Outcomes of lateral femoral sliding osteotomy in primary total knee arthroplasty for type two fixed valgus deformity.

PURPOSE: The aim of our study was to determine the surgical outcomes of patients who underwent lateral femoral sliding osteotomy (LFSO) with total knee arthroplasty (TKA) for Ranawat's type 2 fixed valgus deformity. METHODS: The consecutive patients who underwent primary TKA with posterior-stabilized implant and LFSO for fixed valgus deformity were reviewed. The radiological parameters analyzed were pre- and postoperative hip-knee-ankle (HKA) angle and tibio-femoral angle in varus-valgus stress views. The clinical outcome was measured by Oxford knee score (OKS), knee society score (KSS), and functional score (KSS-F). The complications and any reoperation were noted in the follow-up. RESULTS: There were total 28 patients included with an average follow-up time of 47.2 ± 24.9 months. The average arc of motion was 101.3 ± 23.8° preoperatively and 102.7 ± 11.8° postoperatively (p > 0.05). The average deformity in varus and valgus stress views was 196.6 ± 4.8 and 207.8 ± 7.4°, respectively. There was significant improvement in HKA from 205.2 ± 8.3° preoperatively to 181.9 ± 3.7° postoperatively (p < 0.05). At the final follow-up, bony union of the osteotomy fragment was noted in all the patients. There was significant improvement in OKS, KSS, and KSS-F score from a preoperative 15.1 ± 3.9, 35.1 ± 10.6, and 26.6 ± 12.6 to 40.3 ± 2.9, 85.6 ± 4.8, and 89.4 ± 7.7, postoperatively (p < 0.05), respectively. One patient had acute periprosthetic joint infection that was managed with debridement and polyethylene insert exchange. CONCLUSION: Lateral femoral sliding osteotomy is an effective technique for optimal soft tissue balance in fixed valgus deformity. It provides satisfactory clinical outcome with restoration of knee alignment without using the constrained implants.

Tibial bowing and tibial component placement in primary total knee arthroplasty in valgus knees: Are we overlooking?

PURPOSE: Tibial bowing in valgus knees with arthritis can lead to component malplacement during total knee arthroplasty (TKA). Incidence of valgus knees with medial tibial bowing, its effect on tibial component placement during primary TKA and methods to improve accuracy of the component placement were studied. METHODS: Full-length weight-bearing alignment radiograph was taken in 117 patients (149 knees) with valgus deformity undergoing TKA. In these cases, the proximal tibial reference for extramedullary jig placement was planned preoperatively with reference to the tibial spines and classified as four zones. RESULTS: The mean preoperative hip-knee-ankle (HKA) angle was 192.9° (180.3-234.5°). Bowing >3° was considered significant (p < 0.001) and at this level of bowing, the proximal tibial reference was shifted from centre to medial. Tibial bowing <3° was considered straight and >3° as tibia valga. Tibia was bowed in 70 knees (46.97%). Severity of valgus deformity had strong positive correlation with the tibia valga (p < 0.001). The post-operative medial proximal tibial angle (MPTA) and HKA angle were 91.63° (87.9-95.7°) and 182.6° (178.1-189.7°), respectively. The mean MPTA and post-operative HKA angle in bowed and straight tibiae were 90.35° versus 89.78° (p = 0.547) and 181.5° versus 180.7° (p = 0.5716), respectively, and the difference was not statistically significant. CONCLUSION: Medial tibial bowing is very common in valgus knees. Tibia valga has a strong positive correlation with the severity of valgus deformity. Accurate tibial component placement can be achieved with a medialized reference point for extramedullary tibial cutting jig in knees with significant tibia valga. The study has been registered in clinical trials registry - India (CTRI/2018/03/012283).

Improving the accuracy of tibial component placement during total knee replacement in varus knees with tibial bowing: A prospective randomised controlled study.

BACKGROUND: Lateral tibial bowing leads to varus placement of the tibial component during total knee replacement in varus knees. Lateralised tibial jig placement can improve the accuracy of the tibial cut. METHODS: A total of 227 patients (300 knees) undergoing total knee replacements were randomised into two groups. In the study group, the point of intersection of the distal tibial diaphyseal line at the tibial plateau drawn on long films was represented by zones. Knees with femoral bowing >5° (28%) were excluded. Tibial jig placement on the proximal tibia was lateralised according to the zones. In the control group, the mid-point of the tibial plateau was taken as a reference. Femoral and tibial bowing, postoperative limb alignment and component placement were assessed. RESULTS: Of the 216 knees that were studied, 106 were in the study group and 110 in the control group. Bowing ≥3° had a significant positive correlation with lateralisation of the proximal tibial reference (p < 0.001). The Incidence of tibial bowing ≥3° was 57.33%. The mean postoperative hip-knee-ankle (HKA) angle was 178.31 ±â€¯2.88° and 176.53 ±â€¯2.88° (p < 0.001), whereas the mean medial proximal tibial angle (MPTA) was 89.91 ±â€¯1.42° and 88.79 ±â€¯1.72° (p < 0.001) in the study and control groups, respectively. Considering bowed tibiae alone, HKA angle and MPTA in the study group were 178.08 ±â€¯2.81° and 89.72 ±â€¯1.39° compared with 175.88 ±â€¯2.87° and 88.38 ±â€¯1.38° in the control group (p < 0.001). CONCLUSION: There is a high incidence of tibial bowing in varus knees. Lateralised tibial jig placement improved tibial component placement and postoperative limb alignment in total knee arthroplasty in varus knees with tibial bowing.

Individualised distal femoral cut improves femoral component placement and limb alignment during total knee replacement in knees with moderate and severe varus deformity.

AIM: Our aim was to determine the variation in valgus correction angle and the influence of individualised distal femoral cut on femoral component placement and limb alignment during total knee replacement (TKR) in knees with varus deformity. MATERIALS AND METHODS: The study was done prospectively in two stages. In the first stage, the valgus correction angle (VCA) was calculated in long-limb radiographs of 227 patients and correlated with pre-operative parameters of femoral bowing, neck-shaft angle and hip-knee-ankle angle. In the second part comprising of 240 knees with varus deformity, 140 (group 1) had the distal femoral cut individualised according to the calculated VCA, while the remaining 100 knees (group 1) were operated with a fixed distal femoral cut of 5°. The outcome of surgery was studied by grouping the knees as varus <10°, 10-15° and >15°. RESULTS: Of the 227 limbs analysed in stage I, 70 knees (31 %) had a VCA angle outside 5-7°. Coronal bowing (p < 0.001), neck-shaft angle (p < 0.001) and preoperative deformity (p < 0.001) significantly influenced VCA. Results of the second phase of the study showed a significant improvement in both femoral component placement and postoperative alignment when VCA was individualised in the groups of knees with varus 10-15° (p 0.002) and varus >15° (p 0.002). CONCLUSION: Valgus correction angle is highly variable and is influenced by femoral bowing, neck-shaft angle and pre-operative deformity. Individualisation of VCA is preferable in patients with moderate and severe varus deformity. LEVEL OF EVIDENCE: Level 2.

Surgical excision of heterotopic ossification of hip in a rare case of Moyamoya disease with extra articular ankylosis.

We report a case of isolated ossification of iliopsoas with ankylosis of the left hip in a 27-year-old female. The patient was diagnosed to have Moyamoya disease, a rare chronic occlusive disorder of cerebrovascular circulation following an acute onset of hemiplegia. The patient presented 9 months later to us with ankylosis of left hip which was successfully treated by surgical excision of the heterotopic bone and there was no recurrence at the end of 5 years. A review of literature failed to reveal a similar case with isolated and complete ossification of iliopsoas muscle associated with Moyamoya disease which required surgical intervention. Surgical excision resulted in dramatic improvement in the quality of life. Surgical excision of neurogenic type of heterotopic ossification is a very successful procedure and timely intervention after maturity of mass is very important to prevent the onset of secondary complications and to avoid recurrence.