Varus Deformity Research Articles

Efficacy of the Ponseti Technique in Correcting Clubfoot Deformity and Influence of Residual Deformity in Patient Reported Outcomes: A Prospective Comparative and Controlled Study

Category: Other; Hindfoot Introduction/Purpose: Clubfoot deformity (CFD) is one of the most common congenital deformities of the foot and ankle and is characterized by different severities of foot equinus, cavus, varus, and adduction. The gold-standard treatment is the Ponseti technique, characterized by serial casting and an Achilles tenotomy. Few studies have assessed long-term outcomes of this treatment, and none have utilized three-dimensional (3D) weightbearing analysis of residual CFD. The goals of this study were to elucidate residual 3D foot deformities in CFD patients treated with the Ponseti technique and to compare them with healthy controls. We also aimed to assess how these deformities influenced patient-reported outcomes (PROs). We hypothesized that significant residual deformities would be observed in CFD patients and that these deformities would negatively impact PROs. Methods: IRB-approved, prospective, comparative, and controlled study. We recruited 37 CFD patients (57 feet) treated with the Ponseti technique that had no additional foot and ankle surgical procedures. We also included 14 healthy control volunteers (28 feet) with no history of foot/ankle injuries/deformities. All patients underwent WBCT imaging (CurveBeam, HiRise). Tarsal bones were semi-automatically segmented (Bonelogic®, Disior), and several automatic measurements assessing cavus, varus, adductus, and overall 3D deformity (Foot and Ankle Offset – FAO) were performed. Measurements were then correlated with PROs, which included Visual Analogue Scale for pain, PROMIS general health, PROMIS physical function and pain interference, pain catastrophizing scale (PCS), and European Foot and Ankle Society (EFAS) score. Paired T-tests or Paired Wilcoxon were utilized to compare measurements between CFD patients and controls, depending on normality distribution. A multivariate regression analysis assessed the relationship between residual deformities and PROs in CFD patients. P-values < 0.05 were considered significant. Results: No significant overall residual 3D-deformity was found, with similar FAO measurements in CFD and controls (respectively, 2.63% and 3.2%/P=0.58). Slight cavus overcorrection was observed in CFD, with sagittal plane talus-first metatarsal angle of -0.12° versus -5.2o (p=0.04) and calcaneal inclination angle of 13.01° versus 21.5°, respectively. Varus under-correction was identified in CFD patients, with decreased sagittal and axial talocalcaneal angles (44.3o vs. 57.5o/p < 0.0001 and 17.7o vs. 25.78o/p=0.0012, respectively). Similarly, adductus under-correction was observed in CFD, with talonavicular coverage angle 18.63o vs. 29.19o (p < 0.0001). In the multivariate regression analysis, cavus overcorrection (sagittal talus-first metatarsal angle) was the only deformity influencing VAS (R2=0.19/P=0.02) and EFAS-Scores (R2=0.27/p=0.002). Residual varus deformity (sagittal plane talocalcaneal angle) was the only deformity influencing PROMIS Pain Interference (R2=0.14/p=0.038) and Physical Function (R2=0.32/p=0.0007). Conclusion: This study highlights the efficacy of the Ponseti technique in treating the overall 3D foot and ankle deformity in CFD patients, realigning the ankle joint and the weightbearing foot tripod. However, residual CFD components were identified, including overcorrection of the cavus and under-correction of the adductus and varus deformities. Overcorrection of the cavus negatively influenced VAS pain and EFAS scores, and under-correction of the varus negatively influenced PROMIS scores. The results of this study could potentially guide CFD treatment with the Ponseti technique, with focus on improved correction of the varus and avoidance of overcorrection of the cavus deformities.

Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis.

To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis. Retrospective. Academic medical center. Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type. Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP. Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores. The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group. Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Salvage of Failed Ankle Arthrodesis by Conversion to Total Ankle Arthroplasty: Intermediate Term Results

Category: Ankle; Hindfoot Introduction/Purpose: As ankle arthroplasty has become a reliable treatment for painful ankle arthritis, it has also been employed as a salvage procedure for failed ankle arthrodeses. Published studies of conversion have generally combined patients treated by several surgeons using a variety of different prostheses, with short-term follow-up. Early reports showed failure in patients with an absent distal fibula, and more recently that has been considered a contraindication. Some reports have expressed concerns about doing hindfoot arthrodeses at the same setting. This retrospective study examines the mid-term follow-up of 19 patients treated by a single surgeon using a standard technique with a single prosthesis, and includes patients with a deficient distal fibula and concomitant hindfoot fusions. Methods: Between May 2010 and August 2019, 28 patients underwent conversion of their failed ankle arthrodesis to a total ankle arthroplasty using a prosthesis with an intramedullary tibial component. Nineteen patients (10 males and 9 females) with an average age of 49.8 (45-81) years at the time of surgery were included in the study. Three modes of ankle arthrodesis failure were identified: 1) solid tibial-talar-calcaneal arthrodesis with a painful malposition (n=3); 2) painful pseudarthrosis of the ankle (n=4); and 3) solid ankle fusion with painful adjacent hindfoot arthritis (n=12). The patients in the first two groups were treated with arthroplasty alone, while those in the third group had an arthroplasty and hindfoot fusion. Four patients had a deficient distal fibula. Outcomes were evaluated post-operatively with a Visual Analog Scale, the AOFAS Ankle and Hindfoot Scale, a satisfaction survey, and radiographic assessment of the arthroplasty and any concomitant hindfoot fusions. Results: Mean follow-up was 7.6 (2.6-11.8) years. Complications included fracture with or without subsequent surgery (n=4), subsequent sub-talar fusion (n=1), varus deformity (n=1), and wound dehiscence or infection (n=2). Three patients had revision of their talar components. Postoperative dorsiflexion was 7.8 ± 12.6 degrees and plantarflexion 20.9±13.37 degrees. Two patients developed lucencies about the tibial stem, and two had mild subsidence of the talar components. There were no hindfoot pseudarthroses. Four patients with a deficient distal fibula were all able to be salvaged with an intact ankle arthroplasty. Mean (± SD) VAS Score was 4.6 ± 3.0 and AOFAS score was 71.2±21.7. Sixty-seven percent reported that they were satisfied or very satisfied. Forty-four percent had significant limitations in either activity or ADLs in their ankle function. Conclusion: Total ankle arthroplasty should be considered as a salvage procedure for patients with a failed ankle arthrodesis. With the described techniques it can be combined with concomitant hindfoot arthrodesis procedures and can be used successfully in patients who have a deficient distal fibula. While there can be a high prosthetic retention rate in the medium term, prospective patients must be counseled about potential limitations.

Deltoid Ligament Release for Varus Deformity Correction in Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) with severe varus ankle deformity is balanced in the coronal plane by releasing medial soft tissue constraints. There are no previous reports examining the impacts of TAA with concomitant release of the deltoid. Progressive talar tilt and progressive collapsing foot deformity were evaluated. Methods: A retrospective review included patients undergoing TAA with confirmed preoperative varus deformity. Patients underwent complete soft tissue release of the deltoid ligament complex. Pre- and post-operative weightbearing radiographs quantified Meary’s angle, lateral talo-1st metatarsal angle, calcaneal pitch, talar coronal alignment, and the lateral distal tibial angle. The primary endpoints were degrees of coronal plane correction, longitudinal arch position, and complication rates. Results: Thirty-two patients were included with median 12.5 month follow-up. Coronal plane alignment and VAS pain scores improved significantly in all patients, and statistical analysis revealed that complete deltoid ligament release had no bearing on calcaneal pitch and Meary’s angle at final follow-up. Posterior tibial tenotomy was performed on 3 (9.3%) patients. Median coronal plane alignment correction averaged 17.5° improvement (X2(2)= 50.358, P<.001) from 19.5° varus (11.2-24.5°) to 2.0° varus (0.5- 3.5°)(P <.001). Two degrees of coronal plane varus alignment without tilt progression (0.6-3.4°)(P <.001) was maintained through follow-up. Final calcaneal pitch of 18.2° (14.4-23.2°) mirrored initial median measurement of 18.3° (15.7-21.1°). No significant differences were found between Meary’s angle measurements at any time points (P=.568). Eight of 32 patients had complications with five requiring further ankle surgery. Conclusion: Complete release of the deltoid ligament may improve coronal malalignment when performing TAA. Release did not lead to radiographic or clinical medial instability, valgus talar tilt, or medial arch collapse.

Peroneus Brevis to Longus Tendon Transfer in the Treatment of the Flexible Progressive Collapsing Foot Deformity: A Cadaveric Study

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Although operative treatment of the flexible progressive collapsing foot deformity (PCFD) remains controversial, correction of residual forefoot varus and stabilization of the medial column are important components of reconstruction. An opening wedge medial cuneiform osteotomy or first tarsometatarsal fusion is traditionally performed to plantarflex the first metatarsal. More recently, tendon transfers such as a peroneus brevis (PB) to peroneus longus (PL) have been proposed. However, there is little data to support their use. The aim of our study was to determine the effect of an isolated PB- to-PL transfer (PBT) on medial column and hindfoot joint kinematics in a simulated PCFD (sPCFD) cadaveric model using a robotic gait simulator. We hypothesized that a PBT in a sPCFD model would partially restore kinematics to the intact state. Methods: A validated six-degree of freedom robot (Baxter et al., 2016) was used to simulate the stance phase of level walking for 6 mid-tibia cadaveric specimens (3 male; age: 72 ± 8 years). An eight-camera motion capture system was used to track reflective markers fixed to bones of the foot and ankle. Three conditions were tested for each specimen: intact, sPCFD (Henry et al., 2022), and after PBT. The PBT was performed by transecting the PB and advancing the proximal stump 1 cm into the PL (Sanhudo, 2019). Outcome measures included kinematics of the talonavicular, subtalar, and first tarsometatarsal joints. Maximum differences between the PBT and sPCFD conditions and 95% confidence intervals (95%CIs) were calculated. The percent deformity correction was determined by dividing the difference between the PB and sPCFD states by the difference between the intact and sPCFD states at the site of maximum deformity correction. Results: Relative to the sPCFD condition, the PBT resulted in a maximum increase in talonavicular plantarflexion of 1.8° (95%CI 0.9°-2.7°) with 159% correction during midstance, decrease in talonavicular abduction of 1.5° (95%CI 0.3°-2.8°) with 65% correction during midstance, and decrease in talonavicular eversion of 2.4° (95%CI 1.2°-3.8°) with 90% correction during mid-to- late stance. All deformities had consistent correction at the talonavicular joint during stance (Figure 1). Additionally, the PBT resulted in a maximum increase in subtalar plantarflexion by 0.8° (95%CI 0.3°-1.8°) with 155% correction in early stance, decrease in subtalar abduction by 0.8° (95%CI 0.5°-1.2°) with 191% correction during early stance, and decrease in subtalar eversion by 1.5° (95%CI 0.5°-2.2°) with 178% correction during mid-stance. There was no effect on first tarsometatarsal joint kinematics. Conclusion: A PB-to-PL transfer in a sPCFD model resulted in the correction of multiple deformities including increased plantarflexion and decreased abduction at the talonavicular joint compared to the sPCFD without the transfer, most notably during PB activation in stance. The PBT also decreased eversion at the talonavicular and subtalar joints. Our results suggest that the addition of a PBT as part of the surgical management of the flexible PCFD contributes to correction of the residual forefoot varus, midfoot abduction, and hindfoot valgus deformities by plantarflexing through the medial column and removing a deforming force on the foot by the PB.

Plain Ankle Radiographs Underestimate Valgus Tibiotalar Tilt in Progressive Collapsing Foot Deformity: A Comparative Analysis with WBCT

Category: Ankle Arthritis Introduction/Purpose: Detection and accurate assessment of valgus tibiotalar tilt are important for staging and surgical planning of progressive collapsing foot deformity (PCFD). Plain ankle radiographs (XRs) have been used to evaluate this condition, but recent literature suggests that XRs may underestimate ankle deformities when compared to weightbearing computed tomography (WBCT), which is becoming increasingly utilized in PCFD evaluation. However, the discrepancies between these methods have not been explored. This study aims to: 1) determine the difference in tibiotalar tilt measurements between XRs and WBCTs; 2) compare the prevalence of significant valgus tibiotalar tilt (>4 degrees) between XRs and WBCTs in PCFD patients; and 3) determine the radiographic characteristics of patients who exhibit a discrepancy between XR and WBCT in the presence of significant valgus tibiotalar tilt. Methods: One hundred thirty-eight PCFD patients (Mean age: 55.1 years) having both WBCT and ankle XRs were reviewed. On ankle XRs, tibiotalar tilt (TTXR) and medial distal tibial angle (MDTAXR) were measured. On WBCT, the TTWBCT and MDTAWBCT were assessed at three locations (25% [anterior], 50% [middle], and 75% [posterior] of the sagittal dimension of the distal tibial plafond) in coronal views (Figure 1). The degree of tibiotalar tilt and prevalence of significant valgus tibiotalar tilt were compared between TTXR and the TTWBCT. Bland-Altman plots compared the mean TT and MDTA from XRs to those of the three coronal WBCT images to determine which region in WBCT is most similar to the XRs in each measurement. The radiographic characteristics of patients with and without a discrepancy between XRs and WBCTs for the presence of significant valgus tibiotalar tilt were examined via subgroup analysis. Results: Mean TTXR and TTWBCT were 1.5 (standard deviation [SD] 3) and 4.1(SD 3) degrees, respectively, indicating that XRs underestimate tibiotalar tilt by 63.4%. The prevalence of significant valgus tibiotalar tilt was 10.1% on XRs and 37.7% on WBCTs. Half the patients (4/8) who had bone-on-bone contact with tibiotalar tilt on WBCT didn’t exhibit such findings on XR (Figure 1). Bland-Altman plots showed that TTXR and MDTAXR best correlate with middle TTWBCT and MDTAWBCT (Figure 2). Subgroup analysis revealed that patients who exhibited significant valgus tibiotalar tilt on WBCTs, but not XRs, had smaller anterior TTWBCT and MDTAWBCT than those without such discrepancy (p <.05, Table 1), indicating that patients with a greater varus deformity on the anterior distal tibia are more likely to exhibit the discrepancy. Conclusion: This study demonstrates that ankle XRs underestimate valgus tibiotalar tilt compared to WBCTs in PCFD patients. The ankle XR parameters had the strongest correlation with those of the midpoint of the tibiotalar joint in WBCT and understated anterior side tilt and distal tibial deformity, likely due to beam projection angle and superimposition. Based on the findings of this study, WBCTs may be useful for detecting actual deformities in the ankle joint in PCFD patients; nevertheless, surgeons must be cognizant that they may underestimate the deformity in the anterior ankle when using conventional radiographs to assess ankle deformities in PCFD.

What Do We Know About the Pathoanatomy of Talar Neck Malunions? Results From a 3D Morphometric Analysis

Category: Trauma; Hindfoot Introduction/Purpose: Malunions of the talar neck significantly alter the foot biomechanics and predispose patients to arthrosis and poor functional outcomes. Recent interest has focused on the surgical correction of these deformities, with corrective talar neck osteotomy emerging as a safe and effective treatment for malunions without ankle arthrosis. While a talus malunion is traditionally thought to cause a varus deformity due to the shortening of the medial talar neck, the pathoanatomy of these deformities remains unclear and sparsely reported in the literature. Therefore, this study aimed to investigate the three- dimensional changes in morphometric parameters of the talar neck after malunion and to determine how these changes affect the architecture of the foot. Methods: Adult patients with a talar neck malunion without ankle arthrosis (Rammelt and Zwipp Type 1-3) were prospectively included. Weight-bearing (WB) AP, Lateral and long axial radiographs, and CT scans of both feet were obtained. 3D models of both tali were generated. The malunion side was mirrored and superimposed on the normal side, and distance maps were generated to identify pathoanatomic changes. Deviation of the talar neck in the axial plane (declination angle [DA]), sagittal plane (inclination angle [IA]), coronal plane (torsion angle [TA]) as well as the medial and lateral neck lengths (MNL and LNL) were measured on the 3D talus models using a semi-automated GEOGEBRA script. AP and Lateral Meary’s angle and the hindfoot moment arm (HMA) was determined on WB radiographs. The t-test was used to compare the talar neck parameters, and correlation coefficients were used to determine the association between talar neck parameters and foot radiographic parameters. Results: 10 patients, 6 males, and 4 females, with a mean age of 32.4 years were included. There were 4 cases of Rammelt and Zwipp Type 1 deformity, and 6 cases of Type 3 deformity. Axial plane changes included varus deviation of the talar neck in 8 cases and valgus deviation in 2. Sagittal plane changes included dorsiflexion of the talar neck in 4, neutral alignment in 3 cases, and plantarflexion in 3 cases. The TA was increased in all cases. TA and MNL had a moderate positive correlation with AP Meary’s angle and, and a moderate negative correlation with Lateral Meary’s Angle. DA and MNL had a moderate positive correlation with the HMA. Conclusion: Talar neck malunions are complex three-dimensional deformities resulting in the common varus and dorsiflexion variants, as well as less common valgus and plantarflexion variants. Despite the variation in malunion types, all cases are characterized by an increased TA. Furthermore, the combination of increased TA and DA and decreased MNL leads to forefoot adduction and hindfoot varus. Due to the intricate and diverse three-dimensional nature of these deformities, surgeons must conduct a comprehensive evaluation of the pathoanatomy before planning surgical correction.

Outcomes following Surgical Intervention for Hallux Varus deformity: A Systematic Review

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates following surgical intervention for hallux varus deformity. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical intervention for hallux varus deformity. Data regarding study characteristics, patient demographics, osteoarthritis severity, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Twelve studies were included. In total, 168 patients (186 feet) underwent surgical intervention for hallux varus deformity. at a weighted mean follow-up of 49.6±36.6 months. The weighted mean AOFAS score improved from a pre-operative score of 60.5±18.4 to a post-operative score of 83.9±9.0. The weighted mean hallux valgus angle improved from a pre-operative angle of 16.9±6.5° of varus to a post-operative angle of 5.9±6.6° of valgus. The weighted mean inter-metatarsal angle improved from a pre- operative angle of 12.7±10.0° to a post-operative angle of 7.7±3.4°. The complication rate was 21.5%, the most common of which was 1st MTPJ joint pain and stiffness. Eleven failures (5.9%) were observed at a mean time of 25.0 months following the index procedure. Conclusion: This systematic review demonstrated improvements in subjective clinical outcomes together with a low failure rate following surgical intervention for hallux varus deformity at mid-term follow-up. A high complication rate was recorded. However, the marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions. Further research with a longer follow-up is warranted to determine the optimal surgical technique for hallux varus deformity correction.

Patient Reported and Radiographic Outcomes following the Malerba Osteotomy

Category: Hindfoot; Other Introduction/Purpose: The Malerba calcaneal osteotomy is a step cut Z-type osteotomy with a lateral wedge resection used to treat hindfoot varus deformity. The osteotomy allows for lateral translation while the wedge resection enables lateral rotation of the calcaneal tuberosity. The technique enables a more powerful correction of hindfoot varus without excessive lateral translation of the calcaneus, which has been shown to cause tarsal tunnel syndrome. Thus far, there have been few published clinical and radiographic outcomes on the Malerba osteotomy. The purpose of this article is to report on patient reported outcome scores (PROMIS), complications, and radiographic improvement in a series of patients treated with this osteotomy. Methods: A prospectively collected foot and ankle registry was queried to retrospectively identify patients who underwent a Malerba osteotomy from February 2016 through January 2022. Patients were included if they were over 18 years of age, underwent a Malerba osteotomy, had preoperative and minimum 1-year postoperative PROMIS scores, and preoperative and postoperative radiographs. 40 patients met the inclusion criteria (average age 54.3 years). PROMIS scores from 6 domains including physical function, pain interference, pain intensity, global physical health, global mental health, and depression were compared preoperatively and postoperatively. Radiographic measures including talonavicular coverage angle (TNCA), calcaneal pitch (CP), and lateral talus-1st metatarsal angle (Meary’s angle) were measured and compared preoperatively and postoperatively. Complications and radiographic union were also recorded. Results: At a mean of 22 months, PROMIS domains including physical function, pain interference, pain intensity, global physical health, and global mental health improved significantly; the depression scale did not significantly change (Table 1). Calcaneal pitch and Meary’s angle significantly improved from 22.9 to 19.1 (p <.001) and 8.2 to 5 (p <.001), respectively. The talonavicular coverage angle did not significantly improve (p=.2). There were no delayed unions or nonunions. There was 1 case of sural neuritis but no instances of postoperative tarsal tunnel syndrome. There were 3 (8%) superficial infections treated nonoperatively and 0 deep infections. 4 patients (10%) required reoperation: 2 for removal of hardware and 2 for conversion to subtalar fusion. Conclusion: The Malerba calcaneal Z-osteotomy is an effective and safe method to treat adult hindfoot varus deformity. In our series, patients demonstrated an improvement in PROMIS and radiographic outcomes with minimal complications. In particular, the rate of neurologic complications was very low with only one case of sural neuritis and no cases of iatrogenic tarsal tunnel syndrome.

Postoperative Medial Malleolar Fractures in Total Ankle Replacement are Associated with Medial Malleolar Width and Coronal Alignment

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited evidence regarding risk factors for medial malleolar fractures after total ankle arthroplasty (TAA). A previous study showed that patients with medial pain following TAA had significantly thinner (<11mm) medial malleolar width, which has been used as a threshold for placing a prophylactic screw. However, this study included only six patients with pain over the medial malleolus. Other previously reported risk factors include coronal malalignment and poor bone quality. Therefore, this study examined the risk factors of postoperative medial malleolar stress fractures. In addition, we sought to assess the effect of the prophylactic screw placement. We hypothesized that a medial malleolar width <11mm and varus malalignment would be associated with increased fracture risk and that the prophylactic screw placement would be protective. Methods: A case-control study was conducted on 838 patients undergoing primary TAA between 2015 and. TAA revisions, arthrodesis takedowns, and intraoperative medial malleolar fractures were excluded. Demographic and surgical data were obtained. A total of 21 patients with postoperative medial malleolar stress fractures > 4 weeks postoperatively (cases) were identified through radiologic assessment (radiograph, CT, or MRI) and matched to a control group of 129 patients. Radiographic evaluation included pre- and post-TAA tibial coronal alignment, postoperative medial malleolar width at the tibial component, and prophylactic screw fixation. Demographics and radiographic variables were compared between cohorts using the Mann-Whitney U test for continuous variables and Pearson Chi-square for categorical variables. Logistic regression was used to investigate the association of medial malleolar stress fractures with gender, coronal tibial implant size, postoperative coronal alignment, prophylactic screw fixation, and medial malleolar width using odds ratios (OR), and standard error (SE). Results: Of 838 TAAs, 2.51% sustained a postoperative medial malleolar fracture (n = 21). Of these, 13/21 (61.9%) required reoperation: internal fixation (12) and TAA revision (1). Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.62 mm [1.63]) than in controls (11.78mm [1.75]), P<0.001). Mean (SD) postoperative tibial component coronal alignment was 92.2º (2.82) for patients with medial malleolar fracture and 90.23º (1.68) for the control cohort (P = 0.003). Postoperative varus tibial component alignment (OR = 1.61 [95%CI 1.16 02 − 2.22], P = 0.004) and smaller medial malleolar width (OR = 0.11 [95% CI 0.04 02 − 0.3], P < 0.001) were associated with increased probability of a post-TAA medial malleolar fracture. Prophylactic screw fixation resulted in a 90% reduction in the odds of a fracture (OR = 0.10 [95%CI 0.02 02 − 0.64], P = 0.015). A medial malleolar width of 10.31 mm was identified as a threshold for predicting a medial malleolar stress fracture. Conclusion: In this study, the prevalence of postoperative periprosthetic fractures after TAA was similar to prior studies. Decreased medial malleolar thickness and postoperative varus malalignment were associated with an increased risk of a postoperative medial malleolar stress fracture. A malleolar width of 10.31 mm was identified as a potential threshold. Prophylactic medial malleolar screw fixation was protective and associated with a 90% reduction in fracture probability. Surgeons should consider prophylactic screw fixation patients with a medial malleolar width < 10.31 mm or at risk of postoperative varus deformity.

Predictive Model for Reintervention in Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Osteoarthritis (OA) of the tibiotalar joint is associated with a high degree of morbidity, being comparable with final stages of renal and heart failure. The incidence of OA of the tibiotalar joint is as high as 47.7 per 100,000 habitants, of whom most of them will need a surgical intervention to improve their quality of life. Up to date evidence supports the use of the total ankle arthroplasty for its management. A great effort has been made to elucidate the factors associated with failure of the total ankle prothesis, until now no attempt has been made to look for factors associated with the need of surgical reintervention, beyond revision of the prothesis. Methods: Prospective cohort study in patients with tibiotalar OA operated between 2015 and 2022, with a minimum follow-up of 12 months, excluding revision prothesis and lost to follow-up. Reintervention was considered as any complication, related to the prothesis, that needed a surgical intervention that was not planned. We performed a multivariate logistic regression model with 13 variables (diabetes, hypertension, tabaquism, age, etiology, hind foot alignment, subtalar OA, talonavicular OA, calcaneocuboid OA, pes planus, cavo varus, previous subtalar arthrodesis and surgical time). Confounding effect was assessed with the change of the odds ratio of the principal independent variable, by adding or subtracting potentially confounder variables into the model. The variables that were statistically non-significant and those variables that do not cause confusion effect, were discarded. Goodness of fit was evaluated using the Hosmer-Lemeshow test and the discrimination of the model with the ROC curve. The Kaplan-Meier curve was used for survival analysis. Results: 105 total ankle arthoplasties were included, the statistically significant variables were: take-down etiology OR = 171.73 (CI: 6.87 - 4294.95, p < 0.01), post-traumatic etiology OR = 14.56 (CI: 1.98 - 107.04, p < 0.01) and surgical time OR = 0.96 (CI: 0.92 - 0.99, p = 0.04), while age OR = 1.02 (CI: 0.96 - 1.09, p = 0.57) and cavo varus OR = 4.75 (CI: 0.71 - 31.93, p = 0.11), wereincluded in the model because of its confounding effect. Goodness of fit demonstrates that the data fit the model adequately (p = 0.84). The ROC curve demonstrates 89.03% discriminatory power. The survival rate at 8 years was 80.39%, median of survival rate was not determined, because longer follow-up was needed. Conclusion: The take-down and post-traumatic etiology can be considered as important risk factors for requiring a surgical reintervention. Patients with a take-down etiology that have a cavo varus deformity and higher age, have a higher risk to require a surgical reintervention. Longer surgical time can be considered as a protective factor for needing a surgical reintervention. At 8 years 20.61% of patients will need a surgical reintervention, related to their Total Ankle Arthroplasty.

Distal femoral osteotomy planning: Reversed Miniaci's method is more accurate than Dugdale and Paley methods

PurposesThe purpose of this study was to validate the reversed Miniaci method for distal femoral osteotomies and to compare the accuracy with Dugdale and Paley methods. MethodsBetween January 2019 and October 2021, 59 DFO were performed in a single center. Following application of the eligibility and exclusion criteria, radiographic measurements and analysis was performed for 24 patients by two independent observers, then repeated after one month. Medical planning software: PeekMed v2.3.7.6® was used. For all patients the following measurements were performed: Hip–Knee–Ankle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), joint line obliquity (JLO), width of the proximal tibia and the weight-bearing line (WBL). Each image was then analysed using the following planning methods for realignment surgery: Reversed Miniaci, Dugdale and Paley. Measurements were recorded post deformity correction. Difference between target and post-correction WBL was evaluated. This difference was adjusted by the objective in order to limit biases related to the different objectives according to the method. ResultsEighteen patients were managed for a varus osteotomy and 6 for a valgus osteotomy. Preoperative data was, HKA at 176.7±6.3, mLDFA at 90.6±5.4, MPTA 88.9±1.1, a WBL for valgus 80.9%±9.1 and for varus deformity 23.5%±11.7. Inter- and intra-rater reliability was>0.8 for every method. After normalizing reported precision on the amount of correction expected, reversed Miniaci method was the most accurate with a mean deviation from the target of 3%, compared to the Dugdale's method with 9% (p<0.001) and to Paley's method with 8.6% (p<0.001). ConclusionThe reversed Miniaci method is effective and reliable for planning distal femoral osteotomies. Compared to other planning methods, it is the most accurate approach for achieving a correction goal. Level of evidenceIV; retrospective cohort study.

P24 TB or not TB? A case of severe multi-organ erosive rheumatoid arthritis in a Ukrainian refugee

P24 TB or not TB? A case of severe multi-organ erosive rheumatoid arthritis in a Ukrainian refugee

Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures.

Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal. Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail. In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a10º varus deformity present after surgery in one case. Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.

Observation on Curative Effect of Minimally Invasive Osteotomy Combined with Ilizarov Technique in the Treatment of Knee Osteoarthritis with Varus Deformity

This paper aims to analyze the clinical efficacy of minimally invasive osteotomy combined with Ilizarov technique in the treatment of knee osteoarthritis with varus deformity. 80 patients with knee osteoarthritis and varus deformity who were treated in our hospital from January 2022 to May 2023 were selected, all of whom were affected by one knee. They were randomly divided into groups, including the study group and the control group, each with 40 patients. Patients in the control group were treated with fibula-tibial osteotomy and internal fixation, and patients in the study group were treated with minimally invasive osteotomy combined with Ilizarov technique. The operation time of the patients in the study group was significantly longer than that of the control group (P &lt; 0.05). The intraoperative blood loss of the patients in the study group was significantly more than that of the control group (P &lt; 0.05). The hospitalization expenses of the patients in the study group were significantly more than those of the control group (P &lt; 0.05). The postoperative femorotibial angle and mechanical axis offset distance in the study group were significantly smaller than those in the control group (P &lt; 0.05). The postoperative New York Hospital for Special Surgery (HSS) scores of the study group were significantly higher than those of the control group (P &lt; 0.05). The postoperative visual analogue scale (VAS) score of the study group was significantly lower than that of the control group (P &lt; 0.05). The range of motion of the knee joint in the study group was significantly greater than that in the control group (P &lt; 0.05). The incidence of tendon injury, infection, and nerve injury in the study group (2.50%) was significantly lower than that in the control group (30.00%) (P &lt; 0.05). Minimally invasive osteotomy combined with Ilizarov technique can be applied in the treatment of knee osteoarthritis with varus deformity, although the operation time is longer, with more intraoperative blood loss and higher treatment cost, but it has no effect on the femorotibial angle and mechanical axis deviation of the patient. It can significantly improve the movement distance, knee joint function, and knee joint range of motion, and significantly reduce the postoperative pain of patients, reduce the incidence of complications, and thus has high clinical application value.

The effect of lateral collateral ligament repair tension on elbow stability: An in vitro biomechanical study

BackgroundThe aim of this study was to determine the optimal repair tension of the lateral collateral ligament of the elbow by performing simulated active flexion with the arm in the varus gravity loaded position using an in vitro elbow simulator. MethodsEight cadaveric specimens were mounted in the varus gravity loaded orientation onto an elbow motion simulator. Four states were studied (intact, lateral collateral ligament injured, and 15 N and 20 N lateral collateral ligament repairs) with the forearm in supination and pronation. An electromagnetic tracking system was used to measure joint kinematics during active elbow flexion. FindingsThere was no difference in ulnohumeral rotation between the intact state and the 15 N repair (P = .150 for pronation; P = 1.0 for supination) or the 20 N repair (P = 1.0 for pronation; P = .568 for supination). For varus-valgus angulation, the 20 N repair was not statistically different from the intact state (P = .059 in pronation; P = 1.0 in supination). InterpretationRepair of the lateral collateral ligament following injury can restore joint kinematics with the arm in the varus position. A repair tension of 20 N was successful in restoring joint stability for simulated active motion with the forearm in pronation and supination. This study shows that when the lateral collateral ligament is repaired with adequate tension, avoidance of the varus position may not be as crucial during early motion.

Medial opening-wedge high tibial osteotomy with microfracture in treatment of varus medial compartmental knee osteoarthritis: clinical outcomes and second-look arthroscopic results.

Objective: This study aimed to investigate the clinical outcomes of medial opening high tibial osteotomy (MOWHTO) combined with arthroscopic microfracture in the treatment of varus medial compartmental knee osteoarthritis and to assess cartilage regeneration using second-look arthroscopy. Methods: This study involved 86 patients (86 knees) who underwent MOWHTO and microfracture from August 2016 to August 2020, including 15 men and 71 women with an average age of 55.3 ± 7.6years (range, 42-71years). The patients underwent a second-look arthroscopy to evaluate the status of cartilage regeneration at the time of plate removal, an average of 2years after the initial osteotomy. Clinical and radiological examinations were performed preoperatively and at the final follow-up visit. The radiologic evaluation included the weight-bearing line ratio (WBL ratio), mechanical femorotibial angle (FTA), medial proximal tibial angle (MPTA), posterior tibial slope angle (PTS) and Kellgren-Lawrence (KL) grade. Clinical outcomes were assessed using the Knee Society score (KSS) and International Knee Documentation Committee (IKDC) scores. Arthroscopic findings were assessed by macroscopic evaluation of cartilage repair according to the International Cartilage Repair Society (ICRS) grading system. Results: The mean KSS and IKDC scores significantly improved at the final follow-up compared to the scores obtained preoperatively (p < 0.05). At the time of plate removal, a second-look arthroscopic examination showed that the ICRS grade of the medial femoral condyle was as follows: grade I -11 cases, grade II -56, grade III-12, and grade IV-7, and cartilage regeneration was seen in 85% of knees (73/86). The ICRS grade of medial tibial plateau was grade I-12 cases, grade II-44, grade III-22, and grade IV-8, and cartilage regeneration was seen in 63% of knees (54/86). Significant differences were observed between cartilage regeneration and clinical outcomes (p < 0.05). Clinical results were better in the good cartilage regeneration group (grades I and II) than were in the poor cartilage regeneration group (grades III and IV). Conclusion: MOWHTO combined with arthroscopic microfracture can effectively improve clinical outcomes in the treatment of varus medial compartmental knee osteoarthritis. Cartilage regeneration can be promoted by correcting varus deformities, which affect clinical outcomes.

Two years follow-up of patients with knee varus deformity and medial meniscus extrusion after medial opening wedge high tibial osteotomy and arthroscopic meniscus centralization.

This is a retrospective study and aims to investigate the clinical outcomes of patients with knee varus deformity and extruded medial meniscus who underwent arthroscopic meniscus centralization and medial opening wedge high tibial osteotomy. A total of 24 patients were included in the trial, and arthroscopy intraoperative photographs and standing preoperative and postoperative radiographs were taken to analyze the mechanical tibiofemoral angle and tibial plateau inclination. Postoperative complications and knee motion were recorded, and the surgical results were evaluated using the knee society score. The study observed four cases of surgery-related complications among all patients, but no major complications were reported. The surgery significantly improved knee flexion degrees and total knee range of motion. Satisfactory outcomes were shown in postoperative radiographs and secondary intraoperative photographs. The knee score increased from 39.6 ± 10.0 to 80.1 ± 9.0, and the functional score improved from 48.1 ± 6.9 to 89.4 ± 5.5. The preoperative tibial plateau inclination was 5.3 ± 0.7, while the postoperative data showed a decrease to 4.2 ± 0.7. The preoperative mechanical tibiofemoral angle was - 7.7 ± 1.0, and it improved in all patients postoperatively to 2.8 ± 0.9. By alternating the knee biomechanics and significantly improving symptoms and quality of life, arthroscopic medial meniscus centralization and medial open wedge high tibial osteotomy units are confirmed to be an effective alternative treatment for knee varus deformity.

Split transfer of tibialis anterior for equinovarus foot deformity in cerebral palsy

: Foot deformities in children with cerebral palsy are common. The various foot deformities are equinus, planovalgus, equinovarus, equinovalgus. Treatment for the flexible foot deformity should be with orthotics and manual therapy initially and then with tendon lengthening. Equinovarus deformity of the foot is a result of the muscle imbalance in which invertors of the foot, posterior and anterior tibialis muscle, overpower evertors. Untreated spastic equinovarus deformity may cause severe fixed foot deformity and painful callosities under metatarsal heads and on the lateral side of foot. To evaluate the effectiveness of split transfer of tibialis anterior for equinovarus foot deformity in spastic cerebral palsy children.40 spastic cerebral palsy (13 diplegic and 27 hemiplegic) children between the age of 5-15 years with equinovarus foot deformity were selected. The procedure adopted in all the cases was tendoachilles lengthening and split anterior tibialis tendon transfer to cuboid. The result was graded as good, fair and poor. In 28 of the cases varus deformity of the forefoot and midfoot got corrected with plantigrade foot, in 10 of the cases forefoot and midfoot supination was corrected but heel was in varus and in 2 of the cases there was no improvement.: Spastic T.A. is most often the cause of varus of forefoot. Split transfer utilises the spastic nature of the muscle to counter balance the deformity caused by the original muscle. Hence, it is better solution to the problem. However accurate diagnosis of deforming muscle, i.e, T.A or T.P. is essential to produce good result.

Clinical Analysis of the Frosch Approach in the Treatment of Posterolateral Tibial Plateau Fractures Combined with Lateral Tibial Plateau Fractures.

The treatment of posterolateral tibial plateau fractures is difficult, and providing sufficient exposure and effective fixation is a challenge. There is great controversy regarding the surgical approach for posterolateral tibial plateau fractures. The purpose of the study was to investigate the clinical effects of open reduction and internal fixation using the Frosch approach for the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures. Data from 19 patients with posterolateral tibial plateau fractures combined with lateral tibial plateau fractures treated from May 2018 to January 2022 were retrospectively analyzed. There were nine men and 10 women, ranging in age from 22 to 62 years, with an average age of 45.6 years. All patients were treated using the Frosch approach. Under direct vision, the posterolateral and lateral fractures were reduced, and full bone grafting was performed. We reshaped the oblique "T" shaped plate for the distal radius and placed it on the posterolateral tibial plateau to fix the posterolateral fractures. The lateral inverted "L" shaped locking plate was placed on the lateral tibial plateau to fix the lateral tibial plateau fractures. Within 2 weeks after the operation, the patients were instructed to perform knee joint function exercises within 90°. At the last follow-up, the Rasmussen radiological criteria were used to evaluate the effectiveness of fracture reduction and fixation. And the knee joint function was evaluated using Rasmussen functional score. The operation time ranged from 100 to 180 min, with an average of 134.2 min; intraoperative blood loss ranged from 20 to 150 mL, with an average of 66.8 mL. The follow-up duration ranged from 14 to 58 months, with an average of 36.2 months. There were no complications, such as vascular or nerve injury or incision infection. Fracture healing was achieved in all patients, and the healing time ranged from 10 to 14 weeks, with an average of 11.2 weeks. During the follow-up period, there was no loosening or breakage of the internal fixation, varus or valgus deformity of the knee joint, re-collapse of the articular surface, or instability of the knee joint. At the last follow-up, the effectiveness of fracture reduction and fixation was excellent in 13 patients and good in six patients. And the knee joint function was excellent in 17 patients and good in two patients. The Frosch approach for open reduction and internal fixation in the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures has a definite clinical benefit and is worthy of promotion and application.