Varus Group Research Articles

Humeral stem alignment of curved short stem in reverse shoulder arthroplasty: Varus/Valgus alignment is not a determinant for clinical outcomes

BackgroundThis study aimed to investigate the influence of curved short stem alignment within the proximal humerus on the clinical outcomes of reverse shoulder arthroplasty. We hypothesized that the varus/valgus alignment would yield clinical outcomes comparable to those of a neutral alignment. MethodsWe retrospectively reviewed 167 patients who underwent reverse shoulder arthroplasty using the Aequalis Ascend Flex implant between January 2017 and December 2021. The study categorized the patients into three groups based on the angle difference between the humeral axis and the stem axis: neutral group (GN, defined as within ±5 degrees), valgus group (GL), and varus group (GR). Functional outcomes were assessed using the visual analog scale pain score, subjective shoulder value, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and active range of motion. Routine radiographic evaluations were also conducted to assess the filling ratio and bone resorption. ResultsAmong 138 patients, 89 were in the GN group, 37 (27%) in the GL group, and 12 (9%) in the GR group. The average degree of varus alignment was 6 (range from 5 to 7 degrees), while the average degree of valgus alignment was -7 (range from -8 to -5 degrees). According to our findings, the clinical outcomes did not exhibit significant differences between the three groups. Furthermore, the radiological outcomes showed no significant differences among the three groups. ConclusionsCompared to neutral alignment, varus or valgus alignment of the humeral stem in reverse shoulder arthroplasty using a curved short stem does not significantly affect clinical outcomes.

Outcomes After Osteochondral Allograft Transplantation of the Medial Femoral Condyle in Patients With Varus and Nonvarus Alignment

Background: Fresh osteochondral allograft (OCA) transplantation is an effective technique for the treatment of focal chondral and osteochondral defects in the knee. Coronal-plane malalignment leads to increased contact forces within a compartment and subsequently the cartilage repair site and may lead to higher failure rates. However, the magnitude of the effect of coronal-plane malalignment on graft survivorship and clinical outcomes has not been well characterized. Purpose: To evaluate how varus malalignment affects graft survival and patient-reported outcomes after isolated OCA transplantation of the medial femoral condyle (MFC). Study Design: Cohort study; Level of evidence, 3. Methods: A total of 70 patients (74 knees) who underwent primary OCA transplantation of the MFC between 2005 and 2019 were identified from a prospectively collected single-surgeon cartilage registry with a minimum 2-year follow-up. Coronal-plane alignment was evaluated utilizing standing hip-to-ankle radiographs. OCA failure, defined as removal of the graft or conversion to arthroplasty, and reoperations were recorded. Patient-reported outcomes were obtained preoperatively and postoperatively using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, modified Merle d’Aubigné–Postel score, and overall patient satisfaction score. Results: The mean mechanical tibiofemoral angle for patients with varus alignment was 3.9° of varus (range, 1.1° to 8.9°) and for patients with nonvarus alignment it was 0.02° of valgus (range, 3.6° varus to 4.6° valgus). Graft survivorship was 95.3% in the varus group and 95.8% in the nonvarus group (P = .918) at 5 years postoperatively. Reoperations after OCA transplantation occurred in 14.0% of the varus group and 22.6% of the nonvarus group (P = .336). The mean International Knee Documentation Committee total score improved from 45.2 preoperatively to 74.8 at latest follow-up in the varus group and from 40.5 preoperatively to 72.3 at latest follow-up in the nonvarus group. Patient satisfaction was >85%. Conclusion: Patients undergoing isolated OCA transplantation of the MFC had high rates (>90%) of graft survivorship and significant improvements in pain and function. Patients with mild preexisting varus malalignment were found to have no difference in the failure rate or clinical outcomes compared with patients with nonvarus alignment.

Effect of inverse kinematic alignment total knee arthroplasty on coronal alignment of the ankle joint in patients with varus knee deformity.

Varus or valgus knee deformities influence ankle coronal alignments. The impact of Total Knee Arthroplasty (TKA) on ankle joint alignment has not been entirely illustrated. Inverse Kinematic Alignment (iKA) is a surgical philosophy that aims to restore soft tissue balance, function, and native anatomy within validated boundaries to restore restrictive native kinematics. Therefore, this study aimed to investigate the postoperative association of patient-specific alignment on the coronal alignment of the ankle in patients with varus knee deformity who underwent iKA TKA. We hypothesized that greater preoperative varus malalignments would correlate with significant postoperative ankle coronal alignment changes. This retrospective study of a prospective collected cohort assessed patients who underwent imageless navigation assisted robotic TKA using a single implant design for primary osteoarthritis between January 2022 and August 2023. Preoperative and postoperative full-length standing anteroposterior X-ray imaging was used to measure Hip-Knee-Ankle (HKA), Tibial Plafond Inclination (TPI), Talar inclination (TI), and Tibiotalar Tilt (TTT) angles. Patients were subsequently divided into groups of neutral varus) < 10°) and severe varus (≥ 10°) according to the preoperative HKA angle. Significant changes in preoperative and postoperative HKA angles were found in the severe varus (14.5° vs. 6.4°, p < 0.001) group. Changes were also significant between preoperative and postoperative TPI and TI angles in the severe varus group; however, TTT did not reach statistical significance. Delta change from pre- to postoperative HKA was significantly higher for the severe varus group (8.1° vs. 0.8°, p < 0.019). Delta change of TPI, TI and TTT did not differ between groups. Coronal knee alignment after TKA affects coronal alignment of the ankle. iKA technique in TKA for varus knee deformity preserves or minimizes substantial coronal alignment changes of the ankle joint. These findings may add to the benefits reported for patient specific alignment TKA techniques. III.

Total Ankle Arthroplasty as a Correction Tool for Foot Deformities: Analyzing the Impact on Medial Column Alignment Adaptation Through Weightbearing Computed Tomography.

While weightbearing computed tomography (WBCT) has been instrumental in analyzing total ankle arthroplasty (TAA) positioning, there is a notable gap in the literature regarding adaptive changes in the foot's medial column after TAA. This study aims to bridge this gap by comparing preoperative and postoperative alignments of the foot's medial column and analyzing if a correlation exists between TAA coronal alignment correction and medial column alignment adaptation. Sixty patients who underwent a lateral approach TAA for end-stage osteoarthritis (OA) between January 2021 and April 2023 were included in this retrospective study. Patients were divided into varus (n = 30) and valgus (n = 30) groups. Preoperative and postoperative WBCT scans were analyzed to measure medial column alignment. Statistical analysis evaluated alignment corrections and correlations. Both groups showed significant plantarflexion of the second tarsometatarsal (TMT) angle, with a median adaptation of -1 degree (IQR -3, 0; P < .01) in the valgus group and -1 degree (IQR -3, 0; P = .03) in the varus group. The varus group exhibited increased plantarflexion of the first TMT angle (median -1 degree, IQR -1, -2; P = .03). Both groups demonstrated increased adduction of the medial column. The talonavicular coverage angle adaptation averaged 7.2 ± 14 degrees (P < .01) in the valgus and 9 ± 12 degrees (P < .01) in the varus group. The talo-first metatarsal axial angle adaptation was 5 ± 13 degrees (P = .03) in the valgus group and 9.5 ± 15 degrees (P = .08) in the varus group. WBCT analysis revealed significant medial column adaptation post-TAA in varus and valgus alignments. However, no correlation was found between hindfoot correction and forefoot adaptation, making it challenging to predict the need for additional realignment surgeries. Future studies should explore the relationship between tibiotalar correction and medial column alignment to improve outcomes and the influence of total ankle design on medial column adaptation. Level III, retrospective case control study.

Variability in Alignment and Bone Resections in Robotically Balanced Total Knee Arthroplasties.

Image-based robotic-assisted total knee arthroplasty (RA-TKA) allows three-dimensional surgical planning informed by osseous anatomy, with intraoperative adjustment based on a dynamic assessment of ligament laxity and gap balance. The aim of this study was to identify ranges of implant alignment and bone resections with RA-TKA. We retrospectively reviewed 484 primary RA-TKA cases, stratified by preoperative coronal alignment. Demographics and intraoperative data were collected and compared using Chi-square and ANOVA tests. Planned limb, femoral, and tibial alignment became increasingly varus in a progressive order from valgus to neutral to the highest in varus knees (p < 0.001). Planned external transverse rotation relative to the TEA was lowest in the valgus cohort; relative to the PCA, whereas the varus cohort was highest (p < 0.001, both). Planned resections of the lateral distal femur and of the medial posterior femur were greater in the varus group compared to neutral and valgus (p < 0.001). There were significant differences between cohorts in planned tibia resections, laterally and medially. Varus knees demonstrated higher variability, while valgus and neutral had more metrics with low variability. This study demonstrated trends in intraoperative planned alignment and resection metrics across various preoperative coronal knee alignments. These findings contribute to the understanding of RA-TKA and may inform surgical decision-making.

The relationship between the femoral artery and vastus medialis muscle coverage at the adductor hiatus during medial closed wedge distal femoral osteotomy in valgus knees.

The purpose of this study was to examine the location where the femoral artery contacts the vastus medialis at the adductor tendon hiatus, which is important when using the subvastus approach in medial closed wedge distal femoral osteotomy. We evaluated the correlation between differences in height, vastus medialis morphology, and lower limb alignment. Sixty knees (16 male, 44 female) that underwent plain computer tomography (CT) were included. Using the radiographic hip-knee-ankle (HKA) angle as a reference, the knees were divided into three groups of 20 knees: valgus, varus, and neutral. The mechanical lateral distal femoral angle (mLDFA) and distance from the medial femoral epicondyle to the centre of the femoral head (D1) were measured on full-length weight-bearing anteroposterior radiographs. The first cross-section on CT where the vastus medialis muscle and femoral artery connect was defined as the cross-sectional image for measurement. The direct distance from the medial epicondyle to the measured cross-sectional image (D2) was measured in the coronal view. The ratio of the vastus medialis muscle width to the femoral posterior wall width was defined as the vastus medialis muscle coverage ratio (CR). Correlations between each measurement and group were evaluated. There was a positive correlation between D1 and D2 in the overall, neutral, and varus groups; however, there was no correlation in the valgus group. A positive correlation was observed in terms of the relationship between CR and D2 in the overall and valgus groups. In addition, there was no statistically significant difference in the correlation between the mLDFA and D2, with patient height as a control variable overall and in all groups. In the valgus group, distance to the adductor hiatus was correlated with vastus medialis coverage. Overhang of the vastus medialis may be an important influencing factor of femoral and popliteus artery position. Level III, retrospective cohort study.

Impact of postoperative femorotibial axis on functional outcomes in unicompartmental knee arthroplasty.

This study aimed to compare the functional outcomes of patients undergoing fixed-bearing medial unicompartmental knee arthroplasty (UKA) classified as either varus or neutral based on their postoperative femorotibial angle (FTA), with the goal of evaluating the impact of FTA on functional results. A total of 38 knees of 35 patients (27 females, 8 males; mean age: 63.6±7.1 years; range, 52 to 75 years) were included in this retrospective study. The data was collected between December 15, 2020, and January 15, 2021. Patients were categorized into two groups based on their postoperative FTA. The neutral group consisted of patients with an FTA range of 5.1° to 7.4°, while the varus group included patients with an FTA range of 0.1° to 4.8°. Knee Outcome Osteoarthritis Score (KOOS), Visual Analog Scale (VAS) scores, sit to stand test results, and six minute walk test data were analyzed. The mean follow-up was 42.0±19.3 months. The postoperative VAS score for the varus group was 0.95±0.99, whereas the neutral group had a VAS score of 2.19±1.83 (p=0.021). The mean KOOS for the varus group was 88.01±7.88, whereas the neutral group had a mean KOOS score of 78.46±13.69 (p=0.006). In patients undergoing UKA, mild varus alignment could yield superior early and midterm functional outcomes compared to a neutral femorotibial angle.

Tibia-first, gap-balanced patient-specific alignment restores bony phenotypes and joint line obliquity in a great majority of varus and straight knees and normalises valgus and severe varus deformities.

The present study focuses on testing the capability of a restricted tibia-first, gap-balanced patient-specific alignment technique (PSA) to restore bony morphology and phenotypes. Three-hundred and sixty-seven patients were treated with navigated total knee arthroplastyand tibia-first gap-balanced PSA technique. Boundaries for medial proximal tibial angle were 86°-92°, mechanical lateral distal femoral angle 86°-92°, and hip-knee-ankle angle175°-183°. Knees were classified by coronal plane alignment of the knee (CPAK), with subsequent analyses comparing pre- and postoperative distributions. Phenotype classification within CPAK groups assessed pre- and postoperative distributions. Preoperatively, the largest CPAK group was type II (30.8%), followed by type I (20.5%) and type V (17.8%). Postoperatively, type II remained the largest group (39%), followed by type V (30%). All groups with varus/valgus deformities (I, III, IV and VI) became smaller. While in straight legs (II, IV), the CPAK was restored in more than 70%-75%, in varus groups (I, IV) in 40%-50%and in valgus (III and VI) in 5%-18%. The joint line obliquity remained the same in the majority of knees (straight >75%; varus 63%-80%; valgus VI 95%), with the exception of CPAK III (40%). The phenotype analysis showed for straight legs a phenotype restoration of 85%, for varus 94% and for valgus 37%. Joint line convergence anglewas reduced significantly in all groups from 1.8°-4.3° preoperatively to 0.6°-1.2° postoperatively. PSA restores bony phenotypes and joint line obliquity in the majority of straight and varus knees, while most of the valgus and extreme varus knees are normalised. Level III, retrospective cohort study.

The Effect of Severe Varus Deformity on Clinical and Radiographic Outcomes in Mechanical Aligned Total Knee Arthroplasty with Medial Stabilizing Technique.

Background: The purpose was to compare the clinical and radiographic outcomes between preoperative mild and severe varus deformity after total knee arthroplasty (TKA) with medial stabilizing technique (MST). Methods: We retrospectively analyzed 158 knees of 125 female patients with a 2-year follow-up who underwent mechanically aligned TKA with MST between April 2018 and February 2021. Patients were divided into two groups; the severe varus group was defined as one with preoperative hip-knee ankle (HKA) angle ≥ 15° and the mild varus group with HKA angle < 15°. Pre- and post-operative clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index, Knee Society Knee Score) and radiographic outcomes (medial proximal tibial angle (MPTA), HKA angle, lateral distal femoral angle (LDFA), joint line distance, and femoral component rotation angle) were compared between the groups. Results: Among the 158 knees analyzed, 131 and 27 were allocated to the mild and severe varus groups, respectively. Preoperative data showed that the MPTA (84.7° ± 2.8° vs. 80.7° ± 3.2°, p < 0.001) was significantly less in the severe varus group. In postoperative data, clinical outcomes were not different between the groups. Joint line distance (18.4 mm ± 2.8 mm vs. 18.6 mm ± 2.7 mm, p = 0.676) was also not significantly different. Femoral component rotation angle (-1.7° ± 1.0° vs. -1.0° ± 1.3°, p = 0.018) was more externally rotated in the severe varus group. Conclusions: Severe varus group showed comparable clinical and radiographic outcomes to that of mild varus group after mechanically aligned TKA with MST.

Is Quadriceps-Strengthening Exercises (QSE) in Medial-Compartment Knee Osteoarthritis with Neutral and Varus Malalignment a Paradox? - A Risk-Appraisal of Strength-Training on Disease Progression.

The present inquiry seeks to investigate whether the current regimens of QSEs (Quadriceps-Strengthening Exercises) aggravate the disease while mitigating symptoms. A comparative study was conducted on 32 patients with medial compartment osteoarthritis of knees. While the neutral group of 16 patients was constituted of those with an anatomical-lateral-femoro-tibial-angle (aFTA) 176-180º, varus group comprised an equal number of patients with an aFTA >180º. A home-based 12-week strength-training program involving weekly visits to hospital for supervised sessions was administered. The outcome measures were visual-analog-scale (VAS), medial patello-femoral joint tenderness (MPFJT), time-up-and-go-test (TUGT), stair-climb test, step test, WOMAC, IKDC scores, aFTA, hip-knee-ankle (HKA) angle, lateral-tibio-femoral-joint-separation (LTFJS), and horizontal-distance-from-centre-of-knee-to-Mikulicz-line. There was a significant increase in quadriceps strength (p<0.01) in both groups. Values for neutral group with VAS score (p=0.01), MPFJT (p=0.01), TUGT (p=0.01), timing of the stair climb test (p=0.01), WOMAC (p<0.01), and IKDC (p=0.03) were better compared to varus group with VAS score (p=0.13), MPFJT (p=0.03), TUGT (p=0.90), timing of stair climb test (p=0.68), WOMAC (p<0.02), and IKDC (p=0.05). Varus group also showed an increase in aFTA and LTFJS in 12 patients, increase in HKA in 11, and increase in horizontal distance from the centre of knee to the Mikulicz line in 7 patients. The present study brings to the fore the paradoxical role played by QSEs in management of medial knee OA. While there is a radiological progression of the disease in both neutral and varus mal-aligned knees more so in the latter than the former.

Preoperative Hindfoot Alignment and Outcomes After High Tibial Osteotomy for Varus Knee Osteoarthritis: We Walk on Our Heel, Not Our Ankle.

This article was updated on May 15, 2024 because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 898, in the section entitled "Materials and Methods," the sentence that had read "The WBL ratio of the knee joint was defined as the point where the GA or MA passed through the width of the tibia and intersected a line from the center of the femoral head to the center of the calcaneus (for the GA) or talus (for the MA), with the medial edge defined as 0% and the lateral edge as 100%." now reads "The WBL ratio of the knee joint was defined as the point where the GA or MA passed through the width of the tibia and intersected a line from the center of the femoral head to the lowest point of the calcaneus (for the GA) or the center of the talus (for the MA), with the medial edge defined as 0% and the lateral edge as 100%." Likewise, in the legend for Figure 3 on page 899, the sentence that had read "Depiction of the ground mechanical axis (GA), defined as the line (represented by the solid red line) from the center of the femoral head to the ground reaction point at the center of the calcaneus, passing lateral to the traditional mechanical axis (MA; represented by the dashed red line)." now reads "Depiction of the ground mechanical axis (GA), defined as the line (represented by the solid red line) from the center of the femoral head to the ground reaction point at the lowest point of the calcaneus, passing lateral to the traditional mechanical axis (MA; represented by the dashed red line)." Finally, on page 903, "HKA" was changed to "HKA angle" in Table III. The hip-to-calcaneus axis, previously known as the ground mechanical axis (GA), ideally passes through the center of the knee joint in the native knee. The aim of this study was to elucidate, with use of hip-to-calcaneus radiographs, changes in knee and hindfoot alignment and changes in outcomes following high tibial osteotomy (HTO). We reviewed the records for 128 patients who underwent HTO between 2018 and 2020. Patients were stratified into 2 groups, a hindfoot valgus group (n = 94) and a hindfoot varus group (n = 34), on the basis of their preoperative hindfoot alignment. The hindfoot alignment was evaluated with use of the hindfoot alignment angle (HAA). To evaluate lower-limb alignment, full-length standing posteroanterior hip-to-calcaneus radiographs were utilized to measure 4 radiographic parameters preoperatively and 2 years postoperatively: the hip-knee-ankle (HKA) angle, hip-knee-calcaneus (HKC) angle, and the weight-bearing line (WBL) ratios of the mechanical axis (MA) and GA. The mean HAA improved significantly from 5.1° valgus preoperatively to 1.9° valgus postoperatively in the hindfoot valgus group (p < 0.001). In contrast, in the hindfoot varus group, the HAA showed no meaningful improvement in the coronal alignment of the hindfoot following HTO (p = 0.236). The postoperative mean HKC angle in the hindfoot varus group was 2° more varus than that in the hindfoot valgus group (1.0° versus 3.0°; p = 0.001), and the GA in the hindfoot varus group passed across the knee 8.0% more medially than that in the hindfoot valgus group (55% versus 63% from the most medial to the most lateral part of the tibial plateau). The hindfoot varus group had worse postoperative clinical outcomes than the hindfoot valgus group in terms of the mean Knee injury and Osteoarthritis Outcome Score for pain and American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score. Although our findings did not provide sufficient evidence to establish clinically relevant differences between the groups, they indicated that the group with a preoperative fixed hindfoot varus deformity had a higher rate of undercorrection and worse clinical outcomes, especially pain, following HTO. Therefore, modification of the procedure to shift the GA more laterally may be required for these patients. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Varus-valgus alignment of humeral short stem in reverse total shoulder arthroplasty: does it really matter?

BackgroundThe utilization of short humeral stems in reverse total shoulder arthroplasty (RTSA) has gained attention in recent times. However, concerns regarding the risk of misalignment during implant insertion are associated with their use. MethodsEight fresh-frozen cadaveric shoulders were prepared for dissection and biomechanical testing. A bespoke humeral implant was fabricated to facilitate assessment of neutral, varus, and valgus alignments using a single stem, and 10° was established as the maximum permissible angle for misalignments. Shift in humerus position and changes in deltoid length attributable to misalignments relative to the neutral position were evaluated using a Microscribe 3DLx system. The impingement-free range of motion (IFROM), encompassing abduction, adduction, internal rotation (IR), and external rotation (ER), was gauged using a digital goniometer. The capacity for abduction was evaluated at maximal abduction angles under successive loading on the middle deltoid. A specialized traction system coupled with a force transducer was employed to measure anterior dislocation forces. ResultsRelative to the neutral alignment, valgus alignment resulted in a more distal (10.5 ± 2.4 mm) and medial (8.3 ± 2.2 mm) translation of the humeral component, whereas the varus alignment resulted in the humerus shifting more superiorly (11.2 ± 1.3 mm) and laterally (9.9 ± 0.9 mm) at 0° abduction. The valgus alignment exhibited the highest abduction angle than neutral alignment (86.2°, P<0.001). Conversely, the varus alignment demonstrated significantly higher adduction (18.4±7.4°, P<0.001), IR (68.9±15.0°, P=0.014), and ER (45.2±10.5°, P=0.002) at 0° abduction compared to the neutral alignments. Anterior dislocation forces were considerably lower (23.8N) in the varus group compared to the neutral group at 0°ER (P=0.047). Additionally, abduction capability was markedly higher in varus alignment at low deltoid loads than the neutral alignment (5N, P=0.009; 7.5N, P=0.007). ConclusionsThe varus position enhances rotational ROM but increases instability, while the valgus position does not significantly impact ROM or instability compared to the neutral position.

Comparison of clinical, imaging and second-look arthroscopic outcomes between varus knee patients with and without preoperative tibial varus deformity after medial opening-wedge high tibial osteotomy

PurposeThis study aimed to compare the regeneration status of articular cartilage, clinical, and radiologic outcomes between varus knee patients with and without preoperative tibial varus deformity (PTVD) after medial opening-wedge high tibial osteotomy (OWHTO) MethodsVarus knee patients who had undergone OWHTO were divided into two groups according to preoperative medial proximal tibial angle (MPTA): a great varus (GV) group (MPTA <85°) and a mild varus (MV) group (85°≤preoperative MPTA <87°). The hip–knee–ankle (HKA) angle, weight-bearing line ratio (WBL%), MPTA, joint line convergence angle and joint line obliquity were measured. Second-look arthroscopy was undertaken 24 months after HTO. The Knee Society (KS) function score and knee score, and Lysholm score were used to evaluate the functional outcomes. All parameters were evaluated preoperatively and 24 months after HTO. ResultsThe GV group had greater varus than the MV group in HKA and WBL% before surgery, but greater valgus after surgery. The arthroscopic probe before HTO revealed the advanced chondral damage in the GV group and lighter chondral damage in the MV group. The regeneration of medial femoral condyle was considerably more frequent in the GV group (72.5%, 45/62) than in the MV group (50.0%, 27/54) (P = 0.030). No significant differences were observed in all functional outcomes preoperatively and 24 months after HTO. ConclusionThe extent of cartilage regeneration in patients without PTVD was inferior to that in those with PTVD, but the functional outcomes were comparable. OWHTO may be a treatment option in a selected subset of varus knee patients without PTVD.

The influence of varus and valgus deviation on the contact area of patellofemoral joint in healthy knees

ObjectVarus-valgus lower alignment is a risk factor for patellofemoral osteoarthritis, but malalignment alone affect not only the tibiofemoral joint but also the patellofemoral joint. The aim of the present study was to analyse the contact area of patellofemoral joint in varus alignment and valgus alignment of healthy subjects using magnetic resonance imaging.MethodsTwenty-six healthy subjects with valgus lower limb alignment (Group I, n = 26) and twenty-six volunteers with varus lower limb alignment (Group II, n = 26) was performed. An MRI scan was used to capture and measure the patellofemoral joint articular cartilage contact area at different degrees of knee flexion (20°, 40°,60°) in passive movement. All subjects were categorized on the basis of the global limb alignment and mechanical alignment of the femur and tibia. Varus alignment is hip–knee–ankle angle ≥ 3°; and valgus alignment is hip–knee–ankle angle ≥ − 3°. To obtain medial facet contact area and lateral facet contact area for each slice, the length of each respective line of contact was multiplied by the 5 mm slice thickness.ResultsThe overall joint contact area increased from 168.0 ± 20.5 mm2 at 20° knee flexion to 334.4 ± 30.5 mm2 at 60° knee flexion in group (I) The overall joint contact area increased from 178.0 ± 18.9 mm2 at 20° knee flexion to 328.9 ± 27.2 mm2 at 60° knee flexion in group (II) There was a significant difference in lateral facet contact area between group I and group II at 40° of knee flexion. There was significantly different in medial facet contact area between group I and group II at 20° and 40° of knee flexion.ConclusionsThroughout the knee movement, the contact area on the lateral facet of the patellofemoral joint was greater in the valgus group. In the early phase of knee flexion, the contact area of the medial patellofemoral joint was larger in the varus group. Lower alignment is an important factor in patellofemoral joint degeneration.

Lower Limb Alignment in Patients with Primary Valgus Ankle Arthritis: A Comparative Analysis with Patients with Varus Ankle Arthritis and Controls

Category: Ankle Arthritis; Ankle Introduction/Purpose: A comprehensive analysis of lower limb alignment may be a critical component of successful ankle joint preservation surgery. Although it is widely recognized that the combined effect of lower limb orientation and ankle and hindfoot alignment plays a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. This study aims to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to those with varus ankle arthritis and normal controls. We hypothesize that patients with valgus ankle arthritis will exhibit the opposite pattern of lower limb alignment to those with varus ankle arthritis: valgus mechanical axis, valgus distal tibial plafond, and valgus hindfoot alignment. Methods: A retrospective radiographic analysis was conducted on 61 patients (62 ankles, mean age: 59.2 years) with valgus ankle arthritis with primary origin was performed. Preoperative weightbearing radiographs were used to measure seven radiographic parameters: Talar tilt angle, medial distal tibial angle (MDTA), talar center migration (TCM), anterior distal tibial angle (ADTA), talo-first metatarsal (Meary’s) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD). For comparative radiographic analysis, a varus arthritis group with primary origin (n=55, mean age: 59.7 years) and a control group (n=58, mean age: 29.3 years) were included. Subgroup analyses of lower limb alignment were performed in the valgus arthritis group based on the MDTA (greater or less than 90 degrees, subgroup analysis 1) and Meary's angle (greater or less than -20 degrees, subgroup analysis 2). Results: The valgus group had a significantly lower mean MDTA than the control group (p &lt; 0.0001, Figure 1), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p &lt; 0.05 and p&lt; 0.0001, respectively). On whole limb radiographs, the valgus group showed a greater MAD than the control group (p &lt; 0.05), indicating a varus lower limb alignment. However, there was no significant difference in MAD between the valgus and varus groups (p=0.7031). Subgroup analysis 1 revealed that the MAD was varus- angulated regardless of the MDTA. Subgroup analysis 2 showed that both groups had comparable MDTA (p=0.8504); however, patients with a lower Meary’s angle had a significantly greater MAD. Conclusion: Our findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis, which contradicts our current understanding. The similar lower limb and distal tibia orientation and different foot and hindfoot alignment between the valgus and varus group suggest that foot and hindfoot alignment may play an important role in the development of both types of arthritis. This study adds to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.

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.

Comparison of Clinico-Radiographic Outcome of the 3-Component Salto Total Ankle Arthroplasty According to Degree of Ankle Varus Deformity for End-Stage Ankle Arthritis

Category: Ankle Arthritis Introduction/ Purpose: As the popularity of total ankle arthroplasty (TAA) increases, indication of TAA also expands. Recently, the ankles more than 20º of varus or valgus deformity in the coronal plane are treated with TAA. Commonly, patients with ankle osteoarthritis have preoperative varus deformity. However, preoperative varus deformity should be corrected in the coronal plane to avoid residual mal-alignment that leads to instability, insert wear, and clinical failure. In this study, we compare the clinical and radiologic outcome of the Salto mobile bearing 3-component total ankle prosthesis for ankles according to preoperative degree of ankle varus deformity. Methods: TAA was performed in 106 ankles using 3-component Salto total ankle implant from June 2014 to October 2019. A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 1-year follow-up. All patients were followed up at postoperative three months, six months, at one year and yearly thereafter. Clinical outcome scoring was done pre-operatively and post-operatively. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot functional score, pain VAS, satisfaction score and clinical range of motion (ROM) were collected along with weight-bearing radiographs of the ankle. Post-operative coronal alignment of the component were evaluated with radiographs. More than 10º of tibial anterior surface angle, talta tilt angle (TTA), tibial axis-talar dome angle (T-TDA), talar dome-ground surface angle (TD- GSA), or tibio-calcaneal angle (TCA) was defined as varus deformity. We classified the enrolled ankles as neutral ( &lt; 10 º), moderate varus (10º~20º), and severe varus groups (&gt;20º). Results: The average follow-up was 21.9 months (range, 12-72). Preoperatively, there were 37 ankles (35%) with neutral alignment, 48 ankles (45%) with moderate varus deformity, and 21 ankles (20%) with severe varus deformity. There were no significant differences in mean pain VAS, AOFAS score, and ROM among the groups (p &gt; 0.05). Overall satisfaction rate (more than satisfied) was 87%, and no significant differences were found among the groups. As to radiographic alignment, there were no significant differences among the groups in T-TDA and TD-GSA (p &gt; 0.05). Concomitant additional procedures such as deltoid release, calcaneal osteotomy, and first tarsometatarsal dorsiflexion arthrodesis were more significantly performed in preoperative varus groups. Conclusion: There was no significant difference in clinical and radiographic outcomes a according to degree of ankle varus deformity in the TAA series using single Salto 3-componenet implant. Postoperative neutral alignment was achieved in all ankles. For favorable long-term outcomes, coronal alignment should be corrected with proper additional procedures in TAA.

Idiopathic Slipped Capital Femoral Epiphysis: Demographic Differences and Similarities between Stable, Unstable, and Valgus Types.

Idiopathic slipped capital femoral epiphysis (SCFE) is a known disorder in pre/adolescent children with vague hip/knee pain. We wished to study the demographic differences between stable varus, unstable varus, and valgus idiopathic SCFEs using a retrospective review over a 10-year period of SCFE children seen at a tertiary children's hospital. Standard demographic data was collected, and radiographs were measured to determine the Southwick angle and status of the tri-radiate cartilage. There were 190 patients; 138 had stable varus SCFEs, 45 unstable varus SCFEs, and 7 valgus SCFEs. All unstable SCFEs were varus, and all valgus SCFEs were stable. There were significant differences between the three groups by age at diagnosis, sex, race, SCFE severity, weight percentile, and duration of symptoms. The average age at diagnosis was 11.0 ± 1.2, 11.8 ± 1.8, and 12.3 ± 1.7 years for the valgus, unstable varus, and stable varus groups (p = 0.019), and similarly, SCFE severity was 25° ± 15°, 48° ± 18°, and 35° ± 19° (p = 0.0002) for the three same groups. Patients with valgus SCFEs were mostly female (86%) compared to the stable varus (39.9%) and unstable (47%) groups (p = 0.05) and mostly non-White (86%) (0.011). The duration of symptoms was 4.1 ± 4.1, 2.3 ± 5.0, and 4.5 ± 5.0 months for the valgus, unstable varus, and stable varus groups (p = 0.00005). These three types of idiopathic SCFEs demonstrated differences by age at diagnosis, sex, race, weight percentile, and duration of symptoms.

Spatiotemporal and kinematic gait analysis in patients with knee osteoarthritis and femoral varus deformity

BackgroundKnee osteoarthritis (OA) is commonly combined with the presentation of a coronal deformity of the knee. The bony origin of the knee varus deformity can be classified as tibial origin, femoral origin, or a combination of tibial and femoral causes. Deformities of tibial origin are mostly common clinically, while patients with knee OA with femoral varus deformity are less common. Research questionDo hip, knee and ankle kinematics and spatiotemporal parameters differ between patients with knee OA with femoral varus deformity and healthy subjects? MethodsTwenty-five patients (14 females and 11 males) with knee OA and femoral varus deformity and 20 healthy subjects (12 males and 8 females) as control group were included in this study. The kinematic parameters of the hip-knee-ankle joint and spatiotemporal gait parameters were included in the study. ResultsThis study found that the step speed and step length of the knee OA with femoral varus (KOAF) group were smaller than those of the control group, while double support period percentage was greater in the KOAF group. Significant differences were found in the maximum knee extension angle, maximum knee flexion angle, knee flexion range of motion, maximum hip flexion angle, maximum hip extension angle, and hip flexion range of motion between the two groups. After comparing the ankle motion between the two groups, significant differences were found in the maximum eversion angle, inversion range of motion, maximum ankle abduction angle, and abduction range of motion. SignificanceKnee OA with femoral varus deformity causes adaptive changes in the kinematic parameters of hip, knee and ankle joints and spatiotemporal gait parameters to alleviate symptoms and maintain normal activity.

Short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis

To investigate the short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis. The clinical and radiographic data of patients with moderate to severe varus-type ankle arthritis, who were admitted between May 2017 and November 2021 and treated with total ankle arthroplasty (TAA) using INBONE TM Ⅱ prosthesis, was retrospectively analyzed. A total of 58 patients (58 ankles) met the selection criteria and were included in the study. Among them, there were 24 males and 34 females, with an average age of 62.6 years (range, 41-85 years). According to the preoperative tibiotalar angle (TTA), the patients were divided into a moderate varus group (group A, TTA 5°-15°, n=34) and a severe varus group (group B, TTA>15°, n=24). There was no significant difference in gender, side, etiology, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, ankle dorsiflexion, plantarflexion, and total range of motion, and tibial lateral surface angle (TLS) between the two groups ( P>0.05). Yet the patients in group A were younger than group B, the degrees of oesteoarthritis (Takakura stage) and ankle pain [visual analogue scale (VAS) score] were milder, and the TTA, talar tilt angle (TT), hindfoot alignment angle (HAA) were smaller while the tibial articular surface angle (TAS) was larger, showing significant differences ( P<0.05). The pre- and post-operative VAS score, AOFAS score, the occurrence of early and late complications, the radiographic parameters of the ankle (TTA, TAS, TT, HAA, TLS), ankle dorsiflexion, plantarflexion, and total range of motion were recorded and compared. All patients were followed up 19-72 months, with an average of 38.9 months. Compared with the preoperative data, the VAS score of all patients significantly decreased ( P<0.05); the AOFAS score, ankle dorsiflexion range of motion, and total range of motion significantly increased ( P<0.05); and the TTA, TAS, TT, HAA, and TLS significantly improved at last follow-up ( P<0.05); but there was no significant difference in plantarflexion range of motion ( P>0.05). Early complications occurred in 13 patients, and only 1 patient underwent revision surgery due to a larger size of the talar component. At last follow-up, there was no significant difference in the difference of clinical parameters before and after operation between the two groups ( P>0.05); there was a significant difference in the difference of other radiographic parameters ( P<0.05) except TLS. No significant difference in the incidence of complications between the two groups was found ( P>0.05). TAA using the INBONE TM Ⅱtotal ankle prosthesis is an effective treatment for moderate or severe varus-type ankle arthritis, and good clinical and radiographic results can be obtained. Correcting bony deformities and balancing soft tissue are the keys to successful surgery.