In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment.

We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty.

Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up.

At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5).

HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term.

Cite this article: Bone Joint J 2016;98-B:601–7.

Background: The treatment of extensive soft tissue injury with bony involvement due to orthopaedic trauma or other pathologic conditions has undergone great improvement in the last decade. The main fields that assisted with that progress are: the ability to transfer autogenous vascularized soft and/or bony tissues to the injured areas and the possibility to apply external fixation either statistically for acute stabilization of a limb or using dynamic frames to correct late occurring contractures or deformities. Objectives: To present our experience in treating young patients with severe, post traumatic or tumor resection soft tissue and bony injuries including bone loss and late joint contractures. That was treated by a combination of free vascularized flaps and static or dynamic circular external fixation with special emphasis on preplanning and technical issues critical for the success of such complex procedures. Methods: Seven patients were included in the study; six post traumatic patients who received free vascularized myocutaneous latissimum dorsi or fasciocutaneous anterolateral thigh flaps to the calf and foot. All six patients had an Ilizarov frame for initial stabilization; two of them needed late dynamic correction of equines with the frame. The seventh patient had surgery for removal of osteosarcoma and received a vascularized osteocutaneous fibula flap with fixation by Ilizarov frame, this patient also needed late dynamic frame application for equines correction. Results: The mean age at surgery was 11.6 years (range 7–14 years); mean follow up was 1.8 years (range 2 months – 3.4 years). All microvascular flaps but one survived where the patient with the failed latissimus dorsi flap had the second muscle transferred at the next day. One patient needed 2 vascular revisions. All bone flap showed solid union at 3 months post operatively. Four patients achieved plantigrade foot initially. The three patients with dynamic correction achieved plantigrade foot at frame removal. Complications: Equinus contracture of the ankle in three patients, injury to the vascular anastomosis in one patient. Pin tract infection in all patients that responded well to antibiotics. Conclusions: The circular external fixator is a reliable method for initial fixation of injured limb. It is advised to apply the fixator before the transfer of the free flap. Position of the fixation pins should be discussed before hand with the plastic surgeons to allow free access to the microvascular anastomosis site. Free flaps allow the coverage of large soft tissue defects while the external fixators maintain anatomical position of the limb. Late occurring contractures after the incorporation of the flap can be safely corrected gradually with the circular frame. It is of paramount importance to include the foot in the frame and maintain neutral position of the ankle joint to prevent equines contractures

Introduction: Traditionally, the degree of correction for derotational femoral osteotomies in cerebral palsy has been based on clinical or radiographic measures. Recently, three dimensional gait analysis has been used to plan and evaluate orthopaedic surgery. Our aim was to assess the outcome of derotation osteotomies, where the degree of rotation at surgery was guided by transverse plane kinematics (aiming at reducing peak hip rotations to normal limits). Method: Pre and post-operative gait analyses were reviewed in a group of these patients (16 legs) and compared with a similar group of 8 patients (16 legs) who had soft tissue procedures only. Results: Improvement following derotation osteotomy occurred in all but one case; 11/16 osteotomies resulted in peak internal rotation within one standard deviation (SD) of peak normal internal rotation (normal range −6° to +11°), the other 4 were within 1.4 SDs. Discussion: Objective improvement in hip rotation during gait was measured in 15/16 subjects undergoing dero-tation osteotomy based on gait analysis. There was no rotational change overall in patients who had soft tissue procedures only. Average dynamic correction of internal rotation during gait was slightly less than intra-operative correction, possibly due to tensioning of spastic muscles

The authors comment on the treatment of patients suffering from spina bifida. The indications to surgical-orthopaedic approach for lower limb correction in patients with spina bifida are outlined. According to the authors’ experience, the therapeutic approach should be aimed at treating deformities of the lower extremities in order to apply orthotic devices, particularly for higher levels of medullary lesion, and to obtain standing and/or gait with support. In the natural history of spina bifida, this purpose has become more and more important, since reduced complications, longer average life, and improved clinical, therapeutic and technological knowledge have radically changed the life expectancy of these patients. The analysis of a series of 71 patients with spina bifida, treated over 20 years, has enabled the authors to evaluate the main sites of deformities. They examined the surgical procedures carried out in relation to the levels of damage and observed the resulting functional autonomy. The foot was the site which offered the most frequent opportunities for treatment at all levels. Knee deformities were treated in a few cases. In particular, difficulties arose when treating L3-L4-L5 neurosegmental levels of the hip, with the result that today bone correction of this joint is performed in association with muscle transposition (external oblique abdominis m. pro medio gluteus m.) in order to ensure a dynamic correction. The authors emphasise the need for a more cautious surgical approach, since lower limb alignment, often achieved using orthopaedic aids and splints, is more important from a functional point of view than the anatomic and radiographic correction of the deformities. From a functional point of view, apparently positive neurosegmental levels for functional recovery are damaged by the lack of early training using splints. Actually, even severe clinical conditions can acquire increased functional autonomy if splints are early introduced to aid walking. Moreover, there are increased indications for spinal surgery in patients suffering from severe paraplegia in order to improve cardio-respiratory function. A correct alignment and an adequate application of orthotic devices reduce the frequency of pelvic obliquity, which favours spine deformities

Introduction: Until now, the non-surgical therapeutic approach for idiopathic scoliosis (IS) was based on rigid brace using three points pressure and distraction technique. For the first time we wanted to use a dynamic approach for the treatment of IS. For this goal we have developed a Dynamic Correction Brace (DCB) or SpineCor to use the forces of the dynamic spine to optimise the reduction of spinal curves and permit neuromuscular integration during the period of correction. Methods and results: The effectiveness of the treatment depends on the reducibility of the curve with the brace. The goal of this study is to quantify the reducibility of scoliosis curves through a study of the variation of Cobb angle, during and after treatment. Between 1993 and 1999, 113 adolescents with classic indications of idiopathic scoliosis were treated by the same orthopaedist with the DCB. The mean age at the beginning of the treatment is 12.9 years old. The potential reducibility (PR) of the curves was estimated by the percentage of reduction of the initial Cobb’s angle corresponding to the maximum correction obtained during the course of treatment and after the treatment for the patient at maturity. Fifty patients have completed their treatment and are at maturity. From this cohort of patients treated by the DCB, 73.4% had a reduction of 5° or more than their principal Cobb angle; 22.8% were stable, but non-reducible, with a change of less than 5°; and 3.8% conserved an evolutive potential, with an increase in the Cobb angle of 5° or more. A significant difference was evident for PR between the group presenting an initial Cobb angle < 30° and those presenting an initial Cobb angle > 30° (p< 0.05). 65.8 per cent of the patients presented with an initial Cobb angle < 30° for a mean PR of 40.6% and were categorised according to the following: a) 26% of the patients had a PR ≤20%; b) 41% obtained a PR between 20% and 50%; and c) 33% had a PR > 50%. The other patients (34.2%) with an initial Cobb > 30° and a mean PR 22% were also categorised: 39% had a PR ≤20%; b) 48% had a PR between 20% and 50% and c) 13% > 50%. For patients who have completed their treatment 85% have a correction or are stabilised, 15% are worse or needed surgery during the treatment. For these patients, 53% have a correction of < 20%, 31% have a correction between 20 and 50%, and 16% have a correction of > 50%. Conclusion: The reducibility of the curve during the treatment is very informative concerning the prognosis treatment. The effectiveness of a DCB is comparable to effectiveness of other rigid braces for which the results have been published

In early secondary arthritis due to femoral dysplasia, varus osteotomy achieves a control of arthritis for two decades in 80 % of cases : it is therefore a very reliable conservative treatment. Moreover, in carefully selected cases of severe arthritis in young active patients, a valgus osteotomy can achieve pain relief for a decade in 70 % of cases. THE VARUS OSTEOTOMY is recommended when the arthritis is due to a coxa valga ≥ 140°. By reducing the inclination angle to 125° the abductors level of arm is optimized, and their contracture is decreased. Therefore, the osteotomy reduces the surface strains, but it does not improve the extent of articular surfaces. A – . INDICATIONS. 1) Four factors are mandatory to achieve long term improvement:. The arthritis must be the . consequence. of the dysplasia, with degenerative changes localized at the supero lateral part of the head and of the acetabulum. This can be confirmed by isotope scanning. If the arthritic changes are not localised the desease is rather a primary arthritis, or an inflammatory or a metabolic disease, which are not an indication for a biomecanical treatment. There must be a real . coxa valga. , evidenced by coxometry. Anteversion is mesured by CT scan, and the inclinaison is mesured on a X ray of the pelvis with the hips in internal rotation equal to the ante-version. If there is a shortened femoral neck (such as a post reduction osteonecrosis), the modification of the glutei lever of arm may not change significantly the articular strains, and therefore osteotomy is no indicated. The articular . congruency. must not be impaired by the reduced inclination angle. Pre operative X rays with the hips in an abduction equal to the planned varisation must not reveal any lateral narrowing of the joint space, which would mean incongruity, and lead to failure. The possibility of articular . healing. must be important : varus osteotomy is recommended before 45 years, and if the joint space remains ≥ 50 % of normal. 2) Therefore varus osteotomy is . not recommended. in a non symptomatic dysplasia (as some of them may not lead to arthritis), or if the symptoms are those of a labrum syndrom, with suddent pain, instead of a progressive and mechanical arthritic pain. if the dysplasia is only acetabular : then only the acetabulum has to be treated. if the anatomic abnormality is not an increase of the inclinaison (neck-shaft) angle, but a modification of the head-neck angle, which causes impigement with the labrum, and which is not improved by inter-tro-chanteric osteotomy. 3) The . assosciated dysplasia. have to be taken into consideration. If there is a femoral hyperanteversion there are two different conditions in the adult :. if the patient walks with internal rotation of knees (convergent strabismus of patella), realising a dynamic correction of hyperanteversion, the association an external rotation of the femur to the varisation is recommended. but if, despite hyperanteversion, walking is without abnormal rotations of the knees, this means that the optimum congruity of the hip is in that position. An ostotomy is no advocated as, instead of retroversing the femoral neck, it would rotate externally the femoral shaft. If there are both an acetabular and a femoral dysplasia, they both have to be treated :. if an augmentation is recommended for an anterolateral defect, the shelf osteoplasty can be performed in the same operation that the varus osteotomy. if a medialisation is necessary (Chiari), both osteotomies can be assosciated in one stage. but if a complex reorientation osteotomy is necessary (either periacetabular –Giacometti-,. or pelvic –Ganz-), it could be hazardous to perform a varus osteotomy at the same time. B – . SURGICAL TECHNIC. The importance of the varisation depends on that of the coxa valga. The final inclinaison angle must be 125°, as the lever of arm of the abductors is impaired for a lower angle. Moreover there is a post operative limping due to the ajustement of the glutei length, the duration of which is function of the varisation (one year per 10°). To reduce this limping, only the necessary varisation has to be made. The technic has several important points :. non union is avoided by non dissection of the medial metaphysis or removal of a wedge :. we use a subperiosteal osteotomy, leaving in contact the medial cortex, with a lateral opening, fixed by a nail plate as a tension band. This technique gives a minimum limb shortening (12 mm for 15° varisation). respect of the articulation and soft tissues. There is no arthrotomy as the nail plate is inserted on a guide pin. Later implantation of the THR will not be complicated by the previous osteotomy. precise, « automatic » correction, depends only on the nailplate angle. the resistance of the osteosynthesis allows immediate rehabilitation (this extra articular operation does not reduce ROM), and 10 to 20 kilos weight bearing. Full weight bearing is authorized at three months. C – . RESULTS. There are less thant 5 % mechanical complications. An antalgic effect is obtained within some weeks. In 80 % of cases, painlessness and absence of radiological deterioration for two decades is achieved, a THR becoming necessary in the third decade. In 20 % of cases, only a temporary effect is obtained, leading to a THR after 5 to 10 years. THE VALGUS OSTEOTOMY is at present used in only seldom cases of young patients with a severely damaged articulation, but who prefer an antalgic conservative surgery than a THR, because they wish to continue for a decade a strenuous activity not compatible with an arthroplasty. This can be made only when there are two large osteophytic drops of the acetabulum and of the femoral head, which can be put into contact by the valgisation, and facilitate healing of the superior lesions. In carefully selected cases, a relief of pain is achieved for a decade in 70 % of patients. IN CONCLUSIONS. The femoral varus osteotomy remains one of the most reliable conservative operations in osteoarthritis due to DDH. However to achieve these good results, a clear understanding of the indications and biomechanical demands of this operation is required. In seldom and selected cases of severe arthritis, a palliative valgus osteotomy can achieve a decade of pain relief

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Cite this article: Bone Joint J 2013;95-B:271–8.

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63° (30° to 90°; p < 0.001). The mean active extension gained was 47° (30° to 75°).

Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65° (30° to 90°) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55° (30° to 70°) but the difference was not statistically significant (p = 0.148).

The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment.