Percutaneous epiphyseodesis. Correction of leg length inequalities and frontal plane deformities

The percutaneous epiphysiodesis is recommended as a save and reliable technique. We have performed 21 distal femoral, 17 proximal tibial and 3 proximal fibular percutaneous epiphyseodeses on 25 patients. On 11 patients the epiphysiodesis was caused by an average leg length discrepancy of 2,7 cm (1-4 cm). 13 patients had angular deformity near the knee joint in frontal plane (6 valgus and 7 varus deformities). One patient suffered from a combined deformity with 3, 5 cm shortened leg and varus deviation of 10 degrees. The average deformity angle of the knee was 7,4 degrees (4 degrees -16 degrees ). 9 patients have reached maturity. On 3 patients the deformity could be corrected incompletely with residual deformity of 3 degrees, 4 degrees and 6 degrees as a direct result of late referral. On 1 patient an imminent over-correction could be avoided by hemiepiphysiodesis of the residual epiphysis. Till the present follow up the other patients have been corrected as calculated preoperatively. No complications like epiphysiolysis, infection, stiff knee or angular deformities occurred. We prefer the percutaneous epiphysiodesis as a save and minimal invasive technique instead of the open Phemister-technique to tread leg length discrepancy and angular deformities of the knee in frontal plane.     

Primary total knee arthroplasty in patients with severe varus deformity. A comparative study

Varus deformity is a common finding in candidates for total knee arthroplasty (TKA), but very little has been written concerning the problems encountered in correcting these deformities at the time of arthroplasty. Compared to patients without deformities, this group of patients require more attention to the technical aspects of the arthroplasty, especially bony alignment and ligament balancing. Specific operative techniques used to correct severe varus deformities at primary TKA were evaluated, and the clinical and roentgenographic results were compared with those of a control group of patients without preoperative angular deformity. Operative findings and clinical results in 27 knees (20 patients) with a minimum preoperative varus deformity of 20 degrees (average follow-up period, 58.7 months; range, 24-102 months) were compared with those of 40 knees (31 patients) with a preoperative angulatory deformity of less than 5 degrees varus or valgus (average follow-up period, 50.0 months; range, 24-90 months), in whom a minimally constrained, posterior-cruciate-ligament-sparing prosthesis was implanted. Operative time was an average of 30 minutes longer in the varus deformity group. The average knee evaluation score in the varus group was 89 points, and for the nondeformity group it was 92 points (p less than 0.02). There were no fair or poor results in the varus deformity group; there was one poor result in the nondeformity group. Postoperative knee are of motion was 98 degrees in the varus deformity group and 107 degrees in the nondeformity group. After arthroplasty, the average angle between the mechanical axis of the femur and the tibia was 3 degrees varus in the varus deformity group and 0 degree varus in the nondeformity group (p less than 0.006). Postoperative functional scores of patients in the varus deformity group approached, but were not equal to, the nondeformity group. Greater variability in results and longer operative times were needed in the varus deformity group. Postoperative alignment of the varus deformity group tended to be in residual varus.     

Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years

Background:

Guided growth through temporary hemiepiphysiodesis has gained acceptance as the preferred primary treatment in treating pediatric lower limb deformities as it is minimally invasive with a lesser morbidity than the traditional osteotomy. The tension band plate is the most recent development in implants used for temporary hemiepiphysiodesis. Our aim was to determine its safety and efficacy in correcting coronal plane deformities around the knee in children younger than 10 years.

Materials and Methods:

A total of 24 children under the age of 10 were operated for coronal plane deformities around the knee with a single extra periosteal tension band plate and two nonlocking screws. All the children had a pathological deformity for which a detailed preoperative work-up was carried out to ascertain the cause of the deformity and rule out physiological ones. The average age at hemiepiphysiodesis was 5 years 3 months (range: 2 years to 9 years 1 month).

Results:

The plates were inserted for an average of 15.625 months (range: 7 months to 29 months). All the patients showed improvement in the mechanical axis. Two patients showed partial correction. Two cases of screw loosening were observed. In the genu valgum group, the tibiofemoral angle improved from a preoperative mean of 19.89° valgus (range: 10° valgus to 40° valgus) to 5.72° valgus (range: 2° varus to 10° valgus). In patients with genu varum the tibiofemoral angle improved from a mean of 28.27° varus (range: 13° varus to 41° varus) to 1.59° valgus (range: 0-8° valgus).

Conclusion:

Temporary hemiepiphysiodesis through the application of the tension band plate is an effective method to correct coronal plane deformities around the knee with minimal complications. Its ease and accuracy of insertion has extended the indication of temporary hemiepiphysiodesis to patients younger than 10 years and across a wide variety of diagnosis including pathological physis, which were traditionally out of the purview of guided growth.     

Taylor空间支架矫正创伤后膝内、外翻畸形

  目的 探讨Taylor空间支架（Taylor Spatial Frame, TSF）矫正创伤后膝内、外翻畸形的临床疗效和精确度。方法 回顾性分析2006年6月至2010年12月,采用TSF矫正26例创伤后膝内、外翻畸形患者的病例,男19例,女7例;年龄19～62岁,平均39岁;创伤后膝内翻畸形20例,膝外翻畸形6例。21例行胫骨高位截骨,3例行股骨髁上截骨,2例同时行股骨髁上和胫骨高位截骨。安装TSF、测量支架的安装参数后截骨。术后7～10 d,根据电子处方,每天3次调节TSF支架上的可伸缩螺杆的长度,调节范围为0～3 mm。结果 经过7～35 d调节,20例畸形得到一次性完全矫正,患肢的胫骨、股骨力线恢复,肢体的成角、旋转和短缩畸形均得到矫正。6例尚残存轻微成角和短缩畸形,经第二次4～10 d的支架调整,畸形矫正。截骨处新骨生成和矿化良好,术后2.5～6.0个月去除外固定架。术后随访12～60个月,畸形无复发。术后11例发生针道感染,经应用敏感抗生素治疗,感染控制。1例去除外固定架后1.5个月发生股骨远端截骨处再骨折,经保守治疗骨折愈合。无一例患者发生血管神经损伤和继发性马蹄足畸形。结论 TSF矫正创伤后膝内、外翻畸形疗效确切,精确度高。     

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.     

Remodelling after femoral shaft fracture in children.

Fifty-two children in the 1-14 year age range who had a femoral fracture and were treated by traction and casting, were re-examined 2-17 years later. The results of radiological measurements of femoral length and alignment are analysed by computer. The femoral over-growth following fracture 10.7+/-6.6 mm, did not depend on site or dislocation of fracture. Lateral dislocation completely corrected, varus deformity on an average only up to 40% and valgus deformity up to 60% of the initial defect. Minor deviations corrected less. Repairing continued for over 5 years. Ante- and recurvatum could correct nearly 70%, if the original deformity was over 10 degrees, otherwise less. In neither plane was the correction of axial deviation influenced by site or type of fracture. There were individual cases of complete correction of axial dislocation and cases of complete failure to correct.     

Distal femoral osteotomy for valgus deformity of the knee.

Distal femoral varus osteotomy and blade-plate fixation for valgus deformity of the knee proved effective in restoring axial alignment in 18 of 36 knees (34 patients). Patients were followed for an average of 5.4 years (range: 2 to 19 years). The osteotomies were performed on 14 men and 22 women (average age: 44 years; range: 14 to 77). The patients' average preoperative valgus deformity of the anatomical axis was 19.4 degrees (range: 8 degrees to 33 degrees). The surgical procedures performed were a medial closing wedge osteotomy (14 knees) and a lateral opening wedge osteotomy with bone grafting (22 knees). Postoperative correction of the anatomical axis averaged 3.8 degrees valgus (range: 8 degrees varus to 20 degrees valgus). Maximum improvement was reached within 6.3 months by patients who were less than 60 years old and within 5.1 months by patients who were more than 60 years old. Pain decreased or resolved in 21 of 35 knees (60%); activity level improved in 24 of 35 knees (69%). One patient was unavailable for follow up evaluation. Varus osteotomy in the distal femur was concluded to be an acceptable form of treatment in the valgus knee alone or associated with traumatic or osteoarthritis of the lateral compartment.     

Syndesmosis procedure: a non-osteotomy approach to metatarsus primus varus correction

BACKGROUND: Hallux valgus and metatarsus primus varus deformities usually are the result of failure of the supporting soft tissues rather than bone deformities. Since soft-tissue procedures have been shown to only be suitable for mild deformities, first metatarsal osteotomy has become an integral part of correcting moderate to severe deformities. A soft-tissue technique referred to as the "syndesmosis procedure" by the author was evaluated for its effectiveness in correcting metatarsus primus varus in feet with hallux valgus. METHODS: This is a retrospective clinical and radiographic study of six patients (11 feet) an average of 6 years and 10 months after the "syndesmosis procedure." A cerclage technique using absorbable suture (PDS) was used for the first metatarsal realignment, and its long-term maintenance depended on a syndesmosis (fibrous) bonding between the first and second metatarsal bases. RESULTS: The average preoperative hallux valgus angle of 29.5 (21 to 43) degrees improved to 13.5 (-2 to 24) degrees and the average preoperative metatarsus primus varus angle of 13.6 (12 to 16) degrees improved to 5.2 (2 to 8) degrees at an average of 85.7 (33 to 128) months. All patients were satisfied with their results and were able to return to sports and wearing high-heeled shoes as desired. Complications were few and mild. Followup American Orthopaedic Foot and Ankle Society Hallux scores averaged 93 points. CONCLUSIONS: This small but long-term retrospective study showed encouraging results for the correction of metatarsus primus varus deformity and a high patient satisfaction.     

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.     

骨性关节炎患者人工膝关节假体旋转定位标志研究

目的探讨对合并内、外翻畸形的膝关节骨性关节炎行人工全膝关节置换术，以股骨内外上髁外科轴（surgical epicondylar axis，SEA）作为股骨假体旋转参考轴，以胫骨结节内1／3作为胫骨假体旋转定位的骨性标志，判断股骨假体和胫骨假体的旋转对线情况。方法2004年7月～2005年1月，对32例（62膝）拟行人工全膝关节置换术的膝关节骨性关节炎患者（病例组），男2例，女30例；年龄58～80岁，平均68．9岁；内翻畸形55膝，胫股角平均内翻-8．23°；外翻畸形7膝，胫股角平均外翻＋15．48°。于术前行伸膝旋转中立位CT扫描，测量膝关节股骨后髁角（posterior condylar angle，PCA），并以10个正常膝关节作为对照组，测量SEA中点C与髌腱内1／3连线（BC）和经SEA中点C的垂线（AC）之间的夹角，即α角。结果病例组80％以上膝关节CT图像显示股骨内上髁陷凹；PCA中位数为＋2．36°（0～＋7．5°）；对照组膝关节α角为＋6．45±3．68°（0～＋11．8°）；病例组内翻畸形患者膝关节α角为＋10．85±10．47°（0～＋28．1°），与对照组比较差异有统计学意义（P〈0．05），病例组外翻畸形患者膝关节α角为＋11．6±7．3°（-6．5～＋26．8°），与对照组比较差异有统计学意义（P〈0．05）。结论以胫骨结节内1／3作为胫骨假体旋转参考轴线，胫骨假体相对于股骨假体处于轻度外旋位；合并内、外翻畸形患者的胫骨假体外旋角度明显增大，容易使股骨假体和胫骨假体间出现旋转对线不良。     

Application of bone graft to the medial side of the first metatarsal head in the treatment of hallux varus

BACKGROUND: Hallux varus deformity is not frequent, is usually acquired, and is poorly tolerated by patients. A common cause is the resection of an excessive amount of the head of the first metatarsal during an operation performed to correct a hallux valgus deformity. The purpose of this study was to evaluate the results of application of bone graft to the medial aspect of the first metatarsal head in order to restore missing bone after resection of an excessive amount of bone during a bunionectomy. METHODS: Of thirty patients who had a hallux varus deformity that was treated operatively, eight (ten feet) had bone-grafting to the medial aspect of the first metatarsal head. Six patients (seven feet) were available for evaluation at an average of 8.6 years (range, two to twenty-two years) postoperatively. The original reasons for the consultation for the hallux varus deformity were pain in the great toe, discomfort with shoewear, and the cosmetic appearance of the deformity. The pain typically was located on the medial aspect of the great toe and was caused by the pressure of the shoe; the pain usually was aggravated by walking. Preoperatively, the passive range of dorsiflexion averaged 72 degrees (range, 60 to 80 degrees); the passive range of plantar flexion, 12 degrees (range, 10 to 20 degrees); and the varus deformity, 18 degrees. RESULTS: Six of the seven feet had a satisfactory result. The pain associated with the varus deformity had disappeared in all patients. One patient was dissatisfied because of 20 degrees of valgus angulation. The passive range of dorsiflexion averaged 63 degrees (range, 60 to 70 degrees), and all patients had 10 degrees of plantar flexion. Overall, the valgus angulation of the metatarsophalangeal joint averaged 19 degrees (range, 16 to 22 degrees). There was no recurrence or persistence of the varus deformity. In three feet, the joint space was reduced, but this did not jeopardize the clinical result. CONCLUSIONS: A bone graft screwed onto the medial aspect of the metatarsal head provided a good result. This technique is indicated when the varus deformity is related to a previous resection of an excessive amount of bone during a bunionectomy and when the deformity is passively reducible to neutral.     

Treatment of tibia vara by the Ilizarov method

Sixty-nine lower extremities of 45 patients (mean age, 10 years 8 months) with tibia vara were treated with the Ilizarov circular external fixator and distraction osteogenesis. Twenty-four of the patients had bilateral involvement, six of whom had simultaneous surgery and the remaining 18 had staged operations 8 to 12 months apart. In 11 limbs with femoral valgus deformity greater than 10 degrees simultaneous corrections were done. Active movements of the joints of the extremity were encouraged the day after surgery and partial weightbearing began 2 days later. All patients were followed up 27 to 178 months (mean, 80 months) after surgery. No neurovascular complications, delayed union, or nonunions were observed. The mean 28.6 degrees varus tibiofemoral angle preoperatively (range, 15 degrees -45 degrees ) improved to 7.5 degrees valgus (range, 0 degrees -18 degrees ) postoperatively. The preoperative internal torsion angle also improved from 20.7 degrees (range, 0 degrees -48 degrees ) to 3.5 degrees external torsion (range, 0 degrees -9 degrees ) postoperatively. Residual deformity was seen in six patients, and they had successful revision surgery using the same technique. The Ilizarov method allows early weightbearing and motion and allows all components of the deformity to be corrected.     

Achilles lengthening/posterior tibial tenotomy with immediate weightbearing for patients with significant comorbidities

BACKGROUND: Fixed equinovarus deformities can be challenging to treat especially in medically debilitated patients. The purpose of this study was to evaluate Achilles lengthening with posterior tibial tenotomy and immediate weightbearing in this difficult group of patients. MATERIALS AND METHODS: Thirteen extremities in 10 patients underwent Achilles lengthening and posterior tibial tenotomy for fixed equinovarus deformities with significant medical comorbidities. Pre- and postoperative ambulatory status and deformities were noted. RESULTS: Average age at the time of surgery was 65 with an average duration of deformity 6.3 years. The average equinus corrected from 26 degrees to 1.2 degrees and the average varus deformity improved from -8.5 degrees to 2.7 degrees. All patients except one who was wheelchair-bound had a significant improvement in ambulatory status. CONCLUSION: Achilles lengthening with posterior tibial tenotomy allowed for immediate postoperative weightbearing with improvement in deformity and ambulatory status in this complicated patient group.     

The management of cubitus varus and valgus using the Ilizarov method

Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from -18.7 degrees (-10 degrees to -30 degrees ) to 6.1 degrees (2 degrees to 10 degrees ) in patients with cubitus varus and from 36.5 degrees (25 degrees to 45 degrees ) to 9.4 degrees (4 degrees to 15 degrees ) in patients with cubitus valgus. There were 18 excellent and six good results. The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition.     

Remodeling after femoral shaft fractures in children treated by the modified blount method

One hundred forty-one children with femoral shaft fractures in the 1-12-year age range were treated by simple skin traction without spica cast immobilization. All fractures united in an average traction period of 28 days. Clinical and radiological reevaluation 2-10 years after treatment showed that fracture location, age, and overriding significantly affected overgrowth, whereas the length of the follow-up period and the direction of angular deformity affected correction of angulation. The following conclusions were reached: Distraction should be avoided, and overriding of up to 15 mm can be compensated for by growth acceleration. Initial angular deformities of up to 20 degrees in the coronal plane and up to 30 degrees in the sagittal plane will end in a satisfactory outcome. Rotational deformity was not a problem following this method of treatment.     

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.     

The effect of preoperative knee deformity on the initial results of cruciate-retaining total knee arthroplasty

Between November 1985 and June 1987, 751 posterior cruciate-sparing total knee arthroplasties were performed on 523 patients who exhibited fixed varus or valgus deformities. Patients excluded from this study included the following: those with a postoperative follow-up period of less than 2 years (including patients who had died), patients who became infected, and patients with previous failed total knee arthroplasty in the same knee. A total of 473 knees left for evaluation. All arthroplasties were measured using anatomic axis for alignment measurement. The Hospital for Special Surgery scoring system was used to determine the clinical scores prior to the end of each follow-up examination. All ligament releases were performed sequentially, including balancing of the posterior cruciate ligament. All arthroplasties were divided into six separate groups depending upon the degree of varus or valgus deformity. Kaplan-Meier curves were constructed using three methods of failure definition. Curves were then compared between groups. The mean Hospital for Special Surgery score was no different between any of the groups, except for the group of 6 degrees-10 degrees varus, which was significantly higher than the mean score of the 11 degrees and higher valgus group. All other groups were the same statistically. It is concluded that severe varus and valgus deformities may be satisfactorily corrected with the use of a cruciate-retaining type of total knee arthroplasty.     

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。     

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.     

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.