Distal femoral osteotomy: is internal fixation better than external?

Staged Extra-Articular Deformity Correction in the Setting of Total Knee Arthroplasty

Background

Extra-articular lower-leg deformities mandate unique considerations when planning total knee arthroplasty (TKA). Poor limb alignment may increase perioperative complications and cause early implant failure. This study reports on the safety and efficacy of staged, extra-articular deformity correction about the knee in the setting of osteoarthritis and TKA.

Methods

A retrospective review was conducted from December 2007 to December 2019 identifying 30 deformities in 27 patients (average age: 52.7 years; range 31-74) who underwent staged surgical correction of extra-articular deformity in preparation for TKA. Patient demographics, surgical details, clinical and radiographic measurements, severity of knee arthritis, and complications were collected.

Results

There were 17 femur and 12 tibia deformities. There was an average improvement of 14.7° of deformity measured in the coronal plane and 12.7° of deformity in the sagittal plane in the femur and 13.5° in the coronal plane and 10.3° in the sagittal plane in the tibia. Leg length discrepancies improved by 26 mm on average (1-100 mm). After an average 3.1-year follow-up, 12 out of 27 patients proceeded with primary or revision TKA. There were no cases of blood transfusion, nerve palsy, or compartment syndrome, and all patients achieved bony union.

Conclusions

Staged, extra-articular deformity correction is a safe and effective approach to improve limb alignment in the setting of knee osteoarthritis and TKA.

Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults

Background

Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described1-6. The presently described wedgeless V-shaped osteotomy7,8 is a good option among the various alternative procedures listed below.

Description

The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner.

Alternatives

Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies1-6. All of these procedures have certain limitations and shortcomings.

Rationale

The wedgeless V-shaped osteotomy is another described procedure that is inherently stable7,8. It is a safe procedure and yields good clinical outcomes8,9. The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process.

Expected Outcomes

In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al.8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (range, 16° to 29°) preoperatively to 5.1° (range, 0° to 10°) postoperatively (p < 0.001). Similarly, the mean lateral distal femoral angle improved from 79.2° preoperatively to 89.1° postoperatively (p < 0.001) and the mean mechanical axis deviation improved from 19.6 mm preoperatively to 3.7 mm postoperatively (p < 0.001). A total of 44 of 46 cases had an excellent functional outcome, with the other 2 having good outcomes. None of the patients in the study had an unsatisfactory outcome.

Important Tips

It is important to keep the whole lower limb accessible to the image intensifier intraoperatively.Identification of the leash of vessels underneath the vastus medialis is important to decide the level of the osteotomy.It is important to preserve the periosteal sleeve on the lateral aspect of the femur.

Acronyms and Abbreviations

CORA = center of rotation of angulationECG = electrocardiogramLDFA = lateral distal femoral angleMAD = mechanical axis deviationMPTA = medial proximal tibial angle.

Combination of external fixation using digital six-axis fixator and internal fixation to treat severe complex knee deformity

BACKGROUND

Severe knee valgus/varus or complex multiplanar deformities are common in clinic. If not corrected in time, cartilage wear will be aggravated and initiate the osteoarthritis due to lower limb malalignment. Internal fixation is unable to correct severe complex deformities, especially when combined with lower limb discrepancy (LLD). Based on the self-designed digital six-axis external fixator Q spatial fixator (QSF), which can correct complex multiplanar deformities without changing structures, accuracy of correction can be improved significantly.

METHODS

This retrospective study included 24 patients who suffered from complex knee deformity with LLD treated by QSF and internal fixation at our institution from January 2018 to February 2021. All patients had a closing wedge distal femoral osteotomy with internal fixation for immediate correction and high tibia osteotomy with QSF fixation for postoperative progressive correction. Data of correction prescriptions were computed by software from postoperative CT scans.

RESULTS

Mean discrepancy length of operative side was 2.39 ± 1.04 cm (range 0.9-4.4 cm) preoperatively. The mean difference of lower limb was 0.32 ± 0.13 cm (range 0.11-0.58 cm) postoperatively. The length of limb correction had significant difference (p < 0.05). The mean MAD and HKA decreased significantly (p < 0.05), and the mean MPTA and LDFA increased significantly (p < 0.05). There were significant increase (p < 0.05) in the AKSS-O, AKSS-F and Tegner Activity Score. The lower limb alignment was corrected (p < 0.05). The mean time of removing external fixator was 112.8 ± 17.9 days (range 83-147 days).

CONCLUSIONS

Complex knee deformity with LLD can be treated by six-axis external fixator with internal fixation without total knee arthroplasty. Lower limb malalignment and discrepancy can be corrected precisely and effectively by this approach.

Acute correction of distal femoral deformities by retrograde femoral nail using preoperative planning

PURPOSE

This study presents the technique and results of acute correction of distal femoral deformities using retrograde femoral nailing based on preoperative planning without using a fixator.

METHODS

Twenty-eight patients (34 limbs: 22 left-sided, 12 right-sided, mean age = 36 years) undergoing distal femoral deformity correction with retrograde femoral nailing between 2013 and 2020 were examined retrospectively. The osteotomy line, block screw location and number were identified by detailed preoperative planning. Osteotomy was performed using the percutaneous multiple drill method, and the retrograde femoral nail was placed.

RESULTS

The average follow-up period was 62.7 months (range: 13-84 months). Postoperatively, the mean mechanical axis deviation was corrected to 6.8 mm (range: 0-8 mm) and the mean mechanical lateral distal femoral angle to 87.42° (range: 84-90°). The Association for the Study an Application of the Method of Ilizarov (ASAMI) score was excellent for all patients. None of the patients had fracture, infection, implant failure, or non-union.

CONCLUSION

Distal femoral deformities can be corrected acutely, without applying external fixators, with good preoperative planning and using the retrograde femoral nail. This technique is safe and effective, with a low complication rate.

Surgical principles for complex primary total knee arthroplasty in the presence of extra-articular deformity

Background

Accurate restoration of alignment is vital to the success of a total knee arthroplasty (TKA) procedure. Deformities, whether these are intra-articular and/or extra-articular AND/OR whether these are uniplanar/multiplanar/complex, can impose varying technical challenges in surgical planning and execution. Literature on performing TKA in presence of limb deformity is limited, especially for extra-articular deformities.

Objectives

The objectives of this narrative review are twofold. Firstly, we analyse the existing English literature for studies focussed on TKA and deformity correction and summarise the important points about deformity pathomechanics, clinical and radiological assessment, pre-operative planning and surgical techniques. The second objective is to provide the readers with a simplistic and wholistic management algorithm to assist surgeons in meticulous planning to tackle the technical challenges imposed by lower limb deformities while performing a TKA.

Discussion

Approach to each patient must be holistic and customised on an individual basis according to patient characteristics, deformity characteristics and surgeon experience. The three main options available are: (1) Primary TKA (symmetric cuts/asymmetric cuts with/without computer navigation assistance) (2) Single stage corrective osteotomy and TKA and (3) Two-staged deformity correction and TKA. A multi-disciplinary team approach is required and a knee surgeon well-versed in revision arthroplasty and a limb reconstruction surgeon specialising in deformity correction, should be involved from the outset. The use of computer navigation technology, particularly for deformity correction and TKA, has increased over the last couple of decades and is recommended by the authors for these challenging cases.

FAST- Fixator Assisted Submuscular plating Technique-A simplified technique of submuscular plating in paediatric femur fractures

The surgical management of paediatric femur fractures has evolved over the last few decades. Intramedullary stabilization with titanium elastic nail (TENS) is the preferred surgical management for length stable and mid diaphyseal femur fractures in children between 5-11 years of age. However, TENS is not preferred in length unstable fractures and in proximal or distal metaphyseal femur fractures due to higher incidence of angulation and shortening at fracture site. In such scenarios, submuscular plating has come up as an alternative surgical treatment modality which avoids these complications and provide good functional outcome. Many authors have suggested different surgical variations in techniques of submuscular plating for paediatric femur fracture. We have devised a technique of submuscular plating with help of external fixator (FAST) in paediatric femur fractures which minimises the surgical time and simplifies the procedure.

Accuracy and Safety of Distal Femoral Valgus Correction: A Comparison of Three Techniques

Introduction

There are several methods for correcting distal femoral valgus deformity in skeletally mature patients including fixator-assisted plating (FAP), fixator-assisted nailing (FAN) and nailing using the reverse planning method. The fixator-assisted techniques have been previously compared in the literature and found to be similarly accurate. This study is the first to compare all three procedures in a single series.

Materials and methods

A retrospective review of patients who had undergone distal femoral valgus correction at a single institution between March 2017 and February 2020 was undertaken. Three different patient groups were identified based on the surgical technique used: the FAP, the FAN and the reverse planning method. The mechanical lateral distal fimoral angle (mLDFA) was recorded and compared preoperatively and postoperatively. The body mass index (BMI), duration of surgery, postoperative range of motion (ROM) and complication profile for each patient were also recorded and compared.

Results

A total of 27 limbs in 24 patients were included in this study. There were 8 male and 16 female patients. There were 10 limbs from 9 patients in the reverse planning group, 11 limbs from 11 patients in the FAN group and 6 limbs from 4 patients in the FAP group. There was a statistically significant difference in the mean preoperative and postoperative mLDFA for each of the individual groups (p < 0.0001 for each group). All patients had restoration of the mLDFA to within normal limits except one patient in the reverse planning group. This was purposefully performed to compensate for an ipsilateral proximal tibial deformity. There was no statistically significant difference in the mean preoperative and postoperative mLDFA across the groups (p = 0.2897 and 0.3440, respectively). The operative time of the reverse planning method and the FAP were significantly shorter than FAN (p = 0.0016 and p = 0.0035, respectively). The mean final knee ROM amongst the groups was similar (p = 0.8190). We recorded no infections or union complications in any group. There was one case of hardware irritation causing lateral knee pain that did not require treatment in the reverse planning group and one fracture through a temporary half-pin site in the FAN group. All six plates in the FAP group had to be removed following union on account of localised discomfort from the hardware.

Conclusion

The reverse planning method, the FAN and the FAP are comparable in terms of accuracy in achieving correction of distal femur valgus deformity in skeletally mature patients. The reverse planning method had the best combination of outcomes in this study since it was just as accurate as the FAN and the FAP techniques and did not require any additional surgeries. While both the reverse planning and the FAP were faster than the FAN technique, the reverse planning method allows the ability to perform both deformity correction and lengthening. Ultimately, the decision of which technique to use depends on a combination of the patient's preference and the surgeon's level of comfort with the technique.

How to cite this article

Iobst C, Waseemuddin M, Bafor A. Accuracy and Safety of Distal Femoral Valgus Correction: A Comparison of Three Techniques. Strategies Trauma Limb Reconstr 2020;15(1):41-46.

Femoral derotation osteotomy in children with cerebral palsy using the pediatric proximal femoral nail

We designed a pediatric proximal femoral nail (PPFN) to overcome fixation method-related complications when performing femoral derotation osteotomy in cerebral palsy patients. Preliminary results of cerebral palsy patients who underwent femoral derotation osteotomy fixed using PPFN to treat in-toeing were evaluated. Sixteen patients with a mean age of 10 years were included. Mean follow-up duration was 36 months. There was no significant difference in the follow-up neck-shaft angle and articulotrochanteric distance values (P = 0.2 and 0.3). PPFN provides stable fixation, early weight-bearing, reduces soft-tissue disruption while limiting the complications due to fixation technique.

Management of Extra-articular Deformity in the Setting of Total Knee Arthroplasty

Extra-articular deformities of the femur and tibia in conjunction with advanced knee osteoarthritis pose unique challenges for the arthroplasty surgeon. Careful preoperative planning is needed to evaluate both the intra- and extra-articular deformities and to determine the best route to total knee arthroplasty. An intra-articular compensatory correction can typically be performed if the extra-articular deformity is distant from the joint or if preoperative templating shows that bony cuts do not interfere with ligamentous attachments. Staged osteotomy followed by arthroplasty is beneficial in severe cases in which bony cuts are excessive or would interfere with soft-tissue structures and in cases with leg-length discrepancy. Osteotomies can be performed percutaneously and fixed with intramedullary nails, external fixators, or plate and screw constructs. Ligamentous laxity after correction and risk of peroneal nerve injury are increased in extra-articular deformity cases and must be considered during the knee arthroplasty procedure with increased implant constraint and patient counseling, respectively. Computer-assisted navigation has an emerging role in total knee arthroplasty in patients with extra-articular deformity.

Correction of distal femoral valgus deformities with fixator-assisted plating: How accurate is the correction?

Objective

The aim of this study was to evaluate the results of fixator assisted correction of the distal femoral valgus deformities and the precision of the correction.

Methods

Seventeen extremities of 13 patients (7 women and 6 men; mean age: 16 ± 5.4 years) who had fixator assisted plating of the distal femur for genu valgum deformity were evaluated. Mechanical axis deviation (MAD) and mechanical lateral distal femoral angles (mLDFA) were measured pre-operatively and post-operatively. mLDFA was graded as perfect if it is between 85° and 90°(85° ≤ x ≤ 90°); overcorrection if it is between 91° and 95° (91° ≤ x ≤ 95°) and undercorrection if it is between 80° and 85° (80° ≤ x < 85°). Measurements beyond those limits were graded as a poor result. The position of the mechanical axis line with respect to center of the knee was graded from zone 1 to zone 4 pre-operatively and post-operatively.

Results

The mean follow-up period was 12.8 ± 3.7 months. The pre-operative and post-operative mLDFA was 70.5°±9.4° (range, 57°–82°) and 87.7° ± 3.5° (range, 80°–94°), respectively (p < 0.001). Based on post-operative standing radiographs, the correction was graded perfect in 12 femurs. The correction in three femurs were graded as overcorrection and graded as undercorrection in two femurs. Sagittal plane correction was also achieved in two femurs. Peroneal nerve decompression was done in three patients (5 extremities) with valgus deformity over 30°. The mechanical axes in all lower extremities were passing through zone 2 or more, pre-operatively, whereas the mechanical axes were in zone 2 or more in five extremities post-operatively.

Conclusion

Fixator assisted plating is an effective treatment modality in patients with distal femoral valgus deformity. Although the technique enables to obtain significant correction in coronal plane it has the disadvantages of over- and undercorrection. Thus, we advise intraoperative confirmation of the correction under fluoroscopic control.

Level of Evidence: Level IV Therapeutic Study.

Total Knee Arthroplasty after Correction of Tibial Diaphyseal Nonunion with Clamshell Osteotomy

Total knee arthroplasty is mostly done to relieve pain and disability from a severe and degenerated knee. Deformities in the coronal and sagittal plane could be corrected with the help of cuts made in tibia and femur during total knee replacement as well as with ligament release. However, large deformities in the lower extremity particularly in the diaphysis region need correction prior to the total knee replacement. It helps to limit the amount of bone that will be cut and helps the ligament release. Several extra articular and intra-articular methods for the correction of diaphyseal deformity have been described. We present the case of clamshell osteotomy for the correction of diaphyseal deformity in the tibia and a total knee replacement after the osteotomy site healed.

Double femoral osteotomy fixed with a Puddu plate and a retrograde intramedullary nail to treat biapical deformity of the femur

Biapical femoral deformities are challenging to treat. In order to correct concomitant metaphyseal and diaphyseal deformities of the femur, the authors propose a double femoral controlled osteotomy with combined internal fixation, consisting of a Puddu plate and an intramedullary nail. The method was described in two patients. Results were analyzed using a visual analog scale (VAS), the Lysholm score, and SF-36. No complications were found. Complete consolidation of the osteotomies and radiographic alignment correction were achieved. Results were obtained with a minimum follow-up of 66 months. Both patients had improved for pain (VAS from 60 to 40 and from 50 to 20 at reassessment), function (Lysholm score from 78 to 93 and from 55 to 73) and quality of life (SF-36, both mental - from 40.7 to 57.1 in case one and from 24.7 to 59.7 in case two - and physical - from 27.7 to 45.6 and from 28.2 to 46.8). The authors have found that this technique is a reliable, accurate, and reproducible solution for biapical deformities of the femur.

Simultaneous Acute Femoral Deformity Correction and Gradual Limb Lengthening Using a Retrograde Femoral Nail: Technique and Clinical Results

INTRODUCTION

Patients with limb-length discrepancies often have concomitant deformity. We describe the outcomes of acute, fixator-assisted deformity correction with gradual lengthening using the retrograde femoral Precice nail (NuVasive).

METHODS

We analyzed a retrospective series of 27 patients in whom an external fixator was combined with a Precice nail to correct angular or rotational deformity and limb-length discrepancy. The fixator was applied temporarily to restore normal alignment. The Precice nail was inserted and locked in place to hold the correction, with gradual restoration of limb length.

RESULTS

The 27 patients (mean age, 28 years) had a mean follow-up of 13 months. Secondary deformities were mainly valgus (15 patients) and varus (10 patients). Postoperatively, 93% of patients had correction of limb length to within 3 mm of the discrepancy (mean lengthening, 30 mm). Mechanical axis deviation was corrected to within 8 mm of neutral (ie, zero) in 81% of patients. The mechanical lateral distal femoral angle was corrected to a mean of 88° postoperatively. Final Association for the Study and Application of Methods of Ilizarov (ASAMI)-Paley scores were excellent for 96% of patients.

DISCUSSION

The use of intramedullary lengthening nails has revolutionized the field of limb lengthening. The results of our study show that a retrograde femoral Precice nail can be used safely and accurately to correct both limb-length discrepancy and deformity with minimal complications. The benefits of using this implant include the ability to maintain knee range of motion during the lengthening process. Rapid bone healing allows a relatively fast return to weight-bearing ambulation.

CONCLUSIONS

The Precice nail was effectively used to correct both limb-length discrepancy and deformity, with excellent overall outcomes. This surgical technique may help avoid the complications that can occur with prolonged postoperative use of an external fixator.

LEVEL OF EVIDENCE

Level IV retrospective study.

Single Cut Distal Femoral Varus Osteotomy (SCFO): A Preliminary Study

BACKGROUND

Genu valgum usually originates from a deformity of distal femur that is often corrected by distal femoral varus osteotomy. The osteotomy includes both components of angulationcorrection and translation because the site of osteotomy is not commonly at the apex of deformity. Improvement of patellar tracking not only depends on valgus correction, but also it may be partially due to centralization of the trochlear groove under the femoral anatomical axis (FAA).We asked whether we could accurately correct the deformities based on our preoperative goals for the correction of the mechanical axis and centralization of the trochlear groove under the FAA by using a single bone cut.This study describes a new lateral single cut distal femoral osteotomy (SCFO) that enables concurrent correction of angulation and translation.

METHODS

This study was done on 12 young adult patients with femoral juxta-articular genu valgum deformity using SCFO. The average age at operation was 21 years (range: 16-25). SCFO is a type of closing-opening distal femoral osteotomy that corrects the valgus deformity of the distal femur while the translation of the distal fragment is done using one oblique cut. It centralizes the trochlear groove under the FAA. We compared the pre and postoperative radiographic and clinical variables including mechanical tibiofemoral angle, knee range of motion (ROM), International knee documentation committee (IKDC) score and the time to union. Mean follow-up of the patients was 24 months.

RESULTS

The average mechanical tibiofemoral angle improved from 16 degrees (10-23) to 1 degrees (-2 to +2). IKDC subjective score slightly improved from preoperative (65) to 2-year follow-up (71). Centralization of the trochlea was achieved in all patients.

CONCLUSION

SCFO can be a reasonable alternative for correction of the distal femur genu valgum deformity. It can centralize the patellar groove under the FAA with satisfactory clinical outcomes.

Open Wedge Distal Femoral Osteotomy: Accuracy of Correction and Patient Outcomes

BACKGROUND

There is a renewed interest in joint preservation surgery, and lateral opening wedge distal femoral osteotomy (DFO), a joint-preserving procedure, has been used to treat symptomatic genu valgum when the deformity originates in the distal femur.

QUESTIONS/PURPOSES

This study aimed to measure the accuracy of lateral opening wedge DFO in achieving deformity correction using radiographic parameters. In addition, the ability of lateral opening wedge DFO to improve patient outcomes as measured by Short Form Health Survey (SF-36) scores and American Academy of Orthopedic Surgeons (AAOS) lower limb module (LLM) scores leading to successful joint preservation was assessed.

METHODS

The clinical charts and radiographs of 28 consecutive patients that underwent 41 DFOs (15 unilateral and 13 staged bilateral) using a locking plate construct were retrospectively reviewed. The mean age of patients undergoing DFO was 44 years (range 22-72), and 22 of the patients were female. The mean follow-up was 26 months (range 12-57 months). Preoperative and postoperative radiographs were evaluated for mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and the patella congruence angle (PCA). These measurements were compared to determine the accuracy of deformity correction. Clinical outcomes were assessed with preoperative and postoperative SF-36 and AAOS LLM, as well as Oxford knee scores at follow-up.

RESULTS

The accuracy of deformity correction was 95%. The MAD significantly improved from 25.3 mm lateral to the midline to 8 mm medial to the midline (p < 0.01). The LDFA significantly improved from 83.4° to 91.7° (p < 0.01). The PCA significantly improved from 30.4° lateral to 5.7° lateral (p = 0.02). Mean SF-36 scores significantly improved from 37.5 to 50.2 (p = 0.01); mean LLM scores improved from 71.6 to 85.9 (p = 0.021), and the mean postoperative Oxford knee score was 35 ± 6.2 (range 23-46). No patients required total knee arthroplasty at the time of final follow-up.

CONCLUSION

Opening wedge lateral DFO is a reliable procedure for the treatment of valgus knee malalignment with or without arthritic changes in the lateral compartment. Deformity correction is accurate, and patient outcomes reveal significant improvement after surgery. Longer follow-up is required to access the survivorship of this procedure.

Corrective osteotomy of the distal femur with fixator assistance: A novel technique of minimally invasive osteosynthesis

PURPOSE

Varus or valgus deformity of the distal femur may progress into knee osteoarthritis. To delay or prevent this, various types of corrective osteotomy techniques have been used to shift the mechanical axis from the diseased compartment to the healthy one. We introduced a new, minimally invasive osteotomy of the distal femur with the assistance of temporary external fixation.

METHODS

We retrospectively studied 25 legs that underwent open-wedge osteotomy of the distal femur, involving insertion of a Schanz pin at the medial femoral condyle and another pin at the distal diaphysis of the femur. At the meta-diaphyseal junction, osteotomy was performed. After achieving angular correction, two pins were locked for temporary external fixation and a locking plate was fixed at the lateral side of the femur submuscularly. Radiological and functional outcomes were evaluated, including mechanical lateral distal femoral angle (m-LDFA), mechanical axis deviation, tibiofemoral angle, osseous union, and knee joint motion.

RESULTS

The minimum follow-up was 12 months (mean, 39 months; range, 12-88 months). Bone healing occurred in all legs, with an average of 16.6 weeks. The m-LDFA was corrected from 77.7° (18 valgus) and 104.6° (7 varus) to 88.1° after surgery, with an average correction of 12.9°. At the final follow-up, the mechanical axis deviation averaged 7.6 mm and the tibia-femoral angle averaged 5.6°. Most of legs (88%) achieved acceptable m-LDFA (87° ± 3°).

CONCLUSIONS

A new, minimally invasive osteotomy of the distal femur offers excellent bone healing with few complications, attributable to preserved blood supply.

Femoral supracondylar focal dome osteotomy with plate fixation for acute correction of frontal plane knee deformity

Focal dome osteotomy (FDO) allows deformity correction without secondary translational deformity. The purpose of this study was to evaluate the degree of correction and knee functional outcome after correction of frontal knee deformity using femoral supracondylar FDO fixed with plate and screws. A prospective study included 12 consecutive cases of femoral frontal plane deformity that underwent correction using supracondylar focal osteotomy fixed by plate and screws. Average age was 27 years, while mean follow-up was 2.1 years. Functional assessment was done using the Hospital for Special Surgery (HSS) knee score. The HSS knee score improved from 85 to 96.8 points. Desired correction was achieved in all cases. Postoperative mechanical axis analysis on long film and scanogram showed no secondary deformity. The overall postoperative mechanical axis was at 3.2 mm medially (range 2-5 mm). Autogenous bone graft was not used in any case, and uneventful osteotomy union was achieved at a mean of 13.8 weeks. Minor complications were encountered in two cases. There were no implant failures or reoperations. Supracondylar FDO of the femur with plate fixation is a reproducible technique that can produce full correction of distal femoral frontal plane deformity, while avoiding creating a secondary deformity. Knee function was improved with good patient satisfaction.

Distal femoral osteotomy

Osteotomies around the knee are well-recognized treatments for unloading the affected compartment in cases of lower limb malalignment. There are few papers in the literature describing the outcomes of distal femoral osteotomy (DFO), as compared with the studies reporting on high tibial osteotomy (HTO), probably because valgus malalignment is less common than the varus one. There is still debate as to what the correct indication is and which surgical techniques lead to the best outcomes in performing a DFO. Besides, it is still controversial whether patellofemoral arthritis should be considered as a contraindication to performing a DFO, as well as in HTO. In this article, we will summarize the indications for DFO, the surgical techniques reported in the literature, and their outcomes.

Deformity correction by femoral supracondylar dome osteotomy with retrograde intramedullary nailing in varus deformity of the distal femur after pathologic fracture of giant cell tumor

Angular deformities of the distal femur occur in congenital diseases or due to acquired causes, such as malunion after a fracture of the distal femur. Angular deformities of the lower extremities affect the mechanical axis, causing changes in the weight pressure on the articular surface. As a result, angular deformities quicken the progression of osteoarthritis. Therefore, correction of deformities should be performed to prevent the progression of osteoarthritis. Distal femoral osteotomy is one of the methods to correct angular deformities in unicompartmental osteoarthritis. However, femoral supracondylar dome osteotomy with retrograde intramedullary nailing in the distal femur with a varus deformity has been rarely reported. Herein, we describe a technique for femoral supracondylar dome osteotomy with retrograde intramedullary nailing in a varus deformity after a pathologic fracture of giant cell tumor in the distal femur with a review of the relevant literature.

The results of corrective osteotomy for valgus arthritic knees

PURPOSE

To evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity.

METHODS

The data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications.

RESULTS

A total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence.

CONCLUSION

The role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates.

LEVEL OF EVIDENCE

IV.