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A new etiology of lateral ankle instability is described. The concept of triplane motion at the ankle joint differs with previous descriptions of ankle joint movement. Triplane movement about the ankle joint creates varus position during plantarflexion, and must be understood when evaluating ankle instability. Functional ankle varus can be assessed and treated appropriately with proper knowledge of its existence.
Metatarsus primus varus occurs in feet which have a normal 1--2 intermetatarsal angle. Fifty-two Caucasian females, average age 18 years, were analyzed radiologically for 1--2 and 1--5 intermetatarsal angles and for metatarsophalangeal and first interphalangeal joint angles. Measurement of the 1--5 rather than the 1--2 intermetatarsal angel is a more reliable indicator of first metatarsal varus. Valgus at the first interphalangeal joint is normally greater than that at the first metatarsophalangeal joint and excessive first interphalangeal valgus (valgus interphalangeus) is significantly linked with the presence of ossia tibiale externa. The high arch foot tends either to feature valgus interphalangeus or become excessively broad. The anatomy of the ungual tuberosity is highly variable.
In 101 supracondylar fractures which had happened in childhood the axial deviations with emphasis on subsequent cubitus varus formation were followed-up 6.6 years later. This varus angulation originates mostly from insufficient reposition and/or immobilisation when treating the fracture after the accident. Concerning surgical correction of the deformity we are critical and recommend to be reserved.
Hallux varus deformity, which may be either congenital or acquired, can be very painful and disabling, in addition to having a poor cosmetic appearance. In this paper, the author discusses the acquired type. He believes the abductor hallucis tendon transfer to be the procedure of choice for correction of hallux varus deformity, and he discusses its use and results in three cases.
High tibial osteotomy is a reliable method for relieving pain in the varus osteoarthritic knee. In a review of 139 osteotomies, excellent and good results were noted in 64% of the knees after a follow-up period of at least ten years. The ideal candidate for this operation has Grade I or II osteoarthritis; less than 10 degrees of varus deformity, as measured by a single leg standing roentgenogram; no lateral subluxation; and no instability. The lateral closed wedge osteotomy without internal fixation is the preferred technique, and correction beyond the normal anatomic position, to 5 degrees of valgus, is advised. Protected weight-bearing after the second postoperative day is allowed. Complications have been infrequent and minor. Forty-seven knees were managed in this manner, and 88% had an excellent or good result at a four-year follow-up evaluation. In the majority of the well corrected knees, the alignment did not change with time, and the osteoarthritis did not progress. No failures in this series were attributable to the associated patellofemoral osteoarthritis; the reaction of the patellofemoral joint to osteotomy is obscure.
Four patients who had injured the lower end of the humerus in childhood with resulting cubitus varus developed recurrent posterior dislocation of the head of the radius after further injury to the elbow. Dislocation occurred when the forearm was supinated and spontaneous reduction took place on pronation. At operation the lateral ligament complex was seen to be lax and elongated. After tightening of the ligament and with a supracondylar osteotomy of the humerus to correct the cubitus varus the recurrent dislocation was eliminated.
The authors report their experience with the operation of Heyman, i.e. complete release of the tarsometatarsal and intermetatarsal joint for the treatment of congenital metatarsus varus. This operation of Heyman is capable of meeting the requirements of correction if the indications are precise and if the surgical technique is perfect. The operation is indicated in cases of varus over 15 degrees, passively reducible, with good axes of the hindfoot and without bony alterations of the Lisfranc joint, in children between 3 and 8 years old. There should be a dorsal and medial capsulotomy, with section of the medial 2/3 of the plantar aspects of tarsometatarsal and intermetatarsal capsules; the lateral portion, the lateral 1/3 of the capsule and the insertions of the fibularis brevis and tibialis anticus should be spared. A complete capsulotomy is not indicated owing to the risk of dislocation of the tarsometatarsal joint. The correction should be stabilized during the operation by Kirschner wires to avoid a loss of correction when putting the foot in plaster.
Humerus varus, the upper extremity analogue of coxa vara, may be found in association with, and probably as a consequence of hematologic, infectious metabolic, genetic and neurologic disorders. No matter what the etiology, there is a similar pattern of development and progression of the deformity. The medial region of the proximal humeral physis either develops slowly or failed to develop, while the lateral region develops more rapidly, causing varus rotation of the proximal humeral epiphysis and physis. In the more extreme cases, the lateral region of the growth plate is almost parallel to the longitudinal axis of the shaft. In many cases there is a medial lucency, adjacent bony epiphyseodesis, and significant shortening of the humerus. Although abduction is usually decreased, major functional impairment is unusual even in the dominant arm.
The authors describe radiographic results from nine patients in whom hallux varus was repaired by transferring the extensor hallucis longus tendon (EHLT) under the deep transverse intermetatarsal ligament into the proximal-lateral base of the proximal phalanx. X-ray films revealed clinically significant changes in biomechanical relations, specifically in the hallux abductus angle. No clinically significant changes were seen in the intermetatarsal angle. The EHLT transfer procedure described is a valuable surgical alternative for correction of iatrogenic hallux varus deformity when combined with the appropriate adjunctive procedures.
The distribution of pressure force (load) on the tibia-plateau in a normal knee as well as varus or valgus deformity has been measured electronically and also studied by photoelastic experiments. The translocation of it by changing the knee axis has been demonstrated. The significance of the pressure force causing monocompartmental gonarthritis has been shown. The causal therapy is a correction of the valgus or varus deformity. The effect of this operation lies in the biomechanical discharge of the damaged compartment.
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.
Nine children who sustained Lauge-Hansen's supination-inversion injury of distal tibial physeal injury with intact distal fibular physis, were followed until their maturity. The average varus deformity was 39 degrees (maximum, 80 degrees) with 23 degrees of internal rotational deformity. The longitudinal growth of the fibula was retarded compared with opposite normal leg. There was early closure of the medial distal tibial physis, gradual upward migration of medial malleolus, and eventually medial subluxation of the ankle; these resulted in gradual varus and internal rotational deformities of the injured ankle. It is thought that the resultant disabling deformity of ankle should be prevented by any means, though presently there are no available effective methods of treatment. It is suggested that the repeated corrective osteotomy should be carried out before epiphyseal deformity of the distal tibia and subluxation of the ankle joint develop.
INTRODUCTION: 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. MATERIAL AND METHODS: 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). RESULTS: 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. DISCUSSION: 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. CONCLUSION: 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.
Attention is drawn to the high incidence of varus angulation in the lower femur in Ollier's disease; eight of a total of 14 patients with this condition have this deformity. There may be retardation or arrest of the medial portion of the lower femoral growth plate. One case demonstrates a bone bridge, a condition not previously described in Ollier's disease. The limb-length inequality and varus angulation require concurrent management by a variety of techniques, which are described. Three of the eight patients have reached skeletal maturity; the remainder provide useful information on the condition and are a stimulus for discussion of future management.
The authors reviewed 20 patients with cubitus varus deformity who were treated with the interlocking wedge osteotomy. All deformities including medial, posterior tilt and internal rotation of the distal fragment can be simultaneously corrected with this osteotomy. There were 14 males and 6 females whose average age was 5.0 years at injury and 14.1 years at surgery. The average follow-up period was 37 months. Thirteen patients had excellent results, 6 good, and 1 poor. The mean carrying angle was improved from 21.5 degrees of varus to 8.8 degrees of valgus, compared to 9.4 degrees of valgus on the uninjured side. The mean flexion of the elbow increased from 123.9 degrees to 134.3 degrees, and the mean hyperextension decreased from 12.0 degrees to 7.5 degrees. Three-dimensional correction and stable fixation can be achieved with this osteotomy.
From 1984 to 1995, 19 patients with cubitus varus resulting from supracondylar humeral fractures underwent lateral closing-wedge osteotomies at The Royal Alexandra Hospital for Children. As the indication for osteotomy in all cases was the cosmetically unacceptable cubitus varus, we reviewed the cosmetic results. Seventeen patients were available for review. Subjective reports from patients and parents, as well as objective clinical assessment by one of the authors, were used to assess these results. According to our grading system, 12 (76%) patients had excellent results. These patients and their parents were satisfied with the cosmetic results, and there was no clinical evidence of a bony prominence over the lateral condylar region or an unsightly operative scar. One patient had a poor result with a lateral bony prominence and an unsightly scar, both of which were clinically obvious. We report that lateral closing osteotomies in children who have not yet reached skeletal maturity produce excellent cosmetic results.
The persistence of metatarsus adductus varus has been a problem in management. We have treated a series of selected patients with this problem and believe that our results have been better than with the procedure we have used in the past. Fowler has described a procedure which seems ideal for the patients in our series. Through personal communication the procedure and its application were discussed and the series was started eight years ago. Our series is small because our patients are responding to other forms of treatment at an earlier age. The few that do not respond are now considered for the operation described. The procedure is relatively simple to perform. Full correction should be obtained at the time of surgery. Casting is utilized to hold the correction and immobilize the extremity for healing. Our unsatisfactory results occurred because of errors in technique or poor selection of patients. We believe that this procedure should be considered in the older patient with metatarsus varus.
The split tendon transfer is introduced as an additional procedure for the correction of hallux varus. More clinical and statistical evaluations are required to fully appreciate its potential benefits.