Synovial Chondromatosis with Genu Valgum in a Patient of Wilson's Disease.

Introduction: Wilson's disease is an autosomal recessive condition where excessive amount of copper accumulates in the body, especially in the liver, brain, and eyes. It is caused by a mutation in the ATP7B gene on chromosome 13. In 25-30% of patients, joint involvement occurs at the later course of disease; osteoarthritis being the commonest manifestation. Synovial chondromatosis (SC) is a benign metaplasia which occurs in the synovial membrane and it results in the formation of intra-articular loose bodies (LB), but its occurrence in a patient of Wilson's disease has not yet been reported in medical literature. Case Report: A young male in his 30s, a diagnosed case of Wilson's disease on maintenance therapy of d-penicillamine, zinc, trientine, and lithium presented to the hospital with restriction of movement at the knee joints and a valgus deformity. Examination showed firm to hard globular swellings which were partly mobile around the knee joint. The Magnetic Resonance Imaging (MRI) findings were suggestive of a SC after which the patient underwent corrective surgery and debridement and removal of the LB and a histopathology report confirmed the diagnosis. The patient was followed up at 12 weeks and was found to have pain-free movements with minimal support. His 24-h urinary copper excretion was found to be within normal limits and his maintenance therapy was optimized. The patient was initiated on speech therapy for his persistent slurring of speech and psychiatric counseling for rehabilitation in social and personal life. The patient was advised for 6 monthly follow-up. Conclusion: This case summarizes the unique presentation of SC with genu valgum in a patient of Wilson's disease and hence warrants a keen eye for the physician and orthopedician alongside osteoarthritis; which has been widely reported in Wilson's disease, thus providing an opportunity for early correction of valgus deformity of the subject.

Ten-year minimal follow-up of lateral opening wedge distal femoral osteotomy for lateral femorotibial osteoarthritis: Good survivorship and high patient satisfaction.

PURPOSE: This study aimed (1) to determine complications and survival rates of lateral opening wedge distal femoral osteotomy (LOW-DFO) in the long term, (2) to assess their clinical outcomes in the long term and (3) to identify risk factors of failure. METHODS: Between 1991 and 2011, 62 LOW-DFOs were performed in the same department. Inclusion criteria were all isolated LOW-DFO performed for isolated lateral tibiofemoral osteoarthritis and valgus malalignment, with a minimum 10-year follow-up. Thirty-eight patients were included, with a mean age of 48 ± 9 years. All patients had clinical and radiological assessments. The survival curves were calculated based on the following endpoints: unicompartmental or total knee arthroplasty. RESULTS: The mean follow-up was 15.2 ± 4.4 [10-29] years. The mean preoperative mechanical FemoroTibial Axis (mFTA) was 188.8° ± 3.2° [184°-197°], primarily due to femur deformity (mean lateral distal femoral axis [LDFA] 83.2° ± 2.8°). Bone union was achieved in 89.5% of patients (n = 34) at a mean delay of 6.5 ± 6.7 months. The complication rate was 26% (five stiffness, one nonunion, three secondary displacements and one deep vein thrombosis). Nine revision surgeries (24%) were recorded. Survival rates at 5 and 10 years were 92.1% and 78.9%, respectively. The mean delay between DFO and total knee arthroplasty (TKA) was 11.6 ± 5.7 [1-27] years. Nineteen patients (50%) were free of TKA at the last follow-up. KSS scores were improved significantly. Return to sports was obtained in 92% of cases (n = 35), with a mean delay of 11 ± 8 months. Seventy-four per cent of patients were satisfied or very satisfied with the surgery. Eighty-four per cent would be willing to undergo the surgery again. Older age (p = 0.032) was a significant risk factor for TKA conversion. CONCLUSION: LOW-DFO is an efficient procedure to manage lateral knee osteoarthritis in young patients with valgus deformity, with a good survival rate at 10 years and high patient satisfaction. LEVEL OF EVIDENCE: Level III.

Operative Management of Pediatric Physeal Bar Development and Genu Valgum.

Background: Pediatric orthopedic conditions present unique challenges due to ongoing skeletal growth and development. Managing these cases requires addressing both structural anomalies and functional deficits. Care presentation: This case report discusses a 13-year-old male with recurrent left knee pain exacerbated by physical activity. The patient's history of a left knee infection at 1.5 years of age, possibly septic arthritis or osteomyelitis, underscores the long-term consequences of early pathology on skeletal growth and alignment. Imaging studies revealed a distal lateral femur physis bar and genu valgum, necessitating surgical intervention. Management and Outcomes: The surgery involved medial distal femur hemiepiphysiodesis and lateral distal femur bar excision to correct anatomical deformities and restore optimal limb alignment and function. Postoperative rehabilitation, including targeted exercises to improve quadriceps strength, was crucial for functional recovery and reducing the risk of complications such as medial patellofemoral pain. Conclusion: This case highlights the importance of a multidisciplinary approach in managing complex pediatric orthopedic cases.

Guided growth surgery for angular deformity of the knee: one centres experience.

BACKGROUND: Angular deformity in the lower extremity can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth, which has since become the widely accepted treatment for frontal plane angular angular deformity around the knee in skeletally immature patients, treatment consisted of staples, corrective osteotomy or an angular epiphysiodesis. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the lower limb mechanical axis resulting in lower morbidity than previous treatments. In order to assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this elegant procedure. METHODS: We performed a retrospective review of prospectively collected surgical records and diagnostic imaging in our paediatric tertiary national referral centre to identify all patients who had guided growth surgery for coronal plane angular deformity of the knee from 2007 to 2023. We noted the patient demographics, diagnosis, peri-operative experience and outcome. All patients were followed until skeletal maturity, until their hardware was removed or at least 2 years. RESULTS: Two hundred thirty-six patients were assessed for eligibility. Of the 282 treated knees which met the criteria for final assessment 55 (19.5%) were unsuccessful. Complications were few but included infection and metal-work prominence. Procedures that were less likely to be successfully included growth disturbances following trauma (18.8% failure) or infection (40%), tumour (66.6%), mucopolysaccharidoses type I (15.7%), spondyloepiphyseal dysplasia (25%) or Blount's disease (60%). Idiopathic angular deformity showed an 89.5% success rate with guided growth. CONCLUSION: In our hands, guided growth had an 80.5% success rate when all diagnoses were considered. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity however caution should be employed when considering its use in certain patient groups. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Relevance of instrumented gait analysis in the prediction of the rebound phenomenon after guided growth intervention.

Predictors of rebound after correction of coronal plane deformities using temporary hemiepiphysiodesis (TH) are not well defined. The following research questions were tested: (1) Is the dynamic knee joint load useful to improve rebound prediction accuracy? (2) Does a large initial deformity play a critical role in rebound development? (3) Are BMI and a young age risk factors for rebound? Fifty children and adolescents with idiopathic knee valgus malalignment were included. A deviation of the mechanical femorotibial angle (MFA) of ≥ 3° into valgus between explantation and the one-year follow-up period was chosen to classify a rebound. A rebound was detected in 22 of the 50 patients (44%). Two predictors of rebound were identified: 1. reduced peak lateral knee joint contact force in the first half of the stance phase at the time of explantation (72.7% prediction); 2. minor initial deformity according to the MFA (70.5% prediction). The best prediction (75%) was obtained by including both parameters in the binary logistic regression method. A TH should not be advised in patients with a minor initial deformity of the leg axis. Dynamic knee joint loading using gait analysis and musculoskeletal modeling can be used to determine the optimum time to remove the plates.

Efficacy and Complications of Fixator-Assisted Correction with Internal Fixation in the Genu Valgum.

Background and Purpose: Two basic methods for genu valgum correction are osteotomy and internal fixation or external fixator assited correction. External fixators have the advantage of stabilizing fragments before osteotomy allowing better control of fragments and preventing secondary displacements. The purpose of this study was to evaluate the efficacy and complications of fixator assisted correction for genu valgum and internal fixation, using the AO distal femur pediatric osteotomy plate. Materials and Methods: Thirty-six limbs in 26 patients (age 10-16 years) underwent osteotomy in the distal femur at CORA. Open lateral wedge osteotomy was done; the desired position obtained was temporarily stabilized by connecting the pins with the AO external fixator and stabilized with 90 degrees AO distal femur pediatric locking plate and gap grafted with hydroxyapatite bone granules. Results: Translation of distal fragment was required in 17 osteotomies (53.12%). Osteotomies united within 12 weeks; no non-union was observed. The range of motion was full in all patients. The mean tibiofemoral angle was corrected by 12 degrees and the mean mechanical LDFA was corrected to 87 degrees. There was no secondary deformity, either in the rotational or sagittal plane. Conclusion: This method combines the modularity of external fixator and the advantages of internal fixation.

Incidence and management of secondary deformities after megaendoprosthetic proximal femur replacement in skeletally immature bone sarcoma patients.

INTRODUCTION: Megaendoprosthetic reconstruction of bone defects in skeletally immature patients has led to the development of unique complications and secondary deformities not observed in adult patient cohorts. With an increasing number of megaendoprosthetic replacements performed, orthopedic oncologists still gain experience in the incidence and type of secondary deformities caused. In this study, we report the incidence, probable cause and management outcome of two secondary deformities after megaendoprosthetic reconstruction of the proximal femur: hip dysplasia and genu valgum. MATERIALS AND METHODS: Retrospective analysis of 14 patients who underwent primary and/or repeat reconstruction/surgery with a megaendoprosthetic proximal femur replacement between 2018 and 2022. RESULTS: Mean patient age was 9.1 years (range 4-17 years). Stress shielding was observed in 71.4%. Hip dislocation was the most frequent complication (50%). While four dislocations occurred without an underlying deformity, secondary hip dysplasia was identified in 58.3% (n = 7/12) of intraarticular resections and reconstructions, leading to dislocation in 71.4% (n = 5/7). A genu valgum deformity was observed in 41.6% (n = 5/12). The incidence of secondary hip dysplasia and concomitant genu valgum was 42.9% (n = 3/7). Triple pelvic osteotomy led to rebound hip dysplasia in two cases (patients aged < 10 years), whereas acetabular socket replacement led to stable hip joints over the course of follow-up. Temporary hemiepiphyseodesis was applied to address secondary genu valgum. CONCLUSIONS: Patients aged < 10 years were prone to develop secondary hip dysplasia and genu valgum following proximal femur replacement in this study. Management of secondary deformities should depend on remaining skeletal growth. Stress shielding was observed in almost all skeletally immature patients.

LATERAL EPICONDYLE SLIDING OSTEOTOMY IN KNEE ARTHROPLASTIES WITH VALGUS DEFORMITY.

OBJECTIVE: To evaluate the efficacy and safety of sliding osteotomy of the lateral epicondyle in correcting rigid valgus deformity in knee arthroplasty. METHODS: A retrospective study of patients undergoing total knee arthroplasty with lateral epicondyle sliding osteotomy between 2006 and 2018. The main outcome was the incidence of complications and adverse events. Secondary outcomes were Visual Analog Scale for Pain, varus stress test, and varus knee thrust during gait. RESULTS: 19 knees (19 participants) were included in the study. The mean follow-up was 4.2 years. There were no cases of infection or reoperation due to instability. Two participants (10.5%) had mild or moderate knee pain (VAS pain = 4.6 ± 1.9). Two arthroplasties (10.5%) had mild varus stress. No participant presented varus thrust. CONCLUSION: Sliding osteotomy of the lateral epicondyle allows fast and safe ligament balance of knee valgus deformities. Level of Evidence I, Case series.

Avaliar a eficácia e a segurança da osteotomia de deslizamento do epicôndilo lateral na correção da deformidade em valgo rígida na artroplastia de joelho. Métodos: Estudo retrospectivo de pacientes submetidos à artroplastia total do joelho com osteotomia de deslizamento do epicôndilo lateral entre 2006 e 2018. O principal desfecho foi a incidência de complicações e eventos adversos. Os desfechos secundários foram escala visual analógica para dor, teste de estresse em varo e flambagem em varo do joelho durante a marcha. Resultados: Foram incluídos no estudo 19 joelhos (19 participantes). O seguimento médio foi de 4,2 anos. Não houve nenhum caso de infecção ou reoperação devido à instabilidade. Dois participantes (10,5%) apresentaram algum tipo de dor leve ou moderada no joelho (EVA = 4,6 ± 1,9). Duas artroplastias (10,5%) apresentaram estresse em varo leve. Nenhum participante apresentou flambagem em varo. Conclusão: A osteotomia de deslizamento do epicôndilo lateral possibilitou o balanço ligamentar das deformidades em valgo do joelho de forma rápida e segura. Nível de Evidência IV, Série de Casos.

Simultaneous MPFL reconstruction and guided growth result in low rates of recurrent patellofemoral instability.

PURPOSE: Implant-mediated guided growth (IMGG) is used to address coronal plane deformity in skeletally immature patients. Few studies have reported on IMGG and simultaneous medial patellofemoral ligament (MPFL) reconstruction for paediatric patients with concurrent genu valgum and patellofemoral instability (PFI). This study aimed to report on the outcomes of these simultaneous procedures. MATERIALS AND METHODS: This was a retrospective review of paediatric patients undergoing simultaneous MPFL reconstruction and IMGG between 2016 and 2023. Mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle (HKA) and mechanical axis deviation (MAD) were measured on full-length hip-to-ankle plain radiographs. Measurements were taken preoperatively, prior to implant removal and/or at final follow-up with minimum 1-year clinical follow-up. RESULTS: A total of 25 extremities in 22 patients (10 female) underwent simultaneous IMGG and MPFL reconstruction. The mean age at surgery was 12.6 ± 1.7 years. The mean duration of implant retention was 18.6 ± 11.3 months. Nineteen extremities (76%) underwent implant removal by final follow-up. Preoperative HKA corrected from a mean of 5.8 ± 2.3° to -0.8 ± 4.5° at implant removal or final follow-up (p < 0.001), with mLDFA and MAD similarly improving (both p < 0.001). HKA corrected a mean of 0.7 ± 0.9° per month, while mLDFA and MAD corrected a mean of 0.5 ± 0.6°/month and 2 ± 3 mm/month, respectively. At the time of implant removal or final follow-up, 88% of patients demonstrated alignment within 5° of neutral. Only one extremity experienced subsequent PFI (4%). For 14 patients who underwent implant removal with further imaging at a mean of 7.8 ± 4.9 months, only one patient (7%) had a valgus rebound to an HKA > 5°. CONCLUSION: Simultaneous MPFL reconstruction and IMGG provided successful correction of lower extremity malalignment with only one recurrence of PFI. This approach is a reliable surgical option for skeletally immature patients with genu valgum and PFI. LEVEL OF EVIDENCE: Level 4 case series.

Effect of Varus-Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area at Varying Degrees of Knee Flexion.

Background: In patients with valgus alignment and degenerative changes in the lateral compartment, both distal femoral osteotomy (DFO) and high tibial osteotomy (HTO) can be used to unload the lateral compartment. Prior studies have shown that in valgus knees, the tibial wear is posterior and DFO exerts the greatest effect in extension; however, its effect is decreased as flexion angle rises. Hypothesis: Medial closing-wedge (MCW) HTO would significantly decrease contact area, mean contact pressure (MCP), and peak contact pressure (PCP) in the lateral knee compartment through knee flexion to a greater extent compared with lateral opening-wedge (LOW) DFO. Study Design: Controlled laboratory study. Methods: MCWHTO and LOWDFO were performed, correcting a mean of 8° of valgus alignment, in 10 cadaveric knees using plate fixation. Tibiofemoral contact pressure of the medial and lateral compartments was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors and load applied through an Instron device. PCP, MCP, and contact area were measured for each condition. Results: The lateral MCP was significantly decreased in the HTO state compared with the native state in 30° (P = .015), 60° (P = .0199), and 90° (P < .0001) of flexion. The lateral MCP was also significantly decreased in the HTO state when compared with the DFO state in 60° (P = .0093) and 90° of flexion (P < .0001). After DFO, the lateral MCP returned to that of the native state in 60° (P > .999) and 90° (P > .999) of flexion. The lateral PCP decreased for all test states in all degrees of flexion; the HTO state was significantly decreased when compared with the native state in 60° (P < .0001) and 90° (P < .0001). Conclusion: With varus corrections of 8°, MCWHTO was more effective at unloading the lateral compartment than LOWDFO. This effect was significant as the knee flexion angle increased. This study should be considered as one aspect of the surgical decision-making process. Clinical Relevance: In patients with mild to moderate valgus deformity without hypoplastic lateral femoral condyle and without significant joint line obliquity, MCWHTO may improve offloading of the lateral compartment in flexion.

MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum.

BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

Lipoma arborescens with patellofemoral osteoarthritis and genu valgum.

Lipoma arborescens is a rare benign intra articular lesion characterized by lipomatous proliferation of the synovium. The condition typically affects the knee presenting with atraumatic pain and swelling. It should be considered in the differential diagnosis of monoarthritis and joint effusion. Diagnosis is made on MRI with characteristic features. We present a rare case of lipoma arborescens with patellofemoral osteoarthritis and genu valgum. We discuss the clinical presentation, radiological findings, and management.

[Influence of the bony alignment on the ligaments of the knee joint]. / Einfluss des knöchernen Alignments auf den Bandapparat des Kniegelenks.

In recent years biomechanical and clinical studies have shown that the three-dimensional bony alignment of the lower extremities has a relevant influence on the ligamentous structures of the knee and consequently on the stability of the knee joint. Therefore, in the case of pathological ligamentous damage of the knee joint, a possible malalignment must always be thoroughly evaluated and if necessary, included in the treatment planning. Varus malalignment plays an important role especially with respect to the cruciate ligaments as well as the posterolateral ligamentous structures and has been identified as a significant risk factor for failure after surgical reconstruction of these ligamentous structures. Similar data have also been published for valgus malalignment particularly with respect to its negative influence on the anterior cruciate ligament and the medial capsuloligamentous complex. Alignment deviations in the sagittal plane, especially the inclination of the tibial articular surface (slope), have been extensively investigated in several recent studies. It has been demonstrated that the tibial slope has a relevant influence on the anteroposterior stability of the knee joint and hence on the cruciate ligaments. First clinical studies on the surgical correction of the axis in selected patients showed very promising results with the potential of protecting ligament reconstructions against repeated failure; however, further data especially regarding the importance and the exact indications for an additional alignment correction are necessary.

Lateral epicondyle sliding osteotomy in knee arthroplasties with valgus deformity / Osteotomia de deslizamento do epicôndilo lateral nas artroplastias de joelho com deformidade em valgo

ABSTRACT Objective: To evaluate the efficacy and safety of sliding osteotomy of the lateral epicondyle in correcting rigid valgus deformity in knee arthroplasty. Methods: A retrospective study of patients undergoing total knee arthroplasty with lateral epicondyle sliding osteotomy between 2006 and 2018. The main outcome was the incidence of complications and adverse events. Secondary outcomes were Visual Analog Scale for Pain, varus stress test, and varus knee thrust during gait. Results: 19 knees (19 participants) were included in the study. The mean follow-up was 4.2 years. There were no cases of infection or reoperation due to instability. Two participants (10.5%) had mild or moderate knee pain (VAS pain = 4.6 ± 1.9). Two arthroplasties (10.5%) had mild varus stress. No participant presented varus thrust. Conclusion: Sliding osteotomy of the lateral epicondyle allows fast and safe ligament balance of knee valgus deformities. Level of Evidence I, Case series.

RESUMO Avaliar a eficácia e a segurança da osteotomia de deslizamento do epicôndilo lateral na correção da deformidade em valgo rígida na artroplastia de joelho. Métodos: Estudo retrospectivo de pacientes submetidos à artroplastia total do joelho com osteotomia de deslizamento do epicôndilo lateral entre 2006 e 2018. O principal desfecho foi a incidência de complicações e eventos adversos. Os desfechos secundários foram escala visual analógica para dor, teste de estresse em varo e flambagem em varo do joelho durante a marcha. Resultados: Foram incluídos no estudo 19 joelhos (19 participantes). O seguimento médio foi de 4,2 anos. Não houve nenhum caso de infecção ou reoperação devido à instabilidade. Dois participantes (10,5%) apresentaram algum tipo de dor leve ou moderada no joelho (EVA = 4,6 ± 1,9). Duas artroplastias (10,5%) apresentaram estresse em varo leve. Nenhum participante apresentou flambagem em varo. Conclusão: A osteotomia de deslizamento do epicôndilo lateral possibilitou o balanço ligamentar das deformidades em valgo do joelho de forma rápida e segura. Nível de Evidência IV, Série de Casos.

Nonossifying fibroma of the lower femur with genu valgum: a case report.

BACKGROUND: Nonossifying fibroma is common in children and adolescents, and nonossifying fibroma with genu valgum is rare in the clinic. This article evaluated the effectiveness of treatment in a case of nonossifying fibroma of the lower femur with genu valgum. CASE PRESENTATION: A 16-year-old girl complained of pain in the lower part of her right thigh for one year. She was diagnosed as non ossifying fibroma of the right femur with secondary valgus deformity of the right knee, and was treated in our hospital. We performed curettage, bone grafting and internal fixation,and corrected the valgum deformity at the same time. The patient's incision healed well, the pain was disappeared, and the mechanical axis of lower limbs was corrected. No tumor recurrence was found on X- ray examination one year after operation, and the fracture end was healed. The patient could walk normally, and she was satisfied with her limb function. CONCLUSION: Nonossifying fibroma with genu valgum is rare in the clinic. The patient was satisfied with our treatment, which achieved a good curative effect.

Tibia Valga Correction by Extraperiosteal Fibular Release in Multiple Exostosis Disease.

Genu valgum is a frequent deformity encountered in Multiple Hereditary Exostosis (MHE) patients. If left untreated, lower limb deformity leads to poor functional outcomes in adulthood. Our hypothesis was that in some cases, fibular shortening would lead to a lateral epiphysiodesis-like effect on the tibia. We herein report the case of a 6-year-old child with MHE who underwent extraperiosteal resection of the fibula for tibia valga correction. To obtain the lateral release of the calf skeleton, resection included inter-tibio-fibular exostosis along with proximal fibular metaphysis and diaphysis without any osseous procedure on the tibia. Gradual improvement of the valgus deformity occurred during follow-up (HKA from 165° preop to 178° at 27-month follow-up). Lateral release of the fibula led to an increase in the fibula/tibia index (from 93% preop to 96% at follow-up). Studying fibular growth in MHE patients could help understand how valgus deformity occurs in these patients. Even if encouraging, this result is just the report of a unique case. Further research and a larger series of patients are required to assess fibular release as a valuable option to treat valgus deformity in MHE.

Isolating factors for the prediction of rebound after guided growth with tension band plating for the valgus deformity of the knee.

Purpose: The conditions leading to growth rebound after hemiepiphysiodesis are still poorly understood. This article analyzes the radiographical outcomes after guided growth with tension band plating, using plates in idiopathic genu valgum patients and attempts to generate a predictive model of growth rebound. Methods: Patients with idiopathic genu valgum deformity who received tension band plating were selected for evaluation. We only analyzed coronal plane deformities. Only patients with a long-standing X-ray before tension band plating surgery, a long-standing X-ray at tension band plating removal, and a long-standing X-ray at the latest follow-up after tension band plating removal were considered for this study. The change of mechanical axis deviation between the tension band plating removal and the last follow-up was evaluated for rebound, and ordinal logistic regression was performed to determine the relevant variables for predictive modeling rebound growth. Results: Overall, 100 patients (189 legs) were analyzed. The mean mechanical axis deviation at tension band plating removal was 8.4 mm in varus direction, and the mean mechanical axis deviation at the last follow-up was -3.4 mm (p ≤ 0.001). However, 111 legs (59%) showed rebound growth, 57 (30%) stayed stable, and 21 (11%) showed a continuous correction. Six significant factors significantly influencing rebound were isolated which are clinically relevant: sex, age, baseline mechanical axis deviation, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle, and mechanical axis deviation correction rate. Mechanical axis deviation correction rate had the highest odds ratios. The machine learning classification model for predicting rebound growth built from the study data showed a misclassification rate of 39%. Conclusion: There was a high rate of rebound growth in this cohort, especially for patients at a young age at implantation. The highest risk factors for rebound growth were male sex, and high correction rates, such as found during peak growth spurt. The proposed classification model needs more data to improve its predictive power before it can be used in clinics. Level of evidence: Level III.

TT-TG distance decreases after open wedge distal femoral varization osteotomy in patients with genu valgum & patellar instability. A pilot 3D computed tomography simulation study.

BACKGROUND: Genu valgum is considered to be a risk factor for patellar instability. Correction of valgus alone or combined with a tibial tuberosity medialization has been described. However, changes occurring in the tibial tuberosity-trochlear groove (TT-TG) distance after a lateral distal femoral opening wedge osteotomy (LDF-OWO) are not known. PURPOSE: This study aimed to define changes in TT-TG distance with increasing amounts of valgus correction after LDF-OWO. METHODS: Three-Dimensional Computed Tomography (3D-CT) scans of six patients (two females and four males) aged between 19 and 35 years with genu valgum and patellar instability were analyzed. 3D models of femoral, tibial, and patellar bones were created with the advanced segment option of Mimics 21® software. An oblique lateral opening wedge osteotomy of the distal femur was simulated in 2-degree increments up to 12 degrees of varus opening. Change in TT-TG distance was measured in mm on 3D models of the knee. RESULTS: Compared to baseline without osteotomy, the TT-TG distance decreased significantly (p < 0.05) for all corrections from 2 to 12 degrees in 2° steps. The TT-TG distance decreased by an average of 1.7 mm for every 2 degrees of varus opening. CONCLUSION: Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. The surgeon should be aware of the magnitude of this change (1.7 mm decrease for every 2° increment of valgus opening).

A new case of Melnick-Needles syndrome with skeletal manifestations: A case report.

INTRODUCTION AND IMPORTANCE: Melnick-Needles syndrome (MNS) is a rare skeletal dysplasia that affects skeletal and connective tissue. Less than 70 cases of MNS reported in the literature. MNS had various clinical manifestations such as skeletal deformity, cortical bony sclerosis, facial abnormality, and urogenital symptoms. CASE PRESENTATION: We presented a 5-year-old girl who referred to our orthopedic clinic with knee valgus deformity, spinal kyphoscoliosis, bilateral coxa valga, and humerus cortical irregularity. Based on some facial and skeletal feature, MNS was confirmed with genetic evaluation (heterozygote Filamin A genome). CLINICAL DISCUSSION: The diagnosis of MNS requires a thorough medical and family history, physical examination, and radiographic evaluation. Differential diagnoses for patients with skeletal and facial deformities like MNS include Camurati-Engelmann disease, cystinuria, Galloway-Mowat syndrome, Joubert syndrome, and mucopolysaccharidosis. Treatment for MNS patients with bony deformities without lethal conditions can be conservative, but corrective surgery may be necessary in some cases. CONCLUSIONS: MNS was a rare syndrome with common clinical manifestations such as limb and spine deformity. It is important to conduct a careful examination of any patient who presents with limb and skeletal deformity to the orthopedic clinic, as the disease may have some lethal clinical implications.

Effect of multi-component exercises program on pain-related gait adaptations among individuals with osteoarthritis of the knee joint.

BACKGROUND: Osteoarthritis of the knee causes pain and gait disturbances, as well as a distinct gait pattern. Patients with knee OA have decreased range of motion (ROM) and increased ground reaction force. OA reduces stride length and walking speed. OBJECTIVES: To determine the effect of a multi-component exercise program on pain-related gait adaptations among individuals with osteoarthritis of the knee joint and to compare the effect of multi-component exercises with traditional exercises on pain-related gait adaptations among individuals with osteoarthritis of the knee joint. MATERIALS AND METHODS: This was an experimental study done between 120 patients having knee OA, of both genders, and between the age group of 50-65 years. These individuals were residents of the city of Karad and they were randomly divided into group A (conventional/traditional) and group B (experimental). A pretest assessment was done and the treatment was given for 6 weeks. The later posttest assessment was done and further statistical tests like paired and unpaired t tests were used. RESULTS: Among the 120 subjects with OA knee, the age group of 60-65 years (44%) was found to be commonly affected. Thirty-nine were males (32.5%) and 81 were females (67.5%). Fifty-eight subjects (48%) were found to be commonly overweight. Thirty-two subjects (27%) had Genu Valgum deformity, and 88 subjects (73%) had Genu Varum deformity at the knee joint. The Pvalue within both group A and group B was found to be statistically significant for the entire outcome measures used for assessment. The pretest vs post test values of the WOMAC scale for patients with knee OA within both groups were found to be extremely significant (P < 0.0001). As for the MMT score in these patients, the Knee Flexors of Group A were not significant for right side (P = 0.7088) as well as for left side (P = 0.083) and in Group B they were extremely significant (P < 0.0001) for both sides. For the ROM scores within both groups, Knee Flexion of Group A for both sides was found to be extremely significant (P < 0.0001) for both sides. And for the pretest vs posttest values of within the groups'gait parameters among these patients with OA knees, for cadence both groups B were found to be extremely significant (P < 0.0001). The stride length for Group A was found to be very significant (P = 0.0060) and for Group B it was (P < 0.0001). Also, the P values of the various outcome measures between both groups were found to have statistical significance of their own. CONCLUSION: Effect of Multi-Component Exercise Program on Pain-Related Gait Adaptations Among Individuals with Osteoarthritis of the Knee joint was found to be significant in pain reduction, improving strength, range of motion, and the gait parameters such as an increase in cadence, stride length, step length and decrease in the step width.