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PubMed1998

Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures.

OBJECTIVE: To examine predictors of fixation failure in the treatment of displaced subcapital hip fractures. DESIGN: Retrospective study. METHODS: All patients aged sixty-five years and older discharged from a large teaching hospital after treatment for displaced subcapital fracture between April 1, 1989 and February 29, 1995 were identified (n = 344). Of these, 108 patients treated with internal fixation became the study group. Clinical information included demographics, implant, comorbidity, complications, mortality, surgeon' s assessment of reduction, and need for revision. Preoperative x-ray information: Garden grade, Singh Index, Pauwel's angle, medial neck and femoral shaft cortex width, and displacement of fracture fragments. Postoperative: Quality of reduction, a visible gap or step, evidence of union, fracture collapse, and failure. RESULTS: The failure rate was 31 percent. The two most important predictors were varus reduction and perceived difficulty in achieving reduction. If the patient had a varus reduction or the surgeon had difficulty achieving a satisfactory reduction, fixation was 4.3 times more likely to fail (p = 0.007). If the patient had a varus reduction and reduction was difficult, fixation was 13.6 times more likely to fail (p = 0.04). Under this latter scenario, 75 percent of the fixations failed. CONCLUSION: In a fracture of the neck of the femur, if difficulty is encountered in obtaining a closed reduction or there is residual varus angulation, the chance of subsequent fixation failure is high. Hemiarthroplasty may be considered in these cases.

Aged↗

PubMed2003

Valgus intertrochanteric osteotomy for malunion and nonunion of trochanteric fractures.

OBJECTIVE: To evaluate the results of valgus intertrochanteric osteotomy for varus nonunion and malunion of trochanteric fractures. SETTING: University hospital. DESIGN: Retrospective clinical study. PATIENTS: Fifteen patients (age range 29-84 years) with varus malunion (11 cases) or varus nonunion (4 cases). Indication for surgery was nonunion or varus malunion with limb shortening greater than 2 cm associated with limp, abductor muscle insufficiency, hip pain, and back pain. INTERVENTION: The patients were treated by a valgus intertrochanteric osteotomy fixed with a 120 degrees double-angled blade plate. RESULTS: Average follow-up was 5.5 years (range 2-10 years). Fourteen patients healed without complications: 12 patients within 4 months; 2 delayed unions within 6 months. One patient required revision surgery for a loss of fixation due to a fall 6 weeks after surgery. This osteotomy also healed. Average lengthening achieved by osteotomy was 2 cm (range 1-5 cm). In all patients, the resulting range of flexion in the hip joint was greater than 90 degrees, Harris hip score before surgery was 73 points (range 61-83), and after surgery 92 points (range 76-98). Osteoarthritis or avascular necrosis of the femoral head did not develop in any of the cases. CONCLUSION: Valgus intertrochanteric osteotomy is an effective procedure that reliably restores hip function in trochanteric malunion or nonunion.

Adult↗

PubMed1996

Selective muscle activation following rapid varus/valgus perturbations at the knee.

Knee muscles are generally divided into groups based on their function as flexors or extensors. In this study we sought to determine if muscles were selectively activated according to their potential roles as varus or valgus stabilizers following rapid loads to the knee. While subjects were supine, varus or valgus moments were applied to the knees of 10 human subjects using a servomotor-driven perturbation device. During the experiments, electromyograms (EMG) were recorded from seven muscles, four of which had medial moment arms relative to the knee center, and three of which had lateral moment arms. It was observed that, for all medial muscles, a statistically significant increase in muscle activation followed valgus loads as compared with varus loads. All lateral muscles except the vastus lateralis showed the opposite response (as expected). These results suggest that muscles can be reflexively activated independent of their roles as flexors or extensors to provide stability to the human knee during varus or valgus loads. The timing of the reflex is consistent with that arising from joint mechanoreceptors, although polysynaptic stretch reflex may also be involved.

Electromyography↗

PubMed2005

Preoperative tibiofemoral angle predicts survival of proximal tibia osteotomy.

A prospective group study was done to clarify whether perioperative variables such as preoperative and postoperative tibiofemoral angles influence the survivorship of proximal tibia osteotomy as measured by conversion to arthroplasty and patient dissatisfaction. The results of 93 proximal tibial osteotomies in 82 consecutive patients with medial compartment osteoarthrosis were followed up for a mean of 10.9 years. All data were analyzed by the Kaplan-Meier survivorship method and the multivariate Cox proportional hazards model. Only the preoperative tibiofemoral angle was a predictor of conversion to arthroplasty and patient dissatisfaction. The ideal prognostic cutoff angle was 9 degrees or less varus. Increasing the preoperative varus alignment 1 degrees would result in a 1.2 (95% confidence intervals, 1.02-1.50) times higher risk of conversion to a total knee arthroplasty and a 1.5 (95% confidence intervals, 1.27-1.76) times higher chance of patient dissatisfaction. Factors such as age, gender, body mass index, Ahlback's classification, and postoperative tibiofemoral angle were not significant. We think that proximal tibial osteotomy should be considered for patients with medial compartment osteoarthrosis and a preoperative varus alignment of 9 degrees or less, whereas arthroplasty is a more suitable alternative for patients with preoperative varus alignment greater than 9 degrees.

Adult↗

PubMed2007

Influence of high tibial osteotomy on bone marrow edema in the knee.

To determine the influence of high tibial osteotomy on subchondral bone marrow edema in medial osteoarthritis of the varus knee, full leg-length radiographs and magnetic resonance imaging were performed in 20 patients (20 knees) before surgery, 1 year postoperatively, and at a mean of 7 years postoperatively. The extent of bone marrow edema in the medial compartment was quantified with magnetic resonance imaging in two planes using the formula for a prolate ellipsoid as follows: length x width x depth x pi/6. We used the Japanese Orthopaedic Association knee score for clinical evaluation. At the last followup, all knees with valgus alignment (10/10) showed reduced edema. In contrast, bone marrow edema increased or remained unchanged in four of 10 knees with neutral or varus alignment. The percentage of satisfactory results was 100% (10/10) in valgus knees and only 30% (3/10) in neutral or varus knees. Extent of bone marrow edema at the followup correlated with the mechanical axis and knee score. Because of the prognostic value of bone marrow abnormalities in the medial compartment observed on magnetic resonance imaging, early lateral closing wedge osteotomy should be considered in patients with varus malalignment and bone marrow edema even in mild cases of medial osteoarthritis.

Adult↗

PubMedDate not supplied

A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing.

OBJECTIVES: Antegrade femoral intramedullary nailing through a greater trochanteric insertion site has been proposed for the treatment of subtrochanteric fractures. The currently available trochanteric nails have dissimilar characteristics, and the most appropriate insertion site for satisfactory subtrochanteric fracture alignment has not been determined. This study is an analysis of 5 different trochanteric femoral nails and 3 different insertion sites using a cadaveric model of a reverse obliquity subtrochanteric femur fracture to determine the optimal trochanteric entry site. SETTING: OSHA-approved cadaveric laboratory with an OEC 9800 (General Electric Company, Fairfield, CT) fluoroscopic C-arm. METHODS: Twenty-one embalmed human cadaveric femurs were stripped of soft tissues. Three different starting points on the anteroposterior radiograph were used: at the tip of the greater trochanter, and 2 to 3 mm medial and lateral to the tip. A reverse obliquity subtrochanteric fracture was created. The Trochanteric Antegrade Nail (TAN), Gamma nail (2nd and 3rd generations), Trochanteric Fixation Nail (TFN), and the Holland Nail were then inserted. The proximal bend and radius of curvature were calculated for each nail. Varus and valgus angulation as well as lateral gapping were measured on radiographs; also calculated were the mean, range, and standard deviation. Statistical analysis was performed on angulation and gapping at the fracture site by using Fisher least significant differences analysis, based on a 2-way ANOVA test. RESULTS: The Holland nail had a proximal bend of 10 degrees and a radius of 300 cm. TAN was 5 degrees and 350 cm, TFN was 6 degrees and 150 cm, Gamma 2 was 4 degrees and 300 cm, and Gamma 3 was 4 degrees and 200 cm. The tip starting point led to the most neutral alignment regardless of nail. The lateral starting point led to varus with all nails. The medial starting point led to valgus of >6 degrees with the Holland and TFN; Gamma and TAN had better alignment with <4 degrees of valgus. Gapping of the lateral cortex was greatest with a lateral starting point. CONCLUSIONS: An analysis of 5 trochanteric intramedullary nails with different proximal bends and 3 different starting points in the greater trochanter showed that the tip of the trochanter is close to the "universal" starting point. In this cadaveric subtrochanteric fracture model, the tip starting point led to the most neutral alignment regardless of nail used. The lateral starting point led to varus and gapping of the lateral cortex with all nails. CLINICAL RELEVANCE: Subtrochanteric fractures treated with a trochanteric antegrade nail should have an acceptable reduction before nail insertion. The tip of the trochanter, or even slightly medial, on anteroposterior fluoroscopy is recommended as the universal starting point for these nails. However, slight deviations from this point and nail geometry can cause fracture site malalignment. A lateral starting point led to varus alignment and should be avoided.

Bone Nails↗

PubMedDate not supplied

Dynamic lower extremity alignment in children with achondroplasia.

The purpose of this study is to analyze lower extremity dynamic malalignment during gait using a 3-dimensional kinematics and kinetics in 13 children (3-17 years old) with achondroplasia and to compare measurements of alignment and malrotation between gait, radiographic, and clinical measures. Gait analysis in the coronal plane showed a varus malalignment of the knee (19 +/- 13 degrees) and variable tibial torsion abnormalities (13 [internal] +/- 15.7 degrees). Radiographs also showed knee varus malalignment (16 +/- 9 degrees); however, there was poor correlation with gait analysis measures (P > 0.05). In the sagittal plane, radiographs showed genu recurvatum deformity (23.5 +/- 13.2 degrees), although the sagittal plane knee kinematics were normal. Kinetic analyses of the knee showed high internal knee valgus moments (external varus moments, 0.48 +/- 0.25 N m/kg), which were significantly different from the normal population (P < 0.05). In conclusion, there is a 3-dimensional, complex, dynamic deformity of the lower extremity present in children with achondroplasia. We recommend a very careful assessment of the limb focusing on both the static and dynamic varus deformity and tibial torsion using a combination of radiographic, clinical, and gait analysis.

Achondroplasia↗

PubMedDate not supplied

Epiphyseal separation of the distal end of the humeral epiphysis: a follow-up note.

Twenty-one children with fracture-separations of the distal end of the humeral epiphysis were treated. Fifteen of the 21 children developed cubitus varus deformity after treatment. Thirteen children were treated at our hospital, and seven of these children developed cubitus varus deformity. Eight children were treated elsewhere initially and were referred to our institution after development of cubitus varus deformity. Nine patients underwent osteotomies for correction of cubitus varus deformities. Ages at injury ranged from 1-10 years. Fourteen patients were < 6 years of age. Fractures were classified according to Ogden; one was type IA, 16 were type IIA, and four were type IIC. Follow-up was from 10 months to 17 years. Most of the patients who were initially treated at our institution regained nearly normal function. All nine patients who were treated with closing wedge osteotomies regained nearly normal carrying angles. The carrying angles after treatment of the injury and osteotomy for the deformity did not change except in one patient.

Adolescent↗

PubMed2000

Mechanism-based pattern approach to classification of complex injuries of the knee depicted at MR imaging.

Complex knee injuries are common, often resulting from multiple forces: varus, valgus, hyperextension, hyperflexion, internal rotation, external rotation, anterior or posterior translation, and axial load. Certain combinations of forces are known to cause specific injury patterns. After a review of the literature, the authors developed a mechanism-based classification system based on patterns of bone marrow edema and ligament injury for complex knee injuries depicted at magnetic resonance imaging. The classification system takes into account knee position and forces and recognition of patterns of bone injury and complementary soft-tissue injury. Ten mechanism-based injury patterns were recognized: (a) pure hyperextension, (b) hyperextension with varus, (c) hyperextension with valgus, (d) pure valgus, (e) pure varus, (f) flexion with valgus and external rotation, (g) flexion with varus and internal rotation, (h) flexion with posterior tibial translation, (i) patellar dislocation (flexion, valgus, and internal rotation of femur on fixed tibia), and (j) direct trauma. Recognition of these patterns may help assess the full extent of knee injury, particularly at the posterolateral and posteromedial corners of the knee.

Anterior Cruciate Ligament Injuries↗

PubMed2004

An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique.

BACKGROUND: To date, no surgical technique to treat posterolateral knee instability anatomically reconstructs the 3 major static stabilizing structures of the posterolateral knee: the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament. HYPOTHESIS: Static varus and external rotatory stability would be restored to the reconstructed knee with a posterolateral knee injury. METHODS: The anatomical locations of the original fibular collateral ligament, popliteus tendon, and popliteofibular ligament were reconstructed using a 2-graft technique. Ten cadaveric specimens were tested in 3 states: intact knee, knee with the 3 structures cut to simulate a grade III injury, and the reconstructed knee. RESULTS: For the varus loading tests, joint stability was significantly improved by the posterolateral reconstruction compared to the cut state at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. There were no significant differences between the intact and reconstructed knees at 0 degrees, 60 degrees, and 90 degrees for varus translation. For the external rotation torque tests, external rotation was significantly higher for the cut state than for the intact or reconstructed posterolateral knee. There was no significant difference in external rotation between the intact and reconstructed posterolateral knees at any flexion angle. CONCLUSIONS: This 2-graft technique to reconstruct the primary static stabilizers of the posterolateral knee restored static stability, as measured by joint translation in response to varus loading and external rotation torque, to knees with grade III posterolateral injuries.

Aged↗

PubMed2005

Comparison of 2 surgical techniques of posterolateral corner reconstruction of the knee.

BACKGROUND: Various surgical techniques to treat posterolateral knee instability have been described. To date, the recommended treatment is an anatomical form of reconstruction, in which the 3 key structures of the posterolateral corner are addressed: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. HYPOTHESIS: Two methods of surgical reconstruction will restore posterolateral knee instability, in terms of static laxity as well as dynamic 6 degrees of freedom kinematics, to statistically significant levels compared with the intact state. STUDY DESIGN: Controlled laboratory study. METHODS: Two surgical techniques (A and B) were used to reconstruct the posterolateral structures in 10 cadaveric knees. Static tests were performed on the intact, sectioned, and reconstructed knees at 30 degrees and 90 degrees of flexion for anterior-posterior laxity and external rotational laxity, as well as at 0 degrees and 30 degrees of flexion for varus laxity; dynamic 6 degrees of freedom kinematic testing, through a path of motion from 90 degrees of flexion to full extension, was also performed. RESULTS: For the static varus tests, external rotation and varus laxity were significantly increased after the posterolateral structures were cut. Both reconstruction techniques restored external rotation and varus laxity to levels not significantly different from the intact state. For technique B, dynamic testing did not show any significant difference for all degrees of freedom kinematics compared with the intact state. However, for technique A, a significant internal tibial rotation was observed throughout the entire path of motion from 0 degrees to 90 degrees of knee flexion. CONCLUSIONS: Both surgical techniques for anatomical posterolateral corner reconstruction showed good results in the static laxity tests. The anatomical reconstruction of all structures, including the popliteus tendon, resulted in an abnormal internal tibial rotation during dynamic testing.

Adult↗

PubMedDate not supplied

Biceps tendon tenodesis for posterolateral instability of the knee. An in vitro study.

The effects of biceps tendon tenodesis on internal-external and varus-valgus laxity were measured using fresh-frozen cadaveric specimens that had undergone sequential sectioning of the posterolateral structures and of the fibular collateral ligament. Tenodesis (using 89 N graft tension and a fixation point located 1 cm anterior to the fibular collateral ligament's insertion on the femur) was effective in restoring external rotation and varus laxity; the procedure actually overconstrained external tibial rotation at all flexion positions and varus angulation at 60 degrees and 90 degrees of flexion. Internal rotation and valgus laxity were unaffected by the tenodesis procedure. The anterior fixation point was more effective in reducing laxity than a fixation point located 1 cm proximal to the fibular collateral ligament insertion. Tenodesis using the proximal fixation point, which was nonisometric, did not restore external rotation and varus laxities to intact values at 60 degrees and 90 degrees of knee flexion. Graft tension (45 or 89 N) had no measurable effect on the results of the tenodesis. This study has demonstrated that the biceps tenodesis procedure is effective for reducing static laxity in the knee with posterolateral instability.

Biomechanical Phenomena↗

PubMedDate not supplied

The role of the popliteofibular ligament in stability of the human knee. A biomechanical study.

The popliteal tendon has a significant attachment to the fibula, the popliteofibular ligament. The role of this ligament in knee stability has not been determined. In this study we used selective cutting techniques to measure the static contribution of the popliteal tendon attachments to the tibia and the popliteofibular ligament for stability of the knee. Sectioning of all the posterolateral structures except the popliteal tendon attachments to the tibia or the popliteofibular ligament resulted in increased primary posterior translation, varus rotation, external rotation, and coupled external rotation. Although statistically significant, these increases were small. Sectioning of all the posterolateral structures resulted in larger increases in primary posterior translation, varus rotation, external rotation, and coupled external rotation. Our data indicate that the popliteal tendon attachments to the tibia and the popliteofibular ligament are important in resisting posterior translation and varus and external rotation. If an isolated injury to the posterolateral structures occurs, anatomic reconstruction of the major ligaments that restrain posterior translation and varus and external rotation may provide the best functional result. Reconstruction for isolated posterolateral instability should include anatomic attachment of the popliteal tendon to the tibia and the popliteofibular ligament.

Aged↗

PubMed2004

The management of concomitant tears of the peroneus longus and brevis tendons.

BACKGROUND: Concomitant chronic tears of both peroneal tendons rarely are reported. We present our experience in treating these injuries and suggest an algorithm for surgical treatment, determined by the presence of a functioning tendon or tendons, mobility of the remaining peroneal musculature, ankle stability, and position of the heel. METHODS: Twenty-eight consecutive patients (29 feet) were followed postoperatively for a mean of 4.6 (range 1.5 to 8) years. The mean age was 36 (range 19 to 54) years, and all patients had chronic ankle pain with or without instability and with combinations of complete, partial, or longitudinal tears of both tendons. Of the 28 patients, six had hindfoot varus and three had cavovarus. Eight patients had mechanical ankle instability, but there was no correlation between instability and the presence of hindfoot varus. RESULTS: The mean postoperative American Orthopaedics Foot and Ankle Society ankle score was 82 (range 20 to 100) points, and 91% of patients achieved normal or moderate peroneal muscle strength. Ankle instability was successfully corrected in all patients and progressive worsening of varus deformity was prevented. CONCLUSION: The presence of chronic peroneal tendon subluxation or dislocation, chronic ankle instability, or hindfoot varus deformity, in association with retrofibular pain and swelling, should alert the surgeon to the possibility of a tear of the peroneal tendons and is an indication for surgical intervention. At the time of tendon repair, every effort should be made to treat the primary or contributing causes of the tear. Our results suggest that patients with symptomatic concomitant peroneus longus and brevis tendon tears are likely to experience substantial improvement in function if operative treatment is adequate.

Adult↗

PubMed2006

Bone remodelling after total hip arthroplasty using an uncemented anatomic femoral stem: a three-year prospective study using bone densitometry.

PURPOSE: To evaluate the clinical, radiological, and densitometric changes in the bone-remodelling patterns of femoral stems aligned in neutral, valgus, or varus positions. METHODS: Between February and October 2000, 70 patients underwent unilateral total hip arthroplasty for primary osteoarthritis using an uncemented Anatomique Benoist Girard (ABG) II stem. 69 patients (30 males and 39 females) with a mean age of 59 years (range, 38-76 years) and a mean body weight of 79.3 kg (range, 29-110 kg) completed 3 years' follow-up on bone remodelling. The clinical, radiological, and densitometric changes of the neutral, valgus, and varus groups were evaluated, and the difference in bone-remodelling patterns between the 3 groups was analysed. RESULTS: 54 patients had neutrally placed stems, while varus and valgus malalignment occurred in 6 and 9 patients, respectively. Clinical and radiological evaluations were very similar among the 3 groups. Only densitometry could detect traceable changes resulting from the differing biomechanics of the neutral, varus, and valgus stem alignments. CONCLUSION: The ABG II stem design made moderate errors in alignment biomechanically tolerable. Alignment defects had no clinical consequences and resulted in minimal differences in bone remodelling.

Absorptiometry, Photon↗

PubMed1999

The popliteofibular ligament. An anatomical study of the posterolateral corner of the knee.

We designed an experimental study to prove the existence of the popliteofibular ligament (PFL) and to define its role in providing static stability of the knee. We also examined the contribution of the lateral collateral ligament (LCL). We found this ligament to be present in all eight human cadaver knees examined. These specimens were mounted on a specially designed rig and subjected to posterior, varus and external rotational forces. We used the technique of selective sectioning of ligaments and measured the displacement with a constant force applied, before and after its division. We recorded the displacement in primary posterior translation, coupled external rotation, primary varus angulation and primary external rotation. Statistical analysis using the standard error of the mean by plotting 95% confidence intervals, was used to evaluate the results. The PFL had a significant role in preventing excessive posterior translation and varus angulation, and in restricting excessive primary and coupled external rotation. Isolated section of the belly of popliteus did not cause significant posterolateral instability of the knee. The LCL was also seen to act as a primary restraint against varus angulation and secondary restraint against external rotation and posterior displacement. Our findings showed that in knees with isolated disruption of the PFL stability was restored when it was reconstructed. However in knees in which the LCL was also disrupted, isolated reconstruction of the PFL did not restore stability.

Aged↗

PubMed2001

Supracondylar extension fracture of the humerus in children. Manipulative reduction, immobilisation and fixation using a U-shaped plaster slab with the elbow in full extension.

We present a method of manipulative reduction, immobilisation and fixation using a U-shaped plaster with the elbow in extension for extension-type supracondylar fractures of the humerus in children. When the elbow is in full extension, both the extensor and the flexor muscles are neutralised during manipulative reduction and the carrying angle can be easily assessed thus preventing cubitus varus, the most common complication. In order to evaluate the efficiency of this method, we compared the clinical results of the new method with those of conventional treatment. In a group of 95 children who sustained an extension-type supracondylar fracture of the humerus, 49 were treated by the new method and 46 by the conventional method, reduction and immobilisation in a plaster slab with the elbow in flexion. Reduction and immobilisation were easily achieved and reliably maintained by one manipulation for all the children treated by the new method. In 12 children treated by the conventional method, the initial reduction failed and in seven secondary displacement of the distal fragment occurred during the period of immobilisation in plaster. All required a second or third manipulation. Of the 46 children, 28 (60.9%) had developed cubitus varus at a mean follow-up of 4.6 years when treated by the conventional method. None of the children treated by the new method developed cubitus varus. The mean score, according to the Hospital for Special Surgery (HSS) elbow scoring system, was 91 points using the new method and 78 with the conventional method. The results were statistically significant with regard to the incidence of cubitus varus and the elbow score (p < 0.01) suggesting that the new method is reliable and gives a satisfactory outcome.

Adolescent↗

PubMed2005

Double-elevating osteotomy for late-presenting infantile Blount's disease: the importance of concomitant lateral epiphysiodesis.

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount's disease. The mean age of patients was 9.1 years (7 to 13.5). All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time. The mean pre-operative angle of depression of the medial tibial plateau of 49 degrees (40 degrees to 60 degrees ) was corrected to a mean of 26 degrees (20 degrees to 30 degrees ), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6 degrees (14 degrees to 66 degrees ) was corrected to 0 degrees to 5 degrees of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2 degrees to 5 degrees of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.

Adolescent↗