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.

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.