Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount’s disease: a new technique

PurposeSurgical treatment in advanced-stage infantile Blount’s disease with medial plateau (MP) depression is challenging. Several osteotomies and fixation methods have been described with no established benchmark. We conducted this study to evaluate the efficacy and safety of a new single-stage technique for acute medial condyle elevation and metaphyseal osteotomies with internal fixation.MethodsA prospective case series of 19 consecutive patients (21 knees) with severe infantile Blount’s disease underwent a single-stage MP elevation and metaphyseal osteotomies, with internal fixation. The mean age was 10.3 years (8.2 to 13.6) and the mean follow-up was 5.1 years (3.2 to 8.3). The outcome measures included clinical and radiological parameters and patient-reported pediatric outcomes data collection instrument (PODCI) score.ResultsThe mean PODCI score improved significantly from 50% to 88%. The mean internal tibial torsion improved from -27° to 11°. All cases maintained full knee extension, no limitation in flexion range of movement and no signs of instability or lateral thrust gait. All the radiographic parameters improved significantly; the mean tibiofemoral angle improved from -29° to 7°, the metaphyseal-diaphyseal angle improved from 33.4° to 4.7° and the angle of depressed MP improved from 38.3° to 2.4° (p < 0.001). At the latest follow-up, no cases of deformity recurrence were identified, the final limb-length discrepancy was < 1 cm in all patients.ConclusionSingle-stage MP elevation and metaphyseal osteotomies with internal fixation significantly improved the clinical and radiographic parameters and PODCI score in advanced infantile Blount’s disease and precluded the use of external immobilization, with no evidence of deformity recurrence.Level of evidenceIV     

Genu varum and football participation: Does football participation affect lower extremity alignment in adolescents?

BackgroundGenu varum is one of the most common anatomical variations of knee alignment which is considered a risk factor for anterior knee pain and anterior cruciate ligament injury among football players. Considering that millions of children participate in high-level football training, the purpose of this study was to determine the genu varum development in adolescent football players and non-athlete peers. The hypothesis of this study was that genu varum incidence was higher in adolescent football players compared with non-athletic peers.MethodsThe design was a cross-sectional study. Two-hundred and thirty-seven male football players (FG) and aged-matched and anthropometrically similar non-athletes (CG) were recruited into the study. The quadriceps angle and intercondylar–intermalleolar distance were measured to evaluate the leg alignment. The distance between the medial edges of the condyles and malleoli was measured in millimeters using a digital caliper while angle measurements were performed using a photographic technique in a standing position. To analyze the variables, comparison, correlation and regression statistical tests were performed.ResultsThe intercondylar–intermalleolar distance and quadriceps angle values were significantly higher in FG than CG in all ages. In FG, a very strong correlation was found between number of training years and the intercondylar–intermalleolar distance. The prevalence of genu varum was markedly higher in FG than CG (~37% vs. 2%, respectively) based on intercondylar–intermalleolar distance.ConclusionThis study determined that the prevalence of genu varum and abnormal quadriceps angles in adolescent football players is significantly higher compared with their non-athletic peers.     

全膝关节置换术中股骨内髁滑移截骨治疗伴有关节外畸形的膝内翻

目的：探讨股骨内髁滑移截骨术（medial condyle sliding osteotomy, MCSO）在全膝关节置换术中纠正患者内翻膝关节外畸形的临床疗效。方法通过回顾性研究2013年1月至2015年12月在第三军医大学附属西南医院关节外科中心于全膝关节置换术中采用MCSO在关节内纠正股骨侧的关节外内翻畸形的12例患者,统计该组患者手术前后的股骨远端外侧力线角（mechanical lateral distal femoral angle, mLDFA）、髋-膝-踝（hip?knee?ankle, HKA）角、疼痛视觉模拟量表（visual analogue scale, VAS）评分及美国膝关节协会（American Knee Society, AKS）综合评分系统中的膝评分和功能评分等,评价MCSO纠正关节外的内翻畸形的效果。结果本组患者随访6~40个月,无感染、骨折、假体松动、截骨不愈合等并发症发生。本组患者手术前后的mLDFA分别为117.4°±4.7°、91.6°±1.4°;手术前后的HKA角分别为167.2°±9.8°、179.6°±1.6°;手术前后的VAS评分分别为（6.4±1.1）分、（1.8±1.5）分;手术前后的AKS膝评分分别为（60.2±17.6）分、（92.6±9.4）分;手术前后的AKS功能评分分别为（69.4±21.3）分、（87.6±14.9）分。手术前后以上指标的差异均有统计学意义（均P＜0.05）。结论在合并关节外畸形的内翻膝的关节置换手术中,采用MCSO技术可以正确纠正内翻力线,更容易实现伸屈间隙平衡,达到满意的手术疗效。能有效避免对膝关节后内侧和内侧组织结构的过度松解,从而避免单纯依赖软组织松解而导致的屈曲位内侧间隙松弛及髌股关节对位不良等问题。     

Clinical outcome and correction following V osteotomy for genu valgum in adolescents and young adults: A systematic review

BackgroundGenu Valgum usually originates from distal femur and many open and closed wedge osteotomies of distal femur have been reported but none has proved to be the best. Distal femur V osteotomy is a wedgeless osteotomy and is a rarely reported osteotomy with only a few case series and 167 cases of isolated distal femur V osteotomy for genus valgum in young patients (<25 years) in literature but with a tendency to have an excellent outcomes.PurposeTo determine correction and clinical outcome following V osteotomy for genu valgum in adolescents and young adults (10–25 years).Patient and methodsA systematic research was conducted of PubMed, MEDLINE and Google Scholar to identify studies reporting the correction and clinical outcome following V osteotomy in adolescents and young adults (10–25 years) for genu valgum by 2 different authors according to PRISMA guidelines.Results5 studies with 167 patients and 263 knees were identified meeting the inclusion criteria for review. The follow-up period ranged from 3 months to 36 months. Overall complication rate was 12.3%, the most common being plaster sore, 4.2% (11/263) followed by superficial infection, 2.7% (7/263). The mean correction was 19.1° and a mean post-operative valgus was 5.7°. In those compared with Bostman score (157/167), 94.3% had excellent (148/157) and remaining 5.7% (9/157) had good scores (20–27/30) with none showing poor score (<20/30).ConclusionV osteotomy is a reliable method of distal femoral osteotomy to attain a good correction with an excellent clinical outcome even with variations of fixation however longer follow-up period are required for better evaluation of recurrence.     

膝关节外翻畸形股骨侧形态学参数分析

目的探讨膝关节外翻畸形股骨侧形态结构改变特点,并分析各参数的异常分布。方法收集2010年1月至2012年12月北京积水潭医院矫形骨科收治的68例(68膝)膝关节外翻畸形患者的影像学资料,包括下肢全长X线片和膝关节CT容积性数据。在下肢全长X线片上测量解剖学股胫角(aFTA)和解剖学股骨远端外侧角(aLDFA),将DICOM格式的CT容积性数据导入MIMICS17.0软件,测量股骨远髁角(DCA)和股骨后髁角(PCA)。分析膝关节外翻畸形股骨侧各参数异常的构成比,并绘制散点图分析各参数的线性相关性。结果股骨侧形态学参数测量结果:aFTA为(18.42±6.42)°,aLDFA为(74.71±4.63)°,DCA为(6.64±1.36)°,PCA为(4.51±1.82)°,其中DCA异常人数占比最高(95.59%)。DCA、PCA和aLDFA均存在异常的人数占比为51.47%。DCA与PCA和aLDFA之间均不存在线性相关。结论股骨外侧髁远端形态结构异常是膝关节外翻畸形股骨侧骨组织异常的主要来源。约1/2的患者同时存在股骨外侧髁远端、后方和股骨干骺端形态结构异常。     

重度膝关节外翻畸形的全膝关节置换术

 目的 探讨重度膝关节外翻畸形全膝关节置换术的手术方法及临床效果。方法 对2007年1月至2012年12月采用全膝关节置换治疗的重度膝关节外翻畸形患者22例（23膝）进行回顾性分析。男7例,女15例;年龄41~78岁,平均65岁。股胫角（股骨和胫骨解剖轴线的夹角）22°~50°,平均为34.6°。骨关节炎17例,类风湿关节炎5例。髌骨完全脱位3例3膝,内侧不稳定1例1膝,屈曲挛缩畸形3例4膝。21例22膝采用后稳定型假体,1例1膝采用限制型假体。髌旁内侧入路、常规截骨及单纯外侧软组织松解,术中行髌骨置换5例。以膝关节活动度、X线股胫角及美国特种外科医院（Hospital for Special Surgery,HSS）膝关节评分评价术后疗效。结果 全部病例随访时间1~5年,平均2.5年。膝关节活动度由术前平均43.7°±5.8°（0°~80°）提高至末次随访时110.6°±7.5°（80°~130°）,HSS膝关节评分由术前平均（19.6±4.7）分（6~34分）提高至末次随访时（89.7±3.6）分（84~96分）,手术前后的差异有统计学意义。外翻畸形基本得到矫正,末次随访时股胫角平均为8.6°±0.8°（0°~12°）,较术前34.6°±2.4°（22°~50°）明显改善,手术前后的差异有统计学意义。术后2例2膝有膝关节内侧不稳症状,给予膝关节支具保护;1例1膝术前严重髌骨脱位患者术后存在半脱位,未予特殊处理;2例2膝术后出现腓总神经麻痹,未予特殊处理。随访期间未发生感染、松动及深静脉血栓形成等并发症。结论 对重度膝关节外翻畸形患者可采用常规截骨、单纯外侧软组织松解及后稳定型假体植入,能较好地矫正外翻畸形,近期疗效满意。     

An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome

Background

The genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.

Methods

A retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps:

1. Complete proximal to distal surgical decompression of the peroneal nerve
2. Radical release and mobilization of the severe quadriceps contracture and iliotibial band contracture
3. Distal lateral hamstring lengthening/tenotomy and lateral collateral ligament release
4. Proximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocation
5. Proximal tibial varus osteotomy with partial fibulectomy and anterior compartment release
6. Occasionally, distal femoral osteotomy

Results

In all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.

Conclusion

The operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.

Level of evidence

IV.     

The association of equinus and primary genu recurvatum gait in cerebral palsy

Primary genu recurvatum (GR) is less investigated and data presenting the prevalence among patients with bilateral spastic cerebral palsy (BSCP) is lacking in the literature. Equinus is mentioned as one of the main underlying factors in GR, but its influence on the severity and onset type of GR is mainly unanswered, yet. Hence, the purpose of this retrospective study was to assess the prevalence of GR in a large sample size in children with BSCP and to investigate sagittal plane kinematics to evaluate the influence of equinus on different GR types using data of three-dimensional gait analysis. GR was defined as a knee hyperextension of more than one standard deviation of an age matched control group during stance phase in either one or both of the limbs. Primary GR was defined as a GR without having previous surgery regarding the lower extremity, no selective dorsal rhizotomy and/or interventions like botulinum toxin injection, shock wave therapy or serial casting during the last 6 months in the patient history. In a retrospective study 463 patients with BSCP (GMFCS Level I–III) received three-dimensional gait analysis and were scanned for the presence of primary GR. Finally, 37 patients (23 males, 14 females) matched the determined inclusion criteria and were therefore included for further analysis in this study. Out of those patients seven walked with orthoses or a walker and were excluded from further statistical comparison: Kinematics of the lower limbs were compared between patients having severe (knee hyperextension > 15°) and moderate (knee hyperextension 5–15°) GR and between patients showing an early (first half of stance phase) and a late (second half of stance phase) GR. Primary GR was present in 37 patients/52 limbs (prevalence 8.0/5.6%). Severe GR was associated with a decreased ankle dorsiflexion compared with moderate GR. Early GR showed an increased knee hyperextension compared to late GR. In conclusion GR is less frequent compared with crouch or stiff gait. Our findings support the importance of equinus as a major underlying factor in primary GR. In this context the influence of equinus seems to be more important in early GR.