Perioperative complications in osteotomies around the knee: a study in 858 cases.

INTRODUCTION: Eight hundred and fifty-eight consecutive osteotomies around the knee joint were analyzed retrospectively to detect intra- and early postoperative complications in a period of 4 weeks postoperative. Indications for osteotomy were unilateral gonarthritis or torsional deformities resulting in femoropatellar instability or anterior knee pain. MATERIALS AND METHODS: Etiology of deformity, technique and mode of correction and level of osteotomy were registered. Complications were detected and divided in minor complication (superficial wound infection, and deep-vein thrombosis) and major complication (compartment syndrome, deep infection, and vascular lesion). RESULTS: Fifteen major (1.7%) and 17 minor complications (2.0%) were detected: 5 vascular lesions (0.58%), 4 compartment syndromes (0.47%) and 6 deep infections (0.70%), 14 superficial wound infections (1.6%) and 3 deep-vein thrombosis (0.35%). In posttraumatic osteotomies and continuous corrections, risk for a superficial wound infection was significantly higher and with osteoclasia risk for vascular lesion was higher compared to osteotomy with oscillating saw. No difference was found for anatomical level of osteotomy and for the other complications in terms of etiology of deformity, technique of osteotomy and mode of correction. CONCLUSION: Osteotomy around the knee is a safe procedure in the treatment of unicompartmental gonarthritis in terms of intra- and postoperative complications. Major complications are rare. Pit falls for compartment syndromes (LCW and torsional corrections) have to kept in mind. There is no difference in frequency of complications between HTO and supracondylar osteotomies. Risk for superficial wound infection is higher in posttraumatic osteotomies and with continuous corrections. Osteoclasia contains a higher risk for vascular lesion compared to oscillating saw.

Medial open wedge vs. lateral closed wedge high tibial osteotomy - Indications based on the findings of patellar height, leg length, torsional correction and clinical outcome in one hundred cases.

INTRODUCTION: Medial open wedge (MOW) and lateral closed wedge (LCW) osteotomies are established methods to treat medial gonarthritis. Advantages and differences in the outcome of the two techniques have been discussed controversially and there is still no precise recommendation for either technique. We now aimed to assess the effect of each technique on tibial slope (TS), patella height (PH) and leg length discrepancy. METHOD: In a study of 50 consecutive cases of MOW and 50 of LCW osteotomies were registered. The decision for either technique was made pre-operatively according to an algorithm. Demographic data, operation procedures (time of operation, correction angle, torsional correction) and measurement of patellar height, tibial slope, leg length discrepancy, clinical outcome after one year and bone and wound healing were obtained. Pre- and post-operative values were compared between the two groups. RESULTS: In absence of randomization demographic data demonstrate comparability of the two groups. No difference in bone and wound healing, time of operation and clinical outcome was seen. In the MOW group PH decreased significantly, no relevant alteration of PH was detected in the LCW group. In the latter group a statistically significant decrease of TS compared to a slightly decrease in the MOW group was recorded post-operatively. A significant leg lengthening with the MOW and shortening of the leg with the LCW method can be achieved. DISCUSSION: With respect to similar results in operating procedures, bone and wound healing and clinical outcome decision making factors for either technique should be leg length discrepancy and torsional deformities. Changes of PH and TS have to be known and may influence the technique of osteotomy in cases of patella infera / alta or borderline PH. CONCLUSION: An algorithm for valgus high tibial osteotomies based on TS, PH and leg length discrepancy may be proposed.

Corrective osteotomies of the lower limb show a low intra- and perioperative complication rate-an analysis of 1003 patients.

PURPOSE: The purpose of corrective osteotomies in posttraumatic and congenital deformities is anatomic limb reconstruction and joint preservation. The aim of the present study was to analyse intra- and perioperative complications of osteotomies in the lower limb. METHODS: One thousand and three unselected and prospectively registered osteotomies of the long bones of the lower limb, performed between 1995 and 2013, were analysed. In 435 women and 568 men (mean age 39.8 years), 478 correction osteotomies were performed femoral and 525 tibial; 696 osteotomies were performed using the oscillating saw, 42 using the Gigli saw and 265 using drill hole/chisel osteoclasis. A total of 869 deformities were corrected in the acute setting and 134 were corrected continuously via callotaxis. RESULTS: Seventeen (1.7%) major complications requiring revision surgeries were detected: 4 arterial injuries, 2 haematomas, 4 compartment syndromes and 7 deep wound infections. All vascular injuries 4 (0.7%) occurred in osteotomies around the knee (n = 563). Nineteen (1.9%) minor complications could be managed by conservative means: 3 (0.3%) deep vein thromboses and 16 (1.6%) superficial wound infections. No osteomyelitis, pulmonary embolism or death occurred. Gigli saw osteotomy was stained by a higher infection rate. In male patients (p = 0.02), posttraumatic deformities (ns) and continuous procedures (p = 0.025) have a higher risk of superficial infections. No further risks were detected for age, weight, smoking habit and anatomic level of surgery. CONCLUSION: Osteotomies around the knee show a very low complication rate. Less aggressive oscillating saws, saw blades and drills are recommended. Vascular injuries, compartment syndromes and deep infections are limb-threatening emergencies demanding fast and determined interventions. LEVEL OF EVIDENCE: Prospective cohort study, Level III.

Patellofemoral dysbalance and genua valga: outcome after femoral varisation osteotomies.

INTRODUCTION: Patellofemoral dysbalance may be caused by trochlear dysplasia, an elevated TTTG distance, femoral or tibial torsional deformities, patella alta, or a genu valgum. The surgical procedure for the treatment of a genu valgum is varisation osteotomy, usually in the femoral aspect. Several authors believe that a genu valgum is one cause of patellofemoral dysbalance, but studies about the outcome of the treatment with a varisation osteotomy are rare. MATERIALS AND METHODS: Nineteen knees in 18 patients, aged on average 28 (16-52) years were investigated in a retrospective study. The patients had symptoms of patellofemoral instability or anterior knee pain due to a genu valgum, without symptoms of a lateral femorotibial compartment. All patients underwent a femoral varisation osteotomy. The diagnostic investigation prior to surgery included full-leg radiographs and torsional angle CT scans. The pre-surgery and follow-up investigation included the visual analog scale (VAS), the Kujala score, the Japanese Knee Society score, the Lysholm score. RESULTS: The mean duration of follow-up was 44(10-132) months. The mean preoperative mechanical valgus was 5.6° (range 4-10°). Twelve patients mentioned patellar instability as the main symptom while 14 mentioned anterior knee pain. No redislocation occurred in the follow-up period. Anterior knee pain on the VAS (p value < 0.001) was significantly reduced (5.6-2.1). The Japanese Knee Society score improved from 87 to 93 (p value 0.013) points, the Kujala score improved significantly from 72 to 87 (p value 0.009), and the Lysholm score significantly from 76 to 92 (p value < 0.001). CONCLUSION: Genua valga can lead to patellofemoral dysbalance, treatment of this condition is femoral varisation osteotomy. In this study, patellofemoral stability was achieved and anterior knee pain was significantly reduced. Significant improvements in clinical scores proved the success of the treatment. LEVEL OF EVIDENCE: IV, case series.

Torsional osteotomies of the tibia in patellofemoral dysbalance.

BACKGROUND AND PURPOSE: Anterior knee pain or patellofemoral instability is common symptom of patellofemoral dysbalance or maltracking. Tibial torsional deformities can be the reason of this pathology. After appropriate diagnostic investigation, the treatment of choice is a torsional osteotomy. This study addresses the diagnostic investigation, treatment, and the outcome of torsional osteotomies of the tibia. Does this treatment result in patellofemoral stability and provide pain relief? METHODS: Forty-nine tibial torsional osteotomies were included. The major symptoms were patellofemoral instability in 19 cases and anterior knee pain in 42 cases. In addition to clinical and radiographic analysis, a torsional angle CT scan was performed pre-operatively. A visual analog scale (VAS), the Japanese Knee Society score, the Tegner activity score, and the Lysholm score were assessed pre-operatively and at the 42-month follow-up. RESULTS: Mean tibial external torsion was 47.4° (SD 5.41; range 37°-66°; standard value 34°). Surgical treatment consisted of an acute supratuberositary tibial internal torsional osteotomy (mean 10.8°; SD 3.01°; range 5°-18°). At the follow-up investigation, the Tegner activity score was increased 0.4 points (p value 0.014) from 3.9 (SD 1.33; range 2-7) to 4.3 (SD 1.25; range 0-7). The Lysholm score increased 26 points (SD 16.32; p value 0.001) from 66 (SD 14.94; range 32-94) to 92 (SD 9.29; range 70-100) and the Japanese Knee Society score increased 18 points (SD 14.70; p value 0.001) from 72 (SD 13.72, range 49-100) to 90 (SD 9.85, range 60-100). VAS was reduced 3.4 points (SD 2.89; p value 0.001) from 5.7 (SD 2.78; range 0-10) to 2.3 (SD 1.83; range 0-7). As regards patellofemoral instability, no redislocation occurred in the follow-up period. INTERPRETATION: The results of this study show that in cases of tibial maltorsion, a torsional osteotomy can lead to patellofemoral stability and pain relief, and should be considered as a treatment option. The improved clinical scores in the present investigation show the value of the procedure. Level of evidence Level IV.

Correlation of the tibial tuberosity-trochlear groove distance with the Q-angle.

PURPOSE: The Q-angle has been used for years to quantify lateralization of the patella. The tibial tuberosity-trochlea groove distance (TT-TG distance) was introduced to analyse patellar tracking. Does a significant correlation exist between these two parameters? Do other significant interrelations exist between the Q-angle/TT-TG distance, torsion of the femur and tibia, the frontal axis, overall leg length, gender, former patellar dislocation, BMI? METHODS: One hundred knees in 55 patients with patellofemoral symptoms were included in a prospective study. All patients underwent clinical examination, including measurement of the Q-angle. A torsional CT was obtained from all patients. RESULTS: The correlation coefficient was 0.33/0.34 (left/right leg), showing that the TT-TG distance tends to rise in direct ratio to a rising Q-angle. Thus, a significant correlation was found (p = 0.017). Femoral and tibial torsion had a positive effect on the TT-TG distance, but showed no significant correlation. Leg length had a significant effect on the TT-TG distance (p = 0.04). The frontal axis had a nonsignificant influence on the Q-angle or TT-TG distance. On average, the Q-angle in women was 2.38° greater than it was in men, but the difference was not significant. CONCLUSION: A significant correlation was noted between the Q-angle and the TT-TG distance. Both depend on various parameters and must be assessed for the analysis of patellofemoral maltracking. The Q-angle did not differ significantly between men and women; thus, the conclusion is that no different ranges need not be used. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Operative treatment of patellofemoral maltracking with torsional osteotomy.

INTRODUCTION: A femoropatellar syndrome may be caused by a deformity in the torsional axis of the femur or the tibia. The two cardinal symptoms are anterior knee pain and patellar instability. METHODS: We retrospectively evaluated 32 torsional osteotomies. The aim of the study was to prove that a torsional osteotomy could bring about significant pain relief and create a stable femoropatellar joint. Besides clinical and radiographic analysis of leg geometry, a computed-tomography-based measurement of the torsional angle was performed. The mean duration of follow-up was 37 months. RESULTS: The follow-up examination included VAS, the Japanese Knee Society score, the Tegner activity score, and the Lysholm score. 11 patients underwent femoral supracondylar external torsional osteotomy [(11° (5-20)], 19 a tibial osteotomy with internal torsional correction [(9.3° (5-15)] and 2, a bifocal osteotomy. The Tegner activity score increased from 3.6 before surgery to 4.4 post-surgery. The Lysholm score was improved from 56.7 to 83.7, and the Japanese Knee Society score from 65.7 to 86.8 points. VAS was significantly reduced from 7.3 to 2.6, indicating marked pain relief. 12 patients with patellar dislocation experienced no recurrence of dislocation. 88% (28 joints) of the patients were willing to undergo the procedure again. CONCLUSION: We introduce a torsional index for validation and quantification of torsional deformities, and can clearly show that torsional osteotomy is the treatment of choice for a torsional deformity.

Matrix-associated autologous chondrocyte transplantation combined with iliac crest bone graft for reconstruction of talus necrosis due to villonodular synovitis.

We report the case of a 24-year-old driving instructor with osteonecrosis of the talus and a large articular cartilage and osseous defect. The cystic lesion was caused by villonodular synovitis. After magnetic resonance imaging detection and arthoscopic analysis, the defect was filled with a bone graft, followed by matrix-associated autologous chondrocyte transplantation (MACT) combined with a total synovectomy. In general, lesions similar to the one described in this case are treated using osteochondral autografts, but in our case the osseous defect was too large to perform an osteochondral autograft. Our choice of treatment with an iliac crest bone graft combined with a MACT simultaneously has not yet been published, as far as we know. The patient returned to his former activities of daily living and sport activities, without restrictions or complaints, and with only a slight deficit in range of motion. Morphological and biochemical magnetic resonance imaging 12 months after surgery showed excellent bone healing with no intraosseous edema. The MACT resulted in a good clinical outcome, with 100% defect filling and excellent integration and surface and signal intensity of the cartilage repair tissue, and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score increased from 47 to 79 points.

A simple and effective implant for displaced fractures of the greater tuberosity: the "Bamberg" plate.

Displaced fractures of the greater tuberosity are common findings in trauma surgical patients. Nevertheless, osteosynthesis of these fractures impairs the risk of secondary dislocation or secondary impingement due to the implant (e.g., 4.5 mm cancellous screws with spiked washers). We present an easy and simple technique/implant to perform an osteosynthesis of multiple-fractured greater tuberosity fractures. We use a self-adjusted calcaneus titanium plate (Litos) which is cut into a 6 or more holed small plate. In ten patients we had excellent postoperative outcomes with no complications and no secondary loss of reduction. The surgical technique is easy and efficient.

Strength measurement and clinical outcome after pulley ruptures in climbers.

PURPOSE: Ruptures of the finger flexor pulleys are the most frequent injuries in rock climbers. Whereas multiple pulley injuries demand a surgical reconstruction, single ruptures are mainly treated conservatively. Nevertheless, the question of the clinical outcome or a persisting finger strength deficit after conservative therapy arises. METHODS: Twenty-one rock climbers (age 34 +/- 9 yr) with a grade 2-4 pulley injury were reevaluated 3.46 (range: 0.25-18) yr after injury. The clinical evaluation followed a standard questionnaire in combination with an ultrasound examination in extension and forced flexion. In order to determine the finger strengths, the subjects hung with the respective finger in various postures on a ledge attached above a door frame, while standing on a force platform, which measured the relative release. RESULTS: The 21 subjects had old (3.46 yr, range: 0.25-18) pulley injuries in 27 fingers (10 A2, 1 A3, 11 A4, 3 A2/3, 2 A3/4). The clinical outcome was excellent (Buck-Gramcko score of 3) in all cases; the subjects regained their climbing level within a year. There was no difference between the initial ultrasound examination and the follow-up during the study. For 17 finger pairs, data for the relative strength of the injured and the respective healthy finger could be gathered. The finger strength was not significantly different for the injured and the healthy finger in either the hanging or the crimping finger position. CONCLUSIONS: Nonsurgical treatment of single pulley ruptures is recommended. The clinical outcome was good to excellent, and no long-term strength deficit for the injured finger could be observed.

Planning analysis of knee-adjacent deformities. I. Frontal plane deformities.

The planning analysis of leg deformities around the knee joint is based on a standardized clinical examination and on long leg standing anteroposterior (AP) radiographs, which may be complemented by spot-film radiographs and stress radiographs. The principles of true-nominal analysis in six steps are used to characterize the deformity and plan the corrective osteotomy: 1. Drawing in the anatomic points of reference. 2. Establishing the mechanical weight-bearing axis. 3. Determining the axis and orientation angles around the knee joint. 4. Determining the correction goal. 5. Deciding on the osteosynthesis technique and the osteotomy level. 6. Measuring the angle of correction. All the steps are exemplified on a valgus deformity and a varus deformity.

Is a synthetic augmentation in medial open wedge high tibial osteotomies superior to no augmentation in terms of bone-healing?

INTRODUCTION: Medial open-wedge high tibial osteotomy (MOWHTO) is an established method to treat unicompartimental osteoarthritis of the knee joint. However, augmentation of the created tibial gap after osteotomy is controversially discussed. METHODS: We performed a prospective investigation of 49 consecutive cases of MOWHTO at our department. Patients were divided into two groups: group A consisted of 19 patients while group B consisted of 30 patients. In group A, the augmentation of the opening gap after osteotomy was filled with a synthetic bone graft, whereas group B received no augmentation. As an indicator for bone healing we investigated the non-union rate in our study population and compared the non-union-rate between the two groups. RESULTS: The non-union rate was 28% in group A (five of 19 patients had to undergo revision) which received synthetic augmentation, while it was 3.3% in group B (one of 30 patients had to undergo revision) which received no augmentation. The difference between the groups was statistically significant (p-value 0.027). CONCLUSIONS: With regard to bone healing after MOWHTO, synthetic augmentation was not superior to no augmentation in terms of non-union rates after surgery. In fact, we registered a significantly higher rate of non-union after augmentation with synthetic bone graft. LEVEL OF EVIDENCE: III.

Torsional osteotomies of the femur.

Various pathologies of the hip or knee, such as patellofemoral malalignment or femoroacetabular impingement may be caused by a femoral torsional deformity. When diagnosed and analyzed, it is treated by femoral torsional osteotomy. Thirty femoral torsional osteotomies in 25 patients were included, the principal symptoms were patellar dislocation in 15 patients, anterior knee pain in 17, and femoroacetabular impingement in two. A computed-tomography-based measurement of the torsional angle was performed in all patients. Japanese Knee Society score, Tegner activity score, Lysholm score, and visual analog scale score were determined before surgery and at follow-up after 41 (6-113) months. Femoral internal torsion was on average 40.9° (29° - 66°; normal 24°). Surgical treatment consisted of a femoral external torsional osteotomy of on average 13.8° (5° - 26°). Tegner activity score increased non-significantly (p-value 0.326) from 3.57 to 3.71. Japanese Knee Society score improved significantly from 72 to 87 (p-value 0.004) while Lysholm score rose significantly from 66 to 84 points (p-value 0.004). Pain relief was demonstrated by a significant decrease in the VAS score from 5.6 to 2.4 (p-value 0.007). No further patellar dislocation was reported. Torsional deformities of the femur frequently cause symptoms in the knee or hip joint. After thorough assessment and diagnostic investigation, a femoral external torsional osteotomy provides significant pain relief as well as patellofemoral stability.

Buruli ulcer: a systemic disease.

We studied a 4-year-old boy from Angola who presented with 2 cutaneous ulcerations of the right hip and osteomyelitis of the left knee and right ankle. Mycobacterium ulcerans disease was confirmed by direct smear examination and by polymerase chain reaction. The patient was treated with antimycobacterial drugs, repeated surgical debridement, skin grafting, and daily hyperbaric oxygenation. Despite significant improvement of the local lesions in response to hyperbaric oxygenation, swelling of the right knee, without associated skin lesions, was noted. Radiological evaluation and open biopsy revealed extensive metaphyseal osteomyelitis of the right distal femur. A 99technetium bone scan revealed an additional focus in the diaphysis of the left humerus, without soft-tissue involvement. This case documents, for the first time (to our knowledge), the systemic spread of M. ulcerans, with subsequent multifocal osteomyelitis and secondary involvement of soft tissues and supports the hypothesis that low tissue oxygen levels promote hematogenous spread of M. ulcerans. Sickle cell anemia, with associated microthrombosis and microinfarction, may have contributed to tissue hypoxia.

The pattern of preformed cytokines in tissues frequently affected by blunt trauma.

The aim of this prospective study was to determine the local concentrations of inflammatory mediators in various tissue types frequently affected by trauma to estimate the role of prestored cytokine release by mechanical tissue trauma in the induction of a systemic inflammatory response syndrome. The degree of tissue damage, evaluated by its systemic release of inflammatory mediators, represents an important factor concerning the outcome of trauma patients. Clinical trials indicate that the kind of traumatized tissue influences the cytokine pattern measured in patients blood afterwards. However, the tissue-specific mediator composition underlying this systemic mediator release is rarely elucidated. Upon approval of the local IRB/EC, skin, subcutaneous fat, muscle, cancellous bone, and lung tissue were obtained during standard surgical procedures. The protein-based concentrations of Interleukin (IL)-6, IL-8, IL-10, and IL-12 were determined in tissue homogenates by enzyme-linked immunoabsorbant assay (ELISA; n = 60 samples). Albumin was measured to evaluate the degree of blood contamination of tissue samples. IL-6 and IL-8 were consistently detectable in more than 95% of the tissue specimens. Lung and cancellous bone presented by far the highest concentrations of these cytokines, whereas skin, subcutaneous fat, and muscle showed significantly lower levels. IL-10 was not detectable in 88%; IL-12 could not be measured in 63% of the samples. Cytokine concentrations did not correlate with the amount of albumin measured in tissue specimens. Due to their consistent presence at the tissue level, high systemic concentrations of IL-6 and IL-8 in patients blood, seen after pulmonary trauma, long bone fractures, or soft tissue injury, may be interpreted as an overspill of local trauma mediators. This indicates their relevance in post-traumatic monitoring. Furthermore, albumin is a suitable and necessary indicator to evaluate influences of possible blood contamination in tissue samples.

Planning Analysis of Knee-Adjacent Deformities : I. Frontal Plane Deformities.

The planning analysis of leg deformities around the knee joint is based on a standardized clinical examination and on long leg standing anteroposterior (AP) radiographs, which may be complemented by spot-film radiographs and stress radiographs.The principles of true-nominal analysis in six steps are used to characterize the deformity and plan the corrective osteotomy:1. Drawing in the anatomic points of reference.2. Establishing the mechanical weight-bearing axis.3. Determining the axis and orientation angles around the knee joint.4. Determining the correction goal.5. Deciding on the osteosynthesis technique and the osteotomy level.6. Measuring the angle of correction.All the steps are exemplified on a valgus deformity and a varus deformity.

Impact of taping after finger flexor tendon pulley ruptures in rock climbers.

Flexor tendon pulley ruptures are the most common injury in rock climbers. Therapeutic standards usually include a prolonged use of taping applied as a replacement for the lost pulley in a circular fashion at the base of the proximal phalanx. Our biomechanical considerations, however, suggest a new taping method, the H-tape. The purpose of the study is to evaluate whether this new taping method can effectively change the course of the flexor tendon and therefore reduce the tendon-bone distance. In order to compare the effects of different taping methods described in the literature with the newly developed taping method, we performed standardized ultrasound examinations of 8 subjects with singular A2 pulley rupture and multiple pulley ruptures of A2 and A3 pulleys and determined the respective tendon-bone distance for the different taping methods, versus without tape at a preset position on the proximal phalanx. In a second approach, we evaluated the effect of the new taping method on the strength of the injured finger using a force platform on 12 subjects with different pulley ruptures with injuries older than 1 year. The new taping method decreased the tendon-bone distance in the injured finger significantly by 16%, whereas the other taping methods did not. The strength development was significantly better with the new tape for the crimp grip position (+13%), but there was no significant improvement for the hanging position. We recommend taping with the newly presented taping technique after pulley rupture.

Pulley injuries in rock climbers.

OBJECTIVE: The closed traumatic rupture of finger flexor tendon pulleys in rock climbers appeared as a new complex finger trauma in the mid 1980s. The objectives of this study are to characterize this injury and to describe diagnostic and therapeutic guidelines. A grading system for the severity of pulley injuries was developed and used to set therapeutic pathways. METHODS: Six hundred four injured rock climbers were prospectively evaluated from January 1998 to December 2001 with a questionnaire and standard examination protocol. Diagnostic ultrasound was performed in all rock climbers with finger injuries; if necessary, an additional magnetic resonance imaging was done. All pulley injuries were graded according to an introduced pulley-injury score (grade 1-4). RESULTS: Three of four of the most frequent injuries were related to the fingers: pulley injuries accounted for 20%, tendovaginitis for 7%, and joint capsular damage for 6.1%. One hundred twenty-two (20.2%) rock climbers presented an injury of the flexor tendon pulley system, 48 had pulley strains, and 74 had ruptures (a single rupture in 90.5% and multiple pulley ruptures in 9.5%). According to the pulley-injury score, 39% were grade 1, 25% were grade 2, 30% were grade 3, and 6% were grade 4 injuries. CONCLUSION: Pulley injuries were the most frequent injuries in rock climbers. Whereas grade 1-3 injuries respond well to conservative treatment, grade 4 injuries require surgical repair. We recommend the "loop and a half" technique of Widstrom and colleagues and, alternatively, the Weilby repair. We also recommend postoperative initial immobilization and early functional treatment under external pulley protection.