Severe Varus Research Articles

It Is Always the Same—A Complication Classification following Angular Stable Plating of Proximal Humeral Fractures

The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2-4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

Single-Stage Tibial Osteotomy for Correction of Genu Varum Deformity in Children

Conservative and operative treatments with gradual or acute correction of severe varus deformities of the leg have been described. We evaluated whether the corrective osteotomy used within the NGO Mercy Ships is an effective treatment for genu varum deformity of different etiologies in children and which patient specific factors have an influence on the radiographic outcome. In total, 208 tibial valgisation osteotomies were performed in 124 patients between 2013 and 2017. The patients' mean age at the time of surgery was 8.4 (2.9 to 16.9 (min/max)) years. Seven radiographically measured angles were used to assess the deformity. Clinical photographs taken pre- and postoperatively were assessed. The mean time between the surgery and the end of physiotherapeutic treatment was 13.5 (7.3 to 28) weeks. Complications were monitored and classified according to the modified Clavien-Dindo-classification system. The mean preoperative mechanical tibiofemoral angle was 42.1° varus (range: 85°-12° varus). The mean postoperative mechanical tibiofemoral angle was 4.3° varus (range: 30° varus-13° valgus). The factors predicting a residual varus deformity were higher age, greater preoperative varus deformity and the diagnosis of Blount disease. The tibiofemoral angle measured on routine clinical photographs correlated well with the radiographic measurements. The single-stage tibial osteotomy described is a simple, safe and cost-effective technique to correct three-dimensional deformities of the tibia. Our study shows very good mean postoperative results, but with a higher variability than in other studies published. Nevertheless, considering the severity of preoperative deformities and the limited opportunities for aftercare, this method is excellent for the correction of varus deformities.

Severe equinus cavo-varus correction through triplanar tarsectomy and posterior tibial tendon transfer based on 3D-printed biomodel

Surgery for severe equine cavo-varus is complex and must be individualized. The interindividual phenotypic variability demands a personalized planning of each foot to be operated. The study's primary goal was to evaluate the function and satisfaction of a series of patients with severe equinus cavo-varus deformity who underwent a triplanar tarsectomy and transposition of the posterior tibial tendon in a single stage surgery after a patient specific 3D biomodel planning. A series of 12 feet (5 patients bilaterally) operated with this technique was analyzed. The cohort comprised 2 females (28.5 %) and 5 males (71.4 %). The median follow-up time was 38.5 months (interquartile range: 24.75–48.75). The Foot and Ankle Disability Index pre (median 32.85; interquartile range: 20–46) and postsurgery (median 72; interquartile range: 56–75.5) were collected and statistically significant differences were observed (p < 0.002). Furthermore, the main variable evaluated was obtaining a plantigrade stable foot. This was clinically evaluated and was achieved in all patients except 1 patient who presented a residual equinus of 5º. This study shows that triplanar tarsectomy and posterior tibial tendon transfer in a single surgical procedure after patient-specific 3D biomodel planning allows for improved function in patients with severe equinus cavus varus foot deformity.

A Combination of Ilizarov Frame, Externalized Locking Plate and Tibia Bridging for an Adult with Large Tibial Defect and Severe Varus Deformity Due to Chronic Osteomyelitis in Childhood: A Case Report

Background: Various techniques have been reported to treat large, segmental tibial defects, such as autogenous bone graft, vascularized free fibula transfer and bone transport. We present a case of a 24-year-old male with a 17-year history of chronic osteomyelitis with obvious lower limb length discrepancy and severe varus deformity of the tibia secondary to osteomyelitis in childhood. Aim: The aim of this work is to provide an alternative choice for treating patients in developing countries with severe lower limb deformity caused by chronic osteomyelitis. Case Presentations: Without surgical intervention for a prolonged period of time, the patient was admitted in our institute for corrective surgery. Corrective surgery consisted of three stages: lengthening with Ilizarov frame, removal of Ilizarov frame and fixation with externalized locking plate, and removal of externalized locking plate. Tibia bridging was achieved at the distal and proximal junction. The range of motion (ROM) of the knee joint was nearly normal, but the stiffness of the ankle joint was noticeable. The remaining leg discrepancy of 0.1 cm required no application of a shoe lift. Moreover, the patient could engage in daily activities without noted limping. Conclusions: Distraction-compression osteogenesis using the Ilizarov apparatus is a powerful tool to lengthen the shortened long bone and adjust the deformity of the lower limbs. Externalized locking plates provide an alternative to the traditional bulky external fixator, as its low profile makes it more acceptable to patients without compromising axial and torsional stiffness. In all, a combination of Ilizarov frame, externalized locking plate and tibia bridging is an alternative for patients in similar conditions.

Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees.

Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield significantly tilted joint line obliquity (JLO). This study aimed to evaluate the effectiveness of DLO in achieving accurate correction without compromising JLO, using patient-specific cutting guides (PSCGs), in cases of bifocal valgus maligned knees. A single-centre, retrospective analysis of prospectively collected data for a total of 26 patients, who underwent DLO by PSCGs for valgus malaligned knees, between 2015 and 2020. Post-operative alignment was evaluated and the delta for different lower limb0.05, not statistically significant (ns)). All KOOS subs alignment parameters was calculated; the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), and lateral distal femoral angle (ΔLDFA). At the two-year follow-up, changes in the KOOS sub-scores, UCLA scores, lower limb discrepancy (LLD), and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. The Mann-Whitney U test with a 95% confidence interval (95% CI) was used to evaluate the differences between two variables; one-way ANOVA between more than two variables and the paired Student's t-test was used to estimate the evolution of functional outcomes. The postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p > 0.05, not statistically significant (ns)). All KOOS subscore's mean values were improved to an extent two-fold superior to the reported minimal clinically important difference (MCID) (all with p < 0.0001). There was a significant increase in the UCLA score at the final follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3 ± 2cm) to postoperative measures (LLD = 0.3 ± 0.4cm), ns. Complications were 2 femoral hinge fractures, 2 deep vein thromboses, 1 delayed tibial healing, and 1 hardware removal for hamstring irritation syndrome. DLO is effective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO. III.

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.

Primary constrained condylar knee arthroplasty in severe varus deformity: a prospective 5-year functional follow-up study in Iraqi patients.

The outcomes of the constrained condylar knee (CCK) implant used during primary total knee arthroplasty (TKA) in knees with severe varus in patients from low- and middle-income countries (LMICs) such as Iraq are not known. Hence, this study aimed to analyze and report the functional outcome of CCK TKA in patients with severe varus deformities at the end of 5 years in Iraqi patients. In this prospective study, pre- and post-operative (at the end of 5years) clinical outcome using Knee Society Score (KSS) and radiological deformity using hip-knee-ankle (HKA) angle was analyzed in 76 CCK TKAs (20 bilateral and 36 unilateral TKAs) performed in 56 patients with severe varus deformity (> 15°). At a mean follow-up of 60.3months (range 60-68months), the mean preoperative KSS knee score of 6.6 ± 4.5 improved significantly (p < 0.0001) to 87.2 ± 6.6 and the mean preoperative KSS function score of 7.1 ± 6.4 improved significantly (p < 0.0001) to 70.4 ± 7.8. The function score was good to excellent in 64.3% (36 patients), fair in 28.5% (16 patients), and poor in 7.1% (4 patients) at the end of 5years. The mean preoperative HKA angle significantly improved (p < 0.001) from 25.5° ± 6° varus (range 17°-37°) to 3° ± 2.5° varus (range 0°-7.5°) at final follow-up. The CCK implant significantly improved pain and function in patients with severe varus deformity at the end of 5years. The CCK implant is a good option during primary TKA in severe varus knees in patients from LMICs and can help achieve clinical outcomes similar to patients from high-income countries.

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

PurposeThe purpose of this study was to examine the relationship between preoperative Ahlbäck radiographic classification grade and the clinical outcomes of double level osteotomy (DLO) performed for osteoarthritic knees with severe varus deformity.MethodsThe study population comprised a consecutive series of 99 knees (68 patients) for which DLO was performed and follow-up results for a minimum of two years were available. The Ahlbäck radiographic classification system was used to determine the osteoarthritic grade. The following radiological parameters for alignment and bone geometry were measured: mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint-line convergence angle (JLCA), and mechanical tibiofemoral angle (mTFA). Clinical results were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) subjective score preoperatively and at 2 years after surgery. Difference between preoperative and postoperative measurements as well as relationship between Ahlbäck grade and radiological/clinical results were statistically assessed.ResultsThe average age of the study participants was 60.9 ± 6.2 years and the mean follow-up period was 45.4 ± 15.2 months. Each of the radiological parameters exhibited preoperative abnormal values. Knees with Ahlbäck grade 3 and 4 osteoarthritis exhibited significantly greater JLCA and mTFA than grade 1 knees. Two years post-surgery, all radiological parameter values measured within a normal range. Clinical evaluation showed significant improvement in KOOS after surgery. Analysis of the relationship between Ahlbäck grade and clinical score showed that the 2-year postoperative KOOS scores in grade 3 and 4 osteoarthritic knees were significantly lower than grade 1 knees (with the mean 2-year KOOS scores of 350.0 ± 79.9, 317.9 ± 78.3, and 420.2 ± 42.9, respectively).ConclusionsWhile DLO may produce significant radiological and clinical improvement in knees with joint space obliteration, Ahlbäck grade 3 and 4 osteoarthritic knees associated with larger JLCA and mTFA showed less satisfactory clinical results compared to grade 1 knees. Level of Evidence: IV case series.

Clinical and Radiological Comparison of Single and Double Intra-articular Injection of Adipose-Derived Stromal Vascular Fraction for Knee Osteoarthritis

The aim of the article is to compare the clinical and radiological outcomes between single and double stromal vascular fraction (SVF) cell injections in patients with knee osteoarthritis (OA). We included 54 patients treated for varus knee OA with intra-articular SVF cell injection. They were divided into two groups: those who received one injection and those who received two. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, knee range of motion, and knee muscle force were assessed at baseline and 3, 6, 12, and 24 months after the first injection. The preoperative hip-knee-ankle (HKA) angle was evaluated using plain radiographs, and T2 mapping values were assessed. The total WOMAC score improved significantly in the single injection group from 3 to 24 months, but the total WOMAC score in the double injection group improved significantly at 24 months. The T2 mapping values in both the groups improved, with a significant difference at 12 months. The preoperative mean HKA angle and the correlation coefficients between the HKA angle and the total WOMAC score and between the HKA angle and the T2 mapping value of the medial femur were significant. In conclusion, double injections may provide more satisfactory treatment outcomes in patients with severe varus knee alignment. This clinical trial is registered in the Japanese Ministry of Health, Labour and Welfare (URL: https://saiseiiryo.mhlw.go.jp/published_plan/index/2) with the registration name “Cell transplantation therapy for osteoarthritis using autologous subcutaneous adipose tissue-derived regenerative (stem) cells (ADRCs),” and the registration number was “PB5160012.”

Distal Femoral Valgus Resection Angle in Conventional Total Knee Arthroplasty - a CT Scanogram Study.

In conventional total knee arthroplasty (TKA), the distal femur valgus resection angle (DFVA) is decided either by measuring the specific resection angle for each patient on preoperative anteroposterior hip-knee-ankle (HKA) weight-bearing radiograph or using a fixed resection angle of five to seven degrees, when such facilities are not available. This study aims to measure the DVFA in TKA patients using preoperative HKA non-weight-bearing computerized tomography (CT) scanogram scout films and determine its relation with preoperative coronal plane lower-limb deformities. In this retrospective radiological study, various measurements were performed on bilateral, preoperative hip-knee-ankle CT scanograms of 73 knee osteoarthritis patients who had presented for total knee replacement surgery using a standard protocol. The angle between the femoral anatomical axis and femoral mechanical axis was measured as the femoral mechanical anatomical angle (FMAA), which corresponds to the surgical DFVA. The angle between the femoral and tibial mechanical axes was measured as mechanical femorotibial angle (MFTA). The correlation between FMAA and MFTA was studied. The mean FMAA for the study group was 6.45° (range 3° to 11°, SD 1.17°). The MFTA for the study group ranged from 24° varus to 14° valgus. The alignment was valgus in 14.4% (n=21), varus in 84.2% (n=123), and "0 degrees" in 1.3% (n=2). With valgus coronal alignment taken as positive and varus as negative, the Pearson's correlation coefficient for MFTA with FMAA was r = -0.5183 (p<0.001), indicating that valgus knees tended to have a smaller FMA angle and varus knees tended to have a larger FMA angle. In the non-availability of individualized measurements, in primary TKA, we recommend setting DFVA as five degrees for valgus deformities, six degrees for mild/moderate varus deformities (MFTA <15°) and seven degrees for severe varus deformities (MFTA > 15°).

Effects of Severe Varus Deformity on Soft Tissue Balancing in Total Knee Arthroplasty.

This study aimed to establish the effect of severe varus deformity on soft tissue balance in total knee arthroplasty (TKA), which is not yet well established. We retrospectively enrolled 205 patients (270 knees) who underwent primary TKA using the measured resection technique. Four intraoperatively measured TKA gaps and gap differences were compared between the severe varus deformity group (Hip-knee-ankle [HKA] varus angle ≥ 10°) and the mild varus deformity group (HKA varus angle < 10°). Pearson’s correlation analysis and multiple linear regression analysis were used to investigate the factors affecting flexion and extension gap differences (FGD and EGD). A receiver operating characteristic curve was applied to assess the cut-off value of the HKA varus angle to discriminate the rectangular gap. The FGD (1.42 ± 1.35 mm vs. 1.05 ± 1.16 mm, p = 0.019) and the EGD (1.45 ± 1.32 mm vs. 0.97 ± 1.53 mm, p = 0.006) were significantly larger in severe varus deformity group than in mild varus deformity group. The HKA varus angle was positively correlated with both FGD (r = 0.264, p < 0.001) and EGD (r = 0.319, p < 0.001) and was an influencing factor for FGD (β = 0.232, p = 0.040) and EGD (β = 0.229, p = 0.037). A preoperative HKA angle of 12.4° was selected as the cutoff value to discriminate between rectangular and trapezoidal gaps. Thus, the severity of varus deformity (HKA varus angle) was found to be a significant factor affecting the mediolateral gap difference in TKA. When performing TKA in a knee with an HKA varus angle ≥ 12.4°, a trapezoidal gap is more likely to be expected. Level of evidence III, case−control study.

Outcomes of cruciate-retaining total knee arthroplasty for osteoarthritis with severe varus deformity.

Varus deformity is common in osteoarthritic knee. The purpose of this study was to investigate the clinical and radiographic outcomes after cruciate-retaining (CR) total knee arthroplasty (TKA) for severely varus osteoarthritic knees and compare them to those of mildly to moderately deformed osteoarthritic knees. Eight hundred ninety-four subjects were undergone CR TKA, 137 had severe varus deformity (group 1), and 757 had mild-to-moderate deformity (group 2) of the lower limb preoperatively. Pre- and postoperative outcomes were compared between two groups clinically and radiographically. Mean follow-up period was 54.7 ± 28.9months. Mean age was 77.8 ± 6.7years in group 1 and 74.5 ± 7.4years in group 2 (p < 0.001). Preoperative hip-knee-ankle angle (HKAA) was - 17.7°±2.9° in group 1 and - 6.3° ± 5.1° in group 2 (p < 0.001). Preoperative range of motion (ROM) was 127.7° ± 15.2° in group 1 and 130.8 °± 9.6° in group 2 (p = 0.019). Preoperative Knee Society scores and WOMAC score were not significantly different between two groups. Postoperative HKAA was - 0.4° ± 2.3° in group 1 and 0.6 ° ± 2.0° in group 2 (p < 0.001). Postoperative ROM, Knee Society scores, and WOMAC score were not significantly different between two groups. CR TKA showed results in subjects with severe varus deformities comparable to those without severe varus deformities. Whether the degree of preoperative varus deformity of the lower limb should be considered when deciding to perform CR-type or PS-type TKA requires further discussion. Retrospective comparative study, Level III.

Does ankle arthrodesis induce satisfactory changes in the medial longitudinal arch height of the foot for severe varus ankle arthritis?

We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA). We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2mm or < 2mm). A post-operative MCH decrease of ≥ 2mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2mm than in those with < 2mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172). Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.

A novel method of lateral closing wedge osteotomy for cubitus varus deformity in children

BackgroundHumeral osteotomy is the best method for treatment of severe cubitus varus in children. Many osteotomy methods have been developed in the past. In this study, we describe a novel corrective technique by applying the principles described by Paley involving lateral osteotomy using Kirschner wires (K-wires). Vertices of the osteotomy should be located at the center of rotation of angulation. The anatomical and mechanical axes can be corrected with precision.Patients and methodsIn this retrospective study, 21 patients (17 male, 4 female) who fulfilled the study criteria and underwent lateral closing osteotomy for cubitus varus deformity from July 2015 to October 2017 were included into the study. The osteotomy line of all patients was designed according to Paley’s principles. An isosceles triangle template was made according to the design preoperatively. The lateral osteotomy was made with the assistance of C-arm radiographs. The osteotomy was fixed by K-wires laterally. Patients were followed up, and elbows were evaluated by radiography and using the Mayo Elbow Performance Index (MEPI) score.ResultsThe mean correction angle obtained was 32.33°±2.83°. According to the MEPI score assessment, 19 of the 21 patients had an excellent outcome and two had a good outcome. Two patients complained of conspicuous scars; however, no further cosmetic surgery was performed. The range of motion was 135.0° preoperatively and 133.7° postoperatively, showing no significant difference (p = 0.326). None showed evidence of neurovascular injury or complained of prominence of the lateral humerus.ConclusionPaley’s principles for correcting cubitus varus deformity in children are effective and reliable for treating such a condition.Level of evidenceTherapeutic IV.

Enhanced Mid-Resection Workflow Technique for Severe Varus Deformity Correction Using Robotic-Arm Assisted Total Knee Arthroplasty.

Robotic technology in total knee arthroplasty has been proven to improve accuracy of component positioning, achieve alignment targets, and balance the knee objectively. However, the utility of robotics in correction of severe varus deformities of the knee has not been investigated in detail. The aim of this paper was to establish the utility and describe the technique of robotic-arm assisted total knee arthroplasty (RA-TKA) in achieving pre-balance in severe varus deformities of the knee. Among the existing Mako (Stryker, Kalamazoo, Michigan) RA-TKA workflows, pre-resection workflow is limited to knees which can be pre-balanced by component positioning according to functional alignment. Mid-resection workflow (distal femur/tibia first) is reserved for complex cases, whereby the extension gap is balanced first. In our experience, both workflows could not achieve pre-balance in severe varus deformities, necessitating the need to develop a novel technique. The ability of the robot to execute precise bone cuts allows for a provisional postero-medial femoral bone cut in flexion, giving access to remove large inaccessible posterior osteophytes and the tight posterior capsule, thus balancing the knee in extension. The flexion gap is subsequently matched to the extension gap by alterations in axial component positioning. This novel "enhanced mid-resection workflow" technique establishes the utility of the RA-TKA in balancing severe varus deformities of the knee. We also propose an algorithm which simplifies and helps surgeons choose between the three workflows to pre-balance knees irrespective of the severity of the varus deformity.

The severity of preoperative varus deformity affects the feasibility of correcting lower limb alignment with medial unicompartmental knee arthroplasty

BackgroundThe relationship between the severity of preoperative varus deformity and the amount of its correction in unicompartmental knee arthroplasty (UKA) as well as the thickness of the insert has not been well known. MethodsOne hundred and three patients who underwent medial fixed-bearing UKA with the use of the spacer block method were assessed. After the component gap in extension was measured using a UKA tensor, the pre-osteotomy gap was calculated from the thickness of the bone cuts. The relationship between the preoperative hip–knee–ankle (HKA) angle as well as the pre-osteotomy gap and the amount of change in HKA angle were analysed. Also, preoperative HKA angle and the thickness of the bone cuts were compared among groups by the insert thickness. ResultsThe mean preoperative HKA angle was 7.7 ± 3.1° varus. Patients with more varus deformity and those with a wider pre-osteotomy gap showed a more valgus change in HKA angle. As for the thickness of the insert, the preoperative HKA angle of the patients with the thinnest insert was significantly smaller (less varus) than that of those with the thicker insert while no statistically significant difference was found among the insert groups regarding the amount of the bone cuts. ConclusionsThe severity of the preoperative varus deformity as well as the intraoperative pre-osteotomy gap related to the amount of change in HKA angle. As thick inserts tended to be used in severe varus knees, the tibial bone cut can be reduced in such cases.

Short-Term Clinical Outcomes Following Total Ankle Arthroplasty Without Concomitant Osteotomy in Ankles with Severe Preoperative Varus Deformity: Comparison to Ankles with Preoperative Neutral Alignment.

It remains controversial whether satisfactory outcomes can be obtained following total ankle arthroplasty (TAA) without osteotomy in patients with severe varus ankle deformities. This study aimed to examine outcomes following TAA without concomitant osteotomies in patients with severe varus ankle alignment by comparing them with those in patients with neutral alignment. Fifty-one patients (53 ankles; mean age, 71.4 ± 5.6 years) who underwent TAA using the TNK ankle prosthesis were examined (mean follow-up, 36.8 ± 17.8 months). Patients were allocated into groups according to the preoperative talar tilt (TT) angle: the neutral group (preoperative TT angle <10°; n = 37) and the varus group (preoperative TT angle ≥10°; n = 16). Outcome measures, including the Japanese Society for Surgery of the Foot scale, Self-Administered Foot Evaluation Questionnaire, ankle range of motion, and radiographic parameters, were assessed before surgery and at the final follow-up. Significant improvements were observed in clinical and radiographic outcomes in both groups after surgery. Postoperative Japanese Society for Surgery of the Foot scale and subscale scores of pain and shoes in the Self-Administered Foot Evaluation Questionnaire were not significantly different between the groups, whereas subscale scores of function, social, and health were greater in the varus group than in the neutral group at the final follow-up. Radiographic parameters, including TT angle and tibial axis-medial malleolus (TMM) angle, improved postoperatively and were not significantly different between the neutral (mean TT angle, 0.5 ± 0.7°; mean TMM angle, 16.0 ± 4.6°) and varus (meanTT angle, 0.4 ± 0.7°; meanTMM angle, 17.0 ± 5.3°) groups at the final follow-up. To achieve neutral alignment, adjunctive procedures were required more often in the varus group. Outcomes of TAA using the TNK ankle prosthesis were favorable in patients with severe varus ankle and in those with neutral ankle without concomitant osteotomy. Satisfactory outcomes could be achieved in patients with severe varus ankle alignment after TAA without concomitant osteotomy.

Factors Associated With Unfavorable Radiological Outcomes After Opening-Wedge High Tibial Osteotomy for Varus Knees.

Corrective osteotomy around the knee is based on deformity profiles of the femoral and tibial sides. Opening-wedge high tibial osteotomy (OWHTO) can be favored if the outcomes are not different, even if there is a certain degree of abnormal parameters after correction. The purpose of this study was to identify the factors associated with unfavorable radiological outcomes after OWHTO for varus knees. Our hypothesis was that there would be an optimal situation in which double-level osteotomy (DLO) has advantages over isolated OWHTO and an optimal cutoff value of structural parameters for which DLO should be considered in patients with severe varus knees. Case-control study; Level of evidence, 3. The radiological and clinical outcomes of 337 patients who underwent OWHTO were retrospectively evaluated. A subgroup analysis was performed according to the weightbearing line ratio (WBLR) (group 1: <25th percentile; group 2: 25th-75th percentile; and group 3: >75th percentile) and factors associated with unfavorable radiological outcomes. For the assessment of cutoff values of the parameters favoring DLO, unfavorable radiological outcomes were categorized as follows: (1) medial proximal tibial angle (MPTA) >95°, (2) joint-line convergence angle (JLCA) >4° (insufficient medial release), (3) JLCA <0° (medial instability), (4) recurrence of a varus deformity, and (5) lateral hinge fracture. The mean follow-up period was 66.2 ± 19.1 months. A low preoperative WBLR was related to a larger preoperative to postoperative change (Δ) in the WBLR, a larger reduction in coronal translation, a larger ΔMPTA, a wide preoperative lateral joint space, and a narrow preoperative medial joint space (P < .001, P < .001, P < .001, P = .016, and P = .003, respectively). However, only an MPTA >95° was significantly related to a low WBLR in the subgroup analysis according to unfavorable radiological outcomes (P = .038). The cutoff value of ΔWBLR causing an MPTA >95° was 46.5%, which showed a good area under the curve of 0.800, with a sensitivity of 74.4% and a specificity of 82.7%. The clinical outcomes significantly improved at the final follow-up compared with those preoperatively, with no significant differences between the WBLR groups. A ΔWBLR ≥46.5% led to an MPTA >95°. However, clinical outcomes were not affected. DLO should be considered if the surgeon desires a postoperative MPTA ≤95°.

Visual Inspection for Lower Limb Malalignment Diagnosis Is Unreliable.

Visual inspection of the lower limb is often part of standard clinical practice during a physical examination at the outpatient clinic. This study aims to investigate how reliable visual inspections are in terms of detecting lower limb malalignments without additional tools and physical examinations. This study enrolled 50 patients. Each patient underwent a whole leg radiograph (WLR); in addition, a standardized digital photograph was taken of the lower limbs. Four persons (different experience levels) visually rated the digital photograph twice (unaware of the hip knee angle [HKA] on the WLR) and placed them in the category: severe valgus (>5°); moderate valgus (2°-5°); neutral, moderate varus (2°-5°); and severe varus (>5°). Visual ratings were compared with the measured HKA on WLRs for correlation using Spearman's rho. Linear ordinal regression models with significance when P < 0.05 were used to test whether body mass index (BMI), age, gender, and HKA were possible risk factors for incorrect visual HKA assessment. Spearman's rho between the visual assessment and measured HKA on the WLR was moderate with 0.478 (P < 0.01). Women had an increased odds ratio of 3.7 (P = 0.001) for incorrect visual assessment. Higher HKA also increased the odds ratio for erroneous visual assessment with 1.4 (P = 0.003). BMI and age did not significantly increase the odds of erroneous visual leg axis assessments in this study. Visual assessment of the lower limb alignment does not provide clinically relevant information. Lower limb malalignment diagnoses cannot be performed using only a visual inspection. Physical examination tests and radiographical assessments are advised. Diagnostic level II.