Efectividad del ultrasonido pulsado de baja intensidad en pacientes tras osteotomía: una revisión sistemática / Effectiveness of low-intensity pulsed ultrasound in patients after osteotomy: A systematic review

La utilización de la terapia de ultrasonidos pulsados de baja intensidad para la cicatrización ósea y el tratamiento de fracturas es considerada cada vez más como una alternativa terapéutica de coste económico moderado y con efectos adversos nulos o mínimos (p. ej. leve reacción al gel conductor).Con todo, existe cierta controversia con relación a su evidencia científica. La presente revisión busca arrojar algo de luz sobre esta controversia y cubrir un espacio de estudio no ocupado por trabajos previos ni actuales sobre la terapia mediante ultrasonidos. Es necesario conocer el impacto real del tratamiento con ultrasonidos pulsados de baja intensidad en pacientes sometidos a osteotomía, así como su aplicabilidad como protocolo poscirugía para mejorar los procesos de recuperación, rehabilitación y, con ello, disminuir los tiempos de incapacidad. (AU)

The use of low intensity pulsed ultrasound (LIPUS) therapy for bone healing and fracture treatment is increasingly considered as a therapeutic alternative with moderate economic cost and none or minimal adverse effects (e.g., low reaction to the conductive gel).However, there is some controversy regarding its scientific evidence. The present review seeks to shed some light on this controversy and to cover an area of study not occupied by previous or current work on ultrasound therapy. It is necessary to know the real impact of the treatment with low intensity pulsed ultrasound in patients with osteotomy, as well as its applicability as a post-surgery protocol to improve the recovery and rehabilitation processes and, at the end of the day, to reduce the time of disability. (AU)

Mitigation of gap formation resulting from saw blade in single-cut osteotomy.

Bone loss from the kerf of the sawblade may influence the final outcomes when employing three-dimensional-printed surgical guides. However, no studies have systematically addressed saw blade-induced bone loss. This study aims to quantify bone loss and propose a reduction guide to minimize the fracture gap. The postoperative gap tended to decrease as the amount of gap compensation increased. Osteotomy gaps can be attributed to the thickness of the saw blade, and the proposed methodology addresses this surgical error. Surgeons can proactively plan and design reduction guides with applied compensation using the method described in this study.

[Patient-specific cutting guides in corrective osteotomy near to the knee joint]. / Patientenspezifische Schnittblöcke bei kniegelenknahen Korrekturosteotomien.

OBJECTIVE: Patient-specific cutting guides (PSCG) are used in osteotomy near to the knee joint to simplify the operative technique, shorten the duration of surgery, reduce radiation exposure and to exactly realize the preoperative planning during surgery, especially when complex deformities are corrected simultaneously in multiple planes. INDICATIONS: The application of PSCG is in principle possible in all osteotomies near to the knee joint but is especially useful in multidimensional, complex osteotomy. CONTRAINDICATIONS: No specific contraindications. SURGICAL TECHNIQUE: After multidimensional 3D analysis and planning using a preoperative computed tomography (CT) protocol, a 3D-printed patient-specific cutting guide is produced. This PSCG is used during standard osteotomy near to the knee. Using this PSCG the guided sawcut and predrilling of the screw positions inside the bone for the screws of the planned angle stable osteotomy plate are performed. The amount of the deformity correction needed is "stored" in the PSCG and is converted to the bony geometry during placement of the screws in the predrilled holes through the plate after opening or closing the osteotomy. Apart from that, the surgical approach and technique are equivalent to the standard osteotomy types near to the knee. POSTOPERATIVE MANAGEMENT: The application of PSCG in osteotomy near to the knee does not change the postoperative management of the specific osteotomy. RESULTS: The use of patient-specific cutting guides leads to a higher accuracy in the implementation of the preoperative planning and the desired target axis is achieved with greater accuracy. Multidimensional complex corrections can also be exactly planned and implemented. In addition, the intraoperative radiation exposure for the operation team can possibly be reduced.

[Subtuberosity anterior closing wedge osteotomy to correct the increased posterior slope of the tibial plateau]. / Subtuberositäre anterior schließende Osteotomie zur Korrektur der erhöhten posterioren Reklination des Tibiaplateaus.

OBJECTIVE: Reduction of increased reclination of the tibial plateau (posterior slope) to improve the anterior stability of the knee joint. INDICATIONS: Increased posterior reclination of the tibial plateau greater than 12° in combination with recurrent instability after anterior cruciate ligament (ACL) reconstruction. CONTRAINDICATIONS: Hyperextension of more than 15° (relative). SURGICAL TECHNIQUE: Anterior skin incision approximately 8-10 cm above the tibial tuberosity. Insertion of two converging guidewires directly below the patellar tendon ending obliquely in the area of the posterior cruciate ligament (PCL) insertion. Control of the wire position with the image intensifier core. Oscillating saw osteotomy. Removal of the wedge and closure of the osteotomy. Osteosynthesis with interfragmentary screw and medial angle-stable plate. POSTOPERATIVE MANAGEMENT: Partial load with 10-20 kg for 2 weeks, then step by step increase in load. Mobility: free. RESULTS: To date we have operated on 36 patients with recurrent instability after ACL reconstruction (20 men, 16 women, average age 34.4 years) in the manner described in this article. In 25 cases, enlarged bone tunnels were filled with allogeneic bone at the same time. The posterior slope of the tibial plateau could be reduced from an average of 14.5° to 8.8°. In 28 cases another ACL reconstruction was performed after an interval of 4-12 months. The Lysholm score significantly increased from 76.3 points to 89.2 points.

Comparative analysis of gait: Similar coronal but different sagittal effects between closing-wedge and opening-wedge high tibial osteotomy.

BACKGROUND: High tibial osteotomy is an established surgical option for medial compartment osteoarthritis of the knee with varus alignment. It can be divided into open wedge and closing wedge by operative technique. Although they have fundamental differences, little is known about the biomechanical consequences of the two surgical methods. METHODS: Thirty-eight patients with medial compartment osteoarthritis who underwent high tibial osteotomy (19 open-wedge and 19 closing-wedge) were retrospectively reviewed. Clinical scores and radiological measurements were assessed until postoperative two years. Gait analysis was performed preoperatively and again at postoperative one year. FINDINGS: Varus alignment was corrected in both groups without a significant difference between them (p = 0.543). However, posterior tibial slope was higher, and the Blackburne-Peel ratio was lower in the open wedge osteotomy group after surgery (both p < 0.001). Reduction of dynamic knee varus and knee adduction moment were observed in both groups without significant differences. However, after surgery, average knee range of motion (63.3° vs 57.3°, p < 0.001) and the magnitude of knee flexion moment was significantly lower (p = 0.005) in the closing wedge group. There were no significant differences in the Kujala Anterior Knee Pain Scale and the occurrence of patellofemoral arthritis between the groups postoperatively. INTERPRETATION: After osteotomy, a smaller average knee range of motion in the sagittal plane and a higher knee flexion moment were observed in the open wedge osteotomy group, suggesting quadriceps muscle avoidance. However, no differences in clinical scores or the short-term occurrence of patellofemoral arthritis were noted between the two surgical techniques.

Comparison of double chevron-cut and biplanar distal femoral osteotomy techniques: A biomechanical study.

OBJECTIVE: This study aimed to compare the stability and mechanical properties of the double chevron-cut (DCC) and biplanar (BP) distal femoral osteotomy (DFO) techniques, along with analyzing their respective contact surface areas. METHODS: Biomechanical testing was performed using sawbone and 3D modeling techniques to assess axial and torsional stability, torsional stiffness, and maximum torque of both osteotomy configurations. Additionally, 3D models of the sawbone femur were created to calculate and compare the contact surface area of the DCC, BP, and conventional single-plane DFO techniques. RESULTS: Axial stiffness and maximum strength did not significantly differ between the two osteotomy techniques. However, in terms of torsional properties, the DCC technique exhibited superior torsional stiffness compared to the BP group (27 ± 7.7 Nm/° vs. 4.5 ± 1.5 Nm/°, p = 0.008). Although the difference in maximum torque did not reach statistical significance (63 ± 10.6 vs. 56 ± 12.1, p = 0.87), it is noteworthy that the DCC group sawbone model exhibited fracture in the shaft region instead of at the osteotomy site. Therefore, the actual maximum torque of the DCC construct may not be accurately reflected by the numerical values obtained in this study. The contact surface area analysis revealed that the BP configuration had the largest contact surface area, 111% larger than that of the single-plane configuration. but 60% of it relied on the less reliable axial cut. Conversely, the DCC osteotomy offered a 31% larger contact surface area than the single-plane configuration, with both surfaces being weight-bearing. CONCLUSION: The DCC osteotomy exhibited superior mechanical stability, showing improved rotational stiffness and maximum torque when compared to the BP osteotomy. Although the BP osteotomy resulted in a larger contact surface area than the DCC osteotomy, both were larger than the conventional single-plane configuration. In clinical practice, both the DCC and BP techniques should be evaluated based on patient-specific characteristics and surgical goals.

[Clinical outcome of posterior lumbar interbody fusion combined with Ponte osteotomy for reconstruction of coronal sagittal plane balance in degenerative scoliosis].

Objective: To evaluate the clinical efficacy of posterior lumbar interbody fusion combined with Ponte osteotomy in the treatment of patients with degenerative scoliosis. Methods: The medical records and imaging data of degenerative scoliosis in department of orthopedics, Peking Union Medical College Hospital from 2013 to 2022 were retrospectively collected, and the shortest follow-up time was 1 year. A total of 38 patients were included, including 13 males and 25 females, aged 50-87(65.6±10.9) years old.The follow-up was12-119(43±20) months. Standing position full spine anteroposterior lateral X-ray examinations were performed on all patients preoperatively, postoperatively, and at latest follow-up. The length of hospital stay, complications, operation time, blood loss, instrumented segment, fusion segmen were recorded. The clinical scores and coronasagittal imaging indicators at three time points were compared. Results: The operation time was (274.5±70.5)min, and intraoperative blood loss was (619.2±93.5)ml. The coronal vertical axis was improved from (2.9±1.8)cm preoperatively to (1.2±1.0)cm postoperatively. The preoperative coronal Cobb angle was 16.6°±9.9° and the immediate postoperative correction was 6.4°±4.0°(t=-6.83, P<0.001). The difference was statistically significant (t=-6.12, P<0.001). The coronal Cobb Angle at the last follow-up was 5.7°±3.7°, and there was no significant orthopaedic loss at the last follow-up (t=-6.12, P<0.001).The sagittal vertical axis decreased from (5.6±3.9)cm preoperatively to (3.2±2.5) cm immediately after operation (t=-6.83,P<0.001), and was well maintained at the last follow-up[(2.7±1.8) cm,t=-7.77,P<0.001]. Lumbar lordosis increased from 21.8°±10.2° preoperatively to 35.8°±8.3° postoperatively(t=12.01, P<0.001)and 40.1°±8.6° at last follow-up(t=-10.21, P<0.001). Oswestry disability score (ODI score), visual analogue score (VAS) low back pain score and VAS leg pain score were also lower after surgery than before surgery (all P<0.05). Conclusion: Posterior lumbar interbody fusion combined with Ponte osteotomy can significantly improve the coronal and sagittal plane deformity and postoperative functional score in adult patients with degenerative scoliosis.

Outcomes of Ulnar Shortening Osteotomy with an Intramedullary Bone Graft for Idiopathic Ulnar Impaction Syndrome.

Background: Although several techniques for the treatment of ulnar impaction syndrome (UIS) have been introduced, there have still been reports on various complications such as delayed union, nonunion, refracture, wrist pain, plate irritation, and chronic regional pain syndrome. This study aimed to compare the differences in radiological and clinical outcomes of patients in which intramedullary bone grafting was performed in addition to plate stabilization with those without additional bone grafting during ulnar shortening osteotomies (USOs). Methods: Between November 2014 and June 2021, 53 wrists of 50 patients with idiopathic UIS were retrospectively reviewed. Patients were divided into 2 groups according to whether intramedullary bone grafting was performed. Among the 53 wrists, USO with an intramedullary bone graft was performed in 21 wrists and USO without an intramedullary bone graft was performed in 32 wrists. Demographic data and factors potentially associated with bone union time were analyzed. Results: There was no significant difference between the 2 groups when comparing postoperative radioulnar distance, postoperative ulnar variance, amount of ulnar shortening, and postoperative Disabilities of the Arm, Shoulder and Hand score. Compared to the without-intramedullary bone graft group, bone union time of the osteotomy site was significantly shortened, from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group. Moreover, there were no cases of nonunion or plate-induced symptoms. Both in univariable and multivariable analyses, intramedullary bone grafting was associated with shorter bone union time. Conclusions: USO with an intramedullary bone graft for idiopathic UIS has favorable radiological and clinical outcomes. The advantage of this technique is the significant shortening of bone union time.

Arthroscopic Femoral Head Allograft With Proximal Femoral/Periacetabular Osteotomies for Sequelae of Perthes: A Case Report.

CASE: We describe the unique case of a 20-year-old man with a history of Legg-Calve-Perthes disease, hip dysplasia, and osteochondral fragmentation of the medial femoral head. We performed arthroscopic femoroplasty and femoral head allografting, followed by a valgus-producing derotational femoral osteotomy (DFO) and periacetabular osteotomy (PAO). At 1-year follow-up, the patient achieved osseous union and complete femoral head healing with return to his active hobbies. CONCLUSION: We describe the successful utilization of arthroscopic allografting for medial femoral head osteochondral fragmentation. To our knowledge, this is the first report on femoral head arthroscopic allografting before DFO and PAO.

Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review.

BACKGROUND: Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion. PURPOSE: To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion. METHODS: A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed. RESULTS: A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period. CONCLUSION: For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.

Alternative Treatment of Gonarthrosis: Proximal Fibular Osteotomy.

INTRODUCTION: Gonarthrosis is arthrosis of the knee joint, a chronic non-inflammatory disease manifested by progressive destruction of the intra-articular cartilage, accompanied by abnormal formation of the bones form the joint, changes in the synovial membrane and synovial fluid. Gonarthrosis is the most common type of arthrosis. Gonarthrosis can be treated conservatively and operatively. Among well-established surgical options for the treatment of medial gonarthrosis are high tibial osteotomy (HTO), unicompart-mental knee arthroplasty (UKA), and total knee arthroplasty (TKA). Proximal fibular osteotomy (PFO) or superior partial fibulectomy is a relatively recent procedure proposed to reduce knee pain in patients with medial compartment. AIM: Our study aims to demonstrate an alternative treatment for gonarthrosis with proximal fibular osteotomy and reduced knee pain in patients with medial compartment osteoarthritis of the knee. MATERIALS AND METHODS: At the Department of Orthopedics and Traumatology at J.Z.U "Borka Taleski" Prilep in the period from 2018 to 2021, 14 cases were treated, of which 11 were female and 3 were male. All patients were aged between 62 and 82 years with a mean age of 71.3 years. Patients had a severe degree of gonarthrosis (III/IV) according to Kellgren-Lawrence classification. Arthroscopy was performed in 2 patients. The fibula osteotomy was 7 cm away from the fibular head, with 1 cm resected bone fragment from the fibula. RESULTS: The average duration of the surgery was 30 minutes. Patients were followed up on the 7th day, first month, 3 months and 6 months after surgery. The final evaluation of function was done after 6 months by examining the active and passive movements of the knee joint. In all 14 patients we have excellent results with pain reduction, improvement of movement and quality of life. CONCLUSION: Proximal fibular osteotomy is an option for medial compartment osteoarthritis of the knee. Current literature is limited to small case series which report good outcomes in pain reduction, including the correction of varus deformity in medial gonarthrosis. Further studies are needed to determine the place of the PFO in the medial gonarthrosis management algorithm before it can be recommended for routine clinical use.

Increased symptoms of stiffness after opening-wedge high tibial osteotomy are associated with worse postoperative knee function outcomes and lower patient satisfaction rate.

BACKGROUND: Symptoms of knee stiffness after open wedge high tibial osteotomy (OW-HTO) can significantly affect surgical effectiveness, but no studies have reported risk factors for knee stiffness after OW-HTO. METHODS: Patients treated with OW-HTO for the first time between 2018 and 2021 were included. Data were collected on patient demographics, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form (SF) 12 scores, hip-knee-ankle angle (HKA) and patient satisfaction before and after surgery. Patients with worse WOMAC stiffness scores at 1 year were defined as the 'increased stiffness' group and the other cohort as the 'non-stiffness' group. The primary outcome of the study was to compare postoperative knee function scores (WOMAC and SF-12), HKA and patient satisfaction rate between the two groups. The secondary outcome was the use of logistic regression to analyze independent predictors of increased postoperative stiffness symptoms. RESULTS: At 1 year postoperatively, 95 (11.3%) patients had a significant increase in stiffness. Patients had significantly (p < .001) less improvement in pain, function, and total WOMAC scores, and SF-12 score than those in the non-stiffness group (n = 745). However, the differences in WOMAC and SF-12 scores in increased stiffness group at 1 year post-operatively were statistically significant (p < .001) compared to the non-stiffness group. There was no statistically significant difference in HKA in the increased stiffness group (172.9° ± 2.3°) compared to non-stiffness group (173.4° ± 2.6°) at 1 year postoperatively (p = .068). Patient satisfaction was significantly lower in the increased stiffness group (p < .001). Logistic regression analysis showed that diabetes (odds ratio (OR) 1.809, p = .034) and preoperative WOMAC stiffness score of 44 or less (OR 4.255 p < .001) were predictors of increased stiffness. CONCLUSIONS: Patients with increased stiffness after OW-HTO had worse functional outcomes and lower patient satisfaction rates and patients at risk of being in this group should be informed pre-operatively.

Effect of different palatal expanders with miniscrews in surgically assisted rapid palatal expansion: A non-linear finite element analysis.

INTRODUCTION: Surgically assisted rapid palatal expansion (SARPE) has been the treatment of choice in subjects presenting skeletally mature sutures. OBJECTIVE: The purpose of this study was to analyze stress distribution and displacement of the craniofacial and dentoalveolar structures resulting from three types of palatal expanders with surgical assistance using a non-linear finite element analysis. MATERIAL AND METHODS: Three different palatal expanders were designed: Model-I (tooth-bone-borne type containing four miniscrews), Model-II (tooth-bone-borne type containing two miniscrews), and Model-III (bone-borne type containing four miniscrews). A Le Fort I osteotomy was performed, and a total of 5.0 mm palatal expansion was simulated. Nonlinear analysis (three theory) method (geometric nonlinear theory, nonlinear contact theory, and nonlinear material methods) was used to evaluate stress and displacement of several craniofacial and dentoalveolar structures. RESULTS: Regardless of the maxillary expander device type, surgically assisted rapid palatal expansion produces greater anterior maxillary expansion than posterior (ANS ranged from 2.675 mm to 3.444 mm, and PNS ranged from 0.522 mm to 1.721 mm); Model-I showed more parallel midpalatal suture opening pattern - PNS/ANS equal to 54%. In regards to ANS, Model-II (1.159 mm) and Model-III (1.000 mm) presented larger downward displacement than Model-I (0.343 mm). PNS displaced anteriorly more than ANS for all devices; Model-III presented the largest amount of forward displacement for PNS (1.147 mm) and ANS (1.064 mm). All three type of expanders showed similar dental displacement, and minimal craniofacial sutures separation. As expected, different maxillary expander designs produce different primary areas and levels of stresses (the bone-borne expander presented minimal stress at the teeth and the tooth-bone-borne expander with two miniscrews presented the highest). CONCLUSIONS: Based on this finite element method/finite element analysis, the results showed that different maxillary expander designs produce different primary areas and levels of stresses, minimal displacement of the craniofacial sutures, and different skeletal V-shape expansion.

A Novel Surgical Indication for Scheuermann's Kyphosis.

Scheuermann kyphosis can be treated surgically to restore proper sagittal alignment. Thoracic curves >70° are typically indicated for surgical intervention. However, patients who have reached their natural limit of compensatory lumbar hyperlordosis are at risk of accelerated degeneration. This can be determined by comparing lumbar lordosis on standing neutral radiographs and supine extension radiographs. Minimal additional lordosis in extension compared with neutral, abutment of the spinous processes, or greater lumbar lordosis standing than with attempted extension suggest the patient is maximally compensated. We present a case of an adolescent boy with Scheuermann kyphosis who had reached the limit of his hyperlordosis compensation reserve. He subsequently underwent a T4 to L2 posterior spinal fusion with T7 to T11 Ponte Smith-Petersen grade two osteotomies. He tolerated the procedure well with no intraoperative complications or neuromonitoring changes. The patient has continued to do well and progressed to normal activity at 5-month follow-up.

Retrospective Analysis of Radiographic Outcomes After Closing Base Wedge Osteotomy for Correction of Bunion Deformity.

BACKGROUND: Closing base wedge osteotomy (CBWO) is a common procedure to correct severe bunion deformities with high intermetatarsal angles. There are few data demonstrating the radiographic success of CBWOs. METHODS: We evaluated the radiographic outcomes of a CBWO. The primary aim was to assess the change in elevatus after a CBWO. Secondary aims included measuring the change in hallux abductus (HA) and intermetatarsal angles after the osteotomy. The medical records of 24 consecutive patients across 4 years were reviewed. All of the CBWOs were fixated with either one screw and one Kirschner wire or two screws. We hypothesized that the CBWO would reduce the amount of elevatus present. RESULTS: The mean patient age was 35 years. Average preoperative HA and intermetatarsal angles were 35.2° and 15.7°, respectively. Mean postoperative HA and intermetatarsal angles at last radiographic follow-up were 13.3° and 6.1°, respectively. The change in HA and intermetatarsal angles was 21.9° and 9.6°, respectively. All of the patients achieved clinical union. Mean radiographic follow-up was 6 months; median radiographic follow-up was 5 months. The mean preoperative elevatus measurement was 3.5 mm; the mean postoperative elevatus measurement was 2.0 mm (difference, -1.6 mm; P = .0282), indicating that the osteotomy plantarflexed the first metatarsal. Three patients had radiographic evidence of postoperative elevatus; they were asymptomatic at the last clinical follow-up. CONCLUSIONS: Although clinical concern persists for the development of postoperative elevatus with CBWO, this case series showed plantarflexion of the CBWO. The CBWO is a powerful yet stable procedure for severe bunion deformities and should be viewed as a viable alternative to the Lapidus procedure.

[Analysis of the efficacy of high tibial osteotomy combined with medial meniscus centralization in knee osteoarthritis].

OBJECTIVE: To explore the efficacy of high tibial osteotomy （HTO） combined with medial meniscus centralization in knee osteoarthritis. METHODS: A total of 26 patients who underwent surgery from October 2018 to October 2020 were reviewed. Among them, 14 patients underwent high tibial osteotomy combined with arthroscopic meniscus centralization surgery were centralized group, including 8 males and 6 females, with an average age of （50.2±1.4） years old and follow-up time of （16.8±4.0） months. Twelve patients with high tibial osteotomy were in the control group, including 6 males and 6 females, with an average age of （50.9±1.8） years and follow-up time of （19.0±4.8） months. Operation time, the knee Lysholm score, knee 2000 IKDC score, MRI, femoral tibial angle（FTA）, hip knee ankle angle （HKA）, and intraoperative and postoperative complications were recorded. RESULTS: All the incisions healed without any complication. The operation time in the centralized group was longer than that in the control group[（65.0±2.1）min vs（52.0±2.1）min, P<0.05]. The medial meniscus extrusion reduction value in the centralized group was significantly reduced compared with the control group[（2.8±1.4） mm vs （1.1±2.2） mm, P<0.05]. The FTA, HKA, knee Lyshlom score, and 2000 IKDC score between two groups were no significantly （P>0.05）. Postoperative knee Lyshlom score and knee 2000 IKDC score improved in both groups（P<0.05）. CONCLUSION: HTO combined with centralization of medial meniscus can improve the reduction of medial meniscus and improve knee function. The medium and long-term curative effect still needs long-term follow-up of more cases.

Minimial clinically important difference values in distal metaphyseal ulnar shortening for ulnar impaction syndrome and assessment of the relationship between level of the osteotomy and bone union time.

OBJECTIVE: We aimed to define minimal clinically important difference (MCID) values of patient-reported outcome measures (PROMs) for distal metaphyseal ulnar shortening and to assess the relationship between level of the osteotomy and time to bone union. METHODS: 20 patients who had distal metaphyseal ulnar shortening osteotomies due to ulnar impaction syndrome and had at least 6 months of follow-ups were included in this study. The mean follow-up period was 12.3 ± 7.01 months. The PROMs which consisted of patient-rated wrist evaluation (PRWE) and quick disabilities of arm, shoulder, and hand (QDASH) were recorded on the day before the surgery and at follow-up assessments. Grip strength and range of motion were recorded for operated and contralateral wrists at postoperative assessments. Postoperative radiological evaluations of distance of the osteotomy from the distal ulnar articular surface (osteotomy level), the union of osteotomy site; preoperative and postoperative evaluations of styloid-triquetral distance, and ulnar variance were performed using AP wrist x-rays. The MCID values for PRWE and QDASH were calculated using ROC curve analysis. RESULTS: Mean PRWE and QDASH scores decreased statistically significantly. The mean grip strength of contralateral wrists was higher. Mean ulnar variance decreased, whereas styloid-triquetral distance increased postoperatively. Patients with osteotomy levels of greater than 13.7 mm had a longer time from surgery to bone union. Furthermore, patients with time from surgery to bone union shorter than 7 weeks had an osteotomy closer to the ulnar articular surface. The MCID values for PRWE and QDASH were analyzed and calculated through the ROC curve as 22.25 and 20.45, respectively. CONCLUSION: This study has shown us that the osteotomy level affects the time to bone union and an osteotomy closer than 13.7 mm to the ulnar articular surface seems to result in shorter union time. Furthermore, MCID values were defined for PRWE and QDASH as 22.25 and 20.45, respectively. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Unveiling the learning curve of periacetabular osteotomy.

Aims: Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve. Methods: The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time. Results: The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (ß = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (ß = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (ß = 0.7 (95% CI 0.001 to 1.3); p = 0.048). Conclusion: The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO.

Resection Arthroplasty Is a Valuable Strategy for Humeroradial Synostosis - A Case Report.

A 15-year-old girl with humeroradial synostosis since birth underwent a resection arthroplasty. A trapezoidal resection osteotomy of approximately 2 cm was performed at the anterior part of the bone flexure. This resulted at 18 months in an elbow arc of motion of 60°-110° and forearm pronation/supination of 40° and 60° without postoperative complications and improved disabilities of the arm, shoulder and hand and Hand 20 scores. Radiographic analysis revealed a humeroradial joint with a maintained pseudarthrosis and hinged motion at the humeroulnar joint. When performed by an experienced surgeon, resection arthroplasty corrects humeroradial synostosis, resulting in improvement in range of motion and quality of life. Level of Evidence: Level V (Therapeutic).