Results of repositioning osteotomies in delayed healing or pseudarthrosis of the proximal femur]

The results after valgus osteotomy for delayed or nonunion in 20 patients with femoral neck fractures (9 Pauwels type II and 11 type III) and 10 intertrochanteric fractures are reported. The mean age of the patients at presentation with delayed/nonunion of femoral neck fractures and intertrochanteric fractures was 37.5 and 60 years, respectively. The average interval between injury and valgus osteotomy in the first and second group was 8 and 13 months, respectively. The average size of the preoperatively determined and intraoperatively removed wedge was 30 degrees in both groups. The results of the two fracture groups were analyzed separately. All but one osteotomy in a patient with a nonunion of a femoral neck fracture consolidated without complications. This case developed a nonunion at the osteotomy and required additional surgery consisting of bone graft and refixation to heal. Of the femoral neck delayed/nonunion cases, 15 (75%) healed immediately following valgus osteotomy. In the intertrochanteric delayed/nonunion patients, valgus osteotomy led directly to bone consolidation in 6 (60%). In each fracture group 3 additional cases healed following reoperation for a total consolidation rate of 90%. In the femoral neck group one union was complicated by infection, resulting in ankylosis of the hip and 3.5 years later another patient with a revascularized femoral head required total hip arthroplasty because of a large, loose osteochondral fragment. In two cases union of the former femoral neck fracture could not be achieved. Partial avascular necrosis determined the course and total hip arthroplasty was required for both cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion

The dynamic hip screw, which is routinely used for intertrochanteric hip fractures, also provides a technically simple means of fixation for intertrochanteric valgus osteotomies in the treatment of femoral neck nonunions. Eight patients underwent intertrochanteric valgus osteotomy for femoral neck nonunion using a dynamic hip screw for fixation. One patient died 4 months postoperatively of causes unrelated to the procedure. The remaining 7 patients were followed for an average of 24 months postoperatively. The nonunion healed in all 7 cases. The average angle of the fracture plane decreased from 68 degrees to 41 degrees. All the hip fractures were classified as Pauwels type III preoperatively and Pauwels type II postoperatively. The average Harris Hip Score increased from 24 to 73. On radiographic review, no cases of osteonecrosis were identified postoperatively.     

全髋关节置换术中大转子骨折的原因与治疗

目的探讨全髋关节置换术及翻修术中股骨大转子骨折的原因与治疗方法。方法对1996年5月至2005年1月,471髋行全髋关节置换及96例全髋关节翻修术发生大转子骨折及大转子截骨不愈合的14例患者进行回顾性分析。其中大转子骨折11例,截骨不愈合3例。2例保守治疗,12例采用螺钉或克氏针加张力带钢丝固定的方法治疗。结果术后随访5~64个月,平均25个月。14例患者全部愈合。Harris评分从术前平均48分恢复到术后随访时平均90分。结论骨质疏松、髋内翻、髋脱位及股骨颈截骨不当等因素是全髋关节置换术及翻修术中股骨大转子骨折的主要原因。采用螺钉或克氏针加张力带钢丝固定的方法治疗效果良好。     

Salvage of failed dynamic hip screw fixation of intertrochanteric fractures

Twenty-six patients with failed dynamic hip screw fixation of intertrochanteric fractures were included in this study. The mean age of the patients was 61 years (range, 38-84 years). Average limb shortening was 2.4 cm; 18 patients were treated with revision internal fixation and eight patients with prosthetic replacement. The decision depended on the physiological age of the patient, quality of bone, and condition of the femoral head and the acetabulum. The revision internal fixation group included DHS reinsertion in eight patients, valgus osteotomy and revision DHS fixation in six, while four patients were treated by valgus osteotomy and insertion of single-angled 130 degrees plate. The prosthetic replacement group included cemented Thompson endoprothesis in five patients and cemented total hip arthroplasty in three. The mean follow-up period was 31 months (range, 15-72 months). All patients of revision internal fixation group achieved fracture healing without bone grafting. Time to union averaged 17 weeks. Average gain in length was 2 cm Avascular necrosis of the femoral head occurred in one patient. Six patients of the prosthetic replacement group achieved good functional outcome and pain-free gait. The remaining two had unsatisfactory result.     

Extended femoral osteotomy for revision of hip arthroplasty: results and complications

Seventy-five revision total hip arthroplasties (73 patients) performed using an extended greater trochanteric osteotomy for exposure and an extensively porous-coated uncemented stem were reviewed after 2 years (range, 1 to 5). The mean osteotomy length was 14 cm (range, 7 to 19 cm) and fixation was with at least 2 cables. One stem was revised at 4 months for stem subsidence and loosening. Of the remaining 74 osteotomies, 73 healed without further procedures. A single nonunion was reoperated at 4 months and healed. Sixty-eight of 73 osteotomies healed with no migration and 5 did with less than 5 mm of proximal migration of the osteotomy fragment. Complications included 3 intraoperative and 1 postoperative osteotomy fragment fractures. Extended trochanteric osteotomy, executed preserving the fragment's vascularity and fixed with rigid fixation, can be performed with a low rate of complications.     

Long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip

The beneficial role of intertrochanteric varus or valgus osteotomy in the treatment of hip osteoarthrosis has been recognised since the 1920s. Even today, it has an important role to delay the need for hip replacement in younger patients. The purpose of this study was to evaluate the long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip. Between 1980 and 1995, 52 hips with dysplastic osteoarthritis underwent an intertrochanteric varus osteotomy. All patients could be followed up after 17.8 years. Radiographic assessment included centre-edge (CE) angle of Wiberg and collodiaphyseal (CCD) angle. Dysplastic hip dislocation was classified according to Crowe. Osteoarthritis was graded according to Tönnis. Preoperative osteoarthritis was Tonnis grade 1 in 19 hips, grade 2 in 28 and grade 3 in five. Complications were also documented. Clinical evaluation included score according to Merle d’Aubigné, Harris Hip Score and range of motion. Six of 52 patients underwent total hip replacement (THR) within five years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in four cases and grade 2 in one case according to Tönnis. Twenty-five of 52 patients underwent THR after an interval of five to ten years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in one case and grade 2 in 24 cases according to Tönnis. Sixteen of 52 patients underwent THR after an interval of ten to 15 years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 2 in four cases and grade 1 in 12 cases according to Tönnis. In five patients the hip was functioning well after a period longer than 15 years. In all these cases osteoarthritis was grade 1 according to Tönnis. In 40.4% of patients, THR was delayed longer than ten years. The osteotomy performed well at a mean time of 9.7 years after the procedure (range 3–21). Intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip should be considered in early or mild osteoarthritic changes of the hip. Good prognosis with delay of THR of more than ten years can be expected to exceed 40%, even when indications are less than optimum.     

Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: early results of a salvage procedure

The treatment of spondyloepiphyseal dysplasia (SED) congenita patients with severe bilateral hip involvement is difficult because it involves deformities of multiple joints and of the spine. The purpose of this study was to evaluate the results of the procedure described below as a method of treatment for bilateral hip involvement in SED congenita patients. We performed proximal femoral valgus-extension osteotomy with distal femoral varus osteotomy using a hybrid external fixator in eight patients (seven male patients and one female patient) or 16 hips. The patients had a mean age of 16.37 years (range, 9-25 years) at the time of surgery. The mean valgus angle at the proximal osteotomy site was 53.4 degrees on the right side and 52.5 degrees on the left side, and the mean varus angle at the distal osteotomy site was 22 degrees . Mean fixator time was 19.8 weeks (range, 10-42 weeks). After an average follow-up of 25.9 months, the mean modified Harris hip score had improved from 67.9 points to 79.1 points, which was statistically significant (P=0.012). Preoperative knee range of motion was achieved at the last follow-up in all patients. Waddling gait was absent in three patients, reduced in four patients, and was the same in one at the last follow-up. Mean limb length gain was 3.5 cm (range, 0-5 cm), mean limb length discrepancy less than 0.5 cm, and the mechanical axis was realigned in all. In conclusion, our early results suggest that proximal valgus-extension osteotomy with distal femoral varusization can be a useful treatment option in young patients with bilateral hip involvement in SED congenita.     

股骨近段纤维结构不良内翻畸形的手术疗效

目的 评估和分析股骨近段纤维结构不良内翻畸形手术治疗的临床疗效.方法 2000年8月至2009年5月,采用截骨矫形、病灶刮除、打压植骨、股骨重建钉内固定治疗21例(24个)股骨纤维结构不良伴重度内翻畸形患者,男12例,女9例;年龄14～39岁,平均22.7岁.其中15例为单纯髋内翻畸形,6例同时伴髋内翻及股骨内翻畸形.颈干角55°～105°,平均75°;股骨内翻角18°～45°,平均30°;患侧股骨长度较对侧短缩2.0～4.5 cm,平均3.4cm.其中13例患者因发生病理性骨折而行手术治疗.结果 21例患者均获得随访,随访时间21个月至7年,平均3年4个月.24个股骨共30处截骨面中,28处于术后3～6个月骨性愈合,2例双段远端截骨面各有1处在术后12个月时仍不愈合,经再次植骨3个月后骨性愈合.21例内翻畸形股骨力线均完全矫正,术后颈干角矫正为95°～135°,平均118°;股骨内翻角完全纠正.股骨长度较术前延长1.8～3.6 cm,平均2.8cm.术后无一例患者发生感染、畸形进展及再骨折.17例患者疼痛视觉模拟评分(visual analogue scales,VAS)由术前7～10分降至术后0分,4例VAS评分由术前8～10分降至术后3～4分.Harris髋关节功能评分优12例,良6例,可3例.结论 外翻截骨可有效矫正内翻畸形,股骨重建钉可稳定股骨,大量打压式植骨可有效恢复骨量.

Abstract：

Objective To evaluate and analyse the effectiveness of surgical treatment for fibrous dysplasia in proximal femur with severe varus deformity.Methods A retrospective study was performed in 21 patients (24 femora)of fibrous dysplasia who were treated in our hospital between August 2000 and May 2009.All patients had severe femoral varus deformity.The four-step procedures were performed orderlv as valgus osteotomy,lesion curettage,impacting of massive bone allograft,and fixation by femoral intramedullary nail.There were 6 patients with monostotic disease,15 with polyostotic diseases,including 12 males and 9 females with a mean age of 22.7 years(range,14-39 years).The average neck-shaft angle and femoral varus angle was 75°(range 55°-105°)and 30°(range,18°-45°),respectively.The average length of thigh shortened 3.4 cm(range,2.0-4.5 cm)compared with the contralateral thigh.Results All of the 21 patients were followed up from 21 months to 7 years with an average period of 3 years and 4 months.There were 30 osteotomy sites in 24 femurs,28 osteotomy sites showed bone union after 3-6 months from surgery.Two distal location of the double-level osteotomy showed nonunion,which received bone grafting again and got bone union after 3 months finally.The femoral mechanical alignments of the 21 patients had been recriticd.The average neck-shaft angle was 118°(range,95°-135°)postoperatively,the femoral varus angle disappeared.The average extremity lengthening was 2.8 cm(range,1.8-3.6 cm)postoperatively.There were no infection,recurrent fracture and progression of deformity.The visual analogue scales(VAS)score of 17 patients decreased to zero postoperatively from 7-10 preoperatively,and that of the other 4 patients decreased to 3-4 postoperatively from 8-10 preoperatively.The result of Harris hip functional score was excellent in 12 cases,good in 6,and fair in 3.Conclusion The valgus osteotomy can rectify varus deformity effectively.The reconstract nail of the fumer can support the stability of femur.Impacting of massive bone allograft can improve the capacity of the femur.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases

BACKGROUND: The trochanteric nail, a redesigned short gamma nail, (Howmedica, Rutherford, NJ) was introduced in the United States during 1998 for the treatment of intertrochanteric fractures. METHODS: We retrospectively reviewed 93 patients who were treated for an intertrochanteric fracture with either a sliding hip screw (SHS) or the short trochanteric nail (TN). RESULTS: In all, 94% of the patients in the sliding hip screw group healed without complication. There was one case of femoral head necrosis, one lag screw cutout, and one hardware removal for pain. Eighty-nine percent of the patients in the trochanteric nail group healed without complication. There was one late fracture at the tip of the nail, three cases of lag screw cutout, and one nonunion. CONCLUSIONS: This study suggests that the trochanteric nail is a reasonable alternative to the sliding hip screw when used for intertrochanteric fractures, although it may be associated with higher complication rates.     

Early results of the less invasive stabilization system for mechanically unstable fractures of the distal femur (AO/OTA types A2, A3, C2, and C3)

OBJECTIVES: Historically, mechanically unstable fractures of the distal femur have been difficult to treat. Problems such as varus collapse, malunion, and nonunion frequently resulted before fixed-angle plates and indirect reduction techniques were popularized. More recently, the Less Invasive Stabilization System, or LISS (Synthes, Paoli, PA), has been designed to combine these 2 approaches with the intended goals of achieving adequate stable fixation and early healing. Early clinical results for the femoral Less Invasive Stabilization System have been promising. The purpose of this study is to evaluate the clinical results of patients with high energy, mechanically unstable fractures of the distal femur treated with the Less Invasive Stabilization System. DESIGN: Retrospective analysis of a treatment protocol, consecutive patient series. SETTING: Busy level II trauma center. PATIENTS /PARTICIPANTS: Twenty-six patients with 27 high-energy AO/OTA types A2, A3, C2, and C3 fractures of the distal femur. INTERVENTION: Treatment with indirect fracture reduction and internal distal femoral fixation using the Less Invasive Stabilization System. MAIN OUTCOME MEASUREMENTS: Clinical and radiographic assessment. RESULTS: Twenty-one patients with 22 fractures were available for evaluation at an average 19 months postinjury (range 12-35 months). The mechanism of injury included 12 motor vehicle collisions, 4 high falls, 5 motorcycle crashes, and 1 bicyclist struck by a car. Twenty patients had associated injuries. Six fractures were open. All fractures were comminuted; according to the AO/OTA fracture classification there were 4 A2, 3 A3, 12 C2, and 3 C3 fractures. All fractures healed without secondary surgeries at a mean of 13 weeks (range 7-16 weeks). There were no cases of failed fixation, implant breakage, or infection. Average joint line orientation relative to the femoral shaft axis (valgus) measured 99 degrees on postoperative radiographs and 99 degrees on final radiographs. A comparison of postoperative to healed final radiographs for each femur demonstrated no case with greater than a 3 degrees difference in either varus or valgus. Complications included 1 mal-union where the fracture was fixed in 8 degrees of valgus and 2 cases of external rotation between 10 degrees and 15 degrees. Painful hardware occurred in 4 patients, of which 3 underwent implant removal. The average knee range of motion was 5 degrees to 114 degrees. CONCLUSIONS: The Less Invasive Stabilization System allows for stable fixation and facilitates early healing in mechanically unstable high-energy fractures of the distal femur. There were no patients with fixation failure, varus collapse, or nonunion in this "at-risk" population. This treatment safely allows for immediate postoperative initiation of joint mobility and the progression of weight bearing with early radiographic signs of healing.     

踝关节骨折畸形愈合的重建手术

目的 总结踝关节骨折畸形愈合重建术的临床疗效.方法 2006年1月至2009年1O月,共收治23例踝关节陈旧性骨折畸形愈合患者.男14例,女9例;平均年龄45岁(21～69岁).初次受伤至最终重建术平均间隔18个月(12～36个月),其中11例患者曾接受切开复位内固定术.术前常规行X线及CT检查,对畸形进行个体化评估:所有患者均有不同程度的腓骨短缩或旋转,合并内、外翻畸形者4例,下胫腓联合间隙增宽者5例.对所有腓骨短缩或旋转的患者行腓骨延长截骨术,内外翻畸形则行开放或闭合楔形截骨,而下胫腓增宽者则须行下胫腓功能性融合.术后定期行影像学随访评估骨愈合情况,记录并发症发生情况,并采用美国骨科足踝外科协会(American Orthopedic Foot Ankle Society,AOFAS)踝关节与后足功能评分来评估治疗效果.结果 共21例患者获随访,平均随访36个月(12～58个月).所有随访患者均无感染、内固定失败、骨不连、畸形复发等发生.影像学随访显示于术后平均12周(10～14周)骨愈合,且力线恢复良好.AOFAS踝关节与后足功能评分从术前平均28分(15～39分)改善为术后1年平均82分(70～94分).2例患者因严重创伤性关节炎分别于术后18个月和术后2年行踝关节融合术.结论 对于踝关节骨折畸形愈合的患者,通过早期重建手术恢复腓骨长度和旋转及踝穴的匹配,踝关节功能可获得极大的改善,也可延缓创伤性关节炎的发展.

Abstract：

Objective To summarize the clinical outcomes of reconstruction of malunited ankle fractures.Methods From January 2006 to October 2009,23 malunited ankle fractures were treated in our department.All deformities were evaluated individually based on pre-operatively X-ray and CT scan.Varying degrees of fibular shortening or rotational deformity were found in all patients,with 4 cases of varus or valgus deformity,and 5 of a widen syndesmosis.Then different reconstructive techniques were chosen according to the type of malunion:a lengthening fibular osteotomy was performed in patients with fibular shortening or rotational deformity;an opening or closing wedge osteotomy was chosen correspondingly in patients with varus or valgus deformity;functional fusion of syndesmosis was performed in cases of widen syndesmosis.The postoperative follow-up included standard radiography to evaluate bone union;relative complications were also recorded and functional outcome were assessed with American Orthopedic Foot Ankle Society (AOFAS)ankle-hindfoot scores.Results Twenty-one patients were followed up with an average period of 36 months (12-58 months).There were no complications of infection,implant failure,nonunion or malunion.Solid union with a favorable alignment was obtained at an average of 12 weeks (10-14 weeks).The mean pre-operative AOFAS ankle-hindfoot score was 28 (15-39).While the score increased to 82 (70-94) one year after operations.But 2 patients underwent ankle arthrodesis correspondingly 18 months and 24 months post-operatively due to severely post-traumatic arthritis.Conclusion An early realignment reconstruction of the length and rotation of fibula and the congruity of ankle mortise may improve the ankle function and slow down the development of post-traumatic arthritis for patients who suffered from malunited ankle fractures.     

Extended trochanteric osteotomy in complex primary total hip arthroplasty. A brief note

BACKGROUND: The extended trochanteric osteotomy has been a useful approach for patients undergoing revision total hip arthroplasty; however, it has not been well described as an approach for those undergoing complex primary total hip arthroplasty. The purpose of the present report is to describe our experience with the use of an extended trochanteric osteotomy for patients undergoing complex primary total hip arthroplasty. METHODS: Six patients underwent primary total hip arthroplasty with use of an extended trochanteric osteotomy. The reasons for the use of this technique included severe femoral deformity, removal of intraosseous hardware, and high-riding developmental hip dysplasia. A fully porous-coated femoral component with diaphyseal fixation was used for all reconstructions. The mean age of the patients at the time of surgery was fifty-six years. Clinical and radiographic evaluation was performed at a minimum of two years. RESULTS: After a mean duration of follow-up of fifty months, all patients had an osseointegrated, stable femoral component. The site of the extended trochanteric osteotomy healed in five of the six patients. One patient had nonunion at the osteotomy site and a fracture at the base of the greater trochanter, with a subsequent fracture of the femoral component. The mean Merle D'Aubigné and Postel pain and walking scores improved from 2.2 and 2.3 preoperatively to 5.3 and 4.7 at the time of the final follow-up (p < 0.001). CONCLUSIONS: The extended trochanteric osteotomy is useful for the correction of femoral deformity and facilitates the removal of intraosseous hardware in carefully selected patients undergoing complex primary total hip arthroplasty.     

Trochanteric union following revision total hip arthroplasty

Ninety-nine patients (106 hips) with a trochanteric osteotomy during revision total hip arthroplasty were evaluated at a minimum of 5 years after surgery. Trochanteric reattachment was done with monofilament cobalt-chromium wires. The influence of the following variables on trochanteric union was examined: a prior trochanteric osteotomy, an existing trochanteric nonunion, trochanteric advancement to the lateral femur, use of vertical (in addition to horizontal) wires through the trochanter, and use of a trochanteric mesh. Overall, union occurred in 92 of the 106 trochanters (87%). Fifty-three of 61 trochanters (86.9%) healed after an initial osteotomy, whereas 34 of 38 (89.5%) healed after a repeat osteotomy. Five of the 7 trochanters with an existing nonunion healed, and 5 of 5 trochanters reattached to a bulk allograft healed. Twenty-nine of 36 trochanters (80.5%) reattached to cancellous bone healed, compared with 58 of 65 (89.2%) that were reattached to the lateral femoral cortex. Ninety percent (83/92) of the trochanters reattached in conjunction with use of a chrome-cobalt mesh healed, compared with 64.3% (9/14) of those without (P < .05). Of the variables studied, only the use of mesh was statistically significant. Osteotomy through a previously healed trochanter, advancement of the trochanter to cortical bone, existing trochanteric nonunion, trochanteric reattachment to a bulk allograft, and lack of vertical wires for fixation did not adversely affect the likelihood of obtaining trochanteric union.     

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.     

Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty

A review of the results of the extended trochanteric osteotomy through a modified direct lateral approach in revision total hip arthroplasty was done. We reviewed 44 patients (45 procedures) at a minimum of 2 years followup (mean, 3.8 years; range, 2.1-7.2 years). There were 26 men and 18 women with a mean age at the time of surgery of 70.8 years (range, 36.9-90.4 years). Indications for use of the trochanteric osteotomy included facilitation of cement removal (25 procedures), proximal femoral varus deformity (14 procedures), trochanteric malposition (five procedures), and previous trochanteric osteotomies with significant bony overgrowth (three procedures). The mean length of the osteotomy was 133.9 mm. The mean migration of the osteotomized fragment was 2.1 mm (range, 0-20 mm) with significantly more proximal migration seen with the use of cerclage wires when compared with cables. There were two cases of trochanteric escape, for which the patients required repeat open reduction internal fixation. There were two late fractures of the greater trochanter. One femoral component had early subsidence for which the patient required re-revision with a further extended trochanteric osteotomy. The mean time to union of the remaining 40 hips was 10.3 months (range, 6-24 months). There only was one dislocation postoperatively. The extended trochanteric osteotomy through the modified direct lateral approach in revision total hip arthroplasty is a reproducible and reliable technique with a lower dislocation rate but a higher incidence of trochanteric fracture and escape than previously described with its use in the posterior approach.     

Total hip arthroplasty after failed intertrochanteric valgus osteotomy for advanced osteoarthrosis.

Thirty hips that had undergone conversion total hip arthroplasty because of failed intertrochanteric valgus osteotomy for advanced osteoarthrosis were analyzed clinically and radiographically for more than 2 years. The average followup after total hip arthroplasty was 7 years (range, 2-18 years). The average age of the patients at the time of valgus osteotomy was 42 years (range, 30-63 years). The average age of the patients at the time of conversion total hip arthroplasty was 57 years (range, 43-76 years), and the average period between valgus osteotomy and conversion was 14 years (range, 3-24 years). Perioperative complications in conversion total hip arthroplasties were minimal, and intramedullary reaming was performed easily. Of the 30 conversion total hip arthroplasties, 12 cemented and 18 cementless components were used, respectively. Kaplan-Meier's survival analysis indicated that survivorship of cemented stems was significantly higher than that of conventional cementless stems. Cemented stems are preferable for conversion total hip arthroplasty after failed femoral valgus osteotomy.     

Corrective osteotomy for humerus varus

PURPOSE: Humerus varus caused by growth arrest of the medial proximal humeral physis is associated with upper limb length discrepancy and limitations in shoulder motion. The purpose of this study was to assess the results of proximal humeral valgus osteotomy for the treatment of humerus varus in skeletally immature patients. METHODS: Six patients were treated at our institution between 1994 and 2006. The average age at the time of surgery was 13 years (range, 9-17 years). The causes of humerus varus were posttraumatic physeal arrest (n = 2), infection (n = 2), acquired physeal arrest secondary to a benign bone cyst (n = 1), and idiopathic cause (n = 1). All patients underwent proximal humeral valgus osteotomy with tension-band fixation. The average clinical and radiographic follow-up period was 21 months (range, 3-81 months). RESULTS: All patients achieved bony union. Mean forward flexion improved from 76 degrees preoperatively (range, 45-100 degrees) to 148 degrees postoperatively (range, 100-180 degrees) (P = 0.01). Mean abduction improved from 63 degrees preoperatively (range, 30-100 degrees) to 116 degrees postoperatively (range, 90-160) (P = 0.02). Radiographically, the mean humeral neck-shaft angle improved from 95 degrees preoperatively (range, 75-105 degrees) to 130 degrees postoperatively (range, 112-160 degrees) (P = 0.001). Two patients had soft tissue irritation from the tension-band pins, which resolved with subsequent pin removal. CONCLUSIONS: Valgus osteotomy with tension-band fixation is an effective means of improving shoulder function and humeral neck-shaft angle in skeletally immature patients with proximal humerus varus.     

Closing lateral wedge valgus osteotomy with dynamic hip screw for the treatment of varus nonunion of pertrochanteric fracture: can restoration of biomechanics and stabilization alone heal?

Introduction  Nonunion of pertrochanteric fracture is rare and its occurrence especially without prior surgical intervention has been hardly ever reported. Hence there is not much literature describing the best way to treat them. Nonunion of pertrochanteric fracture collapses in to varus by virtue of deforming action of muscles and thus deranging the biomechanics of the hip and indirectly preventing fracture union further. Hence it is very important to re-orient the abductor lever arm to biomechanically advantageous normal configuration favoring fracture healing. In general, principles of treatment of nonunion like open reduction of the fracture with freshening of fracture fragments, stabilization and bone grafting are very difficult to the surgeon and the patient. Method  We herewith describe for the first time in literature a prospective nonrandomized study of closing lateral wedge valgus intertrochanteric osteotomy in addition to dynamic hip screw osteosynthesis in the successful management of seven patients with varus trochanteric nonunion. Average operating time was 63 ± 13 min (range 39–93 min) and blood loss was 212 ± 32 ml (range 156–320 ml). Average pre-operative coxa vara of 94° ± 7° (range 85°–104°) had improved to a femoral neck shaft angle of 139° ± 4° (range 134°–145°) on postoperative radiographs. Results  All fractures and osteotomies had healed uneventfully at the last follow-up with good functional outcome. Harris Hip score had improved from 34 ± 6 (range 22–47) to 89 ± 4 (range 83–95) at an average of 11 months (range 7–13 months) follow-up. Valgus osteotomy converts shear forces across the fracture site into compressive forces thus achieving union.