It is still difficult to determine an appropriate hinge position to prevent fracture in the lateral cortex of tibia in the process of making an open wedge during biplane open wedge high tibial osteotomy. The objective of this study was to present a biomechanical basis for determining the hinge position as varus deformity. T Three-dimensional lower extremity models were constructed using Mimics. The tibial wedge started at 40 mm distal to the medial tibial plateau, and osteotomy for three hinge positions was performed toward the head of the fibula, 5 mm proximal from the head of the fibula, and 5 mm distal from the head of the fibula. The three tibial models were made with varus deformity of 5, 10, 15 degrees with heterogeneous material properties. These properties were set to heterogeneous material properties which converted from Hounsfield's unit to Young's modulus by applying empirical equation in existing studies. For a loading condition, displacement at the posterior cut plane was applied referring to Hernigou's table considering varus deformity angle. All computational analyses were performed to calculate von-mises stresses on the tibial wedges. The maximum stress increased to an average of 213±9% when the varus angle was 10 degrees compared to 5 degrees and increased to an average of 154±8.9% when the varus angle was 15 degrees compared to 10 degrees. In addition, the maximum stress of the distal position was 19 times higher than that of the mid position and 5 times higher than that of the proximal position on average. Conclusion:. For varus deformity angles, the maximum stress of the tibial wedge tended to increase as the varus deformity angle increased. For hinge position of tibial wedge, maximum stress was the lowest in the mid position, while the highest in the distal position. *This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (NRF-2022R1A2C1009995)

High tibial osteotomy (HTO) is a joint preserving alternative to knee replacement for medial tibiofemoral osteoarthritis in younger, more active patients. The procedure is technically challenging and limited also by ‘one size fits all’ plates which can result in patient discomfort necessitating plate removal. This clinical trial evaluated A novel custom-made HTO system – TOKA (3D Metal Printing LTD, Bath, UK) for accuracy of osteotomy correction and improvements in clinical outcome scores. The investigation was a single-arm single-centre prospective clinical trial (IRCCS Istituto Ortopedico Rizzoli; ClinicalTrials.gov NCT04574570), with recruitment of 25 patients (19M/6F; average age: 54.4 years; average BMI: 26.8), all of whom received the TOKA HTO 3D planning and surgery. All patients were predominantly diagnosed with isolated medial knee osteoarthritis and with a varus deformity under 20°. Patients were CT scanned pre- and post-operatively for 3D virtual planning and correctional assessment. All surgeries were performed by the lead clinical investigator – a consultant knee surgeon with a specialist interest in and clinical experience of HTO. On average, Knee Society Scores (KSS) improved significantly (p<0.001) by 27.6, 31.2 and 37.2 percentage points respectively by 3-, 6- and 12-months post-surgery respectively. Other measures assessed during the study (KOOS, EQ5D) produced similar increases. Our early experience using custom implants is extremely promising. We believe the reduced profile of the plate, as well as the reduced invasiveness and ease of surgery contributed to faster patient recovery, and improved outcome scores compared to conventional techniques. These clinical outcome results compare very favourably other case-series with published KOOS scores using different devices

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Introduction and Objective. In recent studies, robotic-assisted surgical techniques for unicompartmental knee arthroplasty (UKA) have demonstrated superior implant positioning and limb alignment compared to a conventional technique. However, the impact of the robotic-assisted technique on clinical and functional outcomes is less clear. The aim of this study was to compare the gait parameters of UKA performed with conventional and image-free robotic-assisted techniques. Materials and Methods. This prospective, single center study included 66 medial UKA, randomized to a robotic-assisted (n=33) or conventional technique (n=33). Gait analysis was performed on a treadmill at 6 months to identify changes in gait characteristics (walking speed, each degree-of-freedom: flexion–extension, abduction–adduction, internal-external rotation and anterior-posterior displacement). Clinical results were assessed at 6 months using the IKS score and the Forgotten Joint Score. Implants position was assessed on post-operative radiographs. Results. Post-operatively, the whole gait cycle was not significantly different between groups. In both groups there was a significant improvement in varus deformity between the pre- and post-operative gait cycle. There was no significant difference between the two groups in clinical scores, implant position, revision and complication rates. Conclusions. No difference of gait parameters could be identified between medial UKA performed with image-free robotic-assisted technique or with conventional technique

Abstract. Background. Tibiotalocalcaneal (TTC) fusion is indicated for severe arthritis, failed ankle arthroplasty, avascular necrosis of talus and as a salvage after failed ankle fixation. Patients in our study had complex deformities with 25 ankles having valgus deformities (range 50–8 degrees mean 27 degrees). 12 had varus deformities (range 50–10 degrees mean 26 degrees) 5 ankles an accurate measurement was not possible on retrospective images. 10 out of 42 procedures were done after failed previous surgeries and 8 out of 42 had talus AVN. Methods. Retrospective case series of patients with hindfoot nails performed in our centre identified using NHS codes. Total of 41 patients with 42 nails identified with mean age of 64 years. Time to union noted from X-rays and any complications noted from the follow-up letters. Patients contacted via telephone to complete MOXFQ and VAS scores and asked if they would recommend the procedure to patients suffering similar conditions. 17 patients unable to fill scores (5 deceased, 4 nails removed, 2 cognitive impairment and 6 uncontactable). Results. In our cohort 33/38 of hindfoot nails achieved both subtalar and ankle fusion in a mean time of 7 months. 25 patients with 26 nails had mean follow up with post op scores of 4 years. Their Mean MOXFQ scores were (Pain: 12.8 Walking: 12 Social: 8) and visual analogue pain score was 3. 85% of patients wound recommend this surgery for a similar condition. 20 complications with 15 requiring surgery(5 screw removals, 1 percutaneous drilling, 1 fusion site injection, 8 nail revisions). Conclusion. In our experience hindfoot nail TTC fusion reliably improves the function of patients with severe symptoms in a variety of pathophysiological conditions and complex deformities. Most of our patients would recommend this procedure. There is a lack of studies with long-term follow-up

Abstract. Objectives. Principal Component Analysis (PCA) is a useful method for analysing human motion data. The objective of this study was to use PCA to quantify the biggest variance in knee kinematics waveforms between a Non-Pathological (NP) group and individuals awaiting High Tibial Osteotomy (HTO) surgery. Methods. Thirty knees (29 participants) who were scheduled for HTO surgery were included in this study. Twenty-eight NP volunteers were recruited into the study. Human motion analysis was performed during level gait using a modified Cleveland marker set. Subjects walked at their self-selected speed for a minimum of 6 successful trials. Knee kinematics were calculated within Visual3D (C-Motion). The first three Principal Components (PCs) of each input variable were selected. Single-component reconstruction was performed alongside representative extremes of each PC to aid interpretation of the biomechanical feature reconstructed by each component. Results. Pre-operatively patient demographics included (age: 50.70 (8.71) years; height: 1.75 (.11) m; body mass: 90.57 (20.17) kg; mTFA: 7.75 (3.72) degrees varus; gait speed: 1.06 (0.23) m/s). The HTO cohort was significantly older and had a higher mass than the NP control participants. For knee kinematics the first three PCs explained 88%, 95% and 89% of the sagittal, frontal, and transverse planes, respectively. The main variances can be explained by sagittal plane magnitude differences, peak swing is associated with toe-off, a reduced knee flexion angle is associated with a longer time spent in stance, pre-HTO remain adducted during stance and pre-HTO patients remain more externally rotated during stance and latter part of swing. Conclusions. This study has introduced PCA in trying to better understand the biomechanical differences between a control group and a cohort with medial knee osteoarthritis varus deformity awaiting HTO. Further analysis will be undertaken using PCA comparing pre- and post-surgery which will be of importance in clinical decision making

Introduction and Objective. Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental knee arthritis after extra-articular injury must rationally be attributed to malalignment. Materials and Methods. The picture archiving system was searched to identify all 1160 long leg x ray films available at a major metropolitan trauma center over a 12-year period. Images were screened for inclusion and exclusion criteria, namely patients >10 years after traumatic long bone fracture without contralateral injury or arthroplasty to give 39 cases. Alignment was measured according to established surgical standards on long leg films by 3 independent reviewers, and arthritis scores Osteoarthritis Research Society International (OARSI) and Kellegren-Lawrence (KL) were recorded independently for each compartment of both knees. Malalignment was defined conservatively as mechanical axis deviation outside of 0–20 mm medial from centre of the knee, to give 27 patients. Comparison of mean compartmental arthritis score was performed for patients with varus and valgus malalignment, using Analysis of Variance and linear regression. Results. In knees with varus malalignment there was a greater mean arthritis score in the medial compartment compared to the contralateral knee, with OARSI scores 5.69 vs 3.86 (0.32, 3.35 95% CI; p<0.05) and KL 2.92 vs 1.92 (0.38, 1.62; p<0.005). There was a similar trend in valgus knees for the lateral compartment OARSI 2.98 vs 1.84 (CI −0.16, 2.42; p=0.1) and KL 1.76 vs 1.31 (CI −0.12, 1.01; p=0.17), but the evidence was not conclusive. OARSI arthritis score was significantly associated with absolute MAD (0.7/10mm MAD, p<0.0005) and Time (0.6/decade, p=0.01) in a linear regression model. Conclusions. Malalignment in the coronal plane is correlated with worsened arthritis scores in the medial compartment for varus deformity and may similarly result in worsened lateral compartment arthritis in valgus knees. These findings support the mechanical hypothesis that arthritis may be related to altered stress distribution at the knee, larger studies may provide further conclusive evidence

3D accurate measurements of the skeletal structures of the foot, in physiological and impaired subjects, are now possible using Cone-Beam CT (CBCT) under real-world loading conditions. In detail, this feature allows a more realistic representation of the relative bone-bone interactions of the foot as they occur under patient-specific body weight conditions. In this context, varus/valgus of the hindfoot under altered conditions or the thinning of plantar tissues that occurs with advancing age are among the most complex and interesting to represent, and numerous measurement proposals have been proposed. This study aims to analyze and compare these measurements from CBCT in weight-bearing scans in a clinical population. Sixteen feet of diabetic patients and ten feet with severe adult flatfoot acquired before/after corrective surgery underwent CBCT scans (Carestream, USA) while standing on the leg of interest. Corresponding 3D shapes of each bone of the shank and hindfoot were reconstructed (Materialise, Belgium). Six different techniques found in the literature were used to calculate the varus/valgus deformity, i.e., the inclination of the hindfoot in the frontal plane of the shank, and the distance between the ground and the metatarsal heads was calculated along with different solutions for the identification of possible calcifications. Starting with an accurate 3D reconstruction of the skeletal structures of the foot, a wide range of measurements representing the same angle of hindfoot alignment were found, some of them very different from each other. Interesting correlations were found between metatarsal height and subject age, significant in diabetic feet for the fourth and fifth metatarsal bones. Finally, CBCT allows 3D assessment of foot deformities under loaded conditions. The observed traditional measurement differences and new measurement solutions suggest that clinicians should consider carefully the anatomical and functional concepts underlying measurement techniques when drawing clinical and surgical conclusions

Introduction and Objective. Hip fractures represent one of the most challenging injuries in orthopaedic practice due to the associated morbidity, mortality and the financial burden they impose on the health care systems. By many still considered as the gold standard in the management of intertrochanteric fractures, the Dynamic Hip Screw utilizes controlled collapse during weight bearing to stabilize the fracture. Despite being a highly successful device, mechanical failure rate is not uncommon. The most accepted intraoperative indicator for lag screw failure is the tip apex distance (TAD), yet lateral femoral wall thickness (LWT) is another evolving parameter for detecting the potential for lateral wall fracture with subsequent medialization and implant failure. The aim of this study is to determine the mean and cut off levels for LWT that warrant lateral wall fracture and the implications of that on implant failure, revision rates and implant choice. Materials and Methods. This prospective cohort study included 42 patients with a mean age of 70.43y with intertrochanteric hip fractures treated with DHS fixation by the same consultant surgeon from April 2019 to December 2019. The study sample was calculated based on a confidence level of 90% and margin of error of 5%. Fracture types included in the study are 31A1 and 31A2 based on the AO/OTA classification system. LWT was assessed in all patients preoperatively using Surgimap (Nemaris, NY, USA) software. Patients were divided into two groups according to the post-operative integrity of the lateral femoral wall, where group (A) sustained a lateral femoral wall fracture intraoperatively or within 12 months after the index procedure, while in group (B) the lateral femoral wall remained intact. All patients were regularly followed up radiologically and clinically per the Harris Hip Score (HHS) for a period of 12 months. Results. At 12 months five patients (12%) suffered a postoperative lateral wall fracture, while in 37 patients (88%) the lateral femoral wall remained intact. The mean preoperative LWT of patients with a postoperative lateral wall fracture was 18.04 mm (SD ± 1.58) compared to 26.22mm (SD ± 5.93) in the group without a lateral wall fracture. All patients with post-operative lateral femoral wall fracture belong to 31A2 group, while 78.4% of the patients that did not develop post-operative lateral femoral wall fracture belong to 31A1 group. Eighty percent of patients in group (A) experienced shortening, collapse, shaft medialization and varus deformity. The mean Harris hip score of group (A) was 39.60 at 3 months and 65.67 at 6 months postoperatively, while that of group (B) was 80.75 and 90.65 at 3 and 6 months respectively, denoting a statistically significant difference (P<0.001). Treatment failure meriting a revision surgery was 40 % in group (A) and 8% in group (B) denoting a statistically significant difference (p<0.001). The cut-off point of LWT below which there is a high chance of post-operative lateral wall fracture when fixed with DHS is 19.6mm. This was shown on the receiver operating curve (ROC) by plotting the sensitivity against the 100 % specificity with a set 95% confidence interval 0.721 – 0.954. When lateral wall thickness was at 19.6 mm, the sensitivity was 100% and specificity was 81.8%. The area under the curve (AUC) was 0.838, which was statistically significant (P = 0.015). Conclusions. Preoperative measurement of LWT in elderly patients with intertrochanteric hip fractures is decisive. The cut off point for postoperative lateral wall fracture according to our study is 19.6 mm; hence, intramedullary fixation has to be considered in this situation

Objectives. The aim of this experimental study on New Zealand’s white rabbits was to investigate the transplantation of autogenous growth plate cells in order to treat the injured growth plate. They were assessed in terms of measurements of radiological tibial varus and histological characteristics. . Methods. An experimental model of plate growth medial partial resection of the tibia in 14 New Zealand white rabbits was created. During this surgical procedure the plate growth cells were collected and cultured. While the second surgery was being performed, the autologous cultured growth plate cells were grafted at the right tibia, whereas the left tibia was used as a control group. . Results. Histological examinations showed that the grafted right tibia presented the regular shape of the plate growth with hypertrophic maturation, chondrocyte columniation and endochondral calcification. Radiological study shows that the mean tibial deformity at the left angle was 20.29° (6.25 to 33) and 7.21° (5 to 10) in the right angle. . Conclusion. This study has demonstrated that grafting of autogenous cultured growth plate cells into a defect of the medial aspect of the proximal tibial physis can prevent bone bridge formation, growth arrest and the development of varus deformity. Cite this article: Bone Joint Res 2014;3:310–16

Supracondylar fractures of the humerus (SCFH) are the most common type of paediatric elbow fractures. Due to beliefs that non-operatively managed SCFH may displace further from the original position, they are monitored with repeated radiographs and a large number are unnecessarily surgically pinned. Very limited evidence currently exists to support these beliefs. This study aimed to determine the incidence of late “significant” displacement (requiring surgical management) of non-operatively managed paediatric SCFH, and whether they necessitate close radiographic follow-up. Patients aged ≤16, with a SCFH, were included in this retrospective cohort study. All were initially managed non-operatively with at least one follow-up radiograph within six weeks of injury. Data from four consecutive years (2013–2016) was collected using the hospital's radiology database. Two observers independently analysed patient radiographs and classified fractures by the Gartland and AO systems. The incidence of late displacement was determined using follow-up radiographs and clinic notes. Of the 164 patients included in the study, one patient (Gartland Type II, AO Type III) suffered late displacement at two weeks, requiring surgical fixation. One further patient (AO Type II) had a persistent cubitus varus deformity (Baumann's angle 90°), with no long-term functional deficit. Incidence of late displacement was 0.6% (n=1). Our findings suggest that stable Gartland Type I/AO Type I and II fractures do not require repeated radiographic follow-up. However, some Gartland Type II/AO Type III fractures require monitoring. This could considerably reduce the financial costs for the healthcare system, and inconvenience to families, associated with repeated follow-ups

Background. The optimal reference for rotational positioning of femoral component in total knee replacement (TKR) is debated. Navigation has been suggested for intra-op acquisition of patient's specific kinematics and functional flexion axis (FFA). Questions/Purposes. To prospectively investigate whether pre-operative FFA in patients with osteoarthritis (OA) and varus alignment changes after TKR and whether a correlation exists between post-op FFA and pre-op alignment. Patients and Methods. A navigated TKR was performed in 108 patients using a specific software to acquire passive joint kinematics before and after TKR. The knee was cycled through three passive range of motions (PROM), from 0° to 120°. FFA was computed using the mean helical axis algorithm. The angle between FFA and surgical TEA was determined on frontal (α. f. ) and axial (α. a. ) plane. The pre- and post-op hip-knee-ankle angle (HKA) was determined. Results. Post-op FFA was different from pre-op FFA only on frontal plane. No significant difference was found on axial plane. No correlation was found between HKA-pre and α. A. -pre. A significant correlation was found between HKA-pre and α. F. –pre. Conclusions. TKR modifies FFA only on frontal plane. No difference was found on axial plane. Pre-op FFA is in a more varus position respect to TEA. The position of FFA on frontal plane is dependent on limb alignment. TKR modifies the position of FFA only on frontal plane. The position of FFA on axial plane is not dependent on the amount of varus deformity and is not influenced by TKR

Total knee arthroplasty (TKA) is a common orthopaedic procedure. Traditionally the surgeon, based on experience, releases the medial structures in knees with varus deformity and lateral structures in knees with valgus deformity until subjectively they feel that they have achieved the intended alignment. The hypothesis for this study was that deformed knees do not routinely require releases to achieve an aligned lower limb in TKA. A single surgeon consecutive cohort of 74 patients undergoing computer navigated TKA was examined. The mechanical axes were taken as the references for distal femoral and proximal tibial cuts. The trans-epicondylar axis was taken as the reference for frontal femoral and posterior condylar cuts. A soft tissue release was undertaken after the bony cuts had been made if the mechanical femoro-tibial (MFT) angle in extension did not come to within 2° of neutral as shown by computer readings. The post-operative alignment was recorded on the navigation system and also analysed with hip-knee-ankle (HKA) radiographs. The range of pre-operative deformities on HKA radiographs was 15° varus to 27° valgus with a mean of 5° varus (SD 7.4°). Only two patients required a medial release. None of the patients required a lateral release. The post implant navigation value was within 2° of neutral in all cases. Post-operative HKA radiographs was available for 71 patients. The mean MFT angle from radiographs was 0.1° valgus (SD 2.1°). The range was from 6° varus to 7° valgus but only six patients (8.5%) were outside the ±3° range. The kinematic analysis also showed it to be within 2 degrees of neutral throughout the flexion making sure it is well balanced in 88% cases. This series has shown that over 90% of patients had limbs aligned appropriately without the need for routine soft tissue releases. The use of computer assisted bone cuts leads to a low level of collateral release in TKA

Rebound growth after hemiepiphysiodesis may be a normal event, but little is known about its causes, incidence or factors related to its intensity. The aim of this study was to evaluate rebound growth under controlled experimental conditions.

A total of 22 six-week-old rabbits underwent a medial proximal tibial hemiepiphysiodesis using a two-hole plate and screws. Temporal growth plate arrest was maintained for three weeks, and animals were killed at intervals ranging between three days and three weeks after removal of the device. The radiological angulation of the proximal tibia was studied at weekly intervals during and after hemiepiphysiodesis. A histological study of the retrieved proximal physis of the tibia was performed.

The mean angulation achieved at three weeks was 34.7° (standard deviation (sd) 3.4), and this remained unchanged for the study period of up to two weeks. By three weeks after removal of the implant the mean angulation had dropped to 28.2° (sd 1.8) (p < 0.001). Histologically, widening of the medial side was noted during the first two weeks. By three weeks this widening had substantially disappeared and the normal columnar structure was virtually re-established.

In our rabbit model, rebound was an event of variable incidence and intensity and, when present, did not appear immediately after restoration of growth, but took some time to appear.

Cite this article: Bone Joint J 2015;97-B:862–8.

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

A cavovarus foot deformity was simulated in cadaver specimens by inserting metallic wedges of 15° and 30° dorsally into the first tarsometatarsal joint. Sensors in the ankle joint recorded static tibiotalar pressure distribution at physiological load.

The peak pressure increased significantly from neutral alignment to the 30° cavus deformity, and the centre of force migrated medially. The anterior migration of the centre of force was significant for both the 15° (repeated measures analysis of variance (ANOVA), p = 0.021) and the 30° (repeated measures ANOVA, p = 0.007) cavus deformity. Differences in ligament laxity did not influence the peak pressure.

These findings support the hypothesis that the cavovarus foot deformity causes an increase in anteromedial ankle joint pressure leading to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.

The treatment of fractures of the proximal tibia is complex and makes great demands on the implants used. Our study aimed to identify what levels of primary stability could be achieved with various forms of osteosynthesis in the treatment of diaphyseal fractures of the proximal tibia. Pairs of human tibiae were investigated. An unstable fracture was simulated by creating a defect at the metaphyseal-diaphyseal junction. Six implants were tested in a uniaxial testing device (Instron) using the quasi-static and displacement-controlled modes and the force-displacement curve was recorded. The movements of each fragment and of the implant were recorded video-optically (MacReflex, Qualysis). Axial deviations were evaluated at 300 N.

The results show that the nailing systems tolerated the highest forces. The lowest axial deviations in varus and valgus were also found for the nailing systems; the highest axial deviations were recorded for the buttress plate and the less invasive stabilising system (LISS). In terms of rotational displacement the LISS was better than the buttress plate.

In summary, it was found that higher loads were better tolerated by centrally placed load carriers than by eccentrically placed ones. In the case of the latter, it appears advantageous to use additive procedures for medial buttressing in the early phase.