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.     

Treatment of osteoarthritis of the knee with valgus deformity by means of varus osteotomy

Nineteen cases of osteoarthritis of the knee with valgus deformity in 17 patients were treated by femoral supracondylar varus osteotomy (17 cases) or by high tibial varus osteotomy (2 cases) over the last 15 years. Fixation was performed using a 95 degrees AO blade-plate in 13 of the femoral osteotomies and a straight plate in the other four. The mean follow-up time was 6.5 years. The valgus deformity was idiopathic in 14 cases, secondary to rheumatoid arthritis in 2 cases and to tibial valgus in one case. The Hospital for Special Surgery (HSS) score was used to evaluate the clinical results: nearly 75% were excellent or good. The causes related to poor results are analyzed regarding indication and surgical technique. It appears that varus osteotomy is an effective procedure for the treatment of osteoarthritis of the knee with valgus deformity, above all in order to alleviate pain, although the operation requires precision, and correct selection of patients is of prime importance.     

Simultaneous femoral osteotomy and total knee arthroplasty for treatment of osteoarthritis associated with severe extra-articular deformity

BACKGROUND: In the presence of large extra-articular deformity, complex imbalance of the collateral ligaments may result if standard techniques of soft-tissue releases and intra-articular bone resection are used during total knee arthroplasty. The purpose of this paper is to review our experience with simultaneous corrective osteotomy and total knee arthroplasty for the treatment of severe extra-articular femoral deformity associated with ipsilateral osteoarthritis of the knee. METHODS: The results of simultaneous corrective osteotomy and total knee arthroplasty in eleven knees with osteoarthritis and associated extra-articular angular deformity of the femur were reviewed retrospectively. The femoral deformity resulted from fracture malunion in ten knees and from hypophosphatemic rickets in one. There were five primarily uniplanar deformities (four varus deformities and one antecurvatum deformity), five biplanar (varus and antecurvatum) deformities, and one triplanar (varus, antecurvatum, and internal rotation) deformity. Four knees were approached through a standard medial parapatellar arthrotomy and seven, through an anterolateral subvastus approach with an osteotomy of the tibial tubercle. The site of the femoral osteotomy was fixed with a blade-plate in seven patients, a press-fit long-stemmed femoral component in two, and a retrograde femoral nail in two. An extramedullary alignment system was utilized in eight patients, and intramedullary alignment was used in three. RESULTS: The duration of follow-up averaged forty-six months (range, twenty-six to eighty-eight months). According to the classification system of the Knee Society, the mean function score increased from 22 points preoperatively to 81 points at the time of follow-up and the mean knee score increased from 10 points preoperatively to 87 points at the time of follow-up. The mean flexion contracture decreased from 19 degrees preoperatively to 2 degrees at the time of follow-up. The arc of motion averaged 56 degrees (range, 30 to 75 degrees) preoperatively and 89 degrees (range, 65 to 115 degrees) at the time of follow-up. The mechanical alignment in the coronal plane was restored to within 2 degrees of normal in each patient. Ten femoral osteotomy sites healed, and one, in a patient treated with a press-fit long-stemmed femoral component, had not healed by the time of follow-up. All seven sites of the tibial tubercle osteotomies healed. There were no complete radiolucent lines at the prosthetic interfaces, and no total knee arthroplasty was revised. One patient had a nonfatal postoperative pulmonary embolism. As determined by clinical examination and the patients' assessment of function, no ligament imbalance was noted at the time of the most recent follow-up. CONCLUSIONS: Simultaneous femoral osteotomy and total knee arthroplasty is a technically difficult but effective treatment for patients with severe femoral deformity associated with ipsilateral osteoarthritis of the knee. We recommend that the femoral osteotomy site be secured with a plate or a locked intramedullary nail, depending on the location of the deformity and the subsequent osteotomy.     

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 inwardly pointing knee. An unrecognized problem of external rotational malalignment

Twelve patients with inwardly pointing knees had chronic knee pain and disability suggestive of patellofemoral subluxation. None had responded well to conservative measures or surgical correction at the level of the soft tissues. Their pattern of limb alignment was studied roentgenographically and was found to differ significantly from the control group of 49 healthy young adults. The deformities primarily related to the tibia were external tibial torsion, excess varus angulation of the tibial plateau, and varus knees. Angulation of the femoral condyles was normal and femoral anteversion did not appear to contribute significantly to the deformity. Surgery in seven cases (nine knees) was by derotation valgus Maquet osteotomy of the tibia and lateral release realignment of the patellae. Outcome assessments after a three-year follow-up period (five knees) were excellent. Early results on the remaining cases were satisfactory.     

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

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

Total knee arthroplasty after varus osteotomy of the distal part of the femur

BACKGROUND: There is little information in the literature regarding the outcome of total knee arthroplasty following distal femoral varus osteotomy. The purpose of the present study was to evaluate the intermediate-term results of total knee arthroplasty following distal femoral varus osteotomy. METHODS: The study group consisted of nine consecutive patients (eleven knees) who had had a total knee arthroplasty following varus osteotomy of the distal part of the femur. The average age of the patients was forty-four years (range, fifteen to seventy years) at the time of the arthroplasty. The results were evaluated with use of the Knee Society score preoperatively and after a mean duration of follow-up of 5.1 years. Radiographs made preoperatively and at the time of follow-up were evaluated for alignment in the coronal plane. RESULTS: The mean Knee Society knee score was 35 points before the arthroplasty and 84 points after the arthroplasty. The mean Knee Society function score was 49 points before the arthroplasty and 68 points after the arthroplasty. The mean interval between the femoral osteotomy and the total knee replacement was fourteen years (range, two to thirty-two years). A constrained prosthesis was required in five of the eleven knees. Two knees had an excellent result, five had a good result, and four had a fair result. The mean arc of motion improved from 81.8 degrees to 105.9 degrees. The mean radiographic alignment was 3.6 degrees of valgus (range, 7 degrees of varus to 18 degrees of valgus) before the arthroplasty and 3.3 degrees of valgus (range, 1 degrees of valgus to 6 degrees of valgus) at the time of the latest follow-up. There were no infections or wound complications. CONCLUSION: Total knee arthroplasty following distal femoral varus osteotomy decreases pain and improves knee function, but the procedure is technically demanding and is associated with inferior results when compared with those of primary arthroplasty performed in a patient without a prior femoral osteotomy. In the present series, the use of an intramedullary femoral alignment guide increased the tendency to place the femoral component in relative varus angulation (that is, in <5 degrees of valgus). We recommend checking the alignment of the femoral component with an extramedullary guide in knees that have had a previous distal femoral varus osteotomy.     

Distal femoral varus osteotomy

The results of twenty-three distal femoral varus osteotomies (in twenty-one patients) that were performed between 1977 and 1984 were evaluated. Fifteen osteotomies were done for osteoarthritis; three, for post-traumatic arthritis or deformity; three, for rheumatoid arthritis; and two, for renal osteodystrophy. The median age of the patients was fifty-six years (range, nineteen to seventy years). The length of follow-up averaged four years (range, two to nine years). The average tibiofemoral angle preoperatively was 18 degrees of valgus, which was corrected postoperatively to an average of 2 degrees of valgus. At follow-up, nineteen (83 per cent) of the twenty-three knees were rated as good or excellent according to The Hospital for Special Surgery knee score, which had improved from an average of 65 points preoperatively to 86 points post-operatively. Of the fifteen patients who had osteoarthritis (93 per cent), all but one had a good or excellent result. Most patients had no substantial improvement in the range of motion of the knee as a result of the operation. Eighty-six per cent of the patients expressed satisfaction with the outcome. We concluded that varus osteotomy of the distal part of the femur is a reliable and effective surgical procedure for the treatment of gonarthrosis associated with valgus deformity due to osteoarthritis or trauma. We do not recommend its use in patients who have rheumatoid arthritis or in those who have inadequate motion of the knee before the operation.     

Distal femoral varus osteotomy in the valgus osteoarthritic knee

The results of 18 distal femoral varus osteotomies performed in 18 patients between 1982 and 1993 were evaluated. All patients had degenerative arthritis of the lateral compartment of the knee associated with a valgus deformity. At surgery, the average patient age was 54 years (range: 38-75 years). The average follow-up was 9 years (range: 5-16 years). The average tibiofemoral angle was 17.5 degrees of valgus preoperatively and 6 degrees postoperatively. Seventeen patients (1 patient died from an unrelated cause) were evaluated at follow-up according to the Knee Society rating system. At follow-up, 13 (77%) were rated as good or excellent by the Knee Society rating system. The Knee score improved from 54 points preoperatively to 89 points postoperatively. The functional score improved from 65 points preoperatively to 86 points postoperatively. One knee required a subsequent total knee arthroplasty (TKA) 5 years after osteotomy due to severe and persistent pain. No patient had infection or nonunion. Varus osteotomy of the distal femur is a reliable and effective surgical procedure for the treatment of gonarthrosis associated with valgus deformity in both young and older active patients, where it can be an alternative to TKA.     

Late recurrence of varus deformity after proximal tibial osteotomy

One hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus-producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years (mean, 6.3 years). Sixty-four knees (57%) were pain free or had only mild discomfort when walking. The standing femorotibial angle decreased from a postoperative average of 9.3 degrees valgus to 7.8 degrees valgus at the final follow-up examination. The tendency for varus recurrence greater than 5 degrees and for medial- or lateral-compartment arthritic progression was evaluated using the Kaplan-Meier survival method. Varus recurred in 18%, lateral-compartment arthritic progression in 60%, and medial-compartment arthritic progression in 83% by nine years after surgery. The probability of arthritic progression is much higher than the probability of significant varus recurrence in long-term roentgenographic follow-up studies of patients with valgus-producing proximal tibial osteotomies.     

Distal femoral varus osteotomy: unloading the lateral compartment: long-term follow-up of 45 medial closing wedge osteotomies

Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.     

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief,Functional Improvement,and Survivorship at 5?Years

Background

Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship.

Questions/purposes

(1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy?

Methods

Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2 years (mean, 5 years; SD, 2; range, 2–12 years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution’s osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded.

Results

Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of ± 3° from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5 years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group.

Conclusions

Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of ± 3° from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic.

Level of Evidence

Level IV, therapeutic study.     

Distal femoral varus osteotomy for valgus deformity of the knee

Twenty-four patients who had degenerative arthritis of the lateral compartment of the knee that was associated with a valgus deformity and a superolateral tilt of the joint line were treated by distal femoral varus osteotomy. A surgical technique that was designed to produce a horizontal joint line and a tibiofemoral angle of zero degrees is described. At an average length of follow-up of four years, twenty-two of twenty-four patients had a successful result as judged by our protocol for evaluation. One osteotomy had to be revised for failure of fixation, and one patient had a pulmonary embolism that had a satisfactory outcome after the administration of anticoagulants. One patient required manipulation of the knee at six months. The simple surgical technique that we used was effective in realigning the femoral with the tibial axis in patients who had a valgus deformity of the knee, a superolateral tilt of the joint line, and osteoarthritis of the lateral compartment.     

Distal femoral valgus osteotomy: bone healing time in single plane and biplanar technique

Varus deformity can be localized in the tibia, in the femur or in both. If varus deformity is localized within the femur, it is mandatory to correct it in the femur. This report presents the technique and results of a consecutive case series of lateral uniplanar and biplanar closed-wedge valgus osteotomy of the distal femur for the treatment of varus deformity of the knee. Retrospectively, fifteen patients (sixteen knees) were identified. Indications for surgery varied from unloading an osteoarthritic medial compartment to reduction to symmetrical varus leg alignment. Pre- and post-operative X-rays, including a full leg radiograph, were assessed as well as bone healing time at follow-up intervals. Clinical outcome was assessed using different questionnaires. There were nine male and six female patients with a median age at surgery of 45 (±14) years. The mLDFA changed from 95.9° (±2.7°) preoperatively to 89.3° (±2.9°) post-operatively. Preoperative planning and the use of angle stable implants resulted in accurate corrections according to preoperative aims in all but one patient. At follow-up (mean, 40 months), the mean VAS score was 2.5 (±2.4) and the WOMAC score averaged 80 (±20). The mean bone healing time of biplanar osteotomies (4 ± 3 months) was shorter than in the uniplanar osteotomies (6 ± 3 months). Distal lateral closed-wedge valgus osteotomy of the femur for the treatment of femoral varus deformities resulted in clinical improvement and accurate corrections in patients with different aims for correction. A biplanar osteotomy technique shortens bone healing time.     

Anatomical analysis of the femoral condyle in normal and osteoarthritic knees.

It is important to understand anatomical feature of the distal femoral condyle for treatment of osteoarthritic knees. Detailed measurement of the femoral condyle geometry, however, has not been available in osteoarthritic knees including valgus deformity. This study evaluated femoral condyle geometry in 30 normal knees, 30 osteoarthritic knees with varus deformity, and 30 osteoarthritic knees with valgus deformity using radiographs and magnetic resonance imaging (MRI). In radiographic analysis in the coronal plane, the femoral joint angle (lateral angle between the femoral anatomic axis and a tangent to femoral condyles) was 83.3 degrees in the normal knees, 83.8 degrees in the varus knees, and 80.7 degrees in the valgus knees. In MRI analysis in the axial plane, the posterior condylar tangent showed 6.4 degrees of internal rotation relative to the transepicondylar axis in the normal knees, 6.1 degrees in the varus knees, and 11.5 degrees in the valgus knees. These results suggested that there was no hypoplasia of the medial condyle in the varus knees, but the lateral condyle in the valgus knees was severely distorted. Surgeons should take this deformity of the lateral femoral condyle into account when total knee arthroplasty is performed for a valgus knee.     

Proximal tibial osteotomy in the treatment of osteoarthritis of the knee

A long-term follow-up study is presented of 162 patients who were treated for knee arthrosis with proximal tibial osteotomy, 10 of whom had undergone a bilateral operation. The average follow-up time was 8 years. Pre-operatively, varus deformity was found in the knees of 117 patients; 45 of them had valgus knees. In 142 knees curved osteotomy was performed and wedge osteotomy in 30. At follow-up, 33% of the patients were found to have no pain. Significant long-term improvement was achieved, as registered at the time of follow-up, in 80% of the patients, whereas in 11% pain remained unchanged. Better results were recorded in women than in men (P less than 0.01). In the present study, slightly better results were obtained statistically using curved osteotomy (P less than 0.05). Postoperative plaster sleeve immobilisation for approximately 6 weeks (10 weeks at the most) gave the best results. Internal fixation seemed unnecessary.     

Distal femoral osteotomy for valgus arthritic knees

BackgroundPatients with genu valgum and isolated osteoarthritis of the lateral compartment are candidates for distal femoral varus osteotomy. Opening wedge osteotomy is a precise method to realign the knee axis with good short to midterm results. The aim of this study was to evaluate the outcome of patients who have had opening wedge distal femoral varus osteotomy utilizing the Puddu plate (Arthrex, Naples, FL, USA) fixation.MethodsThe study included 6 patients (7 knees) followed for an average of 6.5 ± 1.5 years after distal femoral varus osteotomy with Puddu fixation and iliac crest allograft. Clinical outcome was assessed by the Oxford Knee Score and subjective satisfaction rating. Pre- and postoperative radiographs were evaluated for tibiofemoral angle, Insall-Salvati index and Kellgren-Lawrence Grading Scale for osteoarthritis.ResultsThe mean age at surgery was 46.7 ± 10.7 years. The mean body mass index at surgery was 29.6 ± 5.6 kg/m². Overall at the last follow-up the mean Oxford Knee Score improved from 13.1 ± 8.6 to 26 ± 12.5. The average subjective satisfaction rate at the last follow-up was 6.6 ± 2.8. The measured tibiofemoral angle was corrected by an average of 11.9°. There was no worsening of arthritic changes in comparison to the preoperational radiographs. All radiographs showed full incorporation of the bone grafts, and there were no hardware failures. At the end of this study none of the patients required additional surgery, and none had knee replacement.ConclusionsOpening wedge distal femoral varus osteotomy with Puddu plate fixation can be a reliable procedure for the treatment of lateral compartment osteoarthritis of the knee associated with valgus deformity.     

股骨髁上截骨治疗中青年外翻性膝骨关节炎

目的:探讨股骨髁上外侧开放性楔形截骨治疗外翻性膝骨关节炎的临床疗效。方法:自2008年4月至2015年6月,对21例(23膝)符合纳入标准的外翻性膝骨关节炎患者,采取股骨外髁上开放性楔形截骨后自体髂骨植骨并股骨远端解剖钢板内固定的手术方式进行治疗。男8例(8膝),女13例(15膝),年龄30~54岁,平均41.2岁,所有患者伴有膝关节外侧间室疼痛及外翻畸形,术前通过下肢负重位全长X线测量出胫股角平均为(162.0±2.6)°。通过观察术后骨愈合时间、手术并发症,比较治疗前后膝关节炎进展情况、HSS评分及胫股角等,综合评价该手术方法治疗外翻性膝关节炎的效果。结果:所有患者术后膝关节外翻畸形得到矫正,骨愈合时间(3.9±1.5)个月,未发现明显延迟愈合或不愈合病例,无严重并发症发生。HSS膝关节总评分从术前的57.3±3.1提高到末次随访时的88.6±2.7。胫股角提高到术后的(176.0±1.4)°。结论:股骨髁上开放性楔形截骨解剖入路清晰,术中容易控制截骨量,能够有效矫正膝关节外翻畸形,同时改善膝关节功能,是治疗中青年外翻性膝骨关节炎的有效方法。     

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.     

Total knee arthroplasty for arthritis of the knee with extra-articular deformity

BACKGROUND: Simultaneous corrective osteotomy of angular deformity and total knee arthroplasty has been considered the treatment of choice for patients with arthritis of the knee associated with ipsilateral extra-articular deformity. However, this procedure is technically demanding, and the functional outcome of the total knee arthroplasty may be jeopardized if the osteotomy fails. This retrospective study was performed to evaluate the clinical results of total knee arthroplasty combined with intra-articular bone resection, without osteotomy, in patients with extra-articular deformity and arthritis of the knee. METHODS: Fifteen patients with arthritis of the knee and extra-articular deformity underwent total knee arthroplasty with bone resection and soft-tissue balancing. All deformities had resulted from fracture malunion. There were ten uniplanar, three biplanar, and two triplanar deformities. The deformity was in the tibia in eight patients and in the femur in seven. The average angle of the femoral deformities was 15.1 degrees in the coronal plane and 8.1 degrees in the sagittal plane. Two femora had a rotational deformity, consisting of 20 degrees of internal rotation in one and 10 degrees of external rotation in the other. The average angle of the tibial deformities was 19 degrees in the coronal plane. RESULTS: The duration of follow-up averaged thirty-eight months. The average Knee Society knee score improved from 22.3 points preoperatively to 91.7 points at the time of the last follow-up, and the average Knee Society function score improved from 28.0 points preoperatively to 87.3 points at the time of the last follow-up. The average arc of knee motion improved from 77.7 degrees preoperatively to 103.7 degrees postoperatively. The average mechanical axis of the knee improved from 22.7 degrees of varus preoperatively to 0.3 degrees of varus at the time of the last follow-up. Two patients had an unsatisfactory clinical result, which was not related to the total knee arthroplasty. There were no complications such as infection, ligament instability, or component loosening. CONCLUSIONS: Total knee arthroplasty in conjunction with intra-articular bone resection is an effective procedure for patients with arthritis of the knee and extra-articular varus deformity of <20 degrees in the femur or 30 degrees in the tibia in the coronal plane.