A Case Report of Craniofacial Intraosseous Xanthoma in a Patient Seeking Facial Feminization Surgery.

BACKGROUND: Fibrous dysplasia (FD) is a benign developmental disorder of the bone that causes normal skeletal tissue to be replaced by excess fibrous tissue and poorly differentiated osteoblasts. Intraosseous xanthomas are benign intraosseous tumor growths characterized microscopically by the presence of lipid-laden foamy histiocytes, often with cortical expansion or disruption. Although FD commonly occurs in craniofacial bones, primary intraosseous xanthomas of the skull or facial skeleton are extremely rare. Although 2 distinct conditions, each may be difficult to differentiate on CT imaging when occurring in the facial skeleton. METHODS: We report a case of an incidental finding on craniofacial CT of a frontal bone lesion originally thought to be FD. The finding was in a 55-year-old transgender woman who was assigned male at birth before receiving multiprocedural facial feminization surgery. RESULTS: The clinical features, radiological findings, and treatment are discussed. Postoperatively, the patient had no sequelae secondary to facial feminization surgery or to the orbital lesion biopsy procedure. Bone graft appeared stable on CT imaging, although FD did not appear to resolve completely. CONCLUSIONS: Diagnosis of such lesions is challenging and may require both radiographic and histopathologic assessment. As in the case of this patient, intraosseous xanthomas may also be misdiagnosed as other benign lesions such as FD. In most known cases, surgical intervention leads to complete resolution without recurrence of the lesion.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center.

BACKGROUND: Patients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability. METHODS: We investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05). RESULTS: There were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020). CONCLUSIONS: To the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

Palliative Treatment for the Management of Advanced Pelvic Hydatid Bone Disease.

Hydatid bone disease is a zoonotic parasitic infection that is caused primarily by the tapeworm Echinococcus granulosus, and it continues to be a major public health concern in pastoral regions. The reconstruction of limb function after limb salvage surgery remains a challenge for clinicians. The purpose of this study was to determine the clinical efficacy of palliative treatment of the management of advanced pelvic hydatid bone disease. From March 2005 to December 2018, medical records and images of patients with advanced pelvic hydatid bone disease treated with surgery combined with antiparasitic chemotherapy were evaluated retrospectively. The Enneking classification was applied to determine the location of the lesion, and the Musculoskeletal Tumor Society score system was used for outcome evaluation. Fifteen patients who met the criteria were included in this study, with a mean follow-up of 4.40 ± 1.76 years. All patients received treatment with surgery combined with antiparasitic chemotherapy. The mean number of surgical interventions per patient for pelvic cystic echinococcosis was 5.3 (range, 2-9 interventions per patient). Recurrence of pelvic hydatid bone disease occurred in 5 patients and was managed successfully through repeated debridement procedures. Palliative treatment with limb salvage surgery was an effective and practical approach to the management of advanced pelvic hydatid bone disease. Standard antiparasitic chemotherapy, which included albendazole at a dose of 10 mg/kg/day administered in two daily doses for 3 to 6 months, was also considered an essential part of the overall treatment strategy.

Relationship of Pelvic Positional Change with Leg Length and Offset Measurement in Experimental Total Hip Arthroplasty.

OBJECTIVE: During total hip arthroplasty (THA), both pelvic and femur positions affect leg length (LL) and offset (OS) measurements because LL and OS calipers depend on the fixed reference points on the pelvis and femur, respectively. However, LL and OS measurement errors because of pelvic positional changes have not been described. This study aimed to clarify the effects of pelvic positional changes on LL and OS measurements in relation to the pelvic reference using a THA simulator. METHODS: We developed an experimental THA simulator using Sawbones models of the hemipelvis and femur that facilitated modification of the obliquity, tilt, and rotation of the pelvis. Using an LL and OS caliper, LL and OS measurement errors due to pelvic positional changes were determined with the femoral position fixed. Measurements were performed from two pelvic reference positions: the iliac tubercle (P1) and the top of the iliac crest intersecting the line of the femoral long axis (P2). RESULTS: Concerning pelvic obliquity, the total error of LL was 25.0 mm in P1 and 26.5 mm in P2, while the total error of OS was 13.0 mm in P1 and 10.9 mm in P2. For pelvic tilt, the total error of LL was 9.0 mm in P1 and 3.8 mm in P2, while the total error of OS was 0.5 mm in P1 and 1.0 mm in P2. Regarding pelvic rotation, the total error of LL was 13.8 mm in P1 and 3.2 mm in P2, while the total error of OS was 3.8 mm in P1 and 4.0 mm in P2. CONCLUSIONS: Pelvic positional changes alter LL and OS measurements. The acceptable range (error <2 mm) on LL and OS measurement errors of pelvic obliquity was only 2°, regardless of the pelvic reference position. The pelvic reference position should be at the top of the iliac crest intersecting the line of the long axis of the femur because of a small LL measurement error with pelvic tilt and rotation.

A decreased tibial tuberosity-trochlear groove distance is associated with lateral patellofemoral joint degeneration after implantation of medial fixed-bearing unicompartmental knee arthroplasty - a minimum five year follow-up.

PURPOSE: The influence of lateral patellofemoral osteoarthritis (PFOA) in medial unicompartmental knee arthroplasty (UKA) is controversial. Our aim was to identify radiographic factors that may lead to progressive PFOA after implantation of a fixed-bearing medial UKA and their impact on patient-reported outcomes (PROMs). METHODS: A retrospective consecutive cohort of patients undergoing medial UKA with a minimum follow-up of 60 months between September 2011 and January 2017 was identified. All UKAs had a fixed-bearing design with cemented femoral and tibial components. PROMs included documentation of the Oxford Knee Score (OKS). The following radiographic parameters were evaluated on conventional radiographs and computer tomography (CT) scans: patella tilt angle, patella congruence angle, Caton-Deschamps index, medial and lateral patellofemoral degeneration (Kellgren-Lawrence Classification (KL)), mechanical anteroposterior axis, femoral torsion, tibial tuberosity to trochlear groove distance (TTTG), anteroposterior translation of the femoral component. A hierarchical multiple regression analysis and partial Pearson correlation analysis (SPSS) were used to evaluate for predictors of progression of lateral PFOA. RESULTS: Forty-nine knees allowed PFOA assessment and had an average follow-up of 62 months (range 60-108). Twenty-three patients did not exhibit any progression of lateral PFOA. Twenty-two progressed with 1 stage, whereas four had progressed 2 stages according to the KL classification. TTTG negatively correlated with progressive lateral PFOA (r = - 0.436, p = 0.01). Progression of lateral PFOA did not correlate with OKS at last follow-up (p = 0.613). CONCLUSION: A decreased TTGT correlated with radiographic progression of lateral PFOA after medial fixed-bearing cemented UKA. PFOA however did not influence PROMs at a minimum of five years postoperatively.

Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellafemoral osteoarthritis Iwano Stages 3-4: a study based on arthroplasty registry data.

PURPOSE: To determine whether the preoperative degree of degeneration of the patellofemoral joint really affects the outcome of total knee arthroplasty (TKA) surgery without patella resurfacing and thus to establish a parameter that might serve as a guiding factor to decide whether or not to perform retropatellar resurfacing. It was hypothesized that patients with preoperative mild patellofemoral osteoarthritis (Iwano Stages 0-2) would significantly differ from patients with preoperative severe patellofemoral osteoarthritis (Iwano Stages 3-4) in terms of patient-reported outcome (Hypothesis 1) and revision rates/survival (Hypothesis 2) after TKA without patella resurfacing. METHODS: Application of a retrospective-comparative design on the basis of Arthroplasty Registry data that included patients with primary TKA without patella resurfacing. Patients were allocated to the following groups based on preoperative radiographic stage of patellofemoral joint degeneration: (a) mild patellofemoral osteoarthritis (Iwano Stage ≤ 2) and (b) severe patellofemoral osteoarthritis (Iwano Stages 3-4). The Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) score was assessed preoperative and 1 year postoperative (0: best, 100 worst). In addition, implant survival was calculated from the Arthroplasty Registry data. RESULTS: In 1209 primary TKA without patella resurfacing, postoperative WOMAC total and WOMAC subscores did not differ significantly between groups, but potentially suffered from type 2 error. Three-year survival was 97.4% and 92.5% in patients with preoperative mild and severe patellofemoral osteoarthritis, respectively (p = 0.002). Five-year survival was 95.8% vs. 91.4% (p = 0.033) and 10-year survival was 93.3% vs. 88.6% (p = 0.033), respectively. CONCLUSIONS: From the study findings, it is concluded that patients with preoperative severe patellofemoral osteoarthritis have significantly higher risks for reoperation than do those with preoperative mild patellofemoral osteoarthritis-when treated with TKA without patella resurfacing. Hence, it is recommended that patella resurfacing be applied in patients with severe Iwano Stage 3 or 4 patellofemoral osteoarthritis during TKA. LEVEL OF EVIDENCE: III, Retrospective comparative.

Preoperative Leg Length Discrepancy >2 cm in the Supine Decubitus Position May Induce Compensatory Pelvic Obliquity in Patients during Total Hip Arthroplasty.

OBJECTIVES: The leg length discrepancy (LLD) in the supine decubitus position may influence the inclination angle of the acetabular component during total hip arthroplasty (THA). The relationship among LLD, pelvic obliquity, and inclination angle of the acetabular component has not been well studied. This study aimed to evaluate the relationship between LLD in supine position and changes in the inclination angle of the acetabular components during THA, and the compensatory ability of the pelvis based on LLD and inclination. METHODS: A total of 135 patients were prospectively classified into three groups according to the preoperative LLD in the supine decubitus position: the cranial type group had a positive LLD value; the fixed type group had LLD = 0; and the caudal type group had a negative LLD value. Patients in the cranial type group and caudal type group were divided into four subgroups based on the LLD value (either positive or negative): LLD >3 cm subgroup; 2 ≤ LLD ≤ 3 cm subgroup; 1 ≤ LLD < 2 cm subgroup; and LLD <1 cm subgroup. The targeted and final inclination of the acetabular component was measured intra- and postoperatively. RESULTS: The results showed a significant difference in the targeted and final inclination angles among the patients in the cranial type and the caudal type groups. In the caudal type group, increased inclination was observed in the patients of LLD >3 cm subgroup (mean 3.13°) and 2 ≤ LLD ≤ 3 cm subgroup (mean 5.17°) after THA, respectively. Decreased inclination (mean, 6.16°) was observed in 2 ≤ LLD ≤ 3 cm subgroup in the cranial type group after THA. CONCLUSIONS: Our findings revealed that in patients with discrepancy greater than 2 cm, postural pelvic obliquity imposed a remarkable influence on the inclination.

Long-Term clinical results of patellofemoral arthroplasty for isolated patellofemoral osteoarthritis.

OBJECTIVES: The aim of this study was to explore the clinical outcomes and long-term survival of patellofemoral arthroplasty in treatment of isolated patellofemoral osteoarthritis. METHODS: We retrospectively studied a total of 46 type Y-L-Q PFAs that were designed at our institution in 38 patients. Implant survivorship was analyzed with a follow-up of 18.9-29.6 years. Knee Society Score (KSS), Oxford Knee Score (OKS), and University of California Los Angeles activity scale (UCLA) were used to assess functional outcomes. RESULTS: The implant survivorship was 83.6% at 15 years, 76.8% at 20 years, and 59.4% at 25 years 14 PFAs in 12 patients were revised into total knee arthroplasty at 16.0 ± 6.7 years; 13 for progression of tibiofemoral osteoarthritis and one for polyethylene wear. The mean Knee Society Score objective scores and functional scores were 73.0 ± 17.5 (range, 49-95) and 56.4 ± 28.9 (range, 5-90), respectively. The mean Oxford Knee Score was 25.8 ± 11.5 (range, 8-44). CONCLUSION: Type Y-L-Q patellofemoral arthroplasty can be an effective method for treating isolated patellofemoral osteoarthritis with satisfactory survival.

Fully constrained acetabular liner vs. dual mobility hip joint in the surgical treatment of metastatic bone disease of the hip: study protocol for a randomized, open-label, two-arm, non-inferiority trial evaluating the post-operative hip dislocation rate.

BACKGROUND: Patients receiving total hip arthroplasty (THA) due to metastatic bone disease of the hip (MBD) are at an increased risk of post-operative joint dislocation compared to other populations. Different joint solutions have been developed with the purpose of reducing the dislocation risk compared to regular THAs. One of these solutions, the constrained liner (CL), has been used increasingly at our department in recent years. This design, however, is prone to polyethylene wear and higher revision rates. An alternative is the dual mobility cup (DM), which has been shown to reduce the risk of dislocation in other high-risk populations. Few studies have investigated DM for THA due to MBD, and no studies have directly compared these two treatments in this population. We therefore decided to conduct a trial to investigate whether DM is non-inferior to CL regarding the post-operative joint dislocation risk in patients receiving THA due to MBD. MATERIALS AND METHODS: This study is a single-center, randomized, open-label, two-arm, non-inferiority trial. We will include 146 patients with MBD of the hip who are planned for THA at the Department of Orthopedic Surgery, Rigshospitalet. Patients with previous osteosynthesis or endoprosthetic surgery of the afflicted hip, or who are planned to receive partial pelvic reconstruction or total femoral replacement, will be excluded. Patients will be stratified by whether subtrochanteric bone resection will be performed and allocated to either CL or DM in a 1:1 ratio. The primary outcome is the 6 months post-operative joint dislocation rate. Secondary outcomes include overall survival, implant survival, the rate of other surgical- and post-operative complications, and quality of life and functional outcome scores. DISCUSSION: This study is designed to investigate whether DM is non-inferior to CL regarding the risk of post-operative dislocation in patients receiving THA due to MBD. To our knowledge, this trial is the first of its kind. Knowledge gained from this trial will help guide surgeons in choosing a joint solution that minimizes the risk of dislocation and, ultimately, reduces the need for repeat surgeries in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05461313. Registered on July 15 2022. This trial is reported according to the items in the WHO Trial Registration Data Set (Version 1.3.1).

Hip Abduction Can Be Considered the Sole Posterior Precaution Strategy to Lower the Rate of Impingement After Posterior Approach Total Hip Arthroplasty With Large Femoral Head: A Computer Simulation Study.

BACKGROUND: Studies suggest that posterior hip precautions are unnecessary after total hip arthroplasty; however, many surgeons and patients choose to follow these precautions to some extent. In this study, we hypothesized that 20° of hip abduction would be sufficient to prevent impingement and dislocation in motions requiring hip flexion when using larger prosthetic heads (≥36 mm) when the acetabular implant is placed within a reasonable orientation (anteversion:15-25° and inclination: 40-60°). METHODS: Using a robotic hip platform, we investigated the effect of hip abduction on prosthetic and bony impingement in 43 patients. For the flexed seated position, anterior pelvic tilt angles of 10 and 20° were chosen, while anterior pelvic tilt angles of 70 and 90° were chosen for the bending forward position. An additional 10° of hip external rotation and 10 or 20° of hip internal rotation were also added to the simulation. One hip received a 32-mm head; otherwise, 36-, 40-mm, or dual-mobility heads were used. The study power was 0.99, and the effect size was 0.644. RESULTS: In 65% of the cases, bone-bone impingement between the calcar and anterior-inferior iliac spine was the main type of impingement. The absolute risk of impingement decreased between 0 and 16.3% in both tested positions with the addition of 20° hip abduction. CONCLUSION: With modern primary total hip arthroplasty stems (low neck diameter) and an overall acceptable cup anteversion angle, small degrees of hip abduction may be the only posterior hip precaution strategy required to lower the risk of dislocation among patients. Future studies can potentially investigate the concept of personalized hip precautions based on preoperative computer simulations, utilized implants, hip-spine relations, and final implant orientation.

Patellar development after patella instability and early reduction in growing rabbits.

BACKGROUND: Patella-shaped disorder has been considered as a predisposing factor for patella instability. But the influence of early patella reduction for patellar development remains unclear. This study aimed to evaluate whether early operation in patella instability could improve patella morphology in growing rabbits. METHODS: Fifty rabbits (1-month-old) were included in the study. The control group underwent no surgical procedures. The two experimental groups (reduction group and non-reduced group), underwent medial soft tissue restraint release surgery. The reduction group, rabbits underwent the medial soft tissue sutura surgery in order to stabilize the patella 2 months after release surgery. The non-reduced group, rabbits did not undergo suture surgery. Computed Tomography (CT) scans analysis in two experimental endpoints (2, 5 months after release surgery) were selected to evaluate the transverse diameter, thickness, Wiberg index and Wiberg angle. Gross observation was conducted to assess morphological changes of the patella. RESULTS: CT scans showed significant difference in the mean transverse diameter, Wiberg angle between the two experimental groups and the control group 2 months after release surgery. 5 months after release surgery, the indices of patella were found no statistically difference in the reduction group versus the control group. However, the transverse diameter, Wiberg angle in the non-reduced group were significantly differences than that in the reduction group (P < 0.05). Gross observation showed a flattened articular surface of the patella in the non-reduced group. CONCLUSIONS: The results indicated that patella instability may lead to patella-shaped disorder, showing a flattened morphology. Early patella reduction can improve the patella morphology in growing rabbits.

Outcomes of Patellar Subchondroplasty Surgery: A Case Series.

A select subset of patients can present with anterior knee pain in the setting of normal patellar tracking, no significant cartilage damage, and the presence of a bone marrow lesion (BML) involving the patella on advanced imaging. One novel treatment option for this condition is patellar subchondroplasty, where calcium phosphate is injected into the subchondral bone under fluoroscopic guidance. The purpose of this study is to report preliminary outcomes of patients who have undergone subchondroplasty of the patella. The surgical log of the senior author was retrospectively reviewed to identify patients who had undergone patellar subchondroplasty from January 2014 to June 2019. Indications for surgery included the presence of retropatellar pain refractory to conservative management without significant arthritis with a related focal BML on magnetic resonance imaging. International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Veterans Rand 12-item Health Survey (VR-12) were obtained preoperatively, at 6 months and at final follow-up. Eight patients (nine knees) who underwent patellar subchondroplasty with minimum 1-year follow-up participated in the study. On preoperative magnetic resonance imaging, patients had a mean BML that was 2 cm in diameter. Patients had a median Kellgren-Lawrence grade of 2 both preoperatively and at final radiographic follow-up (15.50 ± 20.52 months). No patient underwent subsequent surgery or conversion to arthroplasty. Compared with baseline, VR-12 mental (p = 0.046) and physical (p = 0.003), KOOS joint replacement (p = 0.024), KOOS pain (p = 0.033), and KOOS sports (p = 0.034) scores were significantly increased at final follow-up (24.00 ± 13.55 months). In addition, on a scale of 0 to 100, patient-reported satisfaction was 73.88 ± 33.90. This study introduces patellar subchondroplasty as a surgical treatment for patients with symptomatic BMLs of the patella without significant arthritis after failure of conservative management. Our results demonstrated good outcomes and patient satisfaction. In addition, no patients converted to patellofemoral or total knee arthroplasty. This study suggests that patellar subchondroplasty may be a reasonable treatment option in the correct patient population.

Patient-Reported Outcomes and Risk Factors for Decreased Improvement after Patellofemoral Arthroplasty.

Patellofemoral arthroplasty (PFA) is acknowledged as the method for the treatment of isolated patellofemoral osteoarthritis (PFOA). Few previous studies have assessed the patient-reported outcomes (PROs) and risk factors of less improvement of PROs in patients undergoing PFA. A retrospective analysis was performed, including all patients who had undergone PFA. Pre- and postoperative PROs included the Oxford Knee Score (OKS) and Kujala score. Univariate and multivariate statistical analyses were performed to assess influencing factors of less improvement of PROs including the demographic factors (gender, age, body mass index, smoking, opioid usage, and duration of symptoms [DOSs]), surgical factors (concomitant surgery), and imaging factors (trochlear dysplasia [TD], patellar height, the degree of PFOA). A total of 46 PFAs were analyzed with a mean follow-up of 37 ± 7 months. The mean age at surgery was 61.1 ± 7.7 years. Patients showed significant improvement in all PROs (p < 0.001). Patients with TD preoperatively have greater improvement in OKS and Kujala score postoperatively (19.2 ± 5.0 vs. 23.1 ± 3.6, p = 0.038). Longer DOSs (≥1 year) had a greater mean improvement in OKS and Kujala score (p = 0.011 and p = 0.000). According to the measurement of patella height, patients with patella alta (Caton-Deschamps index [CDI] ≥1.3) showed less improvement in both OKS and Kujala score (p = 0.000 and p = 0.002). PFA is a safe and efficient surgery with good PROs. Patella alta with a CDI ≥1.3 and duration of preoperative symptoms ≤ 1 year were risk factors for decreased OKS and Kujala score improvement, while the preoperative presence of TD was significantly predictive factors for increased OKS improvement.

Surgical Epicondylar Axis of the Knee and Its Relationship to the Axial Tibia Alignment in Knee Osteoarthritis: The Concept of Proximal Twist Tibia.

The proximal tibia and distal femur are intimately linked with the biomechanics of the knee and they are to be considered in total knee arthroplasty (TKA). The aim of the present study was to evaluate the proximal tibial torsion (PTT) in relation to surgical epicondylar axis (SEA) in a healthy cohort and a pathological cohort affected by knee osteoarthritis (OA). We retrospectively analyzed computed tomography of OA knee of 59 patients before they underwent TKA and nonarthritic knee of 39 patients as control. Posterior condylar angle (PCAn), femoral tibial torsion (SEA-proximal tibial condyle [PTC] and SEA-PTT), PTT (PTC-PTT and posterior condylar axes [PCAx]-PTC), and distance between tibial tuberosity and the trochlear groove (TT-TG) were measured. No differences were found for gender, age, TT-TG, and PCAn angles. Statistically significant differences were found for all the other angles considered. Significant correlation was found between tibial torsion and SEA-PTT angles, between PCAx-PTC and SEA-PTC, between SEA-PTT and SEA-PTC, and between PCAx-PTC and SEA-PTT. All measures, except TT-TG and PCAn angles, showed high validity (area under the curve [AUC] > 75%) in associating with OA, with SEA-PTT displaying the highest validity with an AUC of 94.38%. This is the first study to find significant differences in terms of proximal tibia geometry and anatomy between nonarthritic and OA knees. From our results, we reported that OA group was characterized by a greater internal rotation of tibia with respect to SEAs compared with control group. Since the design of the study cannot evaluate a cause-effect relationship, further studies need to be performed to assess the potential implications of these anatomic differences for knee OA and arthroplasty surgeries.

Surgical Treatment of Ossified Cephalhematoma in Young Child.

Cephalhematoma is a subperiosteal collection of blood. The lesion generally spontaneously resolves, but if cephalhematoma persists beyond this period, it typically begins to ossify and may require surgical treatment for correction. The incidence of ossified cephalhematoma is rare, and its pathogenesis is unclear. There have been reports of surgical treatment of ossified cephalhematoma in newborns and infants, but few reports in 5-year-old children. We experienced the surgical treatment of an ossified cephalhematoma in a 5-year-old boy. We performed periosteal reattachment with onlay bone autograft. Follow-up examination at 2 years revealed a good cosmetic result and a computed tomography scan showed excellent reconstitution of the contour of the skull.

Reconstruction of Large Anterior Skull Base Defects After Resection of Sinonasal Tumors With Intracranial Extension by Using Pedicled Double Flap Techniques.

INTRODUCTION: The use of surgical resection for large anterior skull base (ASB) tumors and sinonasal malignancies with intracranial extension will result in a large skull base defect. Reconstruction of large ASB defects using traditional techniques is high risk and may lead to postoperative cerebral spinal fluid (CSF) leakage, meningitis, and an increase in mortality rate. The use of a pedicled double flap technique to reconstruct the ASB defect may decrease complications. This study presents the clinical outcomes of patients who underwent double flap reconstruction techniques after resection of their sinonasal malignancies with significant intracranial extension at Cho Ray hospital in Vietnam. METHODS: The case series study was conducted at Cho Ray hospital from September 2010 to September 2020. All patients with large sinonasal malignancies that invaded intracranially underwent transnasal endoscopic surgery and subfrontal craniotomy. Reconstruction of large skull base defects (>2 cm) were followed up by using the pedicled double flaps technique. This study was performed in line with the principles of the Declaration of Helsinki. Approval of the study was granted by the Independent Ethics Committee of Cho Ray Hospital (Date: March 3, 2014/No: 11/BVCRHDDD). RESULTS: During September 2010 to September 2020, there were 75 patients who underwent a modified multilayer, double flap reconstruction technique after the resection of their ASB tumor. Skull base defects were commonly seen along the horizontal plate of the ethmoid bone and the ethmoid roof (98.6%). Large skull base defects (>2 cm) accounted for 81.3% of cases. Overall, the risk of postoperative CSF leakage and meningitis after double flap repair was considerably low. Of all participants, only 1 experienced postoperative CSF leakage and 1 experienced postoperative meningitis. Despite the complications, these patients improved significantly and remained stable. CONCLUSION: The use of double vascularized pedicled flaps may decrease the incidence of postoperative CSF leakage and meningitis. This technique is an effective method for the reconstruction of ASB tumors with large defects.

Effect of Patellofemoral Arthroplasty on Patellar Height in Patients with Patellofemoral Osteoarthritis.

Osteoarthritis (OA) in the knee is common, painful, and may be uni- or multicompartmental. The compartment affected by arthritis may be due to trauma, malalignment (varus or valgus), or in the case of patellofemoral OA, patella alta. Patellofemoral arthroplasty (PFA) is an effective partial knee replacement surgery for patellofemoral OA. We hypothesized that PFA can decrease patellar height. In addition, we predicted better outcomes for patients with patella alta before PFA and those whose patellar heights decreased after PFA. This is a retrospective cohort study of PFA patients from 2012 to 2020. Before and after PFA, we measured patellar heights on X-ray images and collected patient-reported outcome measures (PROMs) (International Knee Documentation Committee score, Kujala Anterior Knee Pain Score, and Veterans RAND 12-Item Health Survey for mental and physical health). Statistical analyses assessed PROMs and compared outcomes based on pre- and postoperative patella height. Of 133 knees, 73% presented with patella alta and 61% had patellar heights that decreased after PFA. Compared with patients who did not present with patella alta, patients with patella alta reported similar outcomes with respect to knee function, pain, and general physical and mental health. Compared with patients whose patellar heights decreased after PFA, patients whose knees did not decrease in height reported greater improvements in pain and function. Our findings suggest that patella alta is commonly found in patients with patellofemoral OA and that PFA can decrease patellar height. Future studies are needed to assess whether patellofemoral OA patients with greater degrees of patella alta would benefit from staged or concurrent tibial tubercle distalization.

Excessive femoral torsion is not associated with patellofemoral pain or instability if TKA is functionally aligned and the patella denervated.

PURPOSE: Recent data suggest that individual morphologic factors should be respected to restore preoperative patellofemoral alignment and thus reduce the likelihood of anterior knee pain. The goal of this study was to investigate the effect of excessive femoral torsion (FT) on clinical outcome of TKA. METHODS: Patients who underwent TKA and complete preoperative radiographic evaluation including a long-leg radiograph and CT scan were included. 51 patients showed increased FT of > 20° and were matched for age/sex to 51 controls (FT < 20°). Thirteen patients were lost to follow-up. Thirty-eight matched pairs were compared after a 2 year follow-up clinically (Kujala and patellofemoral score for TKA) and radiographically (FT, frontal leg axis, TT-TG, patellar thickness, patellar tilt, and lateral displacement of patella). Functional alignment of TKA was performed (hybrid-technique). All patellae were denervated but no patella was resurfaced. RESULTS: There was no significant difference between clinical scores two years after surgery between patients with normal and excessive FT (n.s.). Kujala score was 64.3 ± 16.7 versus 64.8 ± 14.4 (n.s.), and patellofemoral score for TKA was 74.3 ± 21 versus 78.5 ± 20.7 (n.s.) for increased FT group and control group, respectively. There was no correlation between preoperative FT and clinical scores. Other radiographic parameters were similar between both groups. No correlations between clinical outcomes and preoperative/postoperative frontal leg axis or total leg axis correction were found (n.s.). CONCLUSION: If the leg axis deformity is corrected to a roughly neutral alignment during cemented TKA, including patellar denervation, then excessive FT was not associated with patellofemoral pain or instability. LEVEL OF EVIDENCE: Prospective comparative study, level II.