Background:. It has been suggested that double-level osteotomy can prevent the occurrence of joint line obliquity (JLO), as one of the complications following high tibial osteotomy (HTO). In this study, we aimed to compare the preoperative distal femoral and proximal tibial obliquity in patients with primary genu varum with a group of normal subjects (without genu varum). Materials and methods:. 75 patients with primary genu varum and 75 normal persons, contributed to a case-control study. The medial distal femoral mechanical angle (MDFMA), medial proximal tibial mechanical angle (MPTMA), joint diversion angle (JDA) and femoral and tibial JLO were measured and compared between the two groups. The percentage of patients' with > 4 degrees of JLO in both distal of femur and proximal of tibia, were then determined. Results:. The mean of MDFMA and MPTMA were significantly lower and JDA and femoral and tibial JLO were significantly higherin genu varum group (p < 0.05). Double-level osteotomy was required in 25.3% of patients with genu varum to prevent post-operative JLO. Conclusion:. JLO is a common finding in patients with genu varum and normal group; however, it is significantly higher in patients with genu varum

Introduction. Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. Materials and Methods. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23). Results. There were two cases lost to follow-up with a median follow-up period 17 months (range 1–32 months). Union was achieved in all cases, with 1/23 requiring revision for early fixation failure for technical reasons. The median time to radiographic union 3.2 months (95% Confidence Interval (CI) 2.5–3.8 95% CI). CT scans demonstrated early periosteal callus, beneath the osteoperiosteal flap, bridging the opening wedge cortex. Clinical union occurred at 4.1 months (95% CI 3.9–4.2 months). Complications included superficial surgical site infection (1/23), deep vein thrombosis (1/23), and symptomatic metalwork requiring removal (7/23). Conclusions. The osteoperiosteal flap technique was a safe and effective technique for opening wedge osteotomies around the knee with a reliable rate of union

Purpose:. Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the present study was to evaluate the results of the original Ertl procedure in skeletally immature patients, and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth. Methods:. Four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth and the medial proximal tibial angle (MPTA). Results:. The best mean PEQ result in the Question section was 91.8 (Range 74–100) for ‘Well being’ and the worst mean score was 66.6 (Range 50–78) for the sub-section ‘Residual limb health’. Examination of the residual limbs revealed no bursae were present and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 months (Range 1–2). One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum. Conclusions:. In this series, the original Ertl osteomyoplasty shows good functional and prosthetic use with only one bony overgrowth requiring revision surgery

Introduction. Angular deformity in the lower extremities can result in pain, gait disturbance, deformity and joint degeneration. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the mechanical axis. To assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this simple and elegant procedure. Materials and Methods. We reviewed the surgical records and imaging in our tertiary children's hospital to identify all patients who had guided growth surgery since 2007. We noted the patient demographics, diagnosis, peri-operative experience and outcome. All patients were followed until skeletal maturity or until metalwork was removed. Results. 173 patients with 192 legs were assessed for eligibility. Six were excluded due to inadequate follow-up or loss of records. Of the 186 treated legs meeting criteria for final assessment 19.8% were unsuccessful, the other 80.2% were deemed successful at final follow up. Complications included infection and metal-work failure. Those with a pre-treatment diagnosis of idiopathic genu valgum/ varum had a success rate of 83.6%. Conclusions. In our hands, guided growth had an 80-percent success rate when all diagnosis were considered. Those procedures that were unlikely to be successful included growth disturbances due to mucopolysaccharide storage disease, Blounts disease and achondroplasia. Excluding those three diagnoses, success rate was 85.4%. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity

Instability currently represents one of the main causes of residual pain and symptoms following TKA and thus is a major cause of revision total knee replacement, second only to component loosening in some series. Instability related to ligamentous laxity can be categorised by the pattern of relative laxity of the soft tissue structures and this in turn helps in determination of the bony alignment issue, component sizing or positioning problem or ligamentous abnormality that may be contributory and require correction. Instability patterns associated with TKA can be symmetrical and global type instability where there is laxity in all planes, and can also more commonly be asymmetrical or isolated laxity problems where there is good stability in some planes or positions of the knee but excessive laxity in at least one direction. Isolated laxity problems can be subcategorised into one of 3 patterns: Extension instability, Flexion instability, and Recurvatum. Global laxity can occur due to inadequate tibial component thickness, or globally incompetent soft tissues, and can present initially after TKA or alternatively can present late from slow stretch of soft tissues over time as can be seen with some pathologic states. Asymmetrical or Isolated laxity occurs in the sagittal plane when medial vs. lateral “gaps” are unequal and may be due to contracture of tight structures either medially or laterally or can be due to insufficiency or injury of the ligamentous structures on one side vs. the normal structures on other side. Occasionally there is a combination of both contracture on one side and attenuation/stretch on the other side as seen in some patients with severe long standing genu varum or genu valgum. Asymmetrical laxity in the frontal plane generally results in unequal extension vs. flexion “gaps”. This can cause either anteroposterior laxity in flexion but full extension with good stability or alternatively, there may be AP stability in flexion but a lack of full extension in the presence of the exact same pattern of imbalance when a “too thick” polyethylene insert is used to correct what would otherwise be flexion instability. In both cases, the extension gap is tighter than the flexion gap. Isolated recurvatum occurs when the posterior capsular structures are relatively lax or deficient so that a knee that is otherwise stable in the medial-lateral plane in extension, and is stable in the AP plane when in flexion, hyperextends in the fully extended position. In any TKA procedure (but especially revision for instability) it is critical to understand the effect of selected bone resection (or build ups) on soft tissue balancing in order to avoid or treat ligamentous laxity: distal femur – effects extension gap only; posterior femur – effects flexion gap only; proximal tibia – both flexion and extension spaces. During revision for instability, careful evaluation of the cause of the laxity and failure is critically important, especially if there is associated axial deformity or malalignment which generally must be corrected for any reconstruction or revision components to work. Most knees revised for instability issues will require a posterior stabilised or constrained condylar design. Constrained condylar implants are used to compensate for residual medial-lateral imbalance still present after standard soft tissue releases medially (subperiosteal tibia) or laterally (vis selective pie-crust method). However, if the patient displays residual major medial-lateral or global instability that cannot be corrected, or when there is an excessive flexion gap that cannot be stabilised with maximal allowable component sizing, a rotating hinge constrained total knee replacement design may be required. Recent data has shown that rotating hinges can work reliably in restoring stability to the knee in such cases with satisfactory durability and clinical results over time

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

Hypothesis. The use of cartilage compensated virtual standing CT images for pre surgical planning improves the reliability of preoperative planning. Materials and Method. Sampling included in this study were > 62 years of age (mean age 58.17 yrs ±3.54 yrs, range 55–62) with symptomatic isolated medial osteoarthritis, genu varum (mean varus 5.6°±2.6 °, range 2.1°–8.6°), good range of motion (flexion > 90° and flexion contracture < 10°) and with minimal ligamentous instability. All subjects had obtained a pre-op CT scan, MRI scan and weight-bearing long bone x ray. Post-op CT and long standing x-rays were taken prior to hospital discharge. A virtual software suite (HTO-OP3D, Zapalign Inc, Seoul, Korea) was utilised to determine an optimal osteotomy site, hinge location and a gap necessary to achieve the targeted virtual passing point. Prerequisite to performing the necessary calculations a virtual standing pose for each patient specific bone models was created using the following steps. To transfer the pre surgical plan intra-operatively, a customised alignment jig was manufactured. Results. Analysing the data using three dimensional imagery the femorotibial angle was corrected from a mean varus 5.5° ±2.3 ° (range 2.1°–8.6°) to a mean valgus 4.1° ±1.1° (range 2.9°– 6.1°). There was no statistical difference [p = 0.514] between the virtual simulatedpre-op valgus vs actual post-op valgus results extrapolated from the post op CT data {−0.18° ±0.3° (range −0.7°–1.0°)}. Analysing the same parameters using two dimensional standard X-rays, the femorotibial angle was corrected from a mean varus 6.6° ±2.9 ° (range 3.4°–10.6°) to a mean valgus 3.9° ±1.2° (range 2.9°–6.1°) respectively showing no statistical difference in average change in alignment measured using both modalities [p = 0.13]. The mean opening gap calculated using the three dimensional imagery vs two dimensional were 8.2mm ±2.9mm (range 5mm – 12mm) and 13.3mm ±3.3mm (range 10.2mm – 17.6mm) respectively, the difference between these data sets being statistically different [p = 0.03059]. The post operative evaluation of the posterior slope showed no statistical difference [p = 0.371] between the native slope {11.6° ±3.7° (range 5.3°–15.0°)} vs the post operative tibial slope {11.6° ±3.6° (range 6.2°–16.1°)} respectively indicating that the patients slope was well preserved. Conclusion. The use of patient specific bone model images superimposed into a cartilage compensated full extension simulated weight bearing pose and used to calculate the femorotibial corrective alignment and opening gap produces predictable results that is not influenced by the condition of the patients soft tissue. Corrective angles and opening gap calculations using two dimensional weight bearing X-rays does not always relate to good surgical outcome, primarily due to the influence of laxity on the alignment in standing pose. Furthermore, a patient specific clamping type surgical guide is effective to implement the pre surgical and aid in maintaining the tibial slope

Navigation of Uni knee arthroplasty (UKA) is not common. Usually the software includes navigation of the tibial as well as the femoral implant. In order to simplify the surgical procedure we thought that navigation of the tibial plateau alone could be a good option. Since 2005 we have been using a mobile bearing UKA of which the ancillary is based on dependent bone cuts. The tibial cut is made first and the femoral cut is automatically performed using cutting blocks inserted between the tibial cut and the distal end of the femur. Although we are satisfied with this procedure, it is not rare we have some difficulties getting the right under correction needed to get a good long-term result. The aim of this paper was to present our computer-assisted UKA technique and our preliminary radiological results in genu varum (17 cases) as well as genu valgum (6 cases) deformities. The series was composed of 23 patients, 10 females and 13 males, aged from 63 to 88 years old (mean age: 75 +/− 8). The mean preoperative HKA (Hip-Knee-Ankle) angle was: 172.35° +/− 2.31° (167° to 176°) for the genu vara and 186.33° +/− 2.87° (182° to 189°) for the genu valga. The goal of the navigation was to get an HKA angle of 177° +/− 2° for genu varum deformity and 183° +/− 2° for genu valgum. We used the SURGETICS® device (PRAXIM, GRENOBLE, FRANCE) in the first six cases and the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY) in the other cases. The principles are the same for both devices. The 1rst step consists in inserting percutaneously the rigid-bodies on the distal end of the femur and on the proximal end of the tibia. Then, we locate the center of the hip by a movement of circumduction, the center of the ankle by palpating the malleoli and the center of the knee by palpating intra articular anatomic landmarks to get the HKA angle in real time. This step is probably the most important because it allows checking the reducibility of the deformity in order to avoid an over correction when inserting a mobile bearing prosthesis. The 3. rd. step consists in navigation of the tibial cut such as the height of the resection, the tibial slope (3 to 5° posterior tibial slope) and the varus of the implant (2 to 3°). Once the tibial cut was done, we must use the conventional ancillary to perform the femoral bone cuts (distal and chamfer). The last step consists in inserting the trial implants and checking the HKA angle and the laxity of the medial or lateral side. We used postoperative long leg X-Rays to evaluate the accuracy of navigation and plain radiographs to evaluate the right position of the implant. As far as genu varum deformity was concerned, the mean postoperative HKA angle was 177.23° +/− 1.64° (173°–179°). The preoperative goal was reached in 94% of the cases. Moreover, this angle could be superimposed on the peroperative computer-assisted angle, which was 177° +/− 1.43° (p>0.05). For genu valgum, the mean postoperative HKA angle was 181° +/− 1.41° (179°–183°). The preoperative goal was reached in 66% of the cases but the series is too short to give any conclusion. The navigation of tibial plateau alone can be used with accuracy, provided one has the right ancillary to use dependent bone cuts. The procedure is quick and needs only one tibial cutting guide equipped with a rigid-body. Our results, especially in genu varum deformity, are quite remarkable. Regarding genu valgum, the results seem to be less accurate, but the software was designed for medial UKA and the series is short, so, it is too soon to extrapolate any conclusion. The main interest in this navigation is to avoid too much under correction and even better to avoid over correction when the deformity is over reducible. Indeed, when one uses a mobile bearing plateau, the risk is to have a dislocation of the meniscus. So, when tightening the collateral ligaments, checking the lower limb axis may persuade not to use a mobile bearing plateau but rather a fixed plateau

Double level osteotomy (DLO) for severe genu varum is not a common technique. We performed our first computer-assisted double level osteotomy (CADLO) in March 2001 and we published our preliminary results in 2005 and 2007. The rationale to perform this procedure is to avoid oblique joint line in order to have less difficulty in case of revision to a total knee arthroplasty (TKA). The goal of this paper is to present the results of 37 cases operated on between August 2001 and January 2010. The series was composed of 35 patients (two bilateral), nine females and 26 males, aged from 39 to 64 years old (mean age: 50.5 +/− 7.5). We operated on 20 right knees and 17 left ones. The mean BMI was 29.3 +/− 4.3 for a mean height of 1.71 m and a mean weight of 85.8 kg. The functional status was evaluated according to the LYSHÖLM and TEGNER score. The mean score was of 42.4 +/− 8.9 points (22–69). According to modified AHLBÄCK criteria we operated on seven stage 2, 22 stage 3, five stage 4 and two stage 5. We measured HKA (Hip-Knee-Ankle) angle using RAMADIER's protocol and we also measured the femoral mechanical axis (FMA) and the tibial mechanical axis (TMA) to pose the right indication. These measures were respectively: 168° +/− 3.4° (159°–172°), 87.5° +/− 2.1 (83°–91°) for the FMA and 83.7° +/− 2.6° (78°–88°) for the TMA. The inclusion criteria were a patient younger than 65 years old with a severe varus deformity (more than 8° − HKA angle ≤ to 172°) and a FMA at 91° or less. All the osteotomies were navigated using the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY). The procedure was performed as follows: after inserting the rigid-bodies and calibrating the lower leg, we did first the femoral closing wedge osteotomy (from 4 to 7 mm) which was fixed by a an AO T-Plate, and secondly, after checking the residual varus, the high tibial opening wedge osteotomy using a BIOSORB® wedge (Tricalcium phosphate) and a plate (AO T-plate or C-plate). The goals of the osteotomy were to achieve an HKA angle of 182° +/− 2° and a TMA angle of 90° +/− 2°. The functional results were evaluated using the LYSHÖLM-TEGNER score and the KOOS score. The patients answered the questionnaire at revision or by phone, and the radiological results were assessed by plain radiographs and standing long leg X-Rays between three and six months postoperatively. We had no complication in this series but one case of recurrence of the deformity related to an impaction of the femoral osteotomy on the medial side. Two patients were lost to follow-up after removing of the plates (24 months) but were included in the results because the file was complete at that date. All the patients were assessed at a mean follow-up of 43 +/− 27 months (12–108). The mean LYSHÖLM-TEGNER score was 78.7 +/− 7.5 points (59–91) and the mean KOOS score was 94.9 +/− 3.3 points (89–100). Thirty-five patients were satisfied (18) or very satisfied (17) of the result. Only two were poorly satisfied. Regarding the radiological results, if we exclude the patient who had a loss of correction, the goals were reached in 32 cases (89%) for the HKA angle and in 31 cases (86%) for the TMA with only one case at 93°. The mean angles were: 181.97° +/− 1,89° (177°–185°) for HKA, 89.86° +/− 1,85° (85°–93°) for TMA and 93.05° +/− 2.3° (89°–99°) for FMA. At that mid-term follow-up no patient had revision to a total knee arthroplasty. DLO is a very demanding technique. Navigation can improve the accuracy of the correction compared to non computer-assisted osteotomies. The functional results are satisfying and the satisfaction of the patients is very high. Despite the difficulty of the procedure, complications are, in our hands, very rare. We recommend DLO for severe genu varum deformity in young patients to avoid oblique joint line, which will be difficult to revise to TKA

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.