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.

Femoral supracondylar osteotomy for the treatment of valgus knee osteoarthritis in young and middle-aged patients / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the clinical efficacy of open supracondylar osteotomy of the femoral condyle for the treatment of valgus knee osteoarthritis.</p><p><b>METHODS</b>From April 2008 to June 2015, 21 patients with valgus knee osteoarthritis underwent an open wedge femoral supracondylar osteotomy using the distal femur dissection plates combined with autologous iliac bone graft for the bone defect. There were 8 males (8 knees) and 13 females (15 knees), ranging in age from 30 to 54 years old, with a mean age of 41.2 years old. All the patients had valgus deformity and knee joint pain in the lateral compartment. The average tibiofemoral angle was (162.0±2.6)° which was measured on the image of preoperative lower extremity weight-bearing X-ray. Clinical outcomes were comprehensively assessed according to the bone healing time, postoperative complications, progress of knee osteoarthritis after operation, the Hospital for Special Surgery rating system (HSS), and tibiofemoral angle before and after operation.</p><p><b>RESULTS</b>All 21 patients were followed up, the valgus deformity of knee joint was corrected in all patients after operation. No obvious delayed union or nonunion were found, and no serious complications were found. The HSS knee score was improved from the preoperative 57.3±3.1 to the final follow-up time 88.6±2.7. Tibiofemoral angle was improved to the postoperative(176.0±1.4)°.</p><p><b>CONCLUSIONS</b>Open wedge femoral supracondylar osteotomy has a clear surgical approach, and it is easy to control the bone mass of osteotomy and can effectively correct the valgus deformity and improve the function of knee joint using this method. It is an effective method for the treatment of valgus knee osteoarthritis in young and middle-aged patients.</p>

A Combined Closing Wedge Distal Femoral Osteotomy and Medial Reefing Procedure for Recurrent Patellar Dislocation with Genu Valgum

PURPOSE: Recurrent patellar dislocation is often associated with genu valgum. The purpose of this study was to analyze the short-term results of single-incision, closing-wedge distal femoral osteotomy (CWDFO) combined with medial reefing and lateral release for recurrent patellar instability with genu valgum. MATERIALS AND METHODS: Combined CWDFO/medial reefing/lateral release was performed on 10 knees. Clinical evaluation was based on pre- and postoperative Knee Society Score (KSS) and Kujala patellofemoral score. Radiographic evaluation was performed with reference to the weight-bearing line (WBL), the femorotibial angle (FTA), and the mechanical lateral distal femoral angles in the knee-standing view. RESULTS: At a mean follow-up of 20±11.7 months (range, 12–42 months), KSS scores improved significantly, from 46.7±5.2 preoperatively to 87±4.4 postoperatively (p<0.001), as did the Kujala score, from 44±8 preoperatively to 86.6±6.8 postoperatively (p<0.001). The WBL decreased significantly, from 76±7% preoperatively to 41±11% postoperatively (p<0.001). The FTA was improved significantly, from 12.7±1.7° preoperatively to 4±4° postoperatively (p<0.001), as was the mLDFA, from 83±4° preoperatively to 91±1.3° postoperatively (p<0.001). CONCLUSION: Use of single-incision CWDFO combined with medial reefing and lateral release prevents patellar dislocation, corrects deformity, and improves clinical outcomes.

Prótesis de superficie de cadera en presencia de osteosíntesis femoral proximal / Hip resurfacing in the presence of proximal femoral osteotomy

Describimos un caso de reemplazo de superficie de cadera en un paciente con artrosis posterior a necrosis ósea avascular y material de osteosíntesis femoral proximal de difícil extracción. Con las prótesis de superficie se logran buenos resultados si la indicación y la técnica quirúrgica son las correctas. En este caso, facilitó mucho la artroplastia, con un muy buen resultado funcional; se evita una cirugía con mayor morbilidad y una tasa más alta de complicaciones y revisiones, como ocurre con los reemplazos de cadera convencionales tras el retiro de la osteosíntesis proximal de fémur. Los cirujanos de cadera atendemos a estos pacientes con frecuencia; estamos seguros de que este tipo de cirugías debe incluirse en nuestro arsenal terapéutico. A pesar de las desventajas de esta artroplastia (fricción metal/metal, curva de aprendizaje, fracturas del cuello femoral), consideramos que, en estos casos, dichas complicaciones están compensadas por la simplicidad del procedimiento.

We describe a hip resurfacing case in a patient with arthrosis after avascular necrosis and proximal femoral osteosynthesis material difficult to remove. Hip resurfacing achieves good results when its indication and technique are correct. In this case, it facilitated the arthroplasty achieving an excellent functional result; avoiding a major surgery and the high rate of complications and revisions, as it occurs with conventional hip replacements after osteosynthesis of the proximal femur. Surgeons frequently face this type of patients; therefore we are convinced that this procedure must be in our therapeutic arsenal. Besides the disadvantages of this arthroplasty (metal on metal friction, learning curve, neck fracture) we consider that they are compensated for by the simplicity of the procedure.

Surgical Treatment of Habitual Patella Dislocation with Genu Valgum

Habitual dislocation of patella is a rare disorder. Sometimes it is associated with angular deformity such as genu valgum. We experienced habitual patella dislocation associated with genu valgum that was treated with corrective osteotomy of distal femur and soft tissue realignment procedure including lateral release and medial reefing.

Femoral Osteotomy and Rehabilitation for Osteoarthritis of the Hip / The Japanese Journal of Rehabilitation Medicine

In Japan, most of the osteoarthritis of the hip is secondary due to congenital dislocation of the hip or acetabular dysplasia. Total hip arthroplasty is generally performed as the operative method for treating hip osteoarthritis, but conservative operative methods are recommended for younger patients. Joint congruity is judged good for the hip joint in which the joint surface of the femoral head is parallel to the acetabular joint surface. In the case of an incongruent hip joint, the load concentrates and becomes larger per unit area of the joint. Joint incongruence is found in the early or advanced stage of the hip osteoarthritis. The femoral osteotomy should be performed when joint congruity is improved in the hip abduction or adduction position. Walking exercise begins 2 or 3 days postoperatively, and passive motion exercise is performed as soon as possible. Weight bearing on the operated hip should be limited for the protection of the joint cartilage. In the case of preserving joint space preoperatively, walking with a single crutch is allowed 2 or 3 months after the operation. If there was no or only a narrow joint space before the operation, it is recommended that two crutches be retained for 6 months and that one crutch then be used for another 6 months. Good results in clinical and radiological findings are maintained in 80% or more 10 years after the operation.

Periacetabular Osteotomy in Hip Dysplasia with Deformed Femoral Head / 대한정형외과학회잡지

PURPOSE: To evaluate the results of a periacetabular osteotomy (PAO) combined with a femoral osteotomy (FO) for a dysplastic hip with a deformed femoral head. MATERIALS AND METHODS: Thirteen hips with dysplasia and a deformed femoral head were followed up for more than 12 months. Eight hips were in the PAO group and 5 hips were in the PAO and FO group. The two groups were compared clinically according to the HHS (Harris hip score), pain and limping VAS (visual analogue scale), and radiologically according to the CEA (central edge angle of Wiberg), Tonnis angle (acetabular index of weight bearing surface), FHC (femoral head coverage), AA (acetabular angle of Sharp), DBSPFH (distance between symphysis pubis and femoral head) and AI (acetabular index of depth to width). RESULTS: Regarding the clinical results, the PAO group showed improvement in the HHS from 66.5 preoperatively to 90.4 postoperatively (p=0.01) and the pain VAS from 6.7 to 1.9 (p=0.01). However, there was no significant improvement in limping (p=0.39). In the PAO with FO group, the HHS was improved from 78 to 91 (p=0.04). Radiologically, the CEA, Tonnis angle, FHC, AA and AI improved significantly but there were no significant improvement in the DBSPFH in the two groups. In addition, there was no significant clinical or radiological difference between the two groups. CONCLUSION: Periacetabular osteotomy is recommended for dysplastic hips with deformed femoral head. A concomitant femoral osteotomy should be considered in hips with a severely deformed femoral head.

Treatment of flexion deformity of the knee joint in adult patients with supracondylar femoral osteotomy and internal fixation / 中国矫形外科杂志

[Objective] To investigate the results and to evaluate the validity of the supracondylar femoral osteotomy and internal fixation for treatment of flexion deformity of the knee joint in adult polio patients.[Methods]From April 2002 to August 2008,141 knees in 127 cases with flexion deformity of knee from poliomyelitis were treated with supracondylar femoral extension osteotomy and internal fixation.They were 14~45 years old with an average of 18.3.Of them,62 knees in 56 cases were male,79 knees in 71 cases were female.Eighty-three cases needed pressing knee on walking.Thirty-five cases walked with a crutch and 9 cases walked with two crutches.It should be treated with soft tissue release and skeletal traction before osteotomy in severe flexion deformity(over 40 degrees).All cases took weight-bearing X-ray films of lower extremities before and after operation.Angle of knee flexion,operative complications,bone healing and final function were recorded.Patients can undertake continuous passive flexion and extension motion from the 2nd day postoperatively.The knee operated was put in 10~20? flexion after operation and extended to full extension gradually in 2 weeks.[Results]All patients felt comfortable after operation and no neurovscular complications and infection happened.Follow-up time was 12-72 months with an average of 18 months.Solid bone union showed in all femoral cutting ends.No mal-union,non-union and implant failure happened.All flexion deformities of knees were corrected.The angle of flexion contracture of knee was from 36.4?(18?～61?)preoperatively to 2.8?(-5?～8?)postoperatively.The amount of correction was 18?to 56?with an average of 32.9?.One hundred and eight patients can walk stably by hinself or with brace,19 cases still need some help for walking(pressing knee in 6 case,one crutch in 10 cases and two crutches in 3 cases)at last follow-up.No ankylosis of knee joint or peroneal nerve paralysis occurred.All cases were satisfying with their range of motion of knee.[Conclusion]Supracondylar femoral osteotomy and rigid internal fixation and early rehabilitation exercise is a safe and effective strategy for the adult flexion deformity of knee joint.

Valgus-Flexion Osteotomy of the Proximal Femur in Childhood Hip Diseases / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical and radiological results of valgus-flexion femoral osteotomy (VFFO) in childhood hip diseases. MATERIALS AND METHODS: A VFFO was performed in 15 cases of childhood hip disorders with femoral head deformity: LCP disease (8); chronic SCFE (3); AVN after DDH (2), septic hip (1), femur neck fracture (1). Clinically, we evaluated the pre-and postoperative range of motion (ROM), pain, leg length discrepancy, and limping. Radiological evaluation included the neck-shaft angle, status of the osteotomy site and congruency of the femoral head with the acetabulum. Posterior displacement of femoral epiphysis was also evaluated in SCFE. RESULTS: An average 20.7degrees valgus and 23.0degrees, flexion osteotomy were performed. The average neck-shaft angle changed from 125.9degrees to 146.6degrees, The averaged ROM of the hip joint increased by 16.2degrees (flexion), 17.9degrees (abduction), 16.4degrees (adduction), 26.7degrees (internal rotation), and 15degrees (external rotation). Limitation of motion was greatly improved and the hip joint pain decreased. CONCLUSION: A VFFO of the proximal femur cannot only eliminate pain by making the best joint congruity, but can also help with the remodeling of a deformed femoral head. Moreover, an increased ROM can make a so-called "Yangban-Dali" possible, which makes daily activity as a Korean more comfortable.

Total Hip Replacement in Unreduced Hip Dislocation / 대한정형외과학회잡지

Total hip arthroplasty in patients with chronically dislocated hips poses many challenging technical problems. Abnormal relationship of bones and soft tissues occurs in chronic complete dislocation of the hip (grade IV, Crowe's classification). Problems in placing the acetabular component in the true acetabulum include, first how to cover the acetabular component sufficiently, second how to fix it securely and last how to avoid excessive stretching of the neurovascular structures such as the sciatic nerve. The authors have introduced a technique of one stage distal femoral shortening in order to avoid excessive stretching of the neurovascular structures. From December 1988 to May 1996, the total hip arthroplasties combined with one stage distal femoral shortening were carried out in chronic complete dislocation of 44 hips (grade IV, Crowe's classification) and followed-up more than two years. This method has several advantages: It preserves wide and healthy proximal metaphysis of the femur, does not need greater trochanteric osteotomy, and provides many chances to choose the appropriate stem size and shape, especially in cementless total hip arthroplasty.

Supracondylar Extension osteotomy for Knee Flexion Contracture by the Ilizarov Technique / 대한정형외과학회잡지

In patients with the sequele of poliomyelitis, pyogenic or tuberculous arthritis, or trauma, flexion contracture of the knee could be developed and many difficult problems would be met in treating them. Ilizarov suggested the method of gradual correction of deformities of bone after corticotomy-osteo- clasis, combined with gradual elongation of the shortened soft tissues, and the flexion contracture of knee & limb length discrepancy could be corrected simultaneously or sequentially following a sigle operative procedure. The authors have treated 25 patients with flexion contracture of the knee joint by the principle of Ilizarov treatment at the Sang Gye Paik Hospital between September 1991 and March 1994, The average preoperative flexion contracture of the knee joint, 25° (range, 10°

Comparative Study on the Results of Femoral Osteotomy and Innominate Osteotomy in LCPD / 대한정형외과학회잡지

Methods of treatment of Legg-Calve-Perthes' disease, (L.C.P.D.) are at present generally defined, and the individual approach is now more precise than before. But it is still controversial, particularly in older age groups. We analized the result of intertrochanteric varus osteotomy in 44 hips and innominate osteotomy in 23 hips of L.C.P.D., and compared the former with the later. To find out the influence of the both osteotomies on the femoral head (coxa magna), the relations between the stage and degree of involvement at operation and reult, and the postoperative progression of disease, the cases were analyzed and classified by Elizabethtown's stage and Catterall group. And also the duration of fragmentation stage after osteotomy was observed. Results were as follows: l. At the time of operation 45 hips were in avascular stage, 18 hips in fragmentation stage, and 4 hips in healing stage. 20 hips(29.8%) were classified as group II, 29(43. 3%) group III, and 18(23.1%) group IV. 2. After the osteotmy in case of avasculsr necrosis stage, average duration of fragmentation stage was 6.3 months after femoral osteotomy and 1 year 6 months after innominate osteotomy. 12 among 20 hips were skipped the fragmentation stage, and got into healing stage in case of femoral osteotomy. 3. After the osteotomy at the fragmentation stage, average duration of the fragmentation stage was 9.8 months after femoral osteotomy and 1 year 3 months in case of innominate osteotomy. 4. Regardless of the type of osteotomy, coxa magna was observed more frequently in the case who had surgery at the late stage and severely involoved head at the time of osteotomy. 5. In the case of femoral osteotomy, average preoperative neck shaft angle was 138.5°, and postoperative one was 113.5°. During the follow-up study, 12.0° of revalgarisation took place. 6. The result obtained by femoral osteotomy gave better results than those by innominate osteotomy. Regardless of the type of osteotomy, good results were obtained in case who had surgery at the early stage such as avascular stage, and had mild involvement as such group II.

The Treatment Selection of Knee Flexion Deformity after Poliomyelitis / 昆明医科大学学报

The 98 cases of knee flexion deformity after poliomyelitis were treated in our department. The treatment selection for diffrent degrees of the flexion deformity are discussed. The flexion less that 20? need plaster cast only. The flexion from 20? to 30? can fully correct with su pracondylar femoral osteotomy. In the flexion more that 30?, the skele(?)al traction into inferior tibia should be done previously, then supracondylar femoral osteotomy carried out to correct the flexion less that 30? siter traction. It is pointed out that the muscle balance operation must be done as soon as the flexion was corrected. The muscle balance operation can prevent from recurrence of the deformity and (?)limilate the factor recurrent.