Malalignment Syndrome Research Articles

Lower Limb Rotational Malalignment: Derotational Osteotomies of the Femur and Tibia in the Setting of Recurrent Patellar Instability

Valgus lower extremity alignment with excessive femoral anteversion and tibial external torsion (Miserable Malalignment Syndrome) results in patellar maltracking. Sagittal plane deformities (rotational alignment) should be quantified along with typical frontal plane alignment. Femoral and tibial rotation can be assessed with both physical examination and radiographic studies. Derotational osteotomies of both the femur and the tibia can then be used for correction. In this chapter, we attempt to provide guidelines for assessing lower extremity rotation and an understanding of normal femoral and tibial rotational values. We then provide examples of corrective femoral osteotomies and tibial rotational osteotomies.

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

IntroductionMiserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.MethodsFifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle–trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.ResultsThere was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°–54°), and external tibial torsion 50° (37–70). The mean age at surgery was 21 years (12–37) with a mean follow-up of 20 months (9–83). All osteotomies healed, and the frames were removed at a mean of 111 days (80–168). The mean VAS score improved from 8(5–9) to 1(0–4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30–75) to 92 (54–100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°–50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with − 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.ConclusionGradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

Systematic Literature Review and Meta-Analysis on Miserable Malalignment Syndrome

Background: Miserable malalignment syndrome (MMS) is a rare condition that entails increased femoral anteversion and increased external tibial torsion, as well as the presentation of one, some, or all the following: squinting patella, patella alta, patellar instability, an increased Q angle, genus valgus (knock knees) or genus varum (bow leggedness), genus recurvatum, feet pronation, or pes planus. Methods: The Sample, Phenomenon of Interest, Design, Evaluation, Research type search strategy was used to retrieve eligible studies from databases fitting the established inclusion criteria. Results: All studies agreed that nonoperative treatment is ineffective in improving MMS. Surgical treatment is effective, although it involves osteotomies at 2 levels per limb. Conclusions: Double-level osteotomies were effective in all studies, vastly improving range of motion, chronic knee pain, chronic hip pain, and other factors. Surgical treatment of this condition should only be reserved for severe cases because complications are possible. Level of Evidence: Most articles used were part of a case series, indicating this review article is based on level 4 evidence.

Flexible Flat Foot, Short Tendo-Achilles, and Altered Gait.

BackgroundPediatric patients often present with vague complaints involving the anterolateral foot and ankle, the medial knee, the lower back, and the hip. In our experience, closer examination of these patients reveals a constellation of symptoms that involve pathology in the ankle, knee, back, and hip. This study aimed to detail the identification and treatment of patients with the triad of flexible flat feet, tight Achilles complex, and altered gait, and their clinical course over time.MethodsAll patients of age 18 years or younger who presented to our urban academic center outpatient clinic with foot, ankle, patellar, low back, or hip pain or pathology were included. Patients with identified tarsal coalitions, accessory naviculars, malalignment syndrome, bone cysts or tumors, soft tissue tumors, arthropathy, neuropathy, infection, limb length inequality, patellar subluxation or dislocation, or spinal pathology were excluded. For each patient, demographic information, symptom description, treatment, and clinical course, including the Foot and Ankle Outcome Score (FAOS) was recorded.ResultsA total of 62 patients were included in our study. Patients mostly presented with low back pain (n=24, 38.7%), medial patellar pain (n=36, 58.1%), anterolateral ankle pain (n=35, 56.5%), and vague foot pain (n=13, 21.0%). Overall, 53.8% of patients with back pain at the initial visit, 35.0% of patients with knee pain, 44.4% of patients with ankle pain and 80.0% of patients with foot pain improved at final follow up. While patient-reported sports and recreation subscale scores demonstrated a significant improvement at the final follow-up compared to baseline scores (p=0.02), all other scores did not significantly differ compared to baseline scores. At final follow-up, 12 of 26 (46.2%) patients reported being able to return to play in their desired sport.ConclusionComplaints of back, hip, knee, ankle, or foot pain in the pediatric population can be early markers for a constellation of conditions that include low back pain, flexible flat feet, Achilles contracture, and altered gait due to increased lateral subluxation of the patella and hip flexion.

매트 필라테스 운동이 부정렬 증후군 여성의 자세 정렬, 근력 및 균형 능력에 미치는 영향

Purpose: The purpose of this study is to analyze the changes in postural alignment, muscle strength, and balance ability after mat Pilates exercise, and to propose meaningful clinical evidence for malalignment syndrome.<BR> Method: The independent variable was mat Pilates exercise applied or not, the subjects were randomly assigned to a mat Pilates group (n=10), and a control group (n=10). We performed the exercises for 12 weeks, three times a week, 60 min a day. SPSS 20.0 (SPSS Inc, Chicago, IL, USA) was used for data analysis, and a two-way repeated ANOVA was performed to verify the interaction between programs and periods for all variables between groups. When there was an interaction between periods and exercise group, pre- and post-differences were analyzed by a paired t-test for each group. The statistical significance level was set to =.05.<BR> Results: The results of this study were as follows. 1) The result of postural alignment showed a significant decrease in shoulder tilt (p<.05), pelvic tilt (p<.001), scapula tilt (p<.01), and cervical tilt (p<.01) in the subjects of mat Pilates exercise group. 2) The result of muscle strength showed a significant increase on right·left knee extensors (p<.05), right·left knee flexor (p<.001) in the subjects of mat Pilates exercise group. Waist flexor (p<.001) and extensor (p<.01) also significantly increased in the subjects of the mat Pilates exercise group. 3) The result of balance ability showed significant improvement on the right (p<.05)·left (p<.01) lower extremity, right (p<.001)·left (p<.01) upper extremity in the subjects of mat Pilates exercise group.<BR> Conclusion: As a result, mat Pilates exercise significantly reduces differences in shoulder tilt, pelvic tilt, scapula tilt, and cervical tilt in women in their 20s with malalignment syndrome, which has a positive effect on maintaining postural alignment. It is also thought to be effective in controlling functional movements to maintain posture by improving muscle strength and balance.

Is Longstanding Congenital Muscular Torticollis Provoking Pelvic Malalignment Syndrome?

It has been reported that congenital muscular torticollis (CMT) may result in secondary scoliosis over long-term follow-ups. However, there are few reports on whether CMT causes pelvic malalignment syndrome (PMS). This study aimed to investigate the relationship between CMT and PMS and to determine the factors associated with the development of PMS in children with longstanding CMT. Medical records of 130 children with CMT who had long-term follow-up were reviewed retrospectively. The chi-squared test and logistic regression analysis were used to determine which initial clinical parameters contributed to the development of PMS. Among 130 children with CMT, 51 (39.2%) developed PMS with or without compensatory scoliosis during long-term follow-up, indicating a high prevalence of PMS in children with a CMT history. Initial clinical symptoms such as a limited range of motion of the neck or the presence of a neck mass could not predict the development of PMS. Even if the clinical symptoms are mild, long-term follow-up of children with CMT is essential to screen for PMS.

Derotational Osteotomies of the Femur and Tibia for Recurrent Patellar Instability

Lower extremity rotational alignment must be quantified in cases of recurrent patellofemoral instability. Femoral and tibial rotation can be measured with both physical examination and radiographic studies. Derotational osteotomies of both the femur and the tibia can be used to correct patients with excessive femoral anteversion and tibial external rotation (miserable malalignment syndrome). In this article, we attempt to provide guidelines for assessing lower extremity rotation and an understanding of normal femoral and tibial rotational values. We then provide examples of one type of corrective femoral osteotomy and one type of tibial rotational osteotomy.

Geometry of Torsional Malalignment Syndrom: Trochlear Dysplasia but not Torsion Predicts Lateral Patellar Instability

Aims and Objectives: To analyze parameters of limb malalignment and patellar tracking in patients with torsional malalignment syndrome presenting with clinical symptoms of either patellofemoral pain or patellar instability. Materials and Methods: Between April 2015 and July 2017, 428 patients were treated for lateral patellar instability (LPD), and 333 patients were treated for patellofemoral pain syndrome (PFPS). Sixty-two patients (14.5%) with patellar instability (LPD group) and 29 patients (8.7%) with patellofemoral pain (PFPS group) had additional torsional malalignment and were included in this study. All patients underwent magnetic resonance imaging assessment of torsional alignment and patellar tracking, including femoral antetorsion, tibial torsion, knee rotation, tibial tuberosity-trochlear groove distance, tibial tuberosity-posterior cruciate ligament distance, Dejour’s classification of trochlear dysplasia, lateral trochlear inclination angle, and patellar height Results: Groups differed significantly in terms of trochlear dysplasia (p&lt;0.001), lateral trochlear inclination angle (p&lt;0.001) and tibial tuberosity-trochlear groove distance (p=0.0167) but did not differ in terms of femoral torsion (LPD group 20.02° +/- 8.8°; PFPS group 20.03° +/- 7.91°; p=0.8545), tibial torsion (LPD group 39.53° +/- 9.23°; PFPS group 41.24° +/- 7.28°; p=0.3616), and knee rotation (LPD group 10.42° +/- 5.16°; PFPS group 8.48° +/- 7.81°; p=0.0163). Only measures of coronal alignment were positively correlated. This was also true for the tibial tuberosity-trochlear groove distance and knee rotation but not for any other parameters of torsional limb alignment. Trochlear dysplasia (type B-D) was identified as the only significant predictor of patellar instability. Conclusion: Torsional malalignment syndrome, represented in this study by two clinical entities - PFPS and LPD - is not characterized by a typical constellation of different malalignment parameters. Between groups, parameters differed significantly only in terms of trochlear dysplasia and the tibial tuberosity-trochlear groove distance, with trochlear dysplasia (type B-D), but not torsion, identified as predictor of lateral patellar instability.

Geometry of Torsional Malalignment Syndrome: Trochlear Dysplasia but Not Torsion Predicts Lateral Patellar Instability.

Background:The clinical impact of increased torsion on patellar instability and patellofemoral pain syndrome (PFPS) has been suggested by several studies.Hypothesis:The hypotheses of this study were that (1) torsional malalignment (TM) is characterized by a positive correlation between different malalignment parameters that represent an overall picture of the malalignment syndrome and (2) an increase in overall torsion is the underlying difference between patellar instability and isolated patellofemoral pain.Study Design:Cohort study; Level of evidence, 3.Methods:Between April 2015 and July 2017, a total of 428 patients were treated for lateral patellar dislocation (LPD), and 333 patients were treated for PFPS. Sixty-two patients (14.5%) with patellar instability (LPD group) and 29 patients (8.7%) with patellofemoral pain (PFPS group) had additional TM and were included in this study. All patients underwent magnetic resonance imaging for torsional alignment and patellar tracking, including femoral antetorsion, tibial torsion, knee rotation, tibial tuberosity–trochlear groove (TT-TG) distance, tibial tuberosity–posterior cruciate ligament (TT-PCL) distance, Dejour classification of trochlear dysplasia, lateral trochlear inclination (LTI) angle, and patellar height.Results:The LPD and PFPS groups differed significantly in terms of trochlear dysplasia (P < .001), LTI angle (P < .001), and TT-TG distance (P = .0167) but did not differ in terms of femoral antetorsion (20.02° ± 8.80° vs 20.03° ± 7.91°, respectively; P = .8545), tibial torsion (39.53° ± 9.23° vs 41.24° ± 7.28°, respectively; P = .3616), or knee rotation (10.42° ± 5.16° vs 8.48° ± 7.81°, respectively; P = .0163). Only measures of TT-TG distance and TT-PCL distance and measures of TT-TG distance and knee rotation were positively correlated. Trochlear dysplasia (type B-D) was identified as the only significant predictor of patellar instability.Conclusion:TM in patients with either PFPS or LPD does not appear to be characterized by a fixed constellation of different malalignment parameters. Between groups, the parameters differed significantly only in terms of trochlear dysplasia and the TT-TG distance, and trochlear dysplasia (type B-D) (but not torsion) was identified as a predictor of lateral patellar instability.

Comparison of Pediatric and General Orthopedic Surgeons’ Approaches in Management of Blount’s Disease and Torsional Malalignment Syndrome

Comparison of Pediatric and General Orthopedic Surgeons’ Approaches in Management of Blount’s Disease and Torsional Malalignment Syndrome

The effects of biomechanical foot orthoses on the gait patterns of patients with malalignment syndrome as determined by three dimensional gait analysis.

[Purpose] The biomechanical effects of foot orthoses on malalignment syndrome have not been fully clarified. This experimental investigation was conducted to evaluate the effects of orthoses on the gait patterns of patients with malalignment syndrome. [Subjects and Methods] Ten patients with malalignment syndrome were recruited. For each participant, kinematic and kinetic data were collected under three test conditions: walking barefoot, walking with flat insoles in shoes, and walking with a biomechanical foot orthosis (BFO) in shoes. Gait patterns were analyzed using a motion analysis system. [Results] Spatiotemporal data showed the step and stride lengths when wearing shoes with flat insoles or BFO were significantly greater than when barefoot, and that the walking speed when wearing shoes with BFO was significantly faster than when walking barefoot or with shoes with flat insoles. Kinetic data, showed peak pelvic tilt and obliquity angle were significantly greater when wearing BFO in shoes than when barefoot, and that peak hip flexion/extension angle and peak knee flexion/extension and rotation angles were significantly greater when wearing BFO and flat insoles in shoes than when barefoot. [Conclusion] BFOs can correct pelvic asymmetry while walking.

Primary Bone Lymphoma of the Patella

Background: Primary bone lymphoma (PBL) is a rare bone malignancy that accounts for 7% of all bone tumors. It most commonly involves the long bones, with the distal femur and the proximal tibia being the most common locations. The majority of patients present during adulthood with pain in the absence of trauma. Methods: A case report of a 15 year-old male, with a 6-month history of insidious onset right peripatellar pain. After arriving to our clinic he presented with a 30-pound weight loss over the last year, right inguinal adenopathy and tenderness in the patellar area. Imaging showed an osteolytic lesion of the right patella and an imaging-guided biopsy was performed. Awaiting results, he presented with a non-displaced fracture of the patella while he was walking down the stairs. Treatment with a knee brace and COPAD chemotherapy regime was initiated after a diagnosis of bone lymphoma was established. Results: Our patient received 6-months of chemotherapy and knee immobilization for his pathologic fracture. There was good response to the chemotherapy and no complications arised after the fracture. Our patient is now 2-years after diagnosis, without signs of recurring disease and back to his normal daily activities. Conclusion: There are few reports of PBL arising from the patella in the literature. Most of these reports do not distinguish by age, and the few that do, show patients between 38-77 years of age. To our knowledge, this is the first report of a patellar primary bone lymphoma in the pediatric population. Anterior knee pain is extremely common and its differential diagnosis is very wide. Anterior knee pain is more commonly related to tendinitis, patellar malalignment syndrome and chondromalacia. Clinicians should keep in mind the possibility of a malignant process as a possible underlying cause when there is lack of response to conventional treatment.

Knee Pain and Patellofemoral Symptoms in Patients With Cerebral Palsy.

Knee pain in cerebral palsy (CP) is associated with increased patellofemoral forces present when walking with flexed knees. In typically developing children, knee pain and patellofemoral dysfunction are associated with obesity, genu valgum, femoral anteversion, and external tibial torsion. These problems are also common in CP, and may contribute to knee problems in this population. The purposes of this study were to define the prevalence of knee pain and patellofemoral dysfunction in children with CP, and to identify physical and gait characteristics (using 3-dimensional gait analysis data) that predispose them to such problems. Retrospective review of 121 children with CP, Gross Motor Function Classification System level I to IV, who underwent computerized gait analysis testing. Demographics, range of motion, body mass index and hip, knee, and ankle kinematics were compared between subjects with and without knee pain. Twenty-five of 121 subjects (21%) reported knee pain at the time of testing. Three of 121 subjects (2%) had a history of patellar subluxation/dislocation. Age and sex were significantly related to presence of knee pain. The likelihood of knee pain was almost 5 times higher in females (odds ratio=4.9, [95% confidence interval, 1.8-13.3], P=0.002), with a prevalence of 40% (17/42) in females versus 10% (8/79) in males. The likelihood of knee pain increased with age by approximately 13% per year (odds ratio=1.13, [95% confidence interval, 1.00-1.28], P=0.058). Malignant malalignment syndrome showed a potential relationship to more severe knee pain (P=0.05), which warrants further investigation. Body mass index, pes valgus, and degree of stance knee flexion showed no statistically significant relationships to knee pain (P>0.16). The prevalence of knee pain in ambulatory patients with CP is approximately 21%. Patellar subluxation (2%) and dislocation are rare in these patients. Knee pain is not always related to crouch, femoral anteversion, external tibial torsion, genu valgum, or pes valgus. Knee pain in these patients is more prevalent in females, and increases with increasing age. Level III-case-control study.

The Diagnosis of Knee Pain

The knee is open to injury because it is designed for rapid action, not simply during its large excursion from extension to full flexion, but also lesser accommodative movements of rotation, tilt and glide. As if that were not enough, that highly developed but sometimes temperamental sesamoid, the patella, adds its own unique problems. The complexities of these movements are reflected in the subtleties of the structure of the knee. Regrettably they have also led to a proliferation of clinical tests and surgical repairs whose sophistication confuses rather than enlightens.Before enquiring about the characteristics of the painful knee the general characteristics of the patient should be assessed quickly. In children problems usually relate to patellar malalignment syndromes, possibly a discoid meniscus, and the aching discomfort produced by traction apophysitis such as Osgood-Schlatter's disease of the tibial tuberosity. After puberty girls are particularly likely to develop patellar pain, which may be associated with lateral subluxation of that bone. In the young woman the sources of such pain may be so prolix that the surgeon may do more harm than good if he operates. During adolescence and early adult life males are most likely to suffer from meniscal and ligamentous tears, often brought on by exertion or accidents during sport. A patient with an endomorphic physique usually has associated genu valgum and may present with medial ligament sprains and patello-femoral pain. Those with ligamentous laxity are also prone to sprains and patellar subluxation. The mesomorphic athlete is likely to injure the menisci, or may come in with significant tears of the ligaments and synovium.

Soccer Syndrome - Common Presentations and Manual Diagnostic Techniques for Pelvic Malalignment Syndrome

The pelvic malalignment syndrome is the most common in sports injuries and even in every client who presents with low back & pelvis pain or dysfunction. In this study, we used simple bony palpation method to assess the various pelvic malalignments in football players. While there are many methods to determine pelvic symmetry or asymmetry, this method is very simple one and that consistently works well for me. Our method of assessing the pelvic malalignments, even works well to the common individuals suffering with low back & pelvis pain or dysfunction due to various pelvic malalignment presentation. This study includes the healthy football players from National Football Club (NFC) of our institution, who were training or playing during the period of investigation (September 2012 – September 2014) (n = 40) were eligible for participation. At entry to the study, this eligible sample had a mean age of 22.2 ± 3.9 years, height of 175.8 ± 6.6 cm, and mass of 87.5 ± 7.1 kg. The number of eligible participants at each time point was 40 for all the four session time, point 1 (T1; start of preseason-1), point 2 (T2; end of season-1), point 3 (T3; start of preseason-2), and point 4 (T4; end of preseason-2). We instructed participants to nominate their leg preference for kicking, which was considered the dominant leg. Among the total number of eligible players assessed, 12.5% were left-leg dominant, 80% were right-leg dominant, and 7.5% reported no leg dominance. Subjects were limited to men who had a normal muscle strength and Range of Motion (ROM) of the back and lower extremities and who had no history of orthopaedic or neurologic disorders. All the individuals are subject to gain access the malalignment of both Innominate and Sacral bones of the bony pelvis unit. In addition, to justify our diagnosis we access the muscles of the functional slings and the muscles around the bony pelvis related to the malalignment of the pelvic unit. The techniques were repeated in different position and also performed for two times per day and continued for fifteen days to standardize. In this study, we observed, 87.5% i.e., the majority of the soccer's are suffering with multiple pelvic malalignments , includes innominate & sacral stuck. The soccer's suffering with single component malalignment account for about 10%, includes innominate or sacral stuck and soccer's who had the symmetry pelvis is only 2.5%. Conclusion: This method of assessing the pelvic malalignments until then not documented. In this sense, the objective of this study is to analyze and document the different presentations in pelvic malalignments which are common in soccer players and its simple method of evaluation is the literature state of the art. The present study may provide useful information to analyze common presentations of pelvic malalignments in different sports.

Biomechanics and muscle function during gait

Gait disorders in patients with cerebral palsy (CP) initially lead to functional deformities which later become structural. The deformities may greatly increase energy consumption and thus limit function. Under normal conditions, however, energy consumption is optimal [1]. Correction of biomechanics towards normality improves energy consumption [2, 3]. For this reason, correction of deformities aims at normality. As, in principle, normal function rather than normal anatomy is the goal, biomechanics and muscle function need to be understood in normal and pathological situations. Gait analysis has yielded deep insights into these issues. Kinematics show the interplay of joint movements at a given time, but only the additional use of kinetics can help us to understand muscle function. A major problem in this respect is the anatomical bias of agonist–antagonist interplay: the main motors of motion. When interpreting kinetic gait data, it becomes obvious that this approach applies poorly to the functional situation. Joint moments are, to a great extent, the product of the ground reaction force (GRF) times its distance to the center of the joint. However, segment inertia and acceleration also contribute and should not be underestimated. The external moment is neutralized by an internal moment created by the muscles on the opposite side of the joint in order to maintain stability. As a consequence, under load, the functional antagonist to the muscle is the external moment. Thus, hip flexion (for instance) may not be due to hip flexor activity. The external moment may flex the hip and inadequate hip extension thus results from hip extensor weakness. In this case, the extensor side of the joint needs to be addressed. Another consequence concerns the direction of muscle activity. Anatomically, a muscle pulls from insertion to origin, moving the distal body segment towards the proximal one. Under load, however, the distal body segment is the more stable of the two segments, as it is relatively fixed to the floor; the proximal one has more freedom of movement. This condition inverts the direction of muscle pull, and the proximal segment moves with respect to the distal one. Thus, the interpretation differs depending on whether a loaded (stance phase) and unloaded (swing phase) situation is considered. One example of such a situation is internal rotation of the leg (seen as hip internal rotation) resulting from excessive dorsiflexion in the subtalar joint and the midfoot. Foot dorsiflexion is a compound movement of the ankle, subtalar, and midfoot joints. The contribution of each joint varies and depends on the length of the triceps surae muscle–tendon complex. The result is an oblique dorsiflexion axis that combines pure dorsiflexion with external rotation and pronation with respect to a fixed shank. If, however, the foot is fixed to the floor by loading and friction, the same movement rotates the leg internally [4, 5]. When the hip flexes and adducts, the pelvis also rotates and tilts anteriorly. This phenomenon becomes more important as the triceps surae shortens and the the midfoot break becomes more pronounced. Severe cases present with a malalignment syndrome. Under normal conditions, however, adequate activity of the tibial muscles stabilizes the foot, avoiding this phenomenon. Another physical effect was described as a plantar flexion–knee extension couple [6, 7]. Only under load is the triceps muscle capable of holding the tibia back and in this way extending the knee (Fig. 1). Due to joint connections and inertia, the effect of this single muscle only travels proximally and leads to hip flexion, internal rotation, and adduction, together with R. Brunner (&) E. Rutz Basel, Switzerland e-mail: reinaldbrunner@sunrise.ch

Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up

BackgroundTorsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb.Materials and methodsFrom 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years.ResultsAt final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°–85°) and average hip external rotation of 27.2° (10°–40°). Thigh–foot angle measurement showed an average value of 38.6° (32°–45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°–55°) and average hip internal rotation of 44.3° (20°–48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh–foot angles measurement showed an average value of 21.6° (18°–24°) outward.ConclusionWe recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.

A ganglion of the patellar tendon in patellar tendon-lateral femoral condyle friction syndrome

Intratendinous ganglia are rare. We report the case of a sedentary woman with chronic mechanical anterolateral pain of the knee and an extensive ganglion of the patellar tendon as indicated on magnetic resonance (MR) and ultrasound (US) examinations. There was evidence of a high-riding patella, patellar malalignment and patellar tendon-lateral femoral condyle friction syndrome with significantly close contact between the patellar tendon and the lateral facet of the femoral trochlea. The ultrasound-guided aspiration of the ganglion enabled a localized injection of an anti-inflammatory drug (cortivazol) and the cytopathological examination of the fluid, which confirmed the diagnosis. Clinical improvement was maintained with knee rehabilitation and was satisfactory at follow-up after 1year. To our knowledge, we report the first case of a ganglion of the patellar tendon subsequent to patellar tendon-lateral femoral condyle friction syndrome. We found that this case was illustrative of mucoid degeneration in connective tissue due to chronic repetitive microtraumas. Additionally, this case provided the opportunity to discuss the management of this condition in a sedentary individual with a high-riding patella and patellar malalignment.

전공과 좌우 양 발에 따른 여대생의 발 유형 분석

The purpose of this study is to analyze the differences in foot type of female college students according to academic major in both feet. The subjects for this study were 216 female students who took liberal arts classes in Seoul. Dependent variables were students' field of study -specifically whether or not they majored in physical education. Analysis of students' foot type and Malalignment Syndrome were measured using Resting Calcaneous Stance Position (RCSP). There were five categories for RCSP angle: Severe Pes Planus (< <TEX>$-5^{\circ}$</TEX>), Pes Planus (<TEX>$-3^{\circ}{\sim}-4^{\circ}$</TEX>), Pes Rectus (<TEX>${\pm}2^{\circ}$</TEX>), Pes Cavus (<TEX>$+3^{\circ}{\sim}+4^{\circ}$</TEX>), Severe Pes Cavus (> <TEX>$+5^{\circ}$</TEX>). <TEX>${\chi}^2$</TEX> analysis was used for statistical analysis. RCSP for all subjects (432 feet) occurred at the following frequency: Pes Planus(43.9%), Pes Rectus(43.8%), and Pes Cavus(12.3%). These levels were different for physical education majors, with Pes Planus at 42.6%, Pes Rectus at 49.4%, and Pes Cavusat 8.0%. Non-physical education majors exhibited Pes Planus at 45.0%, Pes Rectus at 39.9%, and Pes Cavus at 15.1%. 15.3% (33 subjects) of all students had Malalignment Syndrome. In conclusion, 56.2% of female college students had a foot deformity. There was nearly four times more Pes Planus than Pes Cavus. According to these results, exercise can be prescribed to alleviate foot deformities, especially supination. Severe pronation and supination problems appeared less amongst students not majoring in physical education. Thus, although exercise might be one cause of foot deformity, it can also help resolve problems with over-supination. Further study will be needed to understand and resolve the specific mechanism of over-supination.

Effects of foot orthoses on gait pattern of malalignment syndrome patients

Effects of foot orthoses on gait pattern of malalignment syndrome patients