above the iliac crest of elevated hemi-pelvis with short limb, where iliolumbar angle converged. In case of abduction contracture of contralateral hip, contracted fascia was released. In the pelvis that had a type I-D or type II-D deformities, treatment might include bony surgeries such as spinal fusion or triple innominate osteotomy, with appropriate soft tissue release. We propose a systemic and comprehensive classification for fixed pelvic obliquity after poliomyelitis. According to this classification, we and decide to combine corrective surgeries, and find the side where the surgery should be performed.

Leg Length Equalization by Correction of Pelvic Obliquity and Acetabular Dysplasia / 대한정형외과학회잡지

Fixed pelvic obliquity refers to a composite deformity induced by contractures both above and below the pelvis and the elements of this deformity are frequently interrelated during the period of growth. From the functional standpoint, leg length discrepancy is caused by deformities of the pelvis and lower extremities, such as pelvic obliquity and acetabular dysplasia, as well as by inequality of true limb bone length, and these deformities either aggravate or compensate functional discrepancy. During fhe fourteen years period, from August 1968 to August 1982, at the Department of Orthopaedic Surgery, Seoul National University Hospital, we treated 35 cases of fixed pelvic obliquity and acetabular dysplasia associated with true or functional limb length discrepancy by means of lumbodorsal fasciotomy or pelvic osteotomies such as Salters innominate osteotomy or Steels triple osteotomy, combined, if necessary, with contralateral abductor fasciotomy to gain functional limb length as well as to improve posture and balance. In many cases of residual poliomyelitis, epiphysiodesis was also performed when indicated. These cases were reviewed and following observations were made: 1. Of the 35 cases, residual poliomyelitis with 29 cases (83%) was by far the main cause of leg length discrepancy. Cerebral palsy (2cases), Legg-Perthes disease (2 cases), and fibrous ankylosis secondary to septic hip (2 cases) comprised the remainder. 2. The male-to-female ratio was about equal, being 17 to 18. 3. The average age at the time of operation was 17.9 years, the youngest being 7 years and the oldest being 30 years. The average age at the time of current follow-up was 18.8 years. 67% of those followed was skeletally mature. 4. An average of 1.35cm of bone length was gained radiographically by pelvic osteotomies. Steels triple osteotomy was more effective in gain than Salters innominate osteotomy. 5. An average of 2.43cm of functional length when standing was gained radiographically by lumbodorsal fasciotomy alone. 6. An average of 2.61cm of functional length when standing was gained radiographically by lumbodorsal fasciotomy and combined contralateral Soutters or Campbells fasciotomy. 7. An average of 3.57cm of functional length when standing was gained radiographically by lumbodorsal fasciotomy and combined ipsilateral Steel's triple osteotomy. 8. An average of 1.73cm of functional lengthening when standing was corrected radiographically by ipsilateral Soutter's fasciotomy. 9. When lumbodorsal fasciotomy and Steel's triple osteotomy were combined with contralateral Soutter's or Campbell's fasciotomy, the average radiographic gain in standing length was 3.77cm. 10. Leg length discrepancy in terms of true bone length is conventionally corrected either by epiphysiodesis or bone shortening on the longer limb, or by bone lengthening on the shorter limb. We believe that when leg length discrepancy is associated with fixed pelvic obliquity, frequently aggravating the disability functionally, lumbodorsal fasciotomy and/or pelvic osteotomies on the shorter side and, combined if necessary, Soutters or Campbells fasciotomy on the longer side, can, in many instances, successfully correct or reduce functional limb discrepancy and improve balance, posture and function. Any residual discrepancy, true or functional, may then be corrected by conventional methods.

Surgical Treatment of the Paralytic Scoliosis / 대한정형외과학회잡지

Paralytic scoliosis is a disease characterized by its long severe curve and the continuous progression of the deformity even after cessation of growth. It is also resistent to conservative treatment and more patients require surgical treatment than those with idiopathic or congenital curvature. Patients suffer from marked limitation of normal activities in walking and sitting due to imbalanced paralysis of trunk muscles and pelvic obliquity. The indication for the conservative treatment with Milwaukee brace allowing for skeletal growth in a straight alignment is much limited and surgical correction and fusion are almost always indicated even in a young age. This paper was aimed to review our experience with ninteen patients with paralytic scoliosis who were treated with various methods of preoperative corrections and surgery from Jan. 1970 to Dec. 1981 and the following results were obtained. 1. The average age when scoliosis was observed was 7.7 years but the average age of surgery was deferred to 17.7 years. 2. No treatment had been done until most of the patients could no longer maintain balanced posture in sitting and walking due to collapsing spine and marked pelvic obliquity. 3. The causes of paralysis were poliomyelitis in 15 cases, meningocele in two, cerebral palsy and Charcots disease in each one. 4. Preoperative average degree of scoliosis was 107.8° and the final correction was 47.9°(44.4%) with loss of correction 3.6° (3.4%) after 5.6 years of follow-up in average. 5. The more severe the curve was, the more flail was the spine and the more correction could be obtained. 6. Preoperative correction was performed for 16 cases and Harrington instrumentation and posterior fusion were performed for all cases except one meningocele with defect of posterior element in which Dwyer instrumentation was indicated. 7. Breakage of Harrington rod was observed in two cases 1.3 and 3.8 years postoperatively but no problem arose from it in seven and two years of follow-up respectively. 8. Significant pelvic obliquity was observed in seven cases, which were treated by Harrington instrumentation with sacral bar or sacral hook and posterior fusion extended to sacrum.