Distal Femur Research Articles

Can Periprosthetic Joint Infection of Tumor Prostheses Be Controlled With Debridement, Antibiotics, and Implant Retention?

Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population. (1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection? From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests. Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001). Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision. Level III, therapeutic study.

Forensic age estimation by MRI of the knee – comparison of two classifications for ossification stages in a German population

Aim and objectivesIn forensic age estimation e.g. for judicial proceedings surpassed age thresholds can be legally relevant. To examine age related differences in skeletal development the recommendations by the Study Group on Forensic Age Diagnostics (AGFAD) are based on ionizing radiation (among others orthopantomograms, plain x-rays of the hand). Vieth et al. and Ottow et al. proposed MRI-classifications for the epiphyseal-diaphyseal fusion of the knee joint to define different age groups in healthy volunteers. The aim of the present study was to directly compare these two classifications in a large German patient population.Materials and methodsMRI of the knee joint of 900 patients (405 female, 495 male) from 10 to 28 years of age were retrospectively analyzed. Acquired T1-weighted turbo spin-echo sequence (TSE) and T2-weighted sequence with fat suppression by turbo inversion recovery magnitude (TIRM) were analyzed for the two classifications. The different bony fusion stages of the two classifications were determined and the corresponding chronological ages assigned. Differences between the sexes were analyzed. Intra- and inter-observer agreements were determined using Cohen’s kappa.ResultsWith the classification of Ottow et al. it was possible to determine completion of the 18th and 21st year of life in both sexes. With the classification of Vieth et al. completion of the 18th year of life for female patients and the 14th and 21st year of life in both sexes could be determined. The intra- and inter-observer agreement levels were very good (κ > 0.82).ConclusionIn the large German patient cohort of this study it was possible to determine the 18th year of life with for both sexes with the classification of Ottow et al. and for female patients with the classification of Vieth et al. It was also possible to determine the 21st year of life for all bones with the classification of Ottow et al. and for the distal femur with the classification of Vieth et al.

Fixation Vs Arthroplasty for Management of Geriatric Distal Femur Fractures

Abstract Background Distal femur fractures are considered challenging to manage, particularly in geriatric patients. Double plating (DP) is a technique that helps with earlier rehabilitation and return to pre-injury level of activity. Distal femoral replacement (DFR) is an alternative technique in the management of these fractures that may help to solve problems like associated knee osteoarthritis, osteoporosis, and severely comminuted condyles. The current study compares the functional and radiological outcomes of DFR and DP in the management of these fracture among geriatric patients. Methods This randomized, comparative, interventional study was performed at a university hospital. A total of 30 patients who underwent DFR or DP after distal femur fractures (AO/OTA 33 A3, 33 C) were analyzed. The primary outcome was Knee Society Score (KSS), whereas secondary outcomes included postoperative complications rate, knee range of motion (ROM), reoperation rate, and operative time. Results No significant difference was observed between DFR and DP except for the knee component of the KSS at 12-month interval (p = 0.03), and knee ROM at 12-month interval (p = 0.001), both of which were in favor of DP. No significant difference in postoperative complications (p = 0.06), reoperation rate (p = 1.00), or operative time (p = 0.06) were noted. Conclusion DFR and DP had comparable functional (KSS) and radiological outcomes with no significant difference in postoperative complications, reoperation rate, or operative time.

Exploration of bone metabolism status in the distal femur of mice at different growth stages

The mouse femur, particularly the distal femur, is commonly utilized in orthopedic research. Despite its significance, little is known about the key events involved in the postnatal development of the distal femur. Therefore, investigating the development process of the mouse distal femur is of great importance. In this study, distal femurs of CD-1 mice aged 1, 2, 4, 6, and 8 weeks were examined. We found that the width and height of the distal femur continued to increase till the 4th week, followed with stabilization. Notably, the width to height ratio remained relatively consistent with age. Micro computed tomography analysis demonstrated gradual increases in bone volume/tissue volume, trabecular number, and trabecular thickness from 1 to 6 weeks, alongside a gradual decrease in trabecular separation. Histological analysis further indicated the appearance of the secondary ossification center at approximately 2 weeks, with ossification mostly completed by 4 weeks, leading to the formation of a prototype epiphyseal plate. Subsequently, the epiphyseal plate gradually narrowed at 6 and 8 weeks. Moreover, the thickness and maturity of the bone cortex surrounding the epiphyseal plate increased over time, reaching peak cortical bone density at 8 weeks. In conclusion, to enhance model stability and operational ease, we recommend constructing conventional mouse models of the distal femur between 4 and 8 weeks old.

The Patient Acceptable Symptom State (PASS) after proximal and distal femoral replacement

IntroductionFemoral megaprostheses are used for bone reconstruction surgery in patients with local tumors or who require multiple revisions. Patient reported outcome measures (PROMs) provide a subjective result and, like patient satisfaction, have become an integral part of the outcomes in orthopedics. However, the threshold of satisfaction (PASS: Patient Acceptable Symptom State) has not yet been defined in a French population after this type of arthroplasty. This led us to carry out a retrospective study on a population of patients who received a femoral reconstruction megaprosthesis in order to 1) define the PASS for the Harris Hip Score (HHS), Knee Society Score (KSS) and the Musculoskeletal Tumor Society score (MSTS), 2) study the complications. HypothesisThe PASS threshold for proximal femur and distal femur reconstruction prothesis for the HHS and the KSS, respectively, will be lower than the threshold for these same scores for primary arthroplasty. Materials and methodsForty-four patients who were operated on between 2009 and 2020 were included: 23 received a proximal femur prosthesis and 21 received a distal femur prosthesis. The PASS threshold was defined using an anchoring strategy by analyzing ROC curves for the HSS for the proximal femur, KSS for the distal femur and the MSTS for all the prostheses. Complications were classified according to Henderson. ResultsThe mean follow-up was 4.5 ± 3.6 (1–12.5) years. The PASS threshold was 47.5 (area under curve (AUC) 0.71 (0.45–0.97)) for the HHS, 69.5 (AUC 0.97 (0.92–1.0)) for the KSS knee and 62.5 (AUC 0.81 (0.61–0.99)) for the KSS function. Thirteen patients (29%) had complications, nine of whom required another surgery (20%). The most frequent were Henderson type 1 (soft tissue lesions, n = 5/44 [11%]) and type 2 (loosening, n = 5/44 [11%]) There was no relationship between satisfaction and postoperative complications (p = 0.071). DiscussionMost of the patients who undergo femoral resection and reconstruction (59%) are satisfied with their function, albeit reduced, despite a high complication rate (29%). Our hypothesis is confirmed for the PASS threshold for the HHS (47.5 versus 93) and the KSS knee and function (69.5 and 62.5 versus 85.5 and 72.5). Level of evidenceIV; retrospective observational single-center study.

Poster 354: Tibiofemoral Bone Shape Features Are Associated with Re-Tear after Anterior Cruciate Ligament Reconstruction

Introduction: Knee bony morphology is linked to anterior cruciate ligament (ACL) injury, ACL graft failure, and osteoarthritis (OA) risk, and employing tools such as statistical shape modeling could identify individuals prone to these joint conditions. Re-tear after ACL reconstruction remains a common and devastating complication, and therefore, recognizing patients at high risk of graft failure before primary ACL reconstruction is crucial for potential intervention to reduce failure rates. Magnetic resonance imaging (MRI) is most commonly obtained in the setting of possible ACL injury and before ACL reconstruction surgery, yet currently available MRI-based bone shape assessment methods require high-resolution sequences or manual segmentation, limiting feasibility of large-scale analysis. The development of automated tools for bone shape extraction from clinical MRI could allow for three-dimensional statistical shape modeling across large datasets. We established an automated pipeline for bone segmentation from proton density (PD)-weighted MRI scans, aiming to extract knee bony morphology from preoperative clinical MRIs in patients with ACL injuries. We hypothesized that our segmentation pipeline could uncover specific tibiofemoral joint bone shape features associated with ACL re-tear after reconstruction. Objective: To identify bone shape features prior to initial primary ACL reconstruction in patients with eventual ACL graft re-tear compared to those with a known, intact ACL graft. Methods: Patients who retrospectively experienced a subsequent re-tear after reconstruction within three years of initial injury were compared to those without a re-tear within three years (20 without subsequent re-tear, 22 with subsequent re-tear for distal femur; 22 without subsequent re-tear, 19 with subsequent re-tear for proximal tibia). The control group had MRI scans at 3 years after reconstruction that confirmed an intact ACL graft. An automatic femur and tibia segmentation framework was developed by training two deep convolutional neural networks using clinical, two-dimensional PD-weighted knee MRI sequences (3.5 mm slice thickness) from patients with ACL tears. Using the segmentation pipeline, bone was automatically segmented from preoperative clinical PD-weighted knee MRI sequence (3 mm slice thickness), three-dimensional triangulated meshes were generated, scaled to a reference, and aligned and matched to an atlas using Iterative Closest Point algorithm. Modes of shape variance were extracted from principal component analysis (PCA). The effect of each mode is modeled by three-dimensional surfaces for each specific shape feature. Modes were considered statistically significant if the mean principal component score between groups was p&lt;0.05 using Students T-test. Results: Statistical shape modeling of the femoral condyles using 15 PCA modes reveals significant differences (p &lt; 0.05) in Modes 1 and 4 at the initial injury in patients who subsequently experienced ACL re-tear after reconstruction compared to those without re-tear. Femur Mode 1 is characterized by a narrower intercondylar notch width, a wider medial condylar width, and an increased ratio of femoral condylar offset in patients with ACL re-tear. Femur Mode 4 illustrates a more prominent trochlear sulcus and increased surface area along the lateral femoral condyle relative to the medial condyle in patients with ACL re-tear. The initial 15 PCA modes of the distal femur collectively account for 75.04% of the normalized accumulated total variance. Statistical shape modeling of the tibial plateau with 15 PCA modes reveals that Mode 7 is significantly different (p &lt; 0.05) at the initial injury in patients who experienced subsequent ACL re-tear after reconstruction compared to those without re-tear. Tibia Mode 7 indicates diminished ACL facet prominence, a squared lateral tibial plateau, and a broader, flatter tibial spine in patients with subsequent ACL re-tear. The first 15 PCA modes of the proximal tibia collectively explain 73.60% of the normalized accumulated total variance. Conclusions: Using an automatic bone segmentation pipeline on preoperative clinical MRIs, we identify specific shape features in the tibiofemoral joint associated with ACL re-tear after reconstruction. Patients with subsequent ACL re-tear exhibit a variety of distinct three-dimensional morphology differences, including reduced intercondylar notch width, wider medial condylar width, increased lateral tibial plateau convexity, and broader, lateralized tibial spine, uncovered using statistical shape modeling. Statistical shape modeling identifies three-dimensional morphology patterns, thus capturing differences otherwise unaccounted for by traditional two-dimensional measurements. This approach offers predictive potential for patients at risk of ACL re-tear, improving treatment decisions for those with high-risk morphologic features.

Gender-wise Description of Morphometric Measures of Knee Joint Based on Magnetic Resonance Imaging Scan: A Descriptive Cross-sectional Study

Background: Customization of Total Knee Replacement (TKR) and the design of knee prostheses are paramount. Conventionally, surgeons select from a spectrum of pre-fabricated implants, assessing their fit based on the patient’s knee morphology via magnetic resonance imaging. Aim and Objective: This research endeavours to identify and quantify gender-related variations in knee morphometry by examining the distal femur and proximal tibia of the population of North India. Materials and Methods: A Descriptive cross-sectional study included 59 males and 59 females’ knees. A 1.5 TESLA MRI unit (Avanto Magnetomtim + dot system, Siemens, Erlangen, Germany) was utilized for imaging. The morphological features of proximal Tibia and distal femur were taken. Correlation between morphometric parameters were calculated using Karl Pearson’s correlation coefficient. P-value &lt;0.05 was set statistically significant. Results: All the FEMUR parameters were significantly higher in males than females. The mean FML in males was 8.04±0.50SD and in females was 6.97±0.33SD (P&lt;0.05). Mean FMAP in males was 5.98±0.46SD and in females it was 5.36±0.35SD (P&lt;0.05). All the TIBIA parameters were significantly higher in males than females. The mean TML in males was 7.56±0.37SD and in females was 6.49±0.28SD (P&lt;0.05). Mean TAP in males was 4.64±0.41SD and in females it was 4.13±0.25 (P&lt;0.05). Conclusion: Variations in bone dimensions were attributed to a complex interplay of genetic, ethnic, and environmental factors. In conclusion, this study makes a substantial contribution to the understanding of knee joint morphology.

Evaluation of The Treatment of Open Intercondylar Fracture Distal Femur by Transosseous Osteosynthesis Technique with Ilizarov External Fixator

Objectives: Treatment of Distal femoral fractures cannot be done following simple set of rules and when it is an open fracture the treatment is more difficult. Several methods were studied by different authors both at home and abroad, but none were conclusive. Methods: This prospective study was done between January 2011 to December 2012, 15 patients of the open intercondylar fractures of Distal femur were treated by transosseous osteosynthesis technique by Ilizarov External Fixator in NITOR (National Institute of Traumatology and Orthopaedic rehabilitation), Dhaka. 2 of the patients were not available for final follow up after removal of the fixator frame. So ultimately the final result based on the results of 13 Cases. Minimum 6 months follow up was done from the date of injury. No patient below age 16, no type IIIB or IIIC fractures and no patients having less than 6 months follow up were included in the study. Patients with severe injuries (Head injury, Abdomen and chest injury) were excluded from the study. Patients with medical illness such as Diabetes Mellitus, Peripheral Vascular diseases were not included in the study. Results: 12 male and 01 female patient between 16 and 56 years were studied. Most common age group in this series were 16-30 year age group (53.85%) and average age of the patients was 31.15 years. Most of the patients were male and road traffic accident was the leading cause of injury (92.31%). Right side involved in (69.23%) most of the cases. All patients were C3 type of fractures and G-II and G-IIIA types were same (38.46%). Most of the patients (53.85%) were operated within 1-2 weeks of admission. Average duration of hospital stay was 22 days ranging from 10 day to 45 days. Most of the patient had soft tissue healing by granulation tissue formation. Others were treated by primary closure, Delayed primary closure or secondary closure. Various complications were observed among them pintract infection, wire breakage, wire loosening, stiffness of joints, angulations and rotations, deep infection of the tissue, leg length discrepancy was observed in this study. According to the criteria of Neer et al, 1967 final results of the treatment were analyzed. Acceptable result was found in 61.54% of cases (Excellent 7.69% and good 53.85%). Results of the rest of 38.46% cases were not acceptable (Fair 23.08% and poor 15.38%). The result is similar with others done for open fractures of distal femur by Ilizarov External Fixator or other methods of fixation. Conclusion: So it can be concluded that transosseous osteosynthesis technique is a satisfactory method for treating open intercondylar fracture of distal femur as a primary and definite mode of treatment.

Rhabdomyosarcoma in a Rabbit

A geriatric Holland Lop rabbit presented for acute lameness. A pathologic fracture of the right distal femur associated with a pleomorphic rhabdomyosarcoma was diagnosed, and staging radiographs showed no overt metastasis upon initial presentation. The limb was amputated and submitted for microscopic examination. Immunohistochemical evaluation revealed the neoplastic cells were positive for desmin and MyoD1, and negative for cytokeratin AE1/AE3, CD204, IBA-1, and SMA. Gross, histologic, and immunohistochemical evaluation confirmed a diagnosis of pleomorphic rhabdomyosarcoma. The patient died 396 days after amputation, and a post-mortem examination showed metastatic sarcoma to multiple organs.

Poster 291: Entry Point-Transition Point Angle as a Novel 3-Dimensional Metric of Patellar Instability

Objectives: Three-dimensional (3D) modeling has increasing utility in identifying differences in trochlear morphology in patients with patellar instability when compared to historical 2-dimensional (2D) attempts. Distortions in the proximal medial ridges of trochleas are a distinguishing feature of trochlear dysplasia. Recently, the entry-point to transition-point (EP-TP) angle was established as a novel 3D metric to quantify degree of dysplasia, as it captures the tracking of the patella within the trochlea. However, previous attempts relied on 3D prints, which are not widely accessible. The purpose of this study is to validate this new measurement and compare differences between patients with patellar instability and the general population. Methods: Forty-three patients with recurrent patellar dislocations who were treated by a single surgeon between January 2020 and July 2023 were included. The study received an institutional review board exemption. Individuals from the New Mexico Decedent Image Database with no history of patellar instability or patellofemoral pain were used to obtain computed tomography (CT) images from the general population. Stereolithography (STL) models of distal femurs in 3D were generated from CT images using ScanIP. Minimum and maximum principal curvature maps were taken as screenshots from maps generated in MeshLab. Two people independently conducted measurements using a custom measuring tool displaying anteroposterior views and curvature maps of the distal femur. The measurers were asked to locate the medial and lateral ridges, transition point, and apex of the trochlea groove for each femur. A Mann–Whitney U test was performed to evaluate whether the recurrent dislocators had higher EP-TP values. P values below 0.01 were regarded as significant. Interclass correlation for both raters (ICC (1, k), reliability of values within this study) and single rater (ICC (1,1), reliability of measurement within clinical practice) and the 95% CI thereof, was computed for the 2 independent measurements. Results: A total of 100 femurs were measured, including 43 recurrent dislocators and 57 population femurs. The recurrent dislocator cohort had a mean EP-TP of 40.9° with a standard deviation of 16.4°. The general population cohort had a mean EP-TP of 11.3° with a standard deviation of 12.3°. EP-TP for dislocators and general population was significantly different. (p &lt; 0.001). ICC (1, k) was 0.81 with a 95%-confidence interval of 0.72 to 0.87. ICC (1,1) was 0.69 with a 95% CI of 0.57 to 0.78. Conclusions: EP-TP angle is a novel metric that helps quantify trochlear dysplasia, which can help clinicians better understand patellar instability. In this study, we validate EP-TP angle by showing that EP-TP angle was significantly different between femurs of recurrent dislocators and the general population.

To investigate the efficacy of dual plate fixation in treating fractures of the distal femur

To investigate the efficacy of dual plate fixation in treating fractures of the distal femur

Three-dimensional bone morphology is a risk factor for medial postmeniscectomy syndrome: A retrospective cohort study.

The study aims to identify differences in tibiofemoral joint morphology between responders (R group, no pain) to arthroscopic partial medial meniscectomy (APMM) versus medial postmeniscectomy syndrome patients (MPMS group, recurrent pain at 2 years postmeniscectomy) in a clinically neutrally aligned patient population. The second aim was to build a morphology-based predictive algorithm for response to treatment (RTT) in APMM. Two patient groups were identified from a large multicentre database of meniscectomy patients at 2 years of follow-up: the R group included 120 patients with a KOOS pain score > 75, and the MPMS group included 120 patients with a KOOS pain score ≤ 75. Statistical shape models (SSMs) of distal femur, proximal tibia and tibiofemoral joint were used to compare knee morphology. Finally, a predictive model was developed to predict RTT, with the SSM-derived morphologic variables as predictors. No differences were found between the R and MPMS groups for patient age, sex, height, weight or cartilage status. Knees in the MPMS group were significantly smaller, had a wider femoral notch and a smaller medial femoral condyle. A morphology-based predictive model was able to predict MPMS at 2 years follow-up with a sensitivity of 74.9% (95% confidence interval [CI]: 74.4%-75.4%) and a specificity of 81.0% (95% CI: 80.6%-81.5%). A smaller tibiofemoral joint, a wider intercondylar notch and smaller medial femoral condyle were observed shape variations related to medial postmeniscectomy syndrome. These promising results are a first step towards a knee morphology-based clinical decision support tool for meniscus treatment. Case-control study. Level IIIb.

Paper 32: Leg Length Changes Following Distal Femoral Osteotomy: Validation of a Predictive Tool and Comparison of Lateral Opening Wedge and Medial Closing Wedge Techniques

Objectives: A DFO can be performed via two techniques: a lateral opening wedge (LOW) osteotomy and a medial closing wedge (MCW) osteotomy. Small case series have looked at how leg length is affected by a lateral opening wedge DFO, however, there is a lack of research comparing these leg length changes to medial closing DFO. Additionally, no studies have presented a model for predicting the leg length changes that will occur following DFO of either technique. Given that limb length differences can lead to accelerated osteoarthritis, back pain, hip pain, and other issues, being able to predict which technique can help prevent this pathology without a secondary procedure would be an important finding. Finally, the medial closing wedge osteotomy can allow for immediate weight-bearing while the lateral opening wedge does not and typically has associated cost with bone grafting. Therefore, we designed this study to validate a tool designed to predict leg length changes after distal femoral osteotomy (DFO) and compare changes following medial closing wedge (MCW) and lateral opening wedge (LOW) techniques. Methods: A collaborative retrospective review was performed of patients from Rush and Mayo Clinic databases who received a DFO and had full-length standing radiographs both pre-and postoperatively. For each preoperative radiograph, the region on the medial (for LOW) or lateral (for MCW) distal femur cortex that would be the “hinge point” during DFO was identified. The distances from the center of the femoral head to the hinge point (“A”), from the hinge point to the center of the tibial plafond (“B”), and the resultant angle at the hinge point (“α”) were measured (Figure 1). Figure 2 demonstrates the equation used to plot a graph of the predicted leg length changes corresponding to the change in α angle produced by DFO. Final leg length was calculated on postoperative radiographs, and the difference between predicted and true leg length changes was compared using paired Wilcoxon signed rank exact tests. Results: 10 MCW and 10 LOW patients were included. For both LOW (n=10) and MCW (n=10) osteotomies, the predicted leg length change was equivalent to the true change measured on postoperative radiographs (LOW P=0.16; MCW P=0.85). LOW DFO’s had 5.10 ± 2.77 mm (range: 1.45-10.87 mm) of leg lengthening, compared to 2.61 ± 1.25 mm (range: 0.50-4.56 mm) of leg shortening (p&lt;0.001) for MCW (Figure 3). On average, there was 0.85 mm of lengthening (range 0.5-1.3 mm) for every 1° of mechanical axis correction with LOW DFO, compared to 0.45 mm of shortening (range: 0.1-1.4 mm) per 1° of MCW correction. Conclusions: This study presents a tool to accurately and reliably predict the leg length changes seen after both medial closing and lateral opening wedge DFO’s. Knowing what leg length changes to expect with each DFO technique is a useful tool that surgeons can utilize during surgical planning. Preoperative radiographic imaging can be used to predict leg length change following DFO with high reliability and accuracy. Surgeons can expect approximately 0.85mm of lengthening per 1° of DFO correction when performing LOW, compared to 0.45mm of shortening per 1° correction for MCW osteotomies.

1008 Can the Nottingham Hip Fracture Score (NHFS) Predict Mortality After a Fragility Distal Femur Fracture?

1008 Can the Nottingham Hip Fracture Score (NHFS) Predict Mortality After a Fragility Distal Femur Fracture?

Functional Outcome of Patients with Malignant Tumors around the Knee Treated by Modular Endoprosthesis: A Comparative Study between Patellar Resurfacing and Nonresurfacing

Abstract Background: Patellar resurfacing with knee arthroplasty has always been controversial. The literature contains data that support both resurfacing and not resurfacing the patella. However, the literature does not review a lot of studies that address the impact of patellar resurfacing on the functional outcome following resection of distal femur tumors and limb salvage using modular prosthesis. Questions/Purposes: Is patellar resurfacing better than nonresurfacing as regards functional outcome of modular prosthesis used for the treatment of tumors around the knee? Patients and Methods: Two groups of patients; both were subjected to wide excision of tumors around the knee and limb salvage using modular prosthesis. The first group underwent reconstruction with patellar resurfacing, while the second underwent reconstruction without patellar resurfacing. The age of these groups of patients ranged from 11 to 71 years. The patients were 17 males and 19 females. We evaluated patients using the musculoskeletal tumor society scoring system (MSTS), knee society final score, knee society function score, and anterior knee pain score. Results: We found that MSTS functional score, knee society final score and knee society function score, and anterior knee pain score were all better in patients who underwent patellar resurfacing compared to nonresurfacing patients. However, only the difference in anterior knee pain score was statistically significant (P = 0.030). Differences in other scores between these two groups were all statistically insignificant (P value of the MSTS difference = 0.103, P value of the knee society final score difference = 0.423, and P value of the knee society function score difference = 0.337). Conclusions: Patellar resurfacing could be helpful in decreasing anterior knee pain and the necessity to future surgeries addressing patellofemoral pain, especially in revision cases, patients with patellofemoral problems, and patients with extensor mechanism weakness and those with anterior knee pain. Since Anterior Knee Pain Scale was the only scoring system, among all scoring systems used, that confirmed a significant impact of patellar resurfacing on the outcome following resections and reconstructions; we cannot give an explicit strong recommendation favoring the routine patellar resurfacing in all cases undergoing resections and reconstructions using modular prosthesis. We recommend patellar resurfacing in older patients, based on our results, which show possible benefit of patellar resurfacing in older patients. We think that old age and the preexisting knee arthritis could be relative indications for patellar resurfacing.

Arthroscopic fibroarthrolysis and mobilization under anesthesia is a simple, reproducible, and satisfactory method for the treatment of patients with severe post-traumatic arthrofibrosis of the knee

ObjectiveTo evaluate the range of motion (ROM) of the knee in patients with severe post-traumatic knee arthrofibrosis after being treated with arthroscopic fibroarthrolysis (AFA) and manipulation under anesthesia (MUA). MethodsCase series of patients with severe post-traumatic knee arthrofibrosis who underwent AFL+MUA in a national referral center. The primary outcome to be assessed was ROM before and after surgery and then at 3-month intervals until a minimum follow-up of one year was completed. Results51 patients were included. The main injuries preceding the stiffness were tibial plateau fracture (37.3%), distal femur fracture (27.5%), and femoral shaft fracture (15.7%). Forty-five patients had severe flexion deficits with a median preoperative flexion of 70°. Intraoperative flexion significantly improved to 110°. Significant loss of flexion was observed at 3 and 6 months, however, patients regained ROM in the 9 and 12-month follow-ups. At discharge, 80% of the patients achieved flexion of 90° or more. There were 4 intraoperative complications and 3 reinterventions were performed. ConclusionAFA+MUA can help patients with severe post-traumatic knee arthrofibrosis to recover ROM in most cases. However, this procedure is not without risks and complications, therefore, careful consideration should be given to its indication and execution.

Seven-Year Longitudinal Study: Clinical Evaluation of Knee Osteoarthritic Patients Treated with Mesenchymal Stem Cells.

Background/Objectives: Numerous studies have demonstrated the safety and efficacy of intraarticular stem cell injections for treating osteoarthritic knee joints, reporting symptom reduction and pain relief within a few months of treatment. Here, we report the results of a 7-year follow-up after a single intraarticular injection of 0.5-1 × 107 autologous adipose tissue-derived mesenchymal stem cells in patients with OA (Kellgren-Lawrence grade 2 to 4). Methods: Nine patients were treated, and two patients had bilateral disease. Patients were evaluated clinically and radiologically using X-ray and MRI. A comprehensive statistical analysis was undertaken to evaluate the obtained results. Results: All clinical scores and range of motion significantly improved within the first six months after injection. At the 18-month time point, a significant improvement in cartilage structure was observed on MRI while X-ray showed no changes in subchondral bone of distal femur and proximal tibia. At the 60-month time point, the clinical scores were still improved compared to baseline, except for the range of motion, which decreased almost back to the baseline level. At 84 months, the clinical scores decreased significantly toward the baseline level, but the MRI structural characteristics of cartilage still remained significantly better than those measured at baseline. Conclusions: Adipose tissue-derived stem cell therapy has substantial long-term clinical effects on patients with knee osteoarthritis.

Radiological and Functional Consequences of Open Reduction Internal Fixation with Locking Plate Versus Dynamic Condylar Screw in Type C1 Complete Articular Fracture of Distal Femur

Background: One of the body's main joints for bearing weight is the knee. Its issues are likewise difficult to resolve. Damage to this joint can cause abnormalities in the alignment, stability, and motion of the knee, which impairs function. Objective: To compare the functional and radiological outcome in AO type C1 distal femur fractures fixed with locking plate versus dynamic condylar screw. Methods: The study comprised 94 patients aged 18 to 60 years who had an isolated distal femur fracture and an Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C1 closed fracture. Patients with diabetes mellitus, chronic renal disease, chronic liver disease, ischemic heart disease, pathological fractures, head injuries with a Glasgow coma scale of less than 14, and malignancy were excluded from the sample. The patients were assigned by lottery to groups A and B. In groups A and B, they were treated with dynamic condylar screws (DCS) and locking plate fixation, respectively.. Results: Among 94 patients, 30 (63.8%) were men and 17 (36.2%) were women in Group A; similarly, 33 (70.2%) were men and 14 (29.8%) were women in Group B. Patients in group A had an average age of 38.8±6.19 years, whereas those in group B had an average age of 39.5±7.36 years. 02 patients (4.2%) in Group-A and 05 patients (10.6%) in Group-B experienced infection. The union rate was 45 (95.7%) in group A (locking plate fixation technique) and 40 (85.10%) in group B (dynamic condylar screw technique). 35 (74.46%) in group A, 08 (17.1%) in good, 03 (6.38%) in average, and 01 (2.1%) in poor; in group B, 25 (53.2%) in excellent, 09 (19.2%) in decent, and 10 (21.3%) had average and 03(6.3%) had poor functional outcome. Conclusion: In terms of clinical and radiological evaluation, the type C1 distal shaft femur fixation with locking plate performs better than the dynamic condylar screw, which has a lower infection rate and better union and functional success

Osteotomy wedge angle - Aiming to achieve perfection with new device: Pre-clinical stage

IntroductionThe surgical execution of osteotomy requires precision in measuring the wedge angle. The pre-operative planning methods are plenty and so are few devices for high tibial osteotomy. But struggle happens for those bony areas other than proximal tibia where alignment correction is needed. The new device is proposed to address this surgical problem. The ease of measuring angle for bony wedge angle, in any bone, independent of its width and in any plane, is the question being solved with the proposed devices. MethodsTwo jig instruments have been shown in the study. First one the curved with direct angle measuring marking in degrees on the body. K wire is accepted through the tower exactly showing the desired angle. The second jig instrument is flat design with marking in millimeters. This device works on trigonometric principle of sum of angles of any triangle is equal to 180°. The jig can be removed leaving the k wires in place to complete the final osteotomy once confirmed. ResultsIt's a pre-clinical stage study. The saw bone models show encouraging measurements and perfect execution of angle at the osteotomy site. DiscussionHTO has been researched a lot with many options of surgical devices. The criticism of using known devices is the variable accuracy, especially for the smaller width of tibial metaphysis. One major limitation of these available instruments is they can be used only for proximal tibial metaphysis. For any other surgical sites like distal femur, distal tibia, distal humerus or tibial slope correction neither these HTO jigs will work nor there is any available universal instrument as such. The common misconception of one degree equal to 1 mm does not stand true at all bony sites. Hence there was a need to solve this problem with universal jig. I have designed two new devices which are currently at pre-clinical stage. The curve device has limitations which get corrected in straight device. The philosophy changes from one direct measurement with two tips of wires forming the angle in a curved device to indirect measurement by simple trigonometric calculation in a straight device. The proposed new device would work in any bone, for any trapezoidal wedge shape osteotomy using simple user-friendly k wires.

Jaffe-Campanacci syndrome; a case series and review of the literature

BackgroundJaffe-Campanacci syndrome is a rare syndrome, characterized by multiple non-ossifying fibromas (NOF) and cafe-au-lait patches. The name was coined in 1982 by Mirra after Jaffe who first described the case in 1958. Although it’s suggested there is a relation with Neurofibromatosis type 1, there is still no consensus on whether Jaffe-Campanacci syndrome is a subtype or variant of neurofibromatosis-1(NF-1).Case presentationIn this article, we present a case series of 2 patients. The first case is a 13-year-old male with Jaffe-Campanacci syndrome who presented with a distal femur fracture. His father had positive features of both Jaffe-Campanacci syndrome and NF-1, while his sister only had features of NF-1, so we presented both.ConclusionJaffe-Campanacci has a clear relationship with type 1 neurofibromatosis, which still has to be genetically established. Due to the presence of several large non-ossifying fibromas of the long bones, it is linked to a significant risk of pathological fractures. We concur with previous authors, that an osseous screening program should be performed for all patients with newly diagnosed type 1 neurofibromatosis, to identify non-ossifying fibromas and assess the potential for pathological fracture. Moreover, siblings of patients with NF-1 should be screened for multiple NOFs that may carry a high risk of pathological fractures.