Revision anterior cruciate ligament reconstruction: associated patholaxity, tibiofemoral malalignment, rehabilitation, and results.
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Anterior Cruciate Ligament↗
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Results for “Bone Malalignment”
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Prevalence of bowlegs among child and adolescent soccer players.
OBJECTIVE: Little is known about the interactions of sports-related demands and human body, in particular on musculoskeletal features, during growth. Focusing on the relationship between soccer and lower limb alignment, we examined the hypothesis that varus knee deviation is more prevalent among high-performance pediatric and adolescent soccer players. DESIGN: Cross-sectional study with focused sampling. SETTING: First league sports clubs. PARTICIPANTS: 106 male child/adolescent soccer players aged 10 to 21 years and 68 age-matched tennis players. INTERVENTIONS: All athletes completed a demographic questionnaire and underwent physical examinations, which included height, weight, generalized laxity, knee, ankle, foot and spine axis, hip range of motion, tibial torsion, Q angle, foot navicular height, and progression angle. MAIN OUTCOME MEASUREMENT: Varus/valgus axis was determined by the intercondylar intermalleolar distance while standing. Soccer and tennis players were compared on knee axis and other outcome variables by analysis of covariance, adjusting for age and by t-tests within age groups. RESULTS: A significantly higher prevalence of knee varus was found among the soccer players compared to that among the tennis players. The difference in intracondylar distance was statistically significant after the age of 13 years (P < 0.001). In addition, compared to tennis players, soccer players had higher foot arches, decreased hip external rotation and increased external tibial torsion. CONCLUSIONS: Varus knee axis deviation was more common among children and adolescent soccer players than among tennis players. The prevalence was more pronounced among players aged 13 years or older. Further research is needed to explore the rationale of this phenomenon.
Adolescent↗
The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease.
OBJECTIVE: Varus and valgus malalignment increase the risk of medial and lateral osteoarthritis (OA) progression, respectively. The impact of a mechanical factor such as alignment depends not only on the factor itself, but also on the state of the joint. The less-damaged joint of mild OA may be less vulnerable to malalignment effects than the more-damaged joint of moderate OA. Our goal was to explore the impact of alignment on subsequent progression of knee OA according to the baseline stage of disease. METHODS: Two hundred thirty patients with knee OA (defined by the presence of osteophytes and symptoms) recruited from the community underwent assessment of both lower limbs at baseline and at an 18-month followup. Alignment was measured on a full-limb radiograph as the angle made by the intersection of the femoral and tibial mechanical axes. Compartment-specific progression was defined as an increase between baseline and 18 months in the grade of severity of joint space narrowing on radiographs of semiflexed knees taken after fluoroscopic confirmation of position. Knees were grouped according to their baseline stage of OA as Kellgren/Lawrence (K/L) grades 0-1, 2, or 3. Progression odds ratios were estimated from logistic regression using generalized estimating equations. RESULTS: There were 377 K/L grade 0-3 knees in 230 subjects (173 women and 57 men, mean age 64.0 years, mean body mass index 30.4 kg/m(2)) in this longitudinal study. In knees with mild OA (K/L grade 2), the odds of 18-month progression in the medial compartment were significantly increased 4-fold by varus alignment at baseline. In K/L grade 2 knees, the odds of lateral progression were increased 2-fold by valgus alignment (approaching significance). In knees with moderate OA (K/L grade 3), the risk of progression was comparably increased by varus or valgus alignment (10-fold). CONCLUSION: While some effect of malalignment was suggested at almost all stages of knee OA examined, the impact of varus or valgus malalignment on the odds of OA progression over the ensuing 18 months was greater in knees with moderate (K/L grade 3) OA at baseline, possibly due to greater joint vulnerability with some contribution from slightly more severe malalignment.
Aged↗
Technical report: radiological evaluation of patellar malalignment using a new frame for axial imaging of the patellae.
Axial radiographs were performed on 59 children and adolescent patients with patellar malalignment using the method described by Laurin. A special frame was used to keep the knees in 20 degrees flexion and to maintain standard conditions. Radiological indices were measured before realignment surgery. A statistically significant difference (P < 0.0001) in the lateral patellofemoral angle was observed comparing malaligned and control patellae. Laurin's technique using a special frame provides a method of obtaining standard radiological measurements of patellar malalignment for use in surgical planning.
Adolescent↗
Patellofemoral malalignment in adolescents. Computerized tomographic assessment with or without quadriceps contraction.
Twenty-seven adolescents with anterior knee pain with or without patellar instability were studied by computerized tomography to detect patellofemoral malalignment. The examination was performed with and without quadriceps contraction with the knee flexed to 15 degrees. Congruence angle, patellar tilt angle, sulcus angle, and trochlear depth were measured. This investigation showed the well-known types of patellofemoral malalignment with quadriceps relaxed (tilted, lateralized, lateralized, and titled patella) and, in 52% of cases, revealed changes in type and severity with quadriceps contraction (in 41%, lateralization and tilting were markedly more evident; in 11%, the type of malalignment changed). The results demonstrate that, in addition to assessment with quadriceps relaxed, computerized tomography with quadriceps contraction is a useful adjunct to diagnose and define the type of malalignment in particularly difficult circumstances.
Adolescent↗
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↗
Unilateral fixators and mechanical axis realignment.
Unilateral fixators have been used successfully for mechanical axis realignment. Immediate correction of angular deformity is usually preferred with monolateral fixation. This article discusses the principles of immediate versus gradual correction and the range of acceptable malalignment. The principles, technique, and results of complex deformity correction also are discussed.
Bone Malalignment↗
A longitudinal study of the association between knee alignment and change in cartilage volume and chondral defects in a largely non-osteoarthritic population.
OBJECTIVE: It remains unclear whether malalignment of the knee is a cause of knee OA or a marker of disease progression. We investigated whether baseline malalignment of the knee predicts subsequent change in knee cartilage volume and chondral defects in subjects with and without radiographic knee osteoarthritis (OA). METHODS: A convenience sample of 315 male and female subjects (mean age 45 yrs, range 26-61) was followed up for a mean period of 2.4 years. Anatomic knee alignment was assessed on a standing anterior-posterior semiflexed view of the right knee and defined as the angle subtended by a line drawn through the midshaft of the femur with respect to one drawn through the midshaft of the tibia. T1-weighted fat saturation magnetic resonance imaging scans were performed on the same knee at baseline and followup for cartilage volume and chondral defects. RESULTS: Knee alignment was normally distributed in this sample with a mean of 178.2 degrees (SD 1.9 degrees). Fifty-five percent of subjects were < 178.5 degrees, while 14% were > 180 degrees. After adjustment for age, sex, body mass index, previous knee injury, and OA family history, neither category of alignment at baseline was associated with subsequent loss of lateral and medial tibial cartilage volume. Similarly, there was no association between malalignment and progression of chondral defects. The results remained the same when stratified by radiographic OA status. CONCLUSION: Our adequately powered study shows that baseline knee alignment is not associated with subsequent loss of cartilage volume or progression of chondral defects over 2 years. Further studies with a longterm followup are needed, but these results suggest malalignment is primarily a marker of disease progression.
Adult↗
A study of radioulnar movements following fractures of the forearm in children.
The range of radioulnar movements, following fractures of the forearm bones treated conservatively in 53 children under the age of 15 years, was measured by a goniometer. The most common age group was 6-10 years. All fractures united within 8 weeks and the average follow-up was 3 years. Although subjective assessment of the result was good in all cases, 52.8% had some limitation of rotational movements. The factors which limited rotation were angulatory deformity of the bones, rotational malalignment or injury to the inferior radioulnar joint. An angulatory deformity of more than 10 degrees in a child above the age of 10 years failed to remodel adequately with growth particularly if the fracture was in the proximal half of the forearm. Rotational malalignment also did not correct with growth.
Adolescent↗
Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique.
Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.
Adolescent↗
[Pediatric forearm fractures: indications, technique, and limits of conservative management].
Although several "minimal invasive" techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4-112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 degrees (15 degrees -50 degrees ). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.
Adolescent↗
MRI study of talonavicular alignment in club foot.
We studied in vivo the talonavicular alignment of club foot in infants using MRI. We examined 26 patients (36 feet) with congenital club foot. The mean age at examination was 9.0 months (4 to 12). All analyses used MRI of the earliest cartilaginous development of the tarsal bones in the transverse plane, rather than the ossific nucleus. The difference in the mean talar neck angle (44.0 +/- 8.1 degrees) in club foot was statistically significant (p < 0.001) when compared with that of the normal foot (30.8 +/- 5.5 degrees). The difference between the mean angles in the group treated by operation (47.9 +/- 6.7 degrees) and those treated conservatively (40.1 +/- 7.5 degrees) was also statistically significant. The anatomical relationship between the head of the talus and the navicular was divided into two patterns, based on the position of the mid-point of the navicular related to the long axis of the head. In the operative group, 18 feet were classified as having a medial shift of the navicular and none had a lateral shift. In the conservative group, 12 showed a medial shift of the navicular and six a lateral shift. All nine unaffected normal feet in which satisfactory MRI measurements were made showed a lateral shift of the navicular. Club feet had a larger talar neck angle and a more medially deviated navicular when compared with normal feet. This was more marked in the surgical group than in the conservative group.
Bone Malalignment↗
The hindfoot alignment view.
A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.
Adult↗
[High tibial open-wedge osteotomy using a tricalcium phosphate substitute: 70 cases with 18 months mean follow-up].
PURPOSE OF THE STUDY: We report our experience with a B tricalcium phosphate ceramic to fill open-wedge tibial osteotomy gaps. MATERIAL AND METHODS: Seventy high tibial open-wedge osteotomies were performed in 70 patients (47 men and 23 women). Ostotomy was performed for osteoarthritis in 56 knees, Ahlback classification stage I (n = 18), stage II (n = 32), stage III (n = 6) and for congenital varus in 14. Mean patient age was 45.2 years (16-69). We used a wedge-shaped piece of ceramic with an appropriate angle, which was associated with granulated material to complete the gap filling for the last 20 cases. One or two staples were used for fixation. Clinical and radiological outcome was assessed at 6 weeks, 3 months, 6 months, and at last follow-up. Mean follow-up was 18 months. RESULTS: There were no biological or clinical complications related to biomaterial intolerance. Tolerance to the osteosynthesis material was mediocre since we observed one infection and 12 cases of pain related to the staples which required material removal in 8 patients. Bone healing was achieved in 98.5%. Final correction was between 3 degrees and 6 degrees valgus in 80.5%. There was a loss of correction angle between the postoperative film and the bone healing film. Factors related to sustained correction were: non-fractured wedge, intact lateral tibial cortical, osteosynthesis with two staples. Osteointegration was good and rapid in 96%. We found two complete lucent lines at last follow-up but with variable resorption depending on the shape of the bone substitute. CONCLUSION: Use of a ceramic wedge to fill high tibial medial open-wedge osteotomy gap is a reliable reproducible technique providing correction without formation of a malalignment callus. Bone healing is achieved in 98.5% of the cases at about three months. Osteointegration is good in 96%. Resorption is complete and rapid when the substitute is implanted in granular form in a cancellous zone and is partial and slow when implanted as a massive wedge.
Adolescent↗
In vivo and noninvasive load sharing among the vasti in patellar malalignment.
PURPOSE: It is not clear how the knee extension torque is distributed quantitatively among the lateral and medial vasti in patellofemoral pain (PFP) patients with patellar malalignment, which was investigated in vivo and noninvasively in ten PFP patients and eleven controls. We hypothesized that the vastus medialis oblique (VMO) and vastus medialis longus (VML) of PFP patients contribute less to knee extension than that in controls. METHODS: Electrical stimulation was used to activate each vastus component selectively. The relationship between the knee extension torque generated by each individual vastus component and the corresponding compound muscle action potential (M-wave) was established over different contraction levels, which was used to calibrate the corresponding voluntary EMG signal and determine torque ratios of VMO/VL (vastus lateralis), VMO/VML, VML/VL and (VMO+VML)NL during voluntary isometric knee extension. RESULTS: The VMO and VML of PFP patients contributed significantly less to knee extension than their counterparts in controls. The combination of VMO and VML generated comparable amount of extension torque as the VL in the controls, while it produced significantly lower extension torque than that of the VL in the PFP patients. In addition, the VMO/VL was lower than VMO/VML and VML/VL in both PFP and control groups. CONCLUSIONS: Compared to controls, the VMO and VML in the PFP patients contributed significantly less to the knee extension torque. The approach can be used to investigate load sharing among quadriceps muscles in vivo and noninvasively, in both healthy subjects and patients with patellofemoral disorder and patellar malalignment.
Action Potentials↗
Anterior knee pain due to biplanar rotatory malalignment of the femoral component in total knee arthroplasty. Case report.
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Aged↗
A comparison of three methods for measuring patella malalignment in children.
This study compared the Insall-Salvati (IS), Blackburne-Peel (BP), and Koshino-Sugimoto (KS) methods for measuring patellar malalignment in children. The IS and BP methods were inaccurate because the traditional landmarks for measurement were absent in the incompletely ossified pediatric knee. The KS method is based on the midpoint of the patella, the distal femoral physis, and the proximal tibial physis. The KS method applied to the extended knee was also inaccurate because of laxity in the patella ligament. However, the KS method applied to the flexed knee was the most accurate method for measuring patella malalignment in children.
Adolescent↗
An analysis of the causes of failure in 57 consecutive posterolateral operative procedures.
PURPOSE: To investigate 57 failed posterolateral procedures in 30 consecutive knees to determine factors that may have contributed to the failure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patient records were reviewed by an independent surgeon. The index posterolateral operations were done for 13 acute and 17 chronic knee injuries. The anterior cruciate ligament was ruptured in 17 knees, the posterior cruciate ligament was torn in 5 knees, and both cruciates were ruptured in 8 knees. In 25 knees, 46 revision posterolateral procedures had been performed, of which 27 had also failed (in 21 knees). Five knees did not undergo revision of the posterolateral structures. RESULTS: In 22 knees, multiple factors were identified that most likely contributed to the failure of the posterolateral procedures. The most common factors were nonanatomical graft reconstruction (23 knees), untreated varus malalignment (10 knees), and failure to successfully reconstruct all ruptured knee ligaments, including cruciates (27 knees). Thirty-nine anterior cruciate ligament procedures were done in 24 knees, including 24 primary and 15 revision operations. Seventeen posterior cruciate ligament procedures were done in 13 knees, including 13 primary and 4 revision operations. At the time of writing, 16 of 24 knees had a functional anterior cruciate ligament graft and 5 of 13 had a functional posterior cruciate ligament graft. CONCLUSION: The results suggest greater emphasis during the index operation for anatomical graft reconstruction of one or more of the posterolateral structures as necessary, restoration of all ruptured cruciate ligaments, and correction of varus malalignment.
Adolescent↗