A New Classification for the Varus Knee.

BACKGROUND: A new classification for osteoarthritis of the knee associated with varus deformity is presented. This classification is derived from the combination of conventional radiographs, stress radiographs (when needed), and clinical examination. METHODS: This study included the analysis of coronal alignment on full-leg standing radiographs of 526 patients awaiting knee arthroplasty for varus deformity in a single institution. Various mechanical and anatomic angles were measured, and these findings were combined with a basic clinical examination of patients. The radiographs were measured on 2 separate occasions to determine the intraobserver reliability. Cross-sectional studies such as computed tomography or magnetic resonance imaging were used to further refine observations about different wear patterns. RESULTS: Varus deformity can either be intra-articular or extra-articular. Intra-articular deformities can be correctable or fixed. In fixed deformities, the status of the lateral ligament is taken into account. Extra-articular deformity can be metaphyseal or diaphyseal, and the possibility for intra-articular correction will depend on the degree of deformity and its distance from the joint. CONCLUSION: This new classification allows for better definition of varus deformity, which can help surgeons during preoperative planning, particularly with their choice of implant and potentially the degree of constraint. The classification can also be a tool for further prospective studies about varus deformity.

Can deformity of the knee and longitudinal growth of the leg be predicted in patients with hereditary multiple exostoses? A cross-sectional study.

BACKGROUND: There is a high rate of knee deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients have a limb length discrepancy. METHODS: A prospective database of 172 patients with HME was compiled. Patient demographics, knee deformity and range of movement, leg length and height, and number of exostoses around the knee were recorded. RESULTS: Nine out of 10 patients with HME were affected by exostoses around the knee, of which the distal femur was the most common site to be involved. Approximately 20% of patients had a valgus deformity and 16% had a fixed flexion deformity of the knee, with 25% having a diminished range of movement. Height was directly proportional to leg length and a quarter of patients were below the 10th centile for height. The presence of a distal femoral exostosis was an independent predictor of knee deformity (p=0.002), diminished range of movement (ROM) (p<0.001), and smaller stature (p<0.001) on multivariate analysis. In addition increasing age, prior surgery, genotype, and gender were also intendant predictors of ROM and height. CONCLUSION: Future studies analysing if surgical excision improves knee function and limits deformity would need to assess whether this is dependent upon anatomical site, as our results suggest that distal femoral exostoses may have the greatest affect upon these outcomes. LEVEL OF EVIDENCE: Level II.

Secondary correction of talar fractures: asking for trouble?

Secondary anatomical reconstruction of malunions or nonunions after talar fractures or fracture-dislocations with preservation of all three joints aims at maximal functional rehabilitation. A corrective osteotmy or revision of a pseudoarthrosis with axial realignment and internal fixation was carried out in 22 patients (aged 15 to 50) at a mean of 9 (range, 1.5 to 45) months after having sustained a fracture of the talar head, neck or body. 20 patients were followed for a mean of 4.8 (range, 1.5 to 14) years after reconstruction. No signs of development or progression of avascular necrosis (AVN) were observed in any case. Some amount of progression of peritalar arthritis was seen in 12 of 20 patients (60%). One patient required ankle fusion 7.5 years after reconstruction, another patient needed talo-navicular fusion after 5 years, and a third required a two-stage fusion of the ankle and the subtalar joint after 18 months. Two patients underwent arthrolysis of the ankle and screw removal after 7 and 14 years for dorsiflexion deficit at the ankle. The mean AOFAS ankle/hindfoot score increased from 36.9 preoperatively to 87.5 after correction (p < 0.001). Secondary correction after talar fractures appears promising in active and compliant patients without symptomatic arthritis, with good bone stock, no or partial AVN (less than one-third of the talar body), and no infection. Late fusion with a well-aligned talus remains a salvage option in cases of progressive arthritis.

Classificação angular para protrusão acetabular utilizada no serviço de ortopedia da Faculdade de Medicina do ABC / Angular classification for protrusio acetabuli used in the orthopedic service of Faculdade de Medicina do ABC

Introdução: a protrusão acetabular foi inicialmente descrita por Otto, em 1824. A incidência é maior no sexo feminino e a bilateralidade, mais comum, é maior nas protrusões de etiologia primária. Sotelo-Garza e Charnley definiram uma classificação que considera a distância da parede medial em relação à linha de Kõhler. Objetivo: apresentar a classificação angular para protrusão acetabular e demonstrar sua aplicabilidade. Método: a classificação da Faculdade de Medicina do ABC (FMABC) foi determinada a partir da medida do ângulo P (ângulo de protrusão), formado pela intersecção de três linhas. Foram avaliadas radiografias de bacia em dois grupos de pacientes: o primeiro, com pacientes sem protrusão acetabular, em que foram definidos os valores de normalidade, e o segundo, com pacientes com protrusão acetabular. Destes, foram medidos o ângulo P e o tamanho da protrusão de acordo com Sotelo-Garza e Charnley, sendo os resultados comparados. Dezenove quadris com protrusão foram submetidos à artroplastia total e comparados os valores do ângulo P no pré e pós-operatório. Resultados: o valor médio do ângulo P, em pacientes sem protrusão acetabular, foi -1,22º. No segundo grupo, observou-se semelhança quando foram comparados os valores da classificação FMABC e os da classificação de Sotelo-Garza e Charnley. A comparação entre os valores do ângulo P pré e pós-operatórios resultou em diferença estatisticamente significante (p<0,001). A classificação angular foi dividida em leve, moderada e grave. Conclusões: o ângulo P foi sempre superior a zero nas protrusões acetabulares, os valores numéricos das duas classificações foram estatisticamente significativos, possibilitando a utilização dos mesmos valores da classificação de Sotello-Garza e Charnley para a classificação FMABC, e o uso de enxerto causou uma lateralização do componente acetabular.

Introduction: protrusio acetabuli was first described by Otto, in 1824. Its incidence is higher among women and the bilaterality, more common, is higher in primary etiology protrusions. Sotelo-Garza and Charnley set a classification that considers the distance of the medial wall on the Kõhler's line. Objective: to present the angular classification for protrusio acetabuli and to demonstrate its applicability. Method: the angular classification of Faculdade de Medicina do ABC (FMABC) was determined from the measure of the P angle (angle of protrusion), formed by the intersection of three lines. Pelvis radiographs were evaluated in two groups of patients: the first, with patients without protrusio acetabuli, in which the values of normality were defined, and the second, with patients who presented the disease. We measured, in the second group, the P angle and size of the protrusion according to Sotelo-Garza and Charnley, and the results were compared. Nineteen hips with protrusion were submitted to total hip arthroplasty and the values of the P angle compared in the pre and postoperative. Results: the average value of the P angle, in patients without protrusio acetabuli, was -1.22º. In the second group, a similarity was observed when we compared the values of the FMABC angular classification and the Sotelo-Garza and Charnley classification. The comparison between the values of the pre and postoperative P angle resulted in significant statistical difference (p < 0.001). The angular classification was divided into mild, moderate and severe. Conclusions: the P angle was always greater than zero in protrusio acetabuli, the values of both classifications were statistically significant, allowing the use of the Sotello-Garza and Chanrley classification values for the FMABC classification, and the use of graft lead to a lateralization of the acetabular component.

The effect of tibial rotation on varus deformity measurement.

PURPOSE: Tibial osteotomy is used to treat a variety of orthopedic conditions, including reduction in pain and improvement of deformity and function. In templating for surgery, accurate radiographic measurement aids in planning for correction. The purpose of our study was to examine the effect of internal rotation and external rotation on measurement of tibial sawbone models with 5 closing wedge varus deformities at 10-degree increments between 10 and 50 degrees. One sawbone without deformity served as the control. STUDY DESIGN: A total of 66 radiographs were measured by 5 individuals. Measurement deviations from the control in each of the 10 positions of rotation were assessed. RESULTS: In the analysis of variance models, increased rotation and varus angulation were associated with increased deviation compared with the control. In external rotation for every 10 degrees of varus angulation, the degree deviation increased 0.69 degrees. In IR for every 10 degrees of angulation, the degree deviation increased by 0.84 degrees. Internal rotation had the greatest impact. Mean differences between different rater's measurements were small (1.1+/-1.2 degrees) and correlations suggested high interrater reliability. CONCLUSIONS: As the degree of rotation from neutral increased and varus angulation increased, deviation from neutral increased. CLINICAL RELEVANCE: Clinically, the results of this study support the importance of proper alignment of the tibia during radiography to more precisely template surgery.

Prognosis in Perthes' disease: a comparison of radiological predictors.

We compared the prognostic value of the Catterall grouping, the Salter-Thompson grading, the arthrographic shape of the femoral head, and the Herring lateral pillar grouping during the fragmentation stage of Perthes' disease in 73 patients with 81 affected hips. Radiographs were available for study from the onset of the disease until skeletal maturity. We used the Stulberg classification to assess outcome. The Herring grade and arthrographic sphericity proved to be the best predictors of final outcome. Combining these two values further increased the predictive value. All but one patient in Herring group A achieved an excellent outcome. In Herring group B, the age of the child and the sphericity of the femoral head influenced the end result. If the child was less than seven years old at the onset of symptoms the prognosis was invariably good and all spherical hips in group B had a good outcome with Stulberg grades 1 or 2. Moderately and severely deformed hips on arthrography resulted in Stulberg 3 and 4 hips. None of the hips in Herring group C had a normal appearance at maturity and the outcome was not significantly influenced by the age at onset or the arthrographic appearance.

[Bone and joint lesions in burns in childhood]. / Kostno-stavnite porazheniia pri izgarianiia v detskata vuzrast.

Bone and joint lesions as an underlying cause of disability require exact and emergency diagnosis and treatment. This is a report on the case material of the Pediatric Clinic of Burns and Plastic Surgery, with emphasis on the characteristic features of the children's population, having an essential bearing on the course of osteoarticular changes in the various stages of burn disease. The basic principles of treating osteoarticular lesions in each of the three groups, adopted in the clinic, are outlined, with special attention focused on the therapeutic approach to each of the groups, and on the emergency operative procedures aimed at maximally prompt removal of necrotic tissues and resurfacing of the osteoarticular lesions in early terms with a view to a varying degree preservation of function. Emphasis is also laid on the important practical implications of early rehabilitation as an element invariably present in the complex of functional recovery of the osteoarticular apparatus.

Complications of limb lengthening. A learning curve.

Major complication rates during limb lengthening were plotted in a consecutive series to produce a learning curve. All unwanted events during and after treatment were considered complications, and graded as minor, serious, and severe. All serious and severe complications were considered major. A novel system was used to classify the preoperative severity of each deformity. One-hundred ten patients had 140 bone segments lengthened between 2.2 cm and 10.5 cm, with a mean of 4.4 cm. Three methods were used in lengthening: the Wagner method in 22 patients, the DeBastiani method in 34 patients, and the Ilizarov method in 84 patients. Ninety-eight complications categorized as serious or severe occurred, for a total major complication rate of 72%. The percentage of major complications began to drop after 30 lengthenings to a current rate of 25%. Major complications were frequent in patients with more severe deformities, particularly in those whose cases occurred early in the series. Bone healing complications were high (72%) in the Wagner segments but were also high (80%) in the first ten patients treated with the DeBastiani technique. The first ten Ilizarov patients, who were treated later in the series, had a 40% rate of bone-healing complications. The current rate of major complications is 13% for those patients treated with DeBastiani's method and 33% for those patients treated with Ilizarov's method. This difference in complication rates appears to relate to the severity of the deformity, rather than the device used. There was a significant decrease in complications as experience was gained. Directed formal study and surgical instruction should help diminish these complications.

Allograft reconstruction of the acetabulum in revision hip surgery.

Acetabular deficiencies seen in revision hip arthroplasty require special attention. Custom components, space-filling cement, relocation of the hip center higher on ilium, and resection arthroplasties have all been used. Allograft reconstruction of acetabular defects has many attractive features, but methods of fixation, long-term success rates, and problems of graft resorption and implant loosening present significant questions. This article presents a classification system for acetabular defects and a surgical technique for correcting them. The results of 218 cementless acetabular reconstructions are reviewed and show the importance of the acetabular rim. When the rim is intact, 97% of reconstructions will remain stable, and 78% of allografts used will consolidate. When the acetabular rim is deficient, special techniques using bulk allograft and internal fixation must be used in order to avoid long-term graft resorption and implant loosening.

Primary total knee arthroplasty in patients with fixed valgus deformity.

Ninety-nine knees in 81 patients evaluated from two to ten years and having enough valgus deformity to require specific soft-tissue release were studied. They were also compared to a control group of 40 knees in 31 patients with no angular deformity greater than 5 degrees, who were matched for age and diagnosis. All procedures were performed using a minimally constrained, posterior-cruciate-ligament-sparing prosthesis. Pre- and postoperative axial alignment was measured on weight-bearing long-standing roentgenographs. Analysis included examination for lucent lines in postoperative fluoroscopically positioned roentgenographs and clinical data summarized using the 100-point scoring systems developed by The Knee Society. Knees were classified as having Type I, II, or III valgus deformities: Type I was defined as valgus deformity secondary to bone loss in the lateral compartment and soft-tissue contracture with medial soft tissues intact; Type II was defined as obvious attenuation of the medial capsular ligament complex; and Type III was defined as severe valgus deformity with valgus malpositioning of the proximal tibial joint line after overcorrected proximal tibial osteotomy. Only cases of Type I and Type II were represented in the 99 knees reported. Type I patients were treated with lateral soft-tissue release, and Type II patients were treated with medial capsular ligament tightening (i.e., ligament reconstruction procedures on the medial side). The Knee Society postoperative knee score was 87.6 (+/- 10.6) and mean postoperative functional score was 52.3. Alignment was well corrected and knee scores for the Type I and II groups were almost identical as were the functional scores. The results were grouped as 72% excellent, 18% good, 7% fair, and 2% poor. Notably, the control group was 39 of 40 patients excellent, and only one poor. Ligament stability was satisfactorily established by lateral release in Type I and with the combined medial plication in the Type II patients. The ligament-tightening procedures were on the average 40 minutes longer than those for the Type I or the control groups. The controversial nature of the simultaneous ligament reconstruction method is recognized, but good experience is reported.