Degrees Varus Research Articles

A New Double Elevating Osteotomy in Management of Severe Neglected Infantile Tibia Vara using the Ilizarov Technique

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.

Minimally invasive anterolateral surgical approach for total hip arthroplasty: Early clinical results

The purpose of this study is to describe our early experience in the development and use of a minimally invasive, anterolateral approach to the hip joint for total hip arthroplasty (THA). This approach uses a specific intraoperative protocol involving leg positioning to maximise exposure and hip joint visualisation. Between October, 2004 and December, 2004, we operated on 18 male and 29 female patients without selection and in consecutive order. The average patient age at surgery was 66 years (range 28 to 86 yrs) with an average body mass index (BMI) of 26 (range 18 36) and with a majority of patients presenting with osteoarthritis as the primary indication for surgery. The average length of the skin incision was 8 cm and the average incision-to-suture time was 45 minutes. The preoperative average Harris Hip Score was 38 and improved to 70 at 10 days postoperatively, and 92 at three and six months. Similarly, the HHS average pain component score increased from 12.6 preoperatively to 39 at 10 days postoperatively, and 40 at three and six months. An exact neutral implantation of the stem was found in 48% of the patients, between one to three degrees out of neutral in 40% and greater than four degrees of varus in 12%. The average inclination angle of the cup was measured at 44 degrees. No intraoperative or perioperative complications of any kind occurred in this series of 47 consecutive patients. From our experience, the MIS AL approach for THA with patients in the lateral position can be applied without restrictions for patient indication. Improved results can be observed when using the MIS AL approach, especially in the ear-ly postoperative phase. Since the abductors can be completely spared during the surgery, improved long-term results may be expected. Moreover and when necessary, an operative expansion is always possible without difficulties. Overall, the approach yields promising results.

Minimally Invasive Anterolateral Surgical Approach for Total Hip Arthroplasty: Early Clinical Results

The purpose of this study is to describe our early experience in the development and use of a minimally invasive, anterolateral approach to the hip joint for total hip arthroplasty (THA). This approach uses a specific intraoperative protocol involving leg positioning to maximise exposure and hip joint visualisation. Between October, 2004 and December, 2004, we operated on 18 male and 29 female patients without selection and in consecutive order. The average patient age at surgery was 66 years (range 28 to 86 yrs) with an average body mass index (BMI) of 26 (range 18 36) and with a majority of patients presenting with osteoarthritis as the primary indication for surgery. The average length of the skin incision was 8 cm and the average incision-to-suture time was 45 minutes. The preoperative average Harris Hip Score was 38 and improved to 70 at 10 days postoperatively, and 92 at three and six months. Similarly, the HHS average pain component score increased from 12.6 preoperatively to 39 at 10 days postoperatively, and 40 at three and six months. An exact neutral implantation of the stem was found in 48% of the patients, between one to three degrees out of neutral in 40% and greater than four degrees of varus in 12%. The average inclination angle of the cup was measured at 44 degrees. No intraoperative or perioperative complications of any kind occurred in this series of 47 consecutive patients. From our experience, the MIS AL approach for THA with patients in the lateral position can be applied without restrictions for patient indication. Improved results can be observed when using the MIS AL approach, especially in the ear-ly postoperative phase. Since the abductors can be completely spared during the surgery, improved long-term results may be expected. Moreover and when necessary, an operative expansion is always possible without difficulties. Overall, the approach yields promising results.

Treatment of Unstable Peritrochanteric Femoral Fractures Using a 95?? Angled Blade Plate

To clarify the efficacy of a 95-degree angled blade plate fixation in the treatment of unstable peritrochanteric fractures of the femur. Retrospective, clinical study. University hospital. Thirty-nine consecutive patients with peritrochanteric femoral fractures were followed for a minimum of 12 months. There were 29 subtrochanteric fractures and 10 intertrochanteric fractures (reverse obliquity pattern) for which the compression hip screw could not be used because of comminution of the trochanteric area and fracture extension to the lateral cortex. The mean age of the patient population at the time of operation was 54 (range, 17-71) years. Open reduction and internal fixation of the pertrochanteric fractures using a 95 degrees angled blade plate. Time to fracture union, operation time, and complications. Duration of clinical follow-up averaged 26 (range, 12-36) months. The average time to osseous union for those fractures that healed primarily was 19 (range, 13-28) weeks. Two of 39 fractures united with 10 degrees varus deformity, but no corrective surgery was warranted. Limb length discrepancy more than 1.5 cm did not occur. Implant failure before solid bony union occurred in 1 case with a severely comminuted subtrochanteric fracture. Postoperative infection or osteonecrosis of the femoral head did not occur any time throughout the follow-up period. A 95 angled blade plate can be a useful alternative fixation device for the treatment of unstable peritrochanteric femoral fractures.

The Relationship Between Forefoot, Midfoot, and Rearfoot Static Alignment in Pain-Free Individuals

Correlational study. To determine whether, and to what degree, a relationship exists between forefoot angle and weight-bearing midfoot and rearfoot position. There have been conflicting reports with regard to the degree to which the structure of the foot may influence the function. The influence of forefoot structure on weight-bearing midfoot and rearfoot position has not been extensively investigated. Fifty-one healthy subjects participated in this study (26 male and 25 female). Forefoot angle was measured in prone as varus (positive numbers), neutral (0), or valgus (negative numbers). Navicular drop was measured from subtalar joint neutral to unilateral standing relaxed. Rearfoot angle was measured in relaxed single-limb stance as the angle between a line that bisected the calcaneus and a line that bisected the lower third of the leg. The relationships between forefoot angle and navicular drop, and between forefoot angle and relaxed rearfoot angle, were investigated. The same relationships were also investigated in the neutral forefoot subgroup when the sample was divided in 3 subgroups based on 1 standard deviation of forefoot angle. There is a significant relationship between forefoot angle and relaxed rearfoot angle (r = 0.52, P < .001), as well as between forefoot angle and navicular drop (r = 0.55, P < .001), in the whole sample (n = 51). Average degrees of forefoot angle in the neutral subgroup (between 1.0 degree and 8 degrees of varus) are not associated with predictable positions of relaxed rearfoot angle (r = 0.19, P = .24) or navicular drop (r = 0.01, P = .96). Based on the results of this study, there is a significant relationship between forefoot angle and relaxed rearfoot angle, as well as between forefoot angle and navicular drop, in healthy subjects. These relationships were not found when forefoot varus values were within a standard deviation of the sample mean.

Tibial Shaft Fractures in Children and Adolescents

Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.

Rotational Deformity in Varus Osteoarthritis of the Knee

Rotational deformities in varus osteoarthritis of the knee were evaluated with computed tomography. Preoperative computed tomography scans of 150 knees (114 patients) having total knee arthroplasty and 31 control knees (20 patients) were included. The femorotibial rotation was quantified using the clinical epicondylar axis of the femur and the tibial tuberosity (patella tendon) as the references. The knees with osteoarthritis were divided into three groups according to the femorotibial angle (Group 1, 0 degrees -9 degrees varus, n = 87; Group 2, 10 degrees -19 degrees varus, n = 51; Group 3, 20 degrees or greater varus, n = 12) and statistically analyzed. Rotational deformities (external rotation of the tibia) existed in knees with osteoarthritis and were larger in knees with increased varus deformities (mean +/- standard deviation, -2.24 degrees +/- 4.19 degrees in Group 1; 0.33 degrees +/- 4.14 degrees in Group 2; and 5.33 degrees +/- 5.71 degrees in Group 3). When the femorotibial rotation of each knee was stratified by the corresponding femorotibial angle, we found a correlation. The information should help minimize the rotational mismatch between the femoral and the tibial components in total knee arthroplasty and elucidate the pathogenesis of varus osteoarthritis of the knee. Diagnostic study, Level III-1 (study of nonconsecutive patients--no consistently applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Midvastus approach in total knee arthroplasty: a randomized, double-blinded study on early rehabilitation

The medial parapatellar approach has become the standard technique in total knee arthroplasty (TKA). However, recent studies have reported superior results regarding functional recovery when using the midvastus approach. It was the aim of this study to evaluate the early functional outcome of both surgical techniques. In a prospective, double-blinded, randomized study, 50 patients for TKA were consecutively operated on either by the medial parapatellar or the midvastus approach. Exclusion criteria were defined as previous open knee surgery and leg deformity of more than 10 degrees varus or valgus. TKA was performed in all patients by one surgeon using the same type of implants in both groups. Pain scores (VAS) were documented and follow-up data including quadriceps strength and proprioception were obtained 3 weeks and 6 weeks postoperatively. Both groups were comparable in preoperative demographic data. Postoperatively, patients in the midvastus group demonstrated significantly lower pain in rest (VAS: mean 2.25 vs. 3.03) and under movement (VAS: mean 2.92 vs. 3.13). Further, they showed superior isometric quadriceps strength at 3 weeks (41.4 vs. 27.6 Nm) and 6 weeks (47.6 vs. 35.5 Nm). Moreover, this group showed a superior postoperative proprioception, while the range of motion was similar in both groups. The midvastus approach offers advantages over the standard parapatellar arthrotomy, in the early rehabilitation period. No adverse effects were observed associated with this approach. Therefore, the midvastus approach should be considered as a valuable alternative in TKA.

The Classic: Replacement of the Severely Damaged Arthritic Knee by the ICLH (Freeman-Swanson) Arthroplasty

A multi-centre clinical trial of ICLH (Freeman-Swanson) arthroplasty has been in progress since 1971. In this paper the results up to two years after operation are reported in seventy-one knees displaying at least 30 degrees of fixed flexion, 25 degrees of valgus or 20 degrees of varus, before operation. It has been found that knees displaying 70 degrees of fixed flexion, 70 degrees of valgus, 30 degrees of varus or 50 degrees of valgus/varus instability can be satisfactorily aligned and stabilised with acceptable function. Three knees required revision. The other complications are listed and were unremarkable in nature. These results depend upon the prosthesis and upon the operative technique. The latter avoids damage to healthy bone but does involve the replacement of the tissues in the midline of the knee.

The Effect of 5-Degree Valgus and Varus Rearfoot Wedging on Peak Hallux Dorsiflexion During Gait

The dynamic effects of 5 degrees varus and valgus rearfoot wedging on peak hallux dorsiflexion were investigated in 30 asymptomatic subjects (5 males and 25 females). Statistically significant reductions in peak hallux dorsiflexion were found with rearfoot varus wedging and rearfoot valgus wedging. Furthermore, the reduction in peak hallux dorsiflexion occurring with rearfoot varus wedging was statistically significant compared with that associated with rearfoot valgus wedging. These findings have implications for the orthotic management of a variety of lower-limb pathologies.

Minimally invasive unicompartmental knee replacement with a nonimage-based navigation system.

In a prospective study, two groups of 20 unicompartmental knee replacements (UKR) each were operated either using a CT-free navigation system or the conventional minimal invasive technique. Radiographic assessment of postoperative alignment was performed by long-leg coronal and lateral radiographs. The results revealed a significant difference between the two groups in favor of navigation. In the computer-assisted group, 95% of UKRs were in a range of 4-0 degrees varus (mechanical axis) compared with 70% in the conventional group. The only inconvenience was a prolonged operation time (+19 min). Due to the limited exposure, the navigation system is helpful in achieving a more precise component orientation. The danger of overcorrection is diminished by real-time information about the leg axis at each step during the operation.

Analysis of Early Failures in Total Knee Arthroplasty

Purpose: To analyze the cause of failure and average period in patients who had revision surgery within 5 years of their primary total knee arthroplasty (TKA). Materials and Methods: 786 total knee arthroplasties were performed between August 1994 and May 2003. During the period, there were 38 cases, 36 females and 2 males, of revision surgery within 5 years. The mean age was 66 years. The most common causes of disease in revision were degenerative arthritis. We analyzed the reasons for early failure retrospectively. Results: Revision TKA were performed at average 2 years after primary TKA. The causes of revision were polyethylene wear in 18 cases (47.4%), deep infection in 16 (42.1%), instability in 2, and aseptic loosening in 1, dissociation of patella component in 1. The degree of varus in tibial cutting was in average in polyethylene wear group. The obliquity of the tibial joint line was more than varus in 14 cases (82.4%). Most patients had their knee in hyperflexion and squatting position during activities of daily living. Conclusion: Thirty eight cases (4.8%) were performed revision surgery within 5 years of primary TKA. Polyethylene wear and deep infection were the common causes of early failure of primary TKA. The component malalignment, hyperflexion and squatting position during activities of daily living may be related to polyethylene wear. Diabetes mellitus and long term steroid application, may be related to infection.

Knee angles and rickets in nigerian children.

Knee angles of 2,036 normal Nigerian children up to 12 years old were measured directly or from photographs. The knees were bowed (varus) in the first 6 months. At 21 to 23 months, the distribution of angles became strongly bimodal: about half were varus and half were valgus (knock-kneed), with few in between. After this they were all valgus, with few exceptions. Hence, the change from varus to valgus in individual infants must be sudden (a few weeks), although the changeover of the whole population appears smooth and gradual. They became maximally and uniformly knock-kneed (-7.1 degrees +/- 1.4 degrees) between 3 and 3.5 years, with little change thereafter. On the other hand, 120 patients with rickets discovered during screening had large knee angles, in either sense, with a bimodal distribution and frequency maxima at +10 degrees (varus) and -12 degrees (valgus). Varus knee is uncommon after 2 years. Large knee angles between 2 and 5 years suggest rickets.

The impacted varus (A2.2) proximal humeral fracture Prediction of outcome and results of nonoperative treatment in 99 patients

BACKGROUND AND PATIENTS: The outcome of the impacted varus proximal humeral fracture has not been described. We present the results of a prospective analysis of 99 such fractures. This fracture was relatively common in the elderly population and non-operative treatment sometimes resulted in increased varus angulation. Decreased shoulder function was associated with increasing age but not with increasing varus angulation. After nonoperative management the outcome was good, regardless of the degree of varus, 1 year after fracture. Age was the main predictor of outcome. Physiotherapy did not improve outcome.

内反肘に伴う肘関節後外側回旋不安定症の一例

We have experienced a case of posterolateral rotatory instability (PLRI) in post-traumatic cubitus varus. The patient was a 35-year-old male with apprehension of his left elbow. He had a history of fracture of the humerus at age nine months. He was treated using a plaster cast, but it slipped off after one week. He had not received any treatment since then. Unstableness of his left elbow has been noticed since five years old. On his visit to our clinic, the range of motion of his left elbow was 5 to 135 degrees. He presented deformity of the left elbow which was 5 degrees cubitus varus and 20 degrees internal rotation. Radiogram showed ulnar deviation of the olecranon, hypertrophy of the radial head, and enlarged curvature of the trochlea notch. He showed not only 20 degrees varus instability but also posteolateral rotatory instability. Correction osteotomy of the humerus and reconstruction of the lateral ulna collateral ligament with use of a palmaris longus tendon were performed. Three years postoperatively, there has been no recurrence of apprehension and lateral instability.

Outcome of osteotomies for the treatment of haemophilic arthropathy of the knee.

The knee is one of the most commonly affected joints in haemophilic arthropathy leading to stiffness and disability. It is the aim of this study to investigate the outcome of corrective osteotomies around the knee. We report on the long-term results of ten osteotomies around the knee for severe haemophilic arthropathy and axial deviation at an average of 7.25+/-1.8 years postoperatively. Seven high tibial (preoperatively 7.2+/-2 degrees varus) and three supracondylar osteotomies (preoperatively 7+/-3 degrees valgus) were performed on seven patients (three of them bilateral). The clinical score of the Advisory Board of the World Federation of Haemophilia (average 7.4 points preoperatively) remained unchanged in two patients, improved in three patients and deteriorated in five patients. The radiological Pettersson score (average 8.2 points preoperatively) showed a worsening of 2.5 points over the time. Patients reported a subjective improvement for seven osteotomies, with sports activity in three patients, although the range of motion did not change significantly. Total knee arthroplasty was considered to be a failure, i.e. endpoint of follow-up. Six knees were replaced in four patients by total arthroplasty after a mean of 6.6 years. Although survival of osteotomies around the knee in haemophilic arthropathy is lower than in non-haemophilic patients, we think that it is a choice of treatment, which, at least, postpones the indication for total knee arthroplasty in this young patient group.

The influence of alignment on the musculo-skeletal loading conditions at the knee.

High tibial osteotomies attempt to recreate physiologically normal joint loading. Previous studies have discussed the influence of mal-alignment on the distribution of static loads to the medial and lateral compartments of the knee. The aim of this study was to determine the influence of mal-alignment on the tibio-femoral loading conditions during dynamic activities. Using a musculo-skeletal model of the lower limb, which had been previously validated with in vivo data, in this study we modified the alignment of the knee in four patients, from a normal position to the extremes of 8 degrees valgus and 10 degrees varus mal-alignment. The resulting tibio-femoral joint contact forces were examined while patients were walking and stair climbing. Varying the mal-alignment resulted in a highly individual response in joint loads. Deviations from the normal alignment produced an increase in loading, with valgus generating a more rapid increase in loading than a varus deformity of the same amount. Varus deformities of 10 degrees resulted in increases in peak contact force from an average of 3.3-times bodyweight (BW) up to a peak of 7.4 BW (+45% to +114%) while patients were walking, whilst increases of 15% up to 35% were determined for stair climbing. Increases of up to 140% were calculated at 8 degrees valgus during walking and up to 53% for stair climbing. This study demonstrated a clear dependence of the individual joint loads on axial knee alignment. Based on the sensitivity of joint loading to valgus mal-alignment, more than 3 degrees of over-correction of a varus deformity to valgus should be carefully reconsidered.

Treatment of tibia vara by the Ilizarov method.

Sixty-nine lower extremities of 45 patients (mean age, 10 years 8 months) with tibia vara were treated with the Ilizarov circular external fixator and distraction osteogenesis. Twenty-four of the patients had bilateral involvement, six of whom had simultaneous surgery and the remaining 18 had staged operations 8 to 12 months apart. In 11 limbs with femoral valgus deformity greater than 10 degrees simultaneous corrections were done. Active movements of the joints of the extremity were encouraged the day after surgery and partial weightbearing began 2 days later. All patients were followed up 27 to 178 months (mean, 80 months) after surgery. No neurovascular complications, delayed union, or nonunions were observed. The mean 28.6 degrees varus tibiofemoral angle preoperatively (range, 15 degrees -45 degrees ) improved to 7.5 degrees valgus (range, 0 degrees -18 degrees ) postoperatively. The preoperative internal torsion angle also improved from 20.7 degrees (range, 0 degrees -48 degrees ) to 3.5 degrees external torsion (range, 0 degrees -9 degrees ) postoperatively. Residual deformity was seen in six patients, and they had successful revision surgery using the same technique. The Ilizarov method allows early weightbearing and motion and allows all components of the deformity to be corrected.

Oblique osteotomy for multiplanar correction of malunions of the femoral shaft.

Between 1990 and 1996, six patients had oblique femoral osteotomies for symptomatic posttraumatic femoral malunions. In each patient, an oblique osteotomy was done that allowed for correction in the coronal, transverse, and sagittal planes. Fixation was achieved with lag screws supplemented by a neutralization plate. The average followup was 49 months (range, 18-99 months). All osteotomies healed at an average of 2.9 months (range, 2.5-4.0 months). Postoperatively, all patients had full range of motion in the ipsilateral hip and knee and could bear full weight without pain. Radiographically, the average deformity measured on anteroposterior radiographs improved from 21.6 degrees to 4.2 degrees varus. The average deformity on lateral radiographs improved from 22.5 degrees to 7.0 degrees antecurvatum. In all patients, the leg lengths were within 0.5 cm of each other and axial alignment was within 10 degrees of the contralateral limb. The use of an oblique osteotomy is a simple and predictable method of correcting complex posttraumatic femoral malunions and provides excellent surgical and clinical results.

Total knee arthroplasty for arthritis of the knee with extra-articular deformity.

Simultaneous corrective osteotomy of angular deformity and total knee arthroplasty has been considered the treatment of choice for patients with arthritis of the knee associated with ipsilateral extra-articular deformity. However, this procedure is technically demanding, and the functional outcome of the total knee arthroplasty may be jeopardized if the osteotomy fails. This retrospective study was performed to evaluate the clinical results of total knee arthroplasty combined with intra-articular bone resection, without osteotomy, in patients with extra-articular deformity and arthritis of the knee. Fifteen patients with arthritis of the knee and extra-articular deformity underwent total knee arthroplasty with bone resection and soft-tissue balancing. All deformities had resulted from fracture malunion. There were ten uniplanar, three biplanar, and two triplanar deformities. The deformity was in the tibia in eight patients and in the femur in seven. The average angle of the femoral deformities was 15.1 degrees in the coronal plane and 8.1 degrees in the sagittal plane. Two femora had a rotational deformity, consisting of 20 degrees of internal rotation in one and 10 degrees of external rotation in the other. The average angle of the tibial deformities was 19 degrees in the coronal plane. The duration of follow-up averaged thirty-eight months. The average Knee Society knee score improved from 22.3 points preoperatively to 91.7 points at the time of the last follow-up, and the average Knee Society function score improved from 28.0 points preoperatively to 87.3 points at the time of the last follow-up. The average arc of knee motion improved from 77.7 degrees preoperatively to 103.7 degrees postoperatively. The average mechanical axis of the knee improved from 22.7 degrees of varus preoperatively to 0.3 degrees of varus at the time of the last follow-up. Two patients had an unsatisfactory clinical result, which was not related to the total knee arthroplasty. There were no complications such as infection, ligament instability, or component loosening. Total knee arthroplasty in conjunction with intra-articular bone resection is an effective procedure for patients with arthritis of the knee and extra-articular varus deformity of <20 degrees in the femur or 30 degrees in the tibia in the coronal plane.