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Le cubitus varus est cal vicieuxle plus souvent secondaire à des fractures supracondyliennes déplacées de l'extrémité inférieure de l'humérus chez l'enfant. Différentes techniques chirurgicales ont été proposées avec un taux de réussite différents mais aussi un taux de complications rapportées différents. Nous évaluons à travers une étude rétrospective de 25 cas colligés au centre hospitalier universitaire de Rabat, les résultats de la technique de soustraction externe que nous utilisons dans notre formation pour prendre en charge cette déformation.

The post operative iatrogenic hallux varus associates varus, big toe's dorsal flexion and supination. The pathogeny is dominated by musculo-tendinous lack of balance created by the initial operation and excessive exostosectomy. The authors have nineteen times surgically corrected this deformation. The procedure included in all cases, a medial arthrolysis; five times associated with a screwed capito-metatarsal osseous shelf (or graft) (when there was a metatarsal's head maiming); thirteen times associated with a metatarso-phalangeal arthrodesis (in cases of impaired joint surfaces). The authors analyse, besides, without excluding them the other surgical procedures for hallux varus, and particularly tendinous transfers. The results show the necessity of a perfect etiopathogenic analysis of the deformation.

Le genu varum sur gonarthrose fémorotibiale interne est une pathologie en nette recrudescence dans notre pays, affectant spécialement les femmes âgées et hautement invalidante chez l'adulte jeune; Souvent, elle pose un problème d'indication et de choix thérapeutique d'ordre multifactoriel. L'ostéotomie tibiale de valgisation par ouverture interne est une technique de référence, bien connue depuis longtemps et d'efficacité validée à court, moyen et long terme, et constitue un outil thérapeutique de choix et d'apport marqué, notamment pour les sujets jeunes actifs avec gonarthrose débutante. Par ailleurs, cette technique peut voir ses indications s’élargir au dépend de l’âge et du stade évolutif. Le but de notre travail est d’évaluer les résultats anatomiques et fonctionnels de notre technique d'ostéotomie tibiale de valgisation avec comblement cimenté chez l'adulte jeune de plus de 40 ans et de préciser les facteurs pronostiques qui régissent ces résultats. Ce travail propose à travers une étude rétrospectivement menée à propos de 38 genoux opérés chez 28 patients de dresser un bilan épidémiologique, clinique, et radiologique afin d’évaluer les résultats anatomiques et fonctionnels immédiats et à distance avec un recul minimum de 2 ans, de l'ostéotomie tibiale de valgisation avec comblement cimenté. Les 28 cas ont été revus à un recul moyen de 3,7 ans avec des extrêmes entre 2 et 9 ans, l’âge moyen de nos malades était de 52 ans avec des extrêmes de 40 à 67 ans, le sexe féminin était prédominant (64%). Le genu varum était primitif dans 20 cas (71,4%), et secondaire dans 8 cas (28,5%). Les stades I et II d'Ahlback constituaient la majorité des cas de l'arthrose fémoro-tibiale (94,7%). La déviation angulaire globale moyenne était de 11,3° avec des extrêmes de 8,5° à 18°. Les résultats évalués selon le protocole du groupe Guépar étaient excellents et très bons dans 86% des cas, et moyens et mauvais dans 14% des cas. Les meilleurs résultats ont été notés avec un âge au moment de l'ostéotomie de 60 ans, une arthrose au stade I et II d'Ahlback et un varus initial moyen ne dépassant pas 15°. La normocorrection a permis d'obtenir de bons résultats. Les complications postopératoires étaient rares sans conséquence sur les résultats thérapeutiques.

Analysis of the correction or over-correction of high valgus and varus tibial osteotomies is generally limited to the frontal plane. Most likely however, the deformation observed radiographically in the frontal plane is simply a one-dimensional expression of a more complex three-dimensional deformation. This might be one of the causes for certain failures after surgery and recurrent problems which are difficult to solve. We proposed using 3D electrogoniometric to measure of the effect of a "dome" osteotomy on patellar and femoro-tibial kinematics and the changes in the moment arms of the knee muscles.We used five lower limbs harvested from non-fixed cadavers. A "dome" osteotomy was stabilized by external fixation. Three-dimensional analysis of the femoro-tibial and femoro-patellar kinematics was performed using two electrogoniometers with six degrees of freedom. Changes in the lengths of the hamstrings and quadriceps was measured using four LVDT linear variable differential transformers. The muscles lever arms were measured with the tendon excursion method.At 90 degrees flexion, varus osteotomy induced internal rotation while valgus osteotomy induced the opposite effect. Beyond 40 degrees flexion, there was a clear internal rotation of the patella for varus and neutral corrections. Valgus corrections however induced external rotation. The peak lever arm of the quadriceps increased with valgus, while the angle of the peak was higher for varus correction. Valgus appeared to increase the lever arm of the semitendinous.Our study demonstrated that the effect of tibial osteotomy is not limited to the frontal plane. Tibial rotations are observed systematically for all corrections in the frontal plane. Varus correction tends to create internal rotation while valgus correction tends to have the opposite effect. Axial correction also affects patellar kinematics. Interanal rotation is induced by varus correction and external rotation by valgus correction. This patellar rotation could result from tibial rotations induced by the different corrections. The loss of the parallelism between the patellar crest and the trochlear groove could produce changes in femoropatellar surface contact and pressure, potentially leading to pain or cartilage degeneration. The maximal value of the quadriceps moment arm appears to increase with valgus. The efficacy of the quadriceps could thus be improved with valgus, potentially increasing extension force. Valgus increases the moment arm, improving limb flexion, while varus correction has the opposite effect. This could explain a loss in flexion amplitude in patients with varus or who underwent varus osteotomy. Tibial osteotomy is designed to correct the deviation solely in the frontal plane but also has effects in all three planes. Further 3D analyses of the morphology and physiology of the knee joint would be needed to better understand the physiological and pathological processes involved.

We report our experience with eleven patients treated for disabling genu valgum from 1979 to 1994.Genu valgum resulted from femoral deformation in all patients. Ten had a congenital condition and one a post-traumatic knee. IKS scores were used for the clinical evaluation. The lateral femorotibial joint space and the lateral femoral angle (LFA) were measured on plain films. Goniometry was used to measure the axis of the loaded lower limb. All patients underwent osteotomy of the distal femur for varisation and plate fixation. One patient required revision for a unicompartment lateral prosthesis subsequent to fracture of the homolateral lateral tibial plateau. Mean follow-up was 10.5 years (3.5-21.5).There were no cases of nonunion. Four patients had a good or excellent knee score. Eight patients had a good or excellent function score. Osteoarthritis worsened in two patients. The mean LFA increased from 72.5 degrees preoperatively to 83.5 degrees postoperatively and a last follow-up. Mean genu valgum was 13 degrees preoperatively and 2 degrees at last follow-up. All patients except one were satisfied or very satisfied. Insufficient correction appeared to be the main complaint.These results and results reported in the literature demonstrate that distal femoral osteotomy for disabling genu valgum is an effective treatment if the correction is complete and osteosynthesis effective, providing long lasting results when femoral deformation is involved and osteoarthritis limited.

This study was undertaken to evaluate the results of high tibial osteotomies on varus gonarthrosis, on which a mechanical angular correction of more than 20 degrees was performed.This retrospective study concerned 46 knees in 38 patients. The average patients age at operation was 60 (min. 51, max. 71). All the patients were evaluated clinically according to the Knee Society Scoring System and radiologically (standing AP, lateral views and monopodal whole leg weight bearing X-Rays) both pre and post operatively. 3 knees have been excluded because of various reasons. The average follow up of the remaining 43 knees was 50.3 months (min. 24, max. 109 months). The preoperative mechanical axis deviation was 22.8 degrees (min. 16, max. 36 degrees).Postoperatively an optimum valgus alignment was obtained in 31 knees. In 12 knees, the peroperative correction decreased and the mechanical axis was again in varus but with less deformity. According to The Knee Society Scoring System at the last follow-up, the Knee Score was 83, and the Knee Functional Score was 81 (54 and 55 respectively preoperatively). Three cases were reoperated. One internal fixation and bone grafting for nonunion, one reosteotomy for recurrence of the deformity and one total knee replacement for persisting pain were performed. The most frequent complication was the loss of correction which was encountered in 12 knees. Age, follow-up period and alignment were not found to influence significantly the results. Only the arthritis stage, according to Ahlback's radiographic evaluation, was found to be an important factor influencing the results.Dome shaped osteotomy's results were surprisingly good in these patients. This technique, performed with a cheap fixator, allowed an operatively exact correction of the deformity, an early active mobilization and progressive weight bearing. The dome shaped osteotomy displaces the tibial tuberosity medially and if needed anteriorly, treating effectively the patello-femoral arthrosis which is frequently present in these highly deformed knees.Chosen because of necessity by the authors, the dome shaped osteotomy stabilized by a Charnley fixator, performed on knees needing an important angular correction, has given surprisingly good mid term results. Furthermore the good results obtained support our belief of not enlarging the arthroplasty indications against those of the osteotomies, even in severe gonarthrosis.

Sixty two hallux valgus treated by first phalanx varus osteotomy associated to adductor hallux plasty were reviewed with a minimum follow-up of 4 years.48 females and 2 males were operated. Average age was 46 years. The forefoot was grecian 40 times. The pre-operative metatarsus varus was at an average of 14.2 degrees when the metatarso-phalangeal valgus was 33.3 degrees. The interphalangeal valgus was 8.25 degrees. The first phalanx base lateral translation measured an average of 5.8 mm. Sesamoids were always dislocated. 36 patients were treated in the same operative time, using this associated approach at different level.Results were evaluated according to 3 Groulier's criteria. In 10 cases, a post-operative pain persisted. Shoe wearing continually improved. The great toe valgus was corrected in 31 cases (50 per cent). The correction was partial in 20 cases (32.3 per cent) but on radiographs, only 34 cases (54.8 per cent) conserved a normal joint space. The first phalanx base lateral translation only improved partially. It measured an average of 408 mm. The global result was good in and very good, 67 per cent, while patients subjective estimation was good or very good in 90.3 per cent.The study of this series of first phalanx varus osteotomy associated to adductor plasty shows lateral subluxation partial correction, factor of long term modification on articular metatarso-phalangeal joint space. The adductor plasty associated to abductor disinsertion showed a results improvement compared with other published series.The first phalanx varus osteotomy associated to adductor plasty should be limited to moderate hallux valgus deformity with interphalangeal valgus and without any major articular incongruity.

The authors describe 2 originals cases with a painful snap or "recurrent" elbow instability in adults after displaced supracondylar fractures in childhood, with a malunion in varus and internal rotation. Varus and internal rotation of the distal humeral epiphysis were responsible for instability because of elbow kinematic modification. Extra-articular osteotomy fixed with a plate allowed pain relief, stability, and range of motion improvement.

Open wedge osteotomy of the first cuneiform was used for correction of metatarsus varus primus. The osteotomy interested the medial, dorsal and plantar face of the first cuneiform, but lateral cortex should be carefully left intact, it is used like a hinge for opening the osteotomy. This procedure is carried out when varus of the tarsometatarsal joint is superior to 20 degree, it is reduced to its normal value, between 5 and 10 degree. Osteotomy is stabilized with bone graft. In resistant metatarsus adductus, closed wedge osteotomy of the cuboid has been added to correct the varus deformity of the fore foot, it allowed lateral swing of the forefoot: the bone excised from cuboid is used to stabilized medial osteotomy. Twelve children, aged 5 to 15 years, underwent medial open wedge osteotomy of the first cuneiform for correction of 16 feet including 8 hallux valgus, 6 serpentine feet, defined as adductus of the forefoot and valgus of the hindfoot, and 2 clubfeet. In all hallux valgus it was associated with release of all contracted lateral structures and in three cases, shortening of the proximal phalanx. In serpentine feet and clubfeet closed wedge osteotomy of cuboid has been added.Results have been studied with follow up ranging between 18 months and 5 years. In 8 cases of hallux valgus, one case showed recurrence; failure was related to technical deficiency, because the lateral cortex of the first cuneiform was cut accidently leading to over lengthening of the first column. In 6 resistant metatarsus varus and 2 clubfeet, we didn't find any recurrence at term of our follow up.In all cases, growth of metatarsals hasn't been disturbed at term of our follow up and tarsometatarsal joint remained well corrected, because proximal epiphyseal plate of metatarsal was normally positioned and saved from damage.

The authors report 24 cases of revision in recurrent club foot deformity. They assessed Cahuzac's procedure for treatment of the residual forefoot adduction. This procedure (opening of the first cuneo-metatarsal joint and proximal abduction osteotomy of the second, third, and fourth metatarsals) was generally associated with postero-medial, plantar release, and split tibialis anterior tendon transfer.Twenty four procedures for 20 children at mean age of five years have been performed. The revision chart comprised 12 clinical and radiological items as proposed by Seringe.Seven feet were considered as excellent, 14 as good, 2 as fair, and 1 as poor. The mean follow-up was four years.Treatment of the adduction component with Cahuzac procedure is focused on the fore part of the foot, and on the calcaneo-pedal block by postero medial release, but never on the midfoot, as no Evans or Lichtblau's procedure has been performed. This series was compared to others procedures, and morphological results were equivalent. Cahuzac's operation is riskless for foot growth, and needs two approaches which can be useful for simultaneous procedures as split lateral transfer of tibialis anterior tendon.Metatarsal osteotomies (Cahuzac's procedure), associated with soft tissues release and split anterior tibial transfer, seems to be effective in surgical treatment of relapsed clubfeet, but the debate concerning the location of the adduction component of the deformity remains still open.

The author describes his experience after treatment of 8 cases of cubitus varus secondary to displaced supracondylar fractures of the humerus in African children. Measurement of the Baumann angle is necessary for the assessment of cubitus varus. The median angle is 24 degrees with a range of 10 degrees to 45 degrees. Indications were dictated by functional problems, discomfort, and esthetic considerations. The surgical treatment consisted in a supracondylar osteotomy of the humerus for correction of cubitus varus.

A total of 126 Perthes diseases (112 patients) were studied. The treatment comprised intertrochanteric femoral varus osteotomy in every patient. In 20 patients (25 hips), the course of the disease was more severe than expected. The early radiological criteria for this severe course were: 1. Lateral calcification extending far laterally towards the greater trochanter, 2. Deformation and widening of the femoral head before the fragmentation phase, 3. The Saturn phenomenon; a sclerotic epiphysis surrounded by a ring of looser bony tissue, 4. Deformation and widening of the femoral neck at the initial phase of the disease, 5. Early wide sclerotic changes in the metaphysis. The overall results were poor. Two hips obtained a fair and 23 poor results. These described radiological changes are readily recognized at early phase of Perthes disease and indicate poor prognosis. In these cases varus osteotomy gave unsatisfactory results which means that other type of treatment in these patients should be considered.

The authors have reviewed 32 cases of severe varus deformity following supra-condylar fractures in childhood. The sequellae were mainly cosmetic, the function being preserved. All cases were treated by supra-condylar osteotomy fixed by screwing. The technique is described. The results were satisfactory in 20 cases.

141 hips were reviewed more than 10 years after operation. The average follow-up was 13.5 years. A close relationship between the pre-operative functional state and the final result was established. The improvement was due to a decrease of pain in most cases, especially severe ones. Mobility and walking ability were little changed. Some worsening of the condition of patients was noted at about the 10th post-operative year. The aetiology, the degree of dysplasia, or degree of displacement of the osteotomy, had little influence on the final result. The degree of post-operative hip congruence was unimportant. The best results were seen in excentrated hips with severe radiological involvement. It is concluded that varus osteotomy is a valuable procedure in severe arthrosis of the hip. The hazards of the procedure are small, and it is indicated in young or middle-aged patients.

The authors have reviewed 250 cases of upper tibial osteotomy for varus deformity of the knee with degenerative arthritis of the medial compartment. Most of the osteotomies (136) were closing osteotomies, the remainder being opening osteotomies using a bone graft. Closing osteotomy is recommended together with an arthrolysis of the upper tibio-fibular joint instead of a fibular osteotomy. Hyper-correction appeared to be beneficial in cases with lateral ligament laxity. The authors do not recommend intra-articular cartilage shaving or meniscectomy. They advocate surgical release of the patella by division of the lateral patellar retinacula or by anterior displacement of the tibial tuberosity.

Congenital coxa vara with severe angulation is a difficult lesion to treat and of uncertain outcome. Many valgus osteotomies have resulted in failure because of inadequate correction or recurrence of deformity. The 27 cases described confirm this view. Out of 18 cases whose results are known, only four were good, compared with six fair and eight bad results. The causes of these failures arise from technical difficulties in the operative procedures, their inadequacy, significant muscle tension and malformation of the growth plates. An effective and lasting valgus is only possible if the internal fixation is well applied in the femoral neck, with a pin inserted into its axis. A moderate shortening avoids excessive tension in the region of the joint.