PACS and Photoshop assisted isosceles triangle osteotomy and Kirschner wire tension buckle fixation in the treatment of cubitus varus in children / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of picture archiving and communication system (PACS) and Photoshop assisted isosceles triangle osteotomy and Kirschner wire fixation with tension band in the treatment of cubitus varus in children.@*METHODS@#The clinic data of 20 children with cubitus varus treated with isosceles triangle osteotomy of distal humerus and Kirschner wire fixation with tension band from October 2014 to October 2019, were retrospectively analyzed. There were 13 males and 7 females, aged from 3.2 to 13.5 years old, the median age was 6.65 years old. PACS system was applied for the osteotomy design preoperatively, simulating and measuring the side length of isosceles triangle osteotomy. Then, Photoshop system was used to simulate the preoperative and postoperative osteotomy graphics, which could guide precise osteotomy during operation.@*RESULTS@#All the 20 patients were followed up for 20 to 24 months, with a median of 22.5 months. At the last follow-up, the carrying angle of the affected limb was 5 ° to 13 °, with a median of 8.3 °. The clinical efficacy was evaluated according to the Flynn elbow function score:excellent in 16 cases, good in 2 cases, and fair in 2 cases.@*CONCLUSION@#The treatment of cubitus varus in children by isosceles triangle osteotomy and Kirschner wire fixation with tension band assisted by PACS and Photoshop system has shown good clinical outcome.

Conceptos actuales en osteotomías en doble nivel alrededor de la rodilla / Current concepts in double-level osteotomies around the knee

Con la osteotomía en un solo nivel, se puede lograr la corrección del eje de la extremidad en pacientes con deformidades combinadas femoral y tibial, pero de forma simultánea generará una alteración patológica de oblicuidad de la interlínea articular, lo que conducirá a elongación ligamentaria, inestabilidad, degeneración condral y, en última instancia, comprometerá su sobrevida y los resultados funcionales. En virtud del análisis de la literatura más reciente, podemos concluir que existe un número significativo de pacientes que requieren de un procedimiento combinado para lograr un objetivo biomecánico óptimo. La finalidad de una osteotomía en doble nivel alrededor de la rodilla consiste en restablecer la anatomía normal, descargar el compartimiento afectado, normalizar los ángulos mecánicos y la orientación de la interlínea articular. Los ejes fisiológicos pueden restablecerse a través de un análisis preoperatorio exhaustivo, respetando principios biomecánicos y fijación estable con placas bloqueadas. Es un procedimiento demandante y con indicaciones en evolución, que progresivamente se ha instaurado como una alternativa de tratamiento justificada en estudios clínicos y biomecánicos para el manejo de deformidades severas alrededor de la rodilla.

With single-level osteotomy, correction of the limb axis in patients with combined femoral and tibial deformities can be achieved. This correction, however, will generate a pathological alteration in the joint line oblicuity, leading to ligament elongation, instability, joint degeneration and, ultimately, it will compromise the longevity and functional results of the correction. By analyzing the most recent literature, we can conclude that there is a significant number of patients who require a combined procedure to achieve an optimal biomechanical goal. The purpose of a double-level osteotomy around the knee is to restore normal anatomy, unload the affected compartment, normalize the mechanical angles and the orientation of the joint line. Physiological axes can be reestablished by means of a thorough preoperative analysis, observing the biomechanical principles and stable fixation with locked plates. It is a demanding procedure with increasing indications, which has progressively been established in clinical and biomechanical studies as a justified treatment alternative for the management of severe deformities around the knee.

Ventajas del abordaje externo para la artroplastia de rodilla por genu valgo severo / Advantages of the lateral approach in severe genu valgus knee arthroplasty

Introducción: El tratamiento del valgo severo es complejo. El abordaje externo descrito por Keblish es ventajoso para tratar estas deformidades. Evaluamos nuestros resultados utilizando un abordaje externo en artroplastias de rodilla con genu valgo severo. Materiales y Métodos: De 795 artroplastias primarias realizadas entre enero de 2012 y marzo de 2020, analizamos 40 que tenían un abordaje externo. Todos los pacientes tenían una deformidad en valgo >20° y un ligamento colateral medial suficiente. Se incluyó a 33 mujeres (3 bilaterales) y 4 hombres, el promedio de edad era de 71 años. La causa fue fundamentalmente osteoartrosis (82%). La deformidad prequirúrgica era de 27°. Las mediciones preoperatorias eran: KSS 15 (rango 5-42) y KFS 17 (rango 0-40). El tiempo promedio de cirugía fue de 91 minutos y el seguimiento, de 37 meses. Resultados: El ángulo femorotibial posoperatorio fue de 6,2° (rango 4-40), el KSS posoperatorio fue de 79 (rango 46-95) y el KFS, de 82 (rango 60-100). Hubo tres complicaciones (7%): una infección, un mal posicionamiento de componentes y uno de neuropraxia peronea. Conclusiones: En la artroplastia de rodilla por genu valgo, este abordaje permite restituir el eje femorotibial, lograr una adecuada estabilidad de la prótesis, aun con implantes sin mayor grado de constreñimiento, con una tasa de complicaciones equiparable a la de otras técnicas. Nivel de Evidencia: IV

Introduction: The treatment of severe valgus is complex. The lateral approach described by Keblish is advantageous for the treatment of these deformities. We decided to evaluate our outcomes using a lateral approach in severe genu valgus knee arthroplasty. Materials and Methods: Of 795 primary arthroplasties from January 2012 to March 2020, we analyzed 40 performed by lateral approach. All had a valgus deformity greater than 20° and a sufficient medial collateral ligament. 33 women (3 bilateral) and 4 men were included. Average age was 71 years (59-79). The main cause was osteoarthrosis (82%). The presurgical deformity was 27° (21-39). The preoperative measurements were: Knee Society Score (KSS) 15 (5 to 42). Preoperative functional score (KFS): 17 (0 to 40). Average surgical time: 91 minutes. The average postoperative follow-up was 37 months. Results: Postoperative femorotibial angle 6.2° (range 4° to 10°). Postoperative KSS 79 (46-95). KFS 82 (60-100). Complications: 3 cases (7%), one infection, one case with poor positioning of components, and one case of peroneal neuropraxia. Conclusion: In knee arthroplasty due to genu valgus, this approach allows restoring the femoro-tibial axis and achieving adequate prosthetic stability, even with implants without a greater degree of constraint, with a complication rate comparable to other techniques. Level of Evidence: IV

Osteotomía en cuña sustractiva supracondílea para el tratamiento del codo valgo del adulto / Supracondylar subtraction wedge osteotomy for the treatment of adult cubitus valgus

Objetivo: Comunicar los resultados de una serie de adultos con consolidaciones en valgo del codo tratados con una osteotomía en cuña sustractiva monoplanar. materiales y métodos: Se incluyeron 5 pacientes. Se describe la técnica quirúrgica que consistió en un abordaje posterior paratricipital, resección en cuña sustractiva y transposición anterior del nervio cubital. El seguimiento promedio fue de 17 meses. Resultados: Se trató a 4 hombres y una mujer, con una edad promedio de 27 años. La movilidad preoperatoria promedio fue de 138-7° y la posoperatoria, de 138-6°, el puntaje de dolor en la EAV fue de 4 y 1, el MEPS de 71 y 97, y el DASH de 26 y 8, respectivamente. La evaluación radiográfica preoperatoria arrojó un valgo promedio de 30° con un valgo contralateral de 11°. La corrección radiográfica demostró un valgo de 13°. Se obtuvo una corrección promedio de 2° menos que del otro lado. Todas las osteotomías consolidaron, y la medición de la prominencia medial fue, en promedio, un 32% mayor que en el preoperatorio. Según la escala de Oppenheim, el resultado fue excelente en 4 pacientes y bueno en uno. La satisfacción personal fue, en promedio, de 8,6. Conclusiones: La osteotomía en cuña sustractiva para tratar un codo valgo es una buena opción terapéutica, con recuperación de valores angulares comparables con el lado contralateral, y alta tasa de satisfacción de los pacientes. Como es una técnica menos compleja que las osteotomías multiplanares, es nuestra elección ante una consolidación viciosa en valgo del codo del adulto. Nivel de Evidencia: IV

Objective: To report the results of a series of adult patients with a valgus malunion of the elbow treated with a supracondylar subtractive monoplanar wedge osteotomy, materials and methods: 5 patients were included. The surgical technique consisted of a posterior paratricipital approach, with resection of a subtractive wedge and the anterior transposition of the ulnar nerve. The average follow-up was 17 months.Results: 4 patients were men and 1 woman with an average age of 27 years. The preoperative range of motion was 138°-7° and the postoperative range of motion was 138-6°. Pain according to VAS was 4 and 1, MEPS was 71 and 97, and DASH was 26 and 8, respectively. The preoperative radiological evaluation showed an average valgus of 30° with a contralateral valgus of 11º. The final valgus obtained was 13°. The final correction was, on average, 2° less than the contralateral side. All osteotomies healed and the medial prominence was on average 32%, more than before surgery. According to Oppenheim scale, the results were excellent in 4 patients and good in 1. Personal satisfaction was, on average, 8.6. Conclusions: Supracondylar subtractive wedge osteotomy is a good option for the treatment of adult cubitus valgus with a recovery of angular values similar to the contralateral side and a high satisfaction rate. As it is a simpler technique, compared to the multiplanar osteotomies, it is our treatment of choice for adult cubitus valgus. Level of Evidence: IV

Outcomes of Non-Operative Management for Pseudarthrosis after Pedicle Subtraction Osteotomies at Minimum 5 Years Follow-Up

OBJECTIVE: Minimal data exist regarding non-operative management of suspected pseudarthrosis after pedicle subtraction osteotomy (PSO). This study reports radiographic and clinical outcomes of non-operative management for post-PSO pseudarthrosis at a minimum 5 years post-detection.METHODS: Nineteen consecutive patients with implant breakage indicating probable pseudarthrosis after PSO surgery (13 women/six men; mean age at surgery, 58 years) without severe pain and disability were treated with non-operative management (mean follow-up, 5.8 years; range, 5–10 years). Non-operative management included medication, intermittent brace wearing and avoidance of excessive back strain. Radiographic and clinical outcomes analysis was performed.RESULTS: Sagittal vertical axis (SVA), proximal junctional angle, thoracic kyphosis achieved by a PSO were maintained after detection of pseudarthrosis through ultimate follow-up. Lumbar lordosis and PSO angle decreased at final follow-up. There was no significant change in Oswestry Disability Index (ODI) scores and Scoliosis Research Society (SRS) total score, or subscales of pain, self-image, function, satisfaction and mental health between detection of pseudarthrosis and ultimate follow-up. SVA greater than 11 cm showed poorer ODI and SRS total score, as well as the pain, self-image, and function subscales (p<0.05).CONCLUSION: Non-operative management of implant failure of probable pseudarthrosis after PSO offers acceptable outcomes even at 5 years after detection of implant breakage, provided SVA is maintained. As SVA increased, outcome scores decreased in this patient population.

Outcomes of Non-Operative Management for Pseudarthrosis after Pedicle Subtraction Osteotomies at Minimum 5 Years Follow-Up

OBJECTIVE: Minimal data exist regarding non-operative management of suspected pseudarthrosis after pedicle subtraction osteotomy (PSO). This study reports radiographic and clinical outcomes of non-operative management for post-PSO pseudarthrosis at a minimum 5 years post-detection. METHODS: Nineteen consecutive patients with implant breakage indicating probable pseudarthrosis after PSO surgery (13 women/six men; mean age at surgery, 58 years) without severe pain and disability were treated with non-operative management (mean follow-up, 5.8 years; range, 5–10 years). Non-operative management included medication, intermittent brace wearing and avoidance of excessive back strain. Radiographic and clinical outcomes analysis was performed. RESULTS: Sagittal vertical axis (SVA), proximal junctional angle, thoracic kyphosis achieved by a PSO were maintained after detection of pseudarthrosis through ultimate follow-up. Lumbar lordosis and PSO angle decreased at final follow-up. There was no significant change in Oswestry Disability Index (ODI) scores and Scoliosis Research Society (SRS) total score, or subscales of pain, self-image, function, satisfaction and mental health between detection of pseudarthrosis and ultimate follow-up. SVA greater than 11 cm showed poorer ODI and SRS total score, as well as the pain, self-image, and function subscales (p<0.05). CONCLUSION: Non-operative management of implant failure of probable pseudarthrosis after PSO offers acceptable outcomes even at 5 years after detection of implant breakage, provided SVA is maintained. As SVA increased, outcome scores decreased in this patient population.

Physiotherapy protocol during initial postoperative period of arthroscopy in horses / Protocolo fisioterápico durante o período pós-operatório inicial de cirurgia artroscópica em equinos

This study evaluated the effects of a physiotherapy protocol applied in joints with osteochondritis dissecans submitted to arthroscopy. Twelve horses totaling twenty joints were used and divided into two uniform groups, according to articular lesion grade. Treated Group (TG) received the physiotherapy protocol (cryotherapy, passive rage motion and controlled exercise) that initiate just after anesthetic recovery and extended for five days. Control Group (CG) remained resting in stall during the same period. Physical examination and synovial fluid analysis were used to evaluate the treatment. The synovial fluid examination consisted of physical analysis (color, aspect, and viscosity), mucin clot evaluation, Serum Amyloid A, Prostaglandin E2 and urea concentration. Synovial samples were collected by arthrocentesis at the beginning of the surgical procedure (D1), 48 hours (D3) and 96 hours (D5) after surgery. Before arthroscopy and daily during the postoperative period joints were evaluated by physical exam: superficial temperature (°C), range of motion (degrees) and circumference (centimeters). The joint physical examination showed no significant difference between groups and neither along the days for the same group. The parameters of synovial fluid showed difference over the moments in each group but didn't have difference between groups. Color and aspect had the same patterns across moments, in CG fluid had significant change when compared D1 with D3 (color and aspect: p<0.001) and D5 (color: p<0.001; aspect: p<0.05) becoming mostly bloody and cloudy in D3 and D5. However in TG the difference was significant just between D1 and D3 (color and aspect: p<0.05), showing an improvement of synovial fluid in D5 (color and aspect: p<0.05). Viscosity and mucin clot evaluation showed significant change in CG between D1 and D3 (viscosity: p<0.01; mucin clot: p<0.05) and between D1 and D5 (viscosity: p<0.01;mucin clot: p<0.01). In TG no significant difference of viscosity and mucin clot was observed over the moments, showing an early improvement of synovial fluid quality. The Serum Amyloid A concentration showed an extremely significant increase in CG (p<0.001) when compared D1 (1217.13±664.47µg/mL) and D3 (42423.80±52309.31µg/mL). The comparison between D1 and D5 in CG, and across moments in TG, had no statistical difference. The PGE2 eicosanoid remained statistically unchanged all over the time. Urea showed significant increase in D3 when compared to D1 (p<0.001) in CG, and had no variation in TG. The physiotherapy protocol minimized the inflammatory mediators and provided minor alterations in synovial fluid after arthroscopy.(AU)

Este estudo avaliou os efeitos de um protocolo fisioterápico, aplicado em articulações com osteocondrite dissecante, submetidas à artroscopia. Foram utilizados 12 cavalos, totalizando 20 articulações, divididas em dois grupos homogêneos de acordo com a graduação da lesão articular. O grupo tratado (GT) recebeu o protocolo fisioterápico (crioterapia, movimentação passiva e exercício controlado) que se iniciou imediatamente após a recuperação anestésica e se estendeu por cinco dias. O grupo controle (GC) permaneceu em repouso na baia, pelo mesmo período. Exame físico da articulação e análise do líquido sinovial foram utilizados para avaliar o tratamento. O exame do líquido sinovial consistiu em análise física (cor, aspecto e viscosidade), avaliação do coágulo de mucina e concentrações de amiloide sérica A, prostaglandina E2 e ureia. Amostras de líquido sinovial foram colhidas por artrocentese no início do procedimento cirúrgico (D1) e após 48 (D3) e 96 horas (D5) do procedimento cirúrgico. Antes da artroscopia e diariamente no período pós-operatório, as articulações foram avaliadas por exame físico: temperatura superficial (°C), ângulo de flexão (graus), circunferência (centímetros). A avaliação física das articulações não apresentou diferença significativa entre os grupos nem ao longo dos dias em cada grupo. Nas análises do líquido sinovial, observou-se uma variação diferente entre os momentos em cada grupo porém sem diferença significativa entre os grupos. A cor e o aspecto tiveram resultados semelhantes ao longo do tempo, no GC houve uma alteração significativa quando comparados D1 e D3 (cor e aspecto: p<0,001) e D1 e D5 (cor: p<0,001; aspecto: p<0,05) tornando-se sanguinolento e turvo na maioria das amostras em D3 e D5. Já no GT, houve diferença significativa apenas entre D1 e D3 (cor e aspecto: p<0,05), demonstrando melhora no líquido sinovial em D5 (cor e aspecto: p<0,05). A viscosidade e o coágulo de mucina apresentou alteração significativa no GC entre D1 e D3 (viscosidade: p<0,01; coágulo de mucina: p<0,05) e entre D1 e D5 (viscosidade e coágulo de mucina: P<0,01). No grupo tratado não foram observadas alterações significativas em viscosidade e coágulo de mucina, ao longo dos momentos, demonstrando uma melhora precoce na qualidade do líquido sinovial. A amiloide sérica A apresentou um aumento extremamente significante no GC (p<0,001) quando comparados D1 (1217,13±664,47µg/dL) e D3 (42423,80±52309,31µg/dL). Quando comparados D1 e D5 no GC e ao longo do tempo no GT não foram observadas diferenças significativas. A concentração de PGE2 permaneceu sem alterações. As mensurações de ureia apresentaram aumento significativo em D3 quando comparado a D1 (p<0,001) no GC e não apresentou variação no GT. O protocolo fisioterápico minimizou os mediadores inflamatórios e proporcionou menor alteração do líquido sinovial após artroscopia.(AU)

Double femoral osteotomy fixed with a Puddu plate and a retrograde intramedullary nail to treat biapical deformity of the femur / Osteotomia femoral dupla fixada com placa Puddu e haste intramedular retrógrada para tratamento de deformidade femoral biapical

ABSTRACT Biapical femoral deformities are challenging to treat. In order to correct concomitant metaphyseal and diaphyseal deformities of the femur, the authors propose a double femoral controlled osteotomy with combined internal fixation, consisting of a Puddu plate and an intramedullary nail. The method was described in two patients. Results were analyzed using a visual analog scale (VAS), the Lysholm score, and SF-36. No complications were found. Complete consolidation of the osteotomies and radiographic alignment correction were achieved. Results were obtained with a minimum follow-up of 66 months. Both patients had improved for pain (VAS from 60 to 40 and from 50 to 20 at reassessment), function (Lysholm score from 78 to 93 and from 55 to 73) and quality of life (SF-36, both mental - from 40.7 to 57.1 in case one and from 24.7 to 59.7 in case two - and physical - from 27.7 to 45.6 and from 28.2 to 46.8). The authors have found that this technique is a reliable, accurate, and reproducible solution for biapical deformities of the femur.

RESUMO O tratamento das deformidades femorais biapicais é desafiador. Para a correção das deformidades metafisárias e diafisárias concomitantes do fêmur, os autores propõem uma osteotomia dupla femoral controlada com uma fixação interna combinada com uma placa de Puddu e uma haste intramedular. O método foi demonstrado em dois pacientes. Os resultados foram analisados com escala visual analógica (EVA) e os escores Lysholm e SF-36. Não foram encontradas complicações. A consolidação total das osteotomias e a correção do alinhamento radiográfico foram alcançadas. Os resultados foram obtidos com um seguimento mínimo de 66 meses. Ambos os pacientes apresentaram melhoria na dor (EVA de 60 a 40 e de 50 para 20), função (Lysholm de 78 a 93 e 55 a 73) e qualidade de vida (SF36, ambos mentais - de 40,7 a 57,1 no caso um e 24,7 a 59,7 no caso dois - e físico - de 27,7 para 45,6 e de 28,2 para 46,8). Os autores concluíram que essa técnica é uma solução confiável, precisa e reprodutível para deformidades biapicais do fêmur.

Mixed-type femoroacetabular impingement associated with subspine impingement: recognizing the trifocal femoropelvic impingement / Impacto femoroacetabular misto associado a impacto subespinhal: reconhecimento do impacto femoropelvico trifocal

ABSTRACT To describe the arthroscopic surgical technique for subspine impingement (SSI) of the anterior inferior iliac spine (AIIS) associated with mixed type femoroacetabular impingement (FAI), through two standard arthroscopic portals (anterolateral and distal mid-anterior) in two patients with trifocal impingement. The authors report the cases of two young male patients, aged 32 and 36 years old, with trifocal femoropelvic impingement (TFPI). The technique consists of segmental capsulectomy, arthroscopic dissection of the AIIS, partial release of the direct head of the rectus femoris, resection of the AIIS projection with a burr and with fluoroscopic aid, correction of the pincer deformity, repair of the labrum with bioabsorbable anchors, and femoral osteoplasty. Details of the diagnostic workup and of the surgical technique are provided and discussed. In these cases, full range of motion was regained after surgery, as well as complete relief of pain, which was sustained in the last follow-up, one year post-operatively. Radiographs show adequate correction of the deformities in all three impingement sites. Simultaneous correction of the three sites (cam, pincer, and subspinal) provided full relief of symptoms and allowed return to work and sports. The authors propose that when approaching the symptomatic SSI, the possibility of concomitant FAI should always be considered and, in those cases, the approach must be comprehensive.

RESUMO O objetivo deste trabalho foi descrever a abordagem cirúrgica artroscópica do impacto subespinhal (ISE) da espinha ilíaca anteroinferior (EIAI) associado ao impacto femoroacetabular (IFA) misto, por meio de dois portais artroscópicos padrão (anterolateral e medioanterior distal) em pacientes com impacto trifocal. Os autores relatam os casos de dois pacientes do sexo masculino, de 32 e 36 anos, com impacto femoropelvico trifocal (IFPT). A técnica consiste na ressecção segmentar da cápsula, dissecção artroscópica da EIAI com liberação parcial do reto femoral, osteoplastia com ressecção da proeminência com lâmina óssea e auxílio radioscópico, correção do pincer, reparo da lesão condrolabial com âncoras e osteoplastia femoral. Detalhes sobre o diagnóstico e a técnica são apresentados e discutidos. Nos casos operados, foi observada recuperação do arco de movimento normal do quadril e ausência de dor, que se mantiveram por um ano pós-operatório. Radiografias demonstram boa correção dos três focos de impacto em ambos os pacientes. A simultânea correção do IFPT nos seus três componentes (came, pincer e subespinhal) promoveu alívio completo dos sintomas e o retorno ao trabalho e aos esportes. Propõe-se que, na abordagem do ISE sintomático, sempre seja considerada a possibilidade da presença de IFA associado; nesses casos, a abordagem deve ser completa.

Artroplastia total de rodilla en genu valgo severo: Seguimiento de 5 a 14 años / Total knee arthroplasty in severe genu valgum. Five to 14 years follow-up

Introducción: El deseje en valgo es una deformidad compleja, con alteracion osea y de partes blandas. Se han descrito numerosas tecnicas quirurgicas que detallan la secuencia de liberacion de las estructuras posterolaterales y la necesidad de utilizar implantes constrenidos. El reemplazo total de rodilla para el genu valgo es un desafio para el ortopedista. Los objetivos fueron evaluar nuestros resultados en el tratamiento quirurgico del genu valgo severo y detallar la tecnica quirurgica empleada. Materiales y Métodos: Se establecio una clasificacion clinico-radiologica y se discriminaron los casos con genu valgo severo. Se evaluaron 42 reemplazos totales de rodilla en 39 pacientes (seguimiento promedio 9.2 anos). Se utilizo el Knee Society Score como parametro de evaluacion clinica. Para la evaluacion radiografica, se conto con la radiografia de mejor calidad del ultimo control. El analisis de supervivencia contemplo la necesidad de revision por cualquier causa y por falla mecanica. Resultados: El Knee Society Score fue, en promedio, de 83,3, con franca mejoria en los parametros dolor y rango de movilidad. Se utilizaron implantes constrenidos en el 16,7% de los casos. El angulo posoperatorio promedio fue de 5,9°. Hubo dos revisiones, con una supervivencia protesica por falla mecanica del 97,6%. No hubo revisiones por causa infecciosa. Conclusiones: Se requiere de un minucioso examen fisico y radiografias preoperatorias. La decision de utilizar implante constrenido se toma durante la cirugia. Es importante la apropiada liberacion de partes blandas. Al margen de la tecnica quirurgica empleada, el requerimiento de protesis constrenida es bajo. Recomendamos nuestra tecnica, pues se trata de un procedimiento poco demandante con resultados alentadores a mediano y largo plazo. Nivel de Evidencia: IV

Introduction: Valgus malalignment is a complex, multiplanar deformity characterized by bone alterations and soft-tissue abnormalities. Several surgical techniques have been described for valgus knee, and the sequence of tight lateral structure release and the need of constrained prosthesis were addressed. Total knee arthroplasty in valgus deformity remains a surgical challenge for orthopaedic surgeons. The objectives of the study were to evaluate our mid- and long-term results in the surgical treatment of severe valgus disease, and to describe the applied surgical technique. Methods: A clinical-radiological classification was developed, and patients treated for severe genu valgum were discriminated. We retrospectively evaluated 42 total knee arthroplasties in 39 patients, with an average follow-up of 9.2 years. Knee Society Score was used for clinical evaluation, and the last control best quality radiograph was considered for radiographic evaluation. Survival analysis contemplated the need for revision for any reason and for mechanical failure. Results: Postoperative average Knee Society Score was 83.3, with marked improvement in pain and range of motion parameters. Constrained implants were used in 16.7% of cases. Postoperative alignment was on average 5.9°. Two patients underwent revision surgery, having achieved a prosthetic survival for mechanical failure of 97.6%. We did not have any revision due to infection. Conclusions: A meticulous physical examination and proper preoperative radiographs are mandatory. The decision to use a constrained device is taken during surgery. Appropriate soft-tissue release is extremely important. Despite the surgical technique, the use of a constrained prosthesis is limited. We recommend our technique as a low-demanding procedure, with encouraging mid- and long-term results. Level of Evidence: IV

Radiologic Outcomes According to Varus Deformity in Minimally Invasive Surgery Total Knee Arthroplasty

PURPOSE: To identify the accuracy of postoperative implant alignment in minimally invasive surgery total knee arthroplasty (MIS-TKA), based on the degree of varus deformity. MATERIALS AND METHODS: The research examined 627 cases of MIS-TKA from November 2005 to December 2007. The cases were categorized according to the preoperative degree of varus deformity in the knee joint in order to compare the postoperative alignment of the implant: less than 5degrees varus (Group 1, 351 cases), 5degrees to less than 10degrees varus (Group 2, 189 cases), 10degrees to less than 15degrees varus (Group 3, 59 cases), and 15degrees varus or more (Group 4, 28 cases). RESULTS: On average, the alignment of the tibial implant was 0.2+/-1.4degrees, 0.1+/-1.3degrees, 0.1+/-1.6degrees, and 0.3+/-1.7degrees varus, and the tibiofemoral alignment was 5.2+/-1.9degrees, 4.7+/-1.9degrees, 4.9+/-1.9degrees, and 5.1+/-2.0degrees valgus for Groups 1, 2, 3, and 4, respectively, in the preoperative stage, indicating no difference between the groups (p>0.05). With respect to the accuracy of the tibial implant alignment, 98.1%, 97.6%, 87.5%, and 86.7% of Groups 1, 2, 3, and 4, respectively, had 0+/-3degrees varus angulation, demonstrating a reduced level of accuracy in Groups 3 and 4 (p0.05). CONCLUSION: Satisfactory component alignment was achieved in minimally invasive surgery in total knee arthroplasty, regardless of the degree of varus deformity.

Posttraumatic progressive cubitus varus deformity managed by lateral column shortening: A novel surgical technique / 中华创伤杂志(英文版)

The outward angulation of elbow with supinated forearm is cubitus varus deformity. This deformity is often seen as sequelae of malunited supracondylar fracture of humerus in paediatric age group of 5e8 years. The deformity is usually non-progressive, but in cases of physeal injury or congenital bony bar formation in the medial condyle of humerus, the deformity is progressive and can be grotesque in appearance. Various types of osteotomies are defined for standard non-progressive cubitus varus deformity, while multiple surgeries are required for progressive deformity until skeletal maturity. In this study we described a novel surgical approach and osteotomy of distal humerus in a 5 years old boy having grotesque progressive cubitus varus deformity, achieving good surgical outcome.

Crecimiento guiado con placas en 8 para corregir deformidades angulares en pacientes esqueléticamente inmaduros / Eight-plate guided growth for angular deformity correction in skeletally inmature patients

La modulación del crecimiento permite corregir deformidades en pacientes esqueléticamente inmaduros. Se propuso el empleo de un nuevo implante con ventajas respecto de sus antecesores. El objetivo del estudio es evaluar los resultados radiográficos y las complicaciones de una serie consecutiva de pacientes tratados con este método. Materiales y Métodos: Se revisaron retrospectivamente las historias clínicas de los pacientes esqueléticamente inmaduros con deformidades angulares sometidos a cirugía de realineación de miembros inferiores (rodilla o tobillo) mediante crecimiento guiado con placas en 8 (eight-plate) entre enero de 2009 y julio de 2013. Se evaluaron los datos demográficos, los cambios radiográficos y la tasa de complicaciones. Todos fueron intervenidos en la misma institución, por tres ortopedistas infantiles. Resultados: Se evaluaron 27 pacientes (47 fisis), 12 niños y 15 niñas. Se trataron 38 deformidades en valgo y nueve en varo. De las 47 fisis tratadas, 33 fueron en fémur distal; 12, en tibia proximal y dos, en tibia distal. La edad promedio al momento del procedimiento fue de 11.8 ± 1.36 años (rango 8-14). El tiempo promedio entre la colocación y el retiro fue de 10.6 ± 3 meses (rango 7-26). En todos los pacientes, menos en uno, se lograron ángulos de medición normales en relación con el eje mecánico de carga. Hubo seis complicaciones posoperatorias, dos requirieron una nueva intervención (un efecto rebote y una migración del implante). Conclusión: El empleo de placas en 8 para corregir deformidades angulares en pacientes esqueléticamente inmaduros es un método eficaz con una baja tasa de complicaciones. Nivel de Evidencia: IV...

Growth modulation allows correction of deformities in skeletally immature patients. A new implant (eightplate) that presents some advantages compared to its predecessors has been proposed. The aim of this study is to evaluate the radiographic results and complication rate in a consecutive series of patients treated with this method. Methods: The medical records of skeletally immature patients operated on to correct angular deformities of the lower extremities with eigth-plate guided growth between January 2009 and July 2013 were retrospectively reviewed. Demographics, radiographic angular deformity correction and complication rate were evaluated. Results: Twenty seven patients (12 boys and 15 girls; 47 physes) were evaluated. Thirty eight valgus deformities and nine varus deformities were treated. Of 47 physis, 33 were in the distal femur, 12 in the proximal tibia and 2 in the distal tibia. Age at the time of surgery averaged 11.8 ± 1.36 years (range 8-14). The average time between placement and removal of the implant was 10.6 ± 3 months (range 7-26). All patients except one achieved complete correction of the deformity. There were 6 postoperative complications, and two required reintervention (a rebound and one implant migration). Conclusion: The use of plates in 8 for correction of angular deformities in skeletally immature patients is an effective method with a low complication rate. Level of Evidence: IV...

Comparison of early clinical outcomes between mobile-bearing and fixed-bearing total knee arthroplasty for the valgus knee / 中国骨伤

<p><b>OBJECTIVE</b>To compare the early clinical outcomes of primary total knee arthroplasty in the valgus knee between mobile-bearing prosthesis and fixed-bearing prosthesis.</p><p><b>METHODS</b>From January 2011 to December 2013, 17 patients (23 knees) treated by the same surgeon were selected for a retrospective study in the First Hospital of Jilin University, including 2 males and 15 females with a mean age of 61.5 years old (48 to 75 years). The pre-operative diagnosis included osteoarthritis (14 patients, 19 knees) and rheumatoid arthritis (3 patients, 4 knees). The patients with valgus deformity were divided into group A and group B. The patients in group A were treated with the fixed-bearing prosthesis (9 patients, 12 knees), and the patients in group B were treated with the mobile-bearing prosthesis (8 patients, 11 knees). The Knee Society Score (KSS), Hosptial for Special Surgery (HSS), Western Ontario MacMaster (WOMAC), the range of motion (ROM) and femorotibial angle were collected at pre-operation and post-operation follow-up for statistical analysis.</p><p><b>RESULTS</b>All the patients were followed up, and the duration ranged from 6 to 36 months (mean 25 months). The valgus deformity was corrected in all patients, and there were significant differences for all patients between pre-operation and post-operation at the latest follow-up with regard to the KSS knee score, function score, HSS score, WOMAC score, ROM and femorotibial angle (P<0.01). There were no significant differences in KSS knee score, function score, HSS score, WOMAC score, improvement in ROM and femorotibial angle between two groups at the latest follow-up. However there were significant differences in ROM (P<0.05) between fixed-bearing group (101.8±8.8)° and mobile-bearing group (108.4±7.2)° at the latest follow-up. No case with spin-out of mobile bearing was observed. There were no complications in any patient, such as infection, common peroneal nerve injury, dislocation and instability. The X-ary imaging showed no osteolysis or implant loosening.</p><p><b>CONCLUSION</b>The early clinical outcomes of primary total knee arthroplasty by using mobile-bearing prosthesis and fixed-bearing prosthesis are satisfactory for the treatment of the valgus knee, and the short term clinical outcomes of mobile-bearing TKA and fixed-bearing TKA are similar.</p>

Osteotomía de apertura anterior de tibia bilateral en recurvatum de rodilla: a propósito de un caso / Anterior tibial osteotomy in bilateral knee recurvatum. Case report

En los recurvatum de rodilla, existen varios métodos de corrección, la osteotomía descripta por Brett y Lexer E. modificada es una opción para su tratamiento. El objetivo de este trabajo es describir la técnica como una solución para los recurvatum de rodilla tibiales y mostrar la evolución de un caso clínico. El paciente presentaba un recurvatum bilateral de rodilla de origen tibial idiopático, con valores angulares de 26 grados a derecha y 20 grados a izquierda de ángulo diafiso-epifisario. Con el objetivo de corregir la deformación para calmar el dolor de características mecánicas por sobrecarga articular y evitar la pérdida del equilibrio articular, se decidió realizar esta técnica. Las cirugías fueron realizadas comenzando con la derecha y un año y medio después la rodilla izquierda. Para la rodilla derecha se logró corregir la deformidad llevando el platillo tibial de 26° de inclinación anterior a 6°. En cuanto a la rodilla izquierda de 20° se corrigió a 0°. Resulta una técnica reproducible, que soluciona los recurvatum de origen tibial epifiso-metafisarios, que no altera la biomecánica del aparato extensor como otras osteotomías. Esta técnica no permite corregir las deformidades diafisarias. Creemos que es una de las mejores opciones para la corrección del recurvatum, que a pesar de no lograr corrección total de la alteración ósea, mejora la función de la rodilla y la sintomatología, sin alterar la mecánica del aparato extensor.

In the knee recurvatum, there are several methods of correction osteotomy, the modified Brett and Lexer E. osteotomy is an option for this type of pathology. The aim of this paper is to describe the technique as a solution to the tibial recurvatum and show the outcome of a case. The patient had a bilateral tibial idiopathic knee recurvatum, with angular values of 26 degrees right and 20 degrees left of diafiso-epiphyseal angle. In order to correct the deformation and release pain secondary to mechanical overload and prevent loss of articular balance, we decided to perform this technique. The surgeries were performed first the right and a year and a half after his left knee. His right knee, we managed to correct the tibial plateau deformity from 26° of anterior tilt, to 6°. As for the left knee was corrected from 20° to 0°. It is a reproducible technique that solves tibial epiphyseal-metaphyseal origin recurvatum, which does not alter the biomechanics of the extensor mechanism as other osteotomies. This technique does not allow correction of diaphyseal deformities. We believe it is one of the best options for the correction of recurvatum, which despite not achieveing full correction of bone alteration improves knee function and symptoms without altering the extensor mechanism.

Total knee arthroplasty for severe valgus knee deformity / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Primary total knee arthroplasty (TKA) in severe valgus knees may prove challenging, and choice of implant depends on the severity of the valgus deformity and the extent of soft-tissue release. The purpose of this study was to review 8 to 11 years (mean, 10 years) follow-up results of primary TKA for varient-III valgus knee deformity with use of different type implants.</p><p><b>METHODS</b>Between January 2002 and January 2005, 20 women and 12 men, aged 47 to 63 (mean, 57.19 ± 6.08) years old, with varient-III valgus knees underwent primary TKA. Of the 32 patients, 37 knees had varient-III deformities. Pie crusting was carefully performed with small, multiple inside-out incisions, bone resection balanced the knee in lieu of soft tissue releases that were not used in the series. Cruciate-retaining knees (Gemini MKII, Link Company, Germany) were used in 13 knees, Genesis II (Simth & Nephew Company, USA) in 14 knees, and hinged knee (Endo-Model Company, Germany) in 10 knees. In five patients with bilateral variant-III TKAs, three patients underwent 1-stage bilateral procedures, and two underwent 2-stage procedures. All implants were cemented and the patella was not resurfaced. The Hospital for Special Surgery (HSS) knee score was assessed. Patients were followed up from 8 to 11 years.</p><p><b>RESULTS</b>The mean HSS knee score were improved from 50.33 ± 11.60 to 90.06 ± 3.07 (P < 0.001). The mean tibiofemoral alignment were improved from valgus 32.72° ± 9.68° pre-operation to 4.89° ± 0.90° post-operation (P < 0.001). The mean range of motion were improved from 93.72° ± 23.69° pre-operation to 116.61 ± 16.29° post-operation (P < 0.001). No patients underwent revision. One patient underwent open reduction and internal fixation using femoral condylar plates for supracondylar femoral fractures secondary to a fall at three years. Three patients developed transient peroneal nerve palsies, which resolved within nine months. Two patients developed symptomatic deep vein thrombosis that was managed with rivaroxaban and thrombo-embolic deterrent stockings. There was no incidence of pulmonary embolism. Post-operative patient satisfaction was 80.7 ± 10.4 points in the groups. Prosthetic survival rate was 100% at mean 10 years postoperative.</p><p><b>CONCLUSIONS</b>Not only hinged implants can be successfully used in variant-III valgus knees. As our results show, if proper ligament balancing techniques are used and proper ligament balance is attained, the knee may not require the use of a more constrained components. Our results also present alternative implant choices for severe knee deformities.</p>

Case-control study on the occurrence of cubitus varus deformity after humeral supracondylar fractures treated with plaster fixation in pronated or supinated position in children / 中国骨伤

<p><b>OBJECTIVE</b>To retrospectively compare the occurrence of cubitus varus deformity after humeral supracondylar fractures treated with manipulative reduction and plaster fixation in pronated or supinated position in children, and to guide clinical treatment.</p><p><b>METHODS</b>From June 2009 to December 2011, the medical data of 64 children with humeral supracondylar fractures treated by manipulative reduction and plaster fixation were reviewed. All the patients were divided into two groups: group A and group B. The 30 patients in group A were treated with manipulative reduction and plaster fixation in pronation, including 18 males and 12 females, with a mean age of (7.5 ± 3.5) years old. The 34 patients in group B were treated with manipulative reduction and plaster fixation in supination, including 23 males and 11 females, with a mean age of (7.0 ± 2.6) years old. The occurrence rates of cubitus varus and decreases of carrying angle were compared between two groups before and after treatment.</p><p><b>RESULTS</b>There were 13 patients in group A and 16 patients in group B having cubitus varus,which had no statistical difference (χ2 = 0.089, P = 0.765). The decrease of carrying angle were (8 ± 4) degrees in group A and (9 ± 5) degrees in group B, which had no statistical difference (t = 0.584, P = 0.564). Within group A, the occurrence rate of cubitus varus and the decrease of carrying angle between the radial deviation and the ulnar deviation had statistically significant difference (χ2 = 6.160, P = 0.013; t = - 2.409, P = 0.035). Within group B, the occurrence rate of cubitus varus and the decrease of carrying angle between the radial deviation and the ulnar deviation had statistically significant difference (χ2 = 5.120, P = 0.024; t = -2.250, P = 0.041). The elbow function Flynn evaluation score had no significant difference between two groups (P = -0.822).</p><p><b>CONCLUSION</b>The occurrence rate of cybutys varys and the decrease of carrying angle have no obvious difference in children with humeral supracondylar fractures treated with fixation in pronated or supinated position. However, when treating with pediatrics humerus supracondylar fractures with ulnar deviation, the fixation in pronation is more helpful for reducing the occurrence rate of elbow varus and decrease of carrying angle. When treating with the pediatrics humerus supracondylar fractures with radial deviation, fixation in supination is helpful for reducing the occurrence rate of elbow varus and decrease of carrying angle.</p>

Microartroplastía de superficie y osteotomía tibial de apertura simultánea / Simultaneous resurfacing arthroplasty with open high tibial osteotomy

El compromiso degenerativo articular de la rodilla caracterizado por exposición de hueso subcondral, en pacientes jóvenes y de mediana edad con expectativa de actividad recreacional, es actualmente un desafío para el especialista. Ante el fracaso del tratamiento médico, la indicación terapéutica debe ser fundamentada en el análisis de una serie de factores, destacando las expectativas del paciente: sintomatología dominante, alineación, estabilidad y área lesional. Se presenta un caso de procedimiento reconstructivo de indicación excepcional sobre el cual no se ha hallado referencia publicada. El procedimiento consistió en asociar: a) Reemplazo segmentario de superficie con Arthrosurface NR (“Artroplastia focal de superficie”) con b) Osteotomía de apertura tibial en el mismo acto quirúrgico. Se describe la metodología aplicada para la decisión terapéutica consistente en un análisis sistemático multifactorial.

Lower-limb valgus deformity associated with developmental hip dysplasia / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Treating developmental dysplasia of the hip is often challenging. The difficulties include not only the hip surgery itself but also the treatment of the associated lower-limb valgus deformity. However, there have been very few studies on such deformity in patients with developmental hip dysplasia. In this study, we investigated the prevalence and severity of lower-limb valgus deformity, along with the relationship between the severity of valgus deformity and mechanical alterations of the hip or the ipsilateral knee.</p><p><b>METHODS</b>Two hundred and six affected lower limbs of 116 adult patients with untreated developmental dysplasia of the hip were included in the study, grouped according to the severity of hip dysplasia. Each study participant's radiographs were measured to quantitatively evaluate the mechanical axis deviation of the lower limb, and further to evaluate the prevalence and severity of the lower-limb valgus deformity. Some mechanical alterations of the hip and the ipsilateral knee were also measured on the radiographs.</p><p><b>RESULTS</b>Of the affected lower limbs, 14.1% had valgus deformities. Study participants with Crowe type III hip dysplasia had the most severe deformity and the highest prevalence of deformity. Severity of valgus deformity had a strong positive correlation with the lateral migration of the femoral head but not with the superior migration. A decreased lateral distal femoral angle contributed to the lower-limb valgus deformity, and the lateral distal femoral angle had a strong negative correlation with the severity of valgus deformity.</p><p><b>CONCLUSIONS</b>Hip dysplasia is commonly associated with lower-limb valgus deformity, and the severity of the lower-limb valgus deformity is mostly affected by lateral migration but not superior migration of the femoral head. The valgus deformity may originate mainly in the distal femur, in addition to the hip joint itself. These findings can be taken into account when planning to treat the patients with hip dysplasia.</p>

Fractura de espina tibial con fisis abierta. Deformidad tibial secundario en varum-recurvatum / Spine tibial fractures with open physis

Las complicaciones descriptas en relación al tratamiento quirúrgico de las fracturas de espinas tibial son: déficit de extensión y artrofibrosis, laxitud ligamentaria (por elongación de fibras del LCA en el momento de la lesión o reducción insuficiente) y compromiso fisario vinculable con la instrumentación, para la osteosíntesis en pacientes con cartílagos abiertos. Se presenta un caso de una paciente de 17 años con secuela de trauma fisario tibial izquierdo por fractura de espina tibial tratado en forma quirúrgica a sus 9 años, utilizando para su fijación un tornillo cortical de 4 mm transfisario. Consulta por deformidad varo-recurvatum. Se realizó osteotomía de apertura tibial proximal y anterior. Estabilización con placa de Puddu (Arthrex NR) y relleno del foco con aloinjerto corticoesponjoso congelado no irradiado.