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.

Simultaneous Osteosynthesis and Distal Femoral Osteotomy in a Patient With Distal Femoral Fracture Combined With Valgus Knee Deformity: A Case Report.

Distal femoral fractures are commonly treated with osteosynthesis. However, in older patients with osteoarthritis of the knee, acute primary total knee arthroplasty (TKA) may be performed to treat these fractures. Notably, no studies have documented the use of osteosynthesis in combination with distal femoral osteotomy (DFO) for treating distal femoral fractures in patients with knee osteoarthritis. This report presents the case of a 66-year-old woman with lateral compartment osteoarthritis accompanied by severe valgus knee deformity who underwent osteosynthesis for a distal femoral fracture combined with medial closing-wedge distal femoral osteotomy (MCWDFO) to correct the knee valgus deformity. She experienced a distal femoral fracture (AO/OTA 33B1.1) of the right knee because of a fall. Before the injury, she exhibited a limp due to severe knee pain with some limitations in knee flexion. Non-weight-bearing radiographs of the entire lower extremity suggested a percentage mechanical axis (%MA) of 115%, indicating severe valgus deformity. On day nine after the injury, we performed osteosynthesis for the distal femoral fracture and conducted an MCWDFO to correct the right knee valgus deformity. After MCWDFO, the %MA was corrected to 70%. Partial weight-bearing was initiated three weeks postoperatively and progressed to full weight-bearing at six weeks. To facilitate bone healing, low-intensity pulsed ultrasound (LIPUS) was applied for three months after surgery. Bone union was successfully achieved by month five. Some medial knee pain persisted for six months after surgery; nonetheless, the patient could walk without a limp. We considered that the integration of MCWDFO with osteosynthesis could provide a treatment option for patients with distal femoral fractures and lateral compartment osteoarthritis.

Outcomes of Medial Closing-Wedge Distal Femoral Osteotomy for Femoral- and Tibial-Based Valgus Deformity.

BACKGROUND: In carefully selected patients with an arthritic valgus knee, distal femoral osteotomy (DFO) can improve symptoms at medium- to long-term follow-up, reducing osteoarthritis progression. To date, there is no clear evidence in the current literature regarding the role of postoperative joint line obliquity (JLO) in valgus deformity correction. PURPOSE: To assess the clinical and radiological outcomes of medial closing-wedge DFO (MCW-DFO) for the treatment of valgus knees, considering both tibial- and femoral-based deformities, as well as to verify the efficacy and safety of MCW-DFO according to JLO boundaries (≤4°). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was conducted on a cohort of patients with valgus knees. Patients were divided into 2 groups: femoral-based valgus (FB-V) and tibial-based valgus (TB-V). Knee radiographs were collected before surgery and at the last follow-up. The clinical outcome was evaluated through several validated scores (International Knee Documentation Committee, Knee Society Score, Knee injury and Osteoarthritis Outcome Score, Tegner, Numeric Rating Scale, Crosby-Insall). RESULTS: A total of 30 patients (34 knees) with a mean age of 49.3 ± 9.1 years were included in the study. The overall mean follow-up was 9.4 ± 5.9 years. The mean preoperative hip-knee-ankle angle was 187.6°± 3.3° (range, 181.5°-191°) and the postoperative angle was 180°± 3.1° (range, 176°-185°). Most postoperative JLOs were within the safe zone of ≤4° in both groups (the postoperative JLO was >4° in 4 patients in the TB-V group and 1 patient in the FB-V group), although FB-V knees exhibited significant superior JLO correction (postoperative JLO in the TB-V group: mean, 4.0°± 2.5° [P = .1]; postoperative JLO in the FB-V group: mean, 2.4°± 1.4° [P = .5]). Significant improvements in all clinical scores were observed in both groups (P < .01). Additionally, the severity of the osteoarthritis did not worsen at the last follow-up. CONCLUSION: MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. Both FB-V and TB-V groups showed comparable improvements in the clinical scores, development of osteoarthritis, and the restoration of a neutral mechanical axis. Notably, FB-V knees achieved more JLO correction compared with the TB-V ones.

Distal femur fractures in elderly treated with internal fixation or distal femoral replacement - retrospective cohort study on 75 patients assessing functional outcomes, reoperations, and mortality.

PURPOSE: This cohort study aimed to describe the functional outcomes, complications, and mortality of patients over 65 with acute distal femur fractures treated with open reduction and internal fixation (ORIF) or distal femoral replacement (DFR). METHODS: We retrospectively analyzed all patients older than 65, operated consecutively for a distal femur fracture treated with ORIF or DFR. We included 75 patients (9 33A, 5 33B, and 61 33C AO/OTA fractures), 55 treated with ORIF, and 20 with DFR. We used Parker's mobility index (PMI) to assess functional outcomes at 1, 3, and 12 months and study closure. We analyzed complications, reoperations, and mortality at 30 days, one year, and at the end of the study. RESULTS: The PMI was significantly higher in the DFR group at months 1 (p = 0.023) and 3 (p = 0.032). We found no significant differences between cohorts at one year and the end of follow-up. Postoperative complications were significantly more frequent in the ORIF group (38.10% vs. 10%, p = 0.022). Reoperations were similar in both cohorts (p = 0.98). Mortality at one month was 4% and 20% at one year, and at the end of follow-up, there were no significant differences between groups. CONCLUSION: The outcomes of this study suggest that DFR offers a faster functional recovery with lower complication rates than those treated with ORIF. Additionally, both options have similar reoperation and mortality rates. Appropriately designed studies are needed to define the best treatment strategy for this type of patient.

Comparison of Clinical and Radiological Outcomes of Total Knee Arthroplasty in Osteoarthritic Patients.

Background The knee is the joint most commonly affected by osteoarthritis, more than any other. Osteoarthritis is a progressive, long-term condition that leads to the deterioration of joint tissue and cartilage, resulting in pain and impairment. Total knee arthroplasty (TKA) is a successful intervention that improves functional capability, decreases pain, and enhances quality of life. We conducted this study to evaluate whether radiological parameters following TKA influence the clinical outcomes of patients with knee osteoarthritis. Methods The study was conducted on patients treated for knee osteoarthritis at the Department of Orthopedics, Rajindra Hospital and Government Medical College, Patiala, Punjab, in collaboration with the Department of Radiology over a period of 1.5 years. A total of 152 patients diagnosed with knee osteoarthritis were included in the study; all underwent TKA. Patients underwent clinical evaluation and were graded using the Knee Society Score (KSS) during follow-up examinations. Pain was evaluated using the Visual Analog Scale (VAS). Postoperative X-rays were obtained, and various angles, including the distal femoral angle (DFA), the proximal tibial angle (PTA), and the posterior slope angle (PSA), were measured. Patient follow-up was conducted at three days, three months, and six months. Subsequently, a comparison of the clinical and radiological outcomes of TKA was performed. Results In this study, a total of 152 patients participated, with the majority falling into the 61-70 age group. Of these patients, 40.13% were female and 59.87% were male. The average medial DFA was 94.05°, the average medial PTA was 89.31°, and the PSA was 6.6°. Patients with a medial DFA of 94.05° (±3), a medial PTA of 89.31° (±3), and a PSA of 6.6° (±3) were categorized into the normal group. Conclusion Patients with DFA, PTA, and PSA in the normal range demonstrate improved KSS and clinical outcomes.

Elucidation of the association between additional distal femoral resection and extension angle improvement following the actual surgical steps with the Robot-TKA system.

BACKGROUND: This study investigates the association between additional distal femoral resection and improved flexion contracture in total knee arthroplasty (TKA) with a robot-assisted system. Flexion contracture is a common issue in patients with knee osteoarthritis, which causes postoperative complications and functional limitations. This study aims to evaluate the effectiveness of additional bone resection in flexion contracture correction and knee extension angle improvement after the actual surgical steps. METHODS: The study included 11 patients who underwent posterior-stabilized (PS)-type TKA with a robot-assisted system. The surgical technique consisted of precise bone resection and range of motion evaluation using a navigation system. A precut technique was used to facilitate posterior access and remove osteophytes that cause the contracture. The amount of additional distal femoral resection was determined based on the thickness of the insert trial required for achieving full extension. RESULTS: The flexion contracture correction angle and the amount of additional distal femoral resection demonstrated a linear relationship. An average of 2.0° with the standard error (SE) of 0.6° improvement in flexion contracture was observed per 1.0 mm of additional bone resection. The postoperative evaluation demonstrated a significant improvement in knee extension angle, thereby reducing the contracture degree. CONCLUSION: This study was the first to perform the additional distal femoral resection on the living knee, which closely replicates the actual surgical steps. The current study revealed that an additional 1.0 mm of distal femoral resection in PS-type TKA improves knee extension angle by 2.0° (SE 0.6°) within an additional resection range of 1.0 mm to 3.3 mm.

Small change in the arithmetic hip-knee-ankle angle during unicompartmental knee arthroplasty improves early postoperative functional outcomes.

INTRODUCTION: The optimal lower-limb alignment after unicompartmental knee arthroplasty (UKA) remains controversial. This study aimed to investigate the optimal lower-limb alignment for functional improvement in the early post-UKA period. We hypothesized that a small change (Δ) in the arithmetic hip-knee-ankle (aHKA) angle during surgery would result in better postoperative knee function. MATERIALS AND METHODS: This single-centered, retrospective study analyzed 91 patients (91 knees) who underwent UKA from April 2021 and December 2022. Preoperative and postoperative standing whole-leg radiographs were used to evaluate the mechanical HKA angle and aHKA angle. The aHKA angle was calculated from the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). We defined restored aHKA angle as a postoperative aHKA angle within ± 3° of the preoperative aHKA angle. Functional improvement was evaluated using the preoperative and one-year postoperative Knee Society Scoring 2011 (KSS 2011). A multivariate regression analysis was performed to investigate the optimal lower-limb alignment for functional improvement. RESULT: Postoperative restored aHKA angle (p = 0.020) was the only significant factor for improved KSS 2011 scores. Postoperative restored aHKA angle was obtained in 64 patients (70%). ΔMPTA (p < 0.001) and ΔLDFA (p = 0.037) were significant factors associated with a postoperative restored aHKA angle. CONCLUSIONS: UKA restores the native knee, including resurfacing constitutional alignment and medial collateral ligament tension. Minimal change in the aHKA angle during UKA improves the functional outcomes of the knee during the early postoperative period, consistent with the minimally invasive surgical concept of UKA.

Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review.

BACKGROUND: Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion. PURPOSE: To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion. METHODS: A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed. RESULTS: A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period. CONCLUSION: For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy.

BACKGROUND: Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS: We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS: Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION: Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE: Therapeutic level IV.

Patient-Specific 3D-Printed Osteotomy Guides and Titanium Plates for Distal Femoral Deformities in Dogs with Lateral Patellar Luxation.

The aim of this study was to describe the diagnosis and treatment of grade IV lateral patellar luxation (LPL) in two adult large breed dogs with complex femoral deformities using patient-specific three-dimensionally (3D) printed osteotomy guides and implants. Computed tomography (CT) scans were obtained for virtual surgical planning (VSP) using computer-aided design (CAD) software, which allowed for 3D reconstruction and manipulation of the femoral deformities, providing a preoperative view of the correction. Of the two patients, one was affected bilaterally and the other unilaterally, but both dogs were from the same litter. Therefore, the healthy femur of the unilaterally affected patient was used as the physiological reference for the virtual surgical correction. Three distal femoral trapezoid osteotomies (DF-TO) followed by reduction and internal fixation with plates were performed using patient-specific 3D-printed osteotomy guides and implants. This type of osteotomy permitted correction of procurvatum in all the femurs to increase knee extension, raise the dog's lumbar spine and correct the kyphosis. Preoperative, expected and postoperative femoral angles were compared to evaluate the efficacy of virtual surgical planning and the outcome of surgical correction. Radiographic follow-up, passive range of motion and functional recovery were recorded. There were no major complications requiring revision surgery. Significant clinical improvement was observed in both patients. This study suggests that the treatment used represents a viable surgical alternative to restore limb alignment in patients with complex femoral deformities.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies.

PURPOSE: This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO). METHODS: A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests. RESULTS: An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees. CONCLUSION: In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered. LEVEL OF EVIDENCE: Level Ⅳ, retrospective case-control study.

Management of fixed flexion contracture in primary total knee arthroplasty: recent systematic review.

INTRODUCTION: This study aimed to systematically review the literature and identify the surgical management strategy for fixed flexion contracture in primary total knee arthroplasty (TKA) surgery, pre-, intra-, and post-operatively. Secondary endpoints were etiologies and factors favoring flexion contracture. MATERIALS AND METHODS: Searches were carried out in November 2023 in several databases (Pubmed, Scopus, Cochrane, and Google Scholar) using the following keywords: "flexion contracture AND TKA", "fixed flexion deformity AND TKA", "posterior capsular release AND TKA", "posterior capsulotomy in TKA", "distal femoral resection AND TKA". Study quality was assessed using the STROBE checklist and the Downs and Black score. Data concerning factors or strategies leading to the development or prevention of flexion contracture after TKA were extracted from the text, figures, and tables of the included references. The effect of each predictive factor on flexion contracture after TKA was recorded. RESULTS: Thirty-one studies were identified to meet the inclusion and exclusion criteria. These studies described a variety of preoperative and intraoperative factors that contribute to the development or correction of postoperative flexion contracture. The only clearly identified predictor of postoperative flexion contracture was preoperative flexion contracture. Intraoperative steps described to correct flexion contracture were: soft-tissue balancing (in posterior and medial compartments), distal femoral resection, flexion of the femoral component, and posterior condylar resection. However, no study has investigated these factors in a global model. DISCUSSION: This review identified various pre-, intra-, and post-operative factors predictive of post-operative flexion contracture. In practice, these factors are likely to interact, and it is therefore crucial to further investigate them in a comprehensive model to develop an algorithm for the management of flexion contracture. LEVEL OF EVIDENCE: IV.

Derotational distal femoral osteotomy corrects excessive femoral anteversion in patients with patellofemoral instability: A systematic review.

PURPOSE: Patellofemoral instability (PFI) is a common condition that can be caused from multiple factors, including lower limb rotational malalignments. Determining precise criteria for performing corrective torsional osteotomy can be a daunting task due to the lack of consensus on normal and excessive values and the limited evidence-based data in the postoperative results. The purpose was to assess the clinical, functional and imaging outcomes following derotational distal femoral osteotomy (DDFO) in patients with PFI and/or anterior knee pain (AKP) associated with lower limb rotational malalignments. METHODS: Searches were conducted on PubMed, EMBASE and Web of Science databases up to October 2023. Studies reporting outcomes after DDFO in patients with PFI and/or AKP were eligible for the systematic review. The primary outcome was imaging metrics, especially femoral anteversion. Secondary outcomes included the patient-reported outcome measures (PROMs) (clinical and functional). Quantitative synthesis involved the use of weighted averages to calculate pre- to postoperative mean differences (MD) and compare them against the minimal clinically important difference (MCID). RESULTS: Ten studies (309 knees) were included with a mean follow-up of 36.1 ± 11.7 months. Imaging outcomes consistently indicated the correction of femoral anteversion (MD = -19.4 degrees, 95% confidence interval: -20.1 to -18.7) following DDFO. PROMs showed significant improvements in most studies, exceeding the MCID. Patient satisfaction with the DDFO was high (93.3%). CONCLUSIONS: The DDFO was an effective treatment option for correcting excessive femoral anteversion in patients with PFI associated with clinically relevant functional and clinical improvement and a high satisfaction rate. LEVEL OF EVIDENCE: Level IV, systematic review of level II-IV studies.

Increased knee torsional misalignment associated with femoral torsion is related to non-contact anterior cruciate ligament injury: a case-control study.

BACKGROUND: Altered axial biomechanics of the knee are recognized as a risk factor for non-contact anterior cruciate ligament (ACL) injury. However, the relationship of knee and segmental torsion to non-contact ACL and combined anterolateral ligament (ALL) injury is unclear. This study aims to determine the relationship of knee and segmental torsion to non-contact ACL injury and to explore their relationship with ALL injuries. METHODS: We divided 122 patients with arthroscopically confirmed non-contact ACL injuries into an ACL injury group (isolated ACL injury, 63 patients) and an ACL + ALL injury group (ACL combined with ALL injury,59 patients). Additionally, 90 normal patients with similar age, gender and body mass index (BMI) were matched as a control group. The tibial tubercle-trochlear groove (TT-TG) distance, distal femoral torsion (DFT), posterior femoral condylar torsion (PFCT) and proximal tibial torsion (PTT) were measured using magnetic resonance imaging (MRI). We assessed the differences between the groups using an independent samples t test and utilized receiver operating characteristic (ROC) curves to determine the cut-off value for the increased risk of ACL injury. RESULTS: In patients with ACL injury, the measurements of the TT-TG (11.8 ± 3.1 mm), DFT (7.7° ± 3.5°) and PFCT (3.6° ± 1.3°) were significantly higher compared to the control group (9.1 ± 2.4 mm, 6.3° ± 2.7° and 2.8° ± 1.3°, respectively; P < 0.05), but the PTT did not differ between the two groups. The TT-TG, DFT and PFCT were not significantly larger in patients combined with ALL injury. ROC curve analysis revealed ACL injury is associated with TT-TG, DFT and PFCT. CONCLUSIONS: Knee torsional alignment is associated with ACL injury, predominantly in the distal femur rather than the proximal tibia. However, its correlation with ALL injury remains unclear. These findings may help identify patients at high risk for non-contact ACL injury and inform the development of targeted prevention and treatment strategies.

Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta-analysis.

PURPOSE: The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and medial patellofemoral ligament reconstruction (MPFL-R) in the treatment of recurrent patellar dislocation (RPD) with increased femoral anteversion angle (FAA). METHODS: This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality Of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science and Cochrane Library databases were searched to identify studies reporting clinical outcomes of combined D-DFO and MPFL-R in RPD patients with increased FAA. Data on patient-reported outcome measures, radiological parameters, patellar tracking as revealed by J-sign and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis. RESULTS: Eleven studies with a total of 569 knees in 553 patients were included. Patients were predominantly female (79%). The weighted mean of FAA decreased from 33.6° to 13.0° (weighted mean difference = 20.59; p < 0.00001) after the combined procedure. Significant improvements (p < 0.00001) were identified in the Lysholm score (weighted mean: 55.5 vs. 80.4), International Knee Documentation Committee (IKDC) score (weighted mean: 52.8 vs. 78.6) and Kujala score (weighted mean: 54.5 vs. 80.6). The incidence of residual J-sign ranged from 14.3% to 38.3% with an overall pooled rate of 28.2% (95% confidence interval = 22.8%-33.6%). The overall redislocation rate was 1.1%. No patients experienced surgical site infection or bone nonunion. Two studies compared the clinical outcomes of MPFL-R with and without D-DFO. Compared with isolated MPFL-R, the combined procedure yielded a better Lysholm score (weighted mean: 84.9 vs. 79.3, p < 0.0001), IKDC score (weighted mean: 84.1 vs. 79.9, p = 0.001), Kujala score (weighted mean: 84.3 vs. 79.4, p < 0.0001) and a lower residual J-sign rate (26/97 [26.8%] vs. 44/105 [41.9%], p = 0.02), respectively. CONCLUSION: The combination of D-DFO and MPFL-R led to improved clinical outcomes and a low redislocation rate in patients with RPD and increased FAA. Additional D-DFO can achieve more favourable results in subjective function and patellar tracking than isolated MPFL-R in the setting of excessive FAA. LEVEL OF EVIDENCE: Level IV.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital.

Background: In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients. Methods: Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score. Results: 204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05). Conclusion: Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Definition of normal, neutral, deviant and aberrant coronal knee alignment for total knee arthroplasty.

PURPOSE: One of the most pertinent questions in total knee arthroplasty (TKA) is: what could be considered normal coronal alignment? This study aims to define normal, neutral, deviant and aberrant coronal alignment using large data from a computed tomography (CT)-scan database and previously published phenotypes. METHODS: Coronal alignment parameters from 11,191 knee osteoarthritis (OA) patients were measured based on three dimensional reconstructed CT data using a validated planning software. Based on these measurements, patients' coronal alignment was phenotyped according to the functional knee phenotype concept. These phenotypes represent an alignment variation of the overall hip knee ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA). Each phenotype is defined by a specific mean and covers a range of ±1.5° from this mean. Coronal alignment is classified as normal, neutral, deviant and aberrant based on distribution frequency. Mean values and distribution among the phenotypes are presented and compared between two populations (OA patients in this study and non-OA patients from a previously published study). RESULTS: The arithmetic HKA (aHKA), combined normalised data of FMA and TMA, showed that 36.0% of knees were neutral within ±1 SD from the mean in both angles, 44.3% had either a TMA or a FMA within ±1-2 SD (normally aligned), 15.3% of the patients were deviant within ±2-3 SD and only 4.4% of them had an aberrant alignment (±3-4 SD in 3.4% and >4 SD in 1.0% of the patients respectively). However, combining the normalised data of HKA, FMA and TMA, 15.4% of patients were neutral in all three angles, 39.7% were at least normal, 27.7% had at least one deviant angle and 17.2% had at least one aberrant angle. For HKA, the males exhibited 1° varus and females were neutral. For FMA, the females exhibited 0.7° more valgus in mean than males and grew 1.8° per category (males grew 2.1° per category). For TMA, the males exhibited 1.3° more varus than females and both grew 2.3° and 2.4° (females) per category. Normal coronal alignment was 179.2° ± 2.8-5.6° (males) and 180.5 > ± 2.8-5.6° (females) for HKA, 93.1 > ± 2.1-4.2° (males) and 93.8 > ± 1.8-3.6° (females) for FMA and 86.7 > ± 2.3-4.6° (males) and 88 > ± 2.4-4.8° (females) for TMA. This means HKA 6.4 varus or 4.8° valgus (males) or 5.1° varus to 6.1° valgus was considered normal. For FMA HKA 1.1 varus or 7.3° valgus (males) or 0.2° valgus to 7.4° valgus was considered normal. For TMA HKA 7.9 varus or 1.3° valgus (males) or 6.8° varus to 2.8° valgus was considered normal. Aberrant coronal alignment started from 179.2° ± 8.4° (males) and 180.5 > ± 8.4° (females) for HKA, 93.1 > ± 6.3° (males) 93.8 > ± 5.4° (females) for FMA and 86.7 > ± 6.9° (males) and 88 > ± 7.2° (females) for TMA. This means HKA > 9.2° varus or 7.6° valgus (males) or 7.9° varus to 8.9° valgus was considered aberrant. CONCLUSION: Definitions of neutrality, normality, deviance as well as aberrance for coronal alignment in TKA were proposed in this study according to their distribution frequencies. This can be seen as an important first step towards a safe transition from the conventional one-size-fits-all to a more personalised coronal alignment target. There should be further definitions combining bony alignment, joint surfaces' morphology, soft tissue laxities and joint kinematics. LEVEL OF EVIDENCE: III.

Biomechanical comparison of distal femoral fracture fixation: Polyaxial vs. uniaxial locking screws with different blocking screw configurations in retrograde femoral nailing.

INTRODUCTION: Clinical studies have indicated reduced reliance on blocking screws with the introduction of polyaxial locking nails, yet the biomechanical superiority of polyaxial locking over blocking screws remains unverified, specifically for distal dia-metaphyseal femur fractures. HYPOTHESIS: We hypothesized that the combination of multiaxial locking using three screws and parallel locking reinforced by two blocking screws would result in superior outcomes compared to utilizing only parallel locking with two screws and one blocking screw. MATERIALS AND METHODS: Third-generation custom-made femur models representing AO/OTA 32 A1.2 dia-metaphyseal comminuted oblique fractures were divided into four groups (n=10/group). Group A employed distal fixation with three 4.5-mm polyaxial screws. Group B used two parallel locking screws and two blocking screws, Group C used two parallel locking screws and one blocking screw, and Group D used only two parallel screws. Specimens underwent axial and torsional load testing to assess fatigue strength, ultimate strength, axial stiffness (N/mm), torsional stiffness (N/mm/deg), axial load to failure (N), torsional load to failure (N/mm), coronal and sagittal angulations, and fracture site collapse. RESULTS: Group C exhibited statistically superior torsional stiffness compared to Groups B and D (p=0.039 and p=0.034, respectively). Axial load to failure was highest in Group B and lowest in Group D (p=0.032). Group C demonstrated the highest torsional strength, while Group B exhibited the lowest (p=0.006). Coronal displacement was greatest in Group B, while Group A showed the highest resistance (p=0.009). Group A demonstrated the greatest resistance to fracture site collapse, with the weakest specimens observed in Groups B and C (p=0.01). DISCUSSION: The performance of a single laterally positioned blocking screw is comparable to using two blocking screws. Medial positioning of a second blocking screw is unnecessary for stability enhancement. Multiaxial locking prevents fracture site collapse and coronal plane angulation more effectively than other methods. Multiaxial locking and/or parallel screws with a single laterally positioned blocking screw provide superior stiffness and stability for treating unstable dia-metaphyseal distal femoral fractures. LEVEL OF EVIDENCE: N/A.

Distal femoral osteotomy planning: Reversed Miniaci's method is more accurate than Dugdale and Paley methods.

PURPOSES: The purpose of this study was to validate the reversed Miniaci method for distal femoral osteotomies and to compare the accuracy with Dugdale and Paley methods. METHODS: Between January 2019 and October 2021, 59 DFO were performed in a single center. Following application of the eligibility and exclusion criteria, radiographic measurements and analysis was performed for 24 patients by two independent observers, then repeated after one month. Medical planning software: PeekMed v2.3.7.6® was used. For all patients the following measurements were performed: Hip-Knee-Ankle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), joint line obliquity (JLO), width of the proximal tibia and the weight-bearing line (WBL). Each image was then analysed using the following planning methods for realignment surgery: Reversed Miniaci, Dugdale and Paley. Measurements were recorded post deformity correction. Difference between target and post-correction WBL was evaluated. This difference was adjusted by the objective in order to limit biases related to the different objectives according to the method. RESULTS: Eighteen patients were managed for a varus osteotomy and 6 for a valgus osteotomy. Preoperative data was, HKA at 176.7±6.3, mLDFA at 90.6±5.4, MPTA 88.9±1.1, a WBL for valgus 80.9%±9.1 and for varus deformity 23.5%±11.7. Inter- and intra-rater reliability was>0.8 for every method. After normalizing reported precision on the amount of correction expected, reversed Miniaci method was the most accurate with a mean deviation from the target of 3%, compared to the Dugdale's method with 9% (p<0.001) and to Paley's method with 8.6% (p<0.001). CONCLUSION: The reversed Miniaci method is effective and reliable for planning distal femoral osteotomies. Compared to other planning methods, it is the most accurate approach for achieving a correction goal. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Minimally Invasive Percutaneous Leverage Reduction in the Treatment of Pediatric Salter-Harris IV and V Distal Femoral Physeal Fractures.

OBJECTIVE: Distal femoral physeal fractures (DFPF) are rare but severe injuries in children, and there is no consensus on treatments for Salter-Harris (S-H) IV and V type of DFPF yet. This study aimed to introduce a minimally invasive technique using percutaneous leverage reduction combined with Kirschner wires fixation in treating pediatric DFPF with S-H IV and V type of injury and evaluate the clinical results. METHODS: From July 2008 to June 2018, the authors' institute (Union Hospital, Tongji Medical College) retrospectively reviewed all patients diagnosed with pediatric DFPF. They were divided into two groups according to received treatment: children in the minimally invasive technique group were treated with a minimally invasive percutaneous leverage reduction technique, and the traditional technique group included the other children who received the conventional open reduction with internal fixation (ORIF). The surgical and clinical results of the two groups were collected and analyzed. The independent sample t-test analysis and the chi-square test were applied to compare continuous and categorical variables. RESULTS: A total of 14 pediatric patients were recruited, including five females and nine males with DFEF. All eight patients in the minimally invasive technique group and four of the six patients in the ORIF group were treated successfully. One patient in the minimally invasive technique group opted for conservative treatment due to his good functional recovery, while the other two patients in the ORIF group needed further surgery because of the limb length discrepancy. There was a difference in surgery duration (p < 0.001), intraoperative fluoroscopy numbers (p = 0.006), intraoperative blood loss (p < 0.001), radiological union time (p = 0.003) and knee flexion angle (p < 0.001) between two groups. Patients in the minimally invasive technique group all received total knee society (KSS) scores, while the average scores in the ORIF group were lower (100.00 vs. 97.67). CONCLUSION: The minimally invasive technique is better than conventional ORIF in terms of surgery duration, intraoperative blood loss, radiological union time, knee flexion angle and average KSS score. This percutaneous leverage reduction technique might be a good alternative for treating S-H IV and V DFPF in children.