Varus Osteotomy Research Articles

Arthrographic indicators for decision making about femoral varus osteotomy in Legg-Calvé-Perthes disease

There is not always a good outcome after a femoral varus osteotomy (FVO) in those with Legg-Calvé-Perthes disease (LCPD), even when the severity warrants surgical treatment. The purpose of this study was to find arthrographic indicators for decision making regarding the likely surgical outcome of a FVO. We used an image of an abduction position during preoperative arthrography under general anesthesia that simulated the post-operative relationship between the femoral head and the acetabulum. In the image, we defined two indicators of how deeply the deformed epiphysis was contained within the acetabulum: an acetabular head index in abduction and an epiphyseal slip-in index. Finding the contact point between the top of epiphysis and acetabulum was the key for the epiphyseal slip-in index measurement. In 37 patients (38 hips) who underwent FVOs based on our inclusion criteria, these two indices were measured retrospectively and were analyzed for a correlation with surgical outcome. Surgical outcome was evaluated using a combination of three factors: sphericity of the femoral head (Stulberg's classification), acetabular cover (acetabular head index), and the slope of acetabular roof. The outcome was acceptable in 20 hips (52.6%) and unacceptable in18 hips (47.4%). There was a statistically significance difference in epiphyseal slip-in index between the acceptable group (21.9 +/- 2.8%) and the unacceptable group (15.0 +/- 4.4%) (P < 0.0001). An index of 20% or more determined a safe zone for predicting an acceptable outcome with 80% sensitivity, 89% specificity, and a 7.2 likelihood ratio. However, the acetabular head index in abduction showed no such statistical significance. In this study, we found that the epiphyseal slip-in index was a reliable indicator for predicting the effectiveness of a FVO. It is worth measuring this index when a surgeon is considering a FVO for a patient with severe LCPD. (Level of Evidence Level III.).

Combined Intra-Articular and Varus Opening Wedge Osteotomy for Lateral Depression and Valgus Malunion of the Proximal Part of the Tibia

Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia. From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively. A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two. A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Indikation und Ergebnisse hüftnaher Osteotomien bei Dysplasie

Joint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk-benefit analysis is of major interest. In this study, the surgical techniques and specialties of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences. Only limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today. Reconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.

Behandlungsergebnisse der Varisierungsosteotomie bei Morbus Perthes unter Berücksichtigung des Hüftwertes

A total of 89 patients with 105 hip joints affected by Perthes' disease at Catterall's stages II to IV, which had been treated by varus osteotomy, were re-examined clinically and radiologically between two and ten years after surgery. The clinical and subjective results of treatment were generally good. The best clinical and radiologic results were found in patients who contracted the disease before the age of seven and in whom necrosis was not yet at an advanced stage. The results in children who did not undergo treatment until after the age of eight and those with the disease at Catterall's stage IV were significantly poorer as far as arthrotic deformation of the hip joint was concerned. Radiologic evaluation of the hips examined, with regard to severity of arthrosis, epiphyseal index, and hip value show that the hip value is the best means of distinguishing prearthrotically deformed hip joints from normal findings. For example, at the time of follow-up severe prearthrotic changes were found in 40 of 105 hip joints when the hip values were analyzed. Therefore, in cases of Perthes' disease also, the hip value is of special importance in prognostic counseling of patients as regards the extent to which the hip joint can be subjected to stress either at work or in sports.

Developmental tendency of the femur head following femoral head necrosis due to conservative treatment of a dislocated hip (2nd report)

The development of the proximal femur was studied in a follow up of 64 patients--on average 24.4 years of age--with congenital hip dislocation and 101 subsequent aseptic necroses of the femoral head. For measurement of the angle of antetorsion and the femoral neck-shaft angle, biplanar radiographs were taken. A coxa valga with a true femoral neck-shaft of 137 to 164 degrees was present in one third of the cases with partial necrosis and in the group without necrosis. An increasing degree of necrosis led to coxa vara. Damage of the capital epiphysis caused development of coxa vara (average of 115.77 degrees), overgrowth of the greater trochanter and increase of femoral antetorsion (average of 30.23 degrees). Pre-existing damage of the capital epiphysis following non-operative treatment of congenital hip disease or Perthes disease cannot be recommended for intertrochanteric varisation osteotomy.

Erfahrung mit der PAUWELS-Osteotomie und ihre Weiterentwicklung in den letzten 20 Jahren

Intertrochanteric osteotomies (Pauwels) were performed in 203 hips. Their average age at operation was 41 years (range 15 to 66 years). Average follow-up was 16 years and 5 months. 78 of 203 hips had been undergone varus osteotomies (P1) and valgus osteotomies (P2) were in 125 hips. All the hips were evaluated clinically and radiologically. 140 hips (69%) had no pain. 132 hips (65%) showed no arthritic changes. In summary, we feel that Pauwels' osteotomy is a reliable method in the treatment of the young and middle aged patient.

Analyses of survival time of joints with dysplastic arthrosis after intertrochanteric femoral osteotomy

Survivorship analysis was performed up to 13 years after intertrochanteric femoral osteotomies in 136 dysplastic hip joints with osteoarthritis. Varus-valgus and rotational osteotomies were evaluated. The criterium limiting survival was the recurrence of pain postoperatively. Joints with severely pathological Sharp Angles (> 48 degrees) showed a diminution within 10 years to 50%. Moderately pathological joints (< 49 degrees) needed 13 years to diminish to 50%. 3 groups of the CE angle showed a similar picture with somewhat more difference between the groups, but not statistically significant during this time. This was different when evaluating the 3 grades of arthrosis. Joints with grade 1 were free of pain after 13 years in only 51.2%, joints of grade 2 already after 10 years in only 37% (p < 0.05). The final values of grade 3 joints were found after only 5 years. This demonstrates that varus osteotomy is only of limited value in dysplastic joints with osteoarthritis. Operations correcting the acetabulum have to be compared. In 21 patients rotational osteotomies to correct external rotation contracture had a marked effect on pain in 90.4%, valgus osteotomies with rotation in 75%, varusosteotomies with rotation in 65%. Without rotation a marked reduction of pain was found in varus osteotomy in 61.6% and in valgus osteotomy in only 55%. So far, patients with diminished anteversion of the femur were not separated and treated specially. But diminished anteversion of the femur and/or acetabulum leads to osteoarthritis too.

Severe subluxation of the femoral head after rotational acetabular osteotomy: a case report

We encountered a rare case of severe subluxation of the femoral head after the performance of rotational acetabular osteotomy to treat osteoarthritis of the hip, secondary to acetabular dysplasia. The subluxation was corrected by performing varus and flexion osteotomy.

Growth of the pelvis following pelvic osteotomy by the Chiari technic

A Chiari pelvic osteotomy results in a medical displacement of the hip joint and a bony abutment cranio-lateral of the femoral head. Observations on patients show that in most cases the medial displacement of the hip joint will be completely compensated by the postoperative growth of the pelvis. Similar to revalgisation of the femoral neck following varisation osteotomy thus the pelvis shows a tendency to restore the preoperative geometrical configuration by means of adaptive bone remodeling.

Kalkaneusosteotomien beim kindlichen Knicksenkfuß (Langzeitresultate)

The static of serve flexible flatfeet in children can be positively influenced by the varisation osteotomy of the Calcaneous by Kramer. The method is technically easy and imposes very few complications. This follow-up after a meantime of 12.4 years looks at 30 osteotomies. Subjective results were excellent. Objectively, the results must be regarded as good. Nontheless, the problem remains who should be operated, especially if we keep in mind that the nontreated flatfeet usually develop positively. So this method should remain in the hands of the experienced orthopedic surgeon.

Der Einfluß von Risikofaktoren und der Therapie auf die mittelfristige Hüftdeformität beim M. Perthes

The prognostication of risk factors for the outcome of LCPD was examined. The radiographic results of conservative treatment with Thomas splint and operative treatment with intertrochanteric derotational varus osteotomy (DVO) were compared using the Index of Deformity (D). Radiographs of 153 patients with unilateral LCPD were evaluated retrospectively 1.5-3 years and 3-7 years after diagnosis using the Index of Deformity and Index of Direction. We investigated the radiographic changes in relation to acetabular or metaphyseal reaction, Waldenström classification or limited range of motion at diagnosis and in dependence of therapy. There was a significant better acetabulum-head-index of deformity after DVO. Children with metaphyseal or acetabular reaction had bigger deformities. Patients with metaphyseal reaction had smaller deformities after DVO compared with conservative treatment. Free range of motion (ROM) was prerequisite for good results after DVO. Waldenström classification at diagnosis did not have any influence on morphologic changes after 3-7 years. DVO leads to a better containment than conservative treatment with Thomas splint, metaphyseal reaction should be an indication for operative treatment. Prerequisite for DVO is a free ROM. Because Waldenström class at diagnosis does not influence the outcome, free ROM before starting the treatment is more important than an immediate start of therapy.

Einfluß verschiedener Kriterien auf Verlauf und Therapieergebnis des Morbus Perthes

The present treatise gives an account of the courses of illness as well as of the results of a follow-up examination of 116 patients, which have been treated in the period from 1965 to 1980 at the Orthopedic University Hospital Hamburg-Eppendorf because of a genuine Perthes' disease. Sufficient documented courses are going back to the year 1952. In the centre of interest is the question about the influence of the method of treatment, of the patients' age at the time of giving the diagnosis as well as of the radiological stage of illness at the moment of giving the diagnosis on the course and on the therapeutic result of Perthes' disease. Clinical parameters have been subdivided in the classifications of Renckhoff (1975) as well as of Howorth and Ferguson (1934). The assessment of the radiological results took place according to the classifications of Sundt (1949) as well as of Bauer und Jünger (1977). 4 therapeutic groups, 7 stage of disease and 5 age groups have been differentiated. According to the results of this long-term study at the moment the immediate intertrochanteric varus osteotomy, independent of the radiological stage of disease and of the patient's age, is being looked upon as the best method of treatment for Perthes' disease.

Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: early results of a salvage procedure

The treatment of spondyloepiphyseal dysplasia (SED) congenita patients with severe bilateral hip involvement is difficult because it involves deformities of multiple joints and of the spine. The purpose of this study was to evaluate the results of the procedure described below as a method of treatment for bilateral hip involvement in SED congenita patients. We performed proximal femoral valgus-extension osteotomy with distal femoral varus osteotomy using a hybrid external fixator in eight patients (seven male patients and one female patient) or 16 hips. The patients had a mean age of 16.37 years (range, 9-25 years) at the time of surgery. The mean valgus angle at the proximal osteotomy site was 53.4 degrees on the right side and 52.5 degrees on the left side, and the mean varus angle at the distal osteotomy site was 22 degrees . Mean fixator time was 19.8 weeks (range, 10-42 weeks). After an average follow-up of 25.9 months, the mean modified Harris hip score had improved from 67.9 points to 79.1 points, which was statistically significant (P=0.012). Preoperative knee range of motion was achieved at the last follow-up in all patients. Waddling gait was absent in three patients, reduced in four patients, and was the same in one at the last follow-up. Mean limb length gain was 3.5 cm (range, 0-5 cm), mean limb length discrepancy less than 0.5 cm, and the mechanical axis was realigned in all. In conclusion, our early results suggest that proximal valgus-extension osteotomy with distal femoral varusization can be a useful treatment option in young patients with bilateral hip involvement in SED congenita.

Operative Reconstruction of the Severe Sequelae of Infantile Septic Arthritis of the Hip

We retrospectively reviewed the results of operative reconstruction of 21 hips in 21 patients with severe sequelae due to infantile septic arthritis of the hip. Eleven hips were classified as Choi type IIIA, 4 as type IIIB, 1 as type IVA, and 5 as type IVB sequelae. The average age at the time of the first surgery was 4.2 years, and the average follow-up period was 8.9 years. Successful results were obtained in 8 of the 11 type IIIA hips by means of a combination of open reduction, femoral varus osteotomy, and pelvic osteotomy. However, only 2 of the 4 type IIIB hips treated by femoral valgus osteotomy and/or bone grafting and 2 of the 6 types IVA and IVB hips treated by greater trochanter arthroplasty had successful results.

Is varus osteotomy necessary in one-stage treatment of developmental dislocation of the hip in older children?

Innominate osteotomy, varisation-derotation osteotomy, and shortening osteotomy are the most common surgical procedures used to achieve pelvifemoral realignment in the treatment of children over three years of age with developmental hip dislocation. It is well known that varus osteotomy can improve the acetabular index but it does have some disadvantages. The aim of this study was to discuss the results obtained with patients treated only with Salter osteotomy, derotation osteotomy, and shortening, without varus osteotomy, and to evaluate the need for varisation on the basis of these results. Between 1996 and 2001, twenty-four hips, sixteen unilateral and four bilateral, of a total of twenty patients treated with this method and available for final controls were evaluated. The study included sixteen female and four male patients with a mean age of 4 years 2 months (ranging between 2 years 10 months and 8 years). The mean follow-up period was determined as 6.57 years (range 5-10 years). McKay's clinical criteria, Sever's radiological criteria, and the evaluation system modified by Trevor et al. were used for evaluation of the results. Based on McKay's clinical criteria, eighteen hips (75%) were classified as type I, four hips (16%) as type II, and two hips (9%) as type III. According to Sever's radiological criteria, thirteen hips (54%) were graded as grade I, nine hips (37.5%) as grade II, and two (8.5%) as grade III. According to the modified evaluation system of Trevor et al. the results were categorized as excellent in thirteen hips, good in nine hips, and moderate in two hips. Pre-operative mean acetabular index was measured as 37.3 degrees (28 degrees -50 degrees ) and early post-operative mean acetabular index as 26 degrees (18 degrees -38 degrees ). In the final radiological examination the mean acetabular index was measured as 18.3 degrees and the mean CE angle as 30.1 degrees (15 degrees -38 degrees ). Avascular necrosis affecting the results developed in five hips. It is concluded that in older children with developmental dislocation of the hip (DDH) treated with one-stage combined surgical intervention, adequately stable concentric reduction can be achieved without varisation and that varus osteotomy is not always necessary.

Medial closed-wedge varus osteotomy of the distal femur

Kniegelenknahe Osteotomien erleben in den letzten Jahren einen bemerkenswerten Aufschwung. Die Grunde hierfur sind zum einen speziell fur diese Eingriffe konzipierten Plattenfixateure und zum anderen moderne, verbesserte Operationstechniken. Die varisierende Osteotomie des distalen Femurs zur Behandlung der lateralen Arthrose am Kniegelenk ist ein seit vielen Jahren etabliertes Verfahren. Ziel dieser Operation ist die Verschiebung der mechanischen Beinachse von lateral in das mediale Kompartment, in manchen Fallen auch nur nach interkondylar. Neben der exakten Patientenselektion und Analyse der Deformitat [10] ist die praoperative Planung von entscheidender Bedeutung.

Incomplete Transiliac Osteotomy in Skeletally Mature Adolescents with Cerebral Palsy

Incomplete transiliac osteotomy is commonly used in the surgical treatment of spastic hip disease in children with cerebral palsy. The osteotomy hinges through an intact sciatic notch and an open triradiate cartilage. We asked whether incomplete transiliac osteotomy, combined with varus osteotomy of the femur and soft tissue reconstruction, performed after skeletal maturity could improve hip coverage and acetabular shape and provide pain relief in patients with spastic hip disease. We retrospectively evaluated 27 consecutive adolescent patients (33 hips) with cerebral palsy in whom an incomplete transiliac osteotomy was performed after closure of the triradiate cartilage. The mean age at surgery was 15 years. Five hips were dislocated and 28 hips were subluxated preoperatively. The minimum followup was 2 years (mean, 3.3 years; range, 2 years-7.5 years). The subluxated hips had a minimum Reimers' migration index of 23% (mean, 52%; range, 23-95%), which was reduced to 0% (mean, 7%; range, 0-39%) at followup. The minimum preoperative Sharp's angle was 34 degrees (mean, 52 degrees ; range, 34 degrees -70 degrees ), which was reduced to 20 degrees (mean, 35 degrees ; range, 20 degrees -50 degrees ) at followup. A painless hip was achieved in 26 of 33 hips at followup. An incomplete transiliac osteotomy can be performed after skeletal maturity, resulting in a painless and stable hip in the majority of patients.

Long-Term Follow-Up of Distal Femoral Varus Osteotomy of the Knee

Distal femoral varus osteotomy (DFVO) of the knee may be indicated for young, active patients with unicompartmental arthritis and valgus deformity. We report on 40 DFVOs with a mean follow-up of 123 months. At the most recent follow-up, 24 knees had good or excellent results (60%), 3 had fair results (7.5%), and 3 had poor results (7.5%). Four in the fair/poor group were awaiting total knee arthroplasty. Eight knees (20%) had been converted to total knee arthroplasty. Mean Knee Society objective score improved from 18 (range, 0-74) to 87.2 (range, 50-100). Mean Knee Society function score improved from 54 (range, 0-100) to 85.6 (range, 40-100). Ten-year survival rate of the DFVO was 82% (95% confidence interval, 75%-89%) and the 15-year survival rate was 45% (95% confidence interval, 33%-57%).

Leg-length discrepancy after transtrochanteric curved varus osteotomy for osteonecrosis of the femoral head

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25 degrees (12 degrees to 38 degrees ) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson's correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy.

Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow mononuclear cells

Idiopathic osteonecrosis of the femoral head commonly develops during adolescence and in the prime of adulthood. In Japan, joint-preserving procedures such as transtrochanteric rotational osteotomy, femoral varus osteotomy and vascularized bone grafting are often the surgical treatments of choice. However, the results of these procedures are not necessarily satisfactory. These procedures force patients to endure longer waits for their entire treatment. In addition, it is often difficult for surgeons to choose the appropriate treatment, especially in patients who have bilateral extensive osteonecrosis. We reported transplantation of bone marrow mononuclear cells for osteonecrosis of the femoral head and short-term results.