Ilizarov张力-应力法则在小腿内外翻畸形中的应用

[目的]探讨应用Ilizarov张力-应力法则结合组合式外固定架矫正小腿内外翻畸形的疗效。开创一条微创治疗小腿内外翻畸形的新方法。[方法]本科自2002~2005年应用组合式矫形器矫正小腿内外翻畸形12例,男9例,女3例,年龄10~25岁,平均15岁。左侧8例,右侧4例;胫骨骨上端骺损伤2例,下端骺损伤10例;小腿内翻9例,外翻3例;外伤性骺损伤9例,干骺端感染骺早闭2例,肿瘤致骺早闭1例。根据患者肢体的长短,粗细,术前组装不同长度及周径的带关节的组合式矫形器,微创截骨,依照Ilizarov的穿针固定原则,安装具有多向矫形功能的组合式小腿内外翻矫形器,术后7d开始旋转螺纹杆,一侧撑开,另一侧加压,逐渐矫正内外翻畸形,内外翻畸形矫正后如存在短缩畸形,再行4根螺纹杆的同时撑开,直到与对侧肢体等长。[结果]12例均获随访,随访时间7个月~4年6个月,平均1年3个月,2例因年龄过小畸形复发5~8°,行走功能良好,患者及家属满意未行再次矫正。本组病例无伤口及针道感染,无血管、神经损伤及骨不愈合等并发症。[结论]Ilizarov张力-应力法则结合组合式可调式矫形器是治疗小腿内外翻畸形安全、微创、有效的好方法。     

Ilizarov牵拉组织再生技术矫正胫骨平台骨折内翻畸形

目的 探讨应用Ilizarov牵拉组织再生技术矫正胫骨平台骨折内翻畸形的方法及疗效.方法 2004年1月至2010年3月共收治6例胫骨平台内翻畸形患者,男5例,女1例;年龄28～52岁,平均41.5岁.胫骨平台骨折Schatzker分型:Ⅴ型 3例,Ⅵ型3例.6例患者初次手术至膝关节内翻畸形手术时间为7～12个月(平均9.5个月).术前X线片测量胫股角:外翻15°～28°,平均22.4°.按照Ilizarov牵拉组织再生技术要求,在胫骨近端截骨,安装国产具有三维矫形功能的牵伸矫正器,术后7 d缓慢旋转螺纹牵伸杆,矫正胫骨平台的内翻畸形.在矫正畸形的过程中患肢行膝关节及踝关节屈伸功能锻炼.结果 6例患者下肢术后牵仲时间为17～30 d(平均24.4 d).全部膝父节内翻畸形均获满意矫正.无一例发生血管、神经损伤及骨不连.2例发生钉道感染,经应用抗生素及局部换药治疗,感染愈合.6例患者拆除矫形器后获8～24个月(平均13.5个月)随访.根据Hohl膝关节功能评价方法评定疗效:优3例,良2例,可1例.结论 Ilizarov牵拉组织再生技术可以同期矫正胫骨平台骨折畸形愈合后膝关节的内翻畸形.     

Ilizarov技术结合矫形支具治疗复杂膝关节畸形的临床研究

[目的]研究、探讨在矫治膝关节畸形中,矫形支具与Ilizarov外固定器结合方法、优点与临床疗效.[方法] 2005年5月～ 2012年12月本科采用Ilizarov技术结合矫形支具治疗膝关节畸形患者36例36膝,其中男23例,女13例,左20例,右16例;年龄6～56岁,平均28岁;脊髓灰质炎后遗症膝反屈畸形17例,术中行腘绳肌紧缩后临时用组合式外固定器固定于屈膝20°位,术后2周拆除股骨外固定做大腿支具并用螺纹牵伸杆跨膝关节继续固定;小腿延长致膝关节屈曲畸形10例,直接做大腿支具跨膝关节固定,后侧用螺纹牵伸杆连接,可逐渐矫正屈膝畸形;膝内翻畸形合并外侧副韧带松弛8例,行胫骨截骨矫形,同期行外侧副韧带重建并用组合式外固定器固定膝关节,术后2周拆除股骨外固定改为大腿支具并用螺纹牵伸杆跨膝关节继续固定;血管瘤致屈膝畸形1例,采用股骨外固定器结合小腿支具牵拉矫正屈膝畸形.[结果] 36例患者中,32例获得8～60个月随访,平均19个月,所有膝关节畸形均获满意矫正,下肢负重力线恢复满意,截骨端愈合时间60 ～ 150 d,平均120 d;外固定针道感染5例,经局部换药处理好转;采用HSS评分系统进行评分,优18膝,良10膝,可4膝,优良率为87.5％.[结论]遵循Ilizarov技术原理,采用Ilizarov外固定器联合矫形支具的方法治疗合并有软组织因素的复杂膝关节畸形,可以获得满意的矫形结果及良好的膝关节功能;具有创伤小、固定灵活、制作简单等优点.     

Ilizarov牵拉组织再生技术矫正膝关节重度复合畸形

[目的]探讨Ilizarov牵拉组织再生技术矫正膝关节重度复合畸形(膝关节有2种以上畸形存在,如膝屈曲合并内翻、下肢短缩等)的器械构型、手术方法、术后管理程序与疗效。[方法]遵照Ilizarov牵拉组织再生技术的原理,研制了具有三维矫形功能的膝关节牵伸矫正器,需要同期做下肢延长者,在矫正器的基础上加延长附件。根据膝关节复合畸形的不同类型和骨骼畸形部位,在股骨髁上或胫骨上端截骨,跨膝关节穿针安装固定牵伸矫正器,术后7d缓慢旋转螺纹牵伸杆及其相连的4个万向关节,膝关节的软组织屈曲挛缩、以及并存的膝内翻、外翻、旋转、下肢短缩等骨性畸形能同期缓缓矫正,在牵拉矫正畸形的过程中,患肢可以部分参与持重行走。截骨牵拉处骨愈合后,拆牵伸器,装配膝关节矫形支具行走3~6个月。自1996年5月~2004年2月,共矫正重度膝关节复合畸形14例,年龄5~41岁,平均27岁。共7个病种,其中幼年时膝关节骨骺损伤或感染致膝关节发育畸形4例,其他原因导致膝关节复合畸形10例。[结果]14个病例术后的关节牵拉及骨愈合时间80~390d,平均154d。全部病例膝关节复合畸形皆获满意矫正,双下肢基本等长,行走功能恢复良好,无1例发生针道严重感染、血管、神经损伤、骨不愈合的并发症,但皆并发不同程度的膝关节僵硬。[结论]牵拉成骨技术矫正膝关节重度复合畸形,能够用微创的矫形外科技术同期矫正重度膝关节屈曲、内翻、外翻、小腿旋转和下肢短缩畸形,畸形矫正符合生物学原理,获得了用传统骨科技术无法达到的疗效,具有良好的应用前景。     

单臂非金属外固定架在矫正膝关节畸形中的应用(附20例报告)

小儿麻痹后遗膝关节屈曲、外翻、内翻、小腿外旋等骨性畸形改变,需采用股骨髁上截骨或(和)胫骨结节下截骨矫正,术后一般常规采用石膏外固定,由于固定期间关节不能运动,易并发肌萎缩,膝关节僵直,甚至发生截骨端错位或缺血性肌挛缩等并发症,而且下肢沉重的石膏也不利于患者早期     

Ilizarov技术治疗中老年膝骨关节炎内侧间室疼痛的临床观察

目的探讨胫骨结节下微创截骨,Ilizarov技术牵伸矫形,治疗中老年膝骨关节炎内侧间室疼痛的效果。方法回顾分析2012年4月至2013年10月,采用Ilizarov技术牵伸治疗的34例患者,共计48个膝关节(14人双膝治疗)。其中,男11例,女23例;年龄51到76岁,平均65.7岁。病程2~15年,平均病程为5.1年,症状均以膝内侧间室疼痛为主的膝骨关节炎患者。均有2年以上中、西医结合治疗病史。测量膝关节活动范围(142.0±9.3)°,并根据KSS评分评判患膝功能。34例患者术前均拍双下肢全长X线片,测量双下肢力线移位程度及股胫夹角(FTA)。采用胫骨结节下2~3cm处截骨,安装Ilizarov环形外固定支架。术后第5天行牵伸成骨矫形,10~15d后,拍双下肢X线片,确定下肢力线及股胫夹角达到正常值后,锁定外固定支架。要求扶拐行走锻炼,待截骨端成骨完全钙化达到骨性愈合,约12~16w后,拆除外固定支架。结果 34例患者平均13.8w拆外固定支架;所有患者均获18~36个月随访,平均18.7个月,并行膝关节KSS评分。结论胫骨结节下微创截骨,Ilizarov环形外固定支架牵伸矫正,治疗中老年膝骨关节炎内侧间室疼痛,具有矫正准确、疗效确切、微创伤、成骨矫形等特点。     

穴位穿针联合Ilizarov技术矫形治疗中老年膝骨关节炎

目的:探讨穴位穿针联合Ilizarov技术矫形治疗中老年膝骨关节炎的临床疗效。方法:自2015年3月至2016年2月,采用胫骨截骨并行Ilizarov技术矫形治疗原发性膝骨关节炎患者76例,男24例,女52例;年龄56～75岁,平均61.4岁;病程3～17年,平均5.2年。38例采用穴位穿针外固定(穴位穿针组),38例采用解剖穿针外固定(解剖穿针组)。术前双下肢全长X线片示胫骨内翻畸形,内侧膝关节间隙变窄,外侧间隙增大。体表测量患膝下肢力线内移,KSS膝功能评分降低。所有患者膝关节内侧疼痛、屈伸活动可,保守治疗2年以上。结果:术后两组患者下肢力线均得到矫正,截骨端均愈合良好。未见截骨不愈合、下肢矫正不到位或畸形复发等。75例患者术后3、6、12、24个月随访,两组患者术前、术后6、12、24个月膝关节活动度测量结果变化差异无统计学意义(F=1.346,P0.05)。两组术后3个月复查KSS疼痛与总分比较,差异有统计学意义,穴位穿针组优于解剖穿针组(P0.05);术后12个月KSS评分比较,差异无统计学意义(P0.05)。结论:穴位穿针组在术后调整过程中,通过Ilizarov环形外固定支架上的钢针持续拉紧,在穴位区形成一个潜在的针刺作用,术后佩戴外固定矫正支架的3个月内,膝骨关节炎膝痛症状快速、持续有效缓解方面,明显优于解剖穿针组。     

复杂膝关节畸形的TKA治疗

目的探讨复杂膝关节畸形行人工全膝关节置换术（TKA）的可行性和手术方法。方法回顾性分析自2000-01—2008-12行TKA的20例（26膝）复杂膝关节畸形伴严重功能障碍患者,经过充分术前准备后,针对不同畸形特点采用不同的截骨矫形方式,并进行相应挛缩软组织松解。内翻畸形以调整胫骨截骨矫正为主,外翻以调整股骨截骨矫正为主,屈曲行调整股骨远端及胫骨后倾截骨,术后加以系统的康复训练。结果本组术后获得1~5年随访,平均矫正内翻畸形15°,外翻畸形10°,屈曲畸形35°。末次随访HSS评分平均（86.5±8.6）分,较术前平均（36.2±15.4）分明显提高,差异有统计学意义（t=-12.812,P〈0.05）。结论复杂膝关节畸形患者行TKA需重视术前评估,并依据膝关节骨质畸形、软组织形成等病理特点,选择针对性的手术方式及系统性的康复训练,最终可获得一个畸形矫正、稳定无痛、功能良好的膝关节。     

胫骨平台骨折畸形愈合翻修术治疗进展

胫骨平台骨折畸形愈合会出现膝内外翻、屈曲或反张、旋转畸形、髌骨运动轨迹异常、关节僵硬、膝关节不稳定等。胫骨平台骨折畸形愈合翻修术有切开复位内固定、胫骨近端截骨术、外固定支架固定、胫骨结节远端截骨术、全膝关节置换术等,其中胫骨近端截骨术是胫骨平台骨折畸形愈合常用的治疗方法,可达到满意疗效。翻修术的目的是恢复膝关节稳定性、关节面平整及下肢力线,最大限度地减少膝关节周围并发症发生。该文就胫骨平台骨折畸形愈合翻修术治疗进展作一综述。     

膝部截骨组合式外固定支架固定治疗膝外翻13例

[目的]观察股骨髁上、胫骨近端单独或联合截骨组合式外固定支架固定治疗膝外翻13例临床疗效.[方法]13例病人男8例,女5例;年龄8～24岁,单侧10例,双侧3例,共16个膝.术前膝外翻畸形平均26°,立位双踝之间的距离最大者50cm.手术方法:单纯实施股骨髁上截骨11膝,股骨髁上+胫骨结节下双截骨5膝.[结果]16膝随访14～42个月,平均26个月,畸形完全矫正无并发症者14膝,大部矫正者2膝.[结论]术前认真分析X线片,制定周密的手术方案,术中正确操作,应用组合式外固定支架固定截骨段,对治疗不同程度的膝外翻可获得良好疗效.     

应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效

目的探讨应用牵拉成骨技术治疗股骨、胫骨肥大型骨不愈合合并畸形患者的疗效。方法回顾性分析2016年11月至2019年11月在北京积水潭医院创伤骨科应用牵拉成骨技术治疗的3例股骨、胫骨肥大型骨不愈合合并畸形患者的病历资料。3例均为男性。所有骨折不愈合端均不切开。胫骨不愈合者均需经皮截断腓骨,使用Taylor Spatial Frame(施乐辉公司)固定,将13个参数输入计算机,设定牵开速度1 mm/d,生成电子处方。股骨不愈合者使用Orthofix外固定架固定。术后第2天按照1 mm/d的速度牵拉,在牵开恢复长度的过程中逐渐纠正畸形。随访期间,观察患者畸形纠正情况和骨愈合情况。结果病例A术后20 d畸形完全纠正,术后15个月获得骨性愈合。病例B术后25 d畸形完全纠正,术后15个月获得骨性愈合。病例C术后29 d成角畸形纠正,术后19个月获得骨性愈合。结论牵拉成骨技术可纠正肥大型骨不愈合的成角畸形及短缩,可作为肥大型骨不愈合的一种微创治疗方法。     

Assessment of percutaneous V osteotomy of the calcaneus with Ilizarov application for correction of complex foot deformities

Complex foot deformity can be described as a foot with multiplanar abnormalities with or without shortening of the foot. Conventional surgical treatment may not be able to correct these deformities. In this study we evaluate the results of percutaneous V osteotomy of the calcaneus with an Ilizarov external fixator for treatment of complex foot deformity. Twenty feet with a complex deformity were treated by the Ilizarov method in 15 patients. The aetiologic factors were neglected or relapsed clubfoot (13 patients) and poliomyelitis (2 patients). All patients underwent percutaneous V osteotomy of the calcaneus and gradual correction of the deformity using Ilizarov's method. The mean duration of fixator application was 9.5 months (range, 6-13 months). The mean follow-up period was 1.8 years (range, 1 to 3 years). At the time of fixator removal, a plantigrade foot was achieved in 18 cases; gait was improved in all patients. There was residual varus deformity in two patients. A pin-tract infection was observed in all patients. No recurrence of the deformity occurred. The V osteotomy offers the most options for correction of complex foot deformities. Percutaneous technique is particularly useful for the complex foot deformity that has poor skin coverage, with poor blood supply. Gradual correction with the Ilizarov method yields good results for complex foot deformities.     

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.     

Ilizarov Gradual Distraction Correction for Distal Tibial Severe Varus Deformity Resulting from Epiphyseal Fracture: Case Report and Literature Review

We present a case of a 13-year-old female with severe varus deformity and limb discrepancy resulting from epiphyseal fracture. The preoperative tibial articular surface angle was 64.1°, and the affected tibia was 14 mm shorter than the contralateral tibia. She underwent a medial open osteotomy and fibular osteotomy with gradual distraction correction using Ilizarov fixator. The deformity was corrected at 3 months, and the external fixator was removed when bony union was achieved 6 months postoperatively. At 9 months after surgery, the patient could play basketball without feeling pain. At the last follow-up, namely 36 months after the operation, the American Orthopaedic Foot and Ankle Society hindfoot-ankle score was improved from 58 to 90, the patient was pain free, and the radiological measurements were nearly normal. Ilizarov fixator gradual distraction correction for distal tibial severe varus deformity is a safe and cost-effective method that can yield excellent radiological and clinical outcomes.     

成年人小腿外旋畸形的外科治疗

目的探讨成年人小腿外旋畸形的成因、手术方法和治疗效果。方法回顾性分析138例144条腿,平均年龄29.3岁。小儿麻痹后遗症116例,其它原因22例,其中130例合并髋、膝关节和踝足关节的多种畸形209个。术前小腿外旋平均43°,手术先截断腓骨,在胫骨结节下杵臼形截骨,远端内旋至中立位,测量棘、髌、踝力线正常,合并膝内翻、轻度屈膝和膝反屈畸形者同时矫正,截骨端以外固定器或钢针交叉加石膏外固定。结果术后随访平均14个月,128例小腿外旋畸形完全矫正,10例部分矫正。结论小腿外旋是渐进发生的常见畸形,胫骨结节下内旋截骨是简单有效的手术方法,合并髋、膝、踝关节畸形者尽可能同期手术矫正,恢复下肢的持重力线。     

应用单边外固定支架矫正胫骨近端内翻畸形

目的 探讨应用单边外固定支架矫正胫骨近端内翻畸形的疗效.方法 2004年7月至2010年8月应用单边外固定支架治疗5例胫骨近端内翻畸形患者,男2例,女3例;年龄18～42岁,平均32岁.胫骨平台骨折与胫骨近端骨折畸形愈合各2例,胫骨近端截骨延长后出现牵开骨痂的畸形愈合1例.术中对腓骨进行截骨,在胫骨安装外固定支架,并在胫骨近端进行截骨.术后7～10 d通过外固定支架逐渐牵开并纠正成角畸形.结果 所有患者术后获5～11个月(平均8.4个月)随访.1例患者牵开处不愈合,经植骨治疗后愈合;其余4例均愈合,愈合时间为3～6个月,平均4.8个月,带架时间为4～8个月,平均6.8个月.所有腓骨截骨端均愈合,针道除并发轻微反应外无严重并发症,手术与矫正过程中未出现神经损伤等并发症.机械轴偏向矫正后较健侧平均外移8 mm(1～13mm).胫骨近端内侧角矫正后平均为90°(87°～92°).矫正后患侧肢体和健侧差异为-6～1 mm,胫骨和健侧长度差异为-2～3 mm.结论 单边外固定支架能够成功矫正胫骨近端内翻畸形愈合,与传统的外翻截骨内同定相比,它具有创伤小、无需植骨及截骨方法简单的优点,逐渐矫正能获得更准确的力线,同时可矫正肢体短缩、避免再次手术.

Abstract：

Objective To review gradual correction of proximal tibial varus malunion with a unilateral external fixator for osteogenetic distraction. Methods From July 2004 to August 2010, we treated 5 cases of proximal tibial varus malunion with a unilateral external fixator. They were 2 men and 3 women,with an average age of 32 years (from 18 to 42 years). Two cases were malunion after tibial plateau fracture,2 after proximal tibial fracture, and one after osteogenetic distraction. After fibular osteotomy, a tibial unilateral external fixator was installed before proximal tibial osteotomy. Varus was corrected for 7 to 10 days after surgery by gradual distraction till the same alignment was obtained as the contralateral side. The external fixator was not removed until consolidation and full weight bearing. Results The follow-ups ranged from 5 to 11 months (average, 8. 4 months). Four cases got united after 3 to 6 months (average, 4. 8 months).Time for external fixator ranged from 4 to 8 months (average, 6. 8 months) . One case obtained bone union after bone grafting. All fibulas healed after osteotomy. No other complications were present except mild pin-tract problems. Compared with the contralateral side, the corrected malalignment deviation was laterally displaced by 8 mm on average (from 1 to 13 mm), the corrected medial proximal tibial angle was 90° on average (from 87° to 92°), the limb length discrepancy was -6 to 1 mm, and the tibial length discrepancy was - 2 to 3 mm. Conclusions Proximal tibial varus malunion can be corrected gradually and effectively by a unilateral external fixator. Its advantages over valgus osteotomy and internal fixation are less invasion due to simple transverse osteotomy, accurate correction not only of angulation but also of length discrepancy, and no need of bone grafting or implant removal.     

胫骨高位嵌插截骨与传统高位截骨治疗高龄屈曲型膝内侧间隙骨关节炎的对比研究

目的:报告胫骨高位嵌插截骨治疗高龄屈曲型膝内侧间隙骨关节炎的方法疗效,并与传统高位胫骨截骨的疗效进行比较。方法:2003年7月至2007年7月对年龄60～82岁,病史3～20年,屈曲度7°～19°的膝内侧间隙骨关节炎的30例患者随机分成2组,分别进行胫骨高位嵌插截骨和传统高位截骨手术治疗。术后观察骨折愈合时间、膝关节内翻畸形和屈曲畸形恢复、膝关节功能恢复等情况。要求患者术后第4、6、8、9、10、12、14、16周及5、7、9、12个月复查,记录骨折愈合时间及内翻、屈曲角度纠正情况。术后12个月时根据Lysholm膝关节评分标准进行评分,并对2组的疗效进行比较。结果:胫骨高位嵌插截骨组平均骨折愈合时间(9.26±2.23)周,传统高位截骨组平均(11.53±3.15)周,2组相比差异有统计学意义(P0.05)。膝关节功能恢复方面,术后1年,根据Lysholm评分标准进行评分,胫骨高位嵌插截骨平均(88.5±4.4)分,优14例,良1例;传统高位截骨组平均(78.1±5.7)分,优8例,良5例,可2例。胫骨高位嵌插截骨组术后膝关节伸直位角度0°～-1.1°,术后平均矫正(13±3.3)°;传统高位截骨组术后膝关节伸直位角度与术前相同,为(14°±3.3)°。两组术后站立位X线测量,FTA平均170.2°(l69.1°～172.3°),平均矫正12.3°～12.5°。结论:胫骨高位嵌插截骨手术治疗膝关节内侧间隙骨关节炎缩短了骨折愈合时间,同时矫正了膝关节内翻畸形和屈曲畸形,更好地恢复了膝关节的功能,此手术方式明显优于传统的高位截骨术。     

Distraction osteogenesis for nonunion after high tibial osteotomy.

The purpose of this study was to determine whether distraction osteogenesis can be used to treat hypertrophic nonunion associated with angular deformity and shortening after Coventry style high tibial osteotomy. Five consecutive patients were retrospectively reviewed. In all patients the alignment had collapsed into excessive varus or valgus and leg length discrepancy was present. The leg length discrepancy, malalignment, and nonunion were treated simultaneously with distraction. Union was achieved by the time of fixator removal, which averaged 4.4 months. The Hospital for Special Surgery knee score significantly improved from 42 to 89. The mechanical axis deviation significantly improved by 5 cm. The coronal plane deformity significantly improved by 13 degrees, and leg length discrepancy improved significantly from 2.3 to 0.5 cm. Metaphyseal bone stock increased by 43%, and the Insall-Salvati ratio increased from 1.1 to 1.2 and remained within normal limits. All patients were satisfied with the procedure, and none have had or need a total knee replacement at an average followup of 4 years. Distraction osteogenesis of nonunion after high tibial osteotomy is a minimally invasive and successful procedure. It leads to bony union with correction of deformity and leg length discrepancy and prevents the need for total knee replacement at intermediate-term followup. The increase in metaphyseal bone stock may make total knee replacement technically easier.     

The effect of extraarticular varus and valgus deformity on total knee arthroplasty

Because of trauma, metabolic bone disease, congenital deformity, or prior osteotomy, an extraarticular deformity may be present in patients requiring total knee arthroplasty. If the extraarticular deformity is not corrected extraarticularly, it must be corrected by compensatory distal femoral or proximal tibial wedge resection to produce overall limb alignment. Because such a wedge resection between the proximal and distal attachments of the collateral ligaments will produce asymmetrical ligament length, complex instabilities may result. This article, through overlay templates and trigonometric analysis, evaluates all the issues confronting the surgeon deciding whether to pursue intraarticular or extraarticular correction. The conclusions are as follows: (1) the closer a deformity is to the knee, the greater its importance, (2) femoral deformities are more difficult to correct intraarticularly than tibial deformities because femoral compensatory wedge resection produces instability only in extension, and (3) intraarticular correction of varus deformities produces lateral instability that is usually better tolerated than medial instability, and some extraarticular deformities are best treated by extraarticular correct, independent, or total knee arthroplasty.