Soft Tissue Balancing Research Articles

Sensor guided unicompartmental to total knee arthroplasty revision: Surgical technique.

Unicompartmental Knee Arthroplasty (UKA) is an effective surgical option for managing unicompartmental knee osteoarthritis; it represents 10% of all knee arthroplasties worldwide, increasing 32.5% annually in the United States alone. Despite evolution in surgical technique and implant design, success rate and long-term survivorship of UKA have been historically lower than Total Knee Arthroplasty (TKA). The most common causes of UKA failure leading to revision are polyethylene wear, progression of arthritis, aseptic loosening and patella-femoral symptoms due to poor patient selection in many cases. Historically, UKA revisions have presented technical challenges mainly related to managing residual bone defects and ligament insufficiency ultimately leading to knee instability: the fear of instability has often pushed surgeons to lower the threshold for an increase of the intra-articular level of constraint. Unfortunately, the use of more constrained implants requires sacrificing bone stock and has been related to higher rates of re-revision secondary to recurrence of aseptic loosening. Because of these challenges, the authors developed a surgical technique that could combine balancing the knee during revision surgery with the use of the less constrained polyethylene option. To achieve this, we started evaluating a novel device (VERASENSE, Orthosensor, FL) designed to support soft tissue balancing during primary TKA. This intraoperative sensing technology dynamically quantifies intra-articular loads during TKA trial with the goal of correcting any residual imbalance in real time. Herein we propose a novel surgical technique, which might allow use of a primary TKA design characterized by a lower level of constraint, instead of a constrained or hinged revision knee system, during UKA revision. A key aspect of this technique is the use of sensing technology during intraoperative stability testing.

Difference in the early postoperative change of the joint line convergence angle between opening wedge and closed wedge high tibial osteotomies

BackgroundThe purpose of this study was to investigate the correction error associated with soft tissue balance in high tibial osteotomy (HTO) and the difference between opening wedge HTO (OWHTO) and closed wedge HTO (CWHTO).MethodsA total of 170 knees of 130 patients (85 knees of 68 patients in OWHTO and 85 knees of 62 patients in CWHTO) were evaluated. Anteroposterior radiographs of the knee and full-length leg were taken preoperatively, immediately under general anesthesia postoperatively, 2 days, and 1 and 12 months postoperatively. The femorotibial angle (FTA), joint line convergence angle (JLCA), and medial proximal tibial angle (MPTA) were measured.ResultsThe postoperative FTA was decreased from 170.5 ± 2.1° at 0 day to 168.6 ± 2.2° at 2 days in OWHTO (P < 0.05), whereas it was not changed from 168.7 ± 2.4° at 0 day to 168.1 ± 2.8° at 2 days in CWHTO. The JLCA was 4.8 ± 1.8° preoperatively, 4.2 ± 1.9° at 0 day, 2.2 ± 1.8° at 2 days (P < 0.05 vs 0 day), 2.6 ± 1.7° at 1 month, and 2.7 ± 1.6° at 12 months in OWHTO, and 7.1 ± 3.2° preoperatively, 4.1 ± 2.4° at 0 day (P < 0.05 vs preoperative), 3.4 ± 2.5° at 2 days, 3.9 ± 2.3° at 1 month, and 4.2 ± 2.6° at 12 months in CWHTO. Multiple regression analysis showed that preoperative factors affecting change of the JLCA from preoperative to postoperative 1 month were the correction angle in OWHTO (P = 0.001) and the preoperative standing JLCA in OWHTO (P < 0.001) and CWHTO (P < 0.001).ConclusionsA significant decrease of the JLCA occurred immediately after osteotomy under anesthesia in CWHTO, whereas in OWHTO there was no decrease under anesthesia, but it decreased several days postoperatively.

Total knee arthroplasty and extra-articular deformity: Deformity correction with intra-articular bone resections. 10 years follow up

BackgroundThis study aimed to evaluate the feasibility and clinical results of one stage total knee arthroplasty for patients with knee osteoarthritis with extra-articular femoral or tibial deformity, treated with intra-articular bone resections and soft tissue balance for deformity correction. Methods28 patients (29 knees) with osteoarthritis of the knee associated with extra-articular deformity >10° underwent one-stage total knee arthroplasty from 1997 to 2017. The deformity was corrected in all the patients by mean off the intra-articular bone resections and soft tissue release during the knee arthroplasty. 14 of them had tibial deformities, 15 had femoral deformities, and the etiology was post traumatic in 14 cases and post osteotomy in 15. The Knee Society Score was used to evaluate the patient outcome. ResultsOne-stage total knee arthroplasty with intra-articular correction of the limbs extra-articular deformity and soft tissue releases to balance the knee in flexion and extension was performed in all the patients.The average follow up was of 10.3 years. The average Knee Society Score was of 24.3 points preoperatively and 86 points at one year after surgery. The range of motion improved from 83.7° preoperatively to 107.1° (86°–125°) postoperatively. The average mechanical axis deviation was restored from 11.8° preoperatively to 0.9° postoperatively, and the postoperative average anatomical axis was 6.3°. Two prosthesis were revised, one due to deep infection and one because knee instability. ConclusionThe correction of the extra-articular deformity by intra-articular bone resections performed at the time of a total knee arthroplasty is indicated if the resections do not affect the femoral or tibial insertions of the collateral ligaments of the knee, and is the treatment option to avoid performing an osteotomy to correct de limb axis. This method can be applied to angular deformities up to 20° in the femur and up to 30° in the tibia. Through this technique we have achieved good results, after more than 10 years of follow up, in 27 of the 29 patients treated.This is a retrospective level 2 study.

Radiological and Functional Outcome of Medial Tibial Reduction Osteotomy for Severe Varus Deformity in patients undergoing Total Knee Arthroplasty- A Prospective Cohort Study

Introduction: The deformity and imbalance in an osteoarthritic knee undergoing Total Knee Arthroplasty (TKA) are the result of a combination of bony and soft tissue changes locally. Proper and ideal balancing of ligaments is considered essential to the success of a TKA. There are numerous techniques to achieve soft tissue balance in varus knee. More recently, Medial Tibial Reduction Osteotomy (MTRO) has been described as an adjuvant to soft tissue release. Limited data exists on the outcomes of patients requiring a MTRO. There are not many Indian studies available regarding the radiographic and clinical outcomes of medial reduction osteotomy in severe varus deformity in TKA. Aim: To find out the radiological and functional outcome of MTRO for severe varus deformity in patients undergoing TKA. Materials and Methods: This study was Prospective Cohort study conducted at the Department of Orthopaedics, Rajagiri Hospital, Chunangamveli, Aluva, Kerala from December 2018 to November 2019. Twenty patients 15 females and 5 males (30 knees), in the age group 55-80 years with osteoarthritis of knee with severe varus deformity, were enrolled in the study. Preoperative and postoperative standing leg Antero-posterior radiographs were taken for all patients and hip- knee- ankle angle was measured and amount of deformity correction was calculated. Postoperatively, radiographs were taken on the 5th day and 3rd month. Knee society scores were also recorded preoperatively and on the 5th postoperative day, postoperative visits on 6 weeks, 3 months and clinical outcome was assessed. The statistical analysis was performed by SPSS version 25 using Analysis of Variance(ANOVA) and Wilcoxon Signed Rank test. Results: The median knee score improved from 47±9 to 93±3 postoperatively. Similarly, median function score improved from 50±5 to 80±0. The improvement in function score and knee score were statistically significant (p-value 0.001). The correction of varus between preoperative, postoperative (p-value 0.001) day 5 &amp; 3 months postoperatively was statistically significant. No patient required a release of the superficial Medial Collateral Ligament (MCL). The MTRO was associated with statistically significantly improved Knee Society scores and varus deformity correction. Conclusion: In patients with fixed varus deformity of the knee, the MTRO is found to be safe and adequate to achieve coronal alignment.

Sensor-Assisted Total Knee Arthroplasty: A Narrative Review.

Wireless intraoperative load sensors have been used to improve the quality of soft-tissue balancing during total knee arthroplasty(TKA). Recent studies using the sensors have demonstrated reductions in gap imbalance, as well as early improvement of patient-reported clinical outcomes and low rates of arthrofibrosis. However, well-designed prospective studies are needed to determine whether the application of the sensor technology for TKA will have clinical benefits and improve the survival of prosthesis. Knowledge of the load-sensing technology (advantages and disadvantages, potential pitfalls, and future prediction) is crucial to apply this new TKA technique successfully. Herein, we conduct a narrative review of previous studies on this technique.

Arthroscopic Reduction of a Chronic Locked Posterior Shoulder Dislocation

Posterior shoulder dislocation is a rare condition. It is easily overlooked and often appears in a chronic locked status, which makes the reduction difficult, even through open procedures. Few reports in the literature have described an isolated arthroscopic reduction because it is difficult to elevate the humeral head to the level of the glenoid surface and obtain anterior-posterior soft-tissue balance. On the basis of an analysis of the mechanisms of the locking of the humeral head and the soft-tissue imbalance, we describe a set of arthroscopic shoulder release and reduction techniques, which include mainly the removal of rotator interval tissue; a thorough subscapularis release from the coracoid, the conjoined tendon, and the glenoid; and a 360° capsule-muscle release from the glenoid and the scapula. The described technique is an effective method to obtain a medial-to-lateral humeral head reduction and anterior-to-posterior soft-tissue balance. The introduction of this technique will provide a practical tool for surgeons to realize an arthroscopic shoulder reduction in the case of a chronic locked posterior shoulder dislocation.

Not All Robotic-assisted Total Knee Arthroplasty Are the Same.

Because value in healthcare has shifted to a measurement of quality relative to the cost, a greater emphasis exists on improving clinical and functional outcomes and patient satisfaction. Despite advances in implant design, surgical technique, and postoperative rehabilitation, multiple studies demonstrate that nearly 20% of patients remain dissatisfied with their overall outcomes after primary total knee arthroplasty (TKA). Because implant positioning, alignment, and equal soft-tissue balance are critical for a successful TKA, malalignment in the coronal, sagittal, and rotational planes continue to increase failure rates and cause poor clinical outcomes. Robotic-assisted TKA has gained momentum within the past 10 years to better control surgical variables by mitigating technical errors caused by insecure cutting guides and imprecise bone cuts. Contemporary robotic platforms have evolved along with our ability to collect high-quality patient-reported outcome measures data, and this combination is proving the clinical effectiveness. This comprehensive review investigates the advent of robotic-assisted TKA including advantages, disadvantages, historical, and commercially available newer generation systems, clinical outcomes, and cost analysis to better understand the potential added value of this technology.

Surgical Outcomes and Predictive Factors of Medial Toe Excision for Polysyndactyly of the Fifth Toe.

We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. Level IV, retrospective case series.

P.530 Intestinal permeability and low-grade chronic inflammation in schizophrenia: do they influence cognition and cognitive reserve?

Although knee stability is well known as an important element for the success of total knee arthroplasty (TKA), the direct relationship between clinical outcomes and knee stability is still unknown. The purpose of this study was to determine if postoperative knee stability and soft-tissue balance affect the functional outcomes and patient satisfaction after cruciate-retaining (CR) TKA.Fifty-five patients with varus osteoarthritis of the knee who underwent CR TKA were included in this study, and their postoperative knee stability was assessed by stress radiography at extension and flexion 1 month postoperatively. Timed Up and Go test, patient-derived clinical scores using the 2011 Knee Society Score, and Forgotten Joint Score-12 were also assessed at 1 year postoperatively. The effects of stability parameters on clinical outcomes were analyzed using Spearman's rank correlation.Medial stability at both knee extension and flexion had significant correlations with the shorter Timed Up and Go test and the higher patient satisfaction. Moreover, lateral laxity at extension was significantly correlated with the better patient satisfaction and Forgotten Joint Score-12. However, these correlation coefficients in this study were low in the range of 0.32-0.51.Medial stability and lateral laxity play an important role in influencing 1-year postoperative clinical outcomes after CR TKA. However, we should keep in mind that these correlations are weak with coefficients at 0.50 or less and the clinical results are also affected by various other factors.

Correlation between femorotibial pressure and joint gap in osteoarthritis patients with varus deformity: an intraoperative measurement using sensor device in primary posterior-stabilized total knee arthroplasty.

BackgroundThe normal femorotibial pressure and its variation under different gap values remain unknown. Thus, for the purpose of improving soft-tissue balancing in total knee arthroplasty (TKA), a load-sensor device was used to measure femorotibial pressures. More specifically, the aim of this study was to analyze the trend in pressure changes.MethodsTwenty TKAs were first balanced by conventional techniques, and then femorotibial pressure was measured using the sensor. After this, the difference in pressure among different joint gaps was calculated to analyze the trend. A repeated measure of analysis of variance and a Tukey’s honestly significant difference (HSD) test were used to analyze the data.ResultsThe medial gap pressure was significantly increased at extension and flexion as the thickness of the sensor increased in most patients, while the lateral gap pressure changed without a specific trend. The average medial gap pressure was significantly larger than the average lateral gap pressure at both the full extension and 90° flexion positions. The average extension gap pressure was larger than the average flexion gap pressure at both the medial and lateral gaps.ConclusionsThe tension of the soft tissue around the knee joint changes with the joint gap. The tension at the medial side is higher than that on the lateral side, and that of the extension position is higher than that of the flexion position. The use of the pressure sensor insert has a better auxiliary effect on the operation using the gap-balancing technique.

Long-Term Follow up of Correction of Moderate to Severe Coronal Plane Deformity With the Star Ankle Prosthesis

Background: Addressing coronal plane deformity when performing a total ankle arthroplasty (TAA) remains a topic of controversy. While surgeons have become bolder in correcting deformity, long-term follow-up is sparse regarding maintenance of correction and viability of the prosthesis. The purpose of this study is to assess the long-term follow up of the correction of moderate to severe coronal plane deformity with the use of a mobile bearing prosthesis. Methods: Out of a consecutive series of 130 patients who underwent TAA between 2000 and 2009, 43 patients (44 ankles) had at least 100 of tibiotalar coronal plane deformity, with 25 having between 100 and 200 of deformity and 18 having greater than 200. Average age at time of the index surgery was 66 yrs (range 41-79). Initial deformity was 17.90 (range 10-290) in the entire cohort. All patients underwent intraarticular deformity correction with intraoperative soft-tissue balancing as indicated utilizing the STAR prosthesis. Patients requiring realignment osteotomies were performed in a staged fashion prior to undergoing TAA. Results: Seven patients (16%) were available for long-term follow up (avg 13 yrs; range 9-16 yrs) with retention of the original prosthesis, two of which had greater than 200 of initial deformity. Average final tibiotalar deformity was 4.90, with a mean correction of 130 (p = 0.0001). No additional procedures related to the prosthesis were performed. Eleven patients (12 ankles) were deceased at the time of the study due to unrelated conditions. Of the original cohort, five were deemed failures (2 converted to arthrodesis; 2 underwent component revision; 1 polyethylene fracture) and excluded from long-term follow up. The remaining 20 patients were lost to follow-up, had declined or were unable to participate due to health status. Conclusion: While the low follow-up rate limits the overall generalizability of the results, enduring correction of moderate and severe coronal plane deformity with a mobile bearing prosthesis can be achieved in a cohort of patients traditionally regarded as high-risk. One must be cautious when discussing with patients the utilization of TAA in the setting of moderate and severe coronal plane deformity given the risk of failure. However, provided a well-balanced ankle can be achieved intraoperatively, long-term mobile bearing prosthesis survivorship is achievable.

Complex foot deformities associated with lower limb deformities: a new therapeutic strategy for simultaneous correction using Ilizarov procedure together with osteotomy and soft tissue release

AimThe aim of the current study is to introduce a new therapeutic strategy for simultaneous correction of complex foot deformities (CFD) and the associated lower limb deformities (LLD) by using Ilizarov technique with osteotomy and soft tissue procedure and to report its early clinical results.MethodsA retrospective review of CFD associated with LLD simultaneous correction utilizing the Ilizarov procedure together with osteotomy and soft tissue balance from 2015 to 2019 was conducted.ResultsThirty-two patients were followed for an average of 42.8 months. The mean external fixation time (EFT) was 6.5 months. The mean healing index (HI) was 1.7 months/cm. At the time of fixator removal, plantigrade feet were achieved in all patient and lower limb deformities were corrected. No recurrence of the deformities occurred. The mean LLRS AIM score was improved from 7.5 to 0.3. At the final follow-up, the ASAMI-Paley score was graded as excellent in all limbs in the aspect of bone results, and functional results were defined as excellent in 29 (90.6%) limbs and good in 3 (9.4%) limbs. The mean modified Dimeglio score was significantly improved from 7.2 to 1.3. No deep infection of the osteotomy site or nonunion was noted in the current study.ConclusionThe therapeutic strategy by using the Ilizarov procedure together with osteotomy and soft tissue balance is a safe and effective way to simultaneously correct CFD and LLD.Level of evidenceLevel IV, retrospective case series

A modification of the Bereiter trochleoplasty: indications, technique and outcomes.

The Bereiter technique is one recognised method of trochleoplasty that was described using a lateral para-patellar approach. We present our surgical technique and outcomes of this procedure using a medial para-patellar approach allowing for accurate soft tissue balancing of the patella. In total, 27 consecutive patients underwent a Bereiter trochleoplasty using a medial approach. Patients completed pre- and post-operative Kujala scores. All patients' medical records and imaging were reviewed to identify pre-operative indications, complications and re-dislocations. Data were collected on 31 trochleoplasty procedures in the 27 patients. Mean age at time of surgery was 25 (17-39), and 16 patients were females. Follow-up ranged from 13 to 60months. All patients had severe trochlea dysplasia with recurrent instability. Three patients underwent a planned tibial tubercle transfer for a pre-operative raised TT-TG distance. The mean pre-operative Kujala score was 53.9 (26-79) rising to 91.2 (88.6-100) post-operatively. A low post-operative Kujala score seen in patients had a significantly lower than average pre-operative score. No patients had any further dislocations following surgery. Two patients complained of significant stiffness in the early post-operative period. No patients required additional procedures to adequately balance the patella following the trochleoplasty combined with medial reefing plus lateral release involved in this modified technique. A modified Bereiter trochleoplasty using a medial rather than a lateral para-patella approach gives excellent results. Level II evidence.

Small soft tissue tension changes do not affect patient-reported outcomes one year after primary TKA.

Adequate soft tissue tension and balance is paramount to achieve favourable outcomes of total knee arthroplasty (TKA). Implant manufacturers offer 1-mm liner increments to fine-tune ligament tension and balance. In this study, we assessed if soft tissue tension changes introduced by minimal changes in liner thicknesses affect early patient reported outcomes. Eighty-nine patients undergoing 99 primary, elective TKAs by a single surgeon were included. After achieving adequate ligament balance, the first 50 knees received an insert that would allow 2-3mm of medial and lateral opening (control group), whereas the last 49 received an insert which was 1mm thicker, resulting in a slight increase in ligament tension (study group). Sensor technology was used to record compartmental loads. Knee Society Score (KSS), KOOS Jr., and ROM were recorded pre-operatively, sixweeks, four and 12months post-operatively. The Forgotten Joint Score (FJS) was administered four and 12months post-operatively. No differences were observed in demographic variables, pre-operative outcome scores, and ROM measures between groups. Six weeks post-operatively, there was no statistically significant difference in the outcome variables. Four months post-operatively, statistically significant differences were only observed in KOOS Jr. (79 and 73.6; p = 0.05), and FJS (59.9 and 45.5; p < 0.01); all of which favoured the control group. There was no difference in the outcome variables at 12months. Minor changes in soft tissue tension induced by 1-mm changes in liner thickness resulted in clinically meaningful differences favouring the control group four months post-operatively, but in no clinically noticeable differences 12months post-operatively. It is possible that lower soft tissue tension may lead to transient improvement in patient-reported early outcomes.

Three-dimensional preoperative planning accurately guides surgeons for intraoperative implant selection in shoulder arthroplasty

BackgroundWith the rapid growth of shoulder arthroplasty (SA) over the past decade, the focus has been on improving outcomes and minimizing complications. As a result, preoperative planning tools have become a trend among orthopedic surgeons for SA to aid in achieving optimal implant selection and ultimately continual improvement of outcomes. Success in achieving these goals is predicated on software precision and reliability. Therefore, the purpose of our study was to assess the accuracy of three dimensional (3D) preoperative planning software in guiding orthopaedic surgeons for implant selection in SA. MethodsThis was a retrospective study of 76 patients who underwent SA all with the same manufacturer's implants by a single fellowship-trained shoulder surgeon. All patients had preoperative CT scans and completed 3D preoperative plans. The final implant selection was decided intraoperatively solely under surgeon's discretion based on review of preoperative plan, intraoperative bone quality, and soft tissue balancing, not restricted by the preoperative plan. Software accuracy was assessed by directly comparing each component size planned to the actual implant selected in the procedure for both humeral and glenoid components. Statistical analyses was performed including paired-sample t tests and rate for perfect matching. ResultsOur results demonstrated glenoid implant size matched perfectly in 75% of cases and 100% within 1 size in anatomic total shoulder arthroplasty (TSA). Humeral head diameter matched perfectly in 31% of cases and 100% within 1 size. Humeral head thickness matched perfectly in 69% of cases and 100% within 1 size. For reverse shoulder arthroplasty, glenoid baseplate diameter matched perfectly in 81% of the cases and 100% within 1 size. Glenosphere diameter matched perfectly in 88% of the cases and 98% within 1 size. Humeral stem size in both groups were more variable than the remaining components. ConclusionOur study demonstrates that 3D preoperative planning was accurate to guide intraoperative implant selection for both anatomic and reverse SA including both glenoid and humeral components within 1 size. This tool may decrease the need for extensive inventory and instrumentation by improving operating room workflow and surgeon efficiency and may ultimately be translate into better postoperative outcomes. Level of evidenceLevel IV; Case Series

Correction of Talar Sagittal Alignment in Total Ankle Replacement using Cadence Biased Polyethylene Insert

Category:Ankle; Ankle ArthritisIntroduction/Purpose:The success of total ankle arthroplasty (TAA) depends on many factors, including patient selection, prosthetic design, soft tissue balancing, severity of joint deformity, and component position. Malposition of the components increases contact pressures and diminishes prosthesis survival / patient outcomes; therefore, anatomic alignment of the prosthesis is desirable. Sagittal malalignment of the talar component is common and has been associated with lower outcome scores.Cadance Total ankle system is unique in that it has modular polyethene components with both an anterior and posterior biased option that may help improve reduction of the talus in the sagittal plane. The purpose of this study is to evaluate the effectiveness of anterior and posterior biased polyethylethene liners in improving sagittal component alignment in patients with preoperative sagittal translational deformitiesMethods:This is a prospective radiographic and clinical study of patients that underwent TAA with the CadenceTM system using biased polyethylene liners with at least 12-months follow-up. All surgeries were performed by a single surgeon with extensive experience in TAA between July 2016 and December 2018. Patients underwent TAA in a standard fashion using an anterior approach, and then underwent clinical evaluation at standardized time points with administration of the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-26). Radiographic outcomes included assessment of sagittal plane component alignment using the tibiotalar (TT) ratio and tibial-axis-to-lateral-process distance at preoperative and at postoperative visits.Results:The cohort included a total of 7O TAA which demonstrated pre-operative sagittal talar malalignment and/or intra- operative sagittal instability where a biased polyethylene liner was inserted. Preoperative talar sagittal translation was 54 anterior, 6 posterior and 10 were neutral. 30 anterior biased polyethylene and 40 posterior biased polyethylene were used. Sagittal translation decreased from an average 4.2 mm to 0.8 mm. The T-T ratio averaged 40.8 +- 10.8 % on preoperative x-ray and 38.1+- 3.6 % on postoperative. The pre and post-operative pain and disability scores displayed statistically significant improvements wherein AOS pain scores decreased 25.28 +- 14.34 points from an average of 45.86 points while AOS disability scores decreased-30.11 +- 22.70 from an average of 56.15 points.Conclusion:Sagittal translational deformities associated with end-stage ankle arthritis are common and should be corrected during TAA to improve loading kinematics and implant longevity. The Cadence TAA has anterior and posterior biased polyethylene liners that help to correct sagittal talar translational deformities. This study demonstrates that biased liners are effective in improved postoperative clinical outcomes with significant correction of pathological sagittal translation to near anatomic alignment.

Desenlaces funcionales asociados a las diferentes técnicas de reemplazo total de rodilla en pacientes adultos con deformidades extra-articulares: Revisión sistemática de la literatura

BackgroundTotal knee replacement (TKR) in patients with extra-articular deformities is a challenging procedure for the surgeon. Different types of surgical techniques have been described, such as correction with intra-articular cuts, and concomitant osteotomies. The objective of this study is to evaluate the functional outcomes associated with the different TKR techniques in patients with extra-articular deformities. MethodsA systematic review of the literature was performed. Studies evaluating functional outcomes of primary TKR in adult patients with osteoarthritis and extra-articular deformities were included. The type of deformity and intervention, functional scales records, and range of motion were evaluated. ResultsA total of 29 studies were included with a total of 401 knees. The most frequent mechanical axis deformity was varus, with a mean range below 20° in most studies. The mean after surgery knee score (KS) in the TKR group with intra-articular cuts and conventional guides ranged between 85 and 96.5. Those with cuts guided by navigation had a score between 82 and 95, and between 60.7 and 97 in the group with concomitant osteotomy. The mean post-operative Function Score (FS) was between 69.5 and 91.4, 80 and 95.4, and 72.3 and 90, respectively. More complications were reported in the TKR plus concomitant osteotomy group. DiscussionTKR with intra-articular cuts and soft tissue balance, with conventional guides or by navigation, is a viable option and should be preferred in cases of mild extra-articular deformities. In cases with major deformities, a concomitant corrective osteotomy should be considered. Evidence LevelIV.

Long-Term Follow up of Correction of Moderate to Severe Deformity with the STAR Ankle Prosthesis

Category:Ankle ArthritisIntroduction/Purpose:Addressing coronal plane deformity when performing a total ankle arthroplasty (TAA) remains a topic of controversy. While surgeons have become bolder in correcting deformity, long-term follow-up is sparse regarding maintenance of correction and viability of the prosthesis. The purpose of this study is to assess the long-term follow up of the correction of moderate to severe coronal plane deformity with the use of a mobile bearing prosthesis.Methods:Out of a consecutive series of 130 patients who underwent TAA between 2000 and 2009, 43 patients (44 ankles) had at least 100 of tibiotalar coronal plane deformity, with 25 having between 100 and 200 of deformity and 18 having greater than 200. Average age at time of the index surgery was 66 yrs (range 41-79). Initial deformity was 17.90 (range 10-290) in the entire cohort. All patients underwent intraarticular deformity correction with intraoperative soft-tissue balancing as indicated utilizing the STAR prosthesis. Patients requiring realignment osteotomies were performed in a staged fashion prior to undergoing TAA.Results:Seven patients (16%) were available for long-term follow up (avg 13 yrs; range 9-16 yrs) with retention of the original prosthesis, two of which had greater than 200 of initial deformity. Average final tibiotalar deformity was 4.90, with a mean correction of 130(p=0.0001). No additional procedures related to the prosthesis were performed. Eleven patients (12 ankles) were deceased at the time of the study due to unrelated conditions. Of the original cohort, five were deemed failures (2 converted to arthrodesis; 2 underwent component revision; 1 polyethylene fracture) and excluded from long-term follow up. The remaining 20 patients were lost to follow-up, had declined or were unable to participate due to health status.Conclusion:While the low follow-up rate limits the overall generalizability of the results, enduring correction of moderate and severe coronal plane deformity with a mobile bearing prosthesis can be achieved in a cohort of patients traditionally regarded as high-risk. One must be cautious when discussing with patients the utilization of TAA in the setting of moderate and severe coronal plane deformity given the risk of failure. However, provided a well-balanced ankle can be achieved intraoperatively, long-term mobile bearing prosthesis survivorship is achievable.

Arthrodesis for the treatment of rigid flatfoot

In the case of arigid flatfoot deformity, joint-preserving techniques like soft-tissue balancing and osteotomies do not achieve acceptable results. This is the indication for arthrodesis. The selection of the arthrodesis depends on the amount of deformity, localisation of the rigidity and the general health status of the patient. Isolated arthrodesis can be combined with soft-tissue reconstructions. It is functionally advantageous to preserve as many joints as possible.

Intraoperative two-stage evaluation of muscle contractures in Crowe type IV hips in total hip arthroplasty (a new surgical technique).

It is important to maintain soft-tissue balance and prevent muscle contractures after hip reduction during total hip arthroplasty (THA) in patients with Crowe type IV developmental dysplasia of the hip (DDH). To make such hips functional and durable, the techniques to achieve soft-tissue balance were studied to create an algorithm for intraoperative 2-stage evaluation of muscle contractures, specifying the optimal order for contracture release. Between February 2011 and March 2015, we evaluated 64 patients (75 hips) with DDH for muscle contractures as they underwent THA. Following acetabular implantation, femoral osteotomy was applied of various lengths according to limb-length discrepancy. First, the distal part of the femur was prepared by broaching, and the hip was then reduced. The tensor fascia lata, rectus femoris, sartorius, hamstrings, and adductor muscles were evaluated, and any contractures were released. A trial conjoining of the distal and proximal parts of the femur was made, and the hip was reduced again. Finally, the iliopsoas and abductor muscles were evaluated, and contractures were released. The mean follow-up duration was 4.6 years. Preoperative and postoperative Harris Hip Scores were 52 and 87, respectively. Limb-length discrepancy was mean 4.2 cm preoperatively, and <1 cm postoperatively. All contractures were released according to our newly developed algorithm. It is challenging to pinpoint the main muscle causing contractures, because other muscles acting on the hip joint have similar secondary functions. The method we describe here may provide better and more specific restoration of muscle function in a hypoplastic hemipelvis in DDH.