Aims. Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group. Methods. The inclusion criteria consisted of patients who underwent simultaneous or staged bilateral TKA after prior unilateral DFO between 1972 and 2023. The type of osteotomy performed, osteotomy hardware fixation, implanted TKA components, and revision rates were recorded. Postoperative outcomes including the Forgotten Joint Score-12 (FJS-12), Tegner Activity Scale score, and subjective knee preference were also obtained at final follow-up. Results. A total of 21 patients underwent bilateral TKA following unilateral DFO and were followed for a mean of 31.5 years (SD 11.1; 20.2 to 74.2) after DFO. The mean time from DFO to TKA conversion was 13.1 years (SD 9.7) with 13 (61.9%) of DFO knees converting to TKA more than ten years after DFO. There was no difference in arthroplasty implant systems employed in both the DFO-TKA and TKA-only knees (p > 0.999). At final follow-up, the mean FJS-12 of the DFO-TKA knee was 62.7 (SD 36.6), while for the TKA-only knee it was 65.6 (SD 34.7) (p = 0.328). In all, 80% of patients had no subjective knee preference or preferred their DFO-TKA knee. Three DFO-TKA knees and two TKA-only knees underwent subsequent revision following index arthroplasty at a mean of 12.8 years (SD 6.9) and 8.5 years (SD 3.8), respectively (p > 0.999). Conclusion. In this self-matched study, DFOs did not affect subsequent TKA function as clinical outcomes, subjective knee preference, and revision rates were similar in both the DFO-TKA and TKA-only knees at mean 32-year follow-up. Cite this article: Bone Jt Open 2024;5(11):1013–1019

Background and aim. In 2019, specific diagnostic and antibiotic treatment recommendations for diabetic foot infection (DFI) and osteomyelitis (DFO) were introduced in our institution. They include principles on numbers of biopsies to obtain for microbiological/histopathological examinations, labeling anatomic localization, and antibiotic treatment (ABT) duration based on the aforementioned findings. ABT should be stopped after complete resection of infected bone. In case of incomplete resection, treatment is continued for 4–6 weeks. Two years after the introduction of these recommendations, we investigated the degree of implementation for hospitalized patients. Method. Adult patients with DFI/DFO undergoing surgical intervention from 01/2019–12/2021 were reviewed retrospectively. Diagnostic procedures were assigned to each episode when performed ≤30 days before surgical invention. Chi-square and Mann-Whitney-U tests were performed where appropriate. Results. We included 80 patients with 117 hospital episodes and 163 surgical interventions (mean 1.5 episodes and 2 interventions per patient). The mean age was 69.6 (SD 11.5) years, 75% were male. Vascular examination and MRI were performed in 70.9% and 74.4% of episodes, respectively. Impaired perfusion and DFO were confirmed in 34.9% and 56.3%, respectively. Blood cultures were sampled in 34.2%, bacteremia detected in 7.7% with S. aureus being the most common microorganism. Biopsies were obtained in 71.8% of operations, in 90.5% of those 3–5 samples. These were sent for histological examination in 63.2% of the interventions. In 43.6% the anatomic location was labeled ‘proximal to the resection margin’. Preoperative antibiotics were administered in 41.9% of the episodes because of concomitant soft-tissue infections. The most commonly used compound was amoxicillin/clavulanate (74.4%). ABT duration varied significantly when there were signs of DFO in preoperative MRI (p=0.015). The mean duration of antibiotic therapy was 9 (IQR 5–15) days in surgically cured episodes and 40.5 (IQR 15–42) days in cases with resection margins in non-healthy bone (p<0.0001). The results were similar when analyzing treatment duration with respect to osteomyelitis in histology: 13 (IQR 8–42) versus 29 (IQR 13–42) days, respectively (p=0.026). Conclusions. The adherence to recommendations in terms of biopsy sampling was excellent, moderate for sending samples to histology and poor for labeling the anatomic location. The adherence to ABT duration was good but can be improved by shortening treatment duration for surgically cured cases. Results of preoperative MRI appear to be influential on the decision-making for treatment duration

Introduction. Derotation osteotomies are commonly performed in paediatric orthopaedic and limb reconstruction practice. The purpose of this study was to determine whether the use of a digital inclinometer significantly improves the accuracy in attaining the desired correction. Materials & Methods. We designed an electronic survey regarding derotation femoral osteotomy (DFO) including methods of intra-operative angular correction assessment and acceptable margins of error for correction. This was distributed to 28 paediatric orthopaedic surgeons in our region. A DFO model was created, using an anatomic sawbone with foam covering. 8 orthopaedic surgeons each performed two 30-degree DFOs, one using K-wires and visual estimation (VE), and the other using a Digital Inclinometer (DI). Two radiologists reported pre and post procedure rotational profile CT scans to assess the achieved rotational correction. Results. There was a 68% response rate to the survey. The most popular methods of estimating intra-operative correction were reported to be K-wires and rotation marks on bone. The majority of respondents reported that a 6–10 degree margin of error was acceptable for a 30-degree derotation. This was therefore set as the upper limit for acceptable error margin in the simulation study. The mean error in rotation in the VE group of simulated DFO was 19.7 degrees, with error>5 degrees and error>10 degrees in 7 (88%) and 6 (75%) cases respectively. Mean error in DI group was 3.1 degrees, with error>5 degrees in 1 case (13%). Conclusions. Our results show that the compared to conventional techniques, the use of an inclinometer significantly improves the accuracy of femoral de-rotation and significantly reduces the incidence of unacceptable errors in correction. We would suggest that digital inclinometers be used to assess intra-operative correction during derotation osteotomies

Introduction:. Total hip arthroplasty (THA) is extremely effective in treating debilitating arthritic conditions of the hip. With the many modular prosthetic designs available, surgeons can now precisely construct mechanical parameters such as femoral offset (FO). Although several studies have investigated relationships between offset choice and hip abductor strength, hip range of motion, and prosthetic wear rate, there is scarce data on the effect of FO on pain and functional outcomes following THA. The objective of this study was to assess the effect of restoring FO (within varying degrees compared to the contralateral non-diseased hip [CL]) on physical function, mental well-being, pain, and stiffness outcomes as measured by the Short Form 12 Health Survey (SF-12) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) at post-operative follow-up. Methods:. We prospectively collected data on 249 patients that underwent unilateral THA with no or minimal disease of the contralateral hip. Baseline data collection included: age, gender, diagnosis, femoral head size, type of stem, and pre-operative SF-12 and WOMAC scores. Post-operative SF-12 and WOMAC scores were recorded during annual follow-up visits. Post-operative FO was retrospectively measured on standard anteroposterior (AP) pelvis radiographs and compared to FO of CL. FO was measured as the perpendicular distance from the femoral head center of rotation to the anatomic axis of the femur with appropriate adjustments made for image magnification. Patients were categorized into one of three groups: decreased femoral offset (dFO, less than −5 mm compared to CL), normal femoral offset (nFO, between −5 and +5 mm of CL), and increased femoral offset (iFO, greater than +5 mm compared to CL). Results:. In all, 31 patients were categorized into dFO, 163 categorized into nFO, and 55 categorized into iFO. At baseline, the groups differed in categorical diagnoses (p = 0.01). Further analysis revealed a higher percentage of posttraumatic arthritis in dFO as compared to nFO and iFO (12.9%, 1.2%, and 1.8%, respectively). Moreover, a higher percentage of hip dysplasia was present in iFO as compared to nFO and dFO (14.5%, 3.6%, and 6.5%, respectively). Pre-operatively, dFO had lower WOMAC Pain scores than nFO and iFO (29.68, 43.39, and 43.63, respectively; p < 0.005). (Please see Table 1 for comparison of baseline characteristics between groups.) All other pre-operative demographic and survey characteristics were similar. At most recent post-operative follow-up, dFO had lower WOMAC Physical Function scores than nFO and iFO (72.03, 83.23, and 79.51, respectively; p < 0.02) (see Table 2). Discussion:. Reduction of patients' native FOs by greater than 5 mm during THA can lead to inferior levels of physical function. Furthermore, increasing FO by greater than 5 mm did not lead to increased levels of pain nor decreased levels of function

Objective. Overviewing the literature, pain and redislocation after surgical treatment of patellofemoral instability (PFI) is described with up to 30 %, especially with techniques involving the extensor mechanism, the lateral retinaculum or the medial vastus. However, outcome data about revision surgery is missing. Therefore, it was the purpose of this prospective study to evaluate the clinical outcome after revision surgery with an isolated or a combined reco. of the medial patellofemoral ligament (MPFL) with a follow up of 12 months. The indication for additional procedures such as distal femoral osteotomies (DFO), trochleoplasty, reclosing of the lateral retinaculum (RLR) or lateralisation of the tuberosity (LT) were performed depending on the clinical and radiological pathomorphologies. Methods. In between 3/07–4/09, 42 pat. with a mean age of 24 years (13–46ys) were revised due to persistent PFI after mean 1.8 failed previous operations (lateral release, medial gather/VMO-distal., medial. of the tuberosity) in our department. An isolated reco. of the MPFL was performed in 15 cases, while a combination with a DFO due to massive femoral axis deformity (n=5), trochleoplasty due to a convex trochlear morphology (n=1) and/or LT (n=4) and/or RLR due to medial instability or lateral pain (n=22) was done in 27 cases. The clinical result was evaluated by the pre- and postop. IKDC/Kujala/Tegner-score and by a subjective questionnaire. Radiologically, the patellashift/-tilt/-height and level of the eventual degeneration were defined preop. and at the point of follow up with the help of straight lateral radiographs and by MRI. Significance level was set at p=.05, statistical calculation was done by the use of the t-test. Results. 87 % were very satisfied/satisfied with the treatment., None redislocation of the patella occurred during the follow up. We could evaluate a significant decrease of the pain during daily activities. The IKDC/Kujala/Tegner score have shown a significant increase overall. However, a significant difference concerning the scores could not be noticed in between the groups without and with additional procedures. Patellar shift, tilt, height decreased significantly to anatomical values. The level of preexisting degeneration showed no aggravation. Conclusion. Since it is known that PFI is a multifactorial problem, revision surgery should set about only after comprehensive examinations. Regarding our results, isolated or combined MPFL reco. seems to be a very effective treatment of recurrent patella dislocation and results in a significant increase of stability, functionality as well as in a reduction of pain. Additional pathomorphologies of the bony structures or a lateral release, which causes pain or an aggravation of instability, have to be addressed additionally to reach same results like with an isolated therapy. Level of Evidence. II

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.