Full-length Radiographs Research Articles

Anterior Closing Wedge Osteotomy for Failed Anterior Cruciate Ligament Reconstruction: State of the Art

The sagittal anatomy of the proximal tibia has a bearing on the forces exerted on the cruciate ligaments. A high posterior tibial slope is now a well-known risk factor causing failure of anterior cruciate ligament (ACL) reconstructions. The posterior slope can be calculated on short or full-length radiographs, MRI scans, or three-dimensional CT scans. Reducing the slope surgically by a sagittal tibial osteotomy is biomechanically protective for the ACL graft. An anterior closing wedge osteotomy may be contemplated when the lateral tibial slope is greater than 12°, in the setting of ACL reconstruction failure(s). Careful surgical planning to calculate the correction, taking into account knee hyperextension and patella height, is critical to avoid complications. It can be done above, at, or below the tibial tuberosity level. A transtuberosity correction can be done with or without a tibial tubercle osteotomy. This complex surgery can be conducted safely by meticulous execution to protect the posterior hinge and neurovascular structures and achieving stable fixation with staples. The limited literature available justifies the usage of anterior closing wedge osteotomy in appropriately selected patients.

Influence of implantation of a total hip endoprosthesis on the ipsilateral leg alignment: the effect of sex and dysplasia of the hip

IntroductionDifferences in leg and hip morphology exist between sexes and developmental hip dysplasia is known to alter proximal femoral morphology. The purpose of this study was to determine whether existing differences in leg alignment due to sex or developmental hip dysplasia have an effect on changes in leg alignment after total hip arthroplasty.Materials and methods30 hip osteoarthritis patients underwent biplanar full-length radiography in the standing position preoperatively and 3 months after total hip arthroplasty. Differences in leg alignment between men and women and between patients with primary hip osteoarthritis and patients with developmental dysplasia before and after surgery were tested using a general linear model for repeated measures.ResultsImplantation of a hip prosthesis had no differential effect on ipsilateral leg alignment in patients with hip osteoarthritis due to dysplasia and in patients with primary hip osteoarthritis. However, patients with hip osteoarthritis due to dysplasia had a 2.1° higher valgus both before and after surgery. After total hip arthroplasty, women had a significantly greater increase in varus angle (1.6° vs. 0°) and femoral offset (10.5 vs. 4.6 mm) compared with men. Because the change in acetabular offset was smaller (2.2 vs. 6.2 mm), the global femoral offset was only increased in women. Femoral torsion was constant for men (15.0° and 16.5°), whereas femoral torsion was significantly reduced in women (19.9° and 13.2°).ConclusionsHip arthroplasty has a greater effect on leg axis in women than in men. The axial leg alignment of women could change from a natural valgus to a varus alignment. Therefore, surgeons should consider the effects of total hip arthroplasty on leg alignment in patients with hip osteoarthritis. Whether these changes in leg alignment are also clinically relevant and lead to premature medial or lateral knee osteoarthritis should be investigated in future work.Trial registrationThis study was registered with DRKS (German Clinical Trials Register) under the number DRKS00015053. Registered 1st of August 2018.

Effect of body mass index on postoperative mechanical alignment and long-term outcomes after total knee arthroplasty: a retrospective cohort study of 671 knees.

BackgroundA high body mass index (BMI) is associated with increased rates of complications after total knee arthroplasty (TKA). However, no study has examined the effect of BMI on lower limb alignment using the World Health Organization’s (WHO) BMI classification. We believe that the WHO’s BMI classification allows a uniform standard worldwide. We sought to investigate the potential association between a high BMI and the incidence of postoperative misalignment. We also evaluated whether a higher BMI is associated with worse clinical function.MethodsWe retrospectively reviewed the data of 671 patients who underwent primary TKA for varus osteoarthritis between January 2010 and December 2015. The patients were divided into the following 5 groups based on their BMI: normal weight (<25.0 kg/m2), overweight (25.0–29.9 kg/m2), class I obese (30.0–34.9 kg/m2), class II obese (35–39.9 kg/m2), and class III obese (>40 kg/m2). Both weight and height were measured by nurses on admission. Patients’ preoperative HKA, gender, age, and side of surgery were collected as baseline. All the patients underwent standing, weight-bearing, full-length radiography before and after surgery to measure the mechanical hip-knee-ankle angle (HKA). We followed up patients by telephone. Among the BMI subgroups, we compared the knee function scores, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Society-Knee Score (KS-KS), Knee Society-Function Score (KS-FS), Forgotten Joint Score (FJS), and range of motion (ROM). A multivariate linear regression analysis and a logistic regression was conducted to examine the outcomes.ResultsThe study had a mean follow-up period of 8.16 years. The multivariate and logistic regression analyses revealed that preoperative alignment (P=0.002) and a higher BMI (P=0.015) were associated with a higher risk of postoperative misalignment. The WOMAC scores were higher in the normal and overweight groups than the other groups (P=0.022). The FJS and KS-KS gradually decreased as BMI increased.ConclusionsA higher BMI is associated with a greater risk of misalignment and worse long-term clinical outcome after TKA. When treating patients with high BMI, we should pay more attention to the adjustment of lower limb alignment intraoperatively.

Using short knee radiographs to predict the coronal alignment after TKA: Is it an accurate proxy for HKA on full-length images?

BackgroundThe postoperative clinical outcomes has been extensively demonstrated to correlate with the coronal alignment after total knee arthroplasty (TKA). However, in different studies, either the hip-knee-ankle angle (HKA) on a full-length radiograph or the femorotibial angle (FTA) on a short knee film was used to categorize the postoperative coronal alignment. Meanwhile, several different FTA ranges were regarded as neutral alignment in different studies. As a result, it is still unknown that how FTA on short knee films and HKA related to each other. The FTA may be able to become an accurate proxy of HKA to predict the coronal alignment. The purpose of this study was to explore the correlation between the FTA and the HKA after TKA and to find the most accurate FTA range.MethodsAbout 223 patients were included in this study and standard weight-bearing short knee films as well as full-length radiographs were acquired. The pre- and postoperative FTA, as well as the postoperative anatomical lateral distal femoral angle (aLDFA) and anatomical medial proximal tibial angle (aMPTA) were measured on short knee films by two orthopedic surgeons independently. On full-length films, the pre- and postoperative FTA, the pre- and postoperative HKA, as well as the postoperative mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were also recorded by two other surgeons independently. Pearson correlation analysis was performed to compare FTA and HKA, aMTPA and mMTPA, aLDFA and mLDFA, respectively.ResultsThe postoperative FTA and HKA had a good correlation (r = 0.86). The agreements were reached 82.7%, 71.0%, and 68.2% of all patients using three previously reported FTA ranges. When analyzing the independent alignment of the tibial tray and the femoral component, 84.1% and 57.9% of all patients was reached an agreement on the classification.ConclusionsOn most occasions, the consistence between the FTA and HKA in assessing the coronal limb alignment of the lower extremity and the tibial component is satisfactory. However, the postoperative full-length film is still needed to evaluate accurately the coronal alignment of the femoral component.

Change in sagittal alignment after decompression alone in patients with lumbar spinal stenosis without significant deformity: a prospective cohort study.

The authors' objective was to investigate whether sagittal balance improves in patients with spinal stenosis after decompression alone. This prospective longitudinal cohort study compared preoperative and 6-month postoperative 36-inch full-length radiographs in patients aged older than 60 years. Patients underwent decompression alone for central lumbar spinal stenosis with either a minimally invasive bilateral laminotomy for central decompression, unilateral laminectomy as an over-the-top procedure for bilateral decompression, or traditional wide laminectomy with removal of the spinous processes on both sides. The following radiographic parameters were measured: sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), PI-LL mismatch, coronal Cobb angle, and sacral slope (SS). Patient-reported outcome measures (PROMs) were collected, including scores on the Oswestry Disability Index (ODI), visual analog scale (VAS) for leg and back pain, and EQ-5D. Forty-five patients (24 males) with a mean ± SD age of 71.8 ± 5.6 years were included. Sagittal balance showed statistically significant improvement, with the mean SVA decreasing from 52.3 mm preoperatively to 33.9 mm postoperatively (p = 0.0001). The authors found an increase in LL, from mean -41.5° preoperatively to -43.9° postoperatively, but this was not statistically significant (p = 0.055). A statistically significant decrease in PI-LL mismatch from mean 8.4° preoperatively to 5.8° postoperatively was found (p = 0.002). All PROM scores showed significant improvement after spinal decompression surgery. The correlations between SVA and all PROMs were statistically significant at both preoperative and postoperative time points, although most correlations were weak except for those between preoperative SVA and ODI (r = 0.55) and between SVA and VAS for leg pain (r = 0.58). Sagittal balance and PROMs show improvement at short-term follow-up evaluations in patients who have undergone decompression alone for lumbar spinal stenosis.

Impact of limb length discrepancy on functional outcome in total knee arthroplasty patients: a prospective cohort study

BackgroundLimb length alteration following total knee arthroplasty (TKA) has been under-reported. Few studies have shown a significant association between limb length discrepancy (LLD) and poor functional outcome. This prospective study evaluated the impact of radiographic and perceived LLD on functional outcome in TKA. The variables affecting LLD were also evaluated.MethodsThe preoperative and postoperative limb lengths of TKA patients (112 knees, 81 patients, KL grade ≥ 3) were measured in full-length digital radiographs. The Hip-Knee-Ankle (HKA) angles were also measured. The functional outcome (Western Ontario and McMaster Universities Arthritis Index) and perception about LLD were evaluated after six months.ResultsThe mean preoperative radiographic LLD in the unilateral and bilateral TKA groups was 0.75 cm ± 0.60 cm and 0.58 cm ± 0.52 cm (P = 0.197), respectively. Similarly, postoperative LLD was 0.76 cm ± 0.85 cm in the unilateral group and was 0.59 cm ± 0.92 cm (P = 0.402) in the bilateral group. Only 19.7% of patients had postoperative radiographic LLD of ≥ 10 mm, and 80.2% of patients had LLD of < 10 mm. The functional outcome was significantly affected when LLD exceeded 10 mm (correlation coefficient 0.54, P < 0.001). Linear regression analysis revealed no significant effects of age, sex, height, weight, BMI, preoperative LLD and difference in deformity between the limbs on postoperative LLD. 34.5% of patients perceived LLD in the preoperative period, which decreased to 3.7% in the postoperative period. Perceived LLD did not correlate to radiographic LLD and functional outcome.ConclusionsThere is no significant difference in radiographic LLD between unilateral and bilateral TKA. The functional outcome is adversely affected by radiographic LLD of ≥ 10 mm. Age, sex, BMI, preoperative LLD and difference in deformity angle do not affect the LLD. About one-third of patients perceive LLD in the preoperative period, which improves significantly after TKA.Levels of evidenceII.

The lateral joint line opening: a radiographic indicative parameter for high grade varus knees

PurposeIt is usually assumed that the severity of varus osteoarthritis (OA) of the knee is correlated with the axis deviation of the limb. Despite this, there is currently no clear radiographic definition to define a so-called ‘high degree’ varus knee, which is characterized by a pronounced lateral ligamentous laxity. The purpose of this study was to radiographically determine if the lateral joint line opening (LJLO) is an indicative parameter when defining so-called high grade varus knees.MethodsTwo hundred forty Full length radiographs of patients with end-stage varus osteoarthritis who were scheduled for Total knee arthroplasty (TKA) were evaluated. The Hip-knee-ankle-angle (HKA-angle), Joint-line-convergence-angle (JLCA) and the lateral joint line opening were measured. The lateral joint line opening is the shortest distance between the lateral tibial plateau and the deepest point of the lateral femoral condyle. Linear regression models were used to investigate the relationships between the radiographic measurements.ResultsHip-knee-angle-angle, joint-line-conversion-angle, and lateral joint line opening were all positively correlated (p < 0.001). An increase of 1 mm lateral joint line opening causes an increase of 0.6° joint-line-conversion-angle (p = 0.029) below a cut-off point of 4.7 mm. For lateral opening values beyond 4.7 mm, the gradient increased to 1.2 (p < 0.001). A lateral joint line opening of 4.7 mm corresponds to a hip-knee-ankle-angle of 6.0° (95% CI [5.5; 6.5]).ConclusionA lateral joint line opening of more than 5 mm in end-stage OA knees is indicative of increased lateral joint laxity. Those knees can be radiographically classified as so-called ‘high-grade’ varus knees.Level of evidenceTherapeutic study, Level III.

Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity

ObjectiveThere are several alternative methods for accomplishing epiphysiodesis of the longer limb to address limb length discrepancy (LLD). Consensus is lacking regarding the optimal timing of the intervention and which method is most efficacious. We reviewed a large group of patients with anisomelia treated by tethering with tension band plates (TBP) and who had attained skeletal maturity. We discuss our preferred timing and technique while noting the complications and how they were managed.Materials and methodsWith IRB approval, we reviewed 66 subjects including 32 boys and 34 girls, ranging in age from 3 to 16.6 years at the time of physeal tethering, who were destined to have between 2 and 9 cm LLD at maturity. Inclusion criteria were: (1) at least 1 year of predicted growth at the time of tethering; (2) minimum 18-month follow-up and (3) minimum Risser stage 1 (R1) in the last radiologic study. There were 35 distal femoral, 25 pan genu and five proximal tibial procedures. Patients were seen bi-annually with weight-bearing full-length radiographs to ascertain neutral alignment and assess limb lengths.ResultsWe defined a successful outcome to be <1.5 cm of residual discrepancy. Iatrogenic mechanical axis deviation, observed in nine patients (five varus and four valgus), was successfully managed by repositioning the implants. While the under-corrected patients presented too late to achieve equalization, they benefited from partial improvement. Due to lack of timely follow-up, one patient over-corrected by 2 cm and had a femoral shortening at the time of correcting contralateral femoral anteversion. One patient required a distal femoral osteotomy to correct recurvatum at maturity.ConclusionProperly timed and executed, TBP is an efficacious and reversible means of growth deceleration, rather than growth arrest, that may be applied in a wide age range of patients with modest anisomelia regardless of aetiology. This method offers potential advantages over purportedly rapid and definitive techniques such as percutaneous epiphysiodesis (PE) or percutaneous epiphysiodesis with transphyseal screws (PETS).Level of evidenceLevel III. Retrospective series without controls.How to cite this articleStevens P, Desperes M, McClure PK, et al. Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity. Strategies Trauma Limb Reconstr 2022;17(1):26–31.

Trends in Intraoperative Assessment of Spinal Alignment: A Survey of Spine Surgeons in the United States.

Study Design:Survey.Objectives:To characterize national practices of and shortcomings surrounding intraoperative assessments of spinal alignment.Methods:Spine surgeons in the US were surveyed to analyze their experience with assessing spinal alignment intraoperatively.Results:108 US spine surgeons from 77 surgical centers with an average of 19.2 + 8.8 years of surgical experience completed the survey. To assess alignment intraoperatively, 84% (91/108) use C-arm or spot radiographs, 40% (43/108) use full-length radiographs, and 20% utilize the T-bar (22/108). 88% of respondents’ surgical centers (93/106) possessed a navigation camera and 63% of respondents (68/108) report using surgical navigation for 40% of their deformity cases on average. Reported deterrents for using current technology to assess alignment were workflow interruption (54%, 58/108), expense (33%, 36/108), and added radiation exposure (26%, 28/108). 87% of respondents (82/94) reported a need for improvement in current capabilities of making intraoperative assessments of spinal alignment.Conclusions:Corrective surgery for spinal deformity is a complex procedure that requires a high level of expertise to perform safely. The majority of surveyed surgeons primarily rely on radiographs for intraoperative assessments of alignment. Despite the majority of surveyed surgical practices possessing navigation cameras, they are utilized only for a minority of spinal deformity cases. With the majority of surveyed surgeons reporting a need for improvement in technology to assess spinal alignment intraoperatively, 3 of the top design considerations should include workflow interruption, expense, and radiation exposure.

Lower limb deformities and limb length discrepancies in hereditary multiple exostoses.

There is a high rate of lower limb deformity and limb length discrepancy in patients with hereditary multiple exostoses (HME). The aim of this study was to evaluate the type and frequency of lower limbs axial deviation and limb length discrepancy and the type of exostoses being risk factors for theses deformities. We retrospectively reviewed standing full-length radiograph of 32 HME patients (64 limbs) followed in our institution between October 2009 and December 2020. Patient demographics were recorded. Radiographic analysis of the coronal limb alignment was performed, limb length discrepancy was measured and topography of the exostoses was recorded. We propose a classification of lower legs in 2 groups and 4 types according to the presence and the location of exostoses. In group I, there is an intertibio- fibular exostose with fibular origin at the level of the tibiofibular joints. In type IA, at the level of the distal tibiofibular joint with ascension of the distal fibula; in type IB at the level of the proximal tibiofibular joint with a bracketing effect on the proximal tibia and a lateral slope of the proximal tibial growth plate; the type IC is combining features of both IA and IB. In group II, there is no intertibio-fibular exostose coming from the fibula and no growth abnormality is obvious. A clinically notable lower limb discrepancy (LLD) of ≥2 cm was found in 19% of our patients. Approximately 33% of patients had a knee valgus deformity and 44% had an ankle valgus deformity. The knee valgus deformity was due to fibular growth anomalies and not to distal femur anomalies. The majority of lower legs had fibular growth anomalies (72%) which was a significant risk factor for knee valgus deformity and leg length discrepancy. On the contrary, we found no correlation between number, location and volume of distal femoral exostoses and genu valgum nor leg length discrepancy. Presence of intertibio-fibular exostoses is a risk factor for knee valgus deformity and leg length discrepancy. The presence of these exostoses should lead to a close follow-up of the patient.

Osteofibrous dysplasia of the tibia : the importance of deformity in surveillance.

Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD. A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed. Mean age at presentation was 13.5 years (SD 12.4), and mean follow-up was 5.65 years (SD 5.51). At latest review, 62 lesions (61.4%) were in skeletally mature patients. The most common site of the tibial lesion was the anterior (76 lesions, 75.2%) cortex (63 lesions, 62.4%) of the middle third (52 lesions, 51.5%). Pain, swelling, and fracture were common presentations. Overall, 41 lesions (40.6%) presented with radiological deformity (> 10°): apex anterior in 97.6%. A total of 41 lesions (40.6%) were treated conservatively. Anterior bowing < 10° at presentation was found to be related to successful conservative management of OFD (p = 0.013, multivariable logistic regression). Intralesional excision was performed in 43 lesions (42.6%) and a wide excision of the lesion in 19 (18.8%). A high complication rate and surgical burden was found in those that underwent a wide excision regardless of technique employed. There was progression/recurrence in nine lesions (8.9%) but statistical analysis found no predictive factors. No OFD lesion transformed to adamantinoma. This study confirms OFD to be a benign bone condition with low rates of local progression and without malignant transformation. It is important to distinguish OFD from adamantinoma by a histological diagnosis. Focus should be on angular deformity, monitored with full-length tibial radiographs. Surgery is indicated in symptomatic patients and predicted by the severity of the initial angular deformity. Surgery should focus more on the deformity rather than the lesion. Cite this article: Bone Joint J2022;104-B(2):302-308.

Diagnostic value of full-length femur radiographs in patients with neck of femur fracture and co-existing malignancy.

In the UK, it is common practice to obtain full-length femur radiographs in patients admitted with neck of femur fractures (NOF) and co-existing malignancy. Limited literature exists studying this topic. Our aim was to identify whether full-length femur radiographs are of diagnostic and therapeutic value in this demographic. A retrospective observational analysis of the patients admitted with a neck of femur fracture over a 5-year period (2015-2020) using the National Hip Fracture Database was performed at a major trauma centre. Electronic patient records were accessed to screen the NOF patients who had co-existing malignancy and subsequently underwent a full-length femur radiograph. In addition to patient demographics, we also identified the plan and whether it was affected by findings of the full-length radiograph, the operation performed, any additional investigations undertaken for malignancy, the type of cancer, complications and 1-year mortality. Of the 2416 patients screened, 18% had a co-existing malignancy (n = 431). Of the 431 with underlying malignancy, 424 patients underwent a full-length femur radiograph while only seven of these radiographs identified lesions. From the seven patients with findings of metastatic deposits on full-length radiographs, none required an alternative operation to that which they normally would undergo. Furthermore, no patients required a longer stem arthroplasty or longer internal fixation. One in four fractures was associated with co-existing breast malignancy (26.5%, n = 114), followed by prostate cancer (14.8%, n = 64). Colorectal, lung, bladder and skin (squamous cell carcinoma) contributed 6-10% (n = 44, 40, 33, 29, respectively). Other malignancies contributed to the rest of the 25%. To conclude, full-length radiographs had no diagnostic or therapeutic value in our cohort of patients regardless of the full-length femur findings.

Measuring Proximal Tibial Metaphyseal Width and Lateral Epiphyseal Height Improves Determination of Remaining Growth in Children.

Accurate assessments of skeletal maturity is of critical importance to guide type and timing of orthopaedic surgical interventions. Several quantitative markers of the proximal tibia were recently developed using historical knee radiographs. The purpose of the present study was to determine which marker would be most effective in assessment of full-length radiographs in a modern pediatric patient population. All full-length radiographs at our institutions between 2013 and 2018 were reviewed. Inclusion criteria for our study required that the child reached final height as defined by 2 consecutive unchanged heights, at least 6 months apart, after age 16 for boys and 14 for girls. Patients with metabolic bone disease, prior surgery such as epiphysiodesis, or previous infections around the knee were excluded. Summary statistics for each of the 3 proximal tibial ratios were calculated and multiple linear regression was performed with percent of growth remaining as a dependent variable. A recommended regression model is presented and evaluated. A total of 692 full-length radiographs met inclusion criteria. Proximal tibial ratios were calculated and averaged values for each percent of growth remaining was presented. Multiple linear regression demonstrated that using all 3 variables led to overfitting of the model so tibial metaphyseal width/lateral tibial epiphyseal height was selected as the optimal ratio for use by clinicians. The optimal model for determining growth was found to have R2=0.723 in the developmental set and R2=0.762 in an excluded validation set. This study demonstrates that the proximal tibial metaphyseal width/lateral tibial epiphyseal height is the ideal measurement for clinicians seeking to determine growth remaining in children. It presents average values between 0% and 25% of growth remaining. This study also develops and validates a multivariable regression model for determining percentage of growth remaining in children that will allow for quantitative determination of growth using full-length radiographs. Level III.

Normative Values for Femoral Length, Tibial Length, and the Femorotibial Ratio in Adults Using Standing Full-Length Radiography

Knowledge of the normal length and skeletal proportions of the lower limb is required as part of the evaluation of limb length discrepancy. When measuring limb length, modern standing full-length digital radiographs confer a level of clinical accuracy interchangeable with that of CT imaging. This study reports a set of normative values for lower limb length using the standing full-length radiographs of 753 patients (61% male). Lower limb length, femoral length, tibial length, and the femorotibial ratio were measured in 1077 limbs. The reliability of the measurement method was tested using the intra-class correlation (ICC) of agreement between three observers. The mean length of 1077 lower limbs was 89.0 cm (range 70.2 to 103.9 cm). Mean femoral length was 50.0 cm (39.3 to 58.4 cm) and tibial length was 39.0 cm (30.8 to 46.5 cm). The median side-to-side difference was 0.4 cm (0.2 to 0.7, max 1.8 cm) between 324 paired limbs. The mean ratio of femoral length to tibial length for the study population was 1.28:1 (range 1.16 to 1.39). A moderately strong inverse linear relationship (r = −0.35, p &lt; 0.001, Pearson’s) was identified between tibial length and the corresponding femorotibial ratio. The PACS-based length measurement method used in this study displayed excellent inter-observer reliability (ICC of 0.99). This study presents a normal range of values for lower limb length in adults and is the first to identify a linear relationship between tibial length and the femorotibial ratio.

ASSESSMENT OF RESULTS OF TREATMENT OF PAEDIATRIC FEMORAL DIAPHYSEAL FRACTURES WITH TITANIUM ELASTIC NAILS

Introduction: Femoral fractures are among the most common fractures of long bones. The management of pediatric femur fractures depends basically on the age group of the child although the age of bone and size of the child also determines the treatment choice. The choice of management may also be determined by surgical experience and local trends in practice. Study aimed to assess the results of treatment of paediatric femoral diaphyseal fractures with titanium elastic nails. Material And Methods: The study was conducted at Orthopaedics Department of PMCH, Patna, Bihar. A total of 22 patients with closed shaft femur fractures and age ranging between 5-16 years scheduled to undergo treatment with titanium elastic nails were selected for the study. Children with open fractures, outside this age group with concomitant head injury, bilateral femur fracture or associated fracture of either limb whose xation was done after 7 days were excluded from the study. No control group was used. They were treated by retrograde TENS xation using two nails of equal diameter for each fracture. Pre-operative evaluation includes full length radiograph of the fractured femur both antero–posterior (A–P) and lateral views. Results: In the present study, 22 patients with closed shaft femur fractures were treated with titanium elastic nails. The mean age of the patient was 13.23 years. We observed that in regards to fracture location, proximal fracture was seen in 5 patients, midshaft fracture in 14 patients and distal fracture in 3 patients. However, in regards to pattern of location, transverse fracture was seen in 6 patients, oblique fracture in 8 patients, spiral fracture in 5 patients and comminuted fracture in 3 patients. Conclusion: From this study we can conclude that Intramedullary nailing of the pediatric femoral diaphyseal fractures using titanium elastic nail is an effective surgical modality, with advantages of minimal incisional scar, minimal soft tissue damage, with early union time and excellent union rates, and without affecting shoulder and elbow function.

Clinical value of CT-based patient-specific 3D preoperative design combined with conventional instruments in primary total knee arthroplasty: a propensity score-matched analysis

PurposeTo evaluate the operation and early clinical effect in primary total knee arthroplasty (TKA) about the novel combination of CT-based patient-specific three-dimensional (3D) preoperative design and conventional osteotomy instruments, compared with the conventional method.MethodsAfter a 1:1 propensity score-matching (PSM), patients were matched to the novel technique group and the conventional group, 109 cases in each group. The conventional group adopted a preoperative design based on a full-length radiograph (FLX) and received TKA with conventional osteotomy instruments. The novel technique group used a CT-based patient-specific 3D preoperative design combined with conventional osteotomy instruments; during the surgery, the femoral entry point, femoral valgus osteotomy angle, the fix point of tibial plateau extramedullary guide pin, and the position of tibial extramedullary positioning rod were accurately selected according to the preoperative 3D design to ensure accurate intraoperative implementation. The lower limb alignment, component position, operation time, tourniquet time, hospital stay, blood loss volume, incidence of postoperative complications, visual analog scale (Vas) score, and New Knee Society Score System (NEW-KSS) at 1 day before operation and 1, 6, and 12 months after operation were recorded and compared.ResultsThe novel technique group was significantly better than the conventional group in controlling lateral tibial component angle (LTC) (P < 0.001), and the novel technique group had lower percentages of hip-knee-ankle angle (HKA) outliers (P < 0.001) and overcorrection (P = 0.003). The operation time, tourniquet time, and hospital stay of the novel technique group was shorter (P < 0.05). In 1 month after the operation, the novel technique group achieved a significantly better VAS score (P < 0.05), but a similar NEW-KSS score (P > 0.05) when compared with the conventional group. But in 6 and 12 months after surgery, no statistical differences were seen in the above two scores (P > 0.05).ConclusionThe novel technique of CT-based patient-specific 3D preoperative design combined with conventional instruments can improve the accuracy of osteotomy in primary total knee arthroplasty, with benefits of significantly reducing pain and rapid recovery during the early postoperative period, but having no obvious effect on outcome after a 1-year follow-up.

Short and medium term follow-up study on the changes of spine pelvic parameters in patients with hip-spine syndrome after total hip arthroplasty

To investigate the influence of total hip arthroplasty on the changes of spine pelvic parameters in patients with hip spine syndrome. From January 2013 to October 2014, 22 patients (26 hips) with hip spine syndrome accompanied by necrosis of femoral head, hip osteoarthritis and congenital dysplasia of hip were treated with total hip arthroplasty. There were 12 males and 10 females with an average age of 58.4 years (range, 45 to 76 years). The course of disease was 1.5 to 25 years with an average of 12.8 years. Before and after the operation, the anteroposterior, full length radiographs of both lower limbs, thoracolumbar spine and pelvis in standing position were routinely taken. The balance parameters of spine pelvis coronal plane and sagittal plane before and after the replacement were measured. Visual analogue scale (VAS), Oswestry Disability Index (ODI) and Harris score were performed before and after the operation. All cases were followed up for 21 to 52 (32±8) months. No infection, prosthesis subsidence, loosening, prosthesis dislocation were found in the last follow up. After total hip arthroplasty, sagittal vertical axis(SVA), thoracic kyphosis(TK), lumbar lordosis(LL), pelvic tilt (PT) were significantly reduced(P<0.05), sacral slope(SS) was significantly increased(P<0.05), there was no significant difference in pelvic incidence(PI)(P>0.05); PT and scoliosis (coronal position) were significantly decreased after operation(P<0.05); VAS score of waist, VAS score of hip joint and ODI score of waist were significantly decreased before and after operation (P<0.05). Harris score of hip joint increased significantly after operation, and thedifference was statistically significant (P<0.05). After total hip arthroplasty, the coronal and historical balance parameters of spine and pelvis are significantly improved, and the short term and medium-term effects are satisfactory.

Preoperative Planning and the Use of Free Available Software for Sagittal Plane Corrective Osteotomies of the Lumbar Spine in Ankylosing Spondylitis.

BackgroundAnkylosing spondylitis (AS) may cause a severe rigid thoracolumbar kyphotic deformity (TLKD) that leads to considerable disturbances of posture and spinal balance. In few patients, a corrective osteotomy of the lumbar spine may be considered. Preoperative planning of a lumbar osteotomy for correction of a severe TLKD due to AS is important to correct patient’s sagittal balance and view angle. There is a need for accurate preoperative planning that can be used easily in daily practice.MethodsThe basic biomechanical and mathematical principles of preoperative planning for correction of a TLKD due to AS are described. A search was performed for free available computer programs that can be used for pre-operative planning of spinal osteotomies in AS. Finally, the use of these computer programs is illustrated and described.ResultsSagittal balance is measured on a standing lateral full-length radiograph of the spine. The assessment of the pelvic parameters (PI, PT, SS) in conjunction with sagittal vertical axis (SVA) and chin-brow-to-vertical angle (CBVA) provides a comprehensive picture of the sagittal spinal alignment and compensatory mechanisms of the patient. The relation between the level of lumbar osteotomy and the amount of correction needed can be calculated with different elementary trigonometric equations. Two free available computer programs, ASKyphoplan and Surgimap, are illustrated and described that can be used for pre-operative planning of spinal osteotomies in AS.ConclusionPreoperative planning of the lumbar osteotomy in AS involves assessment of the combined effect of location of the osteotomy, amount of bone resection, SVA, CBVA, and pelvic parameters. Two free available computer programs, ASKyphoplan and Surgimap, are easy to use in clinical practice to predict postoperative sagittal balance of lumbar osteotomies in patients with severe TLKD due to AS.

Radiographic predictive findings of neck pain in patients with ankylosing spondylitis

Objective The aim of this study was to investigate the relationship between neck pain and radiological findings in ankylosing spondylitis (AS) patients. Methods The study groups comprised 257 AS and 50 normal patients. Of the AS patients, 91 had axial neck pain (group 1) and 166 did not (group 2). Full-length radiographs of the spine in the anteroposterior and lateral planes were taken. Radiographic parameters such as the chin brow vertical angle (CBVA), McGregor slope (McGS), slope of the Line of Sight (SLS), C2 slope, C2-C7 lordosis (CL), C2-C7 sagittal vertical axis (C2-C7 SVA), and T1 slope were measured. Statistical analysis was performed. Results The AS and normal patients were found to have significantly different CBVA, McGS, C2 slope, C2-C7 SVA, and T1 slope. However, no significant difference was observed for SLS and CL. Between groups 1 and 2, there were significant differences in the McGS, CL, and T1 slope. However, no significant difference between these two groups was observed for CBVA, SLS, C2 slope, and C2-C7 SVA. Logistic regression analysis was performed to identify statistically significant predictors of neck pain in AS patients and it revealed that the T1 slope and McGS were two such predictors. The T1 slope showed superior discriminatory power to McGS and CL in the receiver operating characteristic curve analysis. Conclusions This study shows that a high T1 slope and McGS are independent radiological predictors of neck pain in AS. Further well-designed studies would be necessary to substantiate our results.

Vertebral growth modulation by posterior dynamic deformity correction device in skeletally immature patients with moderate adolescent idiopathic scoliosis

Study designRetrospective, comparative, multicenter.IntroductionGrowth modulating spinal implants are used in the management of scoliosis such as anterior vertebral body tethering. A motion-sparing posterior device (PDDC) was recently approved for the treatment of moderate AIS. The purpose of this study was to determine if the PDDC can modulate growth in skeletally immature patients with AIS.MethodsFrom a database of patients treated with the PDDC over 4 years, we identified those who had a minimum of 2 years follow-up. Pre-operative and post-operative Cobb angles and coronal plane wedging of the apical vertebra were evaluated on standing full length radiographs. Independent sample t test and one-way ANOVA with post-hoc Tukey HSD analysis was used to compare three groups in varying skeletal maturity: Risser 0–1, Risser 2–3, and Risser 4–5.Results45 patients (14.2-years old, 11–17) were evaluated with a mean pre-op curve of 46° (35°-66°). The average preoperative major curve magnitude, of either Lenke 1 or 5 curve type, was similar among the three groups 47.6°, 46° and 41.5°. Deformity correction was similar in the three groups, with reduction to 26.4°, 20.4° and 26.2°, respectively, at final follow-up [p < 0.05]. Pre-op wedging 7.4° (3.8°–15°) was reduced after surgery to 5.7° (1°–15°) (p < 0.05). Of those patients, Risser 0–1 (n = 16) had preoperative wedging of 9.5° (6°–14.5°) that was reduced to 5.4° (1°–8°) postoperatively (p < 0.05); Risser 2–3 (n = 15) had pre-op 7.7° (4°–15°) vs. post-op 7.0° (3°–15°); Risser 4–5 (n = 14) had pre-op 4.8° (3.8°–6.5°) vs. post-op 4.7° (3.7°–6.5°). Delta Wedging in Risser 0–1 stage was significantly different than for Risser 2–3 and for Risser 4–5.ConclusionThe posterior dynamic deformity correction device was able to modulate vertebral body wedging in skeletally immature patients with AIS. This was most evident in patients who were Risser 0–1. In contrast, curve correction was similar among the three groups. This finding lends support to the device’s ability to modulate growth.