Varus Angulation Research Articles

Evaluation of the Role of Medial Open Wedge Osteostomy with Use of External Ring Fixator in Osteoarthrosis of the Knee in Rural Population

In this era of increasing life expectancy and change in the lifestyle, osteoarthrosis of weight bearing joints, particularly the knee joint has become the most common Orthopaedic problem of enormous magnitude. Medial opened wedge tibial osteotomy fixed with standard ring fixator will be very useful for them as being of low cost and giving them immediate pain free mobilization, so that they can carry out their routine activities freely and as early as possible. Aim and Objectives: To study clinicoradiological findings in cases of Medial compartment osteoarthritis of knee joint. To evaluate the role of Medial opened wedge tibial osteotomy aiming to relieve pain, correct deformity and improve function. To study Biomechanics of knee joint with special reference to knee in osteoarthritis. To study the relevant literature. To compare the results with other available series. Results: 23 cases of medial compartmental osteoarthrosis of knee joint, who were subjected to Medial open wedge high tibial osteotomy, were studied. Osteoarthrosis of knee joint was found to be common in patients between 45 to 65 years of age (82.60%) Most of the patients had right sided involvement (65.22%). In some patients, patello-femoral arthritis became less severe. In the present study 52.81 % patients had 5 to 8degree varus angulation and one patient had 2degree of valgus angulation pre-operatively. Excellent relief of pain in knee can be achieved in patients who presented earlier i.e. whose complaints were of less than 1 year duration. 30 to 50 of over correction are essential t3o unload the medial compartment of the joint. The knee which maintains 5° to 14° of Valgus angulation post-operatively ended with radiologically satisfactory results (78%). 82.58% patients obtained clinically worthwhile relief of pain following Medial opened wedge tibial osteotomy.

Clinico-Radiological Profile of Patients Admitted With Osteoarthrosis of the Knee in Rural Population

AIM AND OBJECTIVES: 1. To study clinicoradiological findings in cases of Medial compartment osteoarthrosis of knee joint. 2. To study Biomechanics of knee joint with special reference to knee in osteoarthrosis. 3. To compare the results with other available series METHODOLOGY: The patients for the present study of A clinical study of role of Medial opened wedge tibial osteotomy in medial compartment osteoarthrosis of knee were selected from cases of osteoarthrosis of knees attending Orthopaedic O.P.O. of Pravara Rural Hospital, Loni India. Clinical and radiological assesement and grading was done. Results: Osteoarthrosis of knee joint we found to be common in patients between 45 to 65 years of age (82.60%), in over weighted patients it was earlier and was more severe. Majority Le. 69.57% patients were females and 31.43% were males. Most of the patients had right sided involvement (65.22%). In Medial compartment osteoarthrosis varus deformity of varying degree was commonly found. Most of the patients had complaints about osteoarthrosis of more than 1 year duration (69.57%). Many of the patients of present study had patella femoral arthritis (43.48%) and could be responsible, at least to some extent, for the persistent or recurrence of pain following osteotomy. In the present study 52.81 % patients had 5 to 8degree varus angulation and one patient had 2degree of valgus angulation pre-operatively. Results of the present series are comparable to other published series of high tibial osteotomies.

Dynamic motion analysis of dart throwers motion visualized through computerized tomography and calculation of the axis of rotation

We used a dynamic three-dimensional (3D) mapping method to model the wrist in dynamic unrestricted dart throwers motion in three men and four women. With the aid of precision landmark identification, a 3D coordinate system was applied to the distal radius and the movement of the carpus was described. Subsequently, with dynamic 3D reconstructions and freedom to position the camera viewpoint anywhere in space, we observed the motion pathways of all carpal bones in dart throwers motion and calculated its axis of rotation. This was calculated to lie in 27° of anteversion from the coronal plane and 44° of varus angulation relative to the transverse plane. This technique is a safe and a feasible carpal imaging method to gain key information for decision making in future hand surgical and rehabilitative practices.

Comparison of the Dyna Locking Trochanteric Nail, Proximal Femoral Nail Antirotation and Gamma 3 Nail in Treatment of Intertrochanteric Fracture of the Femur

Purpose: The purpose of this study is to compare and analyze the radiological and clinical results after treatment of intertrochanteric fractures of the femur by three devices including DLT, PFNA and Gamma 3 nail. Materials and Methods: From January 2007 to January 2012, we reviewed 131 patients who suffered intertrochanteric fractures(33 cases of DLT, 59 cases of PFNA, 39 cases of Gamma 3 nail). The following were measured for all three groups; The tip apex distance (TAD), neck shaft angle and lag screw position at the head of femur, as well as the amount of blood loss and transfusion, operation time, duration of hospitalization and postoperative ICU admission, complications were also assessed. Results: In comparison of the radiological results, there were no statistical differences among the three groups in TAD, neck shaft angle and the lag screw position. There was no statistical difference in clinical results. In the last follow-up, there was one case of nonunion in the PFNA group. There also was, in the last follow up, a development of varus angulation & cut-out of lag screw that occurred in 2 cases (DLT), 4 cases (PFNA), 1 cases (Gamma 3). There was no statistical difference among the three groups in the sliding length of the lag screw. Conclusion: Any certain group was not better than the others with regard to the radiological and clinical results among DLT, PFNA and Gamma nail groups in treating intertrochanteric fracture. To achieve favorable results, precise reduction of fracture site and surgical techniques are important.

The effects of femoral external derotational osteotomy on frontal plane alignment

Femoral osteotomies are the preferred treatment in significant torsional deformity of the femur. The influence of torsional osteotomies on frontal plane alignment is poorly understood. Therefore, the aim of the present study was to evaluate the effects of external derotational osteotomies on proximal, mid-shaft and distal levels onto frontal plane alignment. The effect of rotation around the anatomical axis of the femur on frontal plane alignment was determined with a 3D computer model, created from CT data of a right human cadaver femur. Virtual torsional osteotomies of 10°, 20° and 30° were performed at proximal, mid-shaft and distal levels under five antecurvatum angles of the femur. The change of the frontal plane alignment was expressed by the mechanical lateral femoral angle. Proximal derotational osteotomies resulted in an increased mechanical lateral distal femoral angle (mLDFA) of 0.8°-2.6° for 10°, of 1.6°-5.1° for 20° and of 2.3-7.9° for 30° derotational osteotomy, indicating an increased varus angulation. Supracondylar derotational osteotomy resulted in a decreased mLDFA of -0.1° to -1.7° for 10°, of -0.2 to -3.7° for 20° and of -0.7 to -6.9° for 30° derotational osteotomy, indicating an increased valgus angulation. The effect increased with the amount of torsional correction and virtually increased antecurvatum angles. Mid-shaft torsional osteotomies had the smallest effect on frontal plane alignment. This three-dimensional computer model study demonstrates the relationship between femoral torsional osteotomies and frontal plane alignment. Proximal external derotational osteotomies tend to result in an increased varus angulation, whilst distal external derotational osteotomies tend to result in an increased valgus angulation. As a clinical consequence, torsional osteotomies have an increased risk of unintentional implications on frontal plane alignment.

Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate

Hallux valgus is a complex deformity of the first metatarsophalangeal joint, with varus angulation of the first metatarsal, valgus deviation of the great toe and lateral displacement of the sesamoids and the extensor tendons. The aim of the surgery is to achieve correction of the varus deviation of the 1st metatarsal which is considered by some as the primary intrinsic predisposing factor to hallux valgus deformity. We retrospectively reviewed 85 patients (107 feet) who underwent an opening wedge osteotomy of the 1st metatarsal for correction of moderate to severe hallux valgus and metatarsus primus varus. A medially applied anatomic pre-contoured locking plate was used for fixation of the osteotomy. The mean IMA was decreased from 15.8 (range 12-22) degrees to 7.8 (range 0-12) degrees. The mean pre-operative HVA was 39 (range 21-52) degrees and the mean postoperative HVA was 11.8 (6-19) degrees. The pre-operative AOFAS score was 52 (SD 3.1) and the postoperative score was 85 (SD 5.2). The proximal opening wedge metatarsal osteotomy is a safe, effective and reproducible technique for correction of moderate to severe hallux valgus deformity. The use of a locking plate provides enough control at the fragments, enhancing healing of osteotomy and maintenance of the correction even with a violated proximal lateral cortex.

The Effect of a Coronoid Prosthesis on Restoring Stability to the Coronoid-Deficient Elbow: A Biomechanical Study

The coronoid process has been recognized as a critical component in maintaining elbow stability. In the case of comminuted coronoid fractures, where repair is not possible or has failed, a prosthesis may be beneficial in restoring the osseous integrity of the elbow joint. The hypothesis of this in vitro biomechanical study was that a coronoid prosthesis would restore stability to the coronoid-deficient elbow. An anatomically shaped metallic coronoid prosthesis was designed and developed based on computed tomography-derived measurements and optimized to account for average cartilage thickness. Elbow kinematics and stability were determined for 8 cadaveric arms in active and passive elbow flexion in the varus, valgus, horizontal, and vertical positions using an elbow motion simulator. Varus-valgus angulation and internal-external rotation of the ulna relative to the humerus were quantified in the intact state, after collateral ligament sectioning and repair (control state), after a simulated 40% transverse coronoid fracture, and after implantation of the coronoid prosthesis. Internal rotation of the ulna increased with a 40% coronoid fracture in the horizontal and varus positions. Increases in varus angulation after coronoid fracture were also observed in the horizontal and varus positions, during active and passive flexion, respectively. Following implantation of the coronoid prosthesis, elbow kinematics were restored similar to control levels in all elbow positions. Our findings support our hypothesis that an anatomically shaped coronoid prosthesis would be effective in restoring stability to the coronoid-deficient elbow. This study provides evidence that the use of an anatomical implant restores stability to the coronoid-deficient elbow and rationale for further study and development of this method. For comminuted coronoid fractures, where repair is not possible or has failed, our research indicates that a prosthesis may be a feasible treatment option.

Near-Anatomic Allograft Tenodesis of Chronic Lateral Ankle Instability

Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability. Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications. Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery. Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up. Level IV, retrospective case series.

Does proximal femoral varus osteotomy in Legg–Calvé–Perthes disease predispose to angular mal-alignment of the knee? A clinical and radiographic study at skeletal maturity

Though there is an impression that proximal femoral varus osteotomy (FVO) can result in a valgus deformity at the knee there is no agreement on this issue. This study was undertaken to ascertain whether a FVO predisposes to the development of genu valgum in children with Legg-Calvé-Perthes disease (LCPD). One hundred and one children with unilateral LCPD who underwent a FVO during the active stage of the disease and 32 children who were treated non-operatively were followed till skeletal maturity. The FVO was performed with a 20° varus angulation in all the patients and weight-bearing was not permitted till the stage of reconstitution. The alignment of the knee was assessed clinically at skeletal maturity. A subset of 33 operated children also had full length standing radiographs of the limbs. The mechanical axis deviation, femur-tibial angle, lateral distal femoral angle and the medial proximal tibial angle of both limbs were measured on these radiographs. The frequency of clinically appreciable mal-alignment of the knee was not greater on the affected side in patients who had undergone FVO when compared to the unaffected limb and also when compared to the affected limb in non-operated patients. The mechanical axis of the lower limb of operated children was relatively in more valgus than that of normal limbs but they fell within the normal range. This study does not support the impression that a proximal femoral osteotomy for LCPD predisposes to clinically discernable degrees of genu valgum in children who have had 20° of varus angulation at the osteotomy site and who have avoided weight-bearing for a prolonged period following surgery. Further studies are needed to clarify if genu valgum would develop if early post-operative weight-bearing is permitted. III.

Does cubitus varus cause morphologic and alignment changes in the elbow joint?

In cubitus varus after pediatric supracondylar fracture, late development of trochlear deformity causing additional varus angulation and joint misalignment relating to late complications of the tardy ulnar nerve palsy or posterolateral rotatory instability have been suggested. However, it is unclear whether these morphologic and alignment changes of the elbow joint occur in cubitus varus. The object of this study was to investigate morphologic changes of the bones and alignment changes of the elbow joint in longstanding cubitus varus using 3-dimensional computer bone models created from computed tomography data. We studied 14 patients with longstanding cubitus varus after pediatric supracondylar fractures. Three-dimensional bone models of the bilateral humerus, radius, and ulna were created from computed tomography data. We compared the morphology and alignment of the elbow joint between the affected side and contralateral unaffected side. The posterior trochlea, distal part of the lateral capitellum, diameters of the radial head, and articular surface of the ulna in cubitus varus were larger than those of the contralateral elbow. In the ulna, the convex portion of the trochlear notch shifted laterally in cubitus varus. Joint alignment in cubitus varus was affected by a shift of the ulna to a more distal and medial position with external rotation and flexion. In longstanding cubitus varus, the morphology and alignment of the elbow joint are observed to differ from those of the normal side.

Role of hybrid monolateral fixators in managing humeral length and deformity correction

Background and purpose Humeral lengthening and deformity correction are now being done increasingly for various etiologies. Monolateral external fixators have advantages over traditional Ilizarov circular fixators; they are easy to apply, they are less bulky, and they are therefore more convenient for the patient. We assessed the effectiveness of hybrid monolateral lateral fixators in humeral lengthening and deformity correction.Methods We retrospectively reviewed 23 patients (40 humeri) with various pathologies who underwent lengthening—with or without deformity correction using monolateral external fixator—between 2003 and 2008. Mean age at the time of the surgery was 14 (10–22) years. The mean follow-up time was 3.4 (1–7) years.Results The average duration of external fixator use was 8.3 (6–19) months. The mean lengthening achieved was 8.8 (4–11) cm and percentage lengthening was 49% (19–73). The healing index was 28 (13–60) days/cm. The major complications were refracture in 3 humeri and varus angulation of 2 humeri. The minor complications were superficial pin tract infection (6 segments), transient radial nerve palsy (1 segment), and elbow flexion contracture (5 segments). All complications resolved.Interpretation Hybrid monolateral fixators can be used for humeral lengthening and deformity correction. The advantage over circular fixators is that they are less bulky and patients can perform their day-to-day activities with the fixator in situ.

Treatment of Unstable Pertrochanteric Fractures with a Long Intramedullary Nail

Purpose: The purpose of this study is to analyze the clinical and radiographic results of treatment of unstable pertrochanteric hip fractures in which the fracture line is extended distally or the width of the canal is wide using a long intramedullary nail. Materials and Methods: From January 2005 to January 2010, we conducted an analysis of 20 cases of unstable pertrochanteric hip fractures (over AO/OTA 31 A2.2) treated using a long intramedullary nailing and followed up for more than 12 months. Using postoperative and last follow-up radiographs, we measured TAD, Cleveland index, neck-shaft angle, sliding length of the lag screw, and union time. Clinically, we measured the operation time, the amount of transfusion, and Parker and Palmer’s mobility score. Results: The mean bony union time was 16.4 weeks(10-21 weeks). The mean sliding length of the lag screw was 4.3 mm(1-10 mm) and the mean varus angulation after surgery was 5.1。(3-8。). The mean operative time was 118 min(60-140 min), and the mean transfusion amount was 2.0 pint(0-4 pint). According to Parker and Palmer’s mobility score, mean preoperative score was 7.5 points and mean postoperative score at last follow-up was 6.9 points. Conclusion: In treatment of unstable pertrochanteric hip fractures, when the fracture line was extended to below the lesser trochanteric level or the medullary canal width was wide, use of a long intramedullary nail showed excellent clinical and radiologic results and can be regarded as a good treatment option.

Correction of Multiplanar Deformity of the Second Toe With Metatarsophalangeal Release and Extensor Brevis Reconstruction

Surgical treatment of multiplanar (varus and dorsal angulation) second toe deformities due to degenerative instability can lead to recurrence, stiffness, and pain. The goal of this study was to evaluate the short-term outcomes associated with a new technique using an extensor digitorum brevis (EDB) tendon reconstruction to correct such deviation of the second metatarsophalangeal (MTP) joint. Ten patients (10 female, 0 male) with 11 operated second toes having undergone correction with a reconstruction using the EDB tendon were assessed at an average of 18.5 months (range, 12-34) after surgery. The technique was indicated when MTP and medial partial plantar plate release alone were not sufficient to correct multiplanar deformity. Radiographic parameters (AP and lateral metatarsal-proximal phalanx angles), physical exam (MTP joint range of motion), and subjective outcomes (the Foot and Ankle Outcome Score [FAOS]) were assessed. A toe-specific survey captured more detailed subjective information, including patient satisfaction. Preoperatively, the average MTP joint angle was 4.5 degrees in the varus direction, which changed to 14.2 degrees in the valgus direction postoperatively. On exam, the average MTP joint range of motion was 60.9 ± 11.6 degrees dorsiflexion and 11.1 ± 2.5 degrees plantarflexion. Postoperative FAOS scores demonstrated an average of 89.9 ± 9.8 for the symptoms domain. In all, 9 of 11 patients were either highly satisfied or moderately satisfied (none dissatisfied). With the stated limitations, the EDB tendon reconstruction technique described in conjunction with collateral ligament and partial plantar plate release provided powerful correction. Minimal release of the medial plantar plate and not overtightening the reconstruction are recommended to avoid shifting the toe in the opposite direction. Level IV, retrospective study.

A Three-Dimensional Comparison of Intramedullary Nail Constructs for Osteopenic Supracondylar Femur Fractures

This study developed a new 6 degree-of-freedom, unconstrained biomechanical model that replicated the in vivo loading environment of femoral fractures. The objective of this study was to determine whether various distal fixation strategies alter failure mechanisms and/or offer mechanical advantages when performing retrograde intramedullary nail (IMN) stabilization of supracondylar femur fractures in osteoporotic bone. Forty fresh-frozen human femora were allocated into 2 groups of matched pairs: "locked" (fixed angle locking construct with both distal locking screws rigidly attached to the IMN) versus "unlocked" (conventional locking technique with 2 distal locking screws targeted through the distal locking screw holes of the IMN) and "locked" versus "washer" (fixed angle locking with the most distal screw exchanged for a bolt with condyle washers) distal fixation of a retrograde IM nails. A comminuted fracture (OTA 33-A3) was simulated with a wedge osteotomy. Bone density measurements were completed on all specimens before instrumentation. Instrumented femurs were loaded axially to failure, whereas 6 degree-of-freedom translations and angulations were measured using Roentgen stereophotogrammetric analysis. Mean (± SD) load born by "locked" specimens (1609 ± 667 N) at clinical failure was 38.1% greater (P = 0.09) than the corresponding mean load born by "unlocked" specimens (1165 ± 772 N). Clinical failure for the "washer" group (1738 ± 772 N) was 29.9% greater (P = 0.07) than the corresponding mean of the "locked" counterparts (1338 ± 822 N). Failure load was most clearly related to bone density in the "unlocked" fixation group. Predicting failure load based on bone density using a least squares estimate suggests that the washer construct provides superior fixation to other treatment techniques. The failure mechanism for a comminuted, supracondylar fracture cannot be analyzed accurately with a 1-dimensional measurement. The most common failure mechanism in this model was medial translation and varus angulation.

Ex vivoContact Mechanics and Three‐Dimensional Alignment of Normal Dog Elbows after Proximal Ulnar Rotational Osteotomy

To evaluate the effect of proximal ulnar rotational osteotomy (PURO) on the contact mechanics and 3-dimensional (3D) alignment of cadaveric normal dog elbows. Ex vivo biomechanical study. Unpaired thoracic limbs from 12 dogs (mean ± SD weight, 26 ± 4 kg). PURO consisted of a transverse osteotomy with 30° external rotation of the proximal segment. With the limb under 200 N axial load, contact area (CA), mean contact pressure (CP) and peak contact pressure (PCP) were measured using digital pressure sensors in the medial and lateral compartments and 3D static elbow poses were obtained, before and after PURO. Each specimen was tested at 115°, 135°, and 155° elbow flexion, with the antebrachium in neutral rotation, in 28° supination, and in 16° pronation. Repeated measures ANOVAs with post-hoc Bonferroni (P ≤ .05) were performed. PURO caused significant changes, mostly at 135° elbow flexion and neutral antebrachial rotation, characterized by decreased CP (10%) and PCP (10%) in the medial compartment, and increased CP (27%) and PCP (23%) in the lateral compartment. The apex of the medial coronoid process translated 3.4 mm caudally, 1.7 mm abaxially, and rotated 1.8° externally relative to the radial head. Humeroradial varus angulation reduced by 6.7°. In limited poses, PURO displaces the medial coronoid process caudally and abaxially and shifts contact pressures towards the lateral elbow compartment by decreasing varus angulation.

Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia

With advances in chemotherapy, long-term survival for childhood leukemia is improving. However, chemotherapy-induced osteonecrosis of the proximal femur remains a challenging problem. We present a case of an adolescent female with advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia. She underwent an Ilizarov hip reconstruction with a subtrochanteric valgus extension osteotomy and distal femoral lengthening with varus angulation using an external fixator. At a 3-year follow-up, her symptoms and gait had markedly improved. On the basis of this preliminary report, Ilizarov hip reconstruction is a viable alternative for advanced osteonecrosis of the proximal femur in an adolescent.

Study on outcome of fracture shaft of the humerus treated non-operatively with a functional brace

Non-operatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. The objective of this study is to find out the outcome of fractures of the humeral diaphysis treated with a functional brace that permits motion of shoulder and elbow joints and progressive use of the injured extremity. This was a descriptive analytical study in patients of 16years and above with closed fracture shaft of humerus treated with a functional brace that permits the motion of shoulder and elbow joints. The fracture arms were initially stabilized with U slab or hanging cast for an average of 11days before application of brace. Radiographs were made at each follow-up visit until the fracture union occured. Angulation at fracture site, motion at shoulder and elbow joint were measured at the time of removal of brace. One hundred and five out of 108 fractures (97.2%) were united with mean duration of 12.16weeks (range, 7.5-19.3weeks). Radial nerve injury was present in 6 cases (5.5%). Varus angulation of ≤15° was present in 90.9% out of 99 patients, while no angulation was present in 6 cases (5.7%) out of 105 patients. Apex anterior angulation of ≤10° was present in 100% out of 48 patients, whereas apex posterior angulation of ≤10° was present in 94.1% out of 51 patients. Functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union with nearly normal elbow motion and some restriction of shoulder motion.

Evaluation of shoulder and elbow functions after treatment of humeral shaft fractures

The aim of this study was to evaluate the long-term results of shoulder and elbow functions in humeral shaft fractures treated with functional brace, plate and screw osteosynthesis or intramedullary nailing. The study included 128 patients treated for humeral shaft fracture. The patients were divided into three groups according to treatment method: Group 1 (n=62) received functional brace, Group 2 (n=36) plate and screw osteosynthesis and Group 3 (n=30) intramedullary nailing. Coronal and sagittal humeral angulations were measured radiologically during the final follow-up. Shoulder and elbow functions were evaluated using the Constant shoulder score, the Mayo Elbow Performance Scoring and range of movement measurements. The mean follow-up time was 74 (range: 20 to 132) months. Mean Constant shoulder scores were 92.4 in Group 1, 85.6 in Group 2 and 74 in Group 3. A statistically significant difference was detected between the Constant shoulder scores of Groups 2 and 3 (p<0.05). In the last follow-up, the mean Mayo Elbow Performance Score of Group 1 was 96.9, Group 2 was 95.7 and Group 3 was 89.2. Statistically significant differences were not detected between the Group 2 and 3 (p>0.05). In the statistical evaluation of the Constant shoulder scores, a statistically significant difference was detected between the Constant scores of patients with a varus angulation greater than 20° and those with neutral alignment. Functional results of humeral shaft fractures treated with functional brace appear to be satisfactory. Varus and antecurvatum may affect shoulder and elbow function. In the presence of surgical indications, plate and screw fixation technique is the most effective method in terms of shoulder and elbow functions.

Geometrical values of the normal and arthritic hip and knee detected with the EOS imaging system

EOS 2D/3D is an integrated, low-dose orthopedic digital radioimaging solution, which, due to its groundbreaking properties, has recently shown an increasing application in scoliosis surgery. Its integrated sterEOS 3D software allows creation of patient-specific three-dimensional (3D) lower limb models, and can produce geometrical parameters in 3D. Currently there are a limited number of reports on EOS for lower limb applications. Three-dimensional reconstructions of 256 hip and knee joints of 128 healthy subjects, as well as 53 hips and 46 knees of 69 patients with hip or knee arthritis, were evaluated based on orthogonal EOS two-dimensional (2D) images. Measurements for hips included femur and tibia length, total length of the extremity, femoral antetorsion and offset, femoral neck length, neck-shaft and hip-knee-shaft (HKS) angles. Lower limb alignment in both frontal and sagittal planes were determined in normal and arthritic knees. Values were compared with those obtained by standard methods published by others. Normal hip and knee geometrical parameters were found in our healthy subjects. In osteoarthritic cases, values for neck-shaft angle, femoral antetorsion, femur length and total length of the extremity were shown to decrease non-significantly. Evaluation of lower limb alignment in healthy and arthritic knees showed normal values in healthy subjects apart from three cases with an average six degrees varus. Arthritic knees were most frequently found to have a varus angulation, with the exception of 11 cases with normal or valgus alignment. EOS 2D/3D with its sterEOS 3D reconstruction is useful for a comprehensive 3D examination of the lower limb. In the near future it may be suitable for daily routine diagnostics of orthopedic lower limb deformities as a primary examination method.

Malalignment and subchondral bone turnover in contralateral knees of overweight/obese women with unilateral osteoarthritis: Implications for bilateral disease

To explore whether the risk of incident tibiofemoral (TF) osteoarthritis (OA) in the radiographically normal contralateral knee of overweight/obese women with unilateral knee OA is mediated by malalignment and/or preceded by increased turnover of subchondral bone. We used data of post hoc analyses from a randomized controlled trial. Cross-sectional analyses evaluated the baseline association between frontal plane alignment and bone turnover in the medial TF compartment in 78 radiographically normal contralateral knees. Longitudinal analyses ascertained whether incident radiographic OA (TF osteophyte formation within 30 months) was associated with malalignment and/or increased bone turnover at baseline. Alignment subcategories (varus/neutral/valgus) were based on the anatomic axis angle. (99m)Tc-methylene diphosphonate uptake in a late-phase bone scan was quantified in regions of interest in the medial tibia (MT) and medial femur (MF) and adjusted for uptake in a reference segment of the ipsilateral tibial shaft (TS). MF and MT uptake in varus contralateral knees was 50-55% greater than in the TS. Adjusted MT uptake in varus contralateral knees was significantly greater than that in neutral and valgus contralateral knees (mean 1.55 versus 1.38 and 1.43, respectively; P < 0.05). Among 69 contralateral knees followed longitudinally, 22 (32%) developed TF OA. Varus angulation was associated with a marginally significant increase in the odds of incident OA (adjusted odds ratio 3.98, P = 0.067). While the small sample size limited our ability to detect statistically significant risk factors, these data suggest that the risk of developing bilateral TF OA in overweight/obese women may be mediated by varus malalignment.