Varus ankle osteoarthritis (OA) is typically associated with peritalar instability, which may result in altered subtalar joint position. This study aimed to determine the extent to which total ankle replacement (TAR) in varus ankle OA can restore the subtalar position alignment using 3-dimensional semi-automated measurements on WBCT. Fourteen patients (15 ankles, mean age 61) who underwent TAR for varus ankle OA were retrospectively analyzed using semi- automated measurements of the hindfoot based on pre-and postoperative weightbearing WBCT (WBCT) imaging. Eight 3-dimensional angular measurements were obtained to quantify the ankle and subtalar joint alignment. Twenty healthy individuals were served as a control groups and were used for reliability assessments. All ankle and hindfoot angles improved between preoperative and a minimum of 1 year (mean 2.1 years) postoperative and were statistically significant in 6 out of 8 angles (P<0.05). Values The post-op angles were in a similar range to as those of healthy controls were achieved in all measurements and did not demonstrated statistical difference (P>0.05). Our findings indicate that talus repositioning after TAR within the ankle mortise improves restores the subtalar position joint alignment within normal values. These data inform foot and ankle surgeons on the amount of correction at the level of the subtalar joint that can be expected after TAR. This may contribute to improved biomechanics of the hindfoot complex. However, future studies are required to implement these findings in surgical algorithms for TAR in prescence of hindfoot deformity

Introduction:. Varus alignment of the knee is common in patients undergoing unicondylar knee replacement. To measure the geometry and morphology of these knees is to know whether a single unicondylar knee implant design is suitable for all patients, i.e. for patients with varus deformity and those without. The aim of this study was to identify any significant differences between normal and varus knees that may influence unicondylar implant design for the latter group. Methodology:. 56 patients (31 varus, 25 normal) were evaluated through CT imaging. Images were segmented to create 3D models and aligned to a tri-spherical plane (centres of spheres fitted to the femoral head and the medial and lateral flexion facets). 30 key co-ordinates were recorded per specimen to define the important axes, angles and shapes (e.g. spheres to define flexion and extension facet surfaces) that describe the femoral condylar geometry using in-house software. The points were then projected in sagittal, coronal and transverse planes. Standardised distance and angular measurements were then carried out between the points and the differences between the morphology of normal and varus knee summarised. For the varus knee group, trends were investigated that could be related to the magnitude of varus deformity. Results:. Several significant differences between normal and varus knees were found, but most of these were small differences unlikely to be clinically significant or have an influence on implant design. However, two strong trends were observed. Firstly, the version of the femoral neck was significantly less for patients with varus knees (mean difference 9°; p < 0.05). The second trend was a significant difference in the sagittal morphology of the medial condyle. The kink angle, the angle formed by the intersection of the circles fitted to the flexion and extension facet surfaces, and their centres (Figure 1) was either absent or small in normal knees (mean 1°). An absent kink angle occurs when the circle defining the flexion facet surface lies within or makes a tangent to the circle defining the extension facet. However, for varus knees, the mean kink angle was 9°, with positive correlation with the angle of varus deformity (Figure 2). Discussion:. Varus knees have a significantly larger kink angle than normal knees, influencing the relative positions of the flexion and extension facet spheres that define the medial condylar geometry, contributing to the commonly observed ‘flattening’ of the medial condyle in the sagittal plane. Varus knees are also associated with significantly less anteversion of the femoral neck. It has been shown that reduced femoral neck anteversion causes increased loading of the medial condyle [1], and our results support this finding. The data generated in this study will feed further biomechanical testing to investigate the influence of kink angle and femoral neck version on the kinematics and load distribution in the varus knee

Introduction. Varus alignment in total knee replacement (TKR) results in a larger portion of the joint load carried by the medial compartment. [1]. Increased burden on the medial compartment could negatively impact the implant fixation, especially for cementless TKR that requires bone ingrowth. Our aim was to quantify the effect varus alignment on the bone-implant interaction of cementless tibial baseplates. To this end, we evaluated the bone-implant micromotion and the amount of bone at risk of failure. [2,3]. Methods. Finite element models (Fig.1) were developed from pre-operative CT scans of the tibiae of 11 female patients with osteoarthritis (age: 58–77 years). We sought to compare two loading conditions from Smith et al.;. [1]. these corresponded to a mechanically aligned knee and a knee with 4° of varus. Consequently, we virtually implanted each model with a two-peg cementless baseplate following two tibial alignment strategies: mechanical alignment (i.e., perpendicular to the tibial mechanical axis) and 2° tibial varus alignment (the femoral resection accounts for additional 2° varus). The baseplate was modeled as solid titanium (E=114.3 GPa; v=0.33). The pegs and a 1.2 mm layer on the bone-contact surface were modeled as 3D-printed porous titanium (E=1.1 GPa; v=0.3). Bone material properties were non-homogeneous, determined from the CT scans using relationships specific to the proximal tibia. [2,4]. The bone-implant interface was modelled as frictional with friction coefficients for solid and porous titanium of 0.6 and 1.1, respectively. The tibia was fixed 77 mm distal to the resection. For mechanical alignment, instrumented TKR loads previously measured in vivo. [5]. were applied to the top of the baseplate throughout level gait in 2% intervals (Fig.1a). For varus alignment, the varus/valgus moment was modified to match the ratio of medial-lateral force distribution from Smith et al. [1]. (Fig.1b). Results. For both alignments and all bones, the largest micromotion and amount of bone at risk of failure occurred during mid stance, at 16% of gait (Figs.2,3). Peak micromotion, located at the antero-lateral edge of the baseplate, was 153±32 µm and 273±48 µm for mechanical and varus alignment, respectively. The area of the baseplate with micromotion above 40 µm (the threshold for bone ingrowth. [3]. ) was 28±5% and 41±4% for mechanical and varus alignment, respectively. The amount of bone at risk of failure at the bone-implant interface was 0.5±0.3% and 0.8±0.3% for the mechanical and varus alignment, respectively. Discussion. The peak micromotion and the baseplate area with micromotion above 40 µm increased with varus alignment compared to mechanical alignment. Furthermore, the amount of bone at risk of failure, although small for both alignments, was greater for varus alignment. These results suggest that varus alignment, consisting of a combination of femoral and tibial alignment, may negatively impact bone ingrowth and increase the risk of bone failure for cementless tibial baseplates of this TKR design

Insufficiency of the lateral collateral ligamentous complex causes posterolateral rotatory instability (PLRI). During reconstruction surgery the joint capsule is repaired, but its biomechanical influence on elbow stability has not been described. We hypothesized that capsular repair reduces ROM and varus angle after reconstruction of the lateral collateral complex. Six fresh frozen cadaveric elbow specimens were used. Varus laxity in supination, pronation and neutral forearm rotation with 1 Nm load and forearm rotaitonal range of motion (ROM) with 0.3 Nm torque were measured using a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four different conditions: Intact, Complete Tear with LUCL, RCL and capsule tear, LUCL/RCL reconstruction + capsule repair and LUCL/RCL reconstruction only. Reconstruction was performed according to the docking technique (Jones, JSES, 2013) and the capsule was repaired with mattress sutures. Each condition was tested in 30°, 60° and 90° elbow flexion. A two-way ANOVA with Tukey's post-hoc test was used to detect statistical differences between the conditions. Total ROM of the forearm significantly increased in all flexion angles from intact to Complete tear (p<0.001). ROM was restored to normal in 30° and 60° elbow flexion in both reconstruction conditions (p>0.05). LUCL/RCL Reconstruction + capsule repair in 90° elbow flexion was associated with a significantly lower ROM compared to intact (p=0.0003) and reconstruction without capsule repair (p=0.015). Varus angle increased significantly from intact to complete tear (p<0.0001) and restored to normal in both reconstruction conditions (p>0.05) in 30° and 60° elbow flexion. In contrast varus angle was significantly lower in 90° elbow flexion in both reconstruction conditions compared to intact (both p<0.0001). Reconstruction of the lateral collateral complex restores elbow stability, ROM and varus laxity independent of capsular repair. Over tightening of the elbow joint occurred in 90° elbow flexion, which was aggravated by capsular repair. Over all capsular repair can be performed without negatively affecting elbow joint mobility

Introduction. Varus positioning of cemented ‘composite beam’ stems is associated with increased risks of aseptic loosening and stem fracture. We investigated whether the incidence of varus malalignment of the Exeter polished, double taper design in a multicentre prospective study adversely affected outcome after total hip replacement (THR). Materials & Methods. A multicentre prospective study of 1189 THR was undertaken to investigate whether there is an association between surgical outcome and femoral stem malalignment. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of dislocation and revision, stem subsidence, quality of cementing. 938 (79.89%) were followed-up at five years. Results. 44 from a total of 1189 femoral stems (3.7%) were implanted in varus (=5° to the femoral axis). Pre-operative demographics and OHS were similar in both groups (p>0.05). Varus implantation was commoner after posterior than anterolateral approach (p< 0.001). Differences in the presence of femoral radiolucency, stem subsidence and quality of cement mantle were not significantly different (p>0.05). There was no difference in absolute OHS or OHS gain between the groups (neutral, mean = 40; varus, mean 40, p = 0.45, OHS gain neutral: 24, varus: 23, p=0.46). Differences in dislocation (p=0.54) or revision rates (p=0.35) were not significant. Conclusion. This study provides evidence that the Exeter stem may be tolerant of varus malalignment, both in terms of patient reported outcome and complication rate up to five years following surgery. Establishing whether aseptic loosening will be more common in the varus group will require longer follow-up

Introduction. Varus malpositioning of femoral stems has been recognised as a poor prognostic feature with regard to loosening and failure of cemented composite beam implants, but there have been no published results of the long-term effect on taper-slip designs. Objectives. To determine the results of varus placement of a polished triple tapered femoral stem. Methods. We have prospectively analysed the results of 350 consecutive polished triple-tapered C-Stem implants performed on 322 patients between March 2000 and July 2004, using a standard posterior approach and Palacos-R cement. All patients underwent annual clinical and radiological review. Results. The average duration of follow-up in surviving patients is 140 months (120–172 months). There were 49 femoral implants in 49 patients implanted with more than 5 degrees of varus (14%) with respect to the long axis of the femur, and 14 in 14 patients in more than 5 degrees of valgus (4%). Alignment within 5 degrees of neutral was achieved in 82% of cases. The average age in the varus group was 69.2 years (41–92), which was higher than in the neutral group (67.4 years: 25–89), more patients were male (49% v 36%) but the average BMI was similar (29 v 28). The average duration of follow-up was the same. There was only one re-operation in the varus group, which was a revision for deep infection. There was one dislocation successfully treated by closed reduction and one acetabular component is currently loose. In the neutral group there have been four dislocations, one of which required application of a PLAD; five revisions for aseptic loosening of the acetabular component associated with high wear rates, with a further three currently being loose; four intra-operative, undisplaced fractures of the greater trochanter; two peri-prosthetic femoral shaft fractures treated by internal fixation and two temporary nerve palsies. There has been no aseptic loosening of the femoral components in either group. Subsidence of the femoral stem within the cement mantle was noted in 96% of the entire series. There was no significant difference between the groups with respect to the degree of subsidence. In the varus group 78% subsided less than 2mm compared to 75% in the neutral group. None of the femoral implants in either group subsided more than 4mm and none demonstrated evidence of aseptic loosening or negative bone remodelling. Conclusion. Varus implantation of the femoral component was more common in older, male patients, but there was no increased risk of subsidence or loosening at a minimum follow-up of ten years

Introduction

John Insall described medial release to balance the varus knee; the release he described included releasing the superficial MCL in severe varus cases. However, this release can create instability in the knee. Furthermore, this conventional wisdom does not correct the actual pathology which normally exists at the joint line, and instead it focuses on the distal end of the ligament where there is no pathology.

We have established a new protocol consisting of 5 steps to balance the varus knee without releasing the superficial MCL and we tried this algorithm on a series of 115 patients with varus deformity and compared it to the outcome with a similar group that we have performed earlier using the traditional Insall technique.

The concept of constitutional varus and controversy regarding placing the total knee arthroplasty (TKA) in a neutral versus physiologic alignment in varus osteoarthritic (OA) patients is an important current discussion. However, the physiologic mechanical alignment of a varus OA knee is unknown and the relative contribution of the femur and tibia to the mechanical axis is unknown. The goal of this study was to determine and analyse the physiologic mechanical axis of medial OA knees.

Plain radiographs of the knee and full-leg standing radiographs of 1558 patients were reviewed for inclusion criteria; 313 patients with a non-arthritic knee and a contralateral varus end-stage OA knee were analysed in the coronal plane. The Hip-Knee-Ankle (HKA), Condylar-Hip (CH)(femoral), Condylar-Plateau (CP) (intra-articular) and Plateau-Ankle (PA)(tibial) angles were measured for both the arthritic and non-arthritic/physiologic knee. The relationship and contribution of all angles was analysed for every 2° degrees of progressive varus: from 4° valgus to 8° varus. The proportion of patients with constitutional varus was also determined for the sample population and correlated with increasing HKA.

The mean CH (femoral) angle was valgus in all groups and decreased with progressive varus alignment (p< 0.0001), ranging from 3.8° ± 1.0° with HKA of 2–4° valgus, to 0.1° ± 1.5° with HKA of 6–8° varus. The mean PA (tibial) angle was varus in all groups and decreased from valgus to progressively varus alignment (p p<0.0001), ranging from 0.78° ± 1.4° with HKA 2–4° valgus, to 5.6° ± 1.9° with HKA 6–8° varus. The CP angle showed no difference between all groups (p=0.3). Forty five percent of males and 22% of females with arthritic HKA in varus alignment were found to have constitutional varus.

Correlation of unilateral arthritic knees to the unaffected, physiologic aligned knee using full-leg radiographs indicates that it may be possible to understand the patient's physiologic, pre-arthritic coronal plane alignment. The mechanical axis of physiologic knees in a unilateral varus OA population demonstrates a variable contribution of the femur (CH) and tibia (PA) from overall valgus to varus alignment. In addition, a significant proportion of the sample population possessed constitutional varus. This may provide important information regarding the placement of physiologic TKA's and direct future research questions.

Background:. Varus or Valgus malpositioning of tibial prosthetic components in total knee replacement (TKR) surgery may lead to early failure due to increased polyethelene wear, soft tissue imbalancing, aseptic loosening and eventually revision surgery. Therefore, the clinical success of total knee arthroplasty (TKA) correlates with good component alignment. Conventional methods of coronal tibial alignment result in an acceptable range of prosthetic alignment in relation to the anatomical axis (tibial tangent angle). The measurement ranges from 90° ± 3°, but literature quotes that there is up to 27% of cases with coronal tibial alignment deviation of greater than 3°. Many studies show that the use of conventional intramedullary rod alignment versus extramedullary rod alignment gives similar results. The tibial alignment and overall prosthetic alignment in TKA has improved remarkably by using computerized navigation assisted surgery (CAS), with tibial tangent angle of 90° ± 3 in up to 97% of cases. However, the success of accurate tibial and femoral alignment depends on the surgeon and the data fed to the computer. Also long term results on survival rates of TKR using CAS is still pending. It is clear that assessing tibial alignment (ie. anatomical axis) with whatever method used faces challenges which will affect the tibial bony cuts and the final tibial tangent angle. To achieve a 90° tibial cut in relation to the anatomical axis we made use of fluoroscopy intra-operatively to assess the anatomical axis of the tibia and the correct alignment of the tibial cutting block. Methods:. TKR's were performed on 36 consecutive patients over a 4 month period. The aim was to assess the coronal tibial alignment of the tibial component intra-operatively using fuloroscopy. A conventional manual extramedullary alignment rod with its tibial cutting block was used and the final positioning was confirmed with an image intensifier. The tibial cutting block must be at 90° to the anatomical axis of the tibia. The rest of the TKR procedures were performed as routinely described. Post-operative radiographs were taken on the same day as the surgery and again at six week follow up visit when the tibial tangent angle was measured. Results:. The coronal tibial angulation was consistent at 0° in 32 knees with a 1°–2° deviation in 4 knees. Conclusion:. We conclude that the use of fluoroscopy intra-operatively can improve the tibial component alignment and thus decrease the cumulative errors which have significant and dramatic effects on the function and the longevity of the total knee prosthesis

Introduction. By all developments of new technologies on the improvement of the Total Knee implantation, the discussion about the optimum Alignment is in full way. Besides, is to be considered, that Alignment contains not only static, but also dynamic factors and beside the frontal plan also the sagittal plan as well as in particular the rotation in femur and tibia have a great importance for the outcome after TKR. However, beside the bone alignment, the kapsulo-igamentous structures also play an important role for the results after TKR. If a Varus-Malalignment was valid, in the past the „older” literature described it as a big risk factor for pain, less function and durability. However, in the present literature, we discuss more and more about the optimum Alignment during TKR. In particular, newer publications show no interference of the durability with coronar Alignment also outside from 3 °, also the score results and patient's satisfaction seem to deliver no worse results with slight untercorrection of the varus alignment. Some publications described even better score results and Patient satisfaction with slight untercorrection. Condition for it is probably an exact balancing of the extension and flexion gap. Material and method. With a new developed instruments it was examined with a tibia and extensions-Gap-First-Technique, to what extent a correction of the AMA opposed after digital planning within from 3 ° in distal femur a balancierung of the extension gap could be reached under avoidance of 3° releases with a varusarthritis oft the knee. 103 directly knee arthroplasties following on each other were selected with Varus-OA without exclusion criteria. Surgical technology. Midvastus-Approach, mostly in LIS technology. Besides, tibial 1–2 ° release and the following resection of the exophytes medial, lateral and intercondylar. External adjustment of the proxima tibia cut, place adjustable (Varus/Valgus, Slope) cutting block, control of the varus-(valgus position and slope after Fixation and if necessary postcorrection of these parameters. Resection of the proximal tibia. Next intramedullar adjustment of teh ditals femur cut according digital planning and fixation the adjustable/Varus/Valgus) cutting block for the distal femur resection. Insert the the ligament balancer between the promiumal tibia cut and the the dital femur in extension and examination of the parallelism between prox. Tibia and planned distal femur resektion with the same tension medial and lateral. If necessary correction of the cutting block within 3 ° to the achievement of a balanced extension gap, otherwise further releases necessary to create a balanced extension gap. Distale Femurresektion. Insert the the ligament balancer again between the promimal tibia cut and the the posterior femur condyles in 90° flexion with the same tension medial and lateral. Next step is to transfer the proximal tibia cut on distal Femur to determine femur rotation in gap balance technology. Fixation of the new developed sizing instrumet, final definition of the implant size of the femur according anterior and posterior referencing to avoid undercuts or overstuffing anterior and a reconstructi the posterior offset. Drilling of the admission holes for the 4 in 1 cutting block and at first posterior re section with following resection of posterior exophytes and the possibility of a posterior capsule release. Adapt the extension gap on the flexion gap by means of modular spacer blocks and perhaps necessary postresection oft he distal femur. Now realisation of the remaining femoral cuts with the 4 in 1-cutting block. Results. With 102 of 103 knee prosthesis implantations with Varus-OA a balancing of the extension gap could be realized, outgoing by the presurgical planning with max. 3 ° corrections on the distal femur cut. Only in a 1 case, a 3° release was necessary to achieve a balanced extension gap. The rotation according the posterior condyles with 102 within 3 ° correctable VarusOA lay between 0 and 8 ° with a frequency summit between 4 and 6 °. Summary. With the described Surgical technology by use a ligament tensioner and new developed instruments the balancing of the extension gap with slight to avarage medial release could be carried out in nearly all cases, so that the rotation could take place in these cases also in Gap-balance technology. Therefore it is possible with this technology beside a bone-saving TKR also sparing the capsulo-ligamtous structures. This thereby still wins on importance, that after newer literature data the kapsulo-ligamentous structures show a more physiological tension, in contrast to the correction to the neutral position, with light untercorrection of the preexistently varus deformity. In a projected prospektiv multicenter study we like to find answers to the questions about constitutional or residual Varus-Alignment after TKR in Varus-OA. Further question is if we can also compiled a sure zone within which an untercorrection is admissible

Introduction

Accurate assessment of alignment in pre-operative and post-operative knee radiographs is important for planning and evaluating knee replacement surgery. Existing methods predominantly rely on manual measurements using long-leg radiographs, which are time-consuming to perform and are prone to reliability errors. In this study, we propose a machine-learning-based approach to automatically measure anatomical varus/valgus alignment in pre-operative and post-operative standard AP knee radiographs.

Abstract

Introduction. Varus alignment of the femoral component in total hip arthroplasty (THA) is thought to be a risk factor for implant loosening and early revision surgery. The purpose of this study was to evaluate whether the Exeter stem tolerates varus alignment and assess if this theoretical malalignment has an influence on clinical outcomes. Methods. A total of 4126 consecutive THAs were reviewed for patients between 2006 and 2012 to allow for a minimum five-year follow-up. To determine the effects of the stem alignment on results, the hips were classified into 3 groups on the basis of stem alignment in initial postoperative anteroposterior radiographs. The alignment of the stem was defined as neutral, valgus (≥ 3° of lateral deviation), or varus (≥ 3° of medial deviation). The primary outcome was all cause revision with patient related outcomes assessed with Oxford hip score pre and post-operatively. Results. The mean follow-up period was 8.6 years. 3803 (92.2%), 48 (1.2%), and 275 (6.7%) hips were assessed as neutral, valgus, and varus alignment, respectively. Assessment of outcomes showed that 75 revision surgeries (1.8%) were performed during follow-up for a variety of causes but there was no significant difference in the revision rate among the 3 alignment groups. No stems were revised for aseptic loosening in any of the three groups. Oxford Hip scores were obtained at a mean of 4.6 years post-operatively and no significant difference in patient reported outcome was identified between the different alignment groups. Conclusion. This study suggests that the Exeter stem tolerates varus alignment well with no demonstrable effect on revision rate or patient reported outcome. This tolerance of malposition compared to the negative results reported in the literature with other stem designs can be of reassurance to surgeons using the Exeter system

Background

Iatrogenic hallux varus is a rare complication after hallux valgus surgery. Operative treatment comprises a wide variety of techniques, of which the reversed transfer of the abductor hallucis tendon is the most recent described technique.

Historically, cemented THA femoral stems inserted in varus have yielded poor clinical results. Very few studies to date have addressed the question of the effects of varus alignment on uncemented stems. We have conducted a retrospective review of one hundred and twenty-five uncemented THA femoral stems implanted by a single surgeon from 1994 to 1999. Within this single surgeon group we were able to identify sixteen stems implanted in varus and thus proceeded to analyze the effect of varus alignment on functional outcome. To assess functional and radiographic outcome of uncemented primary THA femoral stems implanted in varus. After four-years of follow-up, there have been no radiographic or clinical problems associated with implanting uncemented femoral stems in varus. Although it is not recommended to implant stems in varus, radiographic and clinical problems associated with implanting uncemented femoral stems in varus appear to be non-consequential. Of the study sample, one hundred and sixteen hips were in neutral alignment as compared to sixteen varus hips. We could not show any significant difference in Harris Hip scores between the varus and non-varus hips (p> 0.5). No cases showed evidence of radiographic loosening, or subsidence (p=0.3) at four-year follow-up. Retrospective radiographic review of one hundred and twenty-five uncemented primary THA femoral stems implanted by a single surgeon (now retired) from 1994 to 1999, using the Watson-Jones approach, identified sixteen femoral stems implanted in varus. These sixteen stems were matched 1:1 for demographics and preoperative diagnosis to a cohort of sixteen non-varus uncemented stems implanted by the same surgeon over the same study period. Functional outcome included Harris Hip score and range of motion at four-years postoperative. Radiographic signs of loosening and subsidence, defined as > 2mm, were measured. Varus alignment was defined as ≥ 5°. Paired t-tests were conducted on all outcome variables, p< 0.05 was considered statistically significant. Study results suggest there to be no consequence of varus femoral alignment in uncemented stems. Patients will need to be followed for a longer duration to further examine the effects of varus implantation of unce-mented femoral stems

Femoral components used in total hip arthroplasty (THA) rely on good initial fixation determined by implant design, femoral morphology, and surgical technique. A higher rate of varus alignment may be of specific concern with short stem implants. Varus placement in uncemented femoral components has been proven not to be detrimental to clinical function; though long-term bone remodeling secondary to varus placement remains unknown. The goal of this study was to compare the clinical and radiographic outcomes in patients who underwent THA with one of two uncemented short stem metaphyseal engaging implants at minimum two-year follow-up. A review of 105 patients (average age 65 years; BMI 29 kg/m. 2. ) who underwent a total of 109 primary THAs using the ABG II short stem femoral implant (Stryker, Mahwah, NJ), and 160 hips in 149 patients (average age 70 years; BMI 28 kg/m. 2. ) who underwent primary THA using the Citation stem (Stryker, Mahwah, NJ). The same surgeon (SDS) performed all surgeries through a less invasive posterolateral approach. Pre-operative and post-operative Harris Hips Scores (HHS) and WOMAC scores were collected. Digital radiograph analysis was performed including measuring the stem alignment relative to the femoral shaft. A stem placed with greater than 5 degrees of varus was considered to be in varus. There was no significant difference in demographics (age, gender or BMI) or pre-operative HHS and WOMAC scores between the two groups. Follow-up HHS was 90 (range 63–100) and 94 (range 70–100) for the ABG II and Citation groups, respectively. Follow-up WOMAC scores were 10 (range 0–24) and 6 (range 0–43) for the ABG II and Citation groups, respectively. There was no statistically significant difference in any of the scores between the two groups (p>0.05). When looking at AP radiographs for postoperative intramedullary alignment, none of the ABG II implants were placed in varus (>5°), while a small number (4.9%) of Citation implants were implanted in varus alignment. No significant difference was observed in the alignment between the two groups (p>0.05). Average post-op alignment with the ABG was 1.10° (range −4.7–4.9°) and 0.88° (range −4.5–8.9°) with the Citation. The clinical results associated with the use of these stems in patients of all ages and bone types have been identical to those achieved by uncemented stems of standard length. Both implants in this study had excellent clinical and functional results in primary THA after a minimum 24-month follow up. In addition, postoperative radiographic analysis demonstrated that these stems can be reliably and reproducibly placed in neutral alignment despite their short length. The lateral flare on the Citation implant led to a greater number of implants in varus alignment, potentially affecting offset and leg-length, yet the relative increased incidence compared to the ABG II was not significant. Further research is needed in designing implants that optimize proximal femoral contact while maintaining alignment and overall hip kinematics

Introduction

Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results.

Objective

To analyze the short-term outcome after medial open-wedge high tibial osteotomy with a 3D-printing technology in early medial keen osteoarthritis and varus malalignment.

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended

Introduction

Studies have shown that dissatisfaction following TKA may stem from poor component placement and iatrogenic factors related to variability in surgical execution. A CT-based robotic assisted system (RA) allows surgeons to dynamically balance the joint prior to bone resection. This study aimed to determine if this system could improve TKA planning, reduce soft tissue releases, minimize bone resection, and accurately predict component size in varus knee.