Impact of medial open-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee

BACKGROUNDMost populations worldwide, who are used to squatting and sitting cross-legged for their activities of daily living, largely comprise the lower socioeconomic strata, thus making them candidates for exclusion for total knee arthroplasty. Proximal/high tibial osteotomy (HTO) is a preferred strategy for clinically symptomatic osteoarthritis (OA) with genu varum due to painful medial compartment OA which is not amenable to conservative measures.AIMTo evaluate the outcomes of medial open-wedge HTO along with autologous bone grafting and buttress plate for the treatment of genu varum due to OA of the knee in a rural population of central India.METHODSA total of 65 knees in 56 patients with a mean age of 58.22 ± 5.63 years with genu varum due to intractable painful knee OA were treated with medial open-wedge HTO along with autologous bone grafting and buttress plate osteosynthesis from June 2015 to May 2018. The mean preoperative radiological angle of genu varum was 13.4°. Clinical outcomes were assessed by the range of movement, knee scores, pain scores, and functional scores. Radiographic studies were performed preoperatively and at regular intervals during the follow-up period.RESULTSAll patients reported pain relief immediately after the osteotomy and during the long-term analysis covering between one to three years. The genu varum angle was overcorrected to approximately four degrees in all patients. There was a loss of reduction by approximately three degrees in all patients at around six weeks postoperatively. Preoperative knee movements were restored in all patients. No major perioperative complications were noted during surgery and postoperative follow-up and the clinical scores were significantly improved during the final analysis which revealed good pain relief.CONCLUSIONMedial open-wedge HTO is a reliable, safe, practical, physiological, and feasible treatment for populations who are used to increased activity in their occupation and lifestyle and is associated with excellent short-term and long-term results for OA in genu varum knees.     

Wedge-less oblique supracondylar femoral osteotomy and casting for genu valgum in older children and young adults

BackgroundGenu valgum is one of the commonest deformities seen by the orthopaedicians. The most common cause is idiopathic but genu valgum secondary to nutritional deficiency is also fairly common in developing and third world countries. Supracondylar osteotomy and internal fixation with plate and screws, is the treatment of choice in older children and young adults, which is costly, requires a wide exposure, a second surgery for implant removal and risk of infection is more. This study was undertaken to measure the outcome of simple oblique percutaneous wedge-less metaphyseal supracondylar osteotomy of the distal femur and casting in older children and adolescents with Genu Valgum in a small centre catering mostly to patients from middle and low income households.Patients and methodsPatients aged between 12 and 22 years with genu valgum deformity with a tibiofemoral angle ≥15°, and an intermalleolar distance of more than 7 cm in unilateral and more than 10 cm in bilateral cases, who are not amenable to be treated with guided growth techniques, were included. Patients having knee instability, restriction of knee range of motion, genu recurvatum, tibial deformity component, open physis, were excluded from the study. The correction was undertaken by a simple supracondylar wedge-less metaphyseal short oblique osteotomy of the distal femur followed by immobilization with a long leg plaster of Paris cast. Functional outcome was assessed using Böstman et al. score.Results46 limbs in 29 patients with a mean age of 14.5 years were operated. The mean follow-up of patients was 6 months. The preoperative radiological tibiofemoral angle (TFA) had a mean value of 19.89° which improved to a mean of 5.31° postoperatively. Intermalleolar distance (IMD) improved from a mean of 13.81 cm to 3.15 cm post-correction. Mean Lateral distal femoral angle (LDFA) improved from 77.11° to 87.20°. Knee score was excellent in all patients at 3 months and 6 months post intervention. There were no serious complications except superficial plaster sores in 4 patients, which healed uneventfully and temporary restriction of knee range of motion in 5 patients. All patients achieved a full range of knee motion after physical therapy.ConclusionSupracondylar wedge-less short oblique metaphyseal distal femoral osteotomy and immobilization with plaster of Paris cast is a simple, cheap, safe & viable option for the correction of genu valgum deformity originating from distal femur, with minimal complications in older children and adolescents with limited growth potential, especially in low income countries and small centres.     

二维及三维超声诊断胎儿Larsen综合征

目的探讨胎儿Larsen综合征的主要超声表现及诊断要点。方法对我院诊断的两例Larsen综合征胎儿的二维及三维超声、引产后X线、CT及病理检查结果进行回顾分析。结果两例胎儿中孕期二维及三维超声均可显示双侧膝关节反屈,X线、CT及病理尸检均证实为多发大关节脱位,为Larsen综合征最具特征性的表现;另可见胎儿颜面异常(鼻骨低平)和手指异常(圆柱状手指),亦为Larsen综合征的典型表现。结论胎儿Larsen综合征具有特征性超声表现,中孕期超声检查时应注意观察胎儿肢体的姿势及活动,并仔细评估各系统异常,结合三维超声检查更有助于诊断。     

Anterior genu corpus callosum and impulsivity in suicidal patients with bipolar disorder

Suicidality is a life-threatening symptom in patients with bipolar disorder (BD). Impulsivity and mood instability are associated with suicidality in mood disorders. Evidence suggests that gray and white matter abnormalities are linked with impulsivity in mood disorders, but little is known about the association between corpus callosum (CC) and impulsivity in BD. We examined the relationship between CC areas, impulsivity and suicidality in BD patients. We studied 10 female BD patients with a history of suicide attempt (mean ± SD age 36.2 ± 10.1 years), 10 female BD patients without suicide attempt history (44.2 ± 12.5 years) and 27 female healthy subjects (36.9 ± 13.8 years). Impulsivity was evaluated by the Barratt Impulsivity Scale (BIS). We traced MR images to measure the areas of the CC genu, anterior body, posterior body, isthmus and splenium. The genu was divided into anterior, middle and posterior regions. The suicidal and non-suicidal BD patients had significantly higher BIS total, attention and non-planning scores than the healthy subjects (ps < 0.01), and the suicidal BD patients had significantly higher BIS motor scores than the non-suicidal BD and healthy subjects (ps < 0.01). There were no significant differences among the three groups on any regional CC areas, although the suicidal BD patients had the smallest areas. The suicidal BD patients showed a significant inverse correlation between anterior genu area and the BIS total (r = −0.75, p = 0.04), motor (r = −0.79, p = 0.02) and non-planning scores (r = −0.79, p = 0.02). These correlations were not found in the non-suicidal BD patients or healthy subjects. The results suggest that the anterior medial frontal region may be involved in the pathophysiology of impulsive and suicidal behaviors in BD.     

Rehabilitation improves walking kinematics in children with a knee varus: Randomized controlled trial

Background

Previous studies have demonstrated increased medial stresses in knee varus alignment. Selecting a suitable treatment strategy for individuals with knee malalignment should be a priority.

Reduction in primary genu recurvatum gait after aponeurotic calf muscle lengthening during multilevel surgery

Knee hyperextension (genu recurvatum, GR) is often seen in children with bilateral spastic cerebral palsy (CP). Primary GR appears essential without previous treatment. As equinus deformity is suspected to be one of the main factors evoking primary GR, the purpose of this study was to determine whether lengthening the calf muscles to decrease equinus would decrease coexisting GR in children with bilateral spastic CP. In a retrospective study, 19 CP patients with primary GR (mean age: 9.4 years, 13 male, 6 female, 26 involved limbs) in whom an aponeurotic calf muscle lengthening procedure was performed during single-event multilevel surgery were included and investigated using three-dimensional gait analysis before and at a mean follow-up of 14 months after the procedure according to a standardized protocol. After calf muscle lengthening, a significant improvement in ankle dorsiflexion (9.5°) and a significant reduction (10.5°) in knee hyperextension (p < 0.001) were found during mid-stance of the gait cycle. Six limbs (23%) showed no improvement concerning knee hyperextension and were designated as nonresponders. In these patients no significant improvement in ankle dorsiflexion was found after surgery either. Improvement in ankle dorsiflexion and reduction in knee hyperextension in stance phase correlated significantly (r = 0.46; p = 0.019). These findings indicate that equinus deformity is a Major underlying factor in Primary GR and that calf muscle lengthening can effectively reduce GR in patients with CP.     

Long-term effects of shoe mileage on knee and ankle joints muscle co-contraction during walking in females with genu varus

BackgroundShoe mileage may influence the risk of sustaining injuries during walking.Research questionWhat are the effects of shoe mileage on knee and ankle muscle co-contraction during walking in females with genu varus?MethodsFifteen healthy and 15 women diagnosed with genu varus received a new pair of running shoes. They were asked to wear these shoes over 6 months. Pre and post intervention, muscle activities of the dominant limb were recorded during a walking test at preferred gait speed. Two dependent variables were assessed to examine muscle co-contraction: (1) directed co-contraction ratios of agonists and antagonists, and (2) general joint muscle co-contraction.FindingsResults demonstrated significant main effects of the “shoe” factor for general ankle co-contraction during the push-off phase (p = 0.013, d = 1.503). Irrespective of experimental group, paired comparisons revealed significantly lower general ankle co-contraction during the push-off phase after the intervention. A significant main effects of “shoe” for general knee co-contraction during loading phase (p = 0.025, d = 0.895) was also observed. In both groups, paired comparison revealed significantly lower general knee co-contraction during the push-off phase in the post condition. We did not find any significant main effect of group nor group-by-shoe interaction for general ankle co-contraction during the stance phase. Likewise, we did not observe any significant main effect of “shoe”, “group” and “group-by-shoe” interaction for mediolateral directed knee co-contraction during stance phase of walking (p > 0.05).SignificanceOur findings showed that the shoe mileage but not the genu varus condition affects the general and directed co-contraction of the muscles stabilizing the knee and ankle joints. Together with the observed findings on ankle and knee muscle co-contraction, it is essential to change running shoes after a long wearing time in both healthy and genu varus females.     

膝内、外翻畸形对膝关节影响的平面有限元计算分析和光弹实验研究

目的采用有限元和光弹的实验方法,研究膝内、外翻畸形对膝关节生物力学影响。方法利用膝关节影像资料在Super-Sap软件上建立平面有限元模型,在内翻30°～外翻30°之间,按每2°加载受力,计算模型中各节点的应力应变情况。按膝关节弹性模量,制成各种膝关节畸形的环氧树脂模型,加载后置于偏振光场中观察应力光图。结果①正常膝关节内、外侧均为压应力。②膝内翻:内翻12°～18°开始显著变化,应力集中于胫骨平台内侧。③膝外翻:角度逐渐增加,外翻20°后应力显著变化,集中于外侧胫骨平台。结论膝内翻12°和膝外翻20°为膝关节应力集中的临界角度。     

固定平台与旋转平台假体置换治疗膝外翻畸形疗效的比较研究

目的：探讨全膝关节置换术治疗膝外翻畸形固定平台（fixed bearing,FB）假体和旋转平台（rotating bearing, RB）假体的疗效。方法2007年1月至2013年12月采用人工全膝关节置换术治疗轻、中度膝外翻畸形患者203例,其中181例为初次置换,按纳入及排除标准共168例（168膝）纳入研究。男57例,女111例;年龄40~79岁,平均（59.3±7.2）岁。退变性骨关节炎153例,类风湿性关节炎15例。根据假体选择不同将患者分为固定平台组（83例）和旋转平台组（85例）。所有患者记录术前及末次随访时膝关节活动度、X线股胫角、美国特种外科医院（Hospital for Special Surgery,HSS）膝关节评分及健康调查简表（the MOS item short from health survey, SF?36）评分。结果168例患者均获得随访,随访时间24~84个月,平均37.4个月。固定平台组及旋转平台组患者的膝关节活动度分别从术前72.8°±13.1°和71.2°±12.8°提高至末次随访时106.5°±9.8°和115.4°±7.9°;X线股胫角由术前16.8°±5.3°和15.2°±4.7°降至末次随访时5.6°±2.3°和5.2°±2.1°;HSS膝关节评分分别由术前（47.5±7.1）分和（49.6±8.9）分提高至末次随访时（89.1±4.6）分和（90.2±5.3）分;SF?36评分由术前（52.3±15.4）分和（50.1±17.9）分提高至末次随访时（81.6±12.3）分和（82.2±14.5）分。两组患者末次随访时除膝关节活动度,其余指标的差异均无统计学意义。2例患者术后发生症状性下肢深静脉血栓。1例患者术后早期出现关节僵硬,加强功能锻炼后症状改善。随访期间无感染、假体松动或下沉、膝关节迟发不稳等并发症。结论对于轻、中度膝关节外翻畸形,两种类型的假体在相同的软组织平衡技术下均可改善患者膝关节活动度、矫正外翻畸形,近期疗效满意。     

Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years

Background:

Guided growth through temporary hemiepiphysiodesis has gained acceptance as the preferred primary treatment in treating pediatric lower limb deformities as it is minimally invasive with a lesser morbidity than the traditional osteotomy. The tension band plate is the most recent development in implants used for temporary hemiepiphysiodesis. Our aim was to determine its safety and efficacy in correcting coronal plane deformities around the knee in children younger than 10 years.

Materials and Methods:

A total of 24 children under the age of 10 were operated for coronal plane deformities around the knee with a single extra periosteal tension band plate and two nonlocking screws. All the children had a pathological deformity for which a detailed preoperative work-up was carried out to ascertain the cause of the deformity and rule out physiological ones. The average age at hemiepiphysiodesis was 5 years 3 months (range: 2 years to 9 years 1 month).

Results:

The plates were inserted for an average of 15.625 months (range: 7 months to 29 months). All the patients showed improvement in the mechanical axis. Two patients showed partial correction. Two cases of screw loosening were observed. In the genu valgum group, the tibiofemoral angle improved from a preoperative mean of 19.89° valgus (range: 10° valgus to 40° valgus) to 5.72° valgus (range: 2° varus to 10° valgus). In patients with genu varum the tibiofemoral angle improved from a mean of 28.27° varus (range: 13° varus to 41° varus) to 1.59° valgus (range: 0-8° valgus).

Conclusion:

Temporary hemiepiphysiodesis through the application of the tension band plate is an effective method to correct coronal plane deformities around the knee with minimal complications. Its ease and accuracy of insertion has extended the indication of temporary hemiepiphysiodesis to patients younger than 10 years and across a wide variety of diagnosis including pathological physis, which were traditionally out of the purview of guided growth.