Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.

Advances in flash flood research based on dendrogeomorpholog

Flash flood is one of the major natural hazards in China. It seriously threatens the lives of people and property in mountainous areas. Various methods have been developed for flash flood study, but most of them focused on the past few decades. As one of the effective methods of historical flash flood events reconstruction, dendrogeomorphology has been used worldwide. It can provide hazard information with long temporal scale and high temporal resolution, sometimes at the seasonal level. By comparing tree ring width and other growth characteristics between disturbed and undisturbed trees, growth disturbance signals can be found in the disturbed trees. Using the growth disturbance in tree rings, flash flood events can be dated, and then the frequency, size, and spatial distribution characteristics of flash floods that have no or little documentary records can be reconstructed. The discharge of flash flood can be reconstructed quantitatively according to the height of scars or by using hydraulic models. With the development of dendrogeomorphology, research tends to probe into the meteorological driving mechanism of flash floods and the pattern of flash floods on a larger spatial scale. In the practical application of dendrogeomorphology, more instrumental data and historical records are applied in the studies. This makes the method increasingly more widely used around the world. But work based on dendrogeomorphology has not been reported in China. In this article, we reviewed the development of the study on flash floods based on tree ring, briefly summarized the research progress, and discussed the advantages, limitations, and potential of this approach, so as to provide some reference information for relevant work in China.

TIBIAL PHYSEAL RESPECTING TUNNEL DRILLING TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN SKELETALLY IMMATURE ATHLETES

Background: ACL reconstruction is common in young patients. Hypothesis/Purpose: To report outcomes of a novel tibial drilling technique using an inside-out socket drilling method, with a drill pin and epiphyseal socket drilling in skeletally immature patients. Minimizing disruption to the tibial physis, attempting to prevent growth disturbance with an anatomic ACL that eliminates the graft bend angle at the tibial tunnel. Methods: We used a standard all-epiphyseal drilling technique for femoral preparation. The tibial drill guide, set at 55° for our tibial physeal respecting approach, is positioned in the posterior third of the ACL footprint in-line with the posterior aspect of the lateral meniscus anterior root. The FlipCutter (Arthrex Inc., Naples, FL) is drilled from the external proximal tibia. Thus, only a 3.5mm diameter tunnel crosses the proximal tibial physis. With the FlipCutter deployed, the cutting radius is checked to confirm proper position without risk of damage to the meniscal root, PCL, or articular cartilage. With fluoroscopic guidance, the tibial socket is drilled from the intra-articular surface towards the physis, stopping proximal to the physis. This results in a 15 to 20 mm all-epiphyseal socket length. We collected demographics, re-tear rate, physeal arrest (partial/complete), and patient reported outcomes in order to understand potential problems and mid-term outcomes of this procedure. Results: Eight male patients were included in the study (average age=10.6±1.5 years). All patients had radiographs >6months post-surgery, and no patient had a clinically significant leg length discrepancy (>2cm) or deformity. The two patients followed >24months post-operatively were cleared to return to sports by one year. No patients demonstrated a positive Lachman or pivot shift test at >6months follow-up. No Patients had a ROM deficit at >6months follow-up. Five patients completed Pedi-IKDC and Lysholm assessments (time from surgery=16.2months+10.6months; range 7–28.8months). Average IKDC and Lysholm scores were 88+10 and 95+9, respectively. There were no graft ruptures in the cohort (average follow-up: 13.8months±8.9 months; range 6.8–30.6months). Conclusion: Our preliminary data from this novel tibial physeal respecting technique suggest it may be appropriate for skeletally immature patients with sufficiently large enough femoral epiphyses to hold a 10mm graft tunnel without disturbance to the physis. This technique seems successful in terms of graft survival, patient reported outcomes, and no growth disturbance within 2 years of surgery, although we recognize our small sample size as a limitation. Further studies will better evaluate long-term outcomes of this pediatric ACLR technique.

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

Madelung Deformity: Surgical Correction with Radial Dome Osteotomy

Madelung deformity is a rare wrist malformation caused by a growth disturbance of the palmar and ulnar part of the distal radial physis. The aim of this study is to evaluate the outcome of radial dome osteotomy in patients affected by Madelung deformity. The endpoint of this operation is to improve the orientation of the articular surface of the radius, so as to support to the carpal bones. Between 2017 and 2019, in our clinic, 4patients were treated using this technique. Post-operative pain was evaluated using the NRS. Functional outcomes were assessed through evaluation of ROM, grip strength via Jamar dynamometer and using DASH questionnaire. The aesthetic defects were estimated using a section of the Michigan Hand Outcome Questionnaire. Correction of deformities was evaluated on post-operative RX using McCarrol Criteria. Were also analyzed the accuracy and tolerance of the plates used.

Reverse wedge osteotomy for Madelung’s deformity in a high school student: A case report

Madelung deformity is a congenital disorder with the malformation of anterior ulnar bowing of radius and a dorsally protruding ulnar head caused by premature growth disturbance at the medial volar aspect of the distal radius. This report describes a bilateral idiopathic Madelung deformity in a 17-year-old woman treated successfully using reverse wedge osteotomy of the distal radius in a symptomatic left wrist. Reverse wedge osteotomy can orient the radial joint surface while correcting the whole radius length by reversely putting the wedge bone removed from the distal metaphysis of radius, the base of which is cut from the surplus of the radial and dorsal cortical bone in the hypotrophic portion. We corrected the palmar subluxation of the carpus, restored her good function, and relieved her wrist pain.

Tibial tuberosity ossification predicts reoperation for growth disturbance in distal femoral physeal fractures

Purpose Distal femoral physeal fractures (DFPF) can cause growth disturbance that requires further surgical intervention. The aim of this study is to determine if Tibial Tuberosity Ossification Stage (TTOS) at the time of injury predicts secondary surgery for growth disturbance in patients who have sustained a DFPF. Methods We retrospectively investigated all patients who had operative treatment for a DFPF at a single centre over a 17-year period. Regression analysis was performed investigating associations between secondary surgery to treat growth disturbance and TTOS, age, Salter-Harris fracture classification type, mode of fixation or mechanism of injury. Results In all, 85 consecutive patients were identified. A total of 74 met the inclusion criteria. The mean age at time of injury was 13.1 years (2.0 to 17.1). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with the need for further surgery (p < 0.001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis (compared with not fused) were 0.12 (95% confidence interval (CI) 0.04 to 0.34). The estimate of the effect of TTOS on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter-Harris type. When accounting for age, the odds of any further operation if the tibial tuberosity is fused to the metaphysis (compared with not fused) were 0.28 (95% CI 0.08 to 0.94). Conclusion TTOS at the time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Level of Evidence Diagnostic Level II