Mitigating calcar fracture risk with automated impaction during total hip arthroplasty.

Background: Automated broaching has recently been introduced for total hip arthroplasty (THA), with the goal of improving surgical efficiency and reducing surgeon workload. While studies have suggested that this technique may improve femoral sizing and alignment, little has been published regarding its safety, particularly with regard to calcar fractures. The purpose of our study was to evaluate the risk of calcar fracture during automated broaching, and to determine if this risk can be mitigated. Methods: We queried our prospective institutional database and identified 1596 unilateral THAs performed by the senior author using automated impaction between 2019 and 2023. We identified the incidence of calcar fracture with automated impaction, and whether the fracture occurred during broaching or stem insertion. We additionally determined calcar fracture incidence within two consecutive subgroups of patients using different stem insertion techniques; subgroup (1): automated broaching with automated stem insertion for all patients; versus subgroup (2): automated broaching with automated stem insertion ONLY if a cushion of cancellous bone separated the broach from the calcar, otherwise the stem was placed manually. Continuous and categorical variables were analyzed with Student's t-test and Fisher's exact test, respectively. Results: Seventeen calcar fractures occurred intraoperatively (1.1 %). Only two fractures occurred during automated broaching (0.1 %), while fifteen occurred during final stem impaction (0.9 %) (p = 0.007). Four calcar fractures (1.4 %) occurred in subgroup 1, compared to two in subgroup 2 (0.6 %) (p = 0.28). Conclusions: Our study found a calcar fracture incidence of 1.1 % using automated impaction, consistent with historically reported rates of 0.4-3.7 %. We found that calcar fractures are more likely to occur during stem insertion than during femoral broaching. We recommend that if any part of the final broach is in direct contact with the calcar, the final stem should be impacted manually to minimize fracture risk.

Small bowel obstruction on food impaction after binge eating.

Small bowel obstruction is a relatively prevalent surgical condition, with the most common underlying cause being postoperative adhesions. However, in patients with no previous history of abdominal surgery, one needs to think more outside the box. In this case study, we have a young and athletic man who presented to the emergency department with an acute abdomen, shortly after binge eating a large amount of food. Obstruction due to food impaction, such as in our case, should always be on the differential list, especially in those without significant medical history and with binge eating pattern where uncontrolled and extreme amounts of food are eaten alternating with restrictive dieting.

Midcarpal Impaction Syndromes as a Rare Cause of Ulnar-Sided Wrist Pain: A Review.

Ulnar-sided wrist pain remains a commonly encountered diagnostic challenge, and its successful management requires a comprehensive understanding of the multiple conditions that can present with this symptom. Midcarpal impaction syndromes in the form of Hamato-lunate and Triquetro-hamate impingement have both previously been reported as rare potential causes of ulnar-sided wrist pain. Despite this, they remain poorly recognized and incompletely understood. This article reviews existing literature that describes the diagnosis and management of these clinical entities.

Evaluation of Efficacy of Aqua Titan Patch in Postoperative Sequelae After Lower Third Molar Surgery: A Prospective Study.

Objective: To evaluate the efficacy of aqua titan patch in postoperative sequelae after mandibular third molar surgery. Material and Methods: A total of 20 patients were selected and divided into two groups, Group A was evaluated by using Aqua titan patch with oral antibiotics and anti-inflammatory analgesics while Group B was only provided with antibiotics and anti-inflammatory analgesics. Results: There were total 20 subjects, with 4 males and 16 females. Pain was evaluated after surgical removal, where significant reduction was observed on 5 and 7th postoperative day in study group with p value 0.004 and 0.013, respectively. Reduction in swelling was observed to be statistically highly significant (p values = 0.000) in study group on 5 and 7th postoperative days. Beneficial results were obtained in study group where mouth opening was statistically significant with p value 0.002 on 5th and 0.049 on 7th postoperative day. For postoperative neurosensory deficit, mean values were constant and difference was found to be statistically insignificant with p value 0.13. Conclusion: Postoperative local application of aqua titan patch in study group provided beneficial effects in terms of reduction in pain, swelling and maximum mouth opening as compared to the control group.

Neglected Ipsilateral Non-Union Neck of Femur with Shaft of Femur Non-Union in A Young Patient and Its Management - A Rare Case Report.

Introduction: The incidence of ipsilateral neck of femur fracture with the shaft of femur going for non-union is not known. Management of this concomitant non-union can be a daunting task in terms of fixation strategy and its outcome. Case Report: In this article, we report a case of a 25-year-old male with ipsilateral neck of femur with shaft non-union. We have done open reduction and dual plating with bone grafting for the shaft of the femur followed by valgus subtrochanteric osteotomy with dynamic hip screw and impaction bone grafting for the neck of femur non-union. Conclusion: The main principle in treating the neck of femur non-union is biomechanical correction of shear forces into compression forces by valgus correction and impaction bone grafting aids fracture healing. Dual plating with bone grafting gives optimal results in shaft non-union.

Prevalence of femoral condyle injuries in the setting of tibial plateau fractures.

BACKGROUND: Tibial plateau fracture patterns are influenced by the direction and energy of the impact, and the bone quality. Associated articular femoral injuries can result from the same impact but are insufficiently studied. This study quantifies the prevalence of three distinct articular femoral condyle injuries: (1) impaction fractures, (2) contusions, and (3) condyle fractures. For impaction fractures we assessed the depth, width, length, and surface area. METHODS: We retrospectively reviewed patients who had undergone surgery for a tibial plateau fracture in a tertiary trauma center. Two fellowship-trained radiologists analyzed preoperative CT scans for associated femoral condyle injuries. We defined (1) impaction fractures (depressions ≥ 1.5 mm) with a sclerotic band, a fracture line, or both; (2) contusions (depressions < 1.5 mm) with a sclerotic band; and (3) condyle fractures as sub- or osteochondral fractures. RESULTS: We identified 149 patients (62 male) with a tibial plateau fracture with a CT scan available. The overall prevalence of articular femoral condyle injuries was 26% (n = 39). The prevalence of impaction fractures was 9.4% (n = 14), of contusions 14% (n = 21), and of condylar fractures 3.0% (n = 4). Factors associated with a higher prevalence of femoral condyle injury were younger age (p = 0.029), male sex (p = 0.014), and absence of comorbidity (p = 0.005). The mean depth of impaction fractures was 2.3 mm (SD: 0.78; range 1.6 to 4). CONCLUSION: Concomitant articular femoral condyle injuries occur in one out of four patients with a tibial plateau fracture. Although most femoral injuries were subtle, and none underwent surgical treatment, they might harbor information regarding the likelihood of future joint degeneration and knee instability. LEVEL OF EVIDENCE: IV.

Palatal canine impaction is associated with craniofacial shape in humans.

BACKGROUND/OBJECTIVES: It is unclear whether palatal canine impaction is related to genetic or local/environmental factors. If a genetic origin is assumed, then it could be expected that palatal canine impaction is associated with overall craniofacial development. Within this context, the aim of this study was to evaluate the craniofacial morphology of individuals with palatal canine impaction and compare it to a matched group of normal controls. MATERIALS/METHODS: The sample for this investigation comprised 404 individuals (232 females and 172 males). Half of these individuals presented with unilateral or bilateral palatal canine impaction confirmed clinically and radiographically. The other half were matched for sex and age with the first half and comprised individuals without tooth impaction, apart from third molars. The shape of the craniofacial structures was outlined on calibrated cephalometric images through 15 curves and 127 landmarks (11 fixed and 116 semi-landmarks). Shape configurations were superimposed using Procrustes Superimposition and the resulting shape coordinates were reduced into principal components for all subsequent analyses. The effect of palatal canine impaction on craniofacial shape was assessed with regression models, separately in females and males. All statistical tests were performed assuming a type-1 error of 5%. RESULTS: Individuals with palatally impacted canines appear to have a less convex face, a more brachyfacial skeletal pattern, and a sagittally extended premaxilla. In females effect sizes ranged between η2 = 0.136-0.397 (P < 0.05) and in males between η2 = 0.125-0.396 (P < 0.05, apart from the entire craniofacial configuration: P = 0.259). LIMITATIONS: Palatal canine impaction was not confirmed through cone beam computer tomography images in all patients, however, in those cases, the treatment history confirmed the diagnosis. CONCLUSIONS/IMPLICATIONS: Palatal canine impaction is related to a distinct craniofacial shape in females and males. These findings allow for speculation that palatal canine impaction is affected by genetic pathways involved in overall craniofacial development.

Microarchitectural properties of compacted cancellous bone allografts: A morphology micro-computed tomography analysis.

Massive bone loss poses a significant challenge in defect reconstruction. The use of compacted allografts is a valuable technique to reconstruct bone stock. This study aimed to assess the impact of compression on the microstructure of native cancellous bone chips with a micro-CT analysis. Bone samples were harvested from 15 femoral heads donated by patients who underwent total hip arthroplasty. Bone chips were prepared using a bone mill. All samples with the same weight were compressed by 25% and 50% of their original volume and subsequently scanned with a micro-CT scanner to determine the microarchitectural morphology of the bone chips. Uniaxial compression test was carried out before and after a standardized compaction procedure. Comparing the samples without compaction to 50%, the number of trabeculae doubled, the volume ratio doubled, and the trabeculae spacing was reduced, showing voids of 800 µm on average. The number of interlocking possibilities tripled, while no differences were seen in the trabeculae morphology. Uniaxial compression test showed a yield limit after compaction of 0.125 MPa. Interlocking might occur three times more with a denser material than in a non-compacted sample. The increase in density comparable to manual intraoperative compaction did not lead to significant fragmentation of the allograft material. The assessed microarchitecture should, therefore, reassemble the intraoperative situation during a manual bone impaction procedure.

Lateral femoral impaction fractures during an ACL tear extend posteriorly on the weight-bearing area of the tibiofemoral joint.

PURPOSE: Posterior elongation of the physiological terminal sulcus (TS) due to lateral femoral condyle impaction fracture (LFC-IF) after an anterior cruciate ligament (ACL) tear could potentially decrease the weight-bearing area of the tibiofemoral joint, decrease the tension on lateral meniscus and cause flattening of the LFC which would influence rotational knee motion and cause anisometry of the lateral and anterolateral stabilizers. Therefore, the purpose of the study was to assess if the LFC-IF elongates the physiological TS posteriorly. METHODS: One hundred patients magnetic resonance images (MRIs) (75 males, 25 females, mean age 32.2 years, SD = 8.2) were included with a 1:1 ratio between the full-thickness ACL tear group and the control group (patients with knee MRI performed due to other reasons, with no tear of ACL on MRI and negative clinical tests). Two independent raters evaluated the sagittal T1-weighted preselected MRI scans. The principal measurement of interest was the distance from the intersection of the Blumensaat line with subchondral bone to the posterior border of the TS/LFC-IF. RESULTS: The median distance from the Blumensaat line to the posterior border of the TS/LFC-IF was significantly higher in the ACL tear group: 14.3 mm, interquartile range (IQR) = 11.6-16.4 mm versus control group: 12.8 mm, IQR = 9.0-15.0 mm, p = 0.038. Intrarater and inter-rater reliabilities were >0.90. CONCLUSION: LFC-IF after full-thickness ACL tear significantly elongates the physiological TS in the posterior direction. LEVEL OF EVIDENCE: Level III.

Three-dimensional assessment of the skeletal characteristics accompanying unilateral maxillary canine impaction: a retrospective cone-beam computed tomography study.

BACKGROUND: Environmental and genetic factors associated with canine impaction have been extensively researched, whereas the bone characteristics in the impaction area have not been thoroughly studied. Accordingly, the objective of this investigation was to provide a skeletal assessment in terms of bone density, bone microstructure, bone volume, and palatal volume in subjects with unilaterally impacted maxillary canines. METHODS: A retrospective design has been employed to address the aim of this study, where the initial pre-treatment cone-beam computed tomography (CBCT) scans of 30 patients with unilateral maxillary canine impaction were assessed. The obtained patients' data were equally divided according to the location of the impaction into 2 groups, one with buccally impacted canines, and another with palatal impactions, with the contra-lateral sides in both groups serving as the controls. Skeletal measurements such as bone density (BD), bone microstructure in terms of fractal dimension (FD), maxillary bone volume (MBV), and palatal volume (PV) were evaluated from the acquired CBCTs in both groups and compared to the controls. RESULTS: With buccal impactions, significantly greater BD and FD have been reported (p < 0.001), whereas non-significant differences were found regarding the PV when compared with controls (p = 0.56). MBV was significantly greater on the non-impaction side in comparison with buccal impaction sides (p < 0.001). For palatal impactions: BD, FD, and MBV were significantly greater on the impaction sides (p < 0.001), and conversely with PV which has been reported to be significantly greater on the non-impaction sides (p < 0.001). CONCLUSIONS: As per the obtained results, buccally impacted canines are associated with greater BD and FD, and less MBV, whereas palatally impacted canines are accompanied with greater BD, FD, and MBV, in addition to less PV, when both conditions are compared with the non-impaction sides.

Comprehensive Management of Mandibular Canine Transmigration: A Multidisciplinary Approach.

Transmigration of mandibular canine teeth is a rare dental anomaly characterized by the tooth's aberrant migration through the alveolar bone. This deviation from the expected eruption pathway can lead to tooth impaction, root resorption, periodontal problems, and aesthetic concerns. The exact cause of transmigration is not fully understood, but it is believed to be influenced by a combination of genetic, developmental, and environmental factors. Early diagnosis and appropriate treatment are essential to prevent complications and achieve optimal functional and aesthetic outcomes. This case report presents a 19-year-old female with impacted left mandibular canine teeth. An interdisciplinary approach involving orthodontic therapy and surgical exposure to disimpact the transmigrated canine into the normal occlusal position. The treatment utilized modified orthodontic mechanics, including uprighting springs and temporary anchorage devices (TADs) to treat transmigration. This case also highlights the importance of early diagnosis and timely intervention for transmigrated canine teeth to prevent complications and achieve optimal aesthetic and functional outcomes.

Mandibular second molar impaction: introducing a novel and validated 3D classification system.

BACKGROUND: Mandibular second molar (M2M) impaction is a clinically significant manifestation of eruption disturbance in dental development. The primary aim of this study was to investigate the impact of the three-dimensional (3D) characterization on clinical and therapeutic decisions for M2M impaction. The secondary aim was to introduce a validated 3D classification system incorporating both surgical and orthodontic parameters. METHODS: Bidimensional (2D) and 3D radiological records of 15 impacted M2M were collected and deidentified. Ten experienced clinicians (5 oral surgeons;5 orthodontists) categorized each case, first based on 2D records and then with 3D scans. The degree of orthodontic and surgical difficulty in treating impacted M2M was evaluated using a novel classification system based on anatomical and radiological features. The primary outcome variable was the assessment of differences in diagnosis and decision-making protocol using 2D or 3D records, where clinical relevance ranged from 0 to 4. The secondary outcome variable was the validation analysis of the proposed 3D classification system to determine the concordance among the clinicians. Descriptive statistics and multivariable inferential analysis based on Akaike information criterion (AIC) were performed (α = 0.05). RESULTS: 3D examination allowed a better visualization of M2M impaction with higher clinical relevance for diagnosis of M2M root relationship to alveolar nerve and lingual plate, height to alveolar crest, depth, and inclination relative to the first molar and position relative to the third molar (range:2.69-3.43). The proposed 3D classification of M2M impaction changed clinical decisions regarding surgical-orthodontic approach, biomechanics, patient education, and treatment time estimate (range:2.59-3.33). In the validation analysis of the classification, no evidence of inter- or intra-group (surgeon/orthodontist) bias in score attribution occurred: the model with the minimum AIC was the null model (AIC = 718.04). CONCLUSION: 3D evaluation of impacted M2Ms could enhance diagnostic accuracy, and a classification system was proposed and validated by a group of experienced surgeons and orthodontists with high concordance.

The influence of arch shape on the incidence of third molar impaction: A cross-sectional study.

Introduction: Impaction of third molar is a pathological problem that reduces the chance of normal eruption of tooth. The main reason for impaction is inadequate space in the maxillary and mandibular arch. The aim of this study is to investigate the relationship between arch shape and the prevalence of third molar impaction. Methods: This cross­sectional study was performed on patients referring to the Department of Oral and Maxillofacial Surgery between December 2023 and February 2024 to obtain an orthopantomogram (OPG). Convenience sampling was employed, and orthopantomograms were analyzed to determine impaction types. Dental arch shape variables were assessed using Budiman's analysis, with a Chi-square test employed to evaluate any significant association between arch shape and impaction type at a significance level of 0.05. Results: Among the 185 maxilla and 185 mandibles studied, 154 were male patients, and 216 were female patients, with a mean age of 26.75 years. A statistically significant difference was found in impacted teeth, among females having more impacted molars than males (p-value = 0.002*). However, no significant differences were found in the type of impaction, Gregory classification, or position based on the shape of the mandible on both the right and left sides (p-value > 0.05). Similarly, no significant differences were observed in Gregory's classification based on the shape of the maxilla on both the right and left sides. However, there is a statistically significant difference in the occurrence impaction based on the maxilla's shape (p-value < 0.05). Conclusion: The study suggests a significant correlation between maxillary arch shape and the occurrence of third molar impaction, with a higher prevalence among females.

Surgical-orthodontic approach of two palatally impacted canines with maxillary lateral incisor anomalies in a growing class II patient: A case report.

INTRODUCTION: After the mandibular third molars, the maxillary canines are the most displaced or impacted teeth in permanent dentition. Surgical-orthodontic disimpaction of impacted canines, followed by aesthetic reconstructions, can be a successful treatment choice. AIM: The aim of this case report was to describe the smile restoration through simultaneous surgical disimpaction of the two upper permanent canines in a 13-year-old patient who also presented with agenesis of the right upper lateral incisor and a conoid-shaped left upper lateral incisor. TREATMENT PROTOCOL: The present case report followed the Care Checklist For Case Reports. After having completed the multibrackets fixed orthodontic therapy phase necessary for the preparation of the anchorage, avulsions of the upper deciduous canines were carried out, followed by the making of surgical full thickness palatal flap in order to perform traction of the permanent canines, and an orthodontic eyelet with passive metal looped ligatures was applied. One week after the surgery, traction was started with Crescini-double arch technique. Subsequently, the avulsion of elements 2.2 and 5.2 were executed. At the end of orthodontic treatment, in order to optimise the aesthetics and function of the canines, a restorative treatment was carried out. RESULTS AND CONCLUSIONS: After the surgical creation of a palatal flap, the disimpaction of the two upper canines, using the double arch technique, allowed the teeth to be moved into the desired position on the upper arch.

Dorsal Preservation Rhinoplasty.

Controversies in Preservation Rhinoplasty" explores the nuanced indications, techniques, and challenges in preservation rhinoplasty (PR), featuring contributions from JC Neves, D Toriumi, and A Göksel. Neves recounts his early career under Wilson Dewes and describes the evolution of PR techniques. Toriumi, having started PR in 2019, discusses his initial cautious approach and subsequent expansion to include patients with more diverse nasal deformities. Göksel highlights the critical role of surgical expertise and individualized patient assessment, advocating for methods like dorsum-plasty osteotomies and the Ballerina maneuver to enhance PR's effectiveness.

Orthodontic traction of a deeply impacted mandibular first molar via a ramus miniscrew through lateral-window technique: A case report.

BACKGROUND: The incidence of mandibular first molar impaction is less than 0.01%, and there are no standard treatment guidelines. Orthodontic traction can be chosen as a treatment plan in some circumstances. One miniscrew in the mandibular ramus can offer sufficient anchorage for the traction of impacted mandibular molars. CASE DESCRIPTION: A 10-year-old boy had a completely labially positioned maxillary left canine and a deeply impacted mandibular left first molar associated with a dentigerous cyst. Using 2 palatal miniscrews for distalization, space was created to align the maxillary left canine. In addition, a miniscrew in the mandibular ramus facilitated the traction of the mandibular left first molar. After 3 years and 6 months of orthodontic treatment, the integrity of the dental arch was restored, and occlusal function was reestablished. PRACTICAL IMPLICATIONS: A ramus miniscrew is an effective and viable treatment option for the orthodontic traction of deeply impacted mandibular molars.

Three-dimensional computed tomography evaluation of the ulnocarpal joint under stress loading.

LEVEL OF EVIDENCE: IV.

Impacted fetal head at cesarean delivery.

PURPOSE: Impacted fetal head (IFH) can be defined as the deep engagement of the fetal head in the maternal pelvis at the time of cesarean delivery that leads to its difficult or impossible extraction with standard surgical maneuvers. In this narrative review, we aimed to ascertain its incidence, risk factors, management and complications from the perspective of the anesthesiologist as a multidisciplinary team member. METHODS: Databases were searched from inception to 24 January 2023 for keywords and subject headings associated with IFH and cesarean delivery. RESULTS: IFH has an incidence of 2.9-71.8 % in emergency cesarean section. Maternal risk factors are advanced cervical dilatation, second stage of labor and oxytocin augmentation. Anesthetic and obstetric risk factors include epidural analgesia and trial of instrumental delivery and junior obstetrician, respectively. Neonatal risk factors are fetal malposition, caput and molding. Current evidence indicates a lack of confidence in the management of IFH across the multidisciplinary team. Simple interventions in IFH include lowering the height or placing the operating table in the Trendelenburg position, providing a step for the obstetrician and administering pharmacological tocolysis. Maternal complications are postpartum hemorrhage and bladder injury while neonatal complications include hypoxic brain injury, skull fracture and death. Surgical complications are reviewed to remind the anesthesiologist to anticipate and prepare for potential problems and manage complications in a timely manner. CONCLUSION: The anesthesiologist has a fundamental role in the facilitation of delivery in IFH. We have proposed an evidence based management algorithm which may be referred to in this emergency situation.

Long-term outcomes of acetabular impaction grafting with cemented cups and trabecular metal for revision hip arthroplasty: a follow-up study.

INTRODUCTION: Revision hip arthroplasty in the presence of complex acetabular deficiencies is challenging. Cement, allograft, reconstruction rings and porous trabecular metal now provide versatile options for acetabular fixation and restoration of acetabular offset. We compare acetabular impaction bone grafting (AIBG) and trabecular metal (TM) cups at long-term follow-up. METHODS: 53 patients who underwent revision hip arthroplasty were retrospectively reviewed from local joint registry data. 36 patients were revised using AIBG and 17 with TM. Median clinical follow-up was 9.57 (2.46-18.72) years and 9.65 (7.22-12.46) years, respectively. 82% of the TM group and 63% of the AIBG group were ⩾ Paprosky 2C. Re-revision was considered failure. Radiographs demonstrating 5 mm of femoral head migration and 5° of acetabular component inclination change were considered loose. RESULTS: Patients receiving AIBG were younger (68 vs. 74 years) with a longer interval from initial arthroplasty to revision (17 vs. 13 years). Revisions in both groups were indicated most commonly for failed cementing (AIBG 88.9% vs. TM 70.5%). No TM reconstructions underwent re-revision, with only 1 failing at 6.3 years, compared with 9 AIBG re-revisions. When revising for sepsis, 33% of AIBG revisions failed. CONCLUSIONS: AIBG demonstrated high failure rates at long-term follow-up when compared to TM constructs. We recommend the use of AIBG in small cavitary defects only. We strongly advise against its use in the setting of significant bony defects and for prosthetic joint infection.

Mandibular Odontogenic Tumors That Caused Delayed Eruption of the First Molar: A Case Report of Two Patients.

Delayed eruption of permanent teeth during the replacement period is relatively common in clinical practice; however, impaction of the mandibular first molar is rare. There are various causes of delayed eruption of permanent teeth such as odontogenic cysts and tumors. This article describes the management of two odontogenic tumors that caused the delayed eruption of the mandibular first molar. In Case 1, an eight-year-old boy was diagnosed with an unerupted right mandibular first and second molar that had an odontogenic tumor around them. Radiographic examination revealed well-defined unilocular radiolucency with impacted first and second molars and scattered radiographic opaque images at the right mandibular. The lesion was completely curettaged with extraction of the second molar, and the first molar was fenestrated. Pathological microscopic examination provided the diagnosis as an ameloblastic fibro-odontoma. In Case 2, an 11-year-old boy was diagnosed with an unerupted right mandibular first molar that had an odontogenic tumor around it. Radiographic examination revealed well-defined unilocular radiolucency with an impacted first molar and scattered radiographic opaque images at the right mandibular The lesion was completely curretaged, and the first molar was fenestrated. Pathological microscopic examination provided the diagnosis of odontoma. Among these two cases, the preserved first molar erupted at each regular position. We demonstrated that even if an odontogenic tumor is present along with an impacted molar, removal of the tumor can result in the eruption of the impacted tooth.