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In two cases of severe genu varum and one case of infantile tibia vara, we employed double-upright knee-ankle-foot orthoses with free knee and ankle joints. The patients tolerated these orthoses well and were able to walk. The results were satisfactory.
The authors report their experience in the treatment of 200 patients affected with osteoarthritic genu varum by proximal tibial osteotomy in valgus according to the Ilizarov technique. The criteria used to select patients is emphasized as the results of surgery depends on it. The surgical technique is described and several important steps are revealed. In conclusion, the advantages and the disadvantages of surgery and the importance of correct indications are discussed.
The mechanical effects of genu valgum and varum deformities on the subtalar joint were investigated. First, a theoretical model of the forces within the foot and lower extremity during relaxed bipedal stance was developed predicting the rotational effect on the subtalar joint due to genu valgum and varum deformities. Second, a kinetic gait study was performed involving 15 subjects who walked with simulated genu valgum and genu varum over a force plate and a plantar pressure mat to determine the changes in the ground reaction force vector within the frontal plane and the changes in the center-of-pressure location on the plantar foot. These results predicted that a genu varum deformity would tend to cause a subtalar pronation moment to increase or a supination moment to decrease during the contact and propulsion phases of walking. With genu valgum, it was determined that during the contact phase a subtalar pronation moment would increase, whereas in the early propulsive phase, a subtalar supination moment would increase or a pronation moment would decrease. However, the current inability to track the spatial position of the subtalar joint axis makes it difficult to determine the absolute direction and magnitudes of the subtalar joint moments.
OBJECTIVE: Restoration of mechanical axis of the leg. INDICATIONS: Osteoarthritis of medial knee compartment. Overload of medial compartment. Genu varum. CONTRAINDICATIONS: Smoker. Vascular impairment. Poor soft-tissue envelope. SURGICAL TECHNIQUE: Straight 12-cm midline incision starting distal to the tibial tubercle medially and continuing parallel to the tibial crest. Oblique osteotomy at 60 degrees distal-medial to proximal-lateral preserving the lateral cortex. Osteotomy wedged open and alignment checked with diathermy cord. Two tricortical bone blocks harvested from ipsilateral iliac crest or bone substitute wedges placed in osteotomy. Stabilization with contoured T-plate. Closure over drain. RESULTS: 44 patients (32 men, twelve women, average age 48 years) with 45 osteotomies. Follow-up 30 months (7-74 months). All osteotomies consolidated. 90% patients had excellent results according to the HSS (Hospital for Special Surgery) Knee Score. In 77% the femorotibial angle was corrected to 5-12 degrees . Patients regained their preoperative range of motion. There were no major complications.
This article reviews the subjective, objective, functional, and radiographic results of five patients with symptomatic anterior cruciate instability, genu varum, and varus rotational instability treated by sequential high tibial osteotomy and anterior cruciate ligament reconstruction at one operative procedure. The average patient age was 27 years (range: 21 to 35), and the average follow up was 2.5 years (range: 2 to 3). All patients had symptomatic instability with anterior tibia subluxation, which was documented by KT-1000 testing. All patients also had a varus alignment clinically and radiographically with medial compartment pain. Postoperatively, the medial compartment pain was improved, and instability episodes were eliminated. Side to side differences (KT-1000--manual maximum) were reduced to 3.1 mm. There were no complications. The instability episodes were eliminated, and functional levels were improved in all patients. We concluded that, for this select group of patients, simultaneous extremity realignment and ligament stabilization will effectively manage both conditions without compromising the results of either procedure.
A age-related morphological changes in bow legs and knock knees were studied on roentgenograms taken in a standing , notably on alignment of the lower extremities. In the present study comparisons of chronological changes of this alignment, which was assessed by the femoro-tibial angle, were made between 3 groups of children under 16 years of age: 350 controls (656 legs), 148 with genu varum (296 legs) and 176 with genu valgum (252 legs). Bone growth at the lower end of the femur and at the upper end of the tibia was found to influence most closely on the changes in the femoro-tibial angle. The femoro-tibial angle of the controls under 3 years of age showed more than 180 degrees, the lower extremities were bowed outwardly, and the axes of the femoral shafts were medially tilted. From the age of 3 to 5 years the lower extremities reversely tended to be knocked inwardly owing to gradual growth of the lateral condyles of the femur and the tibia. Then, with advancing age, the axis of the femoral shaft again tended to tilt outwardly and at the same time the tibial axis tended to be tilted inwardly. Since these changes in the direction of bone axes are counter-balanced, the femoro-tibial angle tended to be 177.37 degrees, approximating to the value of the japanese adults (176 degrees - 178 degrees). Then, the femoro-tibial angle can be estimated by measuring an angle between the proximal epiphyseal line and the axis of the tibial shaft. In children with knock knees there occurred no marked chronological changes in bone alignment and the lower extremities were always knocked inwardly as compared with the controls. In children with bow legs, on the other hand, the deformity tended to be normalized notably with the age advancing as a result of growth of the medial condyle of the femur. The mechanical axis of the lower extremity passed through somewhat lateral side to the center of the knee in the most of the controls aged from 2 to 5 years and through a little medial side in those of the other age group. In children with knock knees and in those with bow legs, on the other hand, the axis was always found to pass through the laternal and the medial side, respectively, to the center of the knee. The rate of deviation of the axis was noted in correlation with the femoro-tibial angle with coefficient index of 0.855 in the controls, 0.875 in a group of knock knees and 0.951 in a group of bow legs.
PURPOSE OF THE STUDY: The aim of this short study is to highlight the role of the hemicallotasis method in correcting genu varum associated with osteoarthritis. MATERIAL AND METHOD: 160 cases are described. The first step was to apply a Dynamic Axial Fixator (DAF) with a lockable ball joint. A metaphyseal osteotomy was performed proximal to the anterior tuberosity of the tibia together with an osteotomy of the middle third of the fibula. After an initial 10 to 12 day neutralization period, distraction began with gradual axial correction to achieve an over correction of 2-3 degrees valgus. This was confirmed by a full limb radiograph allowing evaluation of the mechanical axes. The mean duration of distraction in this series was 14 days and the fixator was removed on the average at 3 months. Partial weight bearing was allowed with crutches on the first postoperative day. RESULTS: Preliminary clinical and radiographic review of 58 patients with an average follow-up of 18 months showed satisfactory results in 80 per cent of the cases. Clinical evaluation was performed with the standardized parameters in use at the Hospital for Special Surgery. Only 2 postoperative complications of any importance occurred, requiring early removal of the fixator. DISCUSSION: Comparison of the hemicallotasis method with traditional methods highlights the quick easy application of the technique with the possibility of gradual axial correction and early weight bearing. In addition, the technique does not preclude subsequent total knee replacement. CONCLUSION: The authors conclude that the method is safe particularly when the indication is well determined.
The authors present the technique of high tibial correction osteotomy by the medial opening procedure, with the use of an angle-stable TomoFix plate. The prerequisite for a long-term good outcome of corrective osteotomy in genu varum is to achieve limb alignment permitting transfer of weight-bearing from the affected medial compartment to the healthy lateral compartment of the knee. The development of implants that maintain a stable angle has facilitated corrective osteotomy with an opening wedge on the medial side of the proximal tibia. These implants provide stable fixation even when a high correction of the mechanical axis is needed. The authors present the case of a patient with varus malalignment following a fracture of the tibia. In order to achieve correction of the limb's mechanical axis, it was necessary to open the proximal tibia osteotomy with a wedge that was 2.5 cm on the outer side.
The authors used computer navigation to perform osteotomies around the knee. The purpose of this article is to present the authors' surgical technique and to discuss double-level osteotomy of the femur and tibia to avoid altered joint line obliquity in genu varum deformity. The authors conducted two studies. The first study was a cohort study comparing navigated high tibial osteotomies and conventional high tibial osteotomies. The results showed a 96% reproducibility in achieving a mechanical axis of 184 degrees +/- 2 degrees in the navigated group compared to a 71% reproducibility in achieving a mechanical axis of 184 degrees +/- 2 degrees in the conventional osteotomy group (P < .0015). The second study was a prospective study on double-level osteotomy and showed that the preoperative goal of 182 degrees +/- 2 degrees has been achieved in 91% of patients.
Hemichondrodiastasis has been reported for treatment of angular deformities in children close to skeletal maturity. The use of distraction through the physis in younger children was not recommended. The authors report three children 3 to 7 years of age who underwent bilateral proximal tibial hemichondrodiastasis for correction of genu varum due to bone dysplasia. Ilizarov external fixators were applied in all cases. The patients underwent gradual angular correction at a rate of 0.5 mm/d. Distraction was continued until a normal mechanical axis was achieved. Normal alignment was achieved in two patients and slight overcorrection in the third. The patients were followed for 3 to 11 years, and no adverse affects on the physis were identified. This is the first report of physeal distraction in patients this young. Our results are good, and we believe that hemichondrodiastasis can be safely used for correction of angular deformities in young children.
The authors have analyzed the results of 193 tibial osteotomies with varus deviation reviewed after an average 8 year follow-up. There were 71 per cent of good results. 14 patients (7.2 per cent) were reoperated for unsuccessful osteotomy. The optimal postoperative tibio-femoral axial alignment was obtained between 3 degrees and 5 degrees valgus. The analysis of the series illustrates clearly the criteria of good results thus providing a guide to surgical indication. It is a question of the preoperative height of medial tibio-femoral space being higher or equal to 50 per cent of the normal, a constitutional tibial varus over 5 degrees, a preoperative mechanical axis of less or equal to a 10 degrees varus, the absence of subluxation of the tibial eminences. Statistically the most important factor (p = 0.0004) was the height of the medial tibio-femoral space of which the decrease illustrates the stage of development of A.O. Finally, in the case of arthritic genu varum, the painful patello-femoral syndrome progresses favorably in the case of good surgical indication on the medial tibio-femoral compartment.
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The authors have treated 63 knees with osteoarthritis associated with varus deformity by valgus osteotomies. The clinical and radiological state of the patello-femoral joints has been studied before and after correction of varus deformity. No correlation was found between the severity of tibio-femoral osteoarthritis and patello-femoral osteoarthritis. Medial patello-femoral discordance was found in 12 p. 100 of the cases. Clinical evidence of pain arising from the patello-femoral joint was more often found than evidence of radiological abnormality. It is concluded that pain arising from the medial compartment may be confused with patellofemoral pain. A five-year follow-up showed that the patello-femoral joint was not influenced radiologically by the valgus osteotomy but patellar pain was improved in most of the cases. Procedures to re-align the patella should not normally be associated with valgus osteotomy in cases in which patellar pain exists in association with osteoarthritis of the knee with varus deformity.