Femoral Varus Osteotomy Research Articles

Early-Stage Femoral Head Hypoperfusion Correlates with Femoral Head Deformity at Intermediate Follow-up in Legg-Calvé-Perthes Disease.

Perfusion MRI (pMRI) can quantify femoral head hypoperfusion in early-stage Legg-Calvé-Perthes disease. We investigated whether the severity of hypoperfusion measured at the early stage correlates with femoral head deformity at intermediate-term follow-up. Sixty-three patients who were 5 to 11 years of age at the diagnosis of Legg-Calvé-Perthes disease and who had pMRI performed at an early stage (Waldenström Stage 1 to 2a) were retrospectively reviewed. Twenty-eight patients were treated nonoperatively and 35 were treated with proximal femoral varus osteotomy (PFVO). The sphericity deviation score (SDS) was used as the primary outcome. Femoral head perfusion and SDS were measured by 2 observers. Models assessing the relationship between hypoperfusion and SDS were fitted without and with stratifications by age at diagnosis and treatment method. All 63 patients had a minimum of 4 years of follow-up (mean follow-up, 7.5 ± 2.6 years). All had reached the healed stage (Stage 4), and their mean age was 15.6 ± 2.8 years. The SDS outcome showed a significant positive correlation with the hypoperfusion % (p < 0.001). In the <50% hypoperfusion range, the SDS indicated no-to-low deformity, with narrow variability of outcome. However, the SDS became exponentially worse and had a wider variability of outcome at the ≥50% hypoperfusion range. Multivariable analyses revealed age at diagnosis, hypoperfusion %, and treatment method as significant prognostic factors for SDS (p = 0.007, <0.001, and 0.042, respectively). When treatment outcomes were stratified by age at diagnosis and hypoperfusion %, PFVO showed significantly better SDS outcome than nonoperative treatment in patients with an age at diagnosis of ≥8 years and low (<50%) and intermediate (50% to 80%) hypoperfusion ranges (p = 0.036 and 0.021, respectively). Our study found a significant relationship between femoral head hypoperfusion measured in early-stage Legg-Calvé-Perthes disease and femoral head deformity at intermediate-term follow-up. This study provides new insight into the relationship between early-stage femoral head hypoperfusion and deformity. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stress Distribution Patterns of the Femorotibial Joint After Medial Closing-Wedge Distal Femoral Varus Osteotomy: An Evaluation Using Computed Tomography Osteoabsorptiometry

Background: Distal femoral varus osteotomy (DFVO) is an established surgical procedure for addressing valgus malalignment across various knee conditions. However, the effect of DFVO on stress distribution within the femorotibial joint has not been explored through in vivo studies. Purpose: To (1) explore the distribution pattern of subchondral bone density across the proximal tibia in nonarthritic knees without arthritis and in those of patients with valgus knees, (2) assess changes in the pattern of bone density distribution in patients with valgus knees before and after medial closing-wedge (MCW) DFVO, and (3) determine the correlation between leg alignment and changes in bone density distribution. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed clinical and radiographic data from 14 patients (14 knees; mean age, 44 years; 3 men, 11 women) treated with MCW-DFVO for lateral compartment osteoarthritis (OA) due to valgus malalignment, alongside a control group of 18 patients (18 knees; mean age, 21 years; 4 men, 14 women) without OA. The distribution patterns of subchondral bone density distribution on the femorotibial articular surface of the tibia were examined both preoperatively and >1 year postoperatively using computed tomography osteoabsorptiometry. Quantitative analyses were conducted on the locations and percentages of the high-density areas (HDAs) on the articular surface. The mean time between surgery and the postoperative radiograph and computed tomography absorptiometry imaging was 13.6 months (range, 11-19 months). The mean length of clinical follow-up was 28.7 months (range, 14-62 months) after surgery. Results: The mean proportion of HDA in the lateral compartment relative to the total HDA (lateral ratio) was significantly greater in the preoperative OA group (58.8%) compared with the control group (41.1%) (P < .001). After MCW-DFVO, the mean lateral ratio in the OA group notably declined to 45.3% (P < .001). The lateral ratio exhibited a significant correlation with the hip-knee-ankle angle in both the control (r = 0.630; P = .011) and OA (r = 0.537; P = .047) groups. Moreover, the alteration in the lateral ratio after MCW-DFVO showed a significant relationship with changes in the hip-knee-ankle angle (r = 0.742; P = .002) and the mechanical lateral distal femoral angle (r = −0.752; P = .002). Within the lateral compartment, HDAs in the 3 lateral regions of the 4 lateral subregions diminished after MCW-DFVO, whereas in the medial compartment, HDAs in the 3 lateral subregions saw an increase. Conclusion: The mean lateral ratio was significantly greater in the preoperative OA group compared with the control group. MCW-DFVO resulted in a redistribution of HDA from the lateral to the medial compartment of the proximal tibial articular surface. The extent of alignment correction after MCW-DFVO was closely linked to the shifts in HDA distribution, reflecting changes in stress distribution.

Single institution clinical results in patients with Legg-Calvé-Perthes disease that undergo femoral varus osteotomy

Background: Legg-Calvé-Perthes disease is a significant topic in pediatric orthopedics due to its high incidence and often unclear prognosis. Both conservative and surgical treatments are widely practiced today, aiming primarily to contain the femoral head, reduce stress on the affected avascular zone, and minimize loss of sphericity of the femoral head. The aim of this study is to evaluate the clinical results in early age patients with Perthes disease which undergo femur osteotomy in a single institution. Materials and Methods: A retrospective study involving 81 hips in 79 patients was conducted at a single institution. Inclusion and exclusion criteria were set. Patients with a primary diagnosis of Legg-Calvé-Perthes disease were operated on – varus femoral osteotomy was done in all patients. The patients were classified using the Stulberg and Herring classifications, and were divided into three main groups depending on the disease severity preoperatively. Clinical and radiographic results were collected and analyzed. Results: Poor clinical outcomes (Stulberg III, IV, V) were observed in 47% of the patients. There was a direct correlation between the degree of poor outcomes and the age at onset of the disease. The average limb length discrepancy was 0.9 cm (range: 0.0–2 cm), with 23 patients having a discrepancy greater than 1 cm. Twelve patients required contralateral epiphysiodesis in the knee area to equalize limb length. Conclusions: Patients with Hering B and B/C, as well as Stulberg I and II stages over the age of six, have excellent outcomes following varus femoral osteotomy. Unsatisfactory and poor results are observed in patients with Hering and Stulberg IV and V grade hip joints. The early onset of the disease, as well as the lack of a unified treatment protocol, necessitate further and more in-depth studies in this area.

Proximal femoral varus osteotomy for Legg–Calvé–Perthes disease: Do age and lateral pillar classifications influence short-to-mid-term clinical and radiological outcomes?

IntroductionProximal femoral varus osteotomy (FVO) is one of the most used treatment methods with acceptable outcomes for Legg–Calvé–Perthes disease (LCPD). We aimed to investigate the influence of age at disease onset and the Lateral Pillar classification on clinical and radiological outcomes of FVO surgery LCPD patients between 6–12years of age. HypothesisProximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up, regardless of preoperative age and Herring type. Material and methodsFifty patients with LCPD (Herring groups B, B/C, and C) who underwent FVO were retrospectively reviewed. We evaluated radiological [center-edge angle, extrusion index, epiphyseal index, acetabular index, articulo-trochanteric distance (ATD)] and clinical [hip abduction range of motion (ROM), Trendelenburg sign, pain, and Harris hip score (HHS)] outcomes with a follow-up of 37.3±10.5months (range: 24–180months). Finally, the overall treatment outcome was assessed using the Stulberg classification. ResultsThe ROC curve analysis did not reveal any significant relationship between age and clinical or radiological outcomes, and there was no predictable age cut-off for surgical outcomes (p=0.13). No significant difference was found in Stulberg classification at the follow-up between patients with type B, B/C, and C of the lateral pillar (p>0.05). DiscussionOur results demonstrated that open-wedge proximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up. Each sample of our study was very small and a lot of variables were measured, making this result not adequately strong enough to draw a robust conclusion. However, FVO surgery remains a possible suggestion for patients in the early fragmentation phase, and age and lateral pillar type may not be limiting factors. Level of evidenceIV; therapeutic retrospective cohort.

Treatment of Hip Displacement in Children With Cerebral Palsy: A 5-year Comparison of Proximal Femoral Osteotomy and Combined Femoral-Pelvic Osteotomy in 163 Children.

This study compared the 5-year outcomes of isolated proximal femoral varus osteotomy (FO) and combined proximal femoral varus and pelvic osteotomy (FPO) for the treatment of hip displacement in children with cerebral palsy (CP) in Sweden, focusing on the number of reoperations and residual hip displacement. The study included 163 children with a 5-year follow-up after FO or FPO in the national Swedish CP surveillance program, CPUP. Descriptive statistics and univariate and multivariate Cox regression analyses were used to identify whether the age at surgery, sex, Gross Motor Function Classification System level, CP dominant symptom, hip migration percentage (MP), type of surgery (unilateral/bilateral), and history of soft tissue hip surgery were related to the 5-year outcomes after surgery. Failure after hip surgery was defined as a skeletal reoperation involving the hip and/or MP >50%. During the period 2001 to 2017, 163 children (65 girls) underwent 246 femoral and/or pelvic osteotomies (154 FO, 47 bilaterally; 92 FPO, 16 bilaterally) and had a 5-year follow-up; 95 and 74 children had ≥1 FO or FPO as the primary skeletal surgery, respectively. The mean preoperative MP (51%±18% for FO and 59%±17% for FPO, P =0.001) and age at surgery (6.2±2.5 years for FO and 7.3±2.8 years for FPO, P =0.014) differed between procedures. At the 5-year follow-up, 5 hips (5%) had reoperations and 5 hips (5%) had radiological failure among the 92 FPOs, and 33 (21%) had reoperations and 14 (9%) radiological failure among the 154 FOs. The difference in outcome failure rate was significant ( P <0.001). Multivariate Cox regression analysis showed a lower risk for failure with FPO [hazard ratio (HR)=0.32, 95% CI: 0.15-0.68] compared with FO. A higher preoperative MP increased the risk for outcome failure (HR=1.21, 95% CI: 1.15-1.36 for each 5% increment). FPO had a higher mean preoperative MP but a lower 5-year outcome failure rate compared with FO. A higher preoperative MP was associated with an increased risk of failure. Level II-prospective comparative study.

Effect of Medial Closing Wedge Distal Femoral Varization Osteotomy on Coronal Ankle and Hindfoot Alignment

Category: Hindfoot; Ankle Introduction/Purpose: To date, only a few studies have reported postoperative changes in coronal ankle alignment after valgus knee correction through Medial Closing Wedge Distal Femoral Varization Osteotomy (MCWDFO). This study aimed to measure the changes of MCWDFO on coronal ankle and hindfoot alignment. Methods: We retrospectively reviewed the radiographic findings of 27 consecutive patients (34 cases) with knee valgus malalignment who underwent MCWDFO for either lateral knee joint osteoarthritis (OA) or recurrent patellar subluxation/dislocation (RPD) . Several radiographic parameters were measured and compared based on the reason for operation, followed by the status of preoperative hindfoot alignment (hindfoot alignment angle [HAA] &gt; 4°, varus; -4° HAA 4°, neutral; HAA &lt; -4°, valgus) in each group. Results: Overall, pre- and postoperative hindfoot alignments were within the neutral alignment range and were not significantly changed after the operation (P &gt; 0.05). Nineteen cases were for lateral knee OA and 15 were for RPD, respectively. In both groups, preoperative neutral hindfoot alignments accounted for the largest portion (52.6% in the lateral OA group; 80.0% in the RPD group). Postoperatively, regardless of the reason for operation, hindfoot alignments changed toward the neutral range in all subgroups (i.e., no changes in the preoperative neutral group; increased in the valgus group; decreased in the varus group). Conclusion: We recommend that surgeons leave the hindfoot untouched when they plan the MCWDFO to correct knee joint valgus malalignment concomitant with hindfoot valgus or varus deviation as the hindfoot malalignment appears to change towards neutral range postoperatively.

TT-TG distance decreases after open wedge distal femoral varization osteotomy in patients with genu valgum & patellar instability. A pilot 3D computed tomography simulation study

BackgroundGenu valgum is considered to be a risk factor for patellar instability. Correction of valgus alone or combined with a tibial tuberosity medialization has been described. However, changes occurring in the tibial tuberosity-trochlear groove (TT-TG) distance after a lateral distal femoral opening wedge osteotomy (LDF-OWO) are not known.PurposeThis study aimed to define changes in TT-TG distance with increasing amounts of valgus correction after LDF-OWO.MethodsThree-Dimensional Computed Tomography (3D-CT) scans of six patients (two females and four males) aged between 19 and 35 years with genu valgum and patellar instability were analyzed. 3D models of femoral, tibial, and patellar bones were created with the advanced segment option of Mimics 21® software. An oblique lateral opening wedge osteotomy of the distal femur was simulated in 2-degree increments up to 12 degrees of varus opening. Change in TT-TG distance was measured in mm on 3D models of the knee.ResultsCompared to baseline without osteotomy, the TT-TG distance decreased significantly (p < 0.05) for all corrections from 2 to 12 degrees in 2° steps. The TT-TG distance decreased by an average of 1.7 mm for every 2 degrees of varus opening.ConclusionLateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. The surgeon should be aware of the magnitude of this change (1.7 mm decrease for every 2° increment of valgus opening).

Outcome Prediction Model Following Proximal Femoral Osteotomy in Legg-Calvé-Perthes Disease Using Machine Learning Algorithms.

The purpose of the current study was (1) to analyze various factors that may be associated with the outcomes of Legg-Calvé-Perthes disease (LCPD), and (2) to develop and internally validate machine learning algorithms capable of providing patient-specific predictions of which patients with LCPD will achieve relevant improvement in radiologic outcomes after proximal femoral varus osteotomy (PFVO). We examined several variables, previously identified as factors, that may influence the outcome of LCPD and developed a machine learning algorithm based on them. In this retrospective study, we analyzed patients aged older than 6 years at the time of LCPD diagnosis who underwent PFVO at our institution between 1979 and 2015. Univariate and multivariate logistic regression analyses were used to examine the effects of variables on the sphericity of the femoral head at skeletal maturity, including age at onset, sex, stage at operation, extent of epiphyseal involvement and collapse, presence of specific epiphyseal, metaphyseal, and acetabular changes, and postoperative neck shaft angle (NSA). Recursive feature selection was used to identify the combination of variables from an initial pool of 13 features that optimized the model performance. Five machine learning algorithms [extreme gradient boosting (XGBoost), multilayer perception, support vector machine, elastic-net penalized logistic regression, and random forest) were trained using 5-fold cross-validation 3 times and applied to an independent testing set of patients. Ninety patients with LCPD who underwent PFVO were included in this study. The mean age at diagnosis was 7.93 (range, 6.0 to 12.33) years. The average follow-up period was 10.11 (range, 5.25 to 22.92) years. A combination of 8 variables, optimized algorithm performance, and specific cutoffs were found to decrease the likelihood of achieving the 1 or 2 Stulberg classification: age at onset ≤ 8.06, lateral classification ≤ B, 12.40 < preoperative migration percentage (MP) ≤ 22.85, Catterall classification ≤ 2, 117.4 < postoperative NSA ≤ 122.90, -10.8 < postoperative MP ≤ 6.5, 139.65 < preoperative NSA ≤ 144.67, and operation at stage 1. The XGBoost model demonstrated the best performance (F1 score: 0.78; area under the curve: 0.84). The XGBoost machine learning algorithm achieved the best performance in predicting the postoperative radiologic outcomes in patients with LCPD who underwent PFVO. In our population, age at onset ≤ 8.06, lateral classification ≤ B, 12.40 < preoperative MP ≤ 22.85, Catterall classification ≤ 2, 117.4 < postoperative NSA ≤ 122.90, -10.8 < postoperative MP ≤ 6.5, 139.65 < preoperative NSA ≤ 144.67, and operation at an early stage had the likelihood of achieving the spherical femoral head for the patients with LCPD that underwent PFVO. After external validation, the online application of this model may enhance shared decision-making. Level III-retrospective cohort study.

A modified angled plate for fixation of proximal femoral varus osteotomy in neuromuscular hip dislocation: Mechanical and clinical study

IntroductionProximal femoral osteotomy is an important step in the management of paralytic hip dislocation. Fixation by the angled plate is demanding and carries the risk of many complications. In this study, we made certain modifications for the angled plate. Does this plate provide a stable fixation for proximal femoral varus osteotomy? The main objective of this study was to assess the results of the modified plate in fixation of proximal femoral varus osteotomy in patients with neuromuscular hip dislocation. HypothesisThis new system would offer significant advantages over the existing systems in terms of easy application and stable fixation. Material and methodsTwenty patients with paralytic hip dislocation were included in this study. The ages ranged from 5 to 15 years with a mean of 8.88±2.92 years. There were 12 boys and 8 girls. Seventeen patients had cerebral palsy and 3 had meningocele disease. Preoperative radiographs were done, and the migration percentage (MP), acetabular index (AI), and neck-shaft angle (NSA) were measured. All patients were treated with open reduction, pelvic osteotomy, and proximal femoral varus osteotomy. The femoral osteotomy was fixed by the modified angled plate in all cases. ResultsThe osteotomy sites united in all patients and the mean time of union was 2.9±0.65 months. The acetabular index, migration percentage, and neck-shaft angle were reduced postoperatively. This reduction was statistically significant. The hips remained stable throughout the period of follow-up in all patients. No cases were complicated by non-union or implant failure. ConclusionThe modified angled plate (canulated interlocking blade Plate 90°) is a good method for the fixation of proximal femoral varus osteotomy in the management of neuromuscular hip dislocation. It provides a stable fixation. Level of evidenceIV; case series.

Effect of Medial Closing Wedge Distal Femoral Varization Osteotomy on Coronal Ankle and Hindfoot Alignment.

To date, only a few studies have reported postoperative changes in coronal ankle alignment after valgus knee correction through medial closing wedge distal femoral varization osteotomy (MCWDFO). This study aimed to measure the changes of MCWDFO on coronal ankle and hindfoot alignment. We retrospectively reviewed the radiographic findings of 27 consecutive patients (34 cases) with knee valgus malalignment who underwent MCWDFO for either lateral knee joint osteoarthritis (OA) or recurrent patellar subluxation/dislocation (RPD). Several radiographic parameters were measured and compared based on the reason for operation, followed by the status of preoperative hindfoot alignment (hindfoot alignment angle [HAA] > 4 degrees, varus; -4 degrees ≤HAA ≤ 4 degrees, neutral; HAA < -4 degrees, valgus) in each group. Overall, pre- and postoperative hindfoot alignments were within the neutral alignment range and were not significantly changed after the operation (P > .05). Nineteen cases were for lateral knee OA and 15 were for RPD, respectively. In both groups, preoperative neutral hindfoot alignments accounted for the largest portion (52.6% in the lateral OA group; 80.0% in the RPD group). Postoperatively, regardless of the reason for operation, hindfoot alignments changed toward the neutral range in all subgroups (ie, no changes in the preoperative neutral group; increased in the valgus group; decreased in the varus group). We recommend that surgeons leave the hindfoot untouched when they plan the MCWDFO to correct knee joint valgus malalignment concomitant with hindfoot valgus or varus deviation as the hindfoot malalignment appears to change toward the neutral range postoperatively. Level III, retrospective comparative study.

A Modified Angled Plate for Fixation of Proximal Femoral Varus Osteotomy in Paralytic Hip Dislocation

Objectives: Femoral osteotomy is an important step in the management of paralytic hip dysplasia. Fixation by the angled plate is demanding and carries the risk of many complications. In this study, we made certain modifications for the angled plate, and we aim to assess the results of the modified plate for fixation of proximal femoral varus osteotomy in paralytic hip dysplasia. Method: Twenty patients with paralytic hip dislocation were included in this study. The ages ranged from 5 to 15 years with an average of 9 years. There were 12 boys and 8 girls. Seventeen patients had cerebral palsy and 3 had meningocele disease. Pre-operative radiographs were done, and the migration percentage (MP), acetabular index (AI), and neck-shaft angle (NSA) were measured. All patients were treated by open reduction, pelvic osteotomy, and proximal femoral varus osteotomy. The femoral osteotomy was fixed by the modified angled plate in all cases. Results: The osteotomy sites united in all patients and the average time of union was 3 months. The acetabular index, migration percentage, and neck-shaft angle were reduced postoperatively. This reduction was statistically significant. The hips remained stable throughout the period of follow-up in all patients. No cases were complicated by nonunion or implant failure. Conclusion: The modified angled plate (canulated interlocking blade plate 90°) is a good method for the fixation of proximal femoral varus osteotomy in the management of paralytic hip dislocation. The modifications have made it easier for application and stable for fixation.

Closing wedge distal femoral osteotomy for knee valgus: indications, technique, rehabilitation and outcomes

IntroductionIn cases of symptomatic knee valgum, in which deformity majorly originated in the femoral distal metaphysis, 2 main types of femoral osteotomy have been described: medial closing or lateral opening. We have been doing medial closing wedges with anterior second plane cut for years. The reason being a proven similar surgical accuracy associated to a higher and faster healing rate promoted by a larger contact area between the 2 sides of the osteotomy site. The aim of this article is to describe up-to-date closing wedge distal femoral osteotomy strategies: from indication, to ideal correction, surgical technique and patient recovery. MethodsDistal femoral varus osteotomy is indicated in painful valgus knee in which deformity originated majorly in the femoral distal metaphysis. The planning is digitally performed according to the Miniaci method using digital software to have a postoperative weight bearing line passing through the knee joint at 45% to 50% measured from the medial tibial plateau border (0%) to the lateral tibial plateau border (100%). The procedure is performed through medial closing wedges created with 2 medial to lateral and 1 posterior to anterior cutting planes creating an anterior biplanar cut. ResultsUsing our step-by-step way to perform closing wedge distal femoral osteotomy, we standardized our radiological and clinical outcomes. Knowing some tips and tricks to avoid intraoperative complications will help readers to master this procedure. ConclusionsFollowing simple intraoperative landmark and technical guidance bony deformity can be fully corrected by medial closing wedges using an anterior biplanar cut. Patients will demonstrate optimal clinical outcomes including high rate of return to recreational and professional activities.

Blade plate versus locking plate fixation of proximal femoral varus osteotomy in children with cerebral palsy.

The hip is commonly affected in children with cerebral palsy (CP), requiring proximal femoral varus derotational osteotomies. Novel locking plates afford a popular alternative to traditional blade plates. The purpose of this study was to compare the effectiveness of blade plate versus locking plate fixation in children with CP undergoing proximal femoral osteotomy. We conducted a retrospective review of patients who underwent proximal femoral osteotomy over an 8-year period. Incidence of healing, failure of the procedure, and loss of varus correction were compared between the two groups (blade plate vs. locking plate). Independent samples t -tests and Chi-square analysis were employed to compare differences between continuous and categorical variables, respectively. A total of 268 hips [137 right (51.1%)] met inclusion criteria. Ninety-eight hips (36.6%) were fixed with blade plates [170 (63.4%) locking plates]. Although those in the blade plate cohort were more likely to achieve complete radiographic healing by 6 weeks postoperatively (41.09% vs. 18.84%; P < 0.050), there was no significant difference ( P > 0.050) between the two groups for healing at 3, 6, and 12 months ( P > 0.050). There was no significant difference between the two cohorts regarding the number of patients experiencing migration percentage at least 50% at 6 (3.06% vs. 3.53%) and 12 (3.06% vs. 5.88%) months ( P > 0.050) or in those undergoing revision surgery at 12 (5.33% vs. 1.18%) and 24 (2.04% vs. 1.76%) months ( P > 0.050). The findings of this retrospective study show similar outcomes between blade plate and proximal femoral locking plates in proximal femoral varus osteotomy in children with CP.

Experimental study of risk of medial hinge fracture during distal femoral varus osteotomy

IntroductionLateral opening wedge distal femoral osteotomy (LOWDFO) is indicated for isolated lateral osteoarthritis in the valgus morphotype. Medial hinge fracture is a factor for poor prognosis. The present study had two aims: (1) to assess the impact of a temporary K-wire on hinge fracture risk; and (2) to assess the impact of LOWDFO opening speed. HypothesisThe main study hypothesis was that a temporary hinge K-wire reduces hinge fracture risk. The second hypothesis was that faster opening speed increases fracture risk. Material and methodTwenty femurs were produced by 3D printing from a CT database, reproducing LOWDFO anatomy. The ABS® polymer showed the same breaking-point behavior as human bone. Ten specimens were included in the “K-wire” group (KW+) and 10 in the “No K-wire” group (KW−). To determine high and low speed, a motion-capture glove was used by 2 operators, providing 3D modeling of the surgeon's hand. High speed was defined as 152mm/min and low speed as 38mm/min. The KW+ and KW− groups were subdivided into high- and low-speed subgroups (HS, LS) of 5 each. Compression tests were conducted using an Instron® mechanical test machine up to hinge fracture. The main endpoint was maximum breaking-point force (N); the secondary endpoints were maximum displacement (mm) and maximum speed (min) at breaking point. ResultsThe K-wire significantly increased maximum breaking-point force (LS, 143.08N vs. 93.71N, p<0.01; and HS, 186.98N vs. 95.22N, p<0.01), but not maximum displacement (LS, 26.17mm vs. 24.11mm, p=0.31; and HS 26.18mm vs. 23.66mm, p=0.14) or maximum time (LS, 27.07s vs. 24.94s, p=0.31; and HS, 5.24s vs. 4.73s, p=0.14). Speed did not affect maximum force (KW+, 143.08N vs. 186.98N, p=0.06; and KW−, 93.71N vs. 95.22N, p=0.42) or maximum displacement (KW+, 26.17mm vs. 26.18mm, p=1; and KW−, 24.11mm vs. 23.66mm, p=0.69). Only maximum time was greater at low speed (KW+, 27.07s vs. 5.24s, p>0.01; and KW−, 24.94s vs. 4.73s, p<0.01), which is obvious for constant distance. DiscussionThe first study hypothesis was confirmed, with significantly lower hinge fracture risk with the K-wire, independently of opening speed. The second hypothesis was not confirmed. The study was performed under strict experimental conditions, unprecedented to our knowledge in the literature. However, complementary clinical studies are needed to confirm the present findings. Level of evidenceIV, experimental study.

Does Prolonged Weight Relief Increase the Chances of a Favourable Outcome After Containment for Perthes Disease?

We have been treating children with Legg-Calvé-Perthes disease (LCPD) with a femoral varus osteotomy (PFVO) and weight relief till the disease evolves to the latter part of the stage of reconstitution (Stage IIIb). This entails weight relief for 18 to 24 months. We undertook this case-control study to test if a shorter period of weight relief would compromise the chance of retaining the spherical shape of the femoral head when the disease healed. Forty-one children diagnosed in the early stages of LCPD (Stages Ia, Ib, and IIa), were treated by PFVO and non-weight-bearing for a period of 6 months following surgery (6m group). Eighty-two children with LCPD matched for age, sex, and stage at surgery, who resumed weight-bearing only once they reached Stage IIIb, served as the control group (3b group). Both groups were followed up till the disease healed. The sphericity deviation score was calculated, and the height and width of the epiphysis were measured on the first radiograph designated as Stage IV. The median sphericity deviation score value at healing was 3 in the 3b group and 11 in the 6m group (P<0.001). The frequency of spherical heads was 76% in the 3b group and 49% in the 6m group (P<0.003). The Odds Ratio of the disease healing with an aspherical head in 6-month group was 3.05 (CI: 1.28 to 7.22) compared with the 3b group. The percentage increase in width of the femoral epiphysis at healing was greater in the 6 group (111.5±8.5% vs. 106.5±7.2%; P<0.001). The study confirms that containment by PFVO performed early in the course of LCPD combined with weight relief till the disease has evolved to Stage IIIb is likely to result in spherical hips in 75% of children. Reducing the period of weight relief to 6 months may yield significantly poorer results with only 49% spherical femoral heads.

Does Flexion Varus Osteotomy Improve Radiographic Findings Compared With Patients Treated in a Brace for Late-onset Legg-Calvé-Perthes Disease?

Does Flexion Varus Osteotomy Improve Radiographic Findings Compared With Patients Treated in a Brace for Late-onset Legg-Calvé-Perthes Disease?

Medial Closing-Wedge Distal Femoral Varus Osteotomy via Lateral Approach: The Modified Technique for Treating Valgus Osteoarthritic Knee as Case Series

Objective: The medial closing-wedge distal femoral varus osteotomy (MCW-DFVO) was an excellent operation for painful valgus lateral unicompartmental osteoarthritic (OA) knee, especially in the young patient. Originally, it requires a medial approach that has more precarious. On top of that, releasing of the iliotibial band that is the deforming force needs added incision. Therefore, this study aims to describe the modified surgical technique of MCW-DFVO that uses a lateral approach and lateral plating to treat the valgus OA knee. Additionally, we also reveal the outcomes of our technique as the case series.&#x0D; Materials and Methods: Ten patients (12 knees) who underwent MCW-DFVO via a lateral approach were retrospectively reviewed. The inclusion criteria were age 18-60 years, isolated lateral compartmental OA knee (Kellgren-Lawrence grade 3-4), no significant patellofemoral pain, and range of motion (ROM) &gt; 90 degrees. We excluded the inflammatory joint disease, unstable knee (femorotibial joint subluxation &gt; 1 cm), and prior surgical procedure. Demographic data, pre- and postoperative ROM, radiographic outcomes, complications, and survivorship were recorded.&#x0D; Results: The mean age, body mass index, and preoperative ROM were 55.3 ± 4.0 years, 25.4 ± 3.7 kg/m2 and 113.3 ± 11.5 degrees, respectively. The preoperative mechanical femorotibial angle was 162.3 ± 4.8 degrees, and the final post-operative alignment was 182.3 ± 2.6 degrees. Overall mean operative time of this technique was 92.5 ± 26.7 minutes. During the mean follow-up period of 8.3 ± 3.1 years, all osteotomy were united and the final postoperative ROM was decreased to 108.8 ± 11.7 degrees. One knee required plate removal due to hardware irritation, and another knee required subsequent total knee arthroplasty at 1 and 8.5 years after MCW-DFVO, respectively. The survivorship of this technique was 91.7% at the mean survival time of 13.8 years (95% confidence interval, 11.9 – 15.7 years).&#x0D; Conclusion: This study proposed the modified surgical technique of MCW-DFVO via a lateral approach. This technique provided the excellent correction angle, union rate and survivorship.

Proximal femoral varus osteotomy in Legg-Calve-Perthes disease

OperationszielDie proximale femorale Varisationsosteotomie (PVO) ist eine chirurgische Technik zur Rezentrierung des Hüftkopfes, sofern es bspw. im Rahmen der ablaufenden Legg-Calvé-Perthes(LCPD)-Krankheit zur Subluxation gekommen ist.IndikationenBis anhin existieren keine einheitlichen Indikationskriterien für die Containment-Therapie bei LCPD-Patienten. Einzelne, für die Deformitätsentwicklung prädiktive radiologische Faktoren, Alter bei Diagnosestellung oder Symptombeginn und Klassifikationen, welche die Pathomorphologie des Femurkopfes bezogen auf die Nekrose beschreiben, können die Indikationsstellung erleichtern.KontraindikationenDie absolute Kontraindikation stellt die Entwicklung eines Scharniergelenkes dar (Hinge-Abduktion). Bleibt der Femurkopf in einer Abduktionsröntgenaufnahme von 20° auch in Abwesenheit einer Hinge-Abduktion dezentriert oder besteht ein Total-Kopf-Befall, ergibt sich ebenfalls eine Kontraindikation. Relativ kontraindiziert ist die PVO bei Kindern mit Beginn der Erkrankung < 6 Jahren, in der Lateral-Pillar-Klassifikation Gruppe A soiwe bei I und II nach Catterall.OperationstechnikLateraler Standardzugang zum proximalen Femur. Platzieren des Anteversions-K-Drahtes ventral des Schenkelhalses. Weitere K-Drähte werden parallel mithilfe von Positionierinstrumenten in den Schenkelhals eingebracht. Der optimale Bereich für die Osteotomie wird aufgesucht. Für die Vereinfachung der Manipulation des distalen Fragments und als Referenz für die Derotation werden am Femurschaft weitere K‑Drähte eingebracht. Nach Femurosteotomie erfolgt proximales Fixieren der Platte durch sukzessives Auswechseln der K‑Drähte gegen winkelstabile Schrauben. Die interfragmentäre Kompression erzeugt eine exzentrisch positionierte Kortikalisschraube im mittleren distalen Plattenloch. Die weitere distale Fixation der Platte erfolgt mit winkelstabilen Schrauben. Auswechseln der Kortikalisschraube gegen eine weitere winkelstabile Schraube. Alternativ zur hier beschriebenen winkelstabilen Technik wurde früher meist mittels Winkelplatte korrigiert.WeiterbehandlungMobilisation unter Abrollbelastung an 2 Gehstöcken über 6 Wochen. Röntgenkontrolle und bei genügender Knochenkonsolidation Steigerung der Belastung. Implantatentfernung nach 9 bis 12 Monaten. Rückkehr zum Sport ab 3 Monaten.ErgebnisseDie PVO ist eine in der Behandlung von LCPD nahezu seit 60 Jahren angewendete und weltweit etablierte chirurgische Technik. Durch ein stetig wachsendes Verständnis der Grunderkrankung wird einerseits die Indikationsstellung für operative Interventionen optimiert. Andererseits tragen neue Implantate zur Verbesserung der klinisch-radiologischen Resultate und Verringerung von Komplikationen während und nach Operation bei.

Massive “risotto bursitis” of the great trochanter bursa after proximal femoral varus osteotomy with 5,0 LCP- a case report

The “risotto phenomenon” is a rare pathologic finding, mostly seen as a nonspecific response to chronic inflammation around the shoulder joint- subacromial and subdeltoid bursitis, rheumatoid arthritis, sero-negative inflammatory arthritis, septic arthritis and tuberculous arthritis. A few scientific reports associate rice body formation with the use of different type of osteosynthesis, bony anchors and bioabsorbable sutures. They are usually an incidental asymptomatic finding, requiring no specific treatment, but could be symptomatic demanding surgical excision. We present the clinical case of a 17-year- old female patient with a “risotto bursitis” of the great trochanter bursa, documented during planned surgical removal of a locking compression plate after proximal femoral varus osteotomy for bilateral developmental dysplasia of the hip treatment.

Proximal femoral varus osteotomies in childhood-development of osteosynthesis materials

Proximal femoral osteotomies are one of the most commonly used surgical techniques and play an important role in the spatial correction of the hip joint in a number of pediatric orthopedic disorders such as Legg-Calve-Perthes disease, Slipped capital femoral epiphysis, Developmental dysplasia of the hip, osteoarthritis, etc.14,21,23,28,30,31&#x0D; The development of orthopaedic osteosynthesis for fixation of bone fragments includes the use of Kirschner wires, intraosseous nail plates, AO-plates with fixed angle, external fixators, etc. Over time, many of the techniques and osteosynthesis materials have fallen into disuse and have remained only of historical significance.&#x0D; The purpose of this study is to follow how osteosynthesis fixation devices for varus osteotomies in the proximal femur have historically evolved and developed from the beginning to the present.