[Patient-specific cutting guides in corrective osteotomy near to the knee joint]. / Patientenspezifische Schnittblöcke bei kniegelenknahen Korrekturosteotomien.

OBJECTIVE: Patient-specific cutting guides (PSCG) are used in osteotomy near to the knee joint to simplify the operative technique, shorten the duration of surgery, reduce radiation exposure and to exactly realize the preoperative planning during surgery, especially when complex deformities are corrected simultaneously in multiple planes. INDICATIONS: The application of PSCG is in principle possible in all osteotomies near to the knee joint but is especially useful in multidimensional, complex osteotomy. CONTRAINDICATIONS: No specific contraindications. SURGICAL TECHNIQUE: After multidimensional 3D analysis and planning using a preoperative computed tomography (CT) protocol, a 3D-printed patient-specific cutting guide is produced. This PSCG is used during standard osteotomy near to the knee. Using this PSCG the guided sawcut and predrilling of the screw positions inside the bone for the screws of the planned angle stable osteotomy plate are performed. The amount of the deformity correction needed is "stored" in the PSCG and is converted to the bony geometry during placement of the screws in the predrilled holes through the plate after opening or closing the osteotomy. Apart from that, the surgical approach and technique are equivalent to the standard osteotomy types near to the knee. POSTOPERATIVE MANAGEMENT: The application of PSCG in osteotomy near to the knee does not change the postoperative management of the specific osteotomy. RESULTS: The use of patient-specific cutting guides leads to a higher accuracy in the implementation of the preoperative planning and the desired target axis is achieved with greater accuracy. Multidimensional complex corrections can also be exactly planned and implemented. In addition, the intraoperative radiation exposure for the operation team can possibly be reduced.

[Subtuberosity anterior closing wedge osteotomy to correct the increased posterior slope of the tibial plateau]. / Subtuberositäre anterior schließende Osteotomie zur Korrektur der erhöhten posterioren Reklination des Tibiaplateaus.

OBJECTIVE: Reduction of increased reclination of the tibial plateau (posterior slope) to improve the anterior stability of the knee joint. INDICATIONS: Increased posterior reclination of the tibial plateau greater than 12° in combination with recurrent instability after anterior cruciate ligament (ACL) reconstruction. CONTRAINDICATIONS: Hyperextension of more than 15° (relative). SURGICAL TECHNIQUE: Anterior skin incision approximately 8-10 cm above the tibial tuberosity. Insertion of two converging guidewires directly below the patellar tendon ending obliquely in the area of the posterior cruciate ligament (PCL) insertion. Control of the wire position with the image intensifier core. Oscillating saw osteotomy. Removal of the wedge and closure of the osteotomy. Osteosynthesis with interfragmentary screw and medial angle-stable plate. POSTOPERATIVE MANAGEMENT: Partial load with 10-20 kg for 2 weeks, then step by step increase in load. Mobility: free. RESULTS: To date we have operated on 36 patients with recurrent instability after ACL reconstruction (20 men, 16 women, average age 34.4 years) in the manner described in this article. In 25 cases, enlarged bone tunnels were filled with allogeneic bone at the same time. The posterior slope of the tibial plateau could be reduced from an average of 14.5° to 8.8°. In 28 cases another ACL reconstruction was performed after an interval of 4-12 months. The Lysholm score significantly increased from 76.3 points to 89.2 points.

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).

[The influence of axial deformities and their correction on the development and progression of osteoarthritis]. / Einfluss von Achsdeformitäten und deren Korrektur auf die Arthroseentstehung und -progression.

A cornerstone in the treatment of osteoarthritis in young patients is the evaluation and correction of the leg axis. The combination of a joint injury (meniscus, cartilage, ligament) and an axis deviation inevitably, depending on its extent and the patient's comorbidities such as obesity, leads to progressive osteoarthritis of the knee after a few years. In addition to the precise deformity analysis for osteotomy planning, it is important to know the normal ranges of the corresponding angles and to define a target value for axis correction. Reflecting the repertoire of different osteotomy options around the knee (open vs. closed, tibial vs. femoral, medial vs. lateral), the side effects in relation to patellofemoral maltracking, ligamentary balancing and leg length should then be assessed. Especially with regard to possible (and probable) prosthetic operations at some time in the future of young patients, new bony deformities or ligamentous insufficiencies, which potentially arise from overcorrection, must be avoided.

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.

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.

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.

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.

Treatment of ingrown toenails using a new conservative method: a prospective study comparing brace treatment with Emmert's procedure.

Ingrown toenails cause incapacitation and pain for the patient and lost time from work. Many different conservative and surgical treatment methods have been described. European chiropodists and podologists have long treated ingrown toenails with orthonyxia, which consists of implantation of a small metal brace or plate onto the dorsum of the nail. To determine whether orthonyxia is an acceptable alternative to surgery, we compared the VHO-Osthold brace (VHO-Osthold-Spange GmbH, Deisenhofen, Germany), a new method of orthonyxia, with Emmert's procedure, a standard surgical method that is virtually identical to the Winograd-type procedure, in a prospective study of 41 patients (21 in the brace group and 20 in the Emmert procedure group). Pain due to treatment was significantly lower in the brace group than in the Emmert procedure group, and patients in the brace group could wear regular shoes again without appreciable pain much earlier than those in the Emmert procedure group. In the brace group, there were four recurrences, and one patient was still receiving treatment at the end of follow-up; in the Emmert procedure group, there were three recurrences. None of the patients in the brace group had to take time off from work, whereas in the Emmert procedure group, working patients were off from work for an average of 14.7 days. Brace treatment proved to be a good conservative alternative to operative procedures.