[Anterior open wedge osteotomy of the distal femur]. / Anteriore Open-Wedge-Osteotomie am distalen Femur.

OBJECTIVE: To treat instability caused by a genu recurvatum using ventral open wedge osteotomy of the distal femur. INDICATIONS: Knee instability caused by Genu recurvatum with femoral extension deformity. CONTRAINDICATIONS: Inadequate blood flow to the lower extremity, soft tissue issues, obesity, osteoporosis. SURGICAL TECHNIQUE: Through a primary medial approach to the distal femur, a ventral open wedge osteotomy is performed using chisel bunch formation and arthrodesis spreader. For symmetrical expansion, another lateral approach at the distal femur and insertion of another arthrodesis spreader is performed. Osteosynthesis was performed with an angle stable plate from the medial side and with additional stabilization using a 4-hole angle stable plate from the lateral side. The osteotomy gap was filled with a bone graft wedge. POSTOPERATIVE MANAGEMENT: Partial weight-bearing of 20 kg was allowed for 6 weeks with passive exercise and lymphatic drainage. A hard frame orthosis for immobilization at 0-10-90° was fitted for 6 weeks. Radiographic controls were performed at 6 weeks, 3 months, and 1 year. After the last radiographic control, hardware was removed. RESULTS: There are no reports in the current literature regarding the effect of a change in the sagittal plane at the distal femur on alignment, stability, and biomechanics of the knee. This case report shows that genu recurvatum with physiological posterior tibial slope can be successfully treated with anterior femoral flexion osteotomy. Hyperextension was completely eliminated at the follow-up examination after hardware removal after 12 months.

[The preventive flexion osteotomy at the head of the tibia]. / Die präventive Flexionsosteotomie am Tibiakopf.

We present the case of a preventive tibial plateau flexion osteotomy in an adolescent patient who had a reduced posterior slope of the tibial plateau. The patient was asymptomatic and without instability at the time. However, magnetic resonance imaging (MRI) showed a dysmorphic posterior cruciate ligament, which was interpreted as an indication for osteotomy. This article demonstrates the surgical technique and postoperative outcome. The postoperative MRI shows a reorganization of the posterior cruciate ligament into a physiological ligament appearance.

[Corrective osteotomies around the knee joint using hexapods]. / Kniegelenknahe Korrekturosteotomien mittels Hexapoden.

OBJECTIVE: Correction of deformities around the knee joint in the frontal and sagittal axis, torsion, length and translation. INDICATIONS: Complex deformities of the proximal tibia, and to a lesser extent of the distal femur, which cannot be treated with acute correction using plate or nail osteosynthesis. CONTRAINDICATIONS: Nicotine abuse, soft tissue problems, lack of patient compliance. SURGICAL TECHNIQUE: First, mounting of the proximal ring of the ring fixator strictly parallel to the joint line in 2 planes, fixation with 3 or 4 pins or wires. Then mounting of the distal ring, fixation also with 3 or 4 wires, connection of both rings with 6 struts (movement units with which the length can be adjusted). Then the fibula osteotomy is performed in the transition from the distal to the middle third, and finally the tibial osteoclasia is performed via a mini-incision as a drill hole chisel osteotomy in the CORA (center of rotation and angulation) of the malposition. POSTOPERATIVE MANAGEMENT: Immediately postoperatively, the deformity is defined usimg computer software, the exact position and size of the ring and struts are entered, and a knee image is taken in 2 planes with X­ray signal adapter (beacon) on the ring fixator to plan the continuous correction. Thereupon continuous correction of the deformity via daily rotation on the 6 struts, which is done by the patients themselves at home after the hospital stay. At the time of correction, pain-adapted partial weight-bearing with 20 kg up to half body weight. After completion of the correction, repeat X­ray diagnosis and check whether the correction goal has been achieved. If necessary, reprogram a program for renewed continuous correction if residual deformity remains. When the correction goal is reached, X­ray check. After 6 weeks, with bony consolidation, gradual loading. The treatment of the correction can either be carried out in the ring fixator (wearing time of 0.5-1 year not unusual) or secondarily via a change of procedure to plate osteosynthesis. RESULTS: We report on 25 knee joint corrections in 23 patients (12 women and 11 men) using hexapods (Taylor spatial frame) during the period 2016-2023. One patient had a femoral and a tibial fixator at the same time; another patient had a triple fixator at the tibia. The mean age was 32 (6-73) years. 15 left and 10 right corrections were performed. 19 fixators had been applied tibial, 5 fixators femoral, and 1 fixator cross-jointly (for contracture). The indications were 6 congenital complex deformities, 10 posttraumatic complex deformities, 3 pseudarthroses after correction osteotomies, 2 patients with osteomyelitis, 1 knee contracture and 1 infection after fracture osteosynthesis with nails. The forms of correction performed were varizations and valgizations in frontal axis, extension and flexion in sagittal plane, torsional corrections, lengthening also after acute shortening (pseudarthrosis resection) and segmental transport. Acute shortening without lengthening was also treated with the fixator only until bone healing and a Masqualet procedure was bridged with it. The average duration of fixator wear was 144 (31-443) days. All patients were followed up until final metal removal. There were 19 change of procedure to another osteosynthesis procedure (18 plate osteosynthesis, 1 ESIN); 6 times the treatment in TSF (Taylor Spatial Frame) was performed until final bone healing.

Double-level torsional osteotomy a treatment for the 'inwardly pointing knee' syndrome.

INTRODUCTION: A 'inwardly pointing knee' syndrome is a combined torsional deformity with increased femoral internal and tibial external torsion. After clinical and radiological verification of the torsional deformity and unsuccessful conservative therapy approach, a combined (double level) torsional osteotomy of femur and tibia might be the appropriate treatment. Here, we present the diagnostic algorithms, treatment, and outcome of combined torsional osteotomies of femur and tibia. The aim of the study is to show that patients treated with the procedure achieve patellofemoral stability and pain relief or reduction. MATERIAL AND METHODS: Twenty torsional osteotomies performed on 18 patients were included. Nine patients had experienced patellar dislocation in 11 joints before. All patients were suffering from anterior knee pain. All patients underwent a clinical and radiographical evaluation, including a torsion angle CT scan. Pre- and post-operatively multiple commonly approved scores (Lysholm Score, Tegner Activity score, Kujala Score, VAS and Japanese Knee Society score) were acquired. RESULTS: In 18 patients we performed 20 double-level torsional osteotomies. 9 patients suffered from patellar dislocations in 11 knee joints prior to surgery. All patients were suffering from anterior knee pain. Of these 7 patients achieved a stable joint after surgery without further patellar dislocations. All achieved more knee stability and experienced less patellar luxation then before surgery. The mean duration of follow-up was 59 months (range 9-173 months). The mean VAS was significantly reduced by 3.75 points (SD 2.09, p value 0.0002) from 5.50 points (SD 2.73, range 0-9) before surgery to 1.75 points (SD 1.67, range 0-5) after surgery. The Lysholm score increased significantly by mean of 27.6 (SD 17.55, p value 0.0001) from mean 62.45 (SD 22.71, range 22-100) before surgery to mean 90.05 (SD 10.18, range 66-100) after surgery. The Kujala Score did improve significantly in average by 25.20 points (SD 13.61, p value 0.00012) from mean 62.9 (SD 16.24, range 35-95) to mean 93.2 (SD 9.20, range 66-100). The Tegner activity score did increase significantly by 1.2 points (SD 1.47, p value 0.004) in average from mean 2.65 (SD 1.11, range 1-5) to mean 3.85 (SD 1.42, range 1-6). The Japanese knee score did increase significantly by 19.15 in average (SD 11.95, p value 0.0001) from mean 74.05 (SD 14.63, range 33-95) to mean 93.05 (SD 10.18, range 68-100). CONCLUSION: This is the first publication reporting about simultaneous double-level torsional osteotomies in a comparatively high number of patients. In addition, this is the first publication assessing the patient collective afterwards with objectifying clinical outcome scores. The results show that double-level torsional osteotomy is an effective treatment for patients with patellar dislocation or subluxation associated to torsional deformities of femur and tibia. Furthermore, we introduce a diagnostic algorithm for 'inwardly pointing knee' syndrome. LEVEL OF EVIDENCE: Level IV.

Patient response to osteotomy around the knee joint at one year post-operation-fulfilment of expectations and current health status.

INTRODUCTION: The aim of this study was to investigate patient satisfaction and fulfilment of expectations after osteotomy around the knee at one year postoperatively, using patient-related outcome measures. MATERIALS AND METHODS: From the initial sample of 264 patients, a total of 132 patients (age 48y ± 11) were enrolled in this prospective study (response rate 49.3%). Data were collected using the Hospital For Special Surgery-Knee Surgery Expectations Survey (HFSS-KSES), items for satisfaction and the Knee injury and Osteoarthritis Outcome Score (KOOS) measures. At one year postoperative follow-up, an individualized questionnaire asked whether the specific person-related expectations had been fulfilled. RESULTS: Satisfaction was high with 83.2% of all participants at one year after surgery. A total of 78% of patients stated they would decide to do the surgery again. This decision was significantly associated with satisfaction, younger age and better KOOS scores scales before surgery for pain, activity and sports. We found high correlations between satisfaction and fulfilment of expectations for the HFES-KSES. Fulfilment of expectations one year after surgery was significantly associated with significant improvements in KOOS scales at one year post-operation. Expectations (1) "to get the knee back to normal status", (2) "improve ability to squat", (3) "improve ability to run", (4) "improve ability to kneel" had been fulfilled worst. A multiple linear regression model for satisfaction had an R2 = 0.797 of the variance. The most influential was the variable fulfilment of "maintain health" that had 70.7% of variance. CONCLUSIONS: The fulfilled expectation concerning an improvement of the ability to maintain health was the most influential parameter for satisfaction at one year post-osteotomy. Patients with better health status of the knee and younger age rated the surgery to be more positive and were also more likely to do the surgery again. This provides an indication for an earlier intervention, before the knee and overall health status becomes more detrimental. LEVEL OF EVIDENCE: Level II (Therapeutic study).

[Reality of care of patella stabilizing operations : A status quo among active members of the German Society for Orthopedic and Trauma Surgery (DGOU)]. / Versorgungsrealität patellastabilisierender Operationen : Ein Status quo unter aktiven Mitgliedern der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

BACKGROUND: Patellofemoral instability is one of the most common pathologies of the knee joint. The planning and implementation of patella-stabilizing operations are very variable. With regard to the operative measures, the preoperative planning is of decisive importance, especially with regard to the complexity of underlying pathologies. OBJECTIVES: The aim of this study was to depict the current healthcare reality in relation to planning and implementation of patella stabilizing operations in Germany. Furthermore, it was to be ascertained whether automated analysis options would facilitate the planning and implementation of surgical procedures (in primary and revision cases). MATERIALS AND METHODS: An online survey with 16 questions was collected by email among all active members of the German Society of Orthopedic and Trauma Surgery. 7974 members were surveyed; 393 responses could then be analyzed. RESULTS: MPFL-reconstruction (89.8%) is the most frequently performed procedure, followed by tibial tubercle transfers (64.9%), osteotomies (51.2%), and trochleoplasty (19.9%). The choice of surgical approach is mainly based on a combination of clinical and radiological findings (90.3%). MRI imaging (81.2%), standard X­ray images (77.4%), and full leg images (76.6%) are mainly used for operative treatment decisions. 59.3% of the respondents would appreciate better preoperative planning and 59.0% would implement more radiologically detectable parameters in their individual preoperative planning if these were automatically available. CONCLUSIONS: The findings of this survey among members of the DGOU identify the MPFL-reconstruction as the central operative approach in the treatment of patellofemoral instabilities, whereas MRI imaging is the diagnostic tool of choice. Future establishment of automated software-based analysis methods could allow a large number of surgeons to expand the radiological parameters taken into account when planning patella-stabilizing operations.

Significant slope reduction in ACL deficiency can be achieved both by anterior closing-wedge and medial open-wedge high tibial osteotomies: early experiences in 76 cases.

PURPOSE: It has been proven that a steep tibial slope (TS) is a risk factor for anterior cruciate ligament (ACL) injury and graft insufficiency after ACL reconstruction (ACLR). Recently, there is an increasing number of case series on slope decreasing osteotomies after failed ACLR utilizing different techniques and strategies. Goal of the present study is to report on early experiences with slope decreasing osteotomies in ACL deficient knees with special emphasis on the amount of slope correction, technical details, and complications; and to further analyze differences of slope corrections between sole sagittal as well as combined coronal and sagittal realignment procedures. In addition, we wanted to study if sole sagittal corrections change the coronal alignment. METHODS: Seventy-six patients with a minimum follow-up of 6 months were identified, who underwent a sole sagittal correction (anterior closed-wedge high tibial osteotomy (ACW-HTO)) or a combined procedure with an additional coronal realignment (medial open-wedge high tibial osteotomy (MOW-HTO)). In ACW-HTO, either infratuberosity or supratuberosity approaches were used. The medial TS was measured on lateral radiographs and the anatomical medial proximal tibial angle (aMPTA) was measured on anterior-posterior radiographs. Technical details and specific complications were recorded. RESULTS: Fifty-eight ACW-HTO and 18 MOW-HTO were performed. Regarding ACW-HTO, an infratuberosity (N = 48) or a supratuberosity (N = 10) approach was chosen. Sixty-seven patients had at least 1 previous ACLR. Mean TS changed from 14.5 ± 2.2° to 6.8 ± 1.9° (P < 0.0001). Mean TS of ACW-HTO was significantly reduced (14.6 ± 2.3° vs. 6.5 ± 1.9°; P < 0.0001), whereas in combined coronal and sagittal realignments, from 14.1 ± 1.9° to 7.6 ± 1.9° (P < 0.0001). The TS reduction in sole sagittal corrections was significantly higher compared to combined procedures (8.1 ± 1.6 vs. 6.4 ± 1.6°; P = 0.0002). Mean aMPTA in ACW-HTO changed from 87.1 ± 2.1° to 87.4 ± 2.8 (n.s.). However, there was a significant inverse correlation between the amount of sagittal correction and coronal alteration (r = - 0.29; P = 0.028). There was one late implant infection, which occurred 5.5 months after the index surgery. CONCLUSIONS: ACW-HTO and MOW-HTO facilitate significant slope reduction with a low-risk profile in patients with ACL insufficiency and a high tibial slope. AOW-HTO does not significantly alter coronal alignment in the majority of patients. LEVEL OF EVIDENCE: IV.

The Impact of Anatomical Predisposition and Mechanism of Trauma on Dislocation of the Patella: A Retrospective Analysis of 104 Cases.

BACKGROUND: The aim of this study was to determine whether traumatic dislocation of the patella is provoked by the presence of predisposing factors and examine the role of the mechanism of injury. METHODS: Cases diagnosed with dislocation of the patella and covered by the workers' compensation program were identified and classified as traumatic based on insurance regulations. We examined predisposing factors (e.g., frontal axis, torsional deviation, trochlear dysplasia, patella alta) in case groups based on age at dislocation and trauma mechanism. Retrospective cohort study, level of evidence III. RESULTS: Our sample size comprised 104 cases, consisting of 54 children and 50 adults. The most common mechanism of injury in children and adults was rotational trauma. Only 20% of the children and 21% of the adults exhibited no relevant predisposing factors. Group specifically, falls accounted for the highest number of cases exhibiting none of the defined anatomical predisposing factors. Children are more frequently affected by predisposition-related dislocations than adults. CONCLUSION: The proportion of predispositions is high. A fall, direct impact, or rotational trauma can be viewed as an adequate mechanism of trauma. For successful treatment, it is paramount to analyze the exact mechanism of the trauma and address any underlying predispositions.

Interobserver reliability is higher for assessments with 3D software-generated models than with conventional MRI images in the classification of trochlear dysplasia.

PURPOSE: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour. METHODS: Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour's 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen's kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement. RESULTS: The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented. CONCLUSION: Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning. LEVEL OF EVIDENCE: Level II.

Anterior Open-Wedge Osteotomy in Posterior Cruciate Ligament Deficient Knees: From a Historical Perspective to First Clinical Results.

Recently, the bony anatomy of the proximal tibia has gained strong interest, particularly in the cruciate ligament deficient knee. Regarding the anterior cruciate ligament (ACL), several studies outlined that a steep tibial slope (≥12 degrees) contributes to early failures after ACL reconstruction. As a consequence, the first clinical reports are available on slope reducing osteotomies in revision ACL surgery. Vice versa, biomechanical as well as clinical reports suggest that a flat slope increases the load on the posterior cruciate ligament (PCL) and might contribute to a poor result after PCL reconstruction. Since many decades, slope increasing anterior open wedge osteotomies are used to treat a symptomatic genu recurvatum. The aim of the current report is to describe different surgical techniques and report our first clinical experience of an anterior open wedge osteotomy as a sole procedure in chronic PCL deficient knees with a flat tibial slope. In six cases, a mean preoperative slope of 3.7 degrees (range = 2-5 degrees) was increased to a mean of 11.5 degrees (range = 9-13 degrees). There was one case with a delayed bone healing, which was successfully treated without loss of correction by revision internal fixation and bone grafting.

Tibial Slope Correction as an Infratuberosity Closing-Wedge Extension Osteotomy in ACL-Deficient Knees. / Die tibiale Slope-Korrektur als infratuberositär zuklappende Extensionsosteotomie bei Insuffizienz des vorderen Kreuzbandes.

ACL insufficiency can be caused by different reasons. Elevated posterior tibial slope is a deformity which is discussed to have relevant influence on the outcome of ACL surgery. A increased posterior tibial slope of 12° or more leads to significant more ACL insufficiency. The surgical therapy of this pathology is a high tibial extension osteotomy. Publications ashowing a clinical follow up and results of this surgery are rare. In this video the technique of a closed wedge high tibial extension osteotomy is shown. Osteosynthesis is performed with two screws and an anklestable plate osteosynthesis. An arthroscopy with bone graft filling of the femoral ACL tunnel is performed first, followed by filling of the tibial tunnel in an open approach.

The effect of open-wedge and closed-wedge high tibial osteotomies on the tibial posterior slope-a study of two hundred seventy-nine cases.

PURPOSE: There are two established techniques for high tibial valgisation osteotomy (HTO): medial open wedge (MOW) and lateral closed wedge (LCW). The aim was to analyze the change of the posterior tibial slope (PTS) caused by HTOs dependent on the technique. METHODS: Four hundred fourteen cases of HTOs were analyzed retrospectively. Two hundred seventy-nine osteotomies in 247 patients matched the inclusion criteria and were divided into two treatment groups (MOW/LCW). The PTS was determined on pre- and post-surgical lateral knee X-rays by measuring the proximal posterior tibial angle (PPTA). RESULTS: One hundred ninety of the included 279 cases were assigned to the MOW and 89 to the LCW group. The mean PPTA in MOW HTOs was 79.9° ± 32° (68-88°) and in LCW HTOs 80.6° ± 2.6° (74-88°). There was no statistically significant change of the PPTA in the MOW group comparing the pre- and post-surgical values (delta PPTA 0.07° ±2.9° (- 12 to 11°)). In the LCW group, the surgery resulted in a statistically significant reduction (p< 0.001) of the PTS (delta PPTA - 3.09° ± 4.5° (- 12 to 5°)). CONCLUSION: The important finding of this study is that the thesis of a slope increase in MOW osteotomies found in the literature could not be approved regarding our results as no statistically significant change of PTS in MOW HTOs was observed. The findings support the common thesis that LCW osteotomies cause a slope reduction.

Torsional Osteotomy.

This article provides an overview of symptomatic torsional deformities of the lower extremity, and operative treatment techniques are described in detail. A definition of torsion versus rotation as well as information to physical examination and the relevance of radiological evaluation is given. Based on current literature and the own personal experience of the authors in osteotomies, surgical techniques at the proximal and at the distal femur, as well as at the tibia are presented.

[Osteotomies around the Knee]. / Kniegelenknahe Korrekturosteotomien.

Osteotomies around the knee in unicompartimental osteoarthritis had an impressing revival in the past few years and have to be kept in mind as an alternative to total knee arthroplasty. The most frequent type of osteotomies around the knee is the medial open wedge high tibia osteotomy (MOWHTO). But still also closed wedge high tibia osteotomies (CWHTO) have their relevance in many cases. Distal femur osteotomies (DFO) are used more and more frequently in most cases as closed wedge, the open wedge DFO shows more problems in bone healing. All osteotomies with isolated correction in frontal plane should be done with a biplanar bonecut. In cases of severe varus and valgus malalignment a double-level osteotomy (combined femoral and tibial osteotomy) has to be executed. Severity and frequency of adverse events in osteotomies around the knee are mostly comparable to those in arthroplasty, except non-union which is only related to osteotomies and more often seen in smokers. There are nearly no age limits for osteotomies around the knee. Ten years-survival in HTOs are about 85 to 91% according to literature.

Patients' expectations of osteotomies around the knee are high regarding activities of daily living.

PURPOSE: This study was conducted to investigate patients' expectations on high tibial osteotomies, distal femur osteotomies, and double-level osteotomies in different health-related domains. It was hypothesized that expectations are high in terms of capacity to work, pain relief, and restoring knee function. METHODS: A total of 264 patients (age 47 years ± 11 years) were enrolled in this study from March 2015 until May 2016 in seven specialized orthopaedic surgery departments. Data were collected via the Knee injury and Osteoarthritis Outcome Score, the Hospital for Special Surgery-Knee Surgery Expectations Survey, and a ten-item (non-validated) questionnaire to specifically ask about expectations of osteotomies around the knee 24-48 h prior to surgery. In addition, self-efficacy was assessed. Parametric tests were used to test the hypothesis. RESULTS: Knee injury and Osteoarthritis Outcome Score test results showed that all patients suffered because of their knee impairments prior to surgery. All participants had high expectations in all aspects regarding the surgical outcome: on a four-point Likert scale ranging from 1 (very important) to 4 (not important), all mean values were between 1.2 and 1.7. For patients who had a demanding physical work, the ability to keep a stressful working posture was more important than for other patients (i.e. to kneel, to squat). Furthermore, preoperative lower quality of life was associated with higher expectations concerning improving the ability to walk, to achieve improvements in activities of daily living and social well-being. CONCLUSIONS: Patients' expectations of osteotomies around the knee are high in terms of capacity to work, pain relief, and restoring functions. The natural course of osteoarthritis and the potential need for conversion to TKA were underestimated by a substantial proportion of the study population. However, the expectation regarding survival rate is in line with the reported literature. The results of this study should assist surgeons in discussing realistic expectations when considering and counselling patients regarding osteotomies around the knee. This may help to clarify realistic expectations preoperatively and ultimately improve patients' satisfaction. LEVEL OF EVIDENCE: Therapeutic study, Level II.

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.

Autologous Conditioned Plasma Versus Placebo Injection Therapy in Lateral Epicondylitis of the Elbow: A Double Blind, Randomized Study.

Introduction There are various therapeutic approaches to the treatment of lateral epicondylitis, a highly prevalent musculoskeletal disorder. Recently, injection therapy with autologous conditioned plasma (ACP) has shown promise as a new approach. Methods Set up as a prospective, double-blind, randomized controlled clinical trial, this study involved 50 patients with lateral epicondylitis. Following external randomization, 25 patients received one round of injection therapy with ACP (platelet rich plasma, PRP), while the remaining 25 patients received a placebo of 0.9 % NaCl. All patients were re-evaluated with respect to lateral epicondylitis of the elbow at four-weeks and six-months post-injection. Results Out of 50 patients, 36 qualified for reevaluation, 18 patients from the ACP therapy group and 18 from the placebo group. The initial Disability of the Arm, Shoulder and Hand (DASH) score for all reevaluated patients was 36.4 in the ACP group, and 41.0 in the placebo group; both groups exhibited decreased DASH scores at the four-week and six-month post-injection follow-up (6 months: ACP 30.1, placebo 25.8). The decrease of the DASH score after 4 weeks was greater and qualified as statistically significant in the placebo group (p = 0.041), compared to the DASH score decrease in the ACP treatment group, which was statistically non-significant. Additionally, the difference between the DASH scores of the treatment and placebo groups was statistically non-significant four weeks and six months after treatment. Discussion The results of this study suggest a therapeutic effect in both the ACP and placebo groups, with no evidence for a therapeutically significant difference between ACP and placebo treatments. It is hypothesized that, in accordance with the study protocols, injection with a local anaesthetic prior to ACP therapy may have an influence on the therapeutic effect of ACP. Future studies have to confirm recent findings that demonstrated a minimizing, or even inhibiting, action of local anaesthetics on the effects of ACP/PRP. Conclusion The effect of ACP/PRP injections needs to be investigated in future studies under standardized conditions.