Residual Varus Research Articles

Functional Alignment Philosophy in Total Knee Arthroplasty—Rationale and Technique for the Valgus Morphotype Using an Image Based Robotic Platform and Individualized Planning

Functional alignment (FA) is a novel philosophy to deliver a total knee arthroplasty (TKA) that respects individual bony and soft tissue phenotypes within defined limitations. The purpose of this paper is to describe the rationale and technique of FA in the valgus morphotype with the use of an image-based robotic-platform. For the valgus phenotype the principles are personalized pre-operative planning, reconstitution of native coronal alignment without residual varus or valgus of more than 3°, restoration of dynamic sagittal alignment within 5° of neutral, implant sizing to match anatomy, and achievement of defined soft tissue laxity in extension and flexion through implant manipulation within the defined boundaries. An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable assessment of soft tissue laxity is performed in extension and flexion. Implant positioning is then manipulated in all three planes if necessary to achieve target gap measurements and a final limb position within a defined coronal and sagittal range. FA is a novel TKA technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that respects variations in individual anatomy and soft tissues within defined limits.

Pre-operative predictive factors of residual varus on the mechanical axis after Oxford unicompartmental knee arthroplasty.

Residual varus after Oxford unicompartmental knee arthroplasty (UKA) happens frequently. This study aims to evaluate the pre-operative contributing factors of residual varus. A total of 1,002 knees (880 patients, 201 patients were male, and 679 were female) underwent Oxford UKA in the Orthopedic Surgery Department of the Beijing Jishuitan Hospital from March 2018 to April 2021. The mean age of the patient was 64.7 ± 7.7 years. To assess residual varus, the full-length lower extremity is placed upright for EOS imaging, with the knee fully extended. The angle of post-operative residual varus was measured as described by Noyes et al. Of the knees studied, they were either categorized into an under-corrected group (post-operative Noyes angle >5°) or a corrected group (post-operative Noyes angle ≤5°). Age, gender, body mass index (BMI), range of motion (ROM), Clinical American Knee Society Score (Clinical AKSS), and Function American Knee Society Score (Function AKSS) were compared. The following additional parameters were measured: pre-operative Noyes angle, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), the posterior slope of the proximal tibia angle (PPTA), joint line converge angle (JLCA), and fixed flexion deformity (FFD). There was no statistically significant difference between the two groups in regards to gender (p = 0.428), surgical leg (p = 0.937), age (p = 0.851), BMI (p = 0.064), pre-operative Clinical AKSS (p = 0.206) and Function AKSS (p = 0.100). However, pre-operative ROM statistically differed between the two groups (p < 0.001). The contributing factors of post-operative residual varus were determined to be the following parameters: pre-operative MPTA (p < 0.001, OR = 4.522, 95% CI: 2.927-6.984), pre-operative Noyes (p < 0.001, OR = 3.262, 95% CI: 1.802-5.907) and pre-operative FFD (p = 0.007, OR = 1.862, 95% CI: 1.182-2.934). The effects of pre-operative LDFA (p = 0.146), JLCA (p = 0.942), and pre-operative PPTA (p = 0.899) on the post-operative mechanical axis did not show statistical significance. Patients with severe pre-operative varus, particularly varus deformity mainly from the tibial side or pre-operative FFD, are more prone to get extremity mechanical axis residual varus after UKA with Oxford.

The Gradual Correction of Adult Severe Rigid Equinus Deformity Using Minimal Invasive U-Osteotomy With Taylor Spatial Frame.

U-osteotomy with Taylor Spatial Frame correction is a rarely reported treatment method particularly well-suited for severe rigid equinus deformity in adults. The purpose of this study was to evaluate the effectiveness and efficacy of deformity correction and clinical outcome using this technique. We present a retrospective review of 30 feet in 26 patients who received U-osteotomy with Taylor Spatial Frame. Radiologic outcomes were measured using the anterior tibiotalar angle (TTA) with conventional weightbearing radiographs. Functional assessments included American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores and patient satisfaction using Likert scale. The etiology included trauma (9), neglected or relapsed clubfoot (6), spina bifida (5), poliomyelitis (4), Charcot-Marie-Tooth disease (4), and iatrogenic (2). All patients had equinus deformity with TTA more than 140 degrees (median 157.5, 141-177). There were varus deformity in 19 feet, limb length discrepancy in 6 legs, and genu procurvatum deformity in 2 legs. The duration of gradual correction was 53.6±13.5 days (33-73 days), and the external fixation time was 147.8±25.2 days (98-203 days). At last follow-up, TTA in all patients improved significantly (P < .001) to 113.5 degrees (111.8-116.0). All patients had plantigrade feet, except for 2 cases of residual mild equinovarus deformity, 2 cases of residual mild hindfoot varus deformity, 1 case of moderate hindfoot varus recurrence. The AOFAS scores significantly improved (P < .001) from 51.0 points (29.0-66.0) to 76.0 points (69.5-88.0). Eighteen patients were very satisfied, 6 patients were somewhat satisfied, and 2 patients were somewhat dissatisfied. Using minimally invasive U-osteotomy with Taylor Spatial Frame to gradually correct the adult severe rigid equinus deformity proved to be an effective and relatively safe method associated with high patient satisfaction rates. Level IV, case series.

Foot and/or ankle problems following limb alignment changes in uni-compartmental knee arthroplasty

Objective Foot and/or ankle (F/A) problems may be encountered in medial uni-compartmental knee (UKA) patients postoperatively due to the limb alignment changes and alterations in weight bearing of F/A. This study aimed to evaluate the risk factors and the incidence of foot and ankle (F/A) problems in (UKA) arthroplasty patients. Methods Patients who underwent UKA between 2016 and 2019 in our clinic were evaluated and the presence of F/A problems was recorded. Radiologic evaluations included hip knee ankle angle (HKA), medial proximal tibial angle, posterior tibial slope angle, talar tilt angle, talar inclination, talar dome to mechanical axis (TDMA), and talocrural angle (TCA) measured on preoperative and follow-up long-leg standing radiographs. The range of motion, Q angles, and muscle strengths were measured. Visual analog scale, physical performance limitations, and patient-reported activity limitations were evaluated for all patients. Patients with reported F/A problems were additionally evaluated with Foot Functional Index. Results Forty-four patients (38 female, 6 male; mean age 58.66 ± 8.6 years; mean BMI 31.30 ± 3.81, mean follow-up period 34.22 ± 18.95 months) were included in the study. There were 13 patients (29.5%) with reported F/A problems. Postoperative comparison of patients with and without F/A problems showed statistically significant differences in only WOMAC and SF12 physical health sub-scores ( p = 0.002, p = 0.003, respectively). There was no significant postoperative change in TDMA in patients with F/A problems ( p &gt; 0.05) in contrast to patients without F/A problems ( p = 0.006). There was no statistically significant difference in preoperative TCA measurements between groups ( p = 0.79). Comparison of knee and ankle radiologic measurements between groups demonstrated significant difference only in postoperative HKA measurements (−2.82 ± 2.53 vs. −0.80 ± 3.12, p = 0.033). Conclusion F/A problems adversely affecting the functional status were frequent in our cohort of UKA patients. Postoperative residual varus deformity may be a risk factor for this. Therefore, if slight varus alignment is aimed at UKA patients, preoperative F/A status should be evaluated.

Effect of a functional brace in combination with physical therapy for early correction of cubitus varus in young children

BackgroundThis study aimed to assess the clinical and radiologic outcomes of a functional brace in combination with physical therapy (FBPT) for early correction of cubitus varus in young children.MethodsEighteen consecutive patients with cubitus varus secondary to supracondylar fractures were enrolled between July 2017 and March 2019. We used the FBPT technique to correct varus and sagittal plane deformity for early cubitus varus in young children. The clinical evaluation included measurement of varus angulation, sagittal plane, and range of motion at three, six, and twelve months post-intervention. The clinical and radiographic results were assessed according to the Bellemore criteria.ResultsPre-treatment humerus-elbow-wrist (HEW) angle measured on the affected side (varus deformity) ranged between -38° and -12° (average, -23.2°) while the post-treatment HEW angle ranged between -10° and + 15° (average, 8.8°). Compared with the unaffected side, no statistically significant difference was found in the affected side post-intervention (P > 0.05). According to the Bellemore criteria, we got excellent results in fourteen patients (77.8%), good results in three patients (16.7%), and poor result in one patient (5.5%). All patients and their parents (except one patient with residual varus deformities) were satisfied with the functional and cosmetic outcomes.ConclusionsThe FBPT is effective for the treatment of cubitus varus in children, especially for young children within 6 months of the injury.

Guided Growth for Varus Deformity Following Early Tibial Osteotomy in Infantile Tibia Vara-A Multi-Center Study.

Despite early osteotomy, many patients with infantile tibia vara (ITV) have persistent or recurrent varus deformity and disordered growth at the medial proximal tibial physis. Our hypothesis was that lateral tibial tension band plating (LTTBP) could guide correction. A retrospective review at 6 centers of 15 patients (16 extremities) was performed of LTTBP for varus deformity following early osteotomy in ITV, diagnosed≤4years of age. Correction of deformity parameters on digital standing anteroposterior lower extremity radiographs determined outcome. Twenty-two LTTBP procedures were performed at mean age of 7.5 years, including 4 revisions for implant failure and 2 reimplantations for recurrence. Single event LLTBP, improved the medial proximal tibial angle with a mean change of 13.4 degrees (0.39 degrees/month). Eleven limbs had preoperative mechanical lateral distal femoral angle (mLDFA)>90 degrees. While n degree femoral procedures were performed, at study end, 11 femurs had mechanical lateral distal femoral angle≤90°. Pretreatment, 13 extremities had mechanical axis zone (MAZone) III varus (81%) and 3 had MAZone II varus (19%). LTTBP's were able to initially correct 13 limbs to MAZone I or valgus but 4 limbs rebounded to MAZone II varus after implant removal. Final limb alignment, after all surgeries and rebound, included 9 in MAZone I, 5 in MAZone II varus and 2 in MAZone III varus. Average follow-up was 3.0 years at mean 10.7 years of age. Fifteen procedures resulted in improvement in MAZone and 7 had no change. On average, those that improved were younger (7.3 vs. 8.0y), weighed less (45.5kg with body mass index 26.5kg/m 2 vs. 67.8kg and body mass index 35.7kg/m 2 ), had lower mechanical axis deviation (37.1mm vs. 43.9mm), lower medial physeal slope (61.7 vs. 68.7 degrees) and had a higher percentage of open triradiate phases (87 vs. 57%). LTTBP for residual varus, after initial osteotomy in ITV, resulted in 81% of limbs initially achieving MAZone I or valgus with implant failure revisions and femoral remodeling. Rebound after implant removal reduced the corrected rate to 56%. Ninety-four percent avoided osteotomy during the study period. IV.

Impact of post-operative hip-knee-ankle angle changes on functional outcome of total knee arthroplasty: a prospective longitudinal study

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Coronal malalignment as residual varus may have deleterious effects on functional outcomes of total knee arthroplasty. This study aimed at highlighting the impact of postoperative hip-knee-ankle (HKA) angle changes on the functional outcome of total knee arthroplasty.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;689 total knee arthroplasty (TKA) knees (from 386 patients) with varus postoperative HKA angle were included. HKA angle was measured on standing orthoscanograms. The knees were divided into 5 subgroups according to postoperative HKA angle as: neutral (0±3.0 degrees); mild (3.1-6.0 degrees); moderate (6.1-10.00 degrees); severe (10.1-5.0 degrees); very severe (&amp;gt;15.0 degrees). Functional outcome of TKA in these subgroups was observed by knee society score (KSS), knee society pain score (KSS-P), Oxford knee score (OKS), lower extremity functional scale (LEFS) at 6 months, 1 year, 2 years, 3 years. Statistical analysis was done by statistical package for social sciences (SPSS) version 16; Spearman’s correlation coefficient and Kruskall Wallis test was used to compare the functional outcome of TKA between COHORTs.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 69 knees were present in the mild varus cohort (mean: -1.92), 223 knees in the moderate varus COHORT (mean: -4.77), 260 knees in the moderate varus COHORT (mean: -7.86), 121 knees in the severe varus COHORT (mean: -11.60) and 16 knees in the very severe varus COHORT (mean: -16.54). Mild to moderate varus knees were maximum, but no significant difference in functional outcome between these COHORTs was found by correlation analysis and Kruskall Wallis test.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Changes in postoperative HKA angle (coronal alignment) has no significant impact on functional outcome of TKA.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;

Functional outcome of mild and moderate residual varus in posterior stabilized total knee arthroplasty in primary osteoarthritis knee: a prospective study

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Total knee arthroplasty (TKA) is one of the most commonly done orthopaedic surgical procedures for treating severe arthritis of the knee joint caused by osteoarthritis or inflammatory arthritis. The current clinical investigation, done at the Sanjay Gandhi Institute of Trauma and Orthopaedics in Bengaluru, provided the short-term functional result of mild and moderate residual varus in posterior stabilized TKA. The aim was to evaluate the efficacy of mild and moderate residual varus in total knee replacement for primary OA knee in terms of pain relief, range of motion and stability of the joint. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;30 total knee replacements were performed. All patients were examined pre- and post-operatively using the knee society clinical and functional score. The average pre-op KSS knee score was 38.7, with a functional score of 23.3. The most common reason for TKR was osteoarthritis. The follow-up time ranged from 6 to 12 months.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;By the knee society clinical, functional score method, 96.6% of our patients received an outstanding assessment after scoring 80 points or higher. The mean post-operative KSS knee score is 86.57, and the knee society functional score is 92. 92% of patients had little/no pain after surgery, and walking ability increased and was unlimited in 80% of patients.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;After a short term follow up of 1 year in a research population of 30 with pre-operative osteo arthritis of the knee, with post-operative mild to moderate varus alignment showed better clinical results. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Surgical planning of osteotomies around the knee differs between preoperative standing and supine radiographs in nearly half of cases

BackgroundTo evaluate the difference in surgical planning of osteotomies around the knee between preoperative standing and supine radiographs and to identify risk factors for discrepancies in surgical planning.MethodsThis study included 117 knees of 100 patients who underwent osteotomies around the knee for knee osteoarthritis with genu varum. Surgical planning was performed so that the target point of the postoperative weight-bearing line (WBL) ratio was 62.5% in preoperative standing and supine radiographs. If the opening gap would be > 13 mm in open-wedge high tibial osteotomy (OWHTO), closed-wedge HTO (CWHTO) was planned. If the postoperative mMPTA would be > 95° in isolated HTO, double-level osteotomy (DLO) was planned. In DLO, lateral closed-wedge distal femoral osteotomy was performed so that the postoperative mechanical lateral distal femoral angle (mLDFA) was 85°, and any residual varus deformity was corrected with HTO.ResultsSurgical planning differed between standing and supine radiographs in 43.6% of cases. In all knees for which surgical planning differed between standing and supine radiographs, a more invasive type of osteotomy was suggested by standing radiographs than by supine radiographs. The risk factors for discrepancies in surgical planning were a lower WBL ratio in standing radiographs and a lower joint line convergence angle in supine radiographs.ConclusionsSurgical planning of DLO, CWHTO and OWHTO, in standing radiographs differed from that in supine radiographs in nearly half of the cases. Surgical planning based on standing radiographs leads to more invasive surgical procedures compared to supine radiographs.

Functional outcomes of residual varus alignment versus mechanical alignment in total knee arthroplasty for varus osteoarthritis: A preferred reporting items for systematic reviews and meta-analyses-compliant meta-analysis.

One in five patients with mechanical alignment (MA) after total knee arthroplasty (TKA) was reportedly dissatisfied. As constitutional varus knees are common, restoring the patients' natural residual varus (RV) alignment is as an appealing alternative to neutral MA. This meta-analysis aimed to evaluate the effects of RV alignment on the functional outcomes compared with those of MA in TKA for the knees with varus osteoarthritis. The MEDLINE/PubMed, Cochrane Library, and EMBASE databases were comprehensively searched for papers comparing the effects of RV alignment and MA on the functional outcomes from the time of inception of the databases to July 2020. Studies comparing the functional outcomes in the knees subjected to TKA with RV alignment (case group) and MA (control group) were included. The Knee Society knee and functional scores (KSKS and KSFS, respectively), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Oxford knee score (OKS), and forgotten joint score (FJS) were compared. Seven studies were finally included; all studies showed a low risk of selection bias and provided detailed demographic data. The pooled mean difference in the KSKS (0.06, 95% confidence interval [CI]: -0.14 to 0.27; p = 0.55) and KSFS (0.08, 95% CI: -0.08 to 0.35; p = 0.56) between RV alignment and MA did not significantly differ. The pooled mean differences in the WOMAC (-0.25, 95% CI: -0.57 to 0.07; p = 0.12), OKS (0.06, 95% CI: -0.15 to 0.27; p = 0.56), and FJS (0.41, 95% CI: -0.18 to 1.00; p = 0.18) between the groups were not significant. The beneficial effects of RV alignment on the functional outcomes are limited compared to those of MA in TKA for varus osteoarthritis to date. Currently, TKA with neutral MA should be considered as the gold standard.

ANTEGRADE NAILING VERSUS LOCKING PLATE OF 2-AND 3-PART PROXIMAL HUMERUS FRACTURES.

To evaluate and compare the proportions of complications and radiographic findings of osteosynthesis of 2- and 3-part proximal humerus fractures with two methods of treatment: third-generation antegrade nailing and locking plate. 46 patients with a mean age of 58.9 ± 16.6 years between January 2020 and January 2021 were evaluated. In sixteen cases (34.8%), antegrade nailing was used, and in thirty cases (65, 2%), a locking proximal humerus plate. The method used included the rate of complications with a minimum follow-up of 6 months after surgery and radiographic evaluation. There was no difference between the groups regarding the proportion of complications (nail group 18.8%, plate group 13.3%; p = 0.681). The nail group had less residual varus loss (cervicodiaphyseal angle nail group with 132.1º ± 2.3º, plate group 123.8º ± 10.1º; p < 0.001). In the plate group, women had the lowest value (1.43 ± 0.22) of the deltoid tuberosity index (DTI) compared to men (1.58 ± 0.11) (p = 0.022). Osteosynthesis, with a locking plate and antegrade nailing, did not show differences in the proportion of complications. The nail group had less change in the postoperative cervicodiaphyseal angle, however, there were two serious complications with screw cut-out and varus deviation, requiring surgical reapproach. Level of Evidence II, Retrospective Observational Study.

Comparison of Outcomes After Total Knee Arthroplasty Involving Postoperative Neutral or Residual Mild Varus Alignment: A Systematic Review and Meta-analysis.

Comparing mainly clinical and functional outcomes as well as prosthesis survival with neutral and residual mild varus alignment, we searched PubMed, Embase, Cochrane Library and Web of Science databases from 1 January 1974 to 18 December 2020 to identify studies comparing clinical and functional outcomes as well as prosthesis survival in the presence of different alignments after total knee arthroplasty (TKA) for varus knees. The included studies were assessed by two researchers according to the Newcastle–Ottawa Scale (NOS). Postoperative neutral alignment (0° ± 3°) was compared to residual mild varus (3°–6°) and residual severe varus (>6°). Meta‐analysis was performed using Review Manager 5.3. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables. The fixed‐effect model and random‐effect model were used to meta‐analyze the data. Nine studies were included in the meta‐analysis with 1410 cases of postoperative neutral alignment, 564 of residual mild varus alignment and 175 of residual severe varus alignment following TKA, all of which were published after 2013. Three studies scored 7 points on the NOS, while the remaining studies scored 8 points, suggesting high quality. The pooled mean differences (MDs) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were 1.07 [95% confidence interval (CI) −1.06 to 3.20; P = 0.32; I 2 = 79%]. The meta‐analysis showed that neutral alignment and mild varus alignment were associated with similar the Oxford Knee Score (OKS), Knee Society Knee Score (KS‐KS), and Knee Society Function Score (KS‐FS), while neutral alignment was associated with lower Forgotten Joint Score (FJS) [mean difference −6.0, 95% confidence interval (CI) −9.37 to −2.64, P = 0.0005]. Neutral alignment was associated with higher KS‐KS than severe alignment (M 2.98, 95% CI 1.42 to 4.55, P = 0.0002; I 2 = 0%) as well as higher KS‐FS (M 8.20, 95% CI 4.58 to 11.82, P < 0.00001; I 2 = 0%). Neutral alignment was associated with similar rate of survival as mild varus alignment (95% CI 0.36 to 9.10; P = 0.48; I 2 = 65%) or severe varus alignment (95% CI 0.94 to 37.90; P = 0.06; I 2 = 61%). There was no statistical difference in others. Residual mild varus alignment after TKA may lead to similar or superior outcomes than neutral alignment in patients with preoperative varus knees, yet the available evidence appears to be insufficient to replace the current gold standard of neutral alignment. Severe varus alignment should be avoided.

Radiographic Analysis and Clinical Efficacy of Hindfoot Arthrodesis With Versus Without Cotton Osteotomy in Stage III Adult Acquired Flatfoot Deformity

Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis.

Fracture reduction has a dominant effect over cerclage wiring in increasing stiffness of intertrochanteric OTA/AO 31-A3.1 (reverse oblique) fractures managed with cephalomedullary osteosynthesis.

Objectives:To investigate the mechanical properties of cephalomedullary nailing of intertrochanteric OTA/AO 31-A3.1 (reverse oblique) fractures and to test the hypothesis that anatomical reduction and augmentation with cerclage wire produces a more stable construct.Methods:A standardized fracture model in composite saw bone was created to stimulate an intertrochaneric 31-A3.1 fracture, using a 3D printed cutting guide. Simulated osteosynthesis was performed with 12 femurs divided into anatomically reduced and varus malreduced groups. Each femur was tested with and without cerclage wire augmentation. All femurs were fixed with a 215 mm, 130 degree, 11.5 mm nail. An Instron 8874 biaxial materials testing machine was used to assess the axial stiffness. Cyclic loading consisted of 5000 cycles of sinusoidal combined axial-torsion loading at 3 Hz. Axial load was 100 N to 2000 N and torsion −4.5 Nm to +4.5 Nm. Stiffness was measured before and after cyclic loading.Results:Reduced constructs were stiffer than residual varus constructs. The mean overall fracture stiffness was 508.7 N/mm for reduced constructs and 379.2 N/mm for varus constructs. Removing the cables significantly decreased the fracture stiffness for both constructs (mean difference 60.0 N/mm, 95% CI 7.7–112.3, P = .032).Conclusions:Anatomical reduction has a dominant effect on facture stiffness. Anatomically reduced fractures are stiffer than varus malreduced fractures. A cerclage wire further improves construct stiffness if anatomical reduction is achieved. Cerclage wiring is less effective if anatomical reduction is not achieved.

Open reduction internal fixation versus minimally invasive percutaneous fixation for calcaneus fractures: Mid-term outcomes and social consequences.

Objectives This study aims to evaluate the mid-term clinical, functional, radiological, and socioeconomic outcomes of calcaneus fractures treated with open reduction-internal fixation (ORIF) versus minimally invasive percutaneous fixation (MIPF).Patients and methods A total of 48 patients (34 males, 14 females; mean age: 44.05 years; range, 19 to 64 years) who underwent either ORIF or MIPF for calcaneus fractures between January 2010 and January 2016 were retrospectively analyzed. The patients were divided into two groups as the ORIF group (n=36) and MIPF group (n=12). The American Orthopaedic Foot & Ankle Society (AOFAS) score, Maryland Foot Score (MFS), and the Short Form-36 (SF-36) scores were assessed for the clinical assessment. The mean duration of operation, mean length of hospitalization, pedobarographic gait analysis, the incidence of contralateral knee pain, increased shoe size, and change of profession due to significant heel pain were also evaluated. The Böhler’s angle, Gissane angle, and calcaneal varus were measured for radiological assessment.Results There was a significant difference in the mean operation time (p=0.001) and length of hospitalization (p=0.001) between the two groups. There was no significant difference between the pre- and postoperative third-year Böhler’s and Gissane angles (p=0.05, p=0.07, p=0.09, respectively). There were no significant differences between the postoperative first-, second-, and third-year AOFAS, MFS, and SF-36 scores (p=0.57, p=0.55 p=0.85, p=0.64, p=0.21, p=0.51, p=0.20, p=0.15, p=0.22, respectively). Thirteen patients in the ORIF group and five patients in the MIPF group changed their job due to significant heel pain. The increased shoe size was correlated with the residual calcaneal varus (p=0.001).Conclusion Both methods have pros and cons in the treatment of calcaneal fractures. Although MIPF is more advantageous in terms of operation duration and length of hospitalization, more favorable radiological results can be obtained with ORIF. Calcaneal varus should be corrected to prevent the increased shoe size and contralateral knee pain.

Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia.

PurposeThe aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus.MethodsThis was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery.ResultsA total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities.ConclusionSoft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery.Level of evidenceLevel IV, retrospective case series

Clinicoradiological Outcome of Concomitant Fractures of Proximal Femur and Femoral Shaft Treated With Second-Generation Cephalomedullary Nailing

BackgroundThe ideal modality of treatment of concomitant fractures of the hip (intertrochanteric/femoral neck) and the femoral shaft is still evolving. The aim of our retrospective study was to assess the clinicoradiological outcome of such fractures managed by closed second-generation cephalomedullary nailing.MethodologyThe study was conducted among skeletally mature patients presenting within one week of injury who underwent closed second-generation cephalomedullary nailing (proximal femoral nail). Those presenting beyond one week or those who had pathological fractures, incomplete follow-ups, or other modes of fixation were excluded. Functional results were evaluated according to Friedman and Wyman’s clinical assessment system. Time required for fracture healing and the presence of any complications were also noted.ResultsA total of 10 patients with the ipsilateral hip (five intertrochanteric and five femoral neck) and femoral shaft fractures were included in the study. Associated injuries found included fractures of the ipsilateral tibia/fibula at varying levels in three patients; hand and wrist injuries in two patients; and contralateral femoral shaft fracture, ipsilateral patella, bilateral crush injury of the foot, and head and chest injury with brachial plexus injury in one patient each. Four patients were diagnosed with intra-articular knee injuries (ligamentous and meniscal injuries) postoperatively. At the final follow-up, the functional outcome results were good in four, fair in one, and poor in five patients. All femoral neck fractures united at a mean of 15.2 weeks (range: 12.0-18.0 weeks) and intertrochanteric fractures at a mean of 14.0 weeks (range: 12.0-22.0 weeks). However, there was residual varus malunion in two intertrochanteric fractures. Eight femoral shaft fractures were infra-isthmic; of these, four resulted in nonunion (two of hypertrophic and two of atrophic type) and two were found to be in the delayed union, which eventually united by 24 weeks.ConclusionsSecond-generation cephalomedullary nail is an acceptable, cost-effective, and minimally invasive alternative for the management of concomitant ipsilateral fractures of the hip and supra-isthmic or isthmic femoral shaft fractures. For infra-isthmic fractures, retrograde femoral nail or distal femoral plate along with a separate implant for addressing the hip fracture (either cannulated cancellous screw or dynamic hip screw, preferably in a rendezvous/overlapping manner) are better options.

Comparative evaluation of pinning and cast fixation vs. external fixation after lateral closing-wedge osteotomy for cubitus varus in children.

Cubitus varus has been regarded as a poor functional and cosmetic consequence of supracondylar humerus fracture in children. The aim of this study was to assess the clinical and radiologic outcomes of cubitus varus treatments based on fixation methods: Kirschner (K)-wire and cast fixation or external fixation. Forty consecutive patients with cubitus varus secondary to supracondylar fractures were retrospectively enrolled between October 2015 and December 2018. Following lateral closing-wedge osteotomy, those undergoing K-wire and cast fixation were included in group A (n = 21) and those who were treated with external fixation comprised group B (n = 19). We measured the bony union, elbow joint range of motion, and carrying angle. The clinical and radiographic results were assessed according to the Bellemore criteria. No significant difference was found between the 2 groups in terms of age, gender, operation duration, union time, and postoperative elbow range of motion (P > .05). A significant difference was noted, however, in postoperative carrying angle and results according to Bellemore criteria in group B (P < .05). No nonunion, myositis ossificans, or neurovascular injury was found at follow-up in the 2 groups. In group A, revision surgery was needed for residual varus in 1 patient and lateral condylar prominence was found in 2 patients. In group B, a superficial pin-site infection occurred in 2 patients, who were treated successfully with oral antibiotics. Both K-wire and external fixation after lateral closing-wedge osteotomy are reliable and effective for the treatment of cubitus varus in children. Compared with the K-wire method, external fixation achieves better functional and cosmetic results with a shorter learning curve.

Fluoroscopic landmarks to recognize iatrogenic varus displacement (wedge effect) during cephalomedullary nailing of intertrochanteric fractures

Iatrogenic varus malreduction after intramedullary nailing of intertrochanteric fractures (wedge effect) may be more common than previously reported. The aim of study is to determine its incidence and to define easy fluoroscopic landmarks to recognize it intraoperatively. We included surgical procedures with residual varus malreduction and sufficient intraoperative fluoroscopy images to assess an intraoperative anatomical reduction at the beginning of the procedure. Two intraoperative fluoroscopic landmarks were defined to assess varus in the anteroposterior view: the position of the greater trochanter (GT) related to the femoral shaft (medialized GT sign), and the position (superior, centre or inferior) of the guide wire in both the neck and the head of the femur (cross wire sign). We describe our current method of treatment to avoid this complication. A total of 369 extracapsular hip fractures were treated using PFNA and Gamma 3 systems. We found 55 (14.9%) fractures with a varus malreduction. Six were underreduced and fixed in varus. Thirty-five (9.48%) were well reduced by closed reduction but suffered a iatrogenic varus displacement when introducing the nail. 31 were female; mean age was 86.6 (range 70-97). Mean postoperative head-shaft angle was 119,2° range (113°-123°). Mean TAD was 24,37 range (14-36 mm). Wedge effect (iatrogenic varus displacement of a well reduced intertrochanteric fracture when introducing the nail) could occur in at least 10% of intertrochanteric fractures. The medialized GT and the "crossing wire sign" seem to be good predictors of iatrogenic varus malalignement.

Medial abrasion syndrome: a neglected cause of persistent pain after knee arthroplasty

IntroductionPersistent post-operative pain (PPOP) has detracted from some otherwise successful knee arthroplasties. This study investigated medial abrasion syndrome (MAS) as a cause of PPOP after knee arthroplasty. The surgical techniques and outcomes of incorporating this concept into the management of both primary arthroplasty cases and patients suffering from unknown causes of PPOP after arthroplasties were presented.Materials and methodsIn a 1-year period, the author performed unicompartmental or total knee arthroplasty (the UKA or TKA group) that also eliminated medial abrasion phenomenon (MAP) on 196 knees of 150 patients at advanced stages of knee osteoarthritis (OA). During the same year, 16 knees of 16 patients with unknown causes of PPOP after knee arthroplasties were referred to the author for the arthroscopic medial release procedure (the AMR group) after being diagnosed as MAS. Subjective satisfaction, Knee Society Score (KSS), and Knee injury and Osteoarthritis Outcome Score (KOOS) evaluations were used for outcome study.ResultsAll 166 patients were followed for more than 3 years (mean 3.7 years, 3.1–4.2) for the outcome study. All knees receiving arthroplasty showed medial plicae with MAP at the time of surgery. Only 2 of them suffered from PPOP: one was a neglected tibial plateau fracture with residual varus deformity after UKA, and the other was a late infection after TKA and received revision. The satisfactory rate was 98.8% in the UKA group, 99.1% in the TKA group, and 100% in the AMR group. The Knee Society Scores and all subscales of KOOS were statistically improved in all groups.ConclusionsMAS is a cause of pain in patients who have received knee arthroplasties, and MAP should be eliminated to ensure a successful knee arthroplasty. PPOP after knee arthroplasty can be caused by MAS, which can be managed by AMR.