胫骨内侧高位楔形截骨治疗膝关节骨性关节炎

目的　探讨胫骨内侧高位楔形截骨治疗伴有膝内翻畸形的膝关节骨性关节炎的疗效。方法　对 1996年 7月～ 1999年 9月 ,采用胫骨内侧高位楔形截骨结合髂骨植骨钢板内固定术治疗 19例 (2 6膝 )膝关节骨性关节炎伴膝内翻畸形 ,病程 1～ 2 4年 ,平均 6 .3年 ,按 Ahlback分类 度 10膝 , 度 9膝 , 度 6膝 , 度 1膝。患者术前、术后 8周和术后 2年进行患肢全长 X线片检查 ,测量胫股角、胫骨角、股骨角、胫股关节面切线夹角及胫股内侧关节间距大小。按膝关节功能评定标准 ,评定术后膝关节功能恢复情况。　结果　 19例 (2 6膝 )术后获随访 2 4～ 4 5个月 ;术后 2年随访膝关节功能自 (4 8.6± 16 .6 )分增至 (81.7± 14 .8)分 ,胫股内侧关节间距自 (2 .2± 1.6 ) mm增至 (4 .9± 1.5 ) mm,胫股关节面切线夹角自 7.4°± 3.1°减少至 1.7°± 3.1°。植骨愈合满意 ,无膝内翻复发。术中出现关节内骨折 1例 ;皮肤感染 2例。结论　胫骨内侧高位楔形截骨结合植骨钢板内固定 ,可作为治疗伴有膝内翻畸形的膝关节骨性关节炎的有效方法之一。     

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.     

Proximal dome-shaped osteotomy for symptomatic bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.     

Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees

One hundred seventy-three knees in 117 patients with varus deformity exceeding 20 degrees were prospectively evaluated. Using selective posteromedial release, reduction osteotomy of posteromedial tibial flare, and extra-articular tibial osteotomy, with the preservation of medial collateral ligament integrity, mean tibiofemoral angle of 22.7 degrees varus preoperatively (range, 15 degrees-62 degrees) was corrected to 5.3 degrees valgus (range, 2 degrees-9 degrees) postoperatively. Eighty-six percent of the knees were in 4 degrees to 10 degrees valgus postoperatively. Mean Knee Society score improved from 22.8 (range, 0-64) to 91.1 (range, 52-99), and function score from 22.8 (range, 0-64) to 72.1 (range, 5-100) at 2.6 years (range, 2-9 years). Mean femoral component valgus was 95.5 degrees (range, 92 degrees-98 degrees), and mean tibial component valgus was 89.8 degrees (range, 86 degrees-94 degrees). Of 30 grafts for posteromedial tibial defects, 28 were successfully incorporated. No patient reported significant instability. Three knees (1.7%) showed tibial component loosening with recurrence of deformity. Correction of severe varus deformity by the technique reported can successfully restore alignment, pain-free motion, and stability.     

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.     

膝关节外翻畸形的人工全膝关节置换术

目的探讨膝关节外翻畸形患者行人工全膝关节置换术(TKA)的手术方法和临床效果。方法对1996年1月至2004年8月74例87个膝关节外翻畸形TKA手术进行回顾分析。患者男11例,女63例,平均年龄63岁(26~80岁);股胫角(股骨和胫骨解剖轴线的夹角)平均为21·59°(12°~40°);应用后稳定型假体,采用髌旁内侧入路、常规截骨加单纯外侧软组织松解方法。随访检查膝关节活动度、X线外翻角度及KSS评分以评价手术效果。结果术后评价随访时间33·8个月(5个月~9年),根据膝关节活动度数及KSS评分评估关节功能情况。膝关节平均活动度为112·4°(80°~130°),KSS评分平均为81·7分(71~93分),比术前提高了59分;功能评分平均为86·3分,比术前提高了59·8分。所有膝关节在行TKA后外翻畸形基本得到矫正,随访时外翻度数(股胫角)平均为8·7°(0°~11°),较术前有明显改善。随访时1例患者有膝关节轻度不稳症状,1例术前严重髌脱位患者术后髌骨存在半脱位,其余正常。结论对于膝关节外翻畸形患者,采用髌旁内侧入路、常规截骨加单纯外侧软组织松解以及安装后稳定型假体的方法,可取得比较满意的临床效果。     

Exposure in difficult total knee arthroplasty using coronal tibial tubercle osteotomy

Exposure in a total knee arthroplasty can be challenging regardless of whether it is a difficult primary or a revision. Various techniques both proximal and distal to the patella have been described and implemented to gain exposure and improve knee flexion. When patella eversion is not possible due to previous surgery or severe preoperative knee flexion contracture, a coronal tibial tubercle osteotomy may be utilized. We present successful results utilizing the coronal tibial tubercle osteotomy procedure. The technique involved in this series is based on that described by Whiteside. It involves the development of a long lateral musculoperiosteal flap incorporating the tibial tubercle and anterior tibia, and leaving the proximal tibial cortex intact. This is extended along the tibia distally for 10 cm. It finishes by gradually osteotomising the anterior surface of the tibial crest. The tubercle is reattached with wires at the end of the procedure. This technique minimizes complications that have been associated with the tibial tubercle osteotomy. The 10 knees in 9 patients, who had total knee arthroplasty with a coronal tibial tubercle osteotomy, were reviewed pre and postoperatively. All knees were assessed using the Hospital for Special Surgery knee score (HSS). The scores averaged 43.6 preoperatively (range, 29 57) and 79.2 postoperatively (range, 67 90), and the mean range of motion was 59.5 degrees preoperatively and 78.0 degrees postoperatively. There were no cases of extension lag. Fixed flexion deformity was present in 3 cases postoperatively. Average time to union at the proximal and distal ends of the osteotomy was 8 and 24 weeks respectively. There was no evidence of nonunion and no other significant complications occurred.     

Präzise computergestützte Beinachsenkorrektur mit öffnender valgisierender Tibiakopfosteotomie

AIM: This prospective study investigates open-wedge high tibial osteotomy performed with the aid of a kinematic computer-guided navigation system. After the X-ray control the osteotomy was stabilized by internal LCP fixation. The aim of the study was to demonstrate the accuracy of the navigation system and to prove the reliability of the LCP fixation. METHOD: A total of 39 patients were operated between 2002 and 2003 following this method. The outcomes were evaluated at least 2 years after the surgery clinically and radiologically; 21 females (1 female underwent bilateral osteotomy) and 18 males were included in the study sample. RESULTS: Prior to the osteotomy, the mean anatomic lateral tibiofemoral angle (aLTFA) was 181.1 degrees . The desired 4 degrees "overcorrection" of valgus (aLTFA 170 degrees) was found on X-rays postoperatively in all cases. The mean correction was 11.1 degrees. The correction achieved was stable during the 2-year follow-up period. The osteotomy healed in all cases after 4 months. The full range of motion remained after the surgery in all cases. All patients were satisfied with their results. The Lysholm score was 55 points before and 82 points after the osteotomy (27 points difference). CONCLUSION: The computer-assisted open-wedge high tibial osteotomy with tricortical grafts stabilized by LCP fixation gives exact and reproducible results without loss of correction.     

Adolescent tibia vara: alternatives for operative treatment.

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)     

High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study

This retrospective study reviewed the long-term experience with high tibial osteotomy and determined which factors influence the results. Between 1980 and 1989, 120 closing wedge high tibial osteotomies for varus gonarthrosis were performed in 102 patients. Twenty-nine knees were excluded because the patients died (17 knees), were bedridden (7 knees), or lost to follow-up (5 knees). Thirty of the remaining 91 knees had a conversion to total knee replacement (TKR) after 11 years on average, leaving 61 knees with a high tibial osteotomy available for clinical and radiographic evaluation at an average follow-up of 15 years (range: 10-21 years). Of the 91 knees, excellent/good results were found in 49% and fair/poor in 51%. Anatomical femorotibial angle in the 61 knees at follow-up averaged 4.7 degrees +/- 5 degrees of valgus (range: 3 degrees varus to 23 degrees valgus). Alignment obtained at consolidation changed with varus recurrence at follow-up in 14% of 61 knees and did not correlate with the clinical results. Twelve (19%) knees showed a patella baja (Caton ratio <0.6) at follow-up, which correlated with patients immobilized postoperatively by a cylinder cast (P=.04). A valgus alignment at consolidation between 8 degrees and 15 degrees, good muscle strength, and male gender correlated with better results (P<.05). Survivorship analysis, considering an unsatisfactory result or revision to TKR as the endpoint, was 96% at 5 years, 88% at 7 years, 78% at 10 years, and 57% at 15 years. High tibial osteotomy provides symptomatic relief for approximately 10 years, but is unlikely to provide permanent relief.     

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.     

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.     

Double-elevating osteotomy for late-presenting infantile Blount's disease: the importance of concomitant lateral epiphysiodesis

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount's disease. The mean age of patients was 9.1 years (7 to 13.5). All knees were in Langenski?ld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time. The mean pre-operative angle of depression of the medial tibial plateau of 49 degrees (40 degrees to 60 degrees ) was corrected to a mean of 26 degrees (20 degrees to 30 degrees ), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6 degrees (14 degrees to 66 degrees ) was corrected to 0 degrees to 5 degrees of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2 degrees to 5 degrees of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.     

外侧闭合楔形胫骨近端截骨术的远期疗效分析

[目的]探讨胫骨近端截骨术治疗原发性胫骨近端骨性关节炎的远期疗效以及最佳的截骨矫正角度.[方法]自1985～1997年,79例(111膝)原发性骨性关节炎患者接受了胫骨近端截骨术.其中男5例(5膝),女74例(106膝);年龄37～70岁(平均55岁).根据术后胫股角(FTA)分为3组.Ⅰ组61膝FTA<7°;Ⅱ组23膝FTA7°～9°;Ⅲ组27膝FTA≥10°.所有病例术前、术后按特种外科医院评分系统(HSS)评分.[结果]术后随访2年4个月～14年1个月(平均9年6个月).术前HSS平均60分,术后1年平均94分,末次随访平均87分.采用2种方法判定手术失败:方法1为需行人工全膝火节置换术者,随访4年和14年手术成功率分别为99%和85%;方法2为需行人工全膝关节置换术者或术后HSS评分<60分,随访4年和14年手术成功率分别为96.4%和75.1%.[结论]胫骨近端截骨术是治疗单间室骨性关节炎的有效方法,但术后胫股角应矫正到外翻7°以上(范围10°～15°).     

Die intertrochantäre Korrekturosteotomie nach Imhäuser

OBJECTIVE: Surgical correction of deformities of the proximal femur caused by epiphyseal displacement by restorative (usually inflection and internal rotation) osteotomy at the intertrochanteric level with the aim of reducing both the offset disorder of the coxal end of the femur that is causing impingement and the prevalence of secondary coxarthrosis. INDICATIONS: Chronic and subacute manifestations of slipped capital femoral epiphysis with an epiphyseal dislocation in the radiographic axial view of 30-60 degrees (ET angle) and DeltaED > 20 degrees (CCD angle minus ED angle) in the anteroposterior view. CONTRAINDICATIONS: Acute phase or course of slipped capital femoral epiphysis. Secondary coxarthrosis (after slipped capital femoral epiphysis). Traumatic epiphyseolysis. SURGICAL TECHNIQUE: Exposure of the proximal femur (anterior femoral neck, intertrochanteric plane, proximal femoral diaphysis) through an anterolateral approach; fixation of the femoral epiphysis with two 3.0-mm Steinmann nails positioned parallel in a posteromedial direction; the seating chisel is hammered in according to the planned, usually inflectional axial correction; intertrochanteric osteotomy by excision of a wedge oriented in accordance with preoperative planning; adaptation of the osteotomy surfaces and osteosynthesis with a 90 degrees AO adolescent plate under interfragmentary compression. POSTOPERATIVE MANAGEMENT: Mobilization on underarm crutches with unloading of the extremity for 2 months postoperatively; gradual increase in loading depending on osseous consolidation of the osteotomy; radiographic assessment 2 and 4 months postoperatively, further clinical and radiologic follow-up until growth is completed (closure of the growth plate); removal of implants at 1 year postoperatively or thereafter. RESULTS: Retrospective follow-up of 51 patients with unilateral, moderate to severe slipped capital femoral epiphysis (indication: epiphyseal displacement angle of 30-60 degrees, average preoperative displacement angle 45 degrees) that was corrected surgically by Imh?user intertrochanteric osteotomy and epiphyseal nailing. After an average observation time of 24 years (range: 20-29 years), 28 (55%) of the 51 hip joints were clinically asymptomatic and radiologically free of degenerative changes; moderate clinical and radiologic changes were recorded for 14 hip joints (28%), and advanced changes for nine (17%). Complications related to surgery were apparent in a total of six hip joints: in one case, the Steinmann nail broke after being damaged by the plate blade; in two cases, revision osteosynthesis of the intertrochanteric osteotomy was necessary due to incorrect implant positioning; partial femoral head necrosis developed in one hip joint; there were two cases of low-grade osteomyelitis that healed after implant removal.     

Proximal tibial segmental prosthetic replacement without the use of muscle flaps

When doing a proximal tibial prosthetic reconstruction, some surgeons think that the subcutaneous location of the proximal tibia necessitates a gastrocnemius muscle flap for closure and function. In this study, 22 patients with bone tumors had proximal tibial segmental prosthetic replacement using direct reattachment of the patellar tendon to the prosthesis without the use of a muscle flap. Two of 19 patients required reoperation in the postoperative period for hematomas. Both were free of infection or other complications at 24 months mean followup. No other wound complications occurred despite initiation of chemotherapy 2 to 3 weeks after surgery in patients with high-grade malignant tumors (15 of 19). The mean followup was 38.6 months (range, 13-99 months). The patients ranged in age from 15 to 74 years (mean, 39 years). The range of motion achieved postoperatively showed a mean of 97 degrees (+/-16.3 degrees). All patients had full passive extension with a mean extensor lag of 7.5 degrees. The mean Musculoskeletal Tumor Society score was 27.6 (+/- 2.0). These results of patients without muscle flaps compare favorably with published results advocating gastrocnemius flaps for the attachment of the patellar tendon to the prosthesis.     

Dome corrective osteotomy for cubitus varus deformity

Between 1994 and 1998, 15 patients had corrective dome-shaped osteotomy of the humerus for posttraumatic cubitus varus deformity. Thirteen patients had surgery before puberty and two patients had surgery after puberty. In the prepuberty group, all the osteotomies were done by a posterior approach with triceps muscle splitting, and cross pins were used to fix the osteotomy. In the postpuberty group, the osteotomies were done by a posterior approach with olecranon osteotomy, and reconstructive plates were used for fixation. The average followup was 2 years and 4 months. Preoperative carrying angle ranged from 19 degrees to 31 degrees varus (average, 26.2 degrees) and postoperative carrying angle ranged from 7 degrees to 15 degrees valgus (average, 10.7 degrees). No loss of correction was observed and all osteotomies united. The preoperative and postoperative differences of the lateral condylar prominence index ranged from -67% to +6% (average, -30.1%). After reviewing these cases, a dome-shaped osteotomy was found to have the following advantages for correction of cubitus varus deformity: the osteotomy site is more stable than a lateral closing wedge osteotomy for maintaining the correction obtained; the domed osteotomy avoids having the lateral condyle becoming prominent; and the posterior scar is more cosmetically acceptable than the lateral scar in the lateral closing wedge osteotomy.     

胫骨高位截骨术后髌骨低位

目的探讨胫骨高位截骨术治疗膝关节内侧间室骨性关节炎后髌骨低位与胫骨近端关节面后倾角度改变之间的关系,并提出预防和控制髌骨低位的措施。方法41例(48膝)膝关节内侧间隙骨性关节炎患者,男30例(33膝),女11例(15膝);年龄45～56岁,平均52岁。所有病例均行胫骨外侧高位楔形截骨术。根据术前测量的截骨角度(内翻角+正常外翻角+过度矫形3°～5°),在槽刀和导向器等辅助下切除楔形骨块,用改良Giebel槽式钢板拉力螺钉内固定,术后不需外固定。测量48膝行胫骨高位截骨术患者术前及术后X线片的Insall-Salvati比值、胫骨近端关节面后倾角度、胫骨结节高度、患肢解剖轴线角度,并用χ2检验和直线回归分析进行统计学处理。检验时假定术后胫骨近端关节面后倾角度减小≥5°以及髌骨高度下降≥10%具有临床意义。结果术后胫骨近端关节面后倾角度比术前平均减小6.14°,Insall-Salvati比值术前、术后相对变化率为10.6%,胫骨结节高度比术前平均下降3.13mm。64.6%的病例胫骨近端关节面后倾角度减小≥5°。按Insall-Salvati比值结果,56.2%的病例髌骨高度相对下降率≥10%。胫骨近端关节面后倾角度的减小与髌骨高度的相对下降具有显著的统计学相关性。结论胫骨近端关节面后倾角度的减小与髌骨低位具有相关性,提示在施行胫骨高     

Distal tibial hypertrophic nonunion with deformity: treatment by fixator-assisted acute deformity correction and LCP fixation

Distal tibial hypertrophic nonunion with angular deformity has been successfully treated by circular external fixator. The inconvenience of the bulky external fixator and frequent pin tract infection would not be accepted in certain cases. This study included thirteen patients (mean age 39 years) with angular deformity of the distal dia-/metaphyseal tibial shaft. Five patients were originally treated by interlocking nail, three were treated by plate and screws fixation, four treated conservatively and one had deformity secondary to fracture of a lengthening regenerate. All patients were treated by osteotomy and acute correction of the deformity using temporary unilateral fixator and internal fixation by a locking compression plate (LCP). The external fixator was removed at the end of surgery. The results were evaluated both clinically and radiologically. All osteotomies healed within 3 (2–4) months. All patients were able to work within an average of 2.3 months. The function of the upper ankle joint was unrestricted in twelve cases, and in 1 case there was a mild functional deficit. The mean follow-up was 60 months (24–120). The frontal plane alignment parameters (the mechanical axis deviation, the lateral distal tibial angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior proximal tibial angle and the anterior distal tibial angle) were within normal values postoperatively. No cases of deep infection or failure of fixation were encountered. Acute correction of distal tibial shaft hypertrophic nonunion with deformity and LCP fixation is a reliable option in well-selected cases.