Femoral Varus Osteotomy Research Articles

Femoral Remodeling after Proximal Femoral Varus Osteotomy in Children with Cerebral Palsy

Purpose: Varus osteotomy of the proximal femur is a commonly used procedure to improve hip congruity and correct the often valgus deformity in children with cerebral palsy (CP). Femoral remodeling can occur over time causing a relapse of coxa valga. The degree to which this remodeling occurs and possible risk factors remain controversial. The purpose of this study is to 1) establish the degree of which femoral remodeling occurs, and 2) to determine the …

Femoral Remodeling after Proximal Femoral Varus Osteotomy in Children with Cerebral Palsy

Femoral Remodeling after Proximal Femoral Varus Osteotomy in Children with Cerebral Palsy

Acetabular Dysplasia in Children with Cerebral Palsy: Can Isolated Femoral Varus Osteotomies Help?

Purpose: The remodeling potential of the dysplastic acetabulum in children with neuromuscular disorders is not clear and how to address residual acetabular dysplasia after femoral osteotomy in children with cerebral palsy remains unknown. The purpose of this study is to 1) quantify acetabular remodeling in patients with CP who received a femoral osteotomy without an acetabular osteotomy and 2) to determine the impact of age and Gross Motor Function …

Acetabular Dysplasia in Children with Cerebral Palsy: Can Isolated Femoral Varus Osteotomies Help?

Acetabular Dysplasia in Children with Cerebral Palsy: Can Isolated Femoral Varus Osteotomies Help?

Medial closing-wedge distal femoral varus osteotomy: Symptoms and functional impact in cases of associated patellofemoral osteoarthritis. A two-year follow-up prospective pilot study

PurposeTo date, indications for distal femoral varus osteotomy (FVO) in cases of associated patellofemoral osteoarthritis (PFO) have yet to be clarified. The purpose of this prospective study is to assess the short-term symptoms, functional and radiological impact of a medial closing-wedge femoral varus osteotomy on the patellofemoral joint in patients with valgus deformities who are afflicted with lateral tibiofemoral osteoarthritis (LTFO) associated with PFO. MethodsFourteen patients (15 knees) received a medial closing-wedge femoral varus osteotomy. The functional impact of an FVO on the patellofemoral joint was assessed based on the KOOS-PF (Knee Injury and Osteoarthritis Outcome Score-Patellofemoral Subscale), the Kujala score and the patellofemoral symptoms. Realignment of the patella was measured by the Merchant's patellofemoral congruence angle. The pre- and post-operative symptoms and functional scores were compiled prospectively and compared two years after the surgery. ResultsThe Kujala patellofemoral functional scores and the KOOS-PF showed considerable improvement with a differential of +37.5 points ± 20.4 and +42.7 points ± 19.3 (p < .01) respectively. The average Merchant's congruence angle went from 8.8° laterally to 3.6° medially, resulting in medialization of the patella, with a significant difference (p < .01). Based on the specific clinical analysis of the patellar joint, preoperative J-sign was identified in 26.7% of patients (n = 4) and was not found during postoperative examination (p = .1). Preoperative apprehension test was identified in 33.3% of patients (n = 5) against 13.3% (n = 2) after surgery (p = .39). Preoperative pain extension test was identified in 40% of patients (n = 6) against 20% during postoperative clinical analysis (p = .43). DiscussionAlthough the threshold of significance for patellofemoral symptoms was not reached, the medial closing-wedge femoral varus osteotomy induces a significant medialization of the patella (Merchant's congruence angle) and improves short-term functional results even with co-existing patellofemoral osteoarthritis. Due to the lack of specificity of the patellofemoral scores, patellofemoral osteoarthritis improvement is difficult to determine on its own, but does not represent a contraindication to FVO. Level of evidenceIII. Prospective clinical study.

Evolution of Legg-Calvé-Perthes disease following proximal femoral varus osteotomy performed in the avascular necrosis stage:a prospective study.

PurposeThis prospective study was undertaken to describe patterns of fragmentation of the femoral epiphysis following a proximal femoral varus osteotomy (PFVO) done during stage I of LCPD and to assess the disease duration and outcome in each pattern.MethodsA total of 25 children treated by a PFVO in stage I of LCPD were followed until healing. The MRI Perfusion Index, radiographic changes in the femoral epiphysis, disease duration and the Sphericity Deviation Score (SDS) at healing were documented. The reproducibility of classification of the pattern of fragmentation, estimation of disease duration and SDS were assessed. The duration of the disease and SDS in the patterns of fragmentation were compared.ResultsFour patterns of fragmentation were noted, namely, typical fragmentation, bypassing fragmentation, abortive fragmentation and atypical fragmentation with horizontal fissuring. The reproducibility of classifying the pattern of fragmentation was moderate (Kappa: 0.48) while the reproducibility of other continuous variables was excellent. The Perfusion Index was less than 50% in every affected hip. The duration of the disease and SDS were lowest in children in whom the stage of fragmentation was bypassed but these differences were not statistically significant.ConclusionFollowing a proximal femoral osteotomy during stage I of LCPD the fragmentation stage may be bypassed partially or completely and the chances of a good outcome appear to be very good if fragmentation is bypassed.Level of EvidenceLevel II Prognostic Study

Distal Femoral Varus Osteotomy for the Valgus Knee after Distal Femoral Growth Plate Fractures in Children: A Case Report

An 18-year-old male suffered a valgus injury to the right knee due to a fall during a bigfoot race he took part in when he was 15 years old. He visited a different hospital at the age of 15. No obvious ligament injury or fracture was noted on MRI and physical examination. However, he gradually became aware of the valgus deformity of the right knee. Finally, he could not take part in a sports activity because of right knee pain. X-ray images at the age of 18 at an initial visit to our department showed severe valgus deformity with mechanical lateral distal femoral angle (mLDFA) of 71 degrees in contrast to left mLDFA which was 87 degrees. We performed a biplane-cut distal femoral varus osteotomy (DFO). Postoperative X-ray images showed an improvement of 86 degrees in mLDFA. Bony fusion was achieved six months after surgery, and he could play several sports activity.

Return to Sport and Outcomes After Concomitant Lateral Meniscal Allograft Transplant and Distal Femoral Varus Osteotomy

To evaluate the time and rate of return to sport (RTS), as well as outcomes, in young and active patients receiving concomitant lateral meniscal allograft transplantation (MAT) and distal femoral varus osteotomy (DFVO) for lateral meniscal deficiency and valgus malalignment. This was a retrospective study of consecutive patients who underwent concomitant MAT and DFVO by a single surgeon. The exclusion criteria were any concomitant procedures other than cartilage restoration procedures for focal full-thickness cartilage defects of the lateral femoral condyle and less than 2years of follow-up. At final follow-up, patients were asked to complete a subjective sports questionnaire, the Marx Activity Rating Scale, a visual analog scale (VAS), the Single Assessment Numeric Evaluation, and a satisfaction questionnaire. Changes in patient-reported outcome measures were assessed using nonparametric statistical testing. A total of 21 patients met the inclusion criteria, of whom 17 were included for analysis at an average follow-up of 7.5years (range, 2.2-13.3years). The average age at the time of surgery was 23.3years (range, 16.9-36.2years), and 76.5% of patients were female patients. The average VAS score decreased from 5.7 preoperatively to 2.6 postoperatively (P= .02). Of the 15 patients who participated in sports within 3years prior to their surgical procedure, 14 (82.4%) returned to 1 or more sports at an average of 16.9months (range, 6-36months); however, only 46.7% were able to return to their preinjury level of participation or higher. Furthermore, 88.2% of patients reported being satisfied with their sport-related outcomes. Direct rates of sport-specific return were as follows: weightlifting, 100%; skiing, 100%; running, 66.7%; and basketball, 50%. In our study population, concomitant MAT and DFVO afforded a high rate of RTS at an average of 16.9months postoperatively, as well as a significant decrease in VAS pain scores. These findings are essential to note when counseling patients receiving these procedures who wish to resume sports and physical activities so that they may expect an extensive recovery process before they can RTS. Level IV, case series.

Femoral osteotomies for the treatment of avascular necrosis of the femoral head.

Unloading of the area of necrosis out of the weight-bearing region by shifting healthy bone in the main weight-bearing area, which may delay the progression of the necrosis and enable healing. Circumscribed osteonecrosis of the femoral head without advanced degenerative signs (Tönnis grade ≤ 1) in the relatively young patient (age < 50years). Radiographic joint degeneration (> Tönnis grade1); extensive avascular necrosis (Kerboul angle > 240°); advanced lesions (≥ Association Research Circulation Osseous [ARCO] classification3b). By performing asurgical hip dislocation, full access to the hip joint is gained. Afemoral varus osteotomy is used to turn the necrotic lesion of the femoral head out of the central weight-bearing area and more medially. Osteosynthesis is performed with an angular stable screw or ablade plate. Via atrapdoor procedure, direct debridement and autologous bone grafting from the trochanter major is possible. The cartilage flap is preserved whenever possible or supplanted by an autologous matrix-induced chondrogenesis (AMIC). Apassive motion device is installed during hospital stay beginning immediately after surgery to prevent capsular adhesions. After surgery, patients are mobilized with partial weight-bearing of 15 kg with the use of crutches for at least 8 weeks. Forced abduction and adduction as well as flexion of more than 90° are restricted to protect the trochanteric osteotomy. After radiographic confirmation of healing at the 8‑week follow-up, stepwise return to full weight-bearing is allowed and abductor training is initiated. Nine patients (10hips) with osteonecrosis of the femoral head were treated with surgical hip dislocation and varus osteotomy. Six hips were treated with autologous bone grafting, four hips with antegrade drilling. Chondral lesions were sutured in four cases, whereas two cases needed an AMIC treatment. The mean age at operation was 29 ± 9years (20-49), and the mean follow-up time for all patients was 3 ± 2years (1-7). Conversion to atotal hip prosthesis was required for one hip with progressing arthrosis. The other nine hips showed no progression of necrosis and an improved clinical outcome. Complications were pseudarthrosis of the femoral osteotomy and pseudarthrosis of the greater trochanter.

Femoral Varus Osteotomy for Treatment of Legg Calve Perthes Disease in Zagazig University Hospitals

Femoral Varus Osteotomy for Treatment of Legg Calve Perthes Disease in Zagazig University Hospitals

Planning a Proximal Femoral Varus Osteotomy in Pediatric Orthopedics

A proximal femoral osteotomy used typically to correct increased femoral anteversion and/or a valgus/varus neck-shaft angle, is one of the most commonly performed operations in pediatric orthopedics. Surgeons with limited experience with the procedure often find conceptualization of the technique to establish the angles of correction and the decision regarding plate angle, difficult. This short article seeks to clear that confusion and describe the technique in 4 simple steps.

Mid-term clinical result of femoral varus osteotomy combined with Pemberton osteotomy in treating spastic hip subluxation.

Hip subluxation in ambulant children with cerebral palsy may lead to limited walking and pain. This study aimed to introduce the indications and methods of femoral varus osteotomy combined with Pemberton osteotomy in treating spastic hip subluxation to evaluate the interim clinical result and outcome and to discuss its corrective mechanism and orthopedic effect. A total of 23 children with spastic hip subluxation, who underwent femoral varus osteotomy combined with Pemberton osteotomy were selected. The clinical effects were evaluated according to the migration percentage, acetabular index, proximal femur neck shaft angle (NSA), and Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The median migration percentage was 55 (50, 75) before operation, 20 (0, 30) at postoperative 1 year, and 22 (5, 32) at last follow-up. The median acetabular index was 30° (25°, 40°) before operation, 20°(15°, 26°) at postoperative 1 year, and 20° (15°, 25°) at last follow-up. The median NSA was 145 (138, 153) before operation, 117 (107, 126) at postoperative 1 year, and 118 (110, 125) at last follow-up. The MCPHCS grade 4 counts 23 (100%) before operation, grade 3 counts 20 (87.0%), grade 2 counts 2 (8.7%) and grade 1 counts 1 (4.3%) at postoperative 1 year, and grade 4 counts 1 (4.3%), grade 3 counts 21 (91.3%) and grade 1 counts 1 (4.3%) at last follow-up. Femoral varus osteotomy combined with Pemberton osteotomy is a good surgical treatment for children with Gross Motor Function Classification System levels I and II and migration percentage greater than 50%.

Femoral and pelvic osteotomies for severe hip displacement in nonambulatory children with cerebral palsy: a prospective population-based study of 31 patients with 7 years’ follow-up

Background and purpose — There is no consensus regarding the optimal treatment of hip displacement in children with cerebral palsy (CP). This prospective study assessed the outcome of femoral and pelvic osteotomies for severe hip displacement in nonambulatory children and analyzed prognostic factors for outcome.Patients and methods — 31 nonambulatory children (20 boys), recruited from a population-based screening program, consecutively underwent unilateral (23) or bilateral (8) osteotomies and bilateral soft-tissue releases at a mean age of 6.1 years (2.2–9.9). The procedures were femoral varus osteotomy alone (20 hips) and combined Dega-type pelvic osteotomy and femoral osteotomy (19 hips). Final outcome was termed good if the patient had not undergone further bony surgery and migration percentage (MP) was < 50%. The mean follow-up time was 7.1 years (3.8–11).Results — The mean preoperative MP was 69% (36–100). The outcome was good in 22 patients (29 hips) and poor in 9 patients (10 hips). Mean time to failure was 3.6 years (1.0–6.0). GMFCS level V and high MP 1-year postoperatively were statistically significant risk factors for poor final outcome. There was a higher rate of good outcome after combined osteotomies compared with isolated femoral osteotomy, but the difference was not statistically significant (p = 0.2).Interpretation — Better primary correction was obtained after combined femoral and pelvic osteotomies than after isolated femoral osteotomy, indicating that combined osteotomies are the preferred method in hips with the most severe degrees of displacement. Prophylactic femoral osteotomy of the contralateral non-subluxated hip is hardly indicated.

Does Early Proximal Femoral Varus Osteotomy Shorten the Duration of Fragmentation in Perthes Disease? Lessons From a Prospective Multicenter Cohort.

The prognosis of Legg-Calvé-Perthes disease (LCPD) is dependent upon several factors, with the length and severity of the fragmentation stage among the most important. Previous retrospectively collected data from a single center have suggested that early proximal femoral varus osteotomy (PFO) may shorten the length of fragmentation and allow 34% of patients to bypass fragmentation altogether resulting in less femoral head deformity. The purpose of this study was to validate these findings in a prospectively collected multicenter cohort. Patients with LCPD treated with early PFO (during Waldenström stage I) were prospectively followed with serial radiographs at 3-month intervals until a minimum of 2-year follow-up. Waldenström stages and lateral pillar class were determined by mode assessments from 3 pediatric orthopaedic surgeons. The duration of fragmentation was defined as the interval between the first radiographs demonstrating features of stage IIa and stage IIIa. "Complete" bypass was defined as the absence of stage IIa or IIb findings on sequential radiographs with no development of femoral head deformity or collapse. "Partial" bypass was defined as the absence of advanced features of fragmentation and femoral head collapse (stage IIb). Forty-six patients (80% male individuals) with initial stage LCPD and a mean age of 8.2±1.2 years were identified. The weighted kappa statistics for Waldenström staging and lateral pillar classifications showed excellent (0.833) and substantial (0.707) agreement, respectively. Ninety-eight percent of patients (45/46) underwent some period of fragmentation lasting between 91 and 518 days; the median duration was 206 days (interquartile range, 181 to 280). One patient (2%) bypassed fragmentation completely; 8 patients (17%) demonstrated partial bypass. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016) and shorter fragmentation duration (P=0.001). In this prospective multicenter cohort, we found a lower rate of fragmentation bypass than previously reported. Nonetheless, our data support the previous contention that early PFO may shorten fragmentation and minimize collapse in LCPD compared with historical controls. Further study with larger cohorts and a more rigorous definition of what constitutes bypass is warranted to clarify the effect of early PFO on the reparative biology of LCPD. Level IV-therapeutic study.

Comparing Conventional and Navigation-assisted Techniques for Lateral Opening-wedge Femoral Varus Osteotomy

Objective: The aim of this study was to assess short-term clinical and radiographic results of opening-wedge distal femoral varus osteotomy performed using either the conventional technique or a navigation (NAV)-assisted technique. Materials and Methods: This study included 25 patients; 12 patients underwent femoral osteotomy with NAV, and 13 patients underwent the conventional procedure. Results: In the NAV osteotomy group, the mean duration of surgery was 73.69 minutes (SD, 12.53 min), and the mean tourniquet time was 59 minutes. Mean preoperative mechanical alignments were 13.84 degrees in the conventional osteotomy group and 14.4 degrees in the NAV osteotomy group (P=0.7432; 95% confidence interval=12.8-15.4 degrees), and the final postoperative mechanical alignment varied between −2 and 3 degrees in both groups, with no significant difference between the results obtained using the 2 techniques (P=0.1316; 95% confidence interval=0.08-1.24 degrees). However, the correlation between initial alignment and postoperative result was strong (P=−0.68) in the NAV osteotomy group and weak (P=−0.07) in the conventional osteotomy group. Conclusions: Duration of surgery and tourniquet time were longer in the NAV osteotomy group. The use of NAV for femoral varus osteotomy did not result in any significant difference in final alignment.

Perthes disease-news in diagnostics and treatment

Perthes disease remains achallenge for paediatric orthopedic surgeons. X‑ray imaging is still the method of choice for diagnostics and follow-up examination. Amore detailed differentiation of Waldenström's classification, especially in early and late fragmentation stages, might be relevant to optimize timing of containment surgery. So-called "advanced MRI" imaging might help to detect patients at risk earlier than conventional x‑ray imaging, which could lead to earlier surgical intervention. Currently there is no treatment modality available which would improve the bone changes in Perthes disease. Non-operative treatment like improving hip range of motion as well as unloading is still the basic standard of care, with analgesic and/or anti-inflammatory medication, according to symptoms or findings. In the case of loss of containment, especially in children older than 6years, surgery is indicated. Currently, there is atrend favoring acetabular reorientation techniques-especially the triple osteotomy, since the biomechanical relations would not be additionally impaired as in case of femoral varus osteotomy.

The Outcomes of Distal Femoral Varus Osteotomy in Patellofemoral Instability: A Systematic Review and Meta-Analysis.

Distal femoral varus osteotomies have been novelly described in the recent years to be successful in the management of patellofemoral instability with genu valgum. However, these publications are limited to case reports and small case series and no published literature have attempted to analyze them in totality. The current review aims to pool together these small case series to evaluate the outcomes and complications of distal varus femoral osteotomies when performed for patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. All studies that reported the outcomes of distal femoral varus osteotomy for patellofemoral instability were included. A total of five publications were included in the review, which included a total of 73 patients. All of the studies reported improvement in the radiological outcomes for genu valgum correction and patellofemoral instability. One study using opening wedge osteotomy reported a decrease in Caton-Deschamps index postoperatively, while another study using closing wedge osteotomy reported maintenance of the Caton-Deschamps index postoperatively. Second look arthroscopy showed an improvement in the status of the chondral lesions of the medial facet of the patellar undersurface, the lateral facet of the patellar undersurface and the trochlear groove 2 years postoperatively. All studies also reported a decrease in the risk of recurrence of patellofemoral instability, reduction in pain, and an improvement in all the clinical outcomes knee scores. Distal femoral varus osteotomy is promising and useful in the management of patellofemoral instability with genu valgum. The procedure can allow for radiological correction of the genu valgum and patellofemoral instability, reduction in the risk of recurrence of patellofemoral instability, reduction in pain, improvement in clinical knee outcome scores, and improvement in the status of the chondral lesions in the patellofemoral joint. It is highly versatile and could accommodate varying degrees of correction. These improvements in radiological and clinical outcomes can be seen in studies for both closing wedge and opening wedge distal femoral osteotomies. However, opening wedge osteotomies appear to decrease the patellar height as compared with closing wedge osteotomies which maintain the patellar height; therefore, the patellar height should be assessed preoperatively prior to deciding whether to perform an opening wedge or closing wedge distal femoral varus osteotomy. The Level of Evidence for this study is IV.

Results of periacetabular osteotomy in adolescent and young adult hip dysplasia

Background Dysplasia of the hip is one of the most common causes of secondary osteoarthritis because of its associated structural instability. The Bernese periacetabular osteotomy (PAO) now is the preferred and the gold standard procedure for the treatment of symptomatic acetabular dysplasia. Objective The primary aim of our study was to evaluate the results of PAO in the treatment of adolescent and young adult patients with symptomatic hip dysplasia. Patients and methods This prospective case series’ study included 22 patients (26 hips, 13 left hips, 13 right hips) with hip dysplasia after surgical reorientation of the acetabulum by PAO procedure. This study included three male patients and 19 female patients. The mean age of our patients was 23 years (13–40 years). The mean follow-up period was 15 months (6–24 months). Twenty-one hips had undergone isolated PAO, while five hips had undergone combined surgery with the PAO at the same time (three hips had proximal femoral varus osteotomy and two hips had arthrotomy and osteochondroplasty). Results Twenty-five hips had good clinical and radiographic outcomes with respect to hip function and radiographic parameters. One patient developed avascular necrosis (AVN) of the femoral head 6 months after PAO and was treated by total hip replacement 1 year after PAO. The mean lateral central edge angle was 10.57°±11.61° preoperatively and was corrected to a mean value of 31.96°±4.42° with a mean correction of 21.38°. The mean postoperative acetabular index was 7.57°±1.81°, with a mean correction of 15.34°. In our series, the mean postoperative Harris hip score was 91.36±4.14, and the mean improvement was 29.08. Conclusion The PAO is an effective and valuable method for preservation of the natural hip joint and should be learned in a specialized center before using it in clinical practice.

Second look arthroscopic findings after distal femoral varus osteotomy

Second look arthroscopic findings after distal femoral varus osteotomy

Single Versus Combined Procedures for Severely Involved Legg-Calvé-Perthes Disease.

The concept of containment as an effective approach to reduce the risk of femoral head deformity has been questioned because modest results have been achieved after nonoperative and operative treatments for severely involved Legg-Calvé-Perthes disease. Several reports have shown the limited effectiveness of some conventional single procedures. However, there is limited data on the effectiveness of combined procedures. The surgical group comprised 77 patients (mean age 8.3 y) and involved 79 hips. The average follow-up term was 9.5 years. Sixty-five patients were unilaterally involved and 12 patients were bilaterally involved (although 10 of the latter patients only received surgery on 1 hip). Among patients, 28 hips were classified as Herring class B/C border (>8 y old) and 51 hips were Herring class C. The 79 hips were divided into 2 treatment groups for further analysis: group 1, single procedures (femoral varus osteotomy) (n=47); group 2, combined procedures [femoral varus osteotomy+Dega (Pemberton) osteotomy] (n=32). Using Stulberg classification I and II (acceptable outcome), the final outcome was statistically significant for group 2 (21 hips, 65.6%) compared with group 1 (18 hips, 38.3%) (P=0.031). The average remodeling efficacy, defined as the change in caput index between preoperation and postoperation, was better in group 2 (12.7%) than in group 1 (3.9%) (P=0.005). The acetabulum-head index and α-angle were also statistically significant in group 2 than in group 1 at the last follow-up. Clinical evaluations were statistically significant in group 2 compared with group 1. Both clinically and radiologically, the combined procedure group demonstrated significantly better outcomes with accelerated remodeling in both the severely affected femoral heads and the acetabula compared with the single procedure group. With this procedure, we anticipate the increased likelihood of preventing or delaying coxarthroses in adulthood. Level III-therapeutic study.