Correction of distal femoral valgus deformities with fixator-assisted plating: How accurate is the correction?

OBJECTIVE: The aim of this study was to evaluate the results of fixator assisted correction of the distal femoral valgus deformities and the precision of the correction. METHODS: Seventeen extremities of 13 patients (7 women and 6 men; mean age: 16 ± 5.4 years) who had fixator assisted plating of the distal femur for genu valgum deformity were evaluated. Mechanical axis deviation (MAD) and mechanical lateral distal femoral angles (mLDFA) were measured pre-operatively and post-operatively. mLDFA was graded as perfect if it is between 85° and 90°(85° ≤ x ≤ 90°); overcorrection if it is between 91° and 95° (91° ≤ x ≤ 95°) and undercorrection if it is between 80° and 85° (80° ≤ x < 85°). Measurements beyond those limits were graded as a poor result. The position of the mechanical axis line with respect to center of the knee was graded from zone 1 to zone 4 pre-operatively and post-operatively. RESULTS: The mean follow-up period was 12.8 ± 3.7 months. The pre-operative and post-operative mLDFA was 70.5°±9.4° (range, 57°-82°) and 87.7° ± 3.5° (range, 80°-94°), respectively (p < 0.001). Based on post-operative standing radiographs, the correction was graded perfect in 12 femurs. The correction in three femurs were graded as overcorrection and graded as undercorrection in two femurs. Sagittal plane correction was also achieved in two femurs. Peroneal nerve decompression was done in three patients (5 extremities) with valgus deformity over 30°. The mechanical axes in all lower extremities were passing through zone 2 or more, pre-operatively, whereas the mechanical axes were in zone 2 or more in five extremities post-operatively. CONCLUSION: Fixator assisted plating is an effective treatment modality in patients with distal femoral valgus deformity. Although the technique enables to obtain significant correction in coronal plane it has the disadvantages of over- and undercorrection. Thus, we advise intraoperative confirmation of the correction under fluoroscopic control. LEVEL OF EVIDENCE: Level IV Therapeutic Study.

Is there an Increase in Valgus Deviation in Tibial Distraction Using the Lengthening Over Nail Technique?

BACKGROUND: During tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone. QUESTIONS/PURPOSES: The purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique. METHODS: Between June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26-71 months). The mean age of the patients was 25 years (range, 18-40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient's BMI. During the period studied, the blocking screw was to maintain the mechanical axis in patients who had neutral or valgus alignment preoperatively, or to prevent more valgus change in patients who underwent acute correction of varus deformity intraoperatively. Uni- and multivariate analyses were conducted. RESULTS: Valgus deviation occurred during the tibial LON. The medial proximal tibial angle increased from 86° (95% CI, 85°-86°) to 90° (95% CI, 89°-91°) (p < 0.001). The mechanical femorotibial angle changed from 2.2° varus (95% CI, 3°-1.4° varus) to 2.6° valgus (95% CI, 1.8°-3.4° valgus) (p < 0.001). Valgus deviation was evident in proximal and distal segments. In the multivariate regression model, use of a blocking screw was the only factor that was associated with decreased valgus deviation, and its effect size, although detectable, was small (-2.62; 95% CI, -4.65 to -0.59; p = 0.013). CONCLUSIONS: We found that valgus deviation does occur during tibial lengthening using the LON technique, but that blocking screw placement may help to minimize the likelihood that severe valgus deviation will occur. Future prospective studies should be conducted to confirm this preliminary finding. LEVEL OF EVIDENCE: Level III, therapeutic study.

Determinants of Hip Displacement in Children With Cerebral Palsy.

BACKGROUND: Coxa valga and femoral anteversion often are seen in patients with spastic hip displacement and osteotomy is recommended. However, the relationship between femoral deformities and hip displacement has not been clearly defined and other factors, such as joint motion and posture, should be considered before recommending treatment. QUESTIONS: For children with cerebral palsy with Gross Motor Function Classification System Level IV or V, we questioned (1) whether hip abduction range correlates with hip displacement, (2) what the relationships are between proximal femoral deformities and hip displacement, and (3) whether the patient with a windblown posture has greater degrees of femoral anteversion? METHODS: We retrospectively studied 31 consecutive children with cerebral palsy with Level IV or V gross motor function who underwent three-dimensional CT for preoperative assessment of hip displacement between January 2010 and December 2013. Among the children, 23 had a windblown posture and eight had symmetric hip motion. Femoral anteversion and true neck-shaft angle were measured from the three-dimensional CT images. Migration percentage was the dependent variable we chose to study in relation to femoral anteversion, neck-shaft angle, maximal hip abduction, and hip flexion contracture, using correlations and multiple linear regressions. Using ANOVA and Scheffé's post hoc tests, we analyzed and compared the data of 23 abducted hips and 23 adducted hips in the 23 children with windblown posture and in 16 displaced hips in the eight children with symmetric hip abduction. RESULTS: Greater migration percentage was associated with less hip abduction range (r = -0.86; p < 0.001). Femoral anteversion had a weak correlation (r = 0.28; p < 0.05) to migration percentage, and the association became insignificant after considering hip abduction motion. Adducted windblown hips had greater femoral anteversion than the symmetric displaced hips and abducted windblown hips (46° vs 36° and 38°, respectively; p < 0.05). CONCLUSIONS: Our study results did not support a relationship between femoral deformities and hip displacement after considering gross motor function and hip abduction motion. Greater femoral anteversion was noted in the adducted hips of patients with windblown posture, and derotation osteotomy is especially recommended. LEVEL OF EVIDENCE: Level III, diagnostic study.

Corrections of lower limb deformities in patients with diastrophic dysplasia.

OBJECTIVE: Accurate understanding of the cause of the underlying pathology in children with diastrophic dysplasia would help in designing targeted management of their locomotion. METHODS: Diastrophic dysplasia was diagnosed in twelve patients (nine girls and three boys; age range 1-14 years), all of whom presented with small stature and apparent short extremities. Club foot (mostly talipes equinovarus) was the most frequent and consistent abnormality. Concomitant abnormalities such as hip flexion contracture, flexion contractures of the knees with excessive valgus deformity and lateral patellar subluxation, were also encountered. Muscle ultrasound and muscle magnetic resonance imaging imaging showed no myopathic changes and muscle biopsies and the respiratory chain were normal. Serum choline kinase and plasma lactate concentrations were normal. RESULTS: Surgical correction of the foot and ankle in patients with diastrophic dysplasia is extremely difficult because of the markedly distorted anatomy. In all of these children, plantigrade foot was achieved along with the improved function of the locomotor system. Mutations of the diastrophic dysplasia sulfate transporter (also known as solute carrier family 26 member 2) were encountered. CONCLUSION: Arthrogryposis multiplex is the usual terminology used to describe the abnormality in infants with multiple contractures. Diligent orthopaedic care should be provided based on an accurate understanding of the associated syndromes in such children.

Kinematic gait analysis in children with valgus deformity of the hindfoot.

Deformities of the feet in children can influence not only optimal foot development but also the development of other body segments. The aim of the study was to compare the hip and pelvis kinematics in groups of children with and without valgus deformity of the hindfoot. Three groups of children participated in the study: bilateral hindfoot valgosity (11 children, age 5.4 ± 1.4 years), unilateral hindfoot valgosity (14 children, age 5.6 ± 1.6 years) and the control group (8 children, 4.8 ± 1.2). Hindfoot valgus angle was measured clinically during standing. Hindfoot valgosity was considered in the range of 6 to 20 degrees. Kinematic data from five trials for each child was obtained using the Vicon MX system (six infrared cameras, frequency 200 Hz, Vicon Motion Systems, Oxford, UK). The results of our study showed significantly higher pelvic anteversion during the whole gait cycle for both unilateral and bilateral hindfoot valgosity children and significantly higher hip external rotation during the first half of the stance phase in bilateral deformity. The differences in the hip and pelvis kinematics, when compared to the control group, are higher for the group with bilateral deformity than in the group with unilateral deformity.

[Crooked legs- just an aesthetic problem]. / Krumme Beine - mehr als ein ästhetisches Problem?

Because the lower extremities are weight bearing, malalignment plays a key role in the development of degenerative disease of the joints. This is particularly true as degenerative arthropathy is of mechanical and not inflammatory cause. Deviation of the axis has been shown to alter the load and force distribution in the joint and thereby causing excessive wear. Whether or not a deformity is clinically relevant or not depends on the symptoms, the amount of the deformity and the location of the deformity. Relevant deformities can be treated with orthotics or corrective osteotomies in early stages. In late stages fusions or joint replacement is the mainstay of treatment.

Parce que les extrémités inférieures portent un poids, un mauvais alignement de ces dernières joue un rôle clé dans le développement des atteintes dégénératives des articulations. Cela est particulièrement vrai puisque l'arthropathie dégénérative est d'origine mécanique et non pas inflammatoire. Une déviation axiale a été montrée modifier la répartition des charges et des forces dans l'articulation et provoquer ainsi un poids excessif. Qu'une déformation soit significative ou non sur le plan clinique dépend des symptômes, de l'importance et de la localisation de la déformation. Les déformations significatives peuvent être traitées dans des stades précoces par des ostéotomies orthotiques ou correctrices. Dans les stades tardifs des fusions ou des remplacements articulaires représentent les options thérapeutiques principales.

Adverse sequelae due to plate retention following submuscular plating for pediatric femur fractures.

OBJECTIVE: Submuscular plating has become a common operative treatment of length-unstable pediatric femur fractures. There has been no consensus regarding the need for plate removal after fracture union. The purpose of this report was to describe the potential constellation of findings that may occur with growth after plate retention. DESIGN: Retrospective case series. METHODS: A retrospective study was done on all patients who underwent a submuscular plate application for a pediatric femur fracture at our institution between 2003 and 2010 by the senior author. We reviewed the clinical and radiographic findings of patients who had returned for problems after being discharged from care after fracture union. RESULTS: We identified 3 patients who returned after having been discharged from care. All 3 patients had been treated with a distally contoured plate. All patients had findings of stress shielding, leg length discrepancy, valgus deformity of the femur, bony overgrowth of the plate, and screw tip prominence in the medial thigh. All these findings were related to plate migration secondary to the normal growth of the femur. One patient required a corrective osteotomy for significant limb malalignment, and 2 patients required removal of prominent distal screws. CONCLUSIONS: Submuscular plates that are distally contoured and applied in growing children for femoral fracture fixation should be removed after complete fracture healing to avoid the potential sequelae of plate retention seen with growth. LEVEL OF EVIDENCE: Therapeutic level IV.

Fovea alta on MR images: is it a marker of hip dysplasia in young adults?

OBJECTIVE: The objective of our study was to investigate the association between high fovea capitis (fovea alta) and hip dysplasia in young adults. MATERIALS AND METHODS: In a retrospective study, blinded observers reviewed 82 pelvic radiographic and hip MRI studies of three groups of patients: those with developmental dysplasia of the hip (DDH) (center-edge angle, ≤20°), those with borderline DDH (center-edge angle, 21°-25°), and control patients (center-edge angle, >25°). The center-edge angle and coxa valga (femoral neck-shaft angle, >135°) were assessed on pelvic radiographs, and fovea alta was assessed on MR images (delta angle, ≤10°). The Mann-Whitney and Fisher exact tests were used to correlate fovea alta with DDH and with coxa valga, respectively. Interobserver agreement for center-edge and delta angles and the diagnostic performance of fovea alta as a marker of DDH were calculated. RESULTS: Thirty-one patients with DDH, 23 with borderline DDH, and 28 without DDH were included. Excellent interobserver agreement was found for center-edge angle (concordance correlation coefficient, 0.94) and for delta angle (concordance correlation coefficient, 0.91). Fovea alta had a significant association with DDH (p<0.001) but no association with coxa valga (p>0.57). A significant difference (p<0.001) was found between patients with DDH (3.4°) and those without DDH (21.7°) with respect to mean delta angle measurements. Fovea alta had 69.4% sensitivity, 82.1% specificity, 67.2% positive predictive value, 81.0% negative predictive value, and 75.6% overall accuracy as an indicator of DDH. CONCLUSION: Fovea alta shows promise as a strong MRI marker of DDH.

Valgus slipped capital femoral epiphysis: report of two cases and a comprehensive review of literature.

Valgus slip of the capital femoral epiphysis is a known but extremely rare form of a slipped capital femoral epiphysis. After the first report in 1926 up to the present, approximately 44 cases have been reported. We report two cases of valgus slip of the capital femoral epiphysis with a comprehensive review of the existing literature and the precautions that are needed while planning surgical management of these patients. Awareness of this condition is essential to make a prompt diagnosis and plan the appropriate management.