Varus Osteotomy Research Articles

Le osteotomie tibiali di addizione nelle gonartrosi e nelle deformità post-traumatiche in valgo: indicazioni, tecnica chirurgica, complicanze, risultati

The effectiveness of tibial osteotomy for the treatment of varus gonarthrosis has been widely discussed in the literature, while works reporting its role in the correction of constitutional or acquired post-traumatic valgus deformities are less numerous, if not rare. We present the study of 16 patients with valgus knee treated by external opening wedge tibial varus osteotomy above the tibial tuberosity between 1998 and 2008. We analyzed the results with a median follow-up of 6 years (range 2–12 years): with the rating scale of Lysholm and Gillquist, the average value was 83 (range 61–93). Our indication for surgical intervention was addressed to subjects aged <60–62 years with unadvanced valgus gonarthrosis, <12°, with medial-lateral laxity, mostly occurring after lateral spontaneous or surgical meniscectomy, outcomes of tibial lateral plateau fracture or constitutional valgus deformities. Under such conditions, this procedure, that is performed in intraligamental area, can restore ligament tension and rebalance the knee, at the cost of an acceptable joint line’s obliquity.

Unpredictability of hip behavior in Dyggve-Melchior-Clausen syndrome: A mid-term assessment of siblings

Dyggve-Melchior-Clausen syndrome is a rare spondylo-epiphyseal disease, which almost constantly leads to both bilateral hip degeneration and dislocation. Few authors have reported to date the surgical management of this orthopaedic disorder. We present two new cases affecting siblings. One brother was treated by unilateral triple pelvic osteotomy combined with varus osteotomy of the proximal femur; the other was treated by bilateral Pemberton osteotomies with varus osteotomy of the proximal femur. At a respective 5-year and 3-year follow-up delay, both cases had evolved towards progressive subluxation recurrence along with severe hip degeneration. Based on both our experience and literature review, it seems that one should avoid operating these hips unless pain renders surgery mandatory. Total hip arthroplasty seems the only reliable surgical solution at the adult age and paediatric surgeons should keep in mind that previous femoral osteotomies will make it more challenging for adult orthopaedic surgeons to implant on a remodeled anatomy.

Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee

IntroductionOsteotomy aims to reduce pain and the rate of progression of arthritis by correcting deformity and offloading the affected compartment. This study reports the results of a case series of opening wedge distal femoral varus osteotomies for valgus lateral osteoarthritis of the knee. Patients and methodsEighteen patients underwent osteotomy surgery (21 knees) with the aim of correcting the mechanical axis to 48–50% from medial to lateral. ResultsThe mean follow-up for the study population was 4.5years (range 1.6 to 9.2years). Four patients underwent conversion to arthroplasty at a mean time of 3.3years postosteotomy. Kaplan–Meier analysis demonstrates a cumulative survival of 79% at 5years. In the remaining 17 osteotomies, all patients reported that outcome measures improved from baseline. However, only the IKDC and pain subdomain of KOOS showed a statistically significant and clinically relevant difference. Re-operation for non-arthroplasty related surgery was common. In part this was due to symptoms related to prominence of metalwork (10). Other reasons included non-union (1), loss of correction (2), infection (1), and persistent symptoms (2). ConclusionCumulative survival of opening wedge DFVO is comparable with that reported in closing wedge series. Clinically relevant differences in the IKDC and KOOS pain scores suggest that opening wedge DFVO is a useful option in the management of valgus gonarthrosis. However, DFVO is a technically demanding procedure and re-operation, particularly for removal of metalwork, is common.

Role of Femoral Head Surgery in Skeletally Mature Perthes Disease

Legg-Calve-Perthes disease (LCPD) nearly always results in femoral deformity at skeletal maturity that may lead to symptoms due principally to femoroacetabular impingement. Treatment for the skeletally mature patient with LCPD varies from observation with activity modifications to surgical procedures which range from isolated femoral or acetabular-sided surgery to the more common combined surgery. On the femoral side, the traditional procedures have been proximal varus and valgus osteotomies (with some component of flexion) to reorient the femoral head and allow better femoral head weight-bearing cartilage across the hip joint. Acetabular procedures have been used less frequently including reorientation or shelf procedures to provide improved femoral head coverage. The challenge in the skeletally mature hip patient is to determine which of these components require addressing at the time of surgical treatment. More recently, procedures to the femoral head itself have been developed to reshape the femoral head and assist in matching the size of the femoral head to the acetabulum, prevent impingement and restore more normal articular cartilage in the weightbearing zone. This review will focus on these surgical treatments specific to the femoral head in skeletally mature LCPD.

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

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

Can Residual Leg Shortening Be Predicted in Patients With Legg-Calvé-Perthes’ Disease?

Although Legg-Calvé-Perthes' disease (LCPD) is frequently associated with varying degrees of femoral head deformity and leg length discrepancy (LLD), no factors that predict residual shortening have been clearly identified. We attempted to determine whether (1) the extent of femoral head involvement; (2) varus osteotomy; and (3) patient demographic characteristics are associated with LLD at skeletal maturity in patients with LCPD. We retrospectively reviewed the records of 168 skeletally mature patients with unilateral LCPD. The mean age at diagnosis was 7 years (range, 2-14 years). The extent of femoral head involvement was determined from the initial radiographs using the Herring lateral pillar and Catterall classifications. LLD was defined as shortening by ≥ 1.0 cm as measured from scanograms. The patient's sex and the treatment modalities used were also recorded. LLD ranging from 10 to 38 mm (mean, 19 mm) occurred in 93 (55%) patients and was associated with the extent of femoral head involvement. Varus osteotomy was not associated with residual shortening. The patient's age at diagnosis did not affect the LLD at skeletal maturity. The strongest predictor of LLD was a lateral pillar classification of B/C or C (odds ratio, 3.5; 95% confidence interval, 1.39-8.79). The extent of femoral head involvement, but not the patient's age at diagnosis or sex or the treatment modality, can predict the LLD at skeletal maturity in patients with unilateral LCPD.

Neutralizing high and low knee moments through surgical realignment

Purpose: To elucidate the effects of frontal plane lower limb alignment on gait biomechanics, we compared knee joint moments and frontal plane angular impulse before and after varus or valgus producing osteotomy in patients with lateral or medial compartment osteoarthritis, and in healthy participants with neutral alignment. Methods: Thirty-nine subjects participated (13 valgus gonarthrosis, 13 varus gonarthrosis, 13 controls). Patients underwent 3D gait analysis and radiographic assessment of alignment (mechanical axis angle; MAA) before and 6 months after surgery, and were compared to controls. Moments in each of the three orthogonal planes of movement were determined throughout stance phase and averaged over five trials of the same limb (operative limb, or limb closest to neutral for controls) while normalizing to body weight and height (%BW·Ht). Knee moments in all three planes were normalized to 100% of stance and peak values in the first and second halves of stance were identified. The frontal plane knee moment waveform was then integrated with respect to time to calculate the frontal plane knee angular impulse (%BW·Ht·s). Results: An ensemble average for the frontal plane knee moment before and after surgery with 95% confidence interval (CI) bars is illustrated in Figure 1. Mean changes (95%CI) in frontal plane angular impulse indicated a 0.82%BW·Ht·s (0.49,1.14) increase in adduction impulse in patients after varus osteotomy, and a 0.61%BW·Ht·s (0.37,0.86) decrease in adduction impulse in patients after valgus osteotomy, equating to a 53% and 45% change from preoperative values, respectively. Preoperative frontal plane angular impulse was significantly different between both patient groups and controls before surgery, but not after. There were less substantial findings in sagittal and transverse plane moment peaks. When compared to controls, the peak knee extension moment was significantly lower for both patient groups after surgery (p=0.008). The association between the changes in lower limb alignment and frontal plane knee angular impulse are plotted in Figure 2 (R=0.88, n=26). Conclusions: The cross-sectional data suggest that frontal plane angular impulse is very highly correlated to MAA before surgery (R=0.87), but not after (R=0.39), and that an adduction impulse predominates until 7º of valgus, at which point an abduction impulse predominates. The prospective surgical realignment data indicate that for every 1º change in MAA toward varus, there is a 0.1%BW·Ht·s (or 1.6N·m·s) change in frontal plane knee angular impulse toward adduction, and vice versa (Figure 2). These overall findings illustrate the potent effects that lower limb alignment can have on gait biomechanics. $$grap ic_94AB0E34-8D38-4F8A-AE45-E659B861CC5A$$ $$grap ic_AC2006D2-0EC3-4301-889F-EBA8CB318D37$$ Figure 2Scatter plot with mean regression line and 95% confidence interval.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Changes in valgus and varus alignment neutralize aberrant frontal plane knee moments in patients with unicompartmental knee osteoarthritis

To elucidate the effects of frontal plane lower limb alignment on gait biomechanics, we compared knee joint moments and frontal plane angular impulse before and after varus or valgus producing osteotomy in patients with lateral or medial compartment osteoarthritis, and in healthy participants with neutral alignment. Thirty-nine subjects participated (13 valgus gonarthrosis, 13 varus gonarthrosis, 13 controls). Patients underwent 3D gait analysis and radiographic assessment of alignment (mechanical axis angle; MAA) before and 6 months after surgery, and were compared to controls. Mean changes (95%CI) in frontal plane angular impulse indicated a 0.82%BW·Ht·s (0.49,1.14) increase in adduction impulse in patients after varus osteotomy, and a 0.61%BW·Ht·s (0.37,0.86) decrease in adduction impulse in patients after valgus osteotomy, equating to a 53% and 45% change from preoperative values, respectively. Preoperative frontal plane angular impulse was significantly different between both patient groups and controls before surgery, but not after. The cross-sectional data suggest that frontal plane angular impulse is very highly correlated to MAA before surgery (R=0.87), but not after (R=0.39), and that an adduction impulse predominates until 7° of valgus, at which point an abduction impulse predominates. The prospective surgical realignment data indicate that for every 1° change in MAA toward varus, there is a 0.1%BW·Ht·s (or 1.6Nms) change in frontal plane knee angular impulse toward adduction, and vice versa. These overall findings illustrate the potent effects that lower limb alignment can have on frontal plane gait biomechanics.

Evaluation of acetabular development after Dega acetabuloplasty in developmental dysplasia of the hip

The Dega acetabuloplasty is considered to be safe and effective in the treatment of hip pathologies, but the number of clinical follow-up series in the literature is not sufficient. The aim of our study was to identify the alterations in acetabular development in 35 patients (43 hips) with developmental dysplasia of the hip who were treated with Dega acetabuloplasty. This study is a retrospective review of 7 years of one surgeon's experience with Dega acetabuloplasty performed between May 2002 and January 2010. A total of 35 patients (43 hips) were evaluated, with an average of 58 months (range 25-108 months) of follow-up. Dega acetabuloplasties that were performed for neuromuscular or other conditions and patients who had a follow-up period of less than 2 years were excluded. Open reduction was performed and femoral shortening or varus osteotomy was added whenever the surgeon considered it necessary. The preoperative mean acetabular index (AI) was 35° (range 27-53°), and the mean age of operation was 35 months (range 18-65 months). The mean AI in the early postoperative period was 20° (range 10-34°). At the last follow-up, all patients were pain-free and had unlimited physical activity with no limp, with an improvement in AI to 13° (range 5-23°). An improvement of 7° was observed in AI within the follow-up period. The maximum improvement was 17° and occurred within an 83-month period. In 42 of 43 (98%) of the hips, the AI improved; in one of 43 (2%) of the hips, it remained unchanged and in none of hips did the AI worsen over time. This study is one of the largest series in the English-language orthopedic literature to report that Dega osteotomy is effective in improving the AI and femoral coverage, and that the index further improves over the course of the follow-up period.

Subchondral insufficiency fracture of the femoral head: a report of two cases with a history of internal fixation of a femoral neck fracture

We report our experience in two cases of subchondral insufficiency fracture of the femoral head with a history of internal fixation of the femoral neck fracture. Both cases were young females (26 and 43 years old, respectively). Their hip pain occurred more than 2 years and 1 year after the primary surgical treatment, respectively. MRI revealed bone marrow edema pattern, as well as a low-intensity band on the T1-weighted images, which are commonly observed in osteonecrosis. However, the low-intensity bands were parallel to the subchondral bone end-plate, which are characteristic findings of subchondral insufficiency fracture. Both patients were administered anti-inflammatory drugs and/or bisphosphonate. One patient underwent a transtrochanteric curved varus osteotomy 1 year and 9 months after the onset, and the other healed without collapse of the femoral head. Our cases indicate that subchondral insufficiency fractures may need to be considered as one of the possible conditions after the internal fixation of a femoral neck fracture, in addition to posttraumatic osteonecrosis.

Effects of intertrochanteric varus osteotomy on Norberg angle and percent coverage of the femoral head in displastic dogs

This study was conducted to assess the effects of femoral varus osteotomy on joint congruency in dogs affected by early stage hip dysplasia. Preoperative planning to move the femoral head within the acetabulum was carried out. Varisation of the femoral inclination angle (fIA) was achieved by Intertrochanteric Osteotomy (ITO). Norberg angle (NA), percent coverage (PC) of the femoral head by the acetabulum and fIA was measured from preoperative, immediate postoperative and first and second recheck radiographs of seven dogs that underwent an ITO (joint n = 9). There was significant (p < 0.05) improvement of both NA and PC in all patients as indicated by a change in the mean ± standard deviation of 78.9° ± 7.5 and 36.9% ± 5.2 to 92.2° ± 6.7 and 50.6% ± 8.3, respectively. No significant difference (p < 0.05) was observed between the values of the planned femoral inclination angle (pfIA) of the femur and the effective femoral inclination angle (efIA) obtained after surgery (115.9° ± 2.5 and 111.3° ± 6.4, respectively). These findings could encourage the use of ITO in veterinary practice and indicate that intertrochanteric varus osteotomy should be re-considered for the treatment of early stage hip dysplasia in dogs with radiological signs of joint incongruency.

Assessment of changes in the loading of menisci following femur structural deformities

Purpose: To evaluate the changes of maximum equivalent stresses (MES) on menisci following femur structural deformities. Materials and methods: Three- Dimensional (3D) solid models were created on MIMICS® by using DICOM formatted longitudinal computed tomography scans. +10° femur neck valgus osteotomy was simulated for coxa valga and -10° varus osteotomy was simulated coxa vara. ANSYS® WorkbenchTM (Version 12) was used to analyze the stress/load distribution on menisci.Results: In the reference model, the MES on medial meniscus was 17.362 Megapascal (MPa), lateral meniscus was 8.621 MPa. The MES was measured 10.632 MPa on medial meniscus and 9.487 MPa on lateral meniscus in coxa vara model. In coxa valga simulated model the MES on medial meniscus was 6.866 MPa while lateral meniscus was 21.854 MPa.Conclusion: Maxiumum equivalent stresses on menisci were affected according to changes in mechanical axis of lower extremity due to proximal femur geometric variations.

Experimentally induced cam impingement in the sheep hip

Sheep hips have a natural non-spherical femoral head similar to a cam-type deformity in human beings. By performing an intertrochanteric varus osteotomy, cam-type femoro-acetabular impingement (FAI) during flexion can be created. We tested the hypotheses that macroscopic lesions of the articular cartilage and an increased Mankin score (MS) can be reproduced by an experimentally induced cam-type FAI in this ovine in vivo model. Furthermore, we hypothesized that the MS increases with longer ambulatory periods. Sixteen sheep underwent unilateral intertrochanteric varus osteotomy of the hip with the non-operated hip as a control. Four sheep were sacrificed after 14, 22, 30, and 38-weeks postoperatively. We evaluated macroscopic chondrolabral alterations, and recorded the MS, based on histochemical staining, for each ambulatory period. A significantly higher prevalence of macroscopic chondrolabral lesions was found in the impingement zone of the operated hips. The MS was significantly higher in the acetabular/femoral cartilage of the operated hips. Furthermore, these scores increased as the length of the ambulatory period increased. Cam-type FAI can be induced in an ovine in vivo model. Localized chondrolabral degeneration of the hip, similar to that seen in humans (Tannast et al., Clin Orthop Relat Res 2008; 466: 273-280; Beck et al., J Bone Joint Surg Br 2005; 87: 1012-1018), can be reproduced. This experimental sheep model can be used to study cam-type FAI.

Distal femoral osteotomy for valgus arthritic knees

BackgroundPatients with genu valgum and isolated osteoarthritis of the lateral compartment are candidates for distal femoral varus osteotomy. Opening wedge osteotomy is a precise method to realign the knee axis with good short to midterm results. The aim of this study was to evaluate the outcome of patients who have had opening wedge distal femoral varus osteotomy utilizing the Puddu plate (Arthrex, Naples, FL, USA) fixation. MethodsThe study included 6 patients (7 knees) followed for an average of 6.5 ± 1.5 years after distal femoral varus osteotomy with Puddu fixation and iliac crest allograft. Clinical outcome was assessed by the Oxford Knee Score and subjective satisfaction rating. Pre- and postoperative radiographs were evaluated for tibiofemoral angle, Insall-Salvati index and Kellgren-Lawrence Grading Scale for osteoarthritis. ResultsThe mean age at surgery was 46.7 ± 10.7 years. The mean body mass index at surgery was 29.6 ± 5.6 kg/m2. Overall at the last follow-up the mean Oxford Knee Score improved from 13.1 ± 8.6 to 26 ± 12.5. The average subjective satisfaction rate at the last follow-up was 6.6 ± 2.8. The measured tibiofemoral angle was corrected by an average of 11.9°. There was no worsening of arthritic changes in comparison to the preoperational radiographs. All radiographs showed full incorporation of the bone grafts, and there were no hardware failures. At the end of this study none of the patients required additional surgery, and none had knee replacement. ConclusionsOpening wedge distal femoral varus osteotomy with Puddu plate fixation can be a reliable procedure for the treatment of lateral compartment osteoarthritis of the knee associated with valgus deformity.

Long-Term Results of Intertrochanteric Varus Osteotomy for the Dysplastic Hip

Total hip arthroplasty (THA) is a well established treatment for arthrosis of the hip, however many problems remain which have not yet been resolved, including component loosening and infection. Therefore, surgeons hesitate to perform THA in younger patients showing early signs of the disease. Intertrochanteric varus osteotomy was developed for osteoarthrosis with coxa valga. This procedure has been commonly used in patients with dysplastic hips. However, femoral head coverage is not sufficiently improved by this procedure. In order to overcome the disadvantages of this procedure, since 1972 we performed intertrochanteric varus osteotomy simultaneously combined with acetabuloplasty for the treatment of osteoarthrosis secondary to dysplasia. Between 1969 and 1994, we performed 104 intertrochanteric varus osteotomies for prearthrosis and early stage arthrosis of the hip due to acetabular dysplasia in 84 patients. In this study, we reviewed these patients clinically and radiographically, over 15 years. The intertrochanteric varus osteotomy alone was employed in 38 hips (varus group). Combined intertrochanteric varus osteotomy and acetabuloplasty was employed in 63 hips (combined group). The average Harris hip score at the latest follow-up in the combined group significantly higher than that in the 'varus' group. Postoperative centre-edge angle and age at operation were correlated with the Harris hip score at the most recent follow-up. The results of the present study indicate that this combined intertrochanteric varus osteotomy and acetabuloplasty for dysplastic hip should be considered in young patients when the disease is at an early stage.

The results of corrective osteotomy for valgus arthritic knees

To evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity. The data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications. A total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence. The role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates. IV.

Opening wedge distal femoral varus osteotomy using the Puddu plate and calcium phosphate bone cement

The goal of this study was to document the outcome at midterm follow-up of 19 patients treated for lateral osteoarthritis of the knee between 1999 and 2007. It was our hypothesis that the results and complication rate would be comparable to or better than those reported in the literature for closing wedge or alternative open wedge techniques. All patients underwent an open wedge distal femoral varisation osteotomy using the Puddu plate system combined with calcium phosphate injection into the defect. Knee Society Knee Score and Kellgren-Lawrence osteoarthritis score were assessed preoperatively and at final follow-up. The average knee score improved significantly from 43 ± 8 preoperatively to 78 ± 23 at final follow-up. The Kellgren-Lawrence osteoarthritis score remained unchanged. Kaplan-Meier analysis using revision surgery or conversion to TKA as an endpoint demonstrated an 82% successful survivorship at 7 years of follow-up. Based upon these results, we believe that a distal femoral varisation osteotomy using the Puddu plate and injectable bone cement is an equivalent treatment option compared to closing wedge techniques and leading to good results at midterm follow-up in patients with lateral gonarthrosis and valgus alignment. IV.

Surgical treatment of hip dislocation in Kabuki syndrome: Use of incomplete periacetabular osteotomy for posterior acetabular wall deficiency

Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome. Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7years, with an average of 3.6years. The follow-up postoperative period ranged from 3.2 to 6.3years, with an average of 5.0years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum. Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.

Distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee. A systematic review of the literature.

The primary objectives of this systematic review were to define the indications, functional outcomes, survivorship and complications associated with distal femoral varus osteotomy (DFVO).Cumulative survival with arthroplasty as the endpoint ranged from 64 to 82% at 10 years, and 45% at 15 years. The mean pre-operative HSS score ranged from 46 to 65 and this improved at latest follow up to means of between 72 and 88. Pooled results show an overall complication rate of 5.8% (5/86) for unanticipated re-operation due to a complication.Poor reporting of included studies and considerable heterogeneity between them precluded any statistical analysis. Further study is required to determine the precise indications for DFVO, optimum surgical technique, implant of choice and post-operative rehabilitation regimen as all of these factors may significantly affect the complication profile and outcomes of this procedure.DFVO is technically demanding and requires a significant period of rehabilitation for the patient. However, long-term survivorship and good function have been demonstrated and it remains a potential option for valgus osteoarthritis in carefully selected patients.

Recurrent knee valgus deformity in Ellis–van Creveld syndrome

We report a case of recurrent knee valgus deformity in a patient with Ellis-van Creveld syndrome. Varus osteotomy, distraction osteogenesis, or epiphyseal stapling is one treatment option for valgus malalignment to improve appearance, gait, and function. However, surgical correction of valgus knee deformity by varus osteotomies of the proximal tibia was not maintained postoperatively, necessitating additional varus osteotomies of the distal femur in this case. The main cause of recurrence was attributed to large bony defect of the anterior segment of the proximal tibia, in addition to depression of the lateral tibial plateau.