Double Arthrodesis, Postero-Medial Release and Posterior Tibial Transfer in One Step in Paralytic Inveterate Equine Varus Foot

Introduction: Varus equine foot deformity is common in developing countries. The management of these deformities is surgical in adults. Several surgical techniques have been described with more or less satisfactory results. To our knowledge, no study has been performed on the simultaneous association of double arthrodesis, posteromedial release, and posterior tibial transfer in a single operation in inveterate paralytic varus equines feet. The purpose of this work was to evaluate the results obtained. Patients and Method: This was a retrospective descriptive study from January 01, 2018 to December 31, 2021. It concerned inveterate paralytic varus equines feet operated on by the simultaneous association in a single operative time of double arthrodesis of the foot, posteromedial release of the back foot and transfer of the posterior tibial muscle to the lateral cuneiform. We identified seven patients with a mean age of 22.1 years with extremes of 11 years and 36 years. There were three males and four females. The cause of the deformity was neurological in all cases. All patients had painful walking discomfort and shoeing difficulties. The average time to management was 13.3 years with extremes of 4 and 25 years. The chronology of the interventional steps was posteromedial release, arthrodesis, and transfer of the posterior tibial muscle to the lateral cuneiform. The average postoperative follow-up was 21.7 months with extremes of 6 and 48 months. The parameters studied were the duration of the procedure, complications related to the procedure, muscle strength at the last recoil, consolidation of the arthrodesis, residual pain, patient activity, gait perimeter, stepping, ankle mobility, residual deformity, footwear, protrusion of the transferred tendon, and the possibility of walking on the heel. Final results were graded according to the Angus and Cowell criteria. Results: No intraoperative complications were noted. An early superficial infection of the surgical site was noted. It was treated with local care and healed without sequel. Residual pain was present in one case. Tibiotalar osteoarthritis was observed in one case, which required a tibiotalar arthrodesis. At the last follow-up, consolidation of the arthrodesis was effective in all patients. The posterior tibial muscle was side 5 (n = 4) and 4 (n = 3). The patients’ activity was normal without assistance in all cases. The walking perimeter was greater than 1 km in six patients. Patient activity was normal without assistance in all cases. Stepping was absent in all patients. No difficulty with footwear was noted. According to the Angus and Cowell criteria, the result was good (n = 6), i.e. 85.7% and bad (n = 1), i.e. 14.3% of cases. Conclusion: This study suggests that double arthrodesis associated with posteromedial release and transfer of the posterior tibial in one step in inveterate paralytic varus equines feet, gives satisfactory results. It allows for easy shoeing and plantigrade walking without stepping. Complications are essentially represented by the absence of fusion of the arthrodesis and tibiotalar arthrosis.

Treatment of Post-traumatic Pediatric Ankle Varus Deformity with Physeal Bar Resection and Hemi-Epiphysiodesis

Children presenting with partial physeal arrest and significant remaining growth may benefit from physeal bar resection,although the operation is a technique demanding procedure.This study evaluates the treatment of post-traumatic pediatric ankle varus deformity using physeal bar resection and hemi-epiphysiodesis with the assistance of two operative methods.Forty-five patients presenting with a distal tibial medial physeal bridge as well as ankle varus deformity following traumatic ankle physeal injury between 2009 and 2017 were followed.These patients were treated w让h physeal bar resection and hemi-epiphysiodesis,with the assistance of either fluoroscopy (10 cases) or intraoperative three-dimensional navigation (35 cases).Of the 45 cases,the median age was 9.0 years (range:3-14 years) with 28 male and 17 female patients.The median of pre-operation ankle varus angle was 20 degrees (IQR 15-25) and 5 degrees (IQR 0-20) at the time of final follow up,representing a statistically significant difference (P<0.05).No differences were observed with regards to age,gender,and surgical history between effective group and ineffective group (P>0.05).The median of pre-operative ankle varus angles of the navigation and fluoroscopy groups were both 20 degrees (P>0.05).The median correction angle of the navigation and fluoroscopy groups was 10 and 15 degrees,respectively (P>0.05).Our results indicate that physeal bar resection and hemiepiphysiodesis are effective treatments for correcting ankle varus deformity due to traumatic medial physeal arrest of the distal tibia.We observe no difference in outcome between fluoroscopy group and three-dimensional navigation group during the procedures.

Modified treatment of knee osteoarthritis complicated with femoral varus deformity:A case report

BACKGROUND Surgical treatment of knee osteoarthritis(KOA)complicated by extra-articular deformity has always been controversial regardless of whether it is simultaneous or staged.Simultaneous total knee arthroplasty(TKA)combined with supracondylar osteotomy without plate for treatment of KOA complicated by femoral varus deformity has not been reported in the literature.CASE SUMMARY A 53-year-old Chinese woman complained of left knee pain for 6 years that worsened for 4 mo during her visit on April 3,2020,accompanied by instability in walking,which seriously affected quality of life.According to her medical history and preoperative imaging,the patient was diagnosed with left KOA with varus deformity.We used the angular center of rotation principle for osteotomy of the femur deformity and placed a poststabilized femur prosthesis into the knee joint.At the same time,a 13 mm×130 mm femur extension rod was used instead of a steel plate to fix the end of the femur osteotomy,reducing the possible complications caused by steel plate implantation and reducing the economic burden on patients.The operation successfully solved two major problems of KOA and varus deformity,and the clinical and imaging evaluation of postoperative followup were satisfactory.CONCLUSION TKA and supracondylar femoral osteotomy can be used for simultaneous KOA treatment and deformity correction.

Three-dimensional printing technology for patient-matched instrument in treatment of cubitus varus deformity:A case report

BACKGROUND Recently,medical three-dimensional printing technology(3DPT)has demonstrated potential benefits for the treatment of cubitus varus deformity(CVD)by improving accuracy of the osteotomy through the use of an osteotomy guide,with or without a patient-mated plate.Here,we present an interesting CVD case,involving a patient who was treated with corrective biplanar chevron osteotomy using an innovative customized osteotomy guide and a newly designed patient-matched monoblock crosslink plate created with 3DPT.CASE SUMMARY A 32-year-old female presented with a significant CVD from childhood injury.A computer simulation was processed using images from computerized tomography scans of both upper extremities.The biplanar chevron osteotomy was designed to create identical anatomy between the mirror image of the contralateral distal humerus and the osteotomized distal humerus.Next,the customized osteotomy guide and patient-matched monoblock crosslink plate were designed and printed.A simulation osteotomy was created for the real-sized bone model,and the operation was performed using the posterior paratricipital approach with k-wire positioning from the customized osteotomy guide as a predrilled hole for screw fixation to achieve immediate control of the reduction after osteotomy.Our method allowed for successful treatment of the CVD case,significantly improving the patient’s radiographic and clinical outcomes,with satisfactory result.CONCLUSION 3DPT-created patient-matched osteotomy guide and instrumentation provides accurate control during CVD correction.

Acute Correction of Varus Knee by Biplanar Medial Opening-Wedge High Tibial Osteotomy and Fixation with TomoFix Plate

Background: Biplanar medial opening wedge high tibial osteotomy (MOWHTO) is a treatment method that allows adequate correction of symptomatic varus knee deformity. However, MOWHTO tends to decrease patellar height and increase the posterior tibial slope, which can affect the knee joint stability. Objective: The aim of this study was to describe the technique of biplanar MOWHTO and fixation by TomoFix plate, as well as to evaluate the accuracy of the planned correction and the postoperative tibial slope. Patients and Methods: This prospective cohort study was conducted on patients who presented with varus knee deformity and underwent biplanar MOWHTO and fixation by TomoFix plate during the period from March 2016 to March 2017. Assessment of patients included pre- and postoperative Knee and function scores, mechanical femorotibial angle (mFTA), posterior tibial slope angle (pTSA), range of motion (ROM) and radiological evaluation of the healing of the osteotomy site. Results: The recruited patients were 13 (8 men and 5 women), with average age 31.7 years old. The knee and functional scores improved from the preoperative mean of 45 and 41 to the postoperative mean of 85 and 72 points, respectively. The average knee flexion was 115 degrees, which at the final follow-up remained unchanged except for one case. The mean preoperative mFTA was 13.5&deg;varus and decreased post-operatively to a mean of 3&deg;valgus. The average postoperative follow-up period was 12 months (10 - 18 M). Conclusion: The biplanar MOWHTO allows preservation of posterior tibial slope while correcting the varus knee adequately.

Biplanar Open-Wedge High Tibial Osteotomy with Locking Plate for Treatment of Osteoarthritic Varus Knee

Aim: To introduce and characterize the modified biplanar opening high tibial osteotomy with rigid fixation to treat unicompartmental knee arthritis with varus deformity in active lifestyle patients. Patients and Method: 48 patients (19 females) with monocompartmental gonarthrosis of the knee combined with varus malalignment, 41 with bilateral affection and 7 cases with unilateral gonarthritis (total 89 knees). Mean age: 53 years (range from 42 to 61 years). They were treated and followed from June 2010 to May 2014 (35 months). Biplanar opening high tibial osteotomy technique was used and fixed by low profile locked T-plate (21 cases) and low profile anatomical proximal tibial plate (27cases). Pre-operative mean varus deformity was 16.5° (9° - 19°). We utilized Lysholm score and Knee Society Score for evaluation of preoperative and follow-up data. Results: The average correction angle was 11.50 ± 2.50° (7° - 19°). Preoperative posterior tibial slope was 8.04° ± 1.30° and at last follow-up 9.15° ± 1.60°, respectively (p = 0.437). The joint space distance increased from 4.05 ± 1.30 mm to 4.83 ± 1.33 mm (p < 0.001). The average time to complete bone union was 14.69 ± 1.5 weeks. There were no cases of delayed union or non-union. No major complications like broken plate, nerve injury, or blood vessel injury occurred. No progression of degenerations developed in the three compartments of the knee at final follow-up. The mean score on the Lysholm-Gillquist knee functional scoring scale was 45.5 ± 21.7 preoperatively, and it improved to 77.0 ± 23.9 (p < 0.001). There was no obvious difference in the range of motion before and after operation. The average knee score improved from 51.19 ± 11.82 to 93.49 ± 5.10. Conclusion: Biplanar opening high tibial osteotomy fixed with locking compression plate gives good results for symptomatic unicompartmental gonarthrosis with genu varum. Also this technique can be applied for medial compartment degeneration of the knee without deformity with good functional outcomes.

Experiences in total knee arthtroplasty after distal femoral varus osteotomy

Introduction: There is only little information available about total knee arthroplasty (TKA) following distal femoral varus osteotomy (DFVO). The aim of our study was to show our experiences and mid-term results of TKA after a previous DFVO. Material and method: In a retrospective study we identified 36 consecutive patients who had undergone TKA after a previous distal femoral varus osteotomy. The average duration of follow-up after the TKA was 8.2 years (min: 5.0, max: 9.2). X-rays were taken in 2 planes before TKA, 1 week after TKA and at latest follow-up. Tibiofemoral alignment was measured on weightbearing long-leg anteroposterior radiographs. Ra- diolucent lines at latest follow-up were documented. Functional evaluations were performed preoperatively and postoperatively (at the time of latest follow-up). Results: The mean Knee Society knee score in- creased from 42 points before the arthroplasty to 91.3 points after the arthroplasty. The mean Knee Society function score increased from 27.4 points preoperatively to 93.2 points postoperatively. The mean overall Knee Society score increased from 91.3 points preoperatively to 163.4 points postoperatively. The mean radiographic alignment was 4.5? of valgus (10? of varus to 19? of valgus) before TKA and 3.1? of valgus (range, 3? of varus to 6? of valgus) at the time of latest follow-up. Postoperative complications included one deep vein thrombosis with non-lethal pulmonary embolism, one wound infection requiring revision and one septic loosening. Discussion: It is possible to perform TKA following DFVO with good mid-term results. In comparison to the literature there is no higher risk of complications in TKA following DFVO in comparison to primary TKA.

TOTAL KNEE ARTHROPLASTY WITH POSTERIOR CRUCIATE LIGAMENT RETENTION IN PATIENTS WITH SEVERE VARUS DEFORMITY

Objective; TO observe the clinical outcome of total knee arthroplasty (TKA ) with posterior cruciate ligament (PCL ) retention in patients with severe varus deformity. Methods We reviewed the clinical treatment results of primary TKA in patients with severe varus deformity (≥20°) between January 1990 and July 1995. All patients, suffered from ostecoarthritis, were performed on a single surgeon using a minimally constrained "Hybrid" Miller-Galante knees (MG-I). Cliniccal evaluation were assessed by using the Knee Society clinical rating system. The Student’s t test was used to analyse the data. Results At a mean follow-up of 6 years (4-9years), 56 knees in 38 patients were available for review. 5 patients (7 knees) lost follow-up and 3 patients (4 knees) died. The average knee score improved from 33 points before operation to 91 points in the latest follow-up with excellent results in 84% of all patients. The Knee Society functional score improved from 39 to 76 points. The improvements were statistically significant (P < 0. 01 ). A functionally acceptable range of motion (ROM) of more than 90° were achieved in 86% of all patients. Most of cases (50/56 ) had postoperative alignment inside the normal range of 5° to 7° valgus. The other 6 cases had postoperative residual deformity of 5°-10°varus. Total revision rate was 21 % (12 /56 ), the average revision time was 5. 5 years after surgery. Other complications included patellar subluxation in 1 case, anterior pain of knee in 4 cases, and superficial cellulitis in 1 case. No early or late infection, aseptic loosening or anterioposterior instability occurred in this series. Conclusion Severs varus deformity can he successfully corrected at the time of primary TKA by using PCL-retention prosthesis. There were more problems from postoperative medial-lateral instability of knee which contributed significantly to early failure after an average of 6. 0 years.

Osteotomy combined with anterior cruciate ligament reconstruction for anterior cruciate ligament injury and biplanar deformity

BACKGROUND It has been confirmed that the increased posterior tibial slope over 12 degrees is a risk factor for anterior cruciate ligament injury,and varus deformity can aggravate the progression of medial osteoarthritis.AIM To evaluate the efficacy of modified high tibial osteotomy(HTO)and anterior cruciate ligament reconstruction(ACLR)in the treatment of anterior cruciate ligament(ACL)injuries with varus deformities and increased posterior tibial slope(PTS)based on clinical and imaging data.METHODS The patient data in this retrospective study were collected from 2019 to 2021.A total of 6 patients were diagnosed with ACL injury combined with varus deformities and increased PTS.All patients underwent modified open wedge HTO and ACLR.The degree of correction of varus deformity and the PTS was evaluated by radiography and magnetic resonance imaging.RESULTS All 6 patients(6 knee joints)were followed up for an average of 20.8±3.7 months.The average age at surgery was 29.5±3.8 years.At the last follow-up,all patients resumed competitive sports.The International Knee Documentation Committee score increased from 50.3±3.1 to 87.0±2.8,the Lysholm score increased from 43.8±4.9 to 86±3.1,and the Tegner activity level increased from 2.2±0.7 to 7.0±0.6.The average movement distance of the tibia anterior translation was 4.8±1.1 mm,medial proximal tibial angle(MPTA)was 88.9±1.3°at the last follow-up,and the PTS was 8.4±1.4°,both of which were significantly higher than those before surgery(P<0.05).CONCLUSION Modified open wedge HTO combined with ACLR can effectively treat patients with ACL ruptures with an associated increased PTS and varus deformity.The short-term effect is significant,but the long-term effect requires further follow-up.

Modified biplanar open-wedge high tibial osteotomy with rigid locking plate to treat varus knee

Objective： To introduce and characterize the modified biplanar opening high tibial osteotomy with rigid fixation to treat varus knee in young and active patients. Methods： Between June 2001 to July 2008, 18 patients with monocompartmental degeneration of the knee combined with a varus malalignment of the leg had the modified biplanar opening high tibial osteotomy and the osteotomy was fixed with the locking plates （Locking Compression Plate System）. The mean varus deformity before operation was 11.5° （5°- 19°） and no degenerative changes were found in other departments. Stability of the knee was normal in 15 patients, but ruptures in anterior cruciate ligaments or lateral collateral ligament were presented in the remaining 3 patients. Preoperative symptom was mainly limited in the pain of medial compartment. The preoperative and follow-up data for the range of motion and Lysholm score were determined. Subjective satisfactory examination was also applied to the patients for the operation they selected. Results： All of the patients were followed up with an average of 32.5 months （12-82 months）. There was no ununion or delayed union in this group during the follow-up period. No complications like broken plate, nerve injury, or blood vessel injury occurred. The postoperative average corrected degree was 9.5° （5.5°-18°）. No degenerations developed in the three departments of the knee. The Lysholm scores before and after surgery were 42.5 and 77.5, respectively （P〈0.01）. The overall fineness rate was 83.3%. The subjective satisfactory survey demonstrated that about 83.3% patients showed satisfactory on the operation. There was no obvious difference in the range of motion before and after operation, but significant changes were found in the Lysholm score and varus degree from preoperative to follow-up. Conclusion： Proximal opening high tibial osteotomy performed in conjunction with the special rigid locking plate yielded good results for symptomatic genu varum. This new classic technique can be effectively applied to the medial compartment degeneration of the knee in active young patients.

Posttraumatic progressive cubitus varus deformity managed by lateral column shortening： A novel surgical technique

The outward angulation of elbow with supinated forearm is cubitus varus deformity. This deformity is often seen as sequelae of malunited supracondylar fracture of humerus in paediatric age group of 5-8 years. The deformity is usually non-progressive, but in cases of physeal injury or congenital bony bar formation in the medial condyle of humerus, the deformity is progressive and can he grotesque in appearance. Various types of osteotomies are defined for standard non-progressive cubitus varus deformity, while multiple surgeries are required for progressive deformity until skeletal maturity. In this study we described a novel surgical approach and osteotomy of distal humerus in a 5 years old boy having grotesque progressive cubitus varus deformity, achieving good surgical outcome.

Lateral epicondylar osteotomy for severe varus deformity during total knee arthroplasty

In most cases of arthritic varus knees, stepwise osteophytes removal and medial soft tissue release could achieve satisfactory soft tissue balance during total knee arthroplasty. However, in some severe cases, conventional balancing techniques are not enough, necessitating other procedures like epicondylar osteotomy. To the best of our knowledge, no published article has reported the application of lateral epicondylar osteotomy in a severe varus knee. Here we reported a case of successful correction of a severe varus knee following lateral epicondylar osteotomy, and described its underlying rationale.

Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke: a randomized controlled trial

No recommended guidelines currently exist for the therapeutic concentration or dose of botulinum toxin type A （BTXA） injected into the muscle to treat limb spasticity. Therefore, in this randomized controlled trial, we explored the safety and efficacy of two concentrations and two doses of BTXA in the treatment of spastic toot after stroke to optimize this treatment in these patients. Eligible patients （n = 104） were randomized into four groups. The triceps surae and tibialis posterior on the affected side were injected with BTXA at one of two doses （200 U or 400 U） and two concentrations （50 U/mL or 100 U/mL）. 2he following assessments were conducted before as well as 4 days and 1, 2, 4, and 12 weeks after treatment： spasticity, assessed using the modified Ashworth scale; basic functional mobility, assessed using a timed up and go test; pace, assessed using a 10-meter timed walking test; and the ability to walk, assessed using Holden＇s graded scale and a visual analog scale. The reported results are based on the 89 patients that completed the study. We found significant differences for the two doses and concentrations of BTXA to improve the ability of patients to walk independently, with the high-dose/low-concentration combination providing the best effect. Onset and duration of the ameliorating effects of BTXA were 4-7 days and 12 weeks, respectively. Thus, BTXA effectively treated foot spasms after stroke at an optimal dose of 400 U and concentration of 50 U/mL.

Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures

Background: Proximal femoral nailing in communited intertrochanteric fractures is increasingly becoming popular in view of superior biomechanics and prevention of varus collapse associated with Dynamic hip screw. However, technical difficulties and implant related complications have been described with this technique, thus we need more studies to address these issues. Our study aims to understand technical difficulties involved in proximal femoral nailing, and specifically analyses neck shaft angle at follow-up indicating varus collapse and also to compare results of stable and unstable fractures. Materials and Methods: In this study, patients who presented to the Orthopedic Unit of Dr. TMA Pai Hospital (An associated hospital of Manipal University, Manipal) with trochanteric fractures included and treated with proximal femoral nailing. The technical difficulties involved with surgical procedure and techniques adapted to overcome such difficulties were recorded. All patients were followed up for a period of 2 years and final outcome assessment included the number of shortening, neck shaft angle and harris hip score. Results: 41 patients (mean age 71) who underwent proximal femoral nailing from January 2004 to December 2009 were included in the study, 38 patients completed 2-year follow-up. The technical difficulties we faced were divided into 3 categories, difficulties in securing entry point and guide wire placement especially when greater trochanter and piriform fossa were gathered, reduction was lost while passing nail, and finally difficulties faced during placement of hip screws. In all except one, neck shaft angle of more than 130 degrees was achieved, and this was also maintained in the final follow-up (Mean 131.9 degrees). All fractures were united, with mean shortening of 2 mm. Conclusions: Although PFN is technically required, with a proper technique PFN gives excellent clinical results with almost negligible varus collapse even in unstable trochanteric fractures. Regarding the techniques, reaming the proximal part of femur adequately and observing the nail passage with image carefully are important in placing the nail correctly, while, placement of lag screw in the inferior part of neck in anterior posterior projection and central in lateral projection reduces risk of implant failure.

Alignment of the hindfoot following total knee arthroplasty: A systematic review

BACKGROUND There appears to be a close relationship between deformities at the knee joint and at the hindfoot in patients with knee osteoarthritis(OA).Despite this intrinsic link,there is a dearth of studies investigating alterations in hindfoot alignment following total knee arthroplasty(TKA)in patients with knee OA.AIM To evaluate changes in alignment of the hindfoot following TKA,foot and ankle clinical outcomes in terms of subjective clinical scoring tools following surgical intervention,and to analyse the level of evidence(LOE)and quality of evidence(QOE)of the included studies.METHODS MEDLINE,EMBASE and Cochrane Library databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Studies reporting changes in the postoperative alignment of the hindfoot following TKA were included.The level and QOE were recorded and assessed.RESULTS Eleven studies with a total of 1142 patients(1358 knees)met the inclusion/exclusion criteria.Six studies were of LOE II and 5 studies were of LOE III.Patients with preoperative varus knee deformity and valgus hindfoot deformity demonstrated improvement in hindfoot alignment post TKA.Patients with preoperative varus knee deformity and varus hindfoot deformity demonstrated no improvement in hindfoot alignment following TKA.Twelve different radiographic parameters were used to measure the alignment of the hindfoot across the included studies,with the tibio-calcaneal angle most frequently utilised(27.3%).CONCLUSION This systematic review demonstrated that the hindfoot may display compensatory changes in alignment following TKA in patients with knee OA.However,the marked heterogeneity between the included studies and poor QOE limits any meaningful cross sectional comparisons between studies.Further,well designed studies are necessary to determine the changes and outcomes of hindfoot alignment following TKA.

The Effects of an Unloading Knee Brace and Insole with Subtalar Strapping for Medial Osteoarthritis of the Knee

Objectives: We evaluated whether a valgus knee brace and an insole with subtalar strapping could reduce pain and improve functional scores over 12 months in patients with medial knee osteoarthritis (OA). Methods: OA was confirmed by radiography in all patients, who were divided into three groups: exercise (n = 44), insole (n = 55), and brace (n = 19). Clinical knee functions and gait analyses were evaluated. Results: After 12 months, the clinical results for all groups had improved compared to pretreatment findings. Although the knee varus moment decreased and the gait speed increased when the insole was worn initially, the effects of the insole decreased at 6 and 12 months. In contrast, the knee varus moment decreased and the gait speed increased when the brace was initially fitted. The effects of the brace were maintained during the 12 months. Conclusions: The insole was effective for patients with Kellgren-Lawrence Grades II and III, and the knee brace was effective for patients with Grades III and IV conditions. Furthermore, the knee brace was more effective when worn for more than 6 months, while the effects of the insoles were not continuous.