Introduction: This study reports a technique and result in the application of an intramedullary tibial nail for patients undergoing an open-wedge proximal tibial osteotomy. Materials and Methods: Fourteen knees of 10 patients with genu varum were treated with proximal tibial osteotomy using an intramedullary tibial nail. The average age at the time of operation was 25 years old. Tibial osteotomy was performed percutaneously through multiple drilling from the average 8.7cm below the joint line and no bone graft was performed in all cases. Concomitant fibular osteotomy was performed in 9 cases. The clinical and radiographic records were reviewed for a minimum 2 years follow up. Result: Union of the osteotomy site was obtained in all knees at a mean of 3.5 months in both anteroposterior and lateral radiographs. The mean postoperative correction angle was 11 degrees in femorotibial angle in frontal plane (P< 0.05). But significant change of tibial posterior slope was not determined (P> 0.05). The osteotomized tibia was lengthened average 6mm in postoperative anteropsterior radiograph. Range of motion of the knee was full at the latest follow up. There was no significant complication such as infection, deep venous thrombosis, nerve palsy, or implant failure. Conclusion: Open-wedge proximal tibial osteotomy using an intramedullary tibial nail for genu varum provides firm initial stability and early rehabilitation. Furthermore, there is no need of bone graft and no significant alteration in tibial slope after surgery. Thus this technique can be a viable option for the proximal tibial osteotomy in the treatment for genu varus

Opening wedge proximal tibial osteotomy has become more popular in recent years, particularly in the management of medial compartment osteoarthritis. Unfortunately, fixation failures and/or non-unions of this osteotomy still occur. The aim of this study is to review two cases of failed opening wedge osteotomies salvaged with the Taylor Spatial frame. Both cases were reviewed clinically and radiographically and an analysis of their deformity was carried out. If required, metalware was removed and the Spatial frame applied and the deformity gradually corrected with either repeat osteotomy (case 1) or distraction of the non-union (case 2) until ideal alignment had been achieved. When the osteotomy regenerate had satisfactorily hardened, the frame was removed, and the patients were initially protected in a range of motion brace. Both patients achieved the desired correction of their deformities and union of their osteotomies, and had the frames removed at an average of 124 days following application. The Taylor Spatial frame is a very powerful tool for correcting complex multi-apical deformities in the juxta-articular region of the proximal tibia through minimally invasive techniques

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporizing measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7- to 10-year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intra-operatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure.

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporizing measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7 to 10 year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intraoperatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure.

Closing wedge tibial osteotomy has been the gold standard in proximal osteotomy procedures to correct uni-compartmental osteoarthritis. Opening wedge tibial osteotomies are achieving similar long-term results while avoiding some of the pitfalls of the closing wedge procedure. Opening wedge osteotomies maintain patellar length, tibial inclination, and proximal tibia bone stock. This allows for a technically easier conversion to a total knee arthroplasty in the future.

The purpose of this study was to assess the functional outcomes as well as the anatomical changes caused by opening wedge high tibial osteotomy

Opening and closing wedge osteotomies have been shown to have near equivolent long-term results. Using functional outcome studies (SF-36 and WOMAC ) and radiographic review we have shown good outcomes while maintaining the original anatomy of the knee.

Opening wedge tibial osteotomy will allow for a less complicated conversion to a total knee arthroplasty than the closing wedge tibial osteotomy

The patients attained a significant valgus correction that was maintained postoperatively (pre-op 6.12 varus to 5.5 valgus)

Clinical status of the patient was improved significantly in the functional outcomes testing using the WOMAC knee score( pre-op value 29.75 to 19.5; p = 0.0318 ) and the SF-36 ( pre-op value 64.4 to 81.7; p = 0.0035 ).

Patellar height (Pre-op Insall-Salvati ratio 1.15 to 1.09; p = 0.2339 ) and tibial inclination( pre-op 7.3 degrees to 6.85 degrees; p = 0.6743 ) were maintained.

This study retrospectively examined twenty-two patients with medial joint uni-compartmental osteoarthritis. Radiographic review of the pre-operative and post-operative films assessed the valgus correction, patellar height, and tibial inclination. The patients were seen in follow-up to assess the clinical exam and functional outcomes were measured using the SF-36 and WOMAC knee scores.

Opening wedge HTO is able to achieve acceptable correction of deformity while maintaining the normal anatomy of the knee.

Closing wedge tibial osteotomy has been the gold standard in proximal osteotomy procedures to correct uni-compartmental osteoarthritis. Opening wedge tibial osteotomies are achieving similar long-term results while avoiding some of the pitfalls of the closing wedge procedure. Opening wedge osteotomies maintain patellar length, tibial inclination, and proximal tibia bone stock. This allows for a technically easier conversion to a total knee arthroplasty in the future.

The purpose of this study was to assess the functional outcomes as well as the anatomical changes caused by opening wedge high tibial osteotomy

Opening and closing wedge osteotomies have been shown to have near equivolent long-term results. Using functional outcome studies (SF-36 and WOMAC ) and radiographic review we have shown good outcomes while maintaining the original anatomy of the knee.

Opening wedge tibial osteotomy will allow for a less complicated conversion to a total knee arthroplasty than the closing wedge tibial osteotomy

The patients attained a significant valgus correction that was maintained postoperatively (pre-op 6.12 varus to 5.5 valgus )

Clinical status of the patient was improved significantly in the functional outcomes testing using the WOMAC knee score( pre-op value 29.75 to 19.5; p = 0.0318 ) and the SF-36 ( pre-op value 64.4 to 81.7; p = 0.0035 ).

Patellar height (Pre-op Insall-Salvati ratio 1.15 to 1.09; p = 0.2339 ) and tibial inclination( pre-op 7.3 degrees to 6.85 degrees; p = 0.6743 ) were maintained.

This study retrospectively examined twenty-two patients with medial joint uni-compartmental osteoarthritis. Radiographic review of the pre-operative and post-operative films assessed the valgus correction, patellar height, and tibial inclination. The patients were seen in follow-up to assess the clinical exam and functional outcomes were measured using the SF-36 and WOMAC knee scores.

Opening wedge HTO is able to achieve acceptable correction of deformity while maintaining the normal anatomy of the knee.

Aims:Short-term results of lateral closing wedge high tibial osteotomy (CWO) is satisfactory in 80–90% of patients but the results of CWO shows steady decline over time. We evaluated results of osteotomies to determine survivorship and to identify risk factors associated with survival of the osteotomies.

Methods:Between 01.01.1986. and 31.12.1991. 113 patients have undergone CWO. We could evaluated 54 patients (31 men and 23 women) with 58 operations. The average age at operation was 57.6 (31–69) years and the mean follow-up was 12.2 (10–15) years.

The probability of failure was estimated as a function of time, with use of the Life-table survivorship method.

The linear correlation, uni and multivariate Stepwise regression method were used for statistical analysis. Results:Using the Life-table survivorship estimate of failure, the probability of survival for CWO was 91.3% at 5 years and 72.5% at 10 years.

An age, preoperative varus deformity and range of movement have not inßuenced long term survivorship (linear correlation).

Uni and multivariate Stepwise regression showed, that overweight, grade III chondromalacia in medial compartment, previous menisectomy and insufþcient valgus correction (FTA< 170¡) were signiþcantly associated with early failure.

Conclusions:Analysis of risk factors suggests that careful patient selection can improve long term survivorship of CWO.

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement. Cite this article: Bone Joint J 2013;95-B:1201–3

The management of osteoarthritis of the knee associated with patellar instability secondary to external tibial torsion > 45° is challenging. Patellofemoral biomechanics in these patients cannot be achieved by intra-articular correction using standard techniques of total knee replacement.

We reviewed seven patients (eight knees) with recurrent patellar dislocation and one with bilateral irreducible lateral dislocation who had undergone simultaneous total knee replacement and internal tibial derotational osteotomy. All had osteoarthritis and severe external tibial torsion. The mean follow-up was for 47.2 months (24 to 120).

The mean objective and functional Knee Society scores improved significantly (p = 0.0001) from 29.7 and 41.5 pre-operatively to 71.4 and 73.5 post-operatively, respectively. In all patients the osteotomies healed and patellar stability was restored.

Excessive external tibial torsion should be identified and corrected in patients with osteoarthritis and patellar instability. Simultaneous internal rotation osteotomy of the tibia and total knee replacement is a technically demanding but effective treatment for such patients.

Total knee arthroplasty (TKA) after proximal tibial valgus osteotomy is thought to be technical demanded and its outcome is not as sufficient as primary TKA. Purpose of this study is to identify particular surgical procedures and outcome of TKA after proximal tibial valgus osteotomy in the different type of osteotomies. Fourteen TKA after proximal tibial valgus osteotomies were underwent for 13 patients with osteoarthritis. Average age at surgery was 72 years old. The mean duration from proximal tibial valgus ostetomy to TKA was 9 years and 10 months and the mean follow up period after TKA was three years and nine months. Four closed wedged osteotomies, five modified Levy’s reversed V shaped osteotomies and five domed osteotomies were underwent before TKA. The V-Y lengthening of quadriceps tendon or osteotomy of the tibial tubercle was necessary for each one knee. Both knee had patella infera due to previous osteotomies of tibial tubercle for patello- femoral osteoarthritis. 11 lateral releases including release of lateral collateral ligament and two lengthening of iliotbial tract were needed to achieve sufficient ligament balance. The stems of tibial components could be placed almost centrally especially in knees, which had reversed V shaped oseteotomies and laterally in knees, which had domed or closed wedged osteotomies. Clinical results evaluated by Japan Orthopedic Association score had improved from 53 points before TKA to 84 points after TKA. This study suggests that 1) approach is difficult in the knee, which had previous osteotomy of tibial tubercle, 2) lateral release including lateral collateral ligament and iliotibial tract is necessary to achieve sufficient ligament balance, 3) the stem of tibial component might be placed laterally in knees, which had previous domed oseteotomy or closed wedged osteotomy, 4) outcome of TKA after proximal valgus osteotomy is as good as primary TKA

Despite multiple published reviews, the optimum method of correction and stabilisation of Blount's disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. This technique was developed to minimise cost in a context of limited resources. This study was conducted between 2016 and 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32tibiae) who had correction of late-onset tibia by proximal tibial osteotomy and Ilizarov external fixator. All cases were followed up to 2 years. The mean proximal tibial angle was 65.7° (±7.8) preoperatively and 89.8° (±1.7) postoperatively. The mean mechanical axis deviation improved from 56.2 (±8.3) preoperatively to 2.8 (±1.6) mm postoperatively. The mean femoral-tibial shaft angle was changed from – 34.3° (±6.7) preoperatively to 5.7° (±2.8) after correction. Complications included overcorrection (9%) and pin tract infection (25%). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity. This simple procedure provides secure fixation allowing early weight bearing and early return to function. It can be used in the context of health care systems with limited resources. It has a relatively low complication rate. Our results suggest that acute correction and simple circular frame fixation is an excellent treatment choice for cases of late-onset tibia vara, especially in severe deformities

Abstract. Introduction. Changes in posterior tibial slope (PTS) and patellar height (PH) following proximal tibial osteotomies have been a recent focus for knee surgeons. Increased PTS and decreased PH following medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. Methodology. A total of 62 cases who underwent MOWHTO were included. Surgery was performed using a dedicated step-by-step protocol focusing on the risks of unintentional slope changes. Clinically, all patients were evaluated preoperatively and at 2 years follow-up with the KOOS scores and UCLA physical activity scale. Preoperative and postoperative radiographic lower limb alignment parameters were measured on full-length lower limb radiographs, including (HKA), (MPTA), (mLDFA), proximal posterior tibial angle (PPTA), (JLCA) and(JLO). PH measurements were assessed on radiographs. Results. There was a significant change in the coronal plane alignment; the mMPTA changed from 84.38° to 90.39°, and the HKA changed from 172.19° to 180.15° (Both P < 0.0001). There was no significant change in the PTS as evidenced by a postoperative PPTA of 80.56 ° from a preoperative of 80.36°. And no significant change in the PH with all the indices; preoperative Caton Deschamps, Insall Salvati, and Schröter indices measured 0.95, 1.03, and 1.56, respectively. In comparison to postoperative measures of 0.93, 1.03, and 1.54, respectively. Conclusion. MOWHTO does not change the PTS or PH when accurate preoperative planning and precise intraoperative freehand technique are adopted. Involuntary modification of these anatomic parameters should be considered surgical errors

Conventional proximal tibial osteotomy is a widely successful joint-preserving treatment for osteoarthritis; however, conventional procedures do not adequately control the posterior tibial slope (PTS). Alterations to PTS can affect knee instability, ligament tensioning, knee kinematics, muscle and joint contact forces as well as range of motion. This study primarily aimed to provide a comprehensive investigation of the variables influencing PTS during high tibial osteotomy using a 3D surgical simulation approach. Secondly, it aimed to provide a simple means of implementing the findings in future 3D pre-operative planning and /or clinically. The influence of two key variables: the gap opening angle and the hinge axis orientation on PTS was investigated using three independent approaches: (1) 3D computational simulation using CAD software to perform virtual osteotomy surgery and simulate the post-operative outcome. (2) Derivation of a closed-form mathematical solution using a generalised vector rotation approach (3) Clinical assessment of synthetically generated x-rays of osteoarthritis patients (n=28; REC reference: 17/HRA/0033, RD&E NHS, UK) for comparison against the theoretical/computational approaches. The results from the computational and analytical assessments agreed precisely. For three different opening angles (6°, 9° and 12°) and 7 different hinge axis orientations (from −30° to 30°), the results obtained were identical. A simple analytical solution for the change in PTS, ΔP. s,. based on the hinge axis angle, α, and the osteotomy opening angle, θ, was derived:. ΔP. s. =sin. -1. (sin α sin θ). The clinical assessment demonstrated that the absolute values of PTS, and changes resulting from various osteotomies, matched the results from the two relative prediction methods. This study has demonstrated that PTS is impacted by the hinge axis angle and the extent of the osteotomy opening angle and provided computational evidence and analytical formula for general use

Aims. The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. Methods. In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. Results. All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. Conclusion. Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required. Cite this article: Bone Joint J 2022;104-B(11):1273–1278

Aim. Arthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction. Method. Between 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (<30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (>30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment. Results. Among 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%. Conclusions. Prompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

Abstract. Background. Distal femoral osteotomy is an established successful procedure which can delay the progression of arthritis and the need for knee arthroplasty. The surgery, however, is complex and lengthy and consequently it is generally the preserve of highly experienced specialists and thus not widely offered. Patient specific instrumentation is known to reduce procedural complexity, time, and surgeons’ anxiety levels. 1. in proximal tibial osteotomy procedures. This study evaluated a novel patient specific distal femoral osteotomy procedure (Orthoscape, Bath, UK) which aimed to use custom-made implants and instrumentation to provide a precision correction while also simplifying the procedure so that more surgeons would be comfortable offering the procedure. Presenting problem. Three patients (n=3) with early-stage knee arthritis presented with valgus malalignment, the source of which was predominantly located within the distal femur, rather than intraarticular. Using conventional techniques and instrumentation, distal femoral knee osteotomy cases typically require 1.5–2 hours surgery time. The use of bi-planar osteotomy cuts have been shown to improve intraoperative stability as well as bone healing times. 2. This normally also increases surgical complexity; however, multiple cutting slots can be easily incorporated into patient specific instrumentation. Clinical management. All three cases were treated at a high-volume tertiary referral centre (Istituto Ortopedico Rizzoli, Bologna) using medial closing wedge distal femoral knee osteotomies by a team experienced in using patient specific osteotomy systems. 3. Virtual surgical planning was conducted using CT-scans and long-leg weight-bearing x-rays (Orthoscape, Bath, UK). Patient specific surgical guides and custom-made locking plates were design for each case. The guides were designed to allow temporary positioning, drilling and bi-planar saw-cutting. The drills were positioned such that the drills above and below the osteotomy became parallel on closing following osteotomy wedge removal. This gave reassurance of the achieved correction allowed the plate to be located precisely over the drills. All screw lengths were pre-measured. Discussion. The surgical time reduced to approximately 30 minutes by the third procedure. It was evident that surgical time was saved because no intraoperative screw length measurements were required, relatively few x-rays were used to confirm the position of the surgical guide, and the use of custom instrumentation significantly reduced the surgical inventory. The reduced invasiveness and ease of surgery may contribute to faster patient recovery compared to conventional techniques. The final post-operative alignment was within 1° of the planned alignment in all cases. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

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

Introduction: The standard treatment of adolescent Blount’s disease includes proximal tibial valgus osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. We performed correction of deformities in eight patients (10 tibiae) with adolescent Blount’s disease using the Taylor Spatial Frame (TSF). In all patients, the origin (virtual hinge) was placed at the level of the proximal tibial fibular joint. The purpose of this study was to review treatment outcome of proximal tibial osteotomy without osteotomy of the fibula in patients with adolescent Blount disease. Methods: Eight patients (10 tibiae) were treated by proximal tibial osteotomies and gradual correction by TSF without fibular osteotomy over a period of three years. All patients were males with a mean age of 14.6 years (range, 14–17 years). All patients had severe proximal tibial varus, four had significant proximal tibial procurvatum, and six had internal tibial torsion. The fibula was not fixed in five patients, and fixed distally in three. Results: Frames were removed at an average of 12.8 weeks (range, 12–15 weeks). The mean preoperative proximal tibial varus was 16.2. o. (range, 12–19. o. ), corrected to normal values in all patients. The mean preoperative MPTA was 71.4. o. (range, 67–77. o. ) and corrected to a mean MPTA 87.1. o. (range, 85–89. o. ). In four patients (5 tibiae) with proximal tibial procurvatum, the PPTA was corrected to normal range. Mean correction of internal tibial torsion was 10. o. (range, 5–15. o. ), performed in six patients (8 tibias). Pre-operative MAD was 55.8 mm medial to center of the knee (range, 44–77 mm), corrected to a mean MAD of 4.9 mm medial to center of the knee (range, 2–11 mm). Complications included superficial pin tract infections in seven patients. No complications related to the fibula were observed during/after correction. Conclusion: Based on our initial experience, we believe that most patients with adolescent Blount disease could have successful and predictable correction of tibial deformities without a need for osteotomy and fixation of the fibula

High tibial osteotomy is an efficient treatment for medial compartment osteoarthritis of the knee; its used for middle aged patients with high activity levels and can delay the need for total arthroplasty. The results of total knee arthroplasty after failed high tibial osteotomy are controversies; several authors reported inferior outcomes, but others have concluded that tibial osteotomy doesn't bias following total arthroplasty. The aim of this study was to evaluate the results of failed high tibial osteotomy subsequently converted to total knee arthroplasty and compare the results to group of patients underwere primary arthroplasty; the authors evaluate some of technical problems that a previous high tibial osteotomy can generate, like scar tissue, patellar tendon shortening and changes of proximal tibial anatomy. Methods. 50 total knee arthroplasty performed after a previous closed wedge osteotomy were matched with 50 patients operated with a primary knee prosthesis for osteoarthritis. The time from a proximal tibial osteotomy to a prosthesis operation was in mean eight years. Results. the Knee Society clinical and radiographic score system and W.O.M.A.C. evaluation were used to evaluate knees before surgery and at each follow up (average 5 years). At an average of five years follow up, the clinical results of total knee arthroplasty after high tibial osteotomy were similar to those of primary knee prosthesis. Discussion. in our study revision of failed proximal tibial osteotomy appears to have more technical difficulties but with overall outcomes that remain comparable at results after primary total knee arthroplasty, so tibial osteotomy is considered a valid option in younger and very active patients with unicompartmental arthritis