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PubMed2004

Transmaxillary osteogenesis distraction combined with orthopedics and orthodontics in the correction of a severe retrusion of the upper maxilla.

A patient having adequate records and diagnosed as having Binder syndrome is presented. Nasomaxillary hypoplasia requires a definitive treatment, use of bone grafts, upper maxillary osteotomies, and advancement or a combination of both. Bone grafts can be reabsorbed, and complete maxillary advance modifies normal occlusion in a certain way, because the posterior sector is not compromised. The aim of this case treatment is to create a new osseous surface that makes the eruption of the permanent dental pieces easier and gives the correct skeletal position to the upper maxilla with distraction osteogenesis combined with an orthopedic appliance, transmaxillary segment osteotomy, and subsequent orthodontics. The absence of the osseous surface in the upper maxilla and the presence of supernumeraries in the anterior region determined the permanence of most of the temporary dental pieces, resulting in the impossibility of making the exchange to permanent dental pieces. The technique and the devices are simple and easy to manipulate. After the treatment, an adequate dental relation is restored as well as effective advance of the upper maxillary bone; thus, an excellent functional and stable esthetic result is achieved, avoiding any complication of velopharingeal incompetence.

Child, Preschool↗
PubMed2006

Assessment of cleft lip and palate patients treated with presurgical orthopedic correction and either primary bone grafts, gingivoperiosteoplasty, or without alveolar grafting procedures.

The effects of alveolar grafting on the development of the craniofacial complex have been reported by numerous investigators. The reported results vary in the literature from significant to very little impediment of maxillary growth. The present work evaluates and compares facial form at age six years in complete unilateral cleft lip and palate patients treated with presurgical orthopedic correction and primary reconstruction with (1) primary bone grafts (n = 14), (2) gingivoperiosteoplasty (n = II), or (3) without alveolar grafting procedures at the time of lip repair (n = 13). The cohort groups were analyzed with a one-way analysis of variance (ANOV A). Statistical analysis revealed significant differences between the three groups for only one of the 12 parameters analyzed. The primary bone grafted group demonstrated less vertical descent-of the anterior maxilla compared to the gingivoperiosteoplasty and non-grafted groups (P = .0027).

Alveoloplasty↗
PubMed1981

Patterns in the excretion of muscle markers after trauma and orthopedic surgery.

The urinary output of 3-methylhistidine (3-MeHis), creatinine, creatine, and zinc has been followed in 13 patients after accidental injuries and in nine patients undergoing elective orthopedic operations. The accidental injuries were classified by their Injury Severity Score (ISS) and according to the amount of muscle damage by the method of Grant and Reeve (15). The latter method gave two groups, (I) "very severe," and (II) "severe." The changes in the urine were not related to ISS. The initial output of 3-MeHis and zinc was greater in Group I than in Group II or in patients after total hip replacement, in whom muscle damage was least. The pattern of excretion of the excess 3-MeHis in Group I and after hip replacement suggested that it was derived from the breakdown of muscle injured in the accident or operation. Only in Group II and after total knee replacement were there additional changes which could be attributed to a generalized increase in muscle breakdown, said to be typical of the post-traumatic "flow" phase, e.g., the simultaneous increase in the output of all four muscle markers, to a peak about 6 days after the injury. In these patients the relative importance of muscle at the injury site and elsewhere is not clear. The most constant changes after accidental or operative trauma were delayed increased in the excretion of creatine and zinc. These changes, and the abnormality of the 3-MeHis/creatinine ratio, showed that alterations in muscle metabolism could persist for long periods after trauma.

Adolescent↗
PubMed1994

A comparison of transferred versus direct admission orthopedic trauma patients.

Trauma patients with orthopedic injuries transferred to Harborview Medical Center (HMC) were compared with all trauma patients directly admitted to HMC and with a set of matched controls regarding injury Severity Score (ISS) and age, if > or = 50 years old. Groups were compared on ISS, Revised Trauma Score (RTS), ICU stay, length of stay (LOS), total charges, reimbursement, payors, and outcome. Comparison of all transferred patients and directly admitted patients showed significant differences in ISS, LOS, ICU stay, and total charges. Despite a higher ISS, transferred patients had no differences in RTS or survival outcome. Comparison of matched transferred patients and directly admitted patients on ISS and age if > or = 50 years old showed a statistically significant increase in LOS, reimbursement, and charges. The survival rate of all transferred and directly admitted trauma patients was approximately 95% for both groups despite a slightly higher degree of injury in transferred patients. The reimbursement rate for both groups was low, 65% for transferred patients and 59% for directly admitted patients. The percentage of transfer patients on Medicaid was 34% and for direct admissions was 37% (p = 0.552). This is a large percentage of indigent care, since only 8.1% of Washington State residents are Medicaid dependent.

Adolescent↗
PubMed1995

Functional status following orthopedic trauma in young women.

OBJECTIVE: To evaluate the general health status and sexual function of women following serious orthopedic injury. METHODS: Women aged 16-44 who were treated at a level I trauma center between 1986 and 1992 for a fracture to the pelvis or lower extremity were interviewed by telephone. The interview included the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) supplemented by questions about sexual function. The SF-36 is a measure of outcome from the respondent's point of view and consists of 36 items representing eight health concepts. RESULTS: Of 289 eligible women, 233 (81%) were interviewed (123 pelvic fracture; 110 lower extremity fracture). Their mean Injury Severity Score was 17.9. Compared to age- and gender-standardized norms, study patients as a group scored significantly worse (lower scores) on all dimensions of the SF-36 except mental health (p < 0.05). Of the women interviewed, 45% reported feeling less sexually attractive due to their injury, and 39% reported a decrease in sexual pleasure. Women who reported arthritis that was attributed to their fracture had significantly poorer health outcomes than study subjects who did not. The most significant predictor of deviations from SF-36 norms was the presence of one or more comorbid chronic conditions. CONCLUSION: The results underscore the importance of considering comorbidities when evaluating health outcomes following major trauma. In addition, the relatively high rates of reported change in sexual function after injury argue for more attention to these issues in both clinical practice and outcomes research.

Activities of Daily Living↗
PubMed1999

Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma.

BACKGROUND: Combined vascular and skeletal injuries are associated with a high limb loss rate. One of the major factors resulting in amputation is frequently because the allowable warm ischemia time for skeletal muscle is exceeded before adequate revascularization. METHODS: Temporary vascular shunting has been used in selected patients with complete ischemia to minimize the ischemic time of the injured limb, allowing identification of vital structures, thorough debridement, and rigid internal fixation before definitive vascular repair. RESULTS: Five male and two female patients with a median age of 46 years (range, 27-76 years) admitted with combined orthopedic and vascular injuries of the upper limbs in four and the lower limbs in three patients underwent primary vascular shunting. The median ischemic time for all patients was 180 minutes (range, 120-210 minutes). Shunt insertion was accomplished in all cases within 30 minutes. Median dwell time for the shunt was 185 minutes (range, 90-390 minutes). No shunt-related complications or limb loss occurred. During follow-up ranging from 2 to 24 months, all vascular repairs remained patent. All fractures healed primarily, except for one patient in whom a necrosis of the humeral head occurred. Five patients had an excellent and two patients a good result. CONCLUSION: Initial temporary vascular shunting in selected patients with combined skeletal and vascular injury of the upper or lower limb may reduce the complications resulting from prolonged ischemia and permits an unhurried and reasonable sequence of treatment.

Adult↗
PubMed2001

Traditional injury scoring underestimates the relative consequences of orthopedic injury.

OBJECTIVE: To demonstrate that patients with multiple injuries who have orthopedic injuries (ORTHO) face greater challenges regarding functional outcome than those without, to identify domains of postinjury dysfunction, and to illustrate the increasing discordance of functional recovery over time for ORTHO patients in relation to nonORTHO patients. METHODS: A convenience sample of adult blunt force trauma patients admitted to a Level I trauma center was evaluated at admission, and at 6 and 12 months after injury. Data were collected from the trauma registry (Trauma One), chart review, and interviews. Mailed surveys were completed 6 and 12 months after injury. The Short Form 36 (SF36) general health survey and the Sickness Impact Profile work scale (SIPw) were administered at both time points. Data are presented as mean +/- SEM or percent (%). To compare means, t tests were conducted, and Injury Severity Score (ISS) was controlled by linear regression before the evaluation of the role of ORTHO injury pattern on outcome measures. Significance is noted at the 95% confidence level (p < 0.05). RESULTS: The 165 patients studied averaged 37.2 +/- 1.1 years in age and were 67% men. The mean ISS was 14.4 +/- 0.6 and 61% had ORTHO injury. ORTHO patients were no different from nonORTHO in any measure of baseline status including the SIPw score and all domains of the SF36, except that the ISS was greater in the ORTHO group (15.6 +/- 0.96 vs. 12.7 +/- 0.73, p = 0.017). Baseline SF36 values were similar to national norms. Follow-up was 75% at 6 months, and 51% at 12 months. Those lost to follow-up differed only in that they were more likely to be men. Sixty-four percent had returned to work 12 months after injury. After controlling for ISS with linear regression, the ORTHO patients had worse scores on all physical measures of the SF36 (bodily pain, physical function, and role-physical). By 12 months after injury, the relative dysfunction of the ORTHO patients had expanded to include the SIPw score (p = 0.016) and six of eight SF36 domains (bodily pain, physical function, role-physical, mental health, role-emotional, and social function, all p < 0.05). CONCLUSION: Injury severity affects both mortality and the potentially more consequential issues of long-term morbidity. Patients with ORTHO injury have relatively worse functional recovery, and this worsens with time. As trauma centers approach the limits of achievable survival, new advances in trauma care can be directed more toward the quality of recovery for our patients. This will be contingent on further development of screening, scoring, and treatment systems designed to address issues of functional outcome across injury boundaries for those who survive.

Activities of Daily Living↗
PubMed2002

Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery.

BACKGROUND: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture. METHODS: In a retrospective cohort study performed at a Level I trauma center, the patient's injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I degrees intramedullary nailing [I degrees IMN]; I degrees external fixation [I degrees EF]; I degrees plate osteosynthesis [I degrees plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981-December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990-December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993-December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure. RESULTS: The patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) ( = 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I degrees EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I degrees IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I degrees EF in the INT (13.6%, = 0.03) and DCO (17.3%, = 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I degrees IMN (15.1%) and I degrees EF (9.1%) in the DCO subgroup were compared. CONCLUSION: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I degrees EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of developing posttraumatic systemic complications such as ARDS and multiple organ failure.

Adult↗
PubMed1997

Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases.

PURPOSE: The use of shock waves in orthopedic diseases was reviewed with special regard to the clinical applications. MATERIALS AND METHODS: Findings in the literature and results from our own studies were analyzed and summarized. RESULTS: Extracorporeal shock waves induced osteoneogenesis in animal models with intact and fractured bones. Based on these findings shock waves were used for the treatment of pseudarthrosis in humans. Most patients had at least 1 unsuccessful operation before shock wave therapy. Complete reunion was noted in 62 to 91% of cases and shock waves are recommended by some as the first choice of treatment for hypertrophic pseudarthrosis. After failed nonoperative therapy shock waves were used for the treatment of patients with various diseases as secondary treatment. The success rate for treatment of tendinopathies, such as tennis elbow, periarthritis humeroscapularis or calcaneal spur, was approximately 80%. For calcific tendinitis shock wave therapy seems to be superior to all other minimal or noninvasive techniques without compromising a potential later operation. CONCLUSIONS: Shock waves have changed medical therapy substantially. Accounting for the epidemiology of the treated diseases, this new change may equal or even surpass the impact of extracorporeal shock wave lithotripsy.

Animals↗
PubMed1990

Comparisons of five health status instruments for orthopedic evaluation.

This study represents a long-term effort to find optimal techniques for evaluating outcome in patients who have undergone total joint arthroplasty. Sensitivity of five health status questionnaires was studied in a longitudinal evaluation of orthopedic surgery. The questionnaires (Arthritis Impact Measurement Scales [AIMS], Functional Status Index [FSI], Health Assessment Questionnaire [HAQ], Index of Well Being [IWB], and Sickness Impact Profile [SIP]) were administered to 38 patients with end-stage arthritis at three points in time: two weeks before hip or knee arthroplasty, and at three-month and 12- to 15-month follow-up. Response values (i.e., changes within patients) were calculated on four scales: global health, pain, mobility, and social function. By the three-month follow-up, most instruments detected large mean responses in global health, pain scores, and mobility. Smaller changes on these scales were found between three and 12 to 15 months. Social function showed small to modest gains at successive follow-ups. Standardized response means were calculated to assess sensitivity to detect change. Confidence intervals for these indices were constructed using a jackknife procedure, and significance tests were performed by pairing selected indices. Finally, the study projected sample sizes required to assess a new therapy, using each response. These statistical tools facilitated comparisons among instruments and may prove useful in other settings.

Aged↗
PubMedDate not supplied

Altering children's distress behavior during orthopedic cast removal.

The hypothesis treated was that discrepancy between expected and experienced physical sensations (what is felt, seen, heard, tasted, and smelled) during a threatening experience will result in distress. The subjects were 84 children, 6 to 11 years of age, male and female. The threatening experience was orthopedic cast removal. Tape recorded preparatory information was used to vary systematically expectations about physical sensations. The children were randomly assigned to one of three information groups: 1) sensory information which described the sensory experience during cast removal, 2) procedure information which described the steps of the experience, 3) control group which heard no tape recorded information. Nonverbal and verbal signs of distress reactions and the pulse rate were observed during cast removal. Signs of distress were scaled from zero to two, with zero meaning no distress behaviors and two, high distress behavior. A two-factor analysis of variance (two levels of pre-fear and three levels of information) was used for analysis. As hypothesized, the mean distress score for the sensation group (.50) differed significantly from the control group mean (1.00 p less than .025). The procedure group distress score mean (.71) fell between the sensation and control group means but did not differ significantly from the control group mean. The no pre-fear group distress score mean (.52) was significantly lower than the some pre-fear group mean (1.00 p less than .02). Mean pulse rate changes for information groups for before to during cast removal were in the same order as the distress scores, but the differences were not statistically significant. The findings were similar to those from other tests of the hypothesis.

Adaptation, Psychological↗
PubMed1999

Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA) compared with previous lip adhesion method: a preliminary study of serial dental casts.

Comparing the treatment protocols for cleft lip and palate requires a study of facial growth and development. Serial orthodontic study models aid in delineating the effects of surgery on maxillary mandibular relationships. In 1978, a new protocol, POPLA (presurgical orthopedics followed by periosteoplasty and lip adhesion), was developed and put into practice. This article compares the results obtained using POPLA (group I) with those using the previous method (lip adhesion alone) (group II) for cases of unilateral and bilateral clefts. Complete orthodontic study models were available for 124 patients, 63 in group I and 61 in group II. Specific timing sequences and surgical details are discussed. Dental cast analyses evaluated alveolar gap, arch width, anteroposterior distance, incisor crossbite (single tooth and multiple tooth), and buccal crossbite (single and multiple tooth) at birth and at 3, 6, and 9 years of age. X-ray studies evaluated the bony bridge. Additional comments are made regarding the incidents and effects of pharyngeal flaps and bone grafts on maxillary-mandibular relationships. Results included less buccal crossbite in the POPLA group, with a wider transverse distance of the upper dental arch. There was a greater frequency of anterior crossbite in the POPLA group, and the anteroposterior distance was shorter at 6 years of age but less so by age 9. This may be because of the different orthodontic care received by the patients in the two groups. In conclusion, the POPLA approach achieves the main goal of moving the palate into a normal position and stabilizing the arch with a bony bridge that attracts teeth. It avoids the difficult anterior fistulae and presents a more symmetrical platform upon which the lip can be united and the nose can be corrected early.

Cleft Lip↗
PubMed2001

Computer-assisted orthopedic surgery with individual templates and comparison to conventional operation method.

STUDY DESIGN: Comparison was made of the accuracy of a pedicle bore performed by conventional technique and by using an individual template in the lumbar spine of cadavers. OBJECTIVES: The fixation of pedicle screws necessitates a high amount of surgical skill and experience to avoid lesions of nerves and vessels. By using individual templates in a cadaver study the goal was to prove the accuracy and efficiency of this less-invasive image-guided surgery in comparison with the conventional technique by fluoroscopy and computed tomographic (CT) scan. SUMMARY OF BACKGROUND DATA: Based on three-dimensional models generated from CT scans of the lumbar spine, precise preoperative planning of the position and trajectory of pedicle screws is possible. In comparison with other means of computer-assisted spine surgery with navigation systems, in which a time-consuming intraoperative matching of the bone surface structure is necessary, the use of individual templates enables the surgeon to reduce the operation time considerably. METHODS: Individual templates are customized on the basis of three-dimensional reconstructions of the bone structures extracted from CT image data and depending on the individual preoperative surgical planning, which uses the desktop image processing system for orthopedic surgery (DISOS). A desktop-computer-controlled milling device is used as a three-dimensional printer to automatically mold the shape of small reference areas of the bone surface into the body of the template. Postoperative CT scans were obtained and the accuracy of the pedicle bore rated by two independent observers. RESULTS: The preparation time with the individual template lasted slightly longer than with the conventional operation technique (555 seconds and 482 seconds, respectively). Fluoroscopic study took a mean time of 31.5 seconds, with the conventional operation technique and 5.5 seconds with the individual template. The assessment of the postoperative CT scans demonstrated a higher accuracy of the pedicle bore with the individual template. CONCLUSIONS: This cadaveric study has shown that overall operation time including the fluoroscopy time can be shortened by using the individual template for the pedicle bore. The individual template is an alternative to the computer-assisted navigation systems with a good cost-performance ratio without excessive technical workload on the physicians or the surgical personnel. Further investigations must be conducted to validate the clinical applicability of this system.

Bone Screws↗
PubMed1996

Endocrine disorders and orthopedic problems in children.

Endocrine excesses or deficiencies frequently result in alterations of height as compared with age-matched children. Less clinically obvious are significant alterations in bone metabolism leading to osteoporosis, which can affect the child and may affect the patient as an adult. Slipped capital femoral epiphysis appears to be associated with a variety of endocrine disorders, particularly hypothyroidism. The hormonal treatment of various endocrine and nonendocrine disorders has been associated with alterations of bone metabolism, or of bone maturation, as well as with producing or aggravating orthopedic disorders.

Adrenocortical Hyperfunction↗
PubMed1994

Working it out: recommendations from a multidisciplinary national consensus panel on medical problems in Workers' Compensation. Committee on Occupational Health, American Academy of Orthopedic Surgeons.

This article presents the recommendations of a national multidisciplinary consensus panel brought together to discuss the medical problems facing the troubled Workers' Compensation System. The process, organized by the American Academy of Orthopedic Surgeons, was needed because participants in the System seldom communicate with nor understand the other's positions. Altogether 119 individuals representing employers, insurers, allied health professionals, administrators, lawyers, legislators, unions, and physicians participated in a year-long iterative process agreeing on 38 high-priority problems, and developing solution papers for 14 of them. These papers were discussed at a workshop that generated 48 recommendations in 6 categories, including guideline development, temporary modified work, education, prevention, patient advocacy, and legislative and regulatory changes. A post-process evaluation by the participants strongly endorsed this process as an effective way to improve communication and urged similar state or regional panels.

Accidents, Occupational↗
PubMed2004

Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options.

The fibula free flap became popular in orthopedic oncology for limb-sparing long bone tumor resection. It is particularly suitable for intercalary or resection arthrodesis options. In the present series, a surgical reconstruction algorithm was used, enabling each patient to receive a personalized technique. During the years 1998 to 2002, 30 patients underwent limb-sparing surgery for long bone sarcoma. There were 18 males and 12 females. Their mean age was 23 years (range, 9 to 70 years). The diagnoses were Ewing's sarcoma (11 patients), osteogenic sarcoma (eight patients), chondrosarcoma (five patients), giant cell tumor of bone (three patients), high-grade soft-tissue sarcoma (two patients), and leiomyosarcoma of bone (one patient). The majority of tumors where located in the lower extremity (23 patients), mostly in the femur (15 patients with four tumors in the proximal femoral shaft, five tumors in the distal femoral shaft, five tumors in the whole femoral shaft, and one tumor in the proximal femoral head). In seven patients, the upper extremity was involved; in six patients, the radius was involved; and in one patient, the humerus was involved. The free fibula flap was used in three types of approaches: vascularized fibula as an osseous flap only (18 patients), a combination of a vascularized fibula flap in conjunction with an allograft (Capanna's technique; 10 patients), and a free double-barreled fibula (two patients). All flaps survived. Postoperatively, all patients were monitored clinically, radiologically, and by radioisotope bone scan studies. Callus formation and union were shown 2.6 to 8 months postoperatively. Patients who underwent lower extremity reconstruction were nonweightbearing for 3 to 9 months, with a transition period in which they used a brace and gradually increased weightbearing until full weightbearing was achieved. Eight patients had 11 recipient-site complications. Two patients (6.7 percent) had hematomas, and three patients (10 percent) had infection and dehiscence of the surgical wound with bone exposure in one patient; all complications resolved with conservative treatment only. Failure of the hardware fixation system occurred in two patients, mandating surgical correction. No fibula donor-site complications were recorded. In intercalary resections, the use of the vascularized fibula flap as an isolated osseous flap might be insufficient. Different body sites have different stress loads to carry, depending on the age of the patient and on his individual physical status. To achieve initial strength in the early period, the authors combined the free fibula flap with an allograft (Capanna's method) or augmented it as a double-barreled fibula. They propose a surgical algorithm to assist the surgeon with the preferred method for reconstruction of various long bone defects in different body locations at childhood or adulthood. Long bone reconstruction using a vascularized fibula flap, alone or in combination with an allograft, autogenous bone graft, or double-barreled fibula for limb-sparing surgery, is a safe and reliable method with a predictable bony union, good functional outcome, and a low complication rate.

Adolescent↗