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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., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2017)

Purpose: The purpose of this retrospective comparative study was to evaluate and compare, radiographically and clinically, progression of osteoarthritis (OA) in the patellofemoral (PF) compartment after open-wedge high tibial osteotomy (OWHTO), and unicompartmental knee arthroplasty (UKA) over a minimum follow-up of 5 years., Methods: In this study, 42 knees in an OWHTO group were compared with 59 knees in a UKA group in terms of radiographic parameters, such as the grading system for OA progression in the PF compartment, and clinical parameters, such as the PF pain and function scores over a minimum follow-up of 5 years., Results: There was no significant difference of OA progression in the PF compartment between the two groups on knee radiography. Compared with the preoperative grades, the UKA group showed significant progression of OA in the medial PF compartment at the final follow-up, whereas the medial PF compartment showed significant stepwise progression by only one grade when compared to the OWHTO group. The PF pain and function scores showed no statistical differences between the two groups at the final follow-up, regardless of OA progression., Conclusions: There was no significant difference between OWHTO and UKA in terms of progression of OA in the PF compartment or deterioration of PF function score over a minimum follow-up of 5 years. However, the medial PF compartment of the UKA group was minimal, and worsened or progressed by only one grade., Level of Evidence: III.

Background: Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The present study investigated whether the weight-bearing limb scanogram (WBS) technique provided a more accurate mechanical axis realignment than the navigation technique in open high tibial osteotomy (OHTO)., Methods: This prospective study involved 80 knees (78 patients) undergoing OHTO. The WBS technique was used in 40 knees and the navigation technique in 40 knees. Each technique was performed by a different surgeon in a different hospital. Postoperative coronal limb alignment was assessed using the weight-bearing line (WBL) ratio on full-length standing hip-to-ankle radiographs., Results: We found that the mean postoperative WBL ratio was greater in the WBS compared to the navigation group (p=0.001), and hence the ratio for the WBS group was closer to the ratio target of 62%. There was a greater proportion of WBL ratio outliers in the navigation group than the WBS group (25% vs. 10%, p=0.034)., Conclusion: We conclude that the WBS technique was more accurate than the navigation technique for restoration of coronal leg alignment in OHTO., Level of Evidence: Level II., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Reduction osteotomy (removing the posteromedial tibial bony flare) is one step to aid in achieving deformity correction in varus arthritic knees during TKA. However, the amount of deformity correction achieved with reduction osteotomy during TKA is unclear., Questions/purposes: We therefore addressed the following questions: (1) What is the amount of deformity correction achieved with reduction osteotomy during TKA in varus knees? (2) What is the correlation of amount of deformity correction achieved to the amount of bone osteotomized and the degree of varus deformity?, Methods: We prospectively collected and analyzed intraoperative data on the degree of varus deformity before and after reduction osteotomy (using computer navigation) and the amount of reduction osteotomy performed (using a measuring scale) in 71 primary, computer-assisted TKAs., Results: For a mean reduction osteotomy of 7.5 ± 2 mm, a mean correction of 3.5° ± 1° was achieved; a mean osteotomy of 2 mm was required (confidence interval, 1.7-2.6 mm) for every 1° correction of varus deformity. Degree of varus correction achieved correlated positively with the amount of osteotomy performed, especially in knees with preoperative varus deformity of < 15° (r = 0.77, p < 0.001) and the preosteotomy residual varus deformity correlated positively with the amount of correction achieved (r = 0.81, p < 0.001)., Conclusions: Reduction osteotomy can achieve deformity correction in a predictable 2 mm for 1° in most varus arthritic knees during TKA. Further studies are required to ascertain its effectiveness as a soft tissue-sparing step when performed early on during TKA to achieve deformity correction.

Background: Extensive posteromedial release to correct severe varus deformity during TKA may result in mediolateral or flexion instability and may require a constrained implant. We describe a technique combining computer navigation and medial condylar osteotomy in severe varus deformity to achieve a primary goal of ligament balance during TKA., Description of Technique: The goal of this procedure was to achieve mediolateral gap balance in varus knees with rigid, recalcitrant medial contracture, with or without excessive lateral laxity, not amenable to extensive medial soft tissue releases. A sliding medial condylar osteotomy (SMCO) was performed under navigation guidance and the condylar block internally fixed using cancellous screws., Methods: We prospectively evaluated mediolateral laxity, Knee Society scores, and knee ROM after SMCO in 12 varus arthritic knees in 11 patients (five men, six women) undergoing TKA with a minimum followup of 2 years (mean, 2 years; range, 2-2.5 years)., Results: The degree of mediolateral knee laxity improved from Grade 2 (in four knees) and Grade 3 (in eight knees) preoperatively to Grade 1 (< 5 mm) in all knees at last followup. Mean Knee Society score improved from 30 (range, 10-54) to 92 (range, 86-100). Mean knee flexion improved from 106° (range, 90°-120°) to 112° (range, 100°-124°), and no knee had any extensor lag or residual flexion deformity (> 5°). Three knees had asymptomatic fibrous union at the osteotomy site., Conclusions: Computer-assisted SMCO in varus knees with recalcitrant medial contracture achieves improved mediolateral stability and knee function after TKA. Our technique uses navigation to accurately reposition the medial condylar block to equalize medial and lateral gaps, thereby ensuring a stable well-aligned knee without deploying constrained implants.

Purpose: The purpose of this cadaveric study was to study the effect of plane of osteotomy on incidence of lateral cortex fracture and to define a "safe zone" through which medial open-wedge high tibial osteotomy (HTO) could be performed with minimal risk of lateral cortex fracture., Methods: Medial open HTO was performed in nine fresh frozen human cadavers (18 knees) with each specimen randomly assigned to a "safe zone" osteotomy (group A, between the tip of the fibular head and the circumference line of the fibular head), or a lower level osteotomy (group B, distal to the circumference line of the fibular head)., Results: Six out of nine knees developed lateral cortex fracture in group B compared to none in group A (P = 0.009) when the osteotomy site was distracted to a maximum of 20 mm., Conclusion: Directing the plane of the osteotomy toward the "safe zone" significantly reduces the risk of lateral cortex fracture compared to an osteotomy, which is directed at a lower level. Confining the plane of a medial open HTO to within the "safe zone" can prevent lateral cortex fracture and subsequent loss of correction.

Despite several advantages of medial opening wedge high tibial osteotomy, this procedure has been noted to have a high rate of complications especially with the use of a spacer plate for fixation. We retrospectively evaluated the early complications of 138 medial opening wedge high tibial osteotomies done using autologous tricortical iliac bone graft and T-plate fixation(AO locking compression T-plate, Ti/3H 4.5-5.0 mm, Synthes, Switzerland, Model No. 440.131 in 30 and low-profile locking T-plate and low-profile locking T-plate in 128 patients. At a mean follow-up of 36.8 months (13 to 78), 26 knees (18.8%) developed complications. Complications varied from osteotomy site infection, loss of correction, broken screws and lateral tibial plateau fracture to joint fluid leakage, pseudoaneurysm and iliac bone fractures. Using the "safe zone" technique and penetrating the lateral cortex with Steinmann pins may help to avoid complications such as loss of correction and lateral tibial plateau fractures. The results of this study indicate that medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation may be a technically demanding procedure associated with a moderate rate of complications. However, these complications could be minimized with proper planning, adequate intra-operative precautions and few modifications to avoid technical error., (Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.)

Extensive release of posterolateral structures may be required to correct rigid and severe valgus deformities during total knee arthroplasty. Current techniques are technically difficult, may not accurately restore soft tissue balance, and are associated with postoperative complications. Computer navigation while performing lateral femoral epicondylar osteotomy allows precise, controlled, quantitative lengthening of lateral structures and restoration of optimum soft tissue balance and alignment., (2010 Elsevier Inc. All rights reserved.)

Our aim was to evaluate the alteration in angle of posterior slope of the tibia and the degree of patellar height following medial opening wedge high tibia osteotomy(HTO) using autologous tricortical iliac bone graft in 32 consecutive patients. Twenty three females and nine males underwent medial opening wedge high tibia osteotomy (HTO) using autologous tricortical iliac bone graft in 34 knees (33 primary medial compartment osteoarthritis and 1 idiopathic osteonecrosis of medial tibial condyle). The posterior slope of tibia was determined by the proximal tibial anatomical axis. Patellar height was measured by the Insall-Salvati and the Blackburne-Peel ratios. Preoperative and postoperative (last follow up) values of these three parameters were compared. The intra- and interobserver variability of these methods was determined before and after operation. At the end of mean follow up of 3 years this procedure produced no significant change in posterior slope. Pre and postoperative posterior slope were 8.7 degrees+/-3.6 degrees and 8.2 degrees+/-2.8 degrees respectively (P=0.412). Pre and postoperative Insall-Salvati ratios were 0.93+/-0.10 and 1.05+/-0.11 respectively (P<0.001). The Insall-Salvati ratio increased in 94% of patients and patellar ligament length was significantly increased. The distance between the patellar and tibiofemoral joint line decreased in 82% of patients. The mean Blackburne-Peel ratio declined from 0.71+/-0.12 to 0.61+/-0.13 (P<0.001). Twenty six percent of postoperative Blackburne-Peel values satisfied the radiographic criterion for patellar infera (Blackburne-Peel ratio<0.54). There was no difference in the intra-and interobserver variability of measurements either before or after HTO. Opening wedge HTO using autologous tricortical iliac bone graft with internal fixation and early mobilisation prevented change in posterior slope of tibia, lengthened the patellar ligament and elevated the tibiofemoral joint line when the mean ratio of anterior and posterior gap at the osteotomy site was around two-thirds.

The treatment of spondyloepiphyseal dysplasia (SED) congenita patients with severe bilateral hip involvement is difficult because it involves deformities of multiple joints and of the spine. The purpose of this study was to evaluate the results of the procedure described below as a method of treatment for bilateral hip involvement in SED congenita patients. We performed proximal femoral valgus-extension osteotomy with distal femoral varus osteotomy using a hybrid external fixator in eight patients (seven male patients and one female patient) or 16 hips. The patients had a mean age of 16.37 years (range, 9-25 years) at the time of surgery. The mean valgus angle at the proximal osteotomy site was 53.4 degrees on the right side and 52.5 degrees on the left side, and the mean varus angle at the distal osteotomy site was 22 degrees . Mean fixator time was 19.8 weeks (range, 10-42 weeks). After an average follow-up of 25.9 months, the mean modified Harris hip score had improved from 67.9 points to 79.1 points, which was statistically significant (P=0.012). Preoperative knee range of motion was achieved at the last follow-up in all patients. Waddling gait was absent in three patients, reduced in four patients, and was the same in one at the last follow-up. Mean limb length gain was 3.5 cm (range, 0-5 cm), mean limb length discrepancy less than 0.5 cm, and the mechanical axis was realigned in all. In conclusion, our early results suggest that proximal valgus-extension osteotomy with distal femoral varusization can be a useful treatment option in young patients with bilateral hip involvement in SED congenita.

Purpose: This study was to determine the efficacy of iliac crest reconstruction using bone cement in reducing pain and morbidity at the donor site in patients undergoing open wedge high tibial osteotomy (OWHTO) with tricortical iliac crest autologous graft. Materials and Methods: Thirty-three patients who underwent iliac crest reconstruction using polymethyl methacrylate (PMMA) bone cement (group A) and thirty patients who had no iliac crest reconstruction (group B) were enrolled in this study. All patients were evaluated for pain and functional disability related to graft harvesting using the pain and functional visual analogue scale (VAS) score during hospital stay and at 6 weeks, 3 months, and 6 months postoperatively. Results: There was significant difference between the two groups in terms of pain and function. The pain VAS score was significantly lower in group A than group B during the first 2 weeks postoperatively (p=0.04) and the functional VAS score was also significantly lower in group A during the first 2 weeks postoperatively (p<0.001) in terms of breathing, sitting up from the supine position, and standing up with crutches from the sitting position. Conclusions: Iliac crest donor site reconstruction using PMMA bone cement in patients undergoing OWHTO significantly decreased pain and improved function during the first 2 weeks postoperatively when compared to patients who underwent OWHTO without iliac crest reconstruction. [ABSTRACT FROM AUTHOR]

Treating complex arthritic knee deformities with hinged total knee arthroplasty may be technically simpler but involves issues of higher cost, uncertain long-term implant survival, particularly in younger and active patients. Using a graduated, step-wise intra-articular correction technique with or without an osteotomy performed concomitantly during total knee arthroplasty allows the surgeon to achieve a well-balanced and well-aligned knee. Full correction of knee deformity and optimum soft-tissue balance can be achieved in the vast majority of arthritic knees with complex deformities using the patient''s own soft-tissue envelope and without resorting to use of hinged implants. [Copyright &y& Elsevier]

Abstract: Forty extra-articular deformities (22 femoral and 18 tibial) in 34 patients (mean age, 63.1 years) were studied. Mean coronal extra-articular deformity was 9.3°; mean preoperative limb alignment was 166.7°. Three limbs underwent simultaneous corrective osteotomy; the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty (TKA). Mean postoperative limb alignment was 179.1°. At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean preoperative score of 49.7 to 90.4 points postoperatively; function score improved from 47.3 to 84.9 points. Computer-assisted TKA is a useful alternative to conventional TKA for knee arthritis with extra-articular deformity where accurate restoration of limb alignment may be challenging because of the presence of a deformed tibia or femur or in the presence of hardware. [Copyright &y& Elsevier]

Background: Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The present study investigated whether the weight-bearing limb scanogram (WBS) technique provided a more accurate mechanical axis realignment than the navigation technique in open high tibial osteotomy (OHTO). Methods: This prospective study involved 80 knees (78 patients) undergoing OHTO. The WBS technique was used in 40 knees and the navigation technique in 40 knees. Each technique was performed by a different surgeon in a different hospital. Postoperative coronal limb alignment was assessed using the weight-bearing line (WBL) ratio on full-length standing hip-to-ankle radiographs. Results: We found that the mean postoperative WBL ratio was greater in the WBS compared to the navigation group (p = 0.001), and hence the ratio for the WBS group was closer to the ratio target of 62%. There was a greater proportion of WBL ratio outliers in the navigation group than the WBS group (25% vs. 10%, p = 0.034). Conclusion: We conclude that the WBS technique was more accurate than the navigation technique for restoration of coronal leg alignment in OHTO. Level of Evidence: Level II. [ABSTRACT FROM AUTHOR]