Correction Of Varus Deformity Research Articles

Supracondylar medial open wedge osteotomy with external fixation for cubitus varus deformity.

Many surgical procedures are used for the correction of cubitus varus deformity in children. Even if the primary indication is cosmetic, but many poor results have been described. The technique of a supracondylar medial opening wedge osteotomy with external fixation is presented and preliminary results in four cases are reported. An antero-medial approach is chosen with exposition and anterior transposition of the ulnar nerve. Under image intensifier control, insertion of four Schanz screws is performed from medial to lateral. In between, an incomplete medial osteotomy is performed obliquely (in the antero-posterior as well as in the medio-lateral plane), leaving a small part of the radial humeral cortex intact. The osteotomy is opened until varus and, if present, hyperextension deformation are corrected. Then, the fixator system is applied. All osteotomies healed primarily. Mean valgus correction of 21.75 degrees was achieved; in only one patient additional flexion modification of 17 degrees was necessary. At a follow-up of at least 2 years clinically three out of four presented symmetric elbow position, one slight residual varus deformity was noted in spite of 20 degrees of valgization due to important valgus position of the contralateral side. No lateral bulging of the corrected elbow was observed. The described technique is an alternative to other procedures, with special regard to the cosmetic outcome as well as to the control of correction for valgus and flexion.

高度内反膝に対する人工膝関節置換術の治療経験

We report clinical results of total knee arthroplasty in 22 knees with severe varus deformity. The mean follow-up period was 5.4 years. We define severe varus knee femorotibial angle (FTA) as over 195 degrees. Severe varus knees were classified into the bone defect type and fixed varus type. Medial tibial bone defect is the main cause of varus deformity in the bone defect type. Altough, the fixed varus type reveals large laxity of the lateral supporting structure, it is difficult to correct varus deformity by valgus stress because of severe medial soft tissue contracture. We evaluated clinical results using the Knee Society Score. The knee score improved from 38.6 points to 76.6 points after TKA. The Function score also improved from 40.7 to 80.9. The mean standing FTA was 198.8° (range 195° to 209°) before surgery and corrected to 176.1° (range: 167° to 188°). Four knees, however, was over 180°. Although slight varus instability was observed on stress Xray, it had no significant effects on clinical results.

Immunolocalization of carboxy-terminal type II procollagen peptide in regenerated articular cartilage of osteoarthritic knees after reduction of mechanical stress

Objective The purpose of this study was to investigate the immunolocalization of carboxy-terminal type II procollagen peptide (pCOL-II-C) in the regenerated articular cartilage grown 1–2 years after reduction of mechanical stress by correction of varus deformity with high tibial osteotomy (HTO) for knees with medial compartmental osteoarthritis.Design The series included 24 knees of 16 patients with a mean age of 70 (56–79) years. Synovial fluid and tissue specimens of the regenerated articular cartilage were obtained at the time of plate removal with arthrotomy. Tissue specimens were decalcified and stained with toluidine blue, safranin O, anti-type I and type II collagen and anti-pCOL-II-C. Pineda's histological grading of articular cartilage repair and Okada's grade of immunostaining were employed to assess the regenerated articular cartilage.Results In knees with regeneration of articular cartilage, there was a positive linear correlation between the grade of immunostaining and the concentration of synovial fluid pCOL-II-C (r=0.652; P< 0.001). Similarly, a positive linear correlation was observed between the grade of immunostaining and the histological grading score (r=0.683; P< 0.001).Conclusions The immunostaining and synovial fluid concentration of pCOL-II-C decreased in accordance with the progression of articular cartilage regeneration observed after reduction of mechanical stress by correction of deformity with HTO. Copyright 2002 OsteoArthritis Research Society International. Published by Elsevier Science Ltd. All rights reserved.

Ｏｌｌｉｅｒ病の下肢変形に対するＩｌｉｚａｒｏｖ法による治療経験

We performed correction of varus and extention deformities of the femur due to Ollier disease using the Ilizarov method. The patient was a 9-year-old-boy, who underwent angular deformity correction and lengthening of the femur using the Orthofix unilateral fixator when he was 7 years old.We measured the %mechanical axis (%MA), deformity angle of AP, and lateral view on X-ray. Before the correction, the %MA was-13.6% and the angles of the deformities were 24 degrees varus and 25 degrees extension.We performed an open osteotomy and angular correction gradually using the Ilizarov apparatus for 118 days. The result wave satisfactory: the %MA improved to 74.6% and the angle of correction on the lowor limb exceeded by 3 degrees.As the Ilizarov system is bulky, intensive physical therapy proved more difficult than the unilateral system. It was however effective for correcting the three dimensional angular deformity close to the joint in older children.

External fixation of select intertrochanteric fractures with single hip screw.

Since 1994, external fixation using a long hip screw was used for osteosynthesis of trochanteric fractures in 41 patients (27 women and 14 men) 76 to 94 years of age (mean age, 85 years) to minimize the risks associated with an open surgical procedure and general or long lasting spinal anesthesia. The patients were operated on under short duration spinal anesthesia, and intraoperative blood transfusion was not required in any patient. The hip screw was inserted on a guide pin within a protective sleeve in such a way as to achieve impaction at the fracture site as compression was applied in 35 patients. The hip screw was left free for sliding and dynamization in six patients. Diaphyseal distraction by the fixator was used in three of nine unstable fractures to correct varus deformity. The range of times to apply the external fixator was 20 to 45 minutes (mean, 35 minutes). The mean hospital stay was 6 days (range, 3-12 days) and the time to fracture union was 12 weeks (range, 11-13 weeks). Five patients died within 3 months. There were no nonunions or deep infections, but in 18 patients superficial skin reactions were seen around the pins and the screw. No material failure occurred. The method is thought to offer easy and safe stabilization of these fractures with the exception of temporary skin problems, which do not create a major problem.

Dome Corrective Osteotomy for Cubitus Varus Deformity

Between 1994 and 1998, 15 patients had corrective dome-shaped osteotomy of the humerus for posttraumatic cubitus varus deformity. Thirteen patients had surgery before puberty and two patients had surgery after puberty. In the prepuberty group, all the osteotomies were done by a posterior approach with triceps muscle splitting, and cross pins were used to fix the osteotomy. In the postpuberty group, the osteotomies were done by a posterior approach with olecranon osteotomy, and reconstructive plates were used for fixation. The average followup was 2 years and 4 months. Preoperative carrying angle ranged from 19 degrees to 31 degrees varus (average, 26.2 degrees) and postoperative carrying angle ranged from 7 degrees to 15 degrees valgus (average, 10.7 degrees). No loss of correction was observed and all osteotomies united. The preoperative and postoperative differences of the lateral condylar prominence index ranged from -67% to +6% (average, -30.1%). After reviewing these cases, a dome-shaped osteotomy was found to have the following advantages for correction of cubitus varus deformity: the osteotomy site is more stable than a lateral closing wedge osteotomy for maintaining the correction obtained; the domed osteotomy avoids having the lateral condyle becoming prominent; and the posterior scar is more cosmetically acceptable than the lateral scar in the lateral closing wedge osteotomy.

Functional medical ligament balancing in total knee arthroplasty.

Function of the anterior and posterior oblique portions of the medial collateral ligament and the posterior capsule in flexion and extension was evaluated in eight knee specimens after posterior cruciate retaining total knee arthroplasty. The posterior oblique portion of the medial collateral ligament was released subperiosteally in four specimens, and the anterior portion was released in four specimens. The medial posterior capsule was released in each group, then the remaining portion of the medial collateral ligament was released. Release of the posterior oblique portion produced moderate laxity at full extension and at 30 degrees flexion, and posterior capsule release produced additional laxity in full extension. Release of the anterior portion produced major laxity at 60 degrees and 90 degrees flexion. Complete medial collateral ligament release increased laxity significantly in both groups in flexion and extension. This rationale was tested in a clinical study of 82 knees (76 patients) in which 62 (76%) required medial collateral ligament release to correct varus deformity during posterior cruciate retaining total knee arthroplasty. Twenty-two knees (35.5%) were tight medially in extension only, and were corrected by releasing the posterior oblique portion. Thirty-one knees (50%) were tight medially in flexion only, and were corrected by releasing the anterior portion. Nine knees (14.5%) were tight medially in flexion and extension and required complete medial collateral ligament release, but three knees (4.8%) remained tight in extension and required medial posterior capsule release to correct flexion contracture and medial ligament contracture. Seventeen (27%) had partial posterior cruciate ligament release to correct excessive rollback of the femoral component on the tibial surface.

Early results of Scarf osteotomies using differentiated therapy of hallux valgus

Summary The differentiated therapy of the hallux valgus includes correction of the varus deformity of the first metatarsal to reduce the intermetatarsal angle. Subcapital osteotomies allow only a small correction of the intermetatarsal angle and may lead to head necrosis of the first metatarsal, whilst proximal correction often has to be fixed with plaster. The Scarf osteotomy represents an alternative operating method which guarantees primary loading stability. The Scarf procedure is an osteotomy of the first metatarsal shaft in a Z-fashion. After parallel and lateral displacement of the distal-plantar fragment osteosynthesis is carried out using two cannulated titanium screws. In addition the pseudoexostosis can be resected, the soft tissue operation and the release of the adductor tendon can be carried out. For this study 53 cases (49 patients) of Scarf osteotomy were evaluated. The follow-up, on average for 1.2 years, included physical examination, radiographs and a podogram. In comparison with the preoperative state a reduction in subjective complaints of up to 74% was obtained. The average improvement of the hallux valgus angle was from 43° to 23° and the intermetatarsal angle was reduced on average from 16° to 8°. The Scarf osteotomy is a technically demanding operation to correct first metatarsal varus deformity. As a matter of principle it should be combined with operation on the soft tissue and release of the adductor tendon. An intermetatarsal angle from 12° to 20° has been the indication for this operation. The major advantage of this method is the primary loading stability which enables early mobilisation. Furthermore, there is the possibility of first metatarsal shortening or lengthening to correct the alignment. Additionally, there is the possibility of a precise change of the metatarsal head position.

Results of Total Knee Arthroplasty With Medial Epicondylar Osteotomy to Correct Varus Deformity

The clinical results of using medial epicondylar osteotomies to correct varus deformities in total knee arthroplasties were investigated. Unlike the traditional method of subperiosteal stripping of tibial ligaments, this alternative does not damage ligaments. Between 1991 and 1996, the senior author performed medial epicondylar osteotomies in 80 patients (93 knees) with primary total knee arthroplasty; of these, 60 patients (70 knees) were available for 2- to 4-year followup. At followup, no patients reported knee instability. Mean varus and valgus stability measured 14.2 points (Knee Society scale, 0-15 points). The Knee Society clinical score was 93 points, compared with a preoperative score of 42 points. The mean range of motion at followup was 111 degrees, compared with a preoperative mean of 101 degrees. The postoperative tibiofemoral angle on full limb radiographs taken with the patient weightbearing averaged 7 degrees valgus, compared with an average 6 degrees varus preoperative angle. Ninety-five percent of the patients were satisfied and reported less pain and improved knee function. Bone union occurred in 54% of the knees and fibrous union occurred in 46%. Focal tenderness, restricted motion, or other symptoms were not associated with fibrous union. The results show that epicondylar osteotomy for varus knee deformity provides excellent patient satisfaction, knee stability, motion, and deformity correction.

Correction of varus deformity with tibial flip autograft technique in total knee arthroplasty

A simple method of autogenous bone grafting is described for correction of varus deformity during total knee arthroplasty. This technique uses a wedge of bone resected from the proximal tibia, which is flipped to augment the medial compartment. It is recommended in osteoarthritic knees with 15° to 20° of varus angular deformity resulting from peripheral rim tibial defects involving the medial compartment. This method corrects varus deformity, preserves bone stock, and creates a stable platform for seating of tibial components without the need for internal fixation.

Poster #13 The clinical results of medial epicondylar osteotomy to correct severe varus deformity with total knee arthroplasty

Poster #13 The clinical results of medial epicondylar osteotomy to correct severe varus deformity with total knee arthroplasty

Fracture-separation of the Distal Humeral Epiphysis in Children

We retrospectively reviewed twelve cases of the fracture-separation of the distal humeral epiphysis, which were treated during the period from 1989 to 1996. The incidence of this injury was about 3 % from 266 pediatric elbow fractures. Four cases were remained misdiagnosed as the lateral or medial humeral condylar fracture until the authors reviewed their radiographs. Though eleven fractures were extension type injury with typical posteromedial displacement, we identified a rare flexion type injury with anterolateral displacement. This case was a 12+7 year old boy, who was the oldest in our series. Cubitus varus deformity of more than 10 o developed in five patients, and cubitus rectus in two patients. One patient underwent osteotomy for the correction of cubitus varus deformity. We feel this injury is not uncommon as previously noted in the literature. The major problem of this fracture was the possibility of misdiagnosis. Whichever treament modality one may choose, careful evaluation of the carrying angle after reduction is mandatory to avoid residual cubitus varus deformity.

Partial Physeolysis with Temporary Transphyseal Bridging for Correction of Physeal Dysplasia and Angular Limb Deformity in Two Yearling Horses*

SummaryPectoral limb varus deformities, caused by medial distal radial physeal dysplasia were corrected in two young growing horses. These horses were (14 and 18 months of age) older than the generally accepted time period when periosteal elevation and transphyseal bridging would be successful. Partial circumferential resection (physeolysis) of the dysfunctional physes and placement of autogenous fat grafts in conjunction with transphyseal bridging appeared to assist correction of the angular deformity in these older horses.The correction of pectoral limb varus deformities in two young growing horses, caused by medial distal radial physeal dysplasia, is described.

片側仮骨延長法（Ｈｅｍｉｃａｌｌｏｔａｓｉｓ）を用いたけい骨骨切り術について

Seven knees with medial osteoarthrosis, in which tibial osteotomy was performed with hemicallotasis over a year previously, were evaluated clinically and radiographically. The average age of patients was 63 years and average follow-up period was 14 months. Femorotibial angle changed from 181 to 167 degrees. JOA knee score improved to 93 postoperatively from 59 points. Hemicallotasis is a method for correcting varus deformity of the proximal tibia. In this method, however, upper displacement of the fibular head occurs and that is a unresolved problem.

Epiphyseal separation of the distal end of the humeral epiphysis: a follow-up note.

Twenty-one children with fracture-separations of the distal end of the humeral epiphysis were treated. Fifteen of the 21 children developed cubitus varus deformity after treatment. Thirteen children were treated at our hospital, and seven of these children developed cubitus varus deformity. Eight children were treated elsewhere initially and were referred to our institution after development of cubitus varus deformity. Nine patients underwent osteotomies for correction of cubitus varus deformities. Ages at injury ranged from 1-10 years. Fourteen patients were < 6 years of age. Fractures were classified according to Ogden; one was type IA, 16 were type IIA, and four were type IIC. Follow-up was from 10 months to 17 years. Most of the patients who were initially treated at our institution regained nearly normal function. All nine patients who were treated with closing wedge osteotomies regained nearly normal carrying angles. The carrying angles after treatment of the injury and osteotomy for the deformity did not change except in one patient.

Surgical correction of varus and equinovarus deformity in the spastic patient

Varus and equinovarus are common deformities of the foot in spastic patients. Most often due to inappropriate activity of the tibialis anterior, they respond well to the split anterior tibial tendon transfer (SPLATT). Additional deformities can be present and are best detected by dynamic electromyogram performed during gait. These additional deformities dictate the need for associated procedures to be done in conjunction with the SPLATT. With the proper combination of procedures, many patients have benefited greatly from achieving a plantigrade foot position.

The Effect of Extraarticular Varus and Valgus Deformity on Total Knee Arthroplasty

Because of trauma, metabolic bone disease, congenital deformity, or prior osteotomy, an extraarticular deformity may be present in patients requiring total knee arthroplasty. If the extraarticular deformity is not corrected extraarticularly, it must be corrected by compensatory distal femoral or proximal tibial wedge resection to produce overall limb alignment. Because such a wedge resection between the proximal and distal attachments of the collateral ligaments will produce asymmetrical ligament length, complex instabilities may result. This article, through overlay templates and trigonometric analysis, evaluates all the issues confronting the surgeon deciding whether to pursue intraarticular or extraarticular correction. The conclusions are as follows: (1) the closer a deformity is to the knee, the greater its importance, (2) femoral deformities are more difficult to correct intraarticularly than tibial deformities because femoral compensatory wedge resection produces instability only in extension, and (3) intraarticular correction of varus deformities produces lateral instability that is usually better tolerated than medial instability, and some extraarticular deformities are best treated by extraarticular correct, independent, or total knee arthroplasty.

A New Three–Dimensional Osteotomy for Cubitus Varus Deformity After Supracondylar Fracture of the Humerus in Children

In the past, supracondylar osteotomy for the correction of cubitus varus deformity has been associated with a high failure rate and significant complications, even in simple lateral closing wedge osteotomy. This is because the supracondylar area is thin and fixation is difficult to maintain. In cubitus varus deformity, not only medial, but posterior, tilt and internal rotation of the distal fragment also frequently occurs. To correct all these deformities and to achieve a wide bony contact and more rigid fixation than simple lateral closing wedge osteotomy, we propose a new three-dimensional osteotomy. Among 12 patients who received this osteotomy, 11 had an excellent result and one had a good result.

A New Three-Dimensional Osteotomy for Cubitus Varus Deformity After Supracondylar Fracture of the Humerus in Children

Summary: In the past, supracondylar osteotomy for the correction of cubitus varus deformity has been associated with a high failure rate and significant complications, even in simple lateral closing wedge osteotomy. This is because the supracondylar area is thin and fixation is difficult to maintain. In cubitus varus deformity, not only medical, but posterior, tilt and internal rotation of the distal fragment also frequently occurs. To correct all these deformities and to achieve a wide bony contact and more rigid fixation than simple lateral closing wedge osteotomy, we propose a new three-dimensional osteotomy. Among 12 patients who received this osteotomy, 11 had an excellent result and one had a good result.

Biomechanical assessment of unicompartmental knee arthroplasty, total condylar arthroplasty and tibial osteotom

A prospective biomechanical study of unicompartmental arthroplasty using the Oxford Meniscal Knee, total condylar arthroplasty, and tibial osteotomy is described. The 50 patients all had degenerative osteoarthrosis of the knee associated with a varus or valgus deformity. The decision as to which operation a patient would undergo was made on clinical grounds alone; 20 patients underwent unicompartmental arthroplasty, 10 patients total condylar arthroplasty, and 20 patients tibial osteotomy. Dynamic assessments of functional knee joint biomechanics were performed both before and after the surgery. Cadence, velocity and stride length improved in all three groups. Changes in sagittal plane knee parameters were generally small. In the corona) plane, all groups showed correction of varus or valgus deformity, with corresponding decreases in the adduction/ abduction moment. In the unicompartmental group the postoperative corona) plane angulation was predictable from its preoperative value. Some overcorrection of the varus deformity was observed after tibial osteotomy, and the total condylar arthroplasty group showed a small degree of residual deformity.