Correction Of Multiplanar Deformity Research Articles

Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb.

Computerised hexapod-assisted orthopaedic surgery (CHAOS) is a method by which complex multiplanar, multilevel deformity can be corrected with a high degree of accuracy utilising minimally invasive techniques within a single operative event. This study's aim was to report the reliability, accuracy and magnitude of correction achieved, alongside patient-reported outcomes and risk factors for complications when using the CHAOS technique throughout the lower limb. Retrospective review of medical records and radiographs for consecutive patients who underwent CHAOS for lower limb deformity correction at a tertiary centre between 2012 and 2020. There were 70 cases in 56 patients, with the site of surgery being the femur in 48 cases, proximal tibia in 17 and distal tibia in 5 cases. Multiplanar correction was performed in 43 cases, and multilevel osteotomy was undertaken in 23 cases. Fixation was undertaken with intramedullary nailing (IMN) in 49 cases and locked plates in 21.The maximum corrections were 40° rotation, 20° coronal angulation, 51° sagittal angulation and 62-mm mechanical axis deviation (MAD). Deformity correction was mechanically satisfactory in all patients bar one who was undercorrected requiring revision. The mean patient global impression of change (PGIC) score was 6.2 out of 7.Overall complication rate was 12/70 (17%). Complications from femoral surgery included two nonunions, one case of undercorrection, one case of stiffness, one muscle hernia and one pulmonary embolism. Complications from tibial surgery were one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, one transient neurapraxia of the common peroneal nerve, one locking plate fatigue failure, one seroma and one superficial wound infection. Computerised hexapod-assisted orthopaedic surgery can be used for accurate correction of complex multilevel and multiplanar deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries, and also to that of traditional circular frame correction. Patients remain highly satisfied with both the functional and symptomatic outcomes. French JMR, Filer J, Hogan K, et al. Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb. Strategies Trauma Limb Reconstr 2024;19(1):9-14.

Isolated Talonavicular Arthrodesis as Treatment for Flexible Progressive Collapsing Foot Deformity: A Case Series

Category: Hindfoot; Other Introduction/Purpose: Progressive collapsing foot deformity (PCFD) remains a challenging condition for foot and ankle surgeons to treat. While there exists more clarity on the treatment for end-stage rigid deformities involving PCFD, there is still significant debate over different surgical treatment options for the flexible collapsing foot. Common surgical corrections for flexible PCFD include the 'All-American Procedure' popularized by Manoli in the 1990s. Isolated talonavicular (TN) arthrodesis has also been described for the treatment of flexible PCFD. The primary objective of this study was to evaluate clinical and radiographic outcomes in patients with AAFD treated with isolated tri-planar corrective TN arthrodesis. A secondary objective was to establish whether there is a correlation between radiographic outcomes and clinical outcomes. Methods: Fifty-four patients (59 feet) from July 2013 to October 2020 with flexible PCFD underwent surgical treatment with isolated TN arthrodesis. Patients with other arthrodesis or hindfoot osteotomies were excluded. Concomitant gastrocnemius lengthening and toe deformity correction procedures were not an exclusion criterion. Weight-bearing radiographs were performed pre- and postoperatively, with Meary angle (or lateral talo-first metatarsal angle) and calcaneal pitch measured on lateral view. The degree of TN coverage on antero-posterior (AP) radiographs were measured with the TN coverage angle and the degree of first ray angular deformity was measured using Simmon angle (or AP talo-first metatarsal angle). Angles were measured by a foot and ankle fellow. The Foot & Ankle Ability Measure (FAAM) and Veterans-Rand 12 Item Health Survey (VR- 12) were used to clinically evaluate the patient. Results: Thirty-seven females and seventeen males were evaluated with a mean age 61 years at the time of surgery and an average length of follow up of 19 months. There were significant improvements in deformity correction found in this study. Radiographically, the lateral radiographs demonstrated Meary angle correction from 27 degrees pre-operatively to 9 degrees post- operatively (p<0.001) and calcaneal pitch improving from 15 degrees pre-operatively to 18 degrees post operatively (p<.001). AP radiographic analysis demonstrated TN coverage angle improving from 35 degrees pre-operatively to 5 degrees post-operatively (p<0.001) and Simmon angle improving from 20 degrees pre-operatively to 6 degrees, post-operatively (p<.001). The only statistically significant improvement in clinical outcomes was in the FAAM score (pre-operative score 48.48, post-operative score 58.45 (p<.001)). Conclusion: Isolated TN arthrodesis is a viable option for multi-planar deformity correction in patients with flexible PCFD. Not only did it provide significant improvements in radiographic alignment, it also provided improved functional outcomes as demonstrated on FAAM scores. Comparative studies with other surgical treatment techniques such as the 'All-American Procedure' should be performed to determine which is the best technique for patients with flexible PCFD.

Correction of multiplanar deformities around the knee with monolateral external fixator

Introduction Angular deformities around the knee are common during childhood and most cases are a variation in the normal growth pattern. Uncorrected deformities change the biomechanics by disturbing stress distribution on the knee joint weight-bearing surface. Monolateral external fixator with osteotomy has shown better results being simple, and offers accurate correction, a low complication rate, the ability to correct valgus, varus, and rotational deformities, with early mobilization of the patient. Patient and methods A multicenter study case series prospective study was conducted from January 2020 to January 2021. A total of 30 patients with coronal plane deformities were included in the study. Of them, 15 patients (all cases were unilateral, 9 left limbs and 6 right limbs) presented with genu valgum with an age range between 10 and 16 years, and mean age was 10.5 years. Eight patients presented with genu varum only and six cases presented with genu varum and internal tibial torsion (all cases were unilateral, seven right limbs and eight left limbs) with an age range between 10 and 16 years and a mean of was 12.4 years. Results There is a statistically significant decrease of tibiofemoral angle (TFA) and mechanical axis deviation (MAD) after surgical correction of genu valgum among the included children with P value=0.001, and there is a statistically significant increase of lateral distal femoral angle (LDFA) after surgical correction of genu valgum with P value=0.001. There is a statistically significant increase of TFA, medial proximal tibial angle (MPTA), and MAD after surgical correction of genu varum among the included children with P value=0.001. Conclusion Correction of multiplanar deformities around knee using monolateral external fixator has good results in genu valgus with the improvement of LDFA and TFA, and with the improvement of MPTA and TFA in genu varum and with correction of MAD in both of the deformity after surgical correction, with rotation correction using the ability of direction of Schanz placement.

Evans Calcaneal Osteotomy: Assessment of Multiplanar Correction

Flatfoot deformity consists of collapse of the medial arch, forefoot abduction, increased talonavicular uncoverage, and hindfoot valgus. Although numerous soft tissue and bony procedures have been proposed to correct each plane of deformity, there is a lack of objective data in the literature quantifying the amount of structural correction. The purpose of this study was to quantify the multiplanar deformity correction of the lateral column lengthening osteotomy (Evans) on hindfoot alignment through objective, reproducible, radiographic measurements. We retrospectively reviewed 45 Evans calcaneal osteotomy procedures in 24 female (53%) and 21 male (47%) feet performed on 40 patients (5 bilateral). The mean follow-up was 53 weeks (range, 32-116). The mean age at the time of surgery was 35 years (range, 11-73). Statistically significant improvement in radiographic alignment was found in the calcaneal inclination angle, tibial-calcaneal angle, tibial-calcaneal position, and the anteroposterior talo-first metatarsal angle (p < .0001 for all). Although a direct correlation between graft size and degree of angular correction was not observed, it should be noted the calcaneal graft size (mean, 11.8 mm) and the amount of hindfoot valgus correction (mean, 12.6°) appear to be clinically related. The results of this study support that the Evans calcaneal osteotomy corrects the hindfoot alignment in 3 planes as evidenced by our multiplanar radiographic measurements.

Management of the Tarsometatarsal Joint in the Rotational Correction of Hallux Valgus by the Modified Lapidus Procedure: Intraoperative Technical Tips to Prevent Complications.

The modified Lapidus procedure is considered a useful tool for correction of multiplanar deformities in the hallux valgus, including first metatarsal pronation. It offers a greater power of correction compared to most other osteotomies. However, postoperative complications can occur in up to 12% of cases. The aim of this study was to describe intraoperative technical tips in the management of the tarsometatarsal joint during multiplanar correction of severe hallux valgus deformity using the modified Lapidus procedure. It is not the authors' intention to describe a new technique, but to draw attention to intraoperative details in order to prevent complications as nonunion, extension of the first metatarsal and undercorrection of the deformity. Rotational correction of the first metatarsal with adequate bone coaptation of the first metatarsal and the medial cuneiform are the cornerstone for a satisfactory result.Levels of Evidence: Level V, expert opinion.

Особенности динамики сосудистых факторов роста (VEGF) в крови пациентов с витамин D-резистентным рахитом в процессе коррекции многоплоскостных деформаций нижних конечностей

Особенности динамики сосудистых факторов роста (VEGF) в крови пациентов с витамин D-резистентным рахитом в процессе коррекции многоплоскостных деформаций нижних конечностей

Two-Level Osteotomy for the Corrective Surgery of Severe Kyphosis From Ankylosing Spondylitis: A Retrospective Series.

Retrospective study. To describe the treatment results of patients with severe ankylosing spondylitis (AS) kyphosis who underwent two-level osteotomy and correction surgery. The best solution for the fixed kyphotic deformity of AS is corrective osteotomy. Many osteotomy options are available: pedicle subtraction osteotomy (PSO), Smith-Peterson osteotomy (SPO), and vertical column resection (VCR). These procedures all provide multiplanar deformity correction. Nevertheless, when the AS deformity is severe, an additional osteotomy site to get more correction, achieve more ideal, and smooth curvature of the spine than single osteotomy. From May, 2008 to August, 2016, 19 patients of severe AS kyphosis underwent two-level spinal osteotomy and correction surgery. The patients had an average kyphosis angle greater than 90°. The radiological features and clinical evaluation, including Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 components were assessed before surgery and at follow-up. The patients underwent either one-level PSO combined with one-level SPO (n = 9) or two-level PSO (n = 10). The height was increased after surgery in all patients (P < 0.05). The median follow-up was 24 months. The kyphosis angle improved from 92.0 ± 16.6° to 30.0 ± 17.2°. The chin-brow vertical angle improved from 37.6 ± 19.2° to -0.6 ± 2.5°. The sacral slope improved from 3.9 ± 11.8° to 21.7 ± 7.4°. Sagittal imbalance improved from 241.4 ± 115.3 mm to 74.6 ± 48.5 mm (P < 0.05). Lumbar lordosis improved from -3.9 ± 20.8° to 29.4 ± 14.1° (all P < 0.05). There were significant improvements in the ODI, VAS, and all components of SRS-22 (all P < 0.05). All patients with pseudarthrosis (n = 5) underwent PSO + SPO and achieved satisfactory results. Six complications were observed perioperatively, but without permanent sequelae. Two-level osteotomy and correction procedure can achieve satisfactory results in severe AS kyphosis. PSO + SPO could be a good option for patients with pseudarthrosis because of relatively easier and faster operation. 4.

Vertical Wire Forefoot Fixation: An Advanced Technique for the Dynamic External Fixation Apparatus

External fixation is used for the correction of select foot and ankle deformities. We have found the traditional forefoot crossing wire technique to be insufficient in terms of both individual metatarsal control and forefoot manipulation when using a dynamic ring fixator to correct forefoot deformities. We developed a forefoot fixation technique at the University of Cincinnati Medical Center, using 5 vertical wires to gain greater forefoot control while performing more precise skeletal manipulation for multiplanar deformity correction. The associated risks of infection, neurovascular injury, and other soft-tissue injury should be further investigated. This proposed vertical wire construct is an advanced method with which the foot and ankle surgeon can correct complex lower limb deformities.

The Role of Taylor Spatial Frame in the Treatment of Blount Disease.

Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised. To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF). From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured. Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8° (58° - 79°) to 92.5° (90° - 95°), the Drennan decreased from 16.6° (14° - 18°) to 3.6° (0° - 6°), the F-T angle changed from 15.4° (10° - 25°) of varus to 5.9° (2° - 10°) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment. In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease.

Spring technique for correction of multilevel deformity using hexapod external fixator

Context: Osteotomies in several parts of one long bone are recommended for correction of a long, curved, and wide-angled deformity. Hexapod external fixators (HEFs) allow for the single-stage correction of multiplanar deformity, but they are heavy, expensive, and requires continuous management of 12 struts, if at more than one level. Aims: We proposed the use of springs with HEF to support the intermediate ring. Deformity between the proximal and distal rings is corrected using one HEF, and the intermediate fragment is automatically corrected by the tension of the springs. Settings and Design: This was a retrospective descriptive study. Subjects and Methods: We treated seven males and eight females with 17 affected limbs. Four patients with familial hypophosphatemic rickets, five posttraumatic deformities, two osteogenesis imperfectas, three fibrous dysplasias, and one neurofibromatosis were included. The mean preoperative angle between the most proximal and distal fragments was 62.5°. First, small distraction at each level was initiated with one HEF fixed to the most proximal and distal rings, and Ilizarov hinges applied between the proximal and intermediate rings. Then, a set of three springs was applied for each interval between the rings. Gradual correction using HEF was performed, considering only the axes of the proximal and distal bone fragments. Results: Good alignment was achieved in all patients without severe complications. The mean correction period was 5.5 weeks and mean fixation period was 33.8 weeks. Conclusion: Combination of HEF and springs is capable of correcting severe deformity.

Decortication and osteotomy for the correction of multiplanar deformity in the treatment of malunion in adult diaphyseal femoral deformity: a case series and technique description

To review patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication. A retrospective review of all patients who have undergone decortication and multiplanar osteotomy, looking at the pre-operative deformity, correction achieved, time to union and complications. Seven patients underwent correction under the senior author from 2003 to 2012. Average age was 46years (range 32-60years). All had femoral shortening deformity (average 2.7cm, range 2-4cm). Each also had at least one other plane of deformity with rotation being the next most commonly encountered in 5 out of the 7 (average 33°, range 0°-45°). Two had tri-planar deformity with the five having bi-planar deformity. Average time to union was 16.3months (range 7-39months) with an average of 1.5 operations (range 1-3 operations) to union. One patient has a non-union after five corrective operations. Correction of multiplanar deformity of the femur is challenging. Osteotomy with decortication provides a technique to achieve significant femoral multiplanar deformity correction in a single operation. This publication provides technical description of the operative technique, guidance and results.

Computer-assisted oblique single-cut rotation osteotomy to reduce a multidirectional tibia deformity: case report

The correction of multiplanar deformity is challenging. We describe preoperative 3-D planning and treatment of a complex tibia malunion using an oblique single-cut rotation osteotomy to correct deformity parameters in the sagittal, coronal and transverse plane. At 5 years postoperatively, the patient ambulates without pain with a well-aligned leg.

Analysis of strut-to-bone lengthening ratio for hexapod frames using mathematical modeling

Background: Hexapod external fixators often incorporate bone lengthening as part of a multi-planar deformity correction plan. The hexapod struts, however, do not distract in the direction of bone lengthening. Their oblique orientation to the ring creates a vector that is the summation of multiple individual strut adjustments. We demonstrate that a 1 mm lengthening of each of all six struts always created more than 1 mm of lengthening at the bone. Methods: The amount of lengthening was analyzed with the Taylor Spatial Frame™ (Smith and Nephew, Memphis, TN, USA) software using two different methods. Results: As the strut lengths got longer the ratio got closer to one but it never reached 1.0. Conclusions: This information is critical when using very short struts or very large rings. In these two scenarios, the Δ frame height relative to the Δ strut length becomes much greater than one. Clinical Relevance: A strut length much greater than one will cause the bone to lengthen much faster than the surgeon desires. It may also lead to unhealthy regenerate bone formation and could create delays in bone healing.

Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction.

Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy. A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed. Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92). Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities. Level IV, case series.

Current concepts of leg lengthening.

Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1mm/day) at a 4×0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.

A new pelvic rod system for the surgical correction and fixation of pelvic obliquity in pediatric neuromuscular scoliosis

To describe surgical outcomes using the new device in pediatric neuromuscular scoliosis. All patients with neuromuscular disorders requiring surgery with pelvic fixation for the correction of scoliosis in the period 2002-2009 were operated by the new pelvic rod fixation device. Coronal and sagittal alignment before and after surgery until the latest follow-up were evaluated by standard X-rays. Intraoperative and postoperative complications were recorded. All 18 study patients (mean age at surgery 15years, range 10-27) achieved solid fusion at a mean follow-up of 41months. The coronal Cobb angle improved from 82°±31° (range 36-168) to 33°±25° at the last follow-up (range 9-95 months) (P<0.0001). Pelvic obliquity improved from 19°±6° (range 10-30) to 5°±5° (range 0-14) (P<0.0001). Early complications included pneumonia, urinary tract infection, disseminated intravascular coagulation (DIC), and hypovolemic shock. Three patients required debriding and received prolonged antimicrobial therapy for deep wound infection (none required implant removal). At the latest follow-up, no patient complained of lumbar pain or worsening of ambulatory status or level of activity. Surgery employing the new pelvic rod fixation device allowed solid fusion and fixation with significant correction of multiplanar deformity, but the complication rate was high.

Less Invasive Surgical Correction of Adult Degenerative Scoliosis, Part I

Adult scoliosis is a condition with increasing prevalence and medical and socioeconomic importance. Surgery is fraught with a significant complication rate in an elderly multimorbid patient population. To assess technical feasibility and radiographic results of image-guided less invasive correction of adult degenerative scoliosis. Thirty individuals (age, 64-88 years) with progressive deformity (coronal Cobb angles > 25 degrees and < 85 degrees), intractable back pain, radiculopathy, or neurogenic claudication were treated by less invasive decompression and fusion (unilateral transforaminal interbody cage instrumentation and bilateral facet fusions) with recombinant human bone morphogenetic protein-2, spanning 3 to 8 segments (average, 6 segments), using biplanar fluoroscopy or intraoperative computed tomography (iCT)-based navigation. Accuracy of screw placement, curve correction, and fusion rate were evaluated during a mean follow-up of 19.6 months. With 415 screws implanted, misplacement (grade II or greater) was not observed, and no implants required revision. Spinal iCT with automated registration required 17.5 +/- 8.5 minutes (single registration for all segments); monosegmental bilateral screw insertion required 6.8 +/- 3.4 minutes. Mean sagittal (coronal) Cobb angle correction was 44.8 +/- 10.7 degrees (31.7 +/- 13.7 degrees). Mean lumbar lordosis increased from 8.8 +/- 8.9 degrees to -36 +/- 6.9 degrees, and sagittal balance was reduced from 31.6 +/- 15.2 to 8 +/- 8.4 mm. Solid fusion was confirmed in 90% of instrumented segments at 16 months. Average radiation dose to the surgeon was 0.025 mSv for single-level transforaminal lumbar interbody fusion with fluoroscopic guidance vs 0 mSv with iCT navigation. Instrumented correction of adult deformity was significantly facilitated by iCT navigation, eliminating radiation exposure to the surgeon. Intraoperative biplanar CT scout views including pelvis and shoulders allow comprehensive assessment of multiplanar deformity correction. Fusion rates obtained with less invasive access equal those of conventional open technique.

Treatment of severe early onset Blount's disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame

Severe Blount's disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity. Four patients were treated for severe Blount's disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest. Mechanical axis was corrected from a mean 23 degrees (13 degrees -30 degrees ) to 0 degrees in three patients and 6 degrees valgus in 1. Tibias were lengthened by 1-4 cm. At follow-up, the mechanical axis was 0 degrees in two patients and 7 degrees varus in two. The overlengthening was diminishing as planned. The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount's disease.

Correction of Tibial Deformity with Use of the Ilizarov-Taylor Spatial Frame

The Ilizarov-Taylor Spatial Frame (TSF; Smith and Nephew, Memphis, Tennessee) is a powerful tool for correcting tibial deformity1-6. A specialized feature of the TSF is its virtual hinge, which allows for the simultaneous gradual correction of multiplanar deformities and limb-lengthening through one osteotomy site. The power of the spatial frame lies in its precise control over the final limb length and alignment and in its ability to correct a residual deformity. The stability of this multiplanar circular fixator permits early weight-bearing and provides an ideal environment for both new-bone formation and soft-tissue healing. The classic principles of the Ilizarov method are followed to ensure proper frame application. The TSF web-based software is user-friendly and has greatly simplified the planning of the correction of an oblique plane deformity by utilizing standard anterior-posterior and lateral radiographic measurements. Computer-generated schedules and easy-to-read struts have greatly simplified patient involvement, which is crucial to the success of this technique. ### Preoperative Planning Patients are evaluated clinically by a history and physical examination including observation of gait. Special attention is directed toward the assessment of leg length, mechanical axis deviation, and rotational alignment (Fig. 1). An erect bipedal 51-in (130-cm) radiograph in the frontal plane is made. If there is a leg-length discrepancy, then blocks are placed under the affected foot to level the pelvis, and the block height is recorded. Accurate limb lengths are measured in this way. Sagittal deformity about the knee is evaluated with a 36-in (91-cm) lateral radiograph made with the knee in full extension. Routine anteroposterior and lateral radiographs of the tibia are made as well. Ankle deformity should be evaluated with the x-ray beam centered on the ankle. Mechanical axis deviation is determined with use of the malalignment test7,8 (Fig. 2). The lateral distal femoral angle, …

Proximal tibial osteotomy with compression plate fixation for tibia vara.

A surgical technique for the accurate intraoperative correction of tibia vara deformities with maintainence of postoperative alignment is presented. This was a retrospective study of 13 knees of nine patients with tibia vara deformities treated by proximal tibial and fibular osteotomies using compression-plate fixation. Average age of the patients was 9 + 1 years, with a range of 3 + 1 to 14 + 11 years. The average preoperative deformity was 20 degrees of varus with a range of 15-36 degrees. Average follow-up was 3 + 3 years, with a range of 2 to 4 + 1 years. All patients had intraoperative correction to an average valgus of 5 degrees (range 4-8 degrees valgus), with an overall valgus correction of 25 degrees (range 20-40 degrees). There was one reoperation for unilateral recurrence of deformity in a child who progressed from stage III to stage VI postoperatively. Proximal tibial osteotomy with compression-plate fixation provides an accurate and reliable method for the correction of multiplanar deformities in children and adolescents.