Does screw position matter for guided growth in cerebral palsy hips?

AIMS: Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. METHODS: We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer's migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. RESULTS: A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. CONCLUSION: Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242-1247.

Modular stem in total hip arthroplasty for patients with trochanter valgus deformity: surgical technique and case series.

BACKGROUND: Trochanter valgus deformity (TVD) is a rare condition of total hip arthroplasty (THA). Femoral osteotomy could be required in correcting the deformity to implant femoral stem in severe TVD. In this study, we described one unpublished technique of reverse sleeve of S-ROM to get through the complex situation. This study aimed to summarize and evaluate its technical challenges, safety and effectiveness. METHODS: From January 2006 to December 2014, we enrolled patients whose sleeves were implanted towards the great trochanter in THA with TVD. Their demographics, perioperative and postoperative information were recorded. To explore its indication, we measured and analyzed the ratio of greater trochanter/lesser trochanter (G/L ratio) and trochanter valgus angle (TVA). RESULTS: Twelve patients (1 male and 11 female, average age 42.30 ± 10.23) had mean follow-up of 6 years. Among them, only two patients had intraoperative femoral fracture. The survivorship of femoral prosthesis was 100%. The Harris hip score (HHS) increased from preoperative 34.31 ± 14.43 to postoperative 84.12 ± 11.33. All patients' G/L ratio were larger than 1.50. CONCLUSIONS: The reverse sleeve of S-ROM was a reliable method for the patients with severe TVD, which brought satisfying clinical outcomes in mid-term follow-up.

Guided Growth Improves Coxa Valga and Hip Subluxation in Children with Cerebral Palsy.

BACKGROUND: Spastic hip subluxation or dislocation that is associated with an excessive coxa valga deformity is a common pathologic condition in children with cerebral palsy (CP) that is often treated with large bone reconstructive procedures. Guided growth techniques (such as stapling, plate, or transphyseal screw) have been widely used to alter the growth axis in patients with a lower-limb deformity but only a few reports have described their use in patients with coxa valga deformities. QUESTIONS/PURPOSES: (1) Does guided growth surgery using a transphyseal screw combined with adductor tenotomy prevent progressive coxa valga deformity and lateral hip subluxation in children with CP? (2) What factors influence the correction of coxa valga deformity and the success of hip stabilization? (3) What complications were associated with this operation and how often did children treated with it undergo reoperation? METHODS: From 2012 to 2016, at our institution, three authors (H-CH, KNK, K-WW) retrospectively studied data on children with CP who underwent guided growth of the hip for progressive bilateral hip subluxation associated with coxa valga deformities. A single percutaneous screw was inserted across the inferomedial portion of proximal femoral physis in an AP view and centered along femoral neck in lateral view under fluoroscopy guidance. During the period, we treated 25 consecutive children with CP who had progressive hip subluxation with coxa valga deformities. The indications for surgery were migration percentage > 30% and head-shaft angle > 155° with at least 2 years growth remaining. Of those, 13 patients underwent guided growth alone, and 48% (12) underwent a combination of guided growth and adductor tenotomy. Of the 25 patients treated with this approach, 96% (24) were available for follow-up with complete data at a minimum of 2 years follow-up (mean 50 months; range 25 to 72). All children (17 boys and seven girls; 48 hips) underwent surgery at a mean age of 8 years (range 5 to 12). With regard to the gross motor function classification system, three patients were Level 1, four patients were Level II, seven patients were Level III, seven were Level IV, and three were Level V. Radiographic parameters including the head-shaft angle, Hilgenreiner's epiphyseal angle, acetabular index, and Reimer's migration percentage were assessed before surgery and at the latest follow-up examination by one author (H-CH). Complications and reoperations were assessed by chart review. During the period in question, we generally offered secondary reconstructive surgery to patients who underwent a guided growth procedure once their subluxation progressed. RESULTS: With the data available, the coxa valga and lateral hip subluxation improved in terms of the reduction of head-shaft angle by a mean of 13° ± 7° (95% CI 11 to 15; p < 0.001) and the reduction of the migration percentage by 10% ± 11% (95% CI 7 to 13; p < 0.001). After controlling for potentially confounding variables like gender, gross motor function classification system, Hilgenreiner's epiphyseal angle and acetabular index, we found that longer follow-up duration (r = 0.234; p < 0.001) and a smaller preoperative migration percentage (r = -0.258; p = 0.004) were associated with larger changes in the head-shaft angle. In terms of complications, we found that the proximal femoral physis grew off the screw tip in 44% (21 of 48 hips) at a mean of 28 months. Among these, 31% of hips (15 of 48) in 33% of patients (eight of 24) underwent replacement with a longer screw. Among the 17% of hips (eight of 48) in 21% of patients (five of 24) who had progressive lateral subluxation and underwent secondary reconstructive surgery, we found that their preoperative acetabular index was higher (mean 29° versus 21°; p < 0.001), as was their head-shaft angle (mean 166° versus 162°; p = 0.045), and migration percentage (mean 54% versus 36 %; p < 0.001). CONCLUSIONS: Although guided growth with single transphyseal screw did not create as large a degree of varus as proximal femoral osteotomy, it did stabilize the hip in children with cerebral palsy with migration percentage less than 50% in our series. It is a simple procedure that can be of benefit to children with cerebral palsy with unstable hip. Reoperation in patients where the physis has grown off the screw tip can be a problem; fortunately, it is a rather minor procedure to replace with a longer screw. LEVEL OF EVIDENCE: Level III, therapeutic study.

A novel sequence variant in COL10A1 causing spondylometaphyseal dysplasia accompanied with coxa valga: A case report.

RATIONALE: Spondylometaphyseal dysplasia (SMD) is an extremely rare disorder of irregular development of spine and metaphyses of long tubular bones. Mutations in the collagen type X alpha 1 gene were found to underlie this condition. Previously reported mutations in the N-terminal non-collagenous NC2 domain and C-terminal non-collagenous NC1 domain failed to be identified in some specific patients. PATIENT CONCERNS: A 23-year-old male was referred to us for fixed, angular thoracolumbar kyphosis with semi-paralysis, numbness, and tremor on his left lower limb. Marked hypoplasia of thoracolumbar vertebra and spinal canal stenosis were observed on radiology. DIAGNOSES: He was diagnosed with spondylometaphyseal dysplasia (Type A4). Gene sequencing was performed using normalized targeted regions sequencing (TRS). A novel heterozygous missense variant p.Gly139Cys in the triple-helical region. Multiple lines of evidence imply this mutation to be pathogenic. INTERVENTIONS: Posterior instrumentation and vertebral column resection were given to correct his fixed, angular thoracolumbar kyphosis. OUTCOMES: The correction was satisfying and the functional outcomes were good. LESSONS SUBSECTIONS AS PER STYLE: The findings corroborated that type X collagen plays a critical role in the formation of the human spine as well as the long bones, and further expanded the range of type X collagenopathy. Surgical procedure could be considered for patients with severe malformation and neurological impairments.

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.

Risk factors of avascular necrosis of the femoral head and fixation failure in patients with valgus angulated femoral neck fractures over the age of 50 years.

INTRODUCTION: The aim of our study was to identify the risk factors for avascular necrosis of the femoral head (AVN) and fixation failure (FF) after screw osteosynthesis in patients with valgus angulated femoral neck fractures. PATIENTS AND METHODS: We conducted a retrospective study of 308 patients (mean age, 72.5 years, range, 50-97 years), with a mean follow-up of 21.4 months (range, 12-64 months). The risk for failure in treatment (FIT) associated with patient- and fracture-related factors was evaluated by logistic regression analyses. RESULTS: FIT was identified in 32 cases (10.3%): 22 cases (7.1%) of AVN and 10 cases (3.2%) of FF. Initial valgus tilt>15° (p=0.023), posterior tilt>15° (p=0.012), and screw sliding distance (p=0.037) were significantly associated with FIT. FIT occurred in 7 patients (5.2%) with B1.2.1 fractures and 17 patients (48.6%) with B1.1.2 fractures (p<0.001). The odds of FIT were 17-fold higher in patients with initial valgus and posterior tilts>15° (B1.1.2) compared to patients with <15° of tilt in both planes (B1.2.1). CONCLUSION: The severity of initial deformity predicts AVN and FF in patients with valgus angulated femoral neck fractures. Patients with an initial valgus and posterior tilt>15° are reasonable candidates for primary arthroplasty due to high risk of FIT.

EFFECT OF TRANEXAMIC ACID USE ON POSTOPERATIVE BLOOD LOSS IN TOTAL KNEE ARTHROPLASTY.

AIM: To monitor the effect of tranexamic acid use (Exacyl) on postoperative bleeding (aspiration), autologous blood transfusion (autotransfusion), allogeneic blood transfusion and postoperative anemia (difference between preoperative and immediate postoperative hemoglobin levels) in total knee arthroplasty. MATERIALS AND METHODS: This retrospective observational study was conducted on a sample of 457 patients who underwent endoprosthetic knee arthroplasty in the interval January 1, 2008-July 3O, 2014 at the Traumatology-Orthopedics Clinic of the Iasi Rehabilitation Hospital. The mean age of the study group was 66 years (range 32-84 years), 74.4% were female, 39.8% presented varus and 6.1% valgus malalignment. The study group was subdivided into two groups: Group 1 served as controls and underwent surgery without the administration of tranexamic acid and Group 2 received tranexamic acid. RESULTS: In group 1 the average amount of blood lost was significantly higher than in group 2, 1168.94 ml vs. 452.9 ml (p < 0.001). The use of a cell saver was required in 70% of group 1 patients with an average amount of auto transfused blood of 480.70 ml, significantly more frequent and in greater amounts than in group 2 (below 10%) with an average of 15.05 ml (p < 0.001). In this study tranexamic acid had not a statistically significant favorable effect on blood transfusion requirements and anemia syndrome. CONCLUSION: Tranexamic acid has a favorable effect on postoperative blood loss and its associated complications, with a favorable impact on both early clinical and functional recovery.

Guided Growth of the Proximal Femur for Hip Displacement in Children With Cerebral Palsy.

BACKGROUND: Guided growth by 1 eccentric transphyseal screw has been used to correct lower limb deformities. Pilot animal studies showed encouraging results in producing varus deformity in the proximal femur. The purpose of this study was to report the preliminary results of guided growth surgery to treat spastic hip displacement. METHODS: This case series study included consecutive patients who received soft-tissue release and guided growth at the proximal femur from January 2004 to May 2012 with minimal 2-year follow-up. Surgical indications were children with spastic cerebral palsy aged 4 to 10 years, a gross motor function classification system level IV or V, and hip displacement on 1 or both sides. Study outcomes were Reimer's migration percentage (MP) and the head-shaft angle (HSA). RESULTS: Nine children with 13 spastic displaced hips received surgery at the age of 6.2 years and were followed up for a mean of 45.6 months. The mean MP improved significantly from 52.2% preoperatively to 45.8% at 3 months, 40.3% at 1 year, and 37.1% at 2 years after operation. HSA was unchanged in the first 3 months, and deceased from 173.3 to 166.4 degrees at 1 year (P<0.01) and to 162.7 degrees at 2 years postoperatively. The screw was usually backed out from the femoral epiphysis in the second postoperative year, and no radiologic bony bar or other surgical complications occurred. CONCLUSIONS: The immediate postoperative improvement of MP was the result of soft-tissue release. From postoperative 3 months to 2 years, the HSA was reduced by 10.6 degrees and the MP further improved by 8.7%. Less surgical dissection, faster recovery of motion, and less comorbidity than varus osteotomy make guided growth surgery a treatment option for coxa valga in spastic hip displacement in nonambulant cerebral palsy children. LEVEL OF EVIDENCE: Level IV-therapeutic, case series.

Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS.

There is a growing concern about elderly valgus impacted proximal humeral fractures. The aim of this study was to evaluate the treatment and clinical outcomes following minimal invasive percutaneous plate osteosynthesis (MIPPO) with the proximal humeral internal locking system (PHILOS) for the treatment of elderly valgus impacted proximal humeral fracture. Between May 2008 and May 2012, 27 patients (average age 67.3, range 61-74) with valgus impacted proximal humeral fractures were enrolled in the study. The patients were treated with MIPPO using PHILOS-plate through the anterolateral delta-splitting approach. Rehabilitation exercises were done gradually. The NEER score and Constant-Murley score were used to evaluate shoulder function. All the patients were followed up by routine radiological imaging and clinical examination. There were 15 cases of II-part greater tuberosity fractures, 10 cases of III-part greater tuberosity fractures, and 2 cases of IV-part fractures according to the NEER classification. The surgery was successful in all patients with an average follow-up of 20.8 (range: 11-34) months. The fractures united in an average of 7.2 (6-14) weeks without implant loosening. According to NEER score, there were 17 excellent, 7 satisfactory, 2 unsatisfactory, and 1 poor. The mean Constant-Murley score was 89.4 ± 4.35. No complication including axillary nerve damage, postoperative nerve or vessel damage, infections, DVT, or death was observed. In conclusion, the MIPPO technique with the PHILOS through the anterolateral delta-splitting approach seems to be a safe and easy treatment for elderly valgus impacted proximal humeral fractures. A case-control study and longer follow-up time are needed.

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.

Degree of axis correction in valgus high tibial osteotomy: proposal of an individualised approach.

PURPOSE: The first purpose of this study was to introduce an individualized, pathology-based approach for the amount of axis correction in valgus high tibial osteotomy (HTO), in which the weight-bearing line (WBL) is transferred in one of three adjacent 5%-areas of the transverse diameter of the tibial plateau. The second purpose was to define the corresponding mechanical femorotibial angle (mFTA) for the margins of each 5%-area. METHODS: Reported indications for valgus HTO were assorted to one of three groups, based on the underlying pathology and expected accompanying degree of osteoarthritis. Three adjacent 5%-areas on the tibial plateau were defined, ranging from the 50% to 65% coordinate. The medial border of the tibial plateau was defined as 0% and the lateral border was defined as 100%. To define the corresponding mFTA, valgus HTO was simulated in 69 patients using commercial available planning software (mediCAD, Hectec GmbH, Germany). The corresponding mFTA was recorded at four different positions (50%, 55%, 60%, and 65%). RESULTS: Within the purposed approach, the WBL is aimed in one of three 5%-areas (50-55%, 55-60%, and 60-65%) of the transverse diameter of the tibial plateau, according to the underlying pathology. Based on the findings of simulated HTO, the mean mFTA was 0.3° ± 0.2° at the 50% position, 1.3° ± 0.2° at the 55 % position, 2.4° ± 0.3° at the 60% position, and 3.4° ± 0.3° at the 65% position. The mean difference of the mFTA between each adjacent valgus position was 1.1° ± 0.1°. CONCLUSION: The present paper introduces an individualized approach to adopt the degree of valgus correction in dependence of the underlying pathology. The area of interest on the tibial plateau lies in between the 50% and 65% coordinate on the tibial plateau, or in between a mean mFTA of 0.3° and 3.4° of valgus, respectively. Differences of the resulting mFTA between each area are small, and therefore a precise surgical technique is mandatory.

Femoral bow predicts postoperative malalignment in revision total knee arthroplasty.

Diaphyseal bowing may compromise axial alignment in revision total knee arthroplasty (TKA). 277 patients undergoing revision TKA were evaluated for coronal bowing and hip-knee-ankle (HKA) axis. The mean femoral bow was 1.52° ± 0.18° varus (-10.1° to +8.4°). The mean tibial bow was 1.25° ± 0.13° valgus (-5.9° to +10°). HKA axis averaged 3.08° ± 0.35° varus preoperatively compared to 0.86° ± 0.25° varus postoperatively. Inter-rater and intra-rater reliability was high. Femoral bow greater than 4° significantly correlated with postoperative HKA axis malalignment (r = 0.402, P = 0.008). 39.7% of patients deviated 3° or greater from a neutral mechanical axis with a significant difference in femoral bow (0.94° ± 0.31°, P = 0.003). Diaphyseal bowing clearly has an important effect on postoperative limb alignment in revision TKA.

Resemblance of valgus malalignment of the distal tibia in 15-degree craniocaudal radiographs.

PURPOSE: To describe and quantify a radiological phenomenon where the distal tibial plafond appears in valgus malalignment in intra-operative fluoroscopy owing to 15 degrees craniocaudal angulation of the X-ray beam. METHODS: The lateral distal tibial angle (LDTA) of 14 male and 9 female skeletally mature patients was measured by a single reviewer using 2 types of anteroposterior radiographs, in which the X-ray beam was projected at 0 (orthogonal to the ankle) and then at 15 (in a craniocaudal direction) degrees. The LDTA was the angle between the long axis of the tibia and a line drawn across the most radiodense part of the tibial plafond. The paired t-test was used to compare the LDTA of the 2 measurements. RESULTS: The mean LDTA on the 0-degree orthogonal radiographs was 89 (range, 87-92) degrees, whereas the mean LDTA on the 15-degree craniocaudal radiographs was 79 (range, 77-81) degrees. The mean difference was 10 degrees (range, 9-12; p<0.0001). In the 15-degree craniocaudal radiographs, the ankle joint appeared to have valgus malalignment. CONCLUSION: During intramedullary nailing of the tibia, the knee is usually flexed and the image intensifier may not swing over far enough. This can result in well-aligned reduction being incorrectly viewed as having valgus malalignment or a varus-malaligned fracture being incorrectly viewed as reduced.

Conversion hemiarthroplasty and valgus osteotomy after failed ORIF of hip intertrochanteric fractures.

Hip arthroplasty after open reduction and internal fixation of the proximal femur presents a challenge to reconstructive surgeons. Bony defects, fracture malunion, and non-union increase the risk of complications, including intraoperative fracture, unrecognized perforation, and trochanteric non-union. The authors describe a novel surgical technique using conversion hemiarthroplasty and valgus osteotomy for failed open reduction and internal fixation of intertrochanteric hip fractures. The described surgical technique resulted in trochanteric advancement and preservation of the bone stock in the intertrochanteric region. This technique was successful in eliminating pain and restoring ambulation and abductor function and resulted in stable ingrowth and healing in these patients.

Clinical implication of subgrouping in valgus femoral neck fractures: comparison of 31-B1.1 with 31-B1.2 fractures using the OTA/AO classification.

OBJECTIVES: This study aimed to identify the clinical implications of valgus-impacted femoral neck fractures and compare fractures with >15-degree angle of impaction (31-B1.1) against fractures with <15-degree angle of impaction (31-B1.2). DESIGN: Retrospective study. PATIENTS/PARTICIPANTS: We enrolled 78 patients with 31-B1 femoral neck fractures who were treated by screw osteosynthesis. MAIN OUTCOME MEASUREMENTS: We evaluated the clinical and radiographic outcomes. RESULTS: Thirty-six patients sustained 31-B1.1 fractures, and 42 patients sustained 31-B1.2 fractures. The average follow-up period was 15 months, and bony union occurred in all cases. The mean femur neck shortening was 8.88 mm for B1.1 and 3.70 mm for B1.2 fractures (P < 0.001). The mean sliding distance of the screw was 3.36 mm for B1.1 fractures and 1.38 mm for B1.2 fractures (P < 0.001). The mean Harris hip score was 82.0 for B1.1 and 88.8 for B1.2 fractures (P = 0.029). Avascular necrosis (AVN) of the femoral head occurred in 4 patients with B1.1 fractures, and none with B1.2 fractures (P = 0.041). Eighteen of the 78 patients required a second operation, and 15 of them were included in 31-B1.1 fracture (P = 0.003). Three patients underwent arthroplasty due to AVN, and 15 patients required hardware removal due to pain after bony union. CONCLUSIONS: More femoral neck shortening and less functional recovery should be expected in valgus-impacted femoral neck fracture patients based on the severity of the initial deformity. Even though we obtained bony union in all of the cases, the risk of AVN and second operation after bony union was higher with greater initial deformity. LEVEL OF EVIDENCE: Therapeutic level III.

Correction of distal femoral valgus deformities in adolescents and young adults using minimally invasive fixator-assisted locking plating (FALP).

The treatment of distal femoral valgus deformities in skeletally mature patients might be a challenging surgical problem with significant morbidity. Treatment options are various and include osteotomy and external fixation, intramedullary nailing, and plating using standard and locking plates. We describe technical notes of minimally invasive technique of fixator-assisted plating using a supracondylar locking plate. During a period of 3 years, we operated on six patients (seven femurs) with distal femoral valgus deformities of different etiologies. All patients achieved correction of the deformities and started full weight bearing with radiographic evidence of union 6 weeks after correction. We believe that fixator-assisted locking plating has advantages over correction using external fixation and intramedullary nailing. This method of correction can be performed by a minimally invasive technique, precisely, and with minimal morbidity.

Better outcomes in severe and morbid obese patients (BMI > 35 kg/m2) in primary Endo-Model rotating-hinge total knee arthroplasty.

The Endo-Model rotating-hinge prosthesis is preferably indicated as a primary implant in patients with advanced axial deviation of the lower limbs or unstable knees with severe bone defects. Outcomes were studied in 111 knees, operated in a three-year period; the mean followup was 28 months. Joint balance enhancement and limbs mechanical axis correction were achieved after surgery. There were 6 deep infections and 16 patients referred postoperative anterior knee pain. WOMAC index scores disaggregated by gender and BMI showed better outcomes in obese patients (specifically, those with a BMI of 35-40 kg/m(2)) and in men. Although the lack of a control group did not allow definite conclusions and despite a nonnegligible complication rate, our results reveal that the Endo-Model total knee arthroplasty can be a useful tool to deal with severe and morbid obese patients affected of severe gonarthrosis associated with marked axial deviations, ligament instability, or bone defects.

Use of temporary external fixation to generate a "customized" osteotomy of proximal femur in pediatric patients.

Proximal femoral osteotomies are performed commonly by pediatric orthopedic surgeons. Traditionally, utilization of a blade plate has been the standard method of realignment and fixation of the osteotomized fragments. In conjunction with use of temporary Schanz screws to generate the most appropriate realignment, newer implants with locking fixation capabilities can be used to stabilize essentially "customized" osteotomies of the proximal femur.

Perthes-like disease in Alagille syndrome.

We describe a unique case of a bilateral osteochondrosis of the femoral heads, similar to Perthes disease, in a boy affected by Alagille syndrome. This is a rare genetic syndrome, caused by vascular anomalies, and characterized by five main features: hepatic, cardiovascular, ophthalmological, skeletal malformations, and characteristic facial appearance. The most frequent skeletal finding is the 'butterfly vertebra'. We have followed the patient from the age of 5 years to the age of 20 years. We performed two bilateral valgus osteotomies when he was 10 years old to limit the progression of the deformity. We believe that the association of a bilateral osteochondrosis of the femoral heads with Alagille syndrome, a disease characterized by a vascular etiology, supports the hypothesis of angiogenic pathogenesis of Perthes disease.