Elevation of medial tibial condyle for severe tibia vara

Clinical and radiological evidence of knee instability was used as criteria for elevation of medial tibial condyle in severe tibia vara. Restoration of tension to the exposed medial collateral ligament was used as a guide for the required amount of elevation. A second-stage proximal tibial osteotomy was performed later for correction of the remaining varus deformity. External fixators were used in all instances. Elevation of the medial tibial condyle is indicated in severe tibia vara with arrest of the medial tibial physis, in which more than a 10 degrees difference exists between valgus and varus stress radiographs with the knee in extension as compared with an opposite normal knee.     

Femoral deformity in tibia vara

BACKGROUND: Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis. METHODS: The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle. RESULTS: The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients. CONCLUSIONS: Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.     

Comprehensive treatment of late-onset tibia vara

BACKGROUND: Late-onset tibia vara (Blount disease) can be difficult to treat because of frequent morbid obesity and associated deformities, including distal femoral varus, proximal tibial procurvatum, and distal tibial valgus, that contribute to lower extremity malalignment. We present a comprehensive approach that addresses all components of the deformity and allows restoration of the anatomic and mechanical axes. METHODS: Fifteen consecutive patients (nineteen lower extremities) with late-onset tibia vara were managed with this comprehensive approach. The mean age of the patients at the time of surgery was 14.9 years, and the mean weight was 113 kg. Standing anteroposterior and lateral radiographs were made preoperatively and at the time of the final follow-up. Preoperatively, the mean mechanical axis deviation was 108 mm, the mean lateral distal femoral angle was 95 degrees , and the mean mechanical medial proximal tibial angle was 71 degrees . In all nineteen extremities, the proximal tibial varus deformity was corrected by means of a valgus osteotomy and application of an Ilizarov ring external fixator. Distal femoral varus was corrected by means of either hemiepiphyseal stapling or valgus osteotomy with blade-plate fixation in thirteen of the nineteen extremities. Distal tibial valgus was treated either with hemiepiphyseal stapling or with varus osteotomy and gradual correction with use of the Ilizarov external fixator in eleven of the nineteen extremities. RESULTS: After a mean duration of follow-up of 5.0 years, the mean mechanical axis deviation had improved to 1 mm (range, 20 to -30 mm), the lateral distal femoral angle had improved to 87 degrees (range, 83 degrees to 98 degrees), and the mechanical medial proximal tibial angle had improved to 88 degrees (range, 83 degrees to 98 degrees ). The mean time required for correction of the proximal tibial varus deformity was thirty-one days, and the external fixator was removed at a mean of 4.5 months postoperatively. All patients had development of one or more superficial pin-track infections (mean, 1.9 pin-site infections per patient). No wound infections, nonunions, or neurovascular complications occurred. Eighteen of the nineteen extremities were pain-free at the time of the final follow-up. CONCLUSIONS: This comprehensive approach allowed restoration of the mechanical and anatomic axes of the lower extremity in patients with late-onset tibia vara, resulting in a resolution of symptoms as a result of normalization of the weight-bearing forces across the knee and ankle. We believe that this approach will decrease the risk of early degenerative arthritis of the knee.     

A reversed tibial flip autograft technique for correcting over-valgus knee after high tibial closing-wedge osteotomy in total knee arthroplasty

Excessive valgus deformity after a failed high tibial osteotomy presents problems for subsequent total knee arthroplasty because the proximal tibia is deformed, necessitating a much larger resection of bone from the medial aspect of the tibia. Other researchers have reported the tibial flip autograft technique to augment the tibial medial compartment to correct varus knee. We have modified this technique, which we call the reversed tibial flip autograft technique, for a patient with valgus knee after failed high tibial osteotomy. Clinical results were excellent, and no signs of loosening were apparent 2 years after surgery, suggesting that this technique is useful for management of tibial bone loss and correction of valgus angular deformity in total knee arthroplasty.     

Recurrent knee valgus deformity in Ellis-van Creveld syndrome

We report a case of recurrent knee valgus deformity in a patient with Ellis-van Creveld syndrome. Varus osteotomy, distraction osteogenesis, or epiphyseal stapling is one treatment option for valgus malalignment to improve appearance, gait, and function. However, surgical correction of valgus knee deformity by varus osteotomies of the proximal tibia was not maintained postoperatively, necessitating additional varus osteotomies of the distal femur in this case. The main cause of recurrence was attributed to large bony defect of the anterior segment of the proximal tibia, in addition to depression of the lateral tibial plateau.     

Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee

From 1960 through 1979, a closing-wedge varus osteotomy of the proximal part of the tibia was performed in thirty-one knees (twenty-eight patients) for painful osteoarthritis of the lateral compartment of the knee that was associated with a valgus deformity. The patients were followed for two to seventeen years (average, 9.4 years). Twenty-four knees (77 per cent) had either no pain or only occasional mild pain at the last evaluation. Six knees had moderate pain and one, severe pain. Six knees required a subsequent total knee arthroplasty at an average of 9.8 years after the osteotomy. No patient had an infection or non-union. Osteotomy of the proximal part of the tibia is a reasonable method of treating unicompartmental degenerative arthritis in a knee with a valgus deformity. Although some patients with as much as 20 degrees of anatomical valgus deformity obtained a good result in this series, osteotomy in the supracondylar region of the femur is probably preferable if the valgus angulation exceeds 12 degrees or if the tilt of the tibial articular surface that will result from the surgery will exceed 10 degrees. Correction beyond the normal 5 to 7 degrees of valgus angulation to zero degree of anatomical tibiofemoral alignment is recommended to prevent recurrence of the valgus deformity and to decrease the load on the lateral tibiofemoral compartment.     

Surgical implications of varus deformity of the knee with obliquity of joint surfaces

Some arthritic knees with varus deformity show excessive valgus angulation of the femoral joint surface with proximal tibia vara. This causes a downward and medial inclination of the articular surfaces in the coronal plane. The patients we studied had a medial shift of the standing load-bearing axis, and arthritic changes mainly in the medial compartment. Some also had lateral tibial subluxation with twisting of the distal femur and proximal tibia in opposite directions. We assessed the articular geometry by precise radiographic analysis, and compared the results with those in normal volunteers and a group of osteoarthritic patients. The prevalence of this type of deformity in our osteoarthritic patients was 11.5%; its recognition allows the use of specific operative correction that may include double osteotomy or the precise orientation of prosthetic components.     

Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results

BACKGROUND: Although high tibial osteotomy has been proved effective for the treatment of painful osteoarthritis of the medial compartment of the knee, the role of proximal tibial varus osteotomy for the treatment of painful osteoarthritis of the lateral compartment still remains controversial. METHODS: From 1974 to 1993, we performed proximal tibial varus osteotomy for the treatment of osteoarthritis of the lateral compartment of the knee in thirty-six consecutive patients. The procedure consisted of a proximal lateral opening-wedge varus osteotomy of the tibia with use of corticocancellous bone grafts from the iliac crest. The valgus deformity was posttraumatic in twenty-three patients, followed a lateral meniscectomy in five, was due to overcorrection of a varus deformity in four, and was idiopathic in four. The preoperative valgus deformity averaged 11.6 degrees (range, 4 degrees to 22 degrees ). RESULTS: At a mean of eleven years (range, five to twenty-one years) after the operation, the clinical results for thirty-four of the thirty-six patients were analyzed. None of the patients had severe progression of the osteoarthritis after the osteotomy, and none had a meaningful loss in the range of motion of the knee joint. A superficial wound infection developed in one patient, and another patient had thrombophlebitis. Three patients (9%) had a transient palsy of the peroneal nerve. According to the system of Insall et al., the mean knee score was 84 points (range, 54 to 99 points). According to the knee score described by Lysholm and Gillquist, the subjective result was excellent in nine patients (26%), good in twenty-one (62%), fair in three (9%), and poor in one (3%). CONCLUSIONS: We concluded that when the indications outlined in this study are followed and our opening-wedge technique is used, a proximal lateral opening-wedge varus osteotomy of the tibia is a good alternative for the treatment of isolated osteoarthritis of the lateral compartment of the knee. High accuracy in preoperative planning, based on a slight overcorrection, is important to prevent failure.     

Outcome of hemiepiphyseal stapling for late-onset tibia vara

BACKGROUND: The results of hemiepiphysiodesis for the treatment of late-onset tibia vara have been reported to be favorable, but the technique requires careful timing and an accurate estimation of skeletal age. Hemiepiphyseal stapling does not require a careful estimation of skeletal age, and it has been reported to yield good results with low morbidity. However, we are not aware of any study evaluating the intermediate-term radiographic results or complications of this procedure. METHODS: Twenty-six patients with thirty-three extremities with late-onset tibia vara were treated with proximal tibial hemiepiphyseal stapling. Fourteen extremities had substantial concomitant distal femoral varus and also had hemiepiphyseal stapling of the distal part of the femur. Eighteen patients (twenty-three involved extremities) had juvenileonset tibia vara and eight patients (ten involved extremities) had adolescent-onset tibia vara. The mean age at the time of stapling was 11.8 years. The mean duration of follow-up was 3.8 years. We reviewed standardized standing radiographs to determine the mechanical axis deviation, the medial proximal tibial angle, the lateral distal femoral angle, and the zone of the knee through which the mechanical axis passed. RESULTS: The mean mechanical axis deviation improved from 58 mm (range, 27 to 157 mm) preoperatively to 22 mm (range, -33 to 117 mm) at the time of the last follow-up, and the mean medial proximal tibial angle improved from 77 degrees (range, 50 degrees to 85 degrees ) to 85 degrees (range, 48 degrees to 95 degrees ). In the fourteen lower extremities in which distal femoral hemiepiphyseal stapling was performed, the mean lateral distal femoral angle improved from 96 degrees (range, 92 degrees to 100 degrees ) to 86 degrees (range, 79 degrees to 97 degrees ). At the time of the final follow-up, seven extremities were considered to be in moderate varus; four, in mild varus; twenty, in normal alignment; and two, in valgus. No differences in radiographic outcome were noted between the juvenile and adolescent forms of tibia vara. Only one of the four extremities with severe preoperative varus was corrected to normal alignment; the remaining three were left with moderate varus. CONCLUSIONS: Hemiepiphyseal stapling of the lateral aspect of the proximal tibial physis and, as needed, the lateral aspect of the distal femoral physis is safe and effective in children with late-onset tibia vara if the physes are sufficiently open and the varus deformity is mild to moderate. Hemiepiphyseal stapling is particularly effective in patients who are ten years of age or younger. LEVEL OF EVIDENCE: Therapeutic Level IV.     

Opening-wedge high tibial osteotomy to treat osteoarthritis of the knee with use of OSTEO+ system--initial report]

The aim of this prospective study was to assess the usefulness of OSTEO+ (Implants Industrie) system in opening-wedge tibial valgus osteotomy in patients with osteoarthritis of the knee. From 2002 to 2003 ten medial opening-wedge tibial osteotomies were performed in ten patients. Patients with varus knee deformity and mild or moderate degenerative changes of the knee were chosen for the procedure. A medial transverse osteotomy was performed proximal to the tibial tuberosity. The medial side of the osteotomy site was opened to the desired angle of correction. The opened osteotomy site was fixed with OSTEO+ system with no bone graft used. The goal was to achieve a final standing alignment of 0 to 5 degrees of anatomical valgus angulation. The average duration of clinical and radiological follow-up was 6 months (range, four to eight months). All patients had paro relief and improvement in walking ability after the osteotomy. There were no cases of recurrence of varus deformity.     

Mechanical overload of a single compartment induces early degenerative changes in the rabbit knee: a preliminary study

The purpose of this experiment was to determine whether mechanical overload of a single compartment of the knee in rabbits via proximal tibial osteotomy could produce early changes consistent with degenerative arthritis. Ten New Zealand white female rabbits were allocated into two groups. Group 1 (five animals) underwent a right 20 degrees valgus proximal tibial osteotomy to overload the lateral compartment of the knee. Group 2 (five animals) underwent a tibial osteotomy without malalignment (sham controls). The osteotomies were stabilized with a mini AO/ASIF plate and screws, allowing early mobilization. The left leg in each animal was left intact and served as a control. Animals were sacrificed after 3 months. Histological grading of the cartilage was performed according to Mankin et al. The mean histological gradings for the right minus the left knee were the same for the lateral and medial compartments in the 0 degrees sham osteotomy group. However, the mean histological grading of the "overloaded" lateral compartment was 2.4 times greater than the medial compartment in the 20 degrees valgus osteotomy group. These findings suggest that histological evidence of degenerative changes can be surgically induced in the rabbit knee by creating a biomechanical overload of one compartment.     

Beinachsenkorrektur nach Epiphysenfraktur und progredientem Fehlwachstum an der proximalen Tibia

Development of an angular deformity around the knee joint, following a posttraumatic premature epiphyseal closure is a rare but serious complication. We present a case report of this complication following a proximal tibial epiphyseal injury in a 9 year old child initially treated conservatively with plaster immobilization. Subsequently, partial closure of epiphysis on medial side resulted in genu varum of 20 degrees, which was treated with medial open wedge osteotomy of the proximal tibia combined with resection of a segment from the proximal fibula, and a percutaneous epiphysiodesis of the proximal tibia and fibula. At three years follow up, the child had shortening of the leg by 1 cm, but no angular deformity. Significance of regular follow-up after an epiphyseal injury to detect the condition and role of operative management with various modalities is discussed.     

Correction of knee deformity in patients with Ellis-van Creveld syndrome.

Six knees in three patients with Ellis-van Creveld syndrome were treated with lateral soft tissue release and corrective osteotomy of the tibia at 10 years of age on average. The main feature was valgus deformity with lateral dislocation of the patella. All patellae were reduced. The valgus deformity improved from 35 degrees (range, 48 degrees-20 degrees) to 17 degrees (range, 35 degrees-5 degrees) of the femorotibial angle (FTA) on average, although the FTA in five of six knees was < 5 degrees after surgery. There was one recurrent case and one transient peroneal nerve palsy. The reason for undercorrection was a depression of the lateral tibial plateau. The deformity of the articular surface is the most important problem in correcting the valgus deformity of the knee in this syndrome.     

Medial epiphysiolysis in severe infantile tibia vara

Recurrent varus deformity and shortening frequently result following valgus osteotomy alone for advanced stage infantile tibia vara (ITV), due to the proximal medial physeal dysfunction which resembles a complete growth arrest in Langenski?ld grade III or greater lesions. Epiphysiolysis is a possible treatment alternative which, if successful, can restore symmetric proximal tibial growth and obviate the need for additional complex treatments to address recurrent angular deformity and limb length inequality. We reviewed 24 patients, ages 5-10 years, with 27 affected tibiae, who underwent epiphysiolysis of the proximal medial tibia combined with valgus osteotomy. The procedure was >80% successful in restoring growth and avoiding varus recurrence in children <7 years old. Patients >age 7, patients with relative undercorrection of their mechanical axis at the time of surgery, and patients with previous failed surgical treatment were more likely not to benefit from epiphysiolysis, and consequently alternative methods may be more appropriate.     

Decrease of osteosclerosis in subchondral bone of medial compartmental osteoarthritic knee seven to nineteen years after high tibial valgus osteotomy

Osteosclerosis of the subchondral bone was measured by densitometer on plain radiographs in 55 medial compartmental osteoarthritic knees of 40 patients who were treated with high tibial valgus osteotomy for correction of varus deformity. The ratio of the osteosclerosis value of the medial side of the knee to that of the lateral side (Medial/Lateral ratio) was calculated and used as a parameter. The Medial/Lateral ratio of osteosclerosis decreased rapidly within three years after osteotomy at the reference points of the femur and the tibia. Even 7 to 19 years after osteotomy, a decrease of the ratio was noted in 16 knees with a standing femorotibial angle (FTA) less than 168 degrees (12 degrees of anatomical valgus angulation). This was interpreted to mean that osteosclerosis of the medial condyle decreased compared with that of the lateral condyle after overcorrection of varus deformity. In the cases of more than 7 years after high tibial osteotomy, a positive straight regression line was drawn by calculation between Medial/Lateral ratio and postoperative limb alignment expressed by standing femorotibial angle, with coefficient of correlation (gamma) of 0.295 (p < 0.01).     

Elevation of the medical plateau of the tibia in the treatment of Blount disease.

Seven children, between ten and thirteen years old, had elevation of the medial plateau of the tibia for correction of severe varus deformity secondary to Blount disease. The deformity was severe (grade V or VI according to the system of Langenski?ld and Riska) in all patients; the average preoperative varus deformity, determined by the angle formed by the femoral shaft and the tibial shaft, was 25 degrees. The goal of the operation was restoration of a more normal configuration of the articular surface of the proximal end of the tibia. This was accomplished by direct elevation of the depressed medial tibial plateau. All patients had an osteotomy to correct the alignment of the tibia. The osteotomy was performed concomitant with the elevation of the plateau in three patients, before the elevation in three, and after the elevation in one patient. Four patients had a concomitant osteotomy of the femur to align the knee joint parallel to the floor. The results were good in five patients and fair in two.     

Regeneration of the proximal tibial epiphysis after infantile osteomyelitis: report of three cases with an eight- to 22-year follow-up

We reviewed three infants with destructive osteomyelitis involving the proximal tibial epiphysis at a follow-up of eight to 22 years. All cases showed early radiographic destructive changes in the medial or lateral aspects of the epiphysis and metaphysis. Despite the ominous early appearance of the epiphysis, all cases showed spontaneous re-ossification of the epiphysis with restoration of the tibial condyle and preservation of joint congruity. The patients, however, developed a valgus or varus deformity which was treated satisfactorily with one to three proximal tibial osteotomies. The potential for regeneration of the epiphysis following infantile osteomyelitis of the proximal tibia suggests these cases should be treated expectantly with regard to joint congruity.     

Tibial condylar valgus osteotomy (TCVO): Surgical technique and clinical results for knee osteoarthritis with varus deformity

Tibial condylar valgus osteotomy (TCVO) is an intra-articular proximal tibial osteotomy developed in 1989 and has since been used for the treatment of knee osteoarthritis (OA) associated with genu varum. This article describes the surgical technique and clinical results of TCVO. TCVO can be used for all grades of varus knee OA in patients of any age. he preoperative range of movement should be at least 90°. Preoperative screening showed varus-valgus instability due to an intra-articular deformity of the proximal tibia. Using intraoperative image intensification, a sagittally oriented “L”-shaped osteotomy is made from the medial to the tibial tuberosity to the center of the tibial plateau between the medial and lateral tibial spines. The separation of the osteotomy using the lamina spreader is gradually increased using an image intensifier guidance until the articular surface of the lateral tibial plateau comes in contact with the articular surface of the lateral femoral condyle. Adequate correction is indicated by parallelism of the lateral tibial plateau and a line tangential to the distal convexity of the lateral femoral condyle on an anteroposterior (AP) image and the elimination of the valgus instability with the knee in extended position. A “T”-plate (locking or non-locking plate or circular external fixator) is used to fix the osteotomy in the corrected position. Synthetic or autologous bone grafts can be used. We used the Japanese Orthopaedic Association score to evaluate the patient's function and also measured the %MAD, medial plateau opening angle, medial plateau angle, and lateral plateau opening angle on an AP view of the long length roentgenogram of the lower limb (standing position). The JOA score, radiologically measured values, and instability of the knee joint remarkably improved.     

Walking ability after treatment of the knee osteoarthritis with OSTEO+ system]

The aim of this prospective study was to assess the walking ability in patients with osteoarthritis of the knee before and after opening-wedge high tibial osteotomy with use of OSTEO+ system. From 2002 to 2005 thirty medial opening-wedge tibial osteotomies were performed in thirty patients. Patients with varus knee deformity and moderate degenerative changes of the knee were chosen for the procedure. A medial transverse osteotomy was performed proximal to the tibial tuberosity. The medial side of the osteotomy site was opened to the desired angle of correction. The opened osteotomy site was fixed with OSTEO+ system with no bone graft used. The goal was to achieve a final standing alignment of 5 degrees of anatomical valgus angulation. We assessed the patients with The Knee Score and The Functional Score before and after the procedure. The average follow-up was 2 years. All patients had pain relief and improvement in walking ability after the osteotomy. There were no cases of recurrence of varus deformity.