Long-term outcomes of total knee arthroplasty in patients with windswept deformity.

BACKGROUND: This study compared the functional outcomes, implant survival rates, and complications of total knee arthroplasty (TKA) performed in patients with windswept deformity (WSD) and non-WSD patients over at least 10 years of follow-up. METHODS: From January 2008 to December 2010, 40 TKAs were performed in 20 patients with WSD (WSD group). Additionally, 60 propensity score-matched patients without WSD who had undergone primary bilateral TKA were chosen for the control group in a three-to-one ratio. Then, the functional outcomes, implant survival rates, and complications of TKA in the two groups were compared. The mean follow-up periods were 10.8 years in the WSD group and 11.5 years in the control group. RESULTS: The mean Knee Society knee scores in the WSD and control groups improved from 37.7 to 38.1 points preoperatively to 79.5 and 79.2 points at final follow-up (p = 0.974), while the mean function scores in the WSD and control groups improved from 36.5 to 37.2 points preoperatively to 77.8 and 77.4 points at final follow-up (p = 0.863). Two knees in the WSD group required revision surgery, including one due to septic loosening and one due to aseptic loosening. Five knees in the control group required revision surgery, including three due to septic loosening and two due to aseptic loosening. Kaplan-Meier survivorship analysis with the revision of either component as an endpoint in the WSD and control groups estimated 95.0% and 95.8% chances of survival for 10 years, respectively (p = 0.824). CONCLUSIONS: TKA performed in patients with WSD yielded good clinical outcomes and survivorship at least 10 years later. LEVEL OF EVIDENCE: IV.

Asymmetric transepicondylar axis between varus and valgus osteoarthritic knees in windswept deformity can be predicted by hip-knee-ankle angle difference.

PURPOSE: Studies regarding the best strategy to determine appropriate femoral component rotation during bilateral total knee arthroplasty (TKA) in wind swept deformities (WSD) are very limited. The purpose of this study was (1) to evaluate whether femoral rotational profiles differ between varus and valgus osteoarthritic knees in WSD and (2) to analyze the correlation between femoral rotational profiles and coronal radiologic parameters. METHODS: A total of 40 patients who were diagnosed with bilateral knee osteoarthritis with WSD between January 2010 and December 2020 at a single institution were retrospectively reviewed. On axial computed tomography scans, femoral rotational profile parameters such as the clinical transepicondylar axis (cTEA) and anterior-posterior (AP) axis were compared between valgus and varus osteoarthritic knees. In standing full-limb AP radiographs, coronal radiographic parameters including hip-knee-ankle angle (HKA), valgus correction angle (VCA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA) were measured in both knees. The correlation between the varus-valgus cTEA difference, and differences in coronal radiologic parameters was analyzed. RESULTS: In valgus osteoarthritic knees, cTEA was significantly increased compared to varus osteoarthritic knees by 1.5° (valgus: 7.65° ± 1.82°, varus: 6.15° ± 1.58°, p < 0.001). All coronal radiologic parameters, including HKA, LDFA, MPTA, JLCA, and VCA, were significantly different between valgus and varus knees. In correlation analysis, the varus-valgus cTEA difference was significantly correlated with LDFA (r = 0.365, p = 0.021), MPTA (r = 0.442, p = 0.004), and HKA differences (r = 0.693, p < 0.001), with the HKA difference showing the strongest correlation with the cTEA difference. CONCLUSION: In bilateral knee osteoarthritis with WSD, valgus knees showed significantly increased cTEA compared to varus knees, and the cTEA difference positively correlated with the HKA difference between valgus and varus knees. To determine the optimal femoral component rotation during TKA in WSD, assessment of cTEA with pre-operative CT scans or careful intra-operative measurement is recommended, especially in patients with large HKA difference. LEVEL OF EVIDENCE: III, Retrospective cohort study.

A cruciate-retaining implant can treat both knees of most windswept deformities when performed with calipered kinematically aligned TKA.

PURPOSE: Surgeons performing total knee arthroplasty (TKA) on the osteoarthritic valgus deformity often use a posterior stabilized (PS) and semi-constrained implants to substitute for the release of a contracted posterior cruciate ligament (PCL) instead of a cruciate retaining (CR) implant. Calipered kinematic alignment (KA) strives to retain the PCL and use a CR implant. The aim of this study of the windswept deformity was to determine whether the level of implant constraint, outcome scores, and alignment after bilateral calipered KA TKA are different between a pair of knees with a varus and valgus deformity in the same patient. METHODS: A review of a prospectively collected database identified all patients with a windswept deformity treated with bilateral TKA (n = 19) out of 2430 consecutive primary TKAs performed between 2014 and 2019. Operative reports determined the level of implant constraint. Patient response to the Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) assessed outcomes at a mean follow-up of 2.3 years. Postoperative alignment was measured on an A-P computer tomographic scanogram of the limb. RESULTS: CR implants were used in 15 of 19 (79%) valgus deformities and 17 of 19 (89%) of varus deformities (n.s.). No knees required a semi-constrained implant. There was no difference in the median postoperative FJS and OKS (n.s.), and a 1° or less difference in the mean postoperative distal lateral femoral angle (p = 0.005) and proximal medial tibial angle (n.s.) between the paired varus and valgus knee deformity. CONCLUSION: Based on this small series, surgeons that use calipered KA TKA can expect to use CR implants in most patients with windswept deformity and achieve comparable outcome scores and alignment between the paired varus and valgus deformity. LEVEL OF EVIDENCE: IV.

A Physiotherapeutic Approach to a Rare Case of Windswept Deformity in a Male Adolescent.

Primary hyperparathyroidism (PHPT) can lead to a rare condition in children and adolescents known as windswept deformity. This deformity involves one knee exhibiting an abnormal outward angulation (valgus deformity), while the other knee shows an abnormal inward angulation (varus deformity). This asymmetrical syndrome, resembling the effect of strong winds, gives the impression that the knees are being swept in opposite directions. Various factors, such as structural bone or joint defects, accidents, or underlying disorders, can contribute to the development of windswept deformity. PHPT, a common endocrine condition characterized by elevated levels of parathyroid hormone and blood calcium, is unusual in the pediatric and adolescent populations. It can result in complications like osteoporosis and bone abnormalities, with genu valgus (outward knee angulation) being an exceptionally rare symptom. This case discusses a 19-year-old male who underwent corrective surgery for genu valgus and presented with windswept deformity due to teenage hyperparathyroidism. The case study outlines the physiotherapeutic rehabilitation strategy, emphasizing treatments such as cryotherapy, patellar mobilization, and gait training. Tailored physical therapy rehabilitation plays a crucial role in the postoperative care of patients undergoing corrective osteotomies. The results indicated a significant improvement in muscle strength, an expansion of the range of motion (ROM), and a noticeable enhancement in the individual's functional autonomy following adherence to the postoperative physiotherapy (PT) plan.

Analysis of Gait Ability and Patient Reported Outcome Measurements after Robotic-assisted Total Knee Arthroplasty for Osteoarthritis of the Knee with Windswept Deformity.

Introduction: Windswept deformity (WD) refers to valgus deformity in one knee and varus deformity in the other. We performed robotic-assisted (RA) total knee arthroplasty (TKA) for osteoarthritis of the knee with WD, made patient reported outcome measurements (PROMs), and performed gait analysis based on triaxial accelerometery. Case Report: A 76-year-old woman presented to our hospital with bilateral knee pain. Image-free handheld RA TKA was performed on the left knee with severe varus deformity and severe pain during walking. RA TKA was performed on the right knee with severe valgus deformity 1 month later. The RA technique was used to determine implant positioning and the plan for osteotomy intraoperatively, taking into account soft-tissue balance. This made it possible to use a posterior stabilized implant instead of a semi-constrained implant for severe valgus knee deformity with flexion contracture (Krachow classification Type 2). At 1 year after TKA, PROMs were inferior in the knee with pre-operative valgus deformity. Gait ability improved after surgery. Even with the RA technique, it took 8 months to achieve left-right balance while walking and for the variability of the gait cycle to become equivalent to that of a normal knee. Conclusion: Primary RA TKA is a viable option for osteoarthritis of the knee with WD. It took time for the gait ability of both knees to become equal and PROMs were better with the varus deformity compared to before surgery.

Side-to-Side Flipping Wedge Osteotomy: Virtual Surgical Planning Suggested an Innovative One-Stage Procedure for Aligning Both Knees in "Windswept Deformity".

(1) Background: The adoption of Virtual Surgical Planning (VSP) and 3D technologies is rapidly growing within the field of orthopedic surgery, opening the door to highly innovative and individually tailored surgical techniques. We present an innovative correction approach successfully used in a child affected by "windswept deformity" of the knees. (2) Methods: We report a case involving a child diagnosed with "windswept deformity" of the knees. This condition was successfully addressed through a one-stage bilateral osteotomy of the distal femur. Notably, the wedge removed from the valgus side was flipped and employed on the varus side to achieve the correction of both knees simultaneously. The surgical technique was entirely conceptualized, simulated, and planned in a virtual environment. Customized cutting guides and bony models were produced at an in-hospital 3D printing point of care and used during the operation. (3) Results: The surgery was carried out according to the VSP, resulting in favorable outcomes. We achieved good corrections of the angular deformity with an absolute difference from the planned correction of 2° on the right side and 1° on the left side. Moreover, this precision not only improved surgical outcomes but also reduced the procedure's duration and overall cost, highlighting the efficiency of our approach. (4) Conclusions: The integration of VSP and 3D printing into the surgical treatment of rare limb anomalies not only deepens our understanding of these deformities but also opens the door to the development of innovative, personalized, and adaptable approaches for addressing these unique conditions.

Windswept Deformity a Disease or a Symptom? A Systematic Review on the Aetiologies and Hypotheses of Simultaneous Genu Valgum and Varum in Children.

OBJECTIVE: The objective of this study is to create an overview of the possible aetiologies of windswept deformity and to emphasize the points of attention when presented with a case. METHODS: A systematic search according to the PRISMA statement was conducted using PubMed, African Journals Online, Cochrane, Embase, Google Scholar, and Web of Science. Articles investigating the aetiology of windswept deformity at the knee in children, and articles with windswept deformity as an ancillary finding were included. The bibliographic search was limited to English-language articles only. The level of evidence and methodological appraisal were assessed. RESULTS: Forty-five articles discussing the aetiology of windswept deformity were included. A variety of aetiologies can be brought forward. These can be divided into the following groups: 'Rickets and other metabolic disorders', 'skeletal dysplasias and other genetic disorders', 'trauma' and 'descriptive articles without specific underlying disorder'. With rickets being the largest group. Interestingly, in the group without a specific underlying disorder, all patients were from African descent, being otherwise healthy and presented with windswept deformity between two and three years of age. CONCLUSION: We have presented an overview that may help identify the underlying disorder in children with windswept deformity. A step-by-step guide for clinicians who see a child with windswept deformity is provided. Even though, according to the Oxford level of evidence, most articles have a low level of evidence.

Bilateral unicompartmental knee arthroplasty for windswept knee osteoarthritis: A report of 13 cases.

BACKGROUND: Windswept deformity is a condition of the lower limbs with a valgus knee on one side and a varus knee on the other. We present a case series of bilateral unicompartmental knee arthroplasty (UKA) for windswept knee osteoarthritis (WSKO). METHODS: We analysed the outcomes of 26 knees of 13 consecutive patients with WSKO treated with bilateral UKA. The mean age was 73.0 years and the mean follow up period was 2.6 years. Pre- and postoperative Oxford Knee Score (OKS) and Japanese Orthopaedic Association (JOA) score, radiological measurements and postoperative complications were evaluated. No knees required revision for either infection or loosening. RESULTS: The mean preoperative OKS was 25.3 ± 9.7, which increased to 34.9 ± 5.8 at the latest follow up. The mean preoperative JOA scores for the varus and the valgus sides were 64.6 ± 12.5 and 66.9 ± 14.1, which increased to 85.0 ± 11.3 and 84.6 ± 11.2, respectively, after operation. CONCLUSIONS: Our results show that good short-term clinical results can be achieved by bilateral UKA in cases of WSKO. Bilateral UKA may be an effective treatment for WSKO if indications are met.

The Windswept Foot: Dealing with Metatarsus Adductus and Toe Valgus.

The windswept foot remains a reconstructive challenge. The hallux valgus associated with the medially displaced lesser metatarsal heads is hard to correct. Either the lesser metatarsal heads need to be displaced laterally or the deformity accepted. With the deformity, all the toes tend to be aligned into valgus with the position of the flexor and extensor tendons. Several treatment alternatives exist and may require a combination of open and percutaneous surgery. The authors think that, in severe metatarsus adductus, proximal correction of the first, second, and third metatarsals is required.

Correction of lower limb deformities in children with renal osteodystrophy by guided growth technique.

PURPOSE: Renal osteodystrophy (ROD) may cause severe lower limb deformities in children. The purpose of this study is to evaluate the efficacy of the temporary hemiepiphysiodesis for the correction of lower limb deformities in children with ROD. METHODS: Guided growth correction by hemiepiphysiodesis has been performed in skeletally immature patients with deformities of the lower limbs caused by ROD. The correction of the mechanical axes of the lower limbs and its correction speed have been evaluated. RESULTS: A total of seven patients with ROD, five males and two females, were treated with the above technique. The average age of the patients at their first surgery was 7.8 years (2.9 to 13.6). The average follow-up time 5.2 years (2.3 to 8). There were 13 valgus deformities and one varus deformity of the knee. The measure of the lower limb angular deformity was in the range of 10° to 47°. Restoration of normal mechanical axis was achieved in all patients at the final follow-up. Three patients relapsed and required further hemiepiphysiodesis. The average time for correction was 20 months (7 to 30). The average speed of correction was 0.49° per month for a tibia and 1.73° per month for a femur. There were two minor complications: a screw mobilisation and a screw breakage occurred during removal. CONCLUSION: Guided growth technique by hemiepiphysiodesis is a mini-invasive surgical procedure that has been found to be effective for the correction of misalignment due to ROD in skeletally immature patients. The method has allowed progressive correction of the deformities at any age in childhood. These patients are predisposed to relapse to their deformities, thus a strict follow-up is required.

Lower Limbs Alignment in Patients with a Unilateral Completely Dislocated Hip.

BACKGROUND: Severe hip osteoarthritis is known to lead to secondary osteoarthritis of the knee joint. It is not clear whether contracture or a leg length discrepancy is more important in determining the knee alignment. METHODS: In this study, 48 hips in 48 patients with a unilateral completely dislocated hip (Crowe IV) were recruited. The patients were divided into two groups (Crowe IVa and IVb). The Crowe IVa group had completely dislocation with psudo-articulation, and the Crowe IVb group had completely dislocation without psudo-articulation. The lower limb alignment was divided into three patterns according to the femorotibial angle; varus (≥176 degrees), neutral(170 to 175 degrees) and valgus(≤169 degrees). RESULTS: The combination of valgus alignment on the affected side and varus alignment on the unaffected side, so-called "windswept deformity" was observed in 12.5% of the patients; this included 18.2% and 7.7%, in the Crowe IVa and Crowe IVb groups, respectively. The valgus alignment on the unaffected side, namely "long leg arthropathy," was found to have occurred in 6.3% of the patients, including 13.6% of the patients in the Crowe IVa group; there were no cases of long "leg arthropathy" in the Crowe IVb group. CONCLUSION: The lower limb alignment on the unaffected side had a tendency to be varus in the Crowe IV patients. The "windswept deformity" was observed in each of the groups; however, "long leg arthropathy" was only found in the Crowe IVa group.

Spinal and extraspinal deformities in a patient with dysspondyloenchondromatosis.

Anisospondyly (irregularly shaped vertebral bodies) and enchondroma-like lesions in the metaphyseal and diaphyseal portions of the long tubular bones are the characteristic features in patients with dysspondyloenchondromatosis (DSC). Thoraco-lumbar scoliosis and windswept deformity of the lower limbs were the major abnormalities encountered in this patient. To the best of our knowledge this is the first case report delineating the spine pathology via reformatted CT scan and the correction of a windswept deformity by means of temporary hemiepiphysiodesis in a patient with (DSC).