Retro-tubercular Biplanar Medial Opening-Wedge High Tibial Osteotomy Results in Superior Patellofemoral Alignment Versus Supra-tubercular Osteotomy.

PURPOSE: To compare the changes in patellofemoral (PF) joint alignment, focusing on multiple planes, between two different types of biplanar medial opening-wedge high tibial osteotomy (OWHTO). METHODS: Patients who underwent biplanar OWHTO between July 2017 and May 2021 were retrospectively evaluated. They were allocated to either the supra-tubercular (ST)- or retro-tubercular (RT)-OWHTO group. The following radiologic parameters were compared between the two groups: 1) weight-bearing line ratio (WBLR), 2) patellar height, 3) posterior tibial slope (PTS), 4) tibial tubercle-trochlear groove (TT-TG) distance, 5) TT-TG angle, and 6) femoral shaft-patellar tendon (FS-PT) angle. Clinical outcomes and the minimal clinically important difference (MCID) were also evaluated. RESULTS: In total, 104 knees that underwent ST-OWHTO and 105 knees that underwent RT-OWHTO were evaluated. The patellar height significantly decreased only after ST-OWHTO (P < .001). The TT-TG distance and FS-PT angle significantly increased, more after ST-OWHTO than RT-OWHTO (mean change value: 5.72 mm vs 1.91 mm; P < .001 for TT-TG distance; and 4.72° vs 1.80°; P < .001 for FS-PT angle). The TT-TG angle increased significantly after ST-OWHTO (mean change value: 7.62°; P < .001) but decreased after RT-OWHTO mean change value: -4.30°; P < .001). The PTS more increased after RT-OWHTO than after ST-OWHTO (mean change value: 0.91° vs 1.69°; P = .003). Clinical outcomes in both groups improved postoperatively, and no significant differences were observed between the groups. CONCLUSIONS: RT-OWHTO resulted in lesser changes in multiplane PF joint alignment than ST-OWHTO. However, no difference was observed in clinical outcomes between both groups, and PTS increased after RT-OWHTO. Therefore, these aspects of RT-OWHTO should also be considered. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Prior tuberosity screw fixation of the osteotomized tubercle can lead to favorable outcomes in retro-tubercular bi-planar opening wedge high tibial osteotomy.

BACKGROUND: Exact information regarding fixing the tuberosity screw during retro-tubercular opening-wedge high tibial osteotomy (RT-OWHTO) is still lacking. The purpose of this study was to determine whether prior tuberosity screw fixation before plate fixation of main osteotomy fragment can prevent complications associated with tuberosity screw. METHODS: From 2019 to 2021, patients who underwent RT-OWHTO were divided into two groups (group I, prior tuberosity screw fixation; group II, later tuberosity screw fixation). A total of 49 and 44 knees were included in groups I and II, respectively. Plain radiographs and computed tomography (CT) were used to analyze the parameters of tuberosity screw fixation, neurovascular (NV) safety and osteotomy configurations. Clinical outcomes and post-operative complications were assessed. RESULTS: The delta (Δ) of the deformation angle of the tuberosity (P = 0.002), delta (Δ) of the posterior tibial slope (PTS) (P < 0.001), extruded screw length (P < 0.001), and retro-tuberosity tip distance (P < 0.001) of group I were significantly smaller than those of group II. All tuberosity screws were fixed medially to the NV structures. Post-operative tuberosity fracture occurred in one knee (2%) in group I and in 10 knees (23%) in group II (P = 0.003). CONCLUSIONS: RT-OWHTO with prior tuberosity screw fixation can minimize the risk of tuberosity fracture and an increase in the PTS. It can also prevent NV injuries by reducing extruded tuberosity screw length and fixing it medially from the NV structures.

Association Between Tunnel Position, Tunnel Angle, Graft Signal Intensity, and Graft Thickness in the Reconstructed Posterior Cruciate Ligament.

Background: An appropriate tunnel position, tunnel angle, and tunnel-graft angle are important factors for maintaining the stability and mechanical properties of a posterior cruciate ligament (PCL) graft. Purpose: To evaluate the association between tunnel position, tunnel angle, graft signal intensity ratio (SIR), and graft thickness after remnant-preserving PCL reconstruction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were patients who had undergone remnant-preserving single-bundle PCL reconstruction using a tibialis anterior allograft between March 2014 and September 2020 and who had minimum 12-month postoperative magnetic resonance imaging scans. Tunnel position and angle were evaluated via 3-dimensional computed tomography, and their association with graft SIR on both the femoral and the tibial sides was determined. Graft thickness and SIR at 3 areas of the graft were evaluated and compared, and their association with tunnel-graft angle was also determined. Results: Overall, 50 knees (50 patients; 43 male, 7 female) were included. The mean time to postoperative magnetic resonance imaging was 25.8 ± 15.8 months. The mean SIR of the graft's midportion was higher compared with that of the proximal and distal portions (P = .028 and P < .001, respectively), and the SIR of the proximal portion was higher compared with that of the distal portion (P = .002). The femoral tunnel-graft angle was more acute than the tibial tunnel-graft angle (P = .004). A more anteriorly and distally located femoral tunnel led to a less acute femoral tunnel-graft angle (P = .005) and a decreased SIR of the proximal portion (P = .040), and a more laterally located tibial tunnel was associated with a less acute tibial tunnel-graft angle (P = .024) and a reduced SIR of the distal portion (P = .044). The mean thicknesses of the graft's midportion and distal portion were larger than that of the proximal portion (P < .001). The SIR of the graft's midportion was positively correlated with its thickness (r = 0.321; P = .023). Conclusion: The SIR of the proximal portion of the graft around the femoral tunnel was higher than that of the distal portion around the tibial tunnel. An anteriorly and distally positioned femoral tunnel and a laterally positioned tibial tunnel resulted in less acute tunnel-graft angles that were associated with decreased signal intensity.

Lipectomy for madelung disease using tumescent technique: a cross-sectional study.

Madelung's disease is a rare disfiguring disorder that affects both function and esthetic appearance in the head and/or shoulder, neck, and arms regions. Lipectomy is typically necessary but such treatment can encounter difficulties due to the large sizes of the tumors, interspersed with important organs in the surrounding region. In this report, the authors evaluate the effectiveness of using tumescent solution in lipectomy to provide a dual treatment of tissue removal for Madelung disease in the head-and-neck region. Methods: A prospective study and clinical descriptions were conducted on 17 patients undergoing 26 head-and-neck lipectomies. A tumescent solution was injected into the surgical region with a blunt-tip cannula 5-10 min before skin incision. The authors recorded systemic manifestations both during and after surgery; tumescent volume; surgical region; clarity of the operative field; weight of fat removed, and early complications. After surgery, the authors followed the patients from periods of 3 months to 4 years. Results: All 17 male patients had a history of alcoholism. In total, 12 lipectomies for the removal of anterior neck fatty masses and 14 lipectomies for the removal of posterior neck fatty masses were performed. The average amount of tumescent injected was 260.1 ml (range 140-550 ml). Surgery was reported as totally bloodless in 10 (38.5%) operative fields, with minimum bleeding in 12 (46.1%) operative fields, acceptable bleeding in four (15.4%) operative fields. The average surgical time was 175.6 min (range 135-250 min). The removed fatty masses weighed between 250 and 2150 g, with an average of 582.9 g. Early complications were seen in four patients, accounting for 15.4% (2 hematoma, 1 skin necrosis, and 1 seroma). Conclusions: Using tumescent solution in lipectomies to treat Madelung disease in the head and neck area is a simple, safe, and useful technique. The technique helps to create a clean operative field, reduces bleeding, and thereby assists surgeons during the operation.

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction.

PURPOSE: In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts. METHODS: Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D). RESULTS: The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D. CONCLUSIONS: Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement. LEVEL OF EVIDENCE: Level III.

Applying Tumescent solution for preserving the facial nerve in parotidectomy.

BACKGROUND: Facial nerve palsy is one of the most common complications in parotid gland surgery. This report evaluates the effectiveness of applying Tumescent solution for preserving the facial nerve in parotidectomy. MATERIAL AND METHODS: Prospective and descriptive clinical study on 34 patients undergoing parotidectomy with facial nerve preservation. Before skin incision, 5-10 min, we injected 100-200 ml of the Tumescent solution into the surgical area. We recorded the surgical method, tumor size, length of surgery, pathological results and facial nerve dysfunction. All patients were followed for a period ranging from 6 to 24 months. RESULTS: There were 14 patients with malignant tumors and 20 patients with benign tumors. The length of surgery lasted from 90 to 180 min, with an average of 126.8 min. The number of patients having temporary facial paralysis was 22 cases (64.7%), recovery time ranged from 1 week to 6 months, and no permanent facial paralysis cases were recorded. The clinical occurrence of Frey's syndrome was five cases (14.7%). CONCLUSIONS: The application of Tumescent solution for preserving facial nerves in parotidectomy could minimize nerve injury and shorten the length of surgery.