Surgical correction of cubitus varus in children with a lateral closing-wedge osteotomy: a comparison between two different techniques.

OBJECTIVES: The primary objective of the present study is to compare the radiographic outcomes and complications of two different techniques for lateral closing-wedge osteotomy in pediatric patients with cubitus varus. METHODS: We retrospectively identified patients treated at five tertiary care institutions: 17 underwent the Kirschner-wire (KW) technique, and 15 patients were treated with the mini external fixator (MEF) technique. Demographic data, previous treatment, pre- and postoperative carrying angle (CA), complications and additional procedures were recorded. Radiographic evaluation included assessment of the humerus-elbow-wrist angle (HEW), and the lateral prominence index (LPI). RESULTS: Patients treated with both KW and MEF achieved significant improvements in clinical alignment (mean pre-op CA -16 ± 6.1 degrees to mean post-op 8.9 ± 5.3 degrees, P < 0.001). There were no differences in final radiographic alignment or radiographic union time; however, time to achieve full elbow motion was faster in the MEF group (13.6 versus 34.3 weeks, P = 0.4547). Two patients (11.8%) in the KW group experienced complications, including one superficial infection and one failed correction that required unplanned revision surgery. Eleven patients in the MEF group underwent a planned second surgical procedure for hardware removal. CONCLUSIONS: Both fixation techniques are effective at correcting cubitus varus in the pediatric population. The MEF technique may have the advantage of shorter recovery of elbow range of motion but may require sedation for hardware removal. The KW technique may present a slightly higher complication rate.

Is modified reverse step-cut osteotomy better than Yun's reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial.

BACKGROUND: Various corrective osteotomy techniques have been described in the literature for correcting paediatric cubitus varus. But we are still in search of the perfect technique that gives maximum possible deformity correction and cosmetic appearance that satisfies parents with minimal complications. We compared the outcomes of two technically sound osteotomy techniques having minimal postoperative lateral condyle prominence described in the literature. RESEARCH QUESTION: Is modified reverse step-cut osteotomy (MRSO) better in terms of clinical, radiological, and cosmetic outcomes than Yun's reverse V osteotomy (RVO) in pediatric cubitus varus deformity correction? METHODS: In total, 20 children with unilateral cubitus varus resulting from malunited supracondylar humerus fractures were included. Randomization was done by computer-generated random slips. A total of ten cases each were operated by MRSO and RVO techniques, respectively. Clinical, radiological, and cosmetic appearance assessments were done at the final two year follow-up and compared between the two groups. RESULTS: The mean age of children in the MRSO and RVO groups is 9.9 years (3-16) and 8.6 years (3-16), respectively. The mean pre-operative carrying angle in the deformed elbow of MRSO and RVO group was - 20.5° and - 19.5°, respectively, and the mean pos-toperative carrying angle in the corrected elbow of MRSO and RVO group was + 6.8° and + 6.5°, respectively. Regarding the lateral prominence index (LPI), a positive correlation was noted between pre-operative and post-operative periods with a value of 0.855 and 0.844 (p value: 0.001 and 0.03, respectively) in both MRSO and RVO groups, respectively. However, the change was statistically not significant when compared between the two groups (p = 0.63). There was no statistically significant difference (p > 0.05) when the clinical, radiological, and cosmetic outcomes were compared between the groups at final follow-up. CONCLUSION: The surgeon can choose either one of these techniques based on their expertise since the results of both the techniques are comparable in terms of clinical, radiological, and cosmetic outcomes.

Unsuccessful mid-term results for distal humeral hemiepiphysiodesis to treat cubitus varus deformity in young children.

Cubitus varus is the most common complication following a pediatric humeral supracondylar fracture. No reports are available on the result of hemiepiphysiodesis to correct this deformity. We report the use of a transphyseal crossed cannulated screw (Metaizeau technique) in five very young children (mean 3 years and 7 months). No correction was observed after a mean of 3 years and 10 months of follow-up. The low growing capacity of the distal humeral physis makes corrective osteotomy the procedure of choice for cubitus varus deformity correction in children.

Comparative evaluation of pinning and cast fixation vs. external fixation after lateral closing-wedge osteotomy for cubitus varus in children.

BACKGROUND: Cubitus varus has been regarded as a poor functional and cosmetic consequence of supracondylar humerus fracture in children. The aim of this study was to assess the clinical and radiologic outcomes of cubitus varus treatments based on fixation methods: Kirschner (K)-wire and cast fixation or external fixation. METHODS: Forty consecutive patients with cubitus varus secondary to supracondylar fractures were retrospectively enrolled between October 2015 and December 2018. Following lateral closing-wedge osteotomy, those undergoing K-wire and cast fixation were included in group A (n = 21) and those who were treated with external fixation comprised group B (n = 19). We measured the bony union, elbow joint range of motion, and carrying angle. The clinical and radiographic results were assessed according to the Bellemore criteria. RESULTS: No significant difference was found between the 2 groups in terms of age, gender, operation duration, union time, and postoperative elbow range of motion (P > .05). A significant difference was noted, however, in postoperative carrying angle and results according to Bellemore criteria in group B (P < .05). No nonunion, myositis ossificans, or neurovascular injury was found at follow-up in the 2 groups. In group A, revision surgery was needed for residual varus in 1 patient and lateral condylar prominence was found in 2 patients. In group B, a superficial pin-site infection occurred in 2 patients, who were treated successfully with oral antibiotics. CONCLUSIONS: Both K-wire and external fixation after lateral closing-wedge osteotomy are reliable and effective for the treatment of cubitus varus in children. Compared with the K-wire method, external fixation achieves better functional and cosmetic results with a shorter learning curve.

Post-traumatic cubitus varus: long-term follow-up of corrective osteotomy using the Ilizarov method of compression distraction osteogenesis.

The term cubitus varus describes the inward inclination of the supinated forearm on the extended elbow. The deformity manifests clinically as a decreased carrying angle, decreased range of motion (ROM) along with a cosmetically unsightly appearance. The aim of the present study was to evaluate the technique of compression-distraction osteogenesis using the Ilizarov apparatus in the management of patients with post-traumatic cubitus varus deformity. The objectives were to study the impact of this method on the ROM, the Humerus Elbow Wrist (HEW) angle as well as the Lateral Prominence Index. A total of 32 patients who presented with a cubitus varus deformity of ≥10° at the elbow were retrospectively analyzed using data retrieved from a computerized hospital database. All patients had undergone a mini-incision subperiosteal osteotomy followed by application of an Ilizarov frame. Cinico-radiological follow-up was carried out at regular intervals until union was achieved and yearly thereafter. The mean time to union was 11 weeks. The mean follow-up period ranged from 2 to 12 years (mean 4.0 years). Results were graded as excellent in 25 cases (78.1%), good in 2 (6.3%) and poor in 5 case (15.6%) using the grading system of Oppenheim. The mean HEW angle at final follow-up improved from 20° of varus to 6° of valgus. The mean flexion/extension improved from 121°/-3° preoperatively to 125°/-4° at final follow-up. The Mayo Elbow Performance scores at final follow-up were excellent in 23 cases, good in 7 and fair in 2. Complications encountered included superficial pintract infections in three cases, lateral condylar prominence in one case, loss of terminal flexion in three cases and valgus over-correction in one case.

Loss of correction in cubitus varus deformity after osteotomy.

ABSTRACT: We aimed to investigate the rate of loss of correction and the factors thereof in pediatric patients undergoing osteotomy for treatment of cubitus varus deformity.Between July 2008 and July 2017, we treated 30 patients who underwent osteotomy for cubital varus. We compared the preoperative and postoperative clinical and imaging findings, including the H-Cobb and Baumman angles, in all patients. Postoperative evaluation was performed by telephonic interviews.Our patients consisted of 17 males and 13 females. The mean age was 75 months. At the first follow-up, approximately 80% of patients had experienced a loss of correction of the humerus-cobb angle (H-Cobb angle); at the second follow-up, the incidence was 83%. Meanwhile, 57% and 43% of patients experienced a loss of correction of the Baumman angle at the first and second follow-ups, respectively. The average interval between the first and second follow-ups was 24 days, and the mean loss in the H-Cobb angle was 2.4°. There was a significant difference between the H-Cobb angles as measured before and after surgery (P < .05). There was no significant difference between the H-Cobb angles of the affected side and the contralateral healthy elbow at the third postoperative follow-up; however, there was a significant difference between the Baumman angle between before and after surgery (P < .05). The Baumman angles as measured at the second and third postoperative follow-ups differed significantly from those of the contralateral healthy elbow joint. According to the survival curve analysis, the median survival times of the H-Cobb and Baumman angles were 27 and 34 months, respectively.The postoperative loss of the 2 angles occurred mainly during the first and second follow-up periods. Therefore, patient follow-up is particularly important in the period directly following the operation. Additional measures may be necessary to avoid rapid angle loss.

A double-closed wedge broken-line osteotomy for cubitus varus deformity.

ABSTRACT: Various osteotomy methods have been proposed in the treatment of cubitus varus. We designed an improved stepped osteotomy to achieve improved deformity correction. We refer to this new approach as double-closed wedge broken-line osteotomy and report a series of clinical and imaging results (deformity correction, range of motion [ROM], function, osteotomy healing, and complications) of patients with cubitus varus treated with this technique.Between July 2014 and July 2019, we treated 9 cases of cubitus varus using the new technique. The study was conducted in accordance with the principles of the Declaration of Helsinki, and the study protocol was approved by the ethics committee of Shenzhen Children's Hospital. We obtained written parental consent for the minors before the study was begun. We compared preoperative and postoperative clinical and imaging parameters (humeral elbow-wrist angle, elbow ROM) in all patients. Postoperative evaluation was performed by telephone interview and outpatient review. The median follow-up was 23.2 months (range, 3-63 months).The median humeral elbow-wrist angle modified from -14.27 to 15.15. The median clinical and imaging parameters after correction of deformity were not different from that of the normal side. Using our rehabilitation program, all patients recovered preoperative elbow ROM at the last follow-up.Our double-closed wedge broken-line osteotomy has a larger cancellous bone contact surface. The deformity correction is satisfactory, the osteotomy healing is reliable, and the incidence of complications is low.Level of Evidence: Level IV.

Translation step-cut osteotomy for posttraumatic Cubitus Varus in adults: a retrospective study.

BACKGROUND: Cubitus varus is a complex three-dimensional deformity. Various osteotomies have been introduced to correct this complex deformity. The objective of the present study was to evaluate clinical and functional outcomes of adult cubitus varus deformity treated with translation step-cut osteotomy. METHODS: Seventeen consecutive patients with a mean age of 25 years (range, 19-50 years) who underwent translation step-cut osteotomy were enrolled in this study. Their average follow-up period was 28.2 months. Radiographic measurements preoperatively, 3-month postoperatively, and at the last follow-up were compared. Functional outcomes were assessed using Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Oppenheim criteria. RESULTS: The mean humerus-elbow-wrist angle improved from 14.7° ± 6.4° (range, 6°-23°) varus preoperatively to 12.1° ± 6.6° (range, 5°-20°) valgus postoperatively (p <  0.001). The lateral prominence index improved 9.6% from its preoperative value, showing no significant difference from that of a normal elbow. Osseous union was radiographically demonstrated in 16 patients (except one out of 17 patients) within a mean of 12.7 weeks (range, 8-18 weeks). The motion arc of the elbow at the last follow-up was not significantly (p > 0.05) different from that at the initial presentation. Based on Oppenheim criteria, results were excellent for 7, good for 8, and poor for 2 patients. Mean final DASH value and MEPS were 2.5 ± 3.8 points (range, 0-15 points) and 97.0 ± 5.8 points (range, 85-100 points), respectively. With regard to complications, one case had delayed union and one case had transient radial nerve injury. CONCLUSION: Translation step-cut osteotomy using Y plate is an efficient procedure to correct varus alignment and flexion-extension deformities so that they are within normal limits of adults with post-traumatic cubitus varus deformity. TRIAL REGISTRATION: Institutional Review Board of Jeonbuk National University Hospital (IRB No. 2020-01-020 ).

Early correction of malunited supracondylar humerus fractures in young children.

INTRODUCTION: Supracondylar fracture malunion usually results in cubitus varus deformity. The long-standing unsightly deformity causes psychological stress to the child and his/her parents in addition to biomechanical disturbances and functional disorders in the affected elbow. The optimal timing of corrective osteotomy is not well-established in the literature. The present study aimed to report the results of early correction of cubitus varus deformity using a simple technique and to focus on the timing of early correction after supracondylar fracture malunion. PATIENTS AND METHODS: Thirty consecutive patients treated for recent cubitus varus deformity after malunited supracondylar fractures, in the period between January 2012 and August 2017, were retrospectively reviewed. All patients had early surgical correction of the deformity within one year after the initial injury. In patients who presented with maluniting supracondylar fracture, the fracture was splinted until union was achieved, then active exercises were encouraged until elbow ROM was regained. The deformity was then corrected with a lateral closing wedge (LCW) osteotomy and fixed with two lateral and one medial wire. RESULTS: All the osteotomies united. All the deformities were corrected. The humerus-elbow-wrist (HEW) angle significantly improved compared to the pre-operative values (p<0.001). All patients achieved satisfactory results at the final evaluation. Twenty-six patients (86.7%) achieved excellent results while four patients (13.3%) achieved good results. CONCLUSION: Early correction of cubitus varus deformity avoids the psychological stress of the long-standing unsightly deformity to the young child and his/her family. It also avoids the delayed biomechanical and functional disturbances to the affected elbow. The LCW osteotomy and the three-wires fixation technique are simple and effective to correct the deformity and maintain the correction.

Results of the modified reverse step-cut osteotomy in paediatric cubitus varus.

PURPOSE: Cubitus varus deformity occurs in children as a late consequence of supracondylar fracture of the distal humerus. Different types of corrective osteotomies have been described, but a gold standard has not yet been established. The aim of this study is to report the clinical, radiological, and cosmetic outcome of the modified reverse step-cut osteotomy technique. METHODS: This study was conducted on 15 cases, which were operated during the period between July 2015 and June 2016. We used the technique modified reverse step-cut osteotomy with the calculated medial translation of the distal fragment to correct varus and sagittal plane deformity and to achieve anatomical alignment of the forearm axis with the axis of the humerus. Follow-up was done for two years. Pre-operative and post-operative clinical and radiological parameters were compared, and patient satisfaction was assessed. RESULTS: The mean pre-operative humerus-elbow-wrist (HEW) angle was - 22.4°; it improved to + 9.4° post-operatively. The pre-operative mean range of motion was 131.6°, and the post-operative mean was 132°. The clinico-radiological outcome was assessed according to Oppenheim criteria. There was an excellent result in nine patients (60%), a good result in five patients (33.3%), and poor results in one patient (6.6%). Cosmetic outcome was assessed as per Barrett's criteria, excellent result in thirteen patients (86.6%) and poor results in two patients (13.3%). Post-operative lateral condylar prominence index (LCPI) was compared with the normal side, and there was no significant difference. CONCLUSION: We have achieved satisfactory results with acceptable cosmetic appearance and functional outcomes with minimal complications. We recommend this technique as a safe, reliable, reproducible, technically easy procedure for correction of cubitus varus deformity.

Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation.

AIMS: Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. METHODS: We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. RESULTS: The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. CONCLUSION: We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470-477.

Forearm Deformity and Radial Head Dislocation in Pediatric Patients with Hereditary Multiple Exostoses: A Prospective Study Using Proportional Ulnar Length as a Scale to Lengthen the Shortened Ulna.

BACKGROUND: Ulnar lengthening is a consensus treatment for hereditary multiple exostoses with radial head dislocation in pediatric patients; however, the optimal amount of ulnar lengthening remains unclear. It is necessary to look for a parameter to decide the amount of ulnar lengthening that will avoid recurrence and complications. The purpose of the present study was to confirm that proportional ulnar length (ulnar length/radial length) can be used as a scale for ulnar lengthening in pediatric patients. METHODS: The normal lengths of the ulna and radius in the pediatric population were measured in different age groups. The proportional ulnar length was calculated as ulnar length/radial length in each group. Thirty forearms in 26 patients with radial head dislocation were treated with ulnar lengthening and deformity correction. The goal of ulnar lengthening was to recover the normal proportional ulnar length. The function of the forearm was evaluated at the time of the latest follow-up. The preoperative and postoperative values for radial bowing, radioarticular angle, ulnar variance, and carpal slip were also compared. RESULTS: The value of proportional ulnar length in the normal population consistently averaged approximately 1.1. In all cases, proportional ulnar length recovered to the normal value of 1.1. Reduction of the dislocated radial head was achieved in 28 forearms (93%); in 16 of these forearms, good-quality reduction was achieved and no recurrence of radial head dislocation was observed during follow-up. The function of the forearm improved markedly (p < 0.001). Ulnar variance improved from 2.51 to -0.79 cm (p < 0.001). Radial deformities improved according to measurements of radial bowing and the radioarticular angle (p < 0.001). All parents were satisfied with the postoperative appearance and function of the forearm. CONCLUSIONS: Proportional ulnar length could be used as a scale to decide the amount of ulnar lengthening for radial head dislocation in pediatric patients with hereditary multiple exostoses. Ulnar lengthening according to proportional ulnar length and deformity correction can prevent recurrence of ulnar variance and avoid impingement of the wrist. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial Open-wedge Osteotomy with Double-plate Fixation for Varus Malunion of the Distal Femur.

OBJECTIVE: To present our clinical experience of treating varus malunion of the distal femur through a medial open-wedge osteotomy with double-plate fixation. METHODS: A prospective cohort study was performed. From January 2005 to February 2015, 15 consecutive patients with varus malunion following distal femur fractures were surgically treated at a single level I trauma center. The coronal and sagittal deformity were corrected by a medial open-wedge osteotomy of the distal femur. A medial buttress plate was used to maintain the realignment. A lateral locking plate was additionally used as a protection plate. The mean age of patients at the time of the surgery was 35.5 years (range, 22-58 years). The radiographical evaluation included the mechanical femorotibial angle, the mechanical lateral distal femoral angle, the anatomic posterior distal femoral angle, and the leg length discrepancy. Clinical outcome evaluation consisted of the range of motion (ROM) and Hospital for Special Surgery (HSS) score. RESULTS: Mean follow-up was 7.4 years (range, 4-11.5 years). Varus and flexion malalignment and limb discrepancy were adequately corrected in all patients. The mechanical femorotibial angle, the mechanical lateral distal femoral angle, and the anatomic posterior distal femoral angle were restored from 17.5° (range, 13°-25°) to 2.3° (range, - 2°-7°), 102.3° (range, 95°-112°) to 85.2° (range, 81°-92°), and 77.1° (range, 65°-87°) to 82.7° (range, 76°-88°), respectively. The leg length discrepancy was diminished from 3.4 cm (range, 2.4-4.5 cm) to 0.8 cm (range, 0-1.7 cm). The average bone healing time was 4.1 months (range, 2.5-6 months). The average ROM of the affected knees at 24-month follow-up was 3.4°-112.55°. The score of HSS at 4-years follow-up was 76.1 (range, 64-88). No internal fixation failure or secondary operation was noted until the last follow-up. CONCLUSION: Medial open-wedge osteotomy can adequately correct the posttraumatic varus malunion of the distal femur. With fixation of the double plate, non-displaced bone healing and good functional outcome are expected.

Pelvic obliquity and measurement of hip displacement in children with cerebral palsy.

Background and purpose - Pelvic obliquity, common in individuals with cerebral palsy (CP), changes the muscle force vector on the hip joint and probably affects the risk of hip dislocation. We evaluated a new method for measurement of hip displacement in CP that takes the pelvic obliquity into account: the pelvic adjusted migration percentage (PAMP). Children and methods - From the Swedish surveillance program for cerebral palsy (CPUP), the first pelvic radiograph of 268 children <18 years in southern Sweden during a 3-year period were evaluated. Pelvic obliquity, PAMP, and the migration percentage (MP) were measured. 50 radiographs were randomly selected for analysis of interrater reliability by three raters using the intraclass correlation coefficient (ICC). The correlations between PAMP/MP and pelvic obliquity were analyzed with Pearson correlation coefficients. Results - The interrater reliability for all 3 measurements was high (ICCs 0.88-0.97). The correlation between the high side of the pelvic obliquity and the difference between right and left hip displacement was higher for PAMP (r = 0.70) than for MP (r = 0.41). Interpretation - The new PAMP measurement showed high interrater reliability and a higher correlation with pelvic obliquity than MP. We suggest the use of PAMP at least in hips with a pelvic obliquity exceeding 5°.

Total knee replacement in Nigeria: An assessment of early functional outcome of 68 consecutive knees.

BACKGROUND: Although there are many methods of treatment for knee osteoarthritis (OA), total knee replacement (TKR) is a very effective way of managing this condition as it improves function and alleviates pain with a consequential improvement on quality of life of patients. To our knowledge, no comprehensive study of the outcome of TKR has been published in our environment, hence the need for a study of our TKR outcomes. OBJECTIVES: The aim of this study is to describe the pattern of presentations of our patients with knee OA who have undergone TKR, assess the outcome, and identify any variables that affect the outcome. PATIENTS AND METHOD: Between November 2008 and November 2013, 68 TKRs for treatment of end stage arthritis were carried out for 52 patients. All the patients were implanted with the same prosthesis design (DePuy and Biomet) and had posterior cruciate substituting knee. The average follow-up was 5 years. The preoperative and postoperative Oxford knee score (OKS) was used for outcome measurement at 1 and 5 years. RESULTS: There were 20 males and 32 females (M:F ratio = 5:8). The mean age of the patients was 63.54 ± 0.62 with a range of 55 to 77. There were 18 (26.47%) valgus knees with a mean angle 22.07° ± 5.73°, 12 (17.65%) varus knees with a mean angle 14.69° ± 2.84°, 8 (11.77%) knees with flexion deformity with a mean angle of 10.2° ± 1.32°, and 30 (44.11%) knees had no deformities at all. The variables like deformities, comorbidities, gender, side-affect, and occupation did not affect the outcome (P > 0.05). At 1 year and 5 years, there was no radiological evidence of osteolysis, loosening, or component subsidence. CONCLUSION: Despite the deformities and comorbidities, our patients presented with quality of life improved based on the improved OKS of the patient. We recommend a well-planned meticulously executed TKR for patients with debilitating OA in our environment.

Missed Monteggia fracture dislocations treated by open reduction of the radial head.

Aims: Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure. Materials and Methods: This retrospective study evaluated 30 children with a chronic Monteggia lesion. There were 18 boys and 12 girls with a mean age of 7.4 years (4 to 13) at the time of open reduction. The mean interval to surgery, after the initial fracture, was 23.4 months (6 to 120). Clinical grading used a Kim modified elbow score: radiological outcome was recorded. The effect of the patient's age, gender, duration from initial injury, Bado classification, and annular ligament reconstruction were analyzed. The mean follow-up was 42.2 months (15 to 20). Results: The Kim elbow scores evaluated at the last clinic visit were excellent in 23 patients, good in three, fair in two, and poor in two. A majority of the patients were found to have significant improvement of elbow flexion (p < 0.001). Six met the criteria of a fair radiological outcome; four of these were operated on more than 24 months after the initial injury, and three had surgery after the age of 11. Univariate analysis failed to find any factor that was significantly associated with a fair or poor outcome. Conclusion: Good clinical and radiological outcomes can be expected in most patients. Osteoarthritic changes were associated with age > 11 years and/or a delay of treatment of > 24 months. However, no statistically significant factor could be identified which correlated with an unfavourable outcome. Cite this article: Bone Joint J 2018;100-B:1117-24.

Primary total knee arthroplasty using constrained condylar knee design for severe deformity and stiffness of knee secondary to post-traumatic arthritis.

BACKGROUND: Key to a successful outcome of total knee arthroplasty (TKA) is to attain optimum alignment, adequate balance, and deformity correction. In primary TKA, this can be achieved efficiently by posterior stabilized (PS) design with or without the sub-periosteal release. However, certain circumstances such as post-traumatic arthritis are often associated with severe deformities with a significant bone defect, stiffness, and instability. Such deformities are extremely difficult to balance with soft tissue release only and require additionally constrained prostheses even in primary TKA. In such situation, constrained condylar knee (CCK) design is the ultimate choice. This study primarily aimed to report on clinical outcome, regain of function, and complication of patients who underwent primary CCK-TKA for severe deformity of the knee secondary to post-traumatic arthritis. The secondary aim was to find out the mid-term prostheses survival. METHODS: Between February 2007 and November 2013, 38 consecutive patients with post-traumatic arthritis of the knee received cemented primary CCK-TKA. Thirty-four patients (21 men and 13 women) who had a minimum of 3 years follow-up were included in this retrospective study. We used Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, and roentgenographic evaluation form to assess the patients. Prostheses survival was assessed using Kaplan-Meier's survival analysis. RESULTS: Patients were followed up for an average duration of 6.47 years. KSS knee score improved from 44 points (23-68) pre-operatively to 91 points (76-100) post-operatively [P < 0.001]. The average KSS functional score improved from 49 points (20-75) pre-operatively to 91 points (65-100) post-operatively [P < 0.001]. The average HSS score improved from 51 points (27-83) pre-operatively to 91 points (75-100) post-operatively [P < 0.001]. Similarly, the average ROM improved from 68.09° ± 35.99° (0°-120°) to 113.68° ± 8.90° (100°-130°) post-operatively [P < 0.001]. The average hip-knee-ankle (HKA) angle was 176.88° ± 14.48° (135°-199°) pre-operatively and 180.24° ± 1.77° (175°-184°) post-operatively. Radiolucencies were evident in 13 knees, mostly on the tibial side. Prostheses survival was 94.7% at a mean follow-up of 6.47 years. CONCLUSION: Despite severe deformity, instability, and stiffness at a relatively young age, mid-term follow-up of primary CCK-TKA in post-traumatic arthritis provides satisfactory clinical and functional outcomes with 94.7% prostheses survival. However, it is not without complication.