Double level osteotomy (DLO) for severe genu varum is not a common technique. We performed our first computer-assisted double level osteotomy (CADLO) in March 2001 and we published our preliminary results in 2005 and 2007. The rationale to perform this procedure is to avoid oblique joint line in order to have less difficulty in case of revision to a total knee arthroplasty (TKA). The goal of this paper is to present the results of 37 cases operated on between August 2001 and January 2010. The series was composed of 35 patients (two bilateral), nine females and 26 males, aged from 39 to 64 years old (mean age: 50.5 +/− 7.5). We operated on 20 right knees and 17 left ones. The mean BMI was 29.3 +/− 4.3 for a mean height of 1.71 m and a mean weight of 85.8 kg. The functional status was evaluated according to the LYSHÖLM and TEGNER score. The mean score was of 42.4 +/− 8.9 points (22–69). According to modified AHLBÄCK criteria we operated on seven stage 2, 22 stage 3, five stage 4 and two stage 5. We measured HKA (Hip-Knee-Ankle) angle using RAMADIER's protocol and we also measured the femoral mechanical axis (FMA) and the tibial mechanical axis (TMA) to pose the right indication. These measures were respectively: 168° +/− 3.4° (159°–172°), 87.5° +/− 2.1 (83°–91°) for the FMA and 83.7° +/− 2.6° (78°–88°) for the TMA. The inclusion criteria were a patient younger than 65 years old with a severe varus deformity (more than 8° − HKA angle ≤ to 172°) and a FMA at 91° or less. All the osteotomies were navigated using the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY). The procedure was performed as follows: after inserting the rigid-bodies and calibrating the lower leg, we did first the femoral closing wedge osteotomy (from 4 to 7 mm) which was fixed by a an AO T-Plate, and secondly, after checking the residual varus, the high tibial opening wedge osteotomy using a BIOSORB® wedge (Tricalcium phosphate) and a plate (AO T-plate or C-plate). The goals of the osteotomy were to achieve an HKA angle of 182° +/− 2° and a TMA angle of 90° +/− 2°. The functional results were evaluated using the LYSHÖLM-TEGNER score and the KOOS score. The patients answered the questionnaire at revision or by phone, and the radiological results were assessed by plain radiographs and standing long leg X-Rays between three and six months postoperatively. We had no complication in this series but one case of recurrence of the deformity related to an impaction of the femoral osteotomy on the medial side. Two patients were lost to follow-up after removing of the plates (24 months) but were included in the results because the file was complete at that date. All the patients were assessed at a mean follow-up of 43 +/− 27 months (12–108). The mean LYSHÖLM-TEGNER score was 78.7 +/− 7.5 points (59–91) and the mean KOOS score was 94.9 +/− 3.3 points (89–100). Thirty-five patients were satisfied (18) or very satisfied (17) of the result. Only two were poorly satisfied. Regarding the radiological results, if we exclude the patient who had a loss of correction, the goals were reached in 32 cases (89%) for the HKA angle and in 31 cases (86%) for the TMA with only one case at 93°. The mean angles were: 181.97° +/− 1,89° (177°–185°) for HKA, 89.86° +/− 1,85° (85°–93°) for TMA and 93.05° +/− 2.3° (89°–99°) for FMA. At that mid-term follow-up no patient had revision to a total knee arthroplasty. DLO is a very demanding technique. Navigation can improve the accuracy of the correction compared to non computer-assisted osteotomies. The functional results are satisfying and the satisfaction of the patients is very high. Despite the difficulty of the procedure, complications are, in our hands, very rare. We recommend DLO for severe genu
It is still difficult to determine an appropriate hinge position to prevent fracture in the lateral cortex of tibia in the process of making an open wedge during biplane open wedge high tibial osteotomy. The objective of this study was to present a biomechanical basis for determining the hinge position as varus deformity. T Three-dimensional lower extremity models were constructed using Mimics. The tibial wedge started at 40 mm distal to the medial tibial plateau, and osteotomy for three hinge positions was performed toward the head of the fibula, 5 mm proximal from the head of the fibula, and 5 mm distal from the head of the fibula. The three tibial models were made with varus deformity of 5, 10, 15 degrees with heterogeneous material properties. These properties were set to heterogeneous material properties which converted from Hounsfield's unit to Young's modulus by applying empirical equation in existing studies. For a loading condition, displacement at the posterior cut plane was applied referring to Hernigou's table considering varus deformity angle. All computational analyses were performed to calculate von-mises stresses on the tibial wedges. The maximum stress increased to an average of 213±9% when the varus angle was 10 degrees compared to 5 degrees and increased to an average of 154±8.9% when the varus angle was 15 degrees compared to 10 degrees. In addition, the maximum stress of the distal position was 19 times higher than that of the mid position and 5 times higher than that of the proximal position on average. For varus deformity angles, the maximum stress of the tibial wedge tended to increase as the varus deformity angle increased. For hinge position of tibial wedge, maximum stress was the lowest in the mid position, while the highest in the distal position. *This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (NRF-2022R1A2C1009995)Conclusion:
Robotics have been applied to total knee arthroplasty (TKA) to improve surgical precision in components’ placement, providing a physiologic ligament tensioning throughout knee range of motion. The purpose of the present study is to evaluate femoral and tibial components’ positioning in robotic-assisted TKA after fine-tuning according to soft tissue tensioning, aiming symmetric and balanced medial and lateral gaps in flexion/extension. Forty-three consecutive patients undergoing robotic-assisted TKA between November 2017 and November 2018 were included. Pre-operative radiographs were performed and measured according to Paley's. The tibial and femoral cuts were performed based on the individual intra-operative fine-tuning, checking for components’ size and placement, aiming symmetric medial and lateral gaps in flexion/extension. Cuts were adapted to radiographic epiphyseal anatomy and respecting ±2° boundaries from neutral coronal alignment. Robotic data were recorded, collecting information relative to medial and lateral gaps in flexion and extension.Introduction
Materials and Methods
In order to restore the neutral limb alignment in total knee arthroplasty (TKA), surgical procedure usually starts with removing osteophytes in varus osteoarthritic knees. However, there are no reports in the literature regarding the exact influence of osteophyte removal on alignment correction. The purpose of this study was to define the influence of osteophyte removal alone on limb alignment correction in the coronal plane in TKA for varus knee. Twenty-eight medial osteoarthritic knees with varus malalignment scheduled for TKA were included in this study. After registration of a navigation system, each knee was tested at maximum extension, and at 30, 40 and 60 degrees of flexion before and after osteophyte removal. External loads of 10 N-m valgus torque at each angle and in both states were applied. Subsequently, the widths of the resected osteophytes were measured.Background
Methods
To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation.Aims
Methods
Adequate soft tissue balance at the time of total knee arthroplasty (TKA) prevents early failure. In cases of varus deformity, once the medial osteophytes have been resected, a progressive release of the medial soft tissue sleeve (MSS) from the proximal medial tibia is needed to achieve balance. The “classic” medial soft tissue release technique, popularised by John Insall et al., consists of a sharp subperiosteal dissection from the proximal medial tibia that includes superficial and deep medial collateral ligament (MCL), semimembranosus tendon, posteromedial capsule, along with the pes anserinus tendons, if needed. However, this technique allows for little control over releases that selectively affect the flexion and extension gaps. When severe deformity is present, an extensive MSS release can cause iatrogenic medial instability and the need to use a constrained implant. It has been suggested that the MSS can be elongated by performing selective releases. This algorithmic approach includes the resection of the posterior osteophytes as the initial balancing gesture. If additional MSS release is necessary in extension, a subperiosteal release of the posterior aspect of the MSS is performed with electrocautery, detaching the posterior aspect of the deep MCL, posteromedial capsule and semimembranosus tendon for the proximal and medial tibia. Dissection is rarely extended more than 1.5 cm distal to the joint line. If additional release is necessary in extension, the medial compartment is tensioned with a laminar spreader and multiple needle punctures (generally less than 8) are performed in the taut portion of the MSS using an 18G or 16G needle. If additional release is necessary to balance the flexion gap, multiple needle punctures in the anterior aspect of the MSS are performed. This stepwise approach to releasing the MSS in a patient with a varus deformity allows the surgeon to target areas that selectively affect the flexion and extension gaps. Its use has resulted in diminished use of constrained TKA constructs and subsequent cost savings. We have not seen an increase in post-operative instability developing within the first post-operative year. We recommend caution when implementing this technique. Unlike the traditional release method, pie-crusting is likely technique-dependent and failure can occur within the MCL itself. Due to the critical importance of the MCL in knee stability, further research and continuous follow up of patients undergoing TKA with this technique are warranted. Intra-operative sensing technology may be useful to quantitate the effect of pie-crusting on the compartmental loads and overall knee balance.
Soft-tissue release plays an integral part in primary total knee arthroplasty by ‘balancing’ the knee. Asian patients often present late and consequently may have large deformities due to significant bone loss and contractures medially, and stretching of the lateral collateral ligament. Extra-articular deformities may aggravate the situation further and make correction of these deformities more arduous. Several techniques have been described for correction of deformity by soft-tissue releases. However, releasing the collateral ligament during TKA has unintended consequences such as the creation of significant mediolateral instability and a flexion gap which exceeds the extension gap; both of these may require a constrained prosthesis to achieve stability. We will show that soft-tissue balance can be achieved even in cases of severe varus deformity without performing a superficial medial collateral ligament release. The steps are: Determining pre-operatively whether deformity is predominantly intra-articular or extra-articular; Individualizing the valgus resection angle and bony resection depth; Reduction osteotomy, posteromedial capsule resection, sliding medial condylar osteotomy, extra-articular corrective osteotomy; Compensating for bone loss; Only rarely deploying a more constrained device. Case examples will be presented to illustrate the entire spectrum of varus deformities.
Soft-tissue release plays an integral part in primary total knee arthroplasty by ‘balancing’ the knee. Asian patients often present late and consequently may have large deformities due to significant bone loss and contractures medially, and stretching of the lateral collateral ligament. Extra-articular deformities may aggravate the situation further and make correction of these deformities more arduous. Several techniques have been described for correction of deformity by soft-tissue releases. However, releasing the collateral ligament during TKA has unintended consequences such as the creation of significant mediolateral instability and a flexion gap which exceeds the extension gap; both of these may require a constrained prosthesis to achieve stability. We will show that soft-tissue balance can be achieved even in cases of severe varus deformity without performing a superficial medial collateral ligament release. The steps are: 1. Determining preoperatively whether deformity is predominantly intra-articular or extra-articular; 2. Individualizing the valgus resection angle and bony resection depth; 3. Reduction osteotomy, posteromedial capsule resection, sliding medial condylar osteotomy, extra-articular corrective osteotomy; 4. Compensating for bone loss; 5. Only rarely deploying a more constrained device. Case examples will be presented to illustrate the entire spectrum of varus deformities.
For correction of cubitus varus deformity many types of osteotomies and fixation methods have been described, but besides technical difficulties, they have limitations such as non-union, stiffness of the elbow joint and neurovascular injury. The prominence of the lateral condyle can also give rise to a poor cosmetic result. To overcome these problems, we reviewed the results of simple dome osteotomy with fixation by cross pins. From 2003 to 2007, eleven children with cubitus varus deformity having full range of movements and good elbow function had surgery. The average age was 9.2 years (range, 7 to 13) and M:F ratio was 4:1. Through a posterior triceps splitting approach a dome-shaped osteotomy is fashioned, the distal part of humerus is aligned as planned and then fixation by cross pinning is achieved. Patients were followed for two years. Pre-operative and post-operative humeral-elbow angles, ranges of motion and lateral prominence indices were compared. The results were evaluated according to the modified criteria of Oppenheim et al.Background
Methods
For restoration of neutral limb alignment in Total Knee Arthroplasty (TKA), we usually start by removing osteophytes in varus osteoarthritic knees. However, we have found no reports in the literature regarding research on the exact influence of osteophyte removal on angle correction. The purpose of this study was to define the influence of osteophyte removal on limb alignment correction in the coronal plane in TKA. Nine patients with varus malalignment that were scheduled for TKA were included in this study. Only patients with degenerative osteoarthritis were considered. After registration of a navigation system, each knee was tested at maximum extension, and 30 and 60 degrees of flexion before and after osteophyte removal. The same examiner applied all external loads of 10 N-m valgus torque at each angle and in both states. Subsequently, the widths of the osteophytes were measured. All data were analyzed statistically using paired t-test and correlation coefficient. A significant difference was determined to be present for P < .05.Introduction
Materials and Methods
Total knee arthroplasty(TKA) for patients with severe varus deformity has become common operation in Japan because of the rapid aging of the population. Treatment of severe malalignment, instability and bone defects is important. Here we report the clinical results of total knee arthroplasty for 23 knees with severe varus deformity. We defined a severe varus knee femorotibial angle(FTA) as one exceeding 195 degrees. The average observation period was 64 months. Autologous bone graft was performed for 3 knees and augmentation and long tibia stem was used for 3 knees. We used SF-36 for clinical evaluation. Image assessment was based on the standing HKA(Hip-Knee-Ankle)angle, and the Knee Society TKA roentgenographic evaluation and scoring system. The mean SF-36 score improved from 47.6 points to 63.7 points after TKA. The standing mean HKA angle was 204°(range 197° to 215°) before surgery and was corrected to 185°(range 176° to 195°). The post-operative standing HKA angle was classified as HKA>184°, 184°>HKA>177°, HKA<176°. A clear zone appeared in zone1 on tibia APX-ray in 4 knees belonging to the HKA>184° group. Our 23 knees achieved good results, and careful postoperative observation is still necessary especially in the vgarus group.
Hallux varus is a rare cause of pain in the foot mostly occurring after failed hallux valgus surgery. We reviewed 12 patients with unilateral hallux varus treated with soft tissue techniques (4x), arthrodesis of the first metatarso-phalangeal joint (3x) or with a distal chevron osteotomy (5x) with medial transposition of the first metatarsal head and reconstruction of the soft tissues on the lateral side of the metatarsophalangeal joint. 10 patients had previous hallux valgus surgery, in 2 cases the deformities were of unknown origin. 1 male and 11 female patients were followed up on average 26.4 months postoperatively. AOFAS hallux score improved from 46 (range 10–75) to 86 (range 72–95) points. The metatarsophalangeal angle measured with the center-head to center-base method was reduced from −16.1° (range −35° to −8°) to 5.1° (range −15° to 21°). The intermetatarsal angle increased from 5.8° (0–11°) t o 10.5° (0–19°). All patients were subjectively satisfied with the procedure. Our results indicate that joint preserving operation techniques are viable methods in the correction of mild and moderate symptomatic hallux varus deformities. Mild remaining varus deformities are well tolerated. In case of severe varus deformity or major signs of osteoarthritis in the first metatarsophalangeal joint MTP arthrodesis provides good results.
To evaluate the outcome of the Modified French osteotomy for the correction of cubitus varus resulting from a supracondylar distal humerus fracture in children. A retrospective review of 90 children, aged 3 to 14, who underwent a modified French osteotomy between 1986 and 2012 for the correction of cubitus varus as a result of a supracondylar distal humerus fracture. Case notes and radiographs were reviewed. The carrying angle was measured clinically and radiologically pre-operatively, post-operatively and at latest follow up. Comparison was made with the unaffected side. The outcome was graded as good if the correction of the carrying angle was within 5 degrees of the unaffected side, satisfactory if the correction was more than 5 degrees of the unaffected side but cubitus valgus was restored and poor if there was persistence of cubitus varus post correction. Any intra-operative and post-operative complications were documented.Purpose of the study
Description of methods
Standard implants (PCL retaining or posterior stabilized types) can be used if soft tissue balancing techniques allow the implant to tension and stabilize the joint in flexion and extension. In severe varus, Greater constraint implant may be used. The indications for the use of these components were inability to balance the knee in both flexion and extension because of severe deformities or intraoperative incompetence of the medial collateral ligament after aggressive release. Fourteen patients with twenty knees had severe varus deformity with average preoperative tibio-femoral angle 25°. The average age was 56 years (from 48 to 64). There was nine males and five females. The pre-operative diagnosis was primary osteoarthritis in 90% of patients and rheumatoid arthritis in 10% (two knees out of twenty). The average follow up was 39 month (from 27 to 57 month). Legacy Constrained Condylar Prosthesis (modular constrained knee of Zimmer) was used in all cases with stemmed both tibial and femoral components.Background
Material and methods
We compared patients, (group A) who had severe varus deformity with posterolateral varus thrust, with patients,(group B) who didn't have varus thrust for results of total knee arthroplasty. The average follow-up period was 33 months in group A (25 cases out of 23 patients) and 67 months in group B (50 cases out of 50 patients). We evaluated which kind of implant the patient had, the thickness of the polyethylene and changes of joint levels. Also we measured preoperative and postoperative mechanical axis deviation, tibio-femoral angle, and implant positions. Clinical results included preoperative and postoperative HSS, KSS, range of motion, and remained posterolateral instability on final follow-ups (Fig 1, Fig 2).Purpose:
Materials and Methods:
The aims of this prospective study were to determine the effect of osteophyte excision on deformity correction and soft-tissue gap balance in varus knees undergoing computer-assisted total knee arthroplasty (TKA). Four-hundred twenty-five consecutive, cemented, cruciate-substituting TKAs were analysed. Pre-operative varus was calculated on long leg weight-bearing HKA film. Limb deformity in coronal (varus) and sagittal (flexion) planes, medial and lateral gap distances in maximum knee extension and 90° knee flexion and maximum knee flexion were recorded before and after excision of medial femoral and tibial osteophytes using computer navigation. Data was extracted and analysed to assess the effect of removal of osteophytes on the correction of deformity and soft tissue balance.Aims
Patients and Methods
Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) is associated with poorer outcomes. Our experience has not reflected this. We examined the Oxford Hip Scores (OHS), Harris Hip Scores (HHS) and outcomes of patients with varus hips against a normal cohort to ascertain any significant difference. We identified 179 patients. Measurement of the femoral neck-shaft angle was undertaken from antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients with a NSA of less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with published anatomical studies. The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74). Mean OHS and HHS were 16 and 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures, early failures or revisions. Normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76). The OHS and HSS were 18.8, 88.9 respectively. Complications included 5 trochanteric non-unions and 1 revision due to an acetabular fracture following a fall. Statistical analysis demonstrated no statistical difference between the cohorts OHS (p=0.583) or HHS (p=0.139). Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no statistical difference in hip scores between the cohorts. We have not yet experienced any femoral neck fractures, which we believe is due to the use of the Ganz trochanteric flip and preservation of blood supply.
Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) has been cited in the literature as contributory factor towards a poorer outcome. Our experience has not reflected this. We examined the outcomes of patients with varus hips against a normal cohort. Measurement of the femoral neck-shaft angle was undertaken from standard antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with the published literature. The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74), mean OHS & HHS, 16 & 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures or revisions. The normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76), mean OHS & HSS, 18.8 & 88.9 respectively. Complications included 5 cases of trochanteric non-union and 1 revision. Statistical analysis demonstrated no difference between the cohorts OHS (p=0.583) or HHS (p=0.139). Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no difference in outcomes between the cohorts.
Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity. Thirty-six ankles with greater than 10 degrees of varus alignment were compared to thirty-six ankles which were matched for implant type, age, gender, and year of surgery. Patients completed preoperative and yearly postoperative functional outcome scores including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, the Ankle Osteoarthritis Scale (AOS) and the Short Form-36 Standard Version 2.0 Health Survey. Weightbearing preoperative and postoperative radiographs were obtained and reviewed by four examiners (AC, AQ, TD, TT) and measurements were taken of the degree of coronal plane deformity.Purpose
Method
The purpose of this paper is to report on the use of a tendon transfer (anterior tibial to midfoot) to correct dynamic foot and ankle varus deformity. Anterior tibial tendon transfer to mid-foot is useful to consider in planning treatment where there is a need to rebalance a foot in which the unopposed or weakly opposed anterior tibial causes the abnormal varus position of the foot and ankle. 12 patients, 22 feet had anterior tibial tendon transfers performed. 10 were bilateral. 10 patients had neuromuscular disease as the underlying cause for the foot imbalance, 1 patient had idiopathic clubfoot with residual, recalcitrant varus after earlier posteromedial release and 1 patient was hemiplegic secondary to stroke caused by encephalopathy. Age of the patients at the time of their initial procedure(s) ranged from 2 to 34. There was at least 1 year follow-up after each procedure for the patient to be entered into this study. A 1-grade functional loss was encountered following tendon transfer of anterior tibial muscles grading between 4–5. (4=good, 5=being normal). The transferred muscles allowed the dynamic varus deformity to be removed and the foot to become plantigrade. In its transferred position, it functioned to actively contract and contributed to give support of the ankle. After an initial period of cast use post-operatively and bracing for 6 months to support the transfer, continued use of AFO was no longer necessary. Anterior tibial tendon transfer to mid-foot, originally described by Garceau continues to be an useful method for rebalancing a foot in which the abnormal pull of the normal or almost normal functioning anterior tibial muscle. This muscle is unopposed or weakly opposed because of the underlying neuromuscular disorder or previous surgery. Thus, it causes the foot and ankle to turn into varus. The technique used is straightforward and simple. It is a useful procedure to consider when rebalancing a foot may be needed.
The purpose of this study is to describe this technique and assess its effectiveness in a series of 31 consecutive patients.
This method involves osseous resections of 10mm from the level of the uninvolved surfaces of the femur and tibia in order to restore the mechanical axis. A transverse release of the contracted posterior capsule is performed with electrocautery at the level of the tibial resection from the posterior margin of the superficial medial collateral ligament (MCL) to the posterolateral corner of the tibia. A controlled lengthening of the superficial MCL is achieved by pie-crusting.
The success of total knee arthroplasty depends on many factors, including the preoperative condition of the patient, the design and materials of the components and surgical techniques. It is important to position the femoral and tibial components accurately and to balance the soft tissues. Malpositioning of the component can lead to failures due to aseptic loosening, instability, polyethylene wear and dislocation of the patella. In order to improve post-operative alignment, computer-aid systems have been developed for total knee arthroplasty. Many clinical and experimental studies of these systems have shown that the accuracy of implanted components can be improved in spite of the increase in costs and operating time. This may not, however, improve the outcome in the short-term. Restoration of the normal mechanical axis of the knee and balancing of the surrounding soft tissues have been shown to have an important bearing on the final outcome of knee replacement operations. In severely deformed knees, whether varus or valgus, these goals may be difficult to achieve. We compared the radiologic results of the mechanical axis and implant position of Total Knee Arthroplasty using a robot-assisted method with conventional manually implanted method in severe varus deformed knee. A data set of 50 consecutive cases that were performed from April 2007 to December 2010 using the robot assisted TKA(Group A) were compared with a data set of 50 consecutive cases from the same period that were done using conventional manual TKA(Group B). All cases had a preoperative mechanical varus deformity >15° and one brand of implant was used on all cases. The diagnosis was primary osteoarthritis in all knees. The operations were performed by one-senior author with the same robot system, ROBODOC (ISS Inc., CA, USA) along with the ORTHODOC (ISS Inc., CA, USA) planning computer. (See Figure 1.) The radiological evaluations included mechanical axis, implant position (α,β,γ,δ angle) according to the system of American Knee Society.Introduction
Materials and Methods
The objective of this study was to compare the results between MCL complete detachment and medial epicondylar osteotomy for severe varus deformity in TKA. We reviewed 8 cases of MCL complete detachment (group I) and 11 cases of medial epicondylar osteotomy (group II) for severe varus deformity (from February 2001 to December 2006). In MCL complete detachment, we performed the reattachment of MCL and putting on the brace. Clinical outcome measures included Knee Society score (KSS), Function scrore (FS), and range of motion (ROM). Radiological outcomes were medial instability as determined by valgus stress radiograph, alignment by whole extremity radiograph. Group I had 4 neutral and 4 varus alignment and group II had 9 neutral, 1 varus and 1 valgus alignment. There were no significant differences in clinical results between both two groups, for KSS (95.1 vs 91.1), FS (82.5 vs 88.2), and ROM (0.6–115° vs 0–118.8°). However, there were significant differences in medial instability compared normal side. Group I had the differences of 4.1 degree at postoperative 3 months and 2.1 degree at final follow-up. Group II had 0.9 degree at postoperative 3 months and 0.4 degree at final follow-up. Medial epicondylar osteotomy for severe varus deformity in TKA could be useful technique for medial stability of the knee regardless of the alignment.
The rationale for high tibial osteotomy (HTO) in medial compartment OA with varus deformity is to correct varus malalignment and to redistribute load to the non-diseased lateral compartment of the knee. Here we present our early to mid-term clinical and radiological findings.
2 patients subsequently underwent matrix induced autologous chondrocyte implant (MACI) for osteochondral defects. In the primary OA group we found an improvement in mean Oxford knee score after HTO from 28.3 to 37.8/48 post-operatively. 1 patient was non-compliant with the correction and required a total knee replacement (TKR) for continued pain at 36 weeks post frame removal. 1 patient required fibular osteotomy during their correction. 6 (67%) of the 9 patients had a documented pin site infection. The median Otterburn grade was 3 (range 0–4). There were no cases of chronic bone infection.
Navigation of Uni knee arthroplasty (UKA) is not common. Usually the software includes navigation of the tibial as well as the femoral implant. In order to simplify the surgical procedure we thought that navigation of the tibial plateau alone could be a good option. Since 2005 we have been using a mobile bearing UKA of which the ancillary is based on dependent bone cuts. The tibial cut is made first and the femoral cut is automatically performed using cutting blocks inserted between the tibial cut and the distal end of the femur. Although we are satisfied with this procedure, it is not rare we have some difficulties getting the right under correction needed to get a good long-term result. The aim of this paper was to present our computer-assisted UKA technique and our preliminary radiological results in genu varum (17 cases) as well as genu valgum (6 cases) deformities. The series was composed of 23 patients, 10 females and 13 males, aged from 63 to 88 years old (mean age: 75 +/− 8). The mean preoperative HKA (Hip-Knee-Ankle) angle was: 172.35° +/− 2.31° (167° to 176°) for the genu vara and 186.33° +/− 2.87° (182° to 189°) for the genu valga. The goal of the navigation was to get an HKA angle of 177° +/− 2° for genu
Osteotomies for valgus deformity are much less frequent than those for varus deformity as evidenced by published series which are, on one hand, less numerous and on the other hand, based on far fewer cases. For genu
Since 2005, the author has performed nearly 1000 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. The indications are 1) Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which has failed prior conservative treatment, 2) Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which has failed prior conservative treatment. Patients are recommended for UKA only if the following anatomic requirements are met: 1) Intact ACL, 2) Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, 3) Unaffected lateral compartment cartilage, 4) Unaffected patellar cartilage on the lateral facet, 5) Less than 10 degrees of flexion deformity, 6) Over 100 degrees of knee flexion, and 7)
BACKGROUND. Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures. Aim. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of tibial fractures treated with external fixation. METHODS. Our limb reconstruction database was used to identify patients who underwent monolateral external fixation for a closed tibial fracture between January 2008 and December 2016. Radiographs of all patients were assessed to determine the original fracture pattern. Time to union was assessed as the time when the fixator was removed and the patient allowed to mobilise independently without any further support of the limb. The presence or absence of residual deformity was assessed on final follow-up radiographs. RESULTS. 22 patients fulfilled the inclusion criteria. 78% of patients had both tibial and fibular fracture. The mean age at injury was 12 years. The mean time taken for the fracture to heal was 18 weeks. The total duration of follow-up averaged 9 months. The mean Valgus deformity at the final follow up was 4 degrees and the mean
Introduction. In order to achieve good clinical results in TKA, soft tissue balance is important. Soft tissue balance is closely related to knee kinematics which affects clinical results. Modified gap balancing technique is one of the standard techniques for posterior stabilized (PS) TKA. On the other hand, appropriate load for the measurement of gap balance has not been established. The purpose of the present study is to measure the mechanical properties of soft tissue structure of knee sleeve in flexion and extension during PS TKA using newly developed balancer. The understanding of the mechanical properties is crucial. In particular if these properties are used as input for surgical procedures, standard technique for many surgeons will be established. Materials and Methods. Medial compartmental osteoarthrosis (OA) patients (13 female and 7 male) were evaluated. Average age, BMI, and
Since 2005, the author has performed 422 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. There were 263 females and 119 males, (40 patients had bilateral UKAs) with a mean age of 62 years. The indications were: Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which had failed prior conservative treatment; Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which had failed prior conservative treatment. Patients were recommended UKA only if the following anatomic requirements were met: Intact ACL, Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, Unaffected lateral compartment cartilage, Unaffected patellar cartilage on the lateral facet, Less than 10 degrees of flexion deformity, Over 100 degrees of knee flexion,
Introduction:. Blount's disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease.
1. Forty-five arthroplasties of the knee with the Walldius prosthesis are reported in forty-two patients, thirty-seven with rheumatoid arthritis and five with osteoarthritis. 2. There has been no structural failure of the prosthesis. 3. Sepsis required removal of the prosthesis in three cases, but arthrodesis was obtained in two of the three. 4. Serious loosening of the prosthesis occurred in one case only.
Introduction: Blount’s disease is an idiopathic, non-physiological form of genu
Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate. Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment. Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu
Renal failure in children is associated with a wide range of musculoskeletal disorders such as osteonecrosis, stress fractures, brown tumours, epiphysiolysis, joint infections and angular deformities. In this paper the authors report their experience concerning the surgical treatment of the angular deformities of the lower limbs in renal osteodystrophy (RO). Between 1995 to 2003, 10 children (five girls and five boys) with RO underwent surgical correction of angular deformities of the lower limbs. Of these, seven had femoral osteotomies because of knee deformities (three genu valgum, four genu varum) and three had osteotomies because of tibial angular deformity. The average age at surgery was 5 years (min. 2 years, max. 12 years). Different types of osteosynthesis were used (staples and cast, Ortho-fix and Ilizarov frames) according to the age of the child and the degree and the site of the angular deformities. All osteotomies healed without complications and the surgical correction was considered appropriate at the end of treatment. At an average follow-up of 4.5 years there was no significant relapse and no need for second surgery. Simple osteosynthesis (staples and cast) was most appropriate in the youngest children and in mildest deformities (particularly at the distal tibial metaphysis). External devices were more suitable in the oldest children and for genu valgum/
Purpose:
Giant cell tumours (GCTs) of the proximal femur are rare, and there is no consensus about the best method of filling the defect left by curettage. In this study, we compared the outcome of using a fibular strut allograft and bone cement to reconstruct the bone defect after extended curettage of a GCT of the proximal femur. In a retrospective study, we reviewed 26 patients with a GCT of the proximal femur in whom the bone defect had been filled with either a fibular strut allograft (n = 12) or bone cement (n = 14). Their demographic details and oncological and nononcological complications were retrieved from their medical records. Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) score.Aims
Methods
Failure of a unicompartmental knee replacement (UKR) may be caused by progressive osteoarthritis of the knee and/or failure of the prosthesis. Limb alignment can influence both of these factors. We have examined the fate of the other compartments and measured changes in leg alignment after UKR. A total of 50 UKRs was carried out on 45 carefully selected patients between 1989 and 1992. At operation, deliberate attempts were made to avoid overcorrection of the deformity. Four patients died, one patient was lost to follow-up and two knees were revised before review which was at a minimum of five years. Standard long-leg weight-bearing anteroposterior views of the knee and skyline views of the patellofemoral joint were taken before and at eight months and five years after operation. The radiographs of the remaining 43 knees were reviewed twice by blind and randomised assessment to measure the progression of osteoarthritis within the joints. Overcorrection of the deformity in the coronal plane was avoided in all but two knees. Only one showed evidence of progression of osteoarthritis within the patellofemoral joint, and this was only identified in one of the four assessments. Deterioration in the state of the opposite tibiofemoral compartment was not seen.
This is an overview of South African iliac crest bone histomorphometric findings. The examination Bone in health: a study of 346 healthy black and white South African subjects revealed thicker trabeculae and greater osteoid and erosion values in blacks. If this finding reflects greater bone turnover, then bone in blacks would be renewed more frequently and be less prone to fatigue failure. The finding of higher bone marrow cellularity in blacks is in keeping with greater bone turnover. Greater bone turnover and sturdier micro architecture may contribute to the lower fragility fracture rates in blacks. Bone disease in black teenagers is discussed. Rickets, due to dietary calcium deficiency, is associated with grotesque limb deformities and severe osteomalacia (OM). Dietary calcium deficiency was found to aggravate Rickets in endemic fluorosis. Genu valgum and
Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening.
The use of stems with constrained condylar knee (CCK) prosthesis components has been advocated both for primary and revision total knee arthroplasty (TKA). CCK “nonmodular” implants without diaphyseal stems reduce the invasion of the medullary canal, thereby reducing operative time and costs; render a subsequent revision procedure easier, and avoid possible stem pain. The present study is the first report on mid-term results of stemless CCK for primary TKA. This cross-sectional study reviewed the outcome for 248 knees (180 patients) in which primary TKA was performed using the Exactech nonmodular CCK between 1997 and 2001. The patients had an average age of 68 years and the preoperative diagnosis was osteoarthritis in 94%. Preoperative deformity was severe (82% Ahlback grade 4–5). Valgus deformity was present in 59% and averaged 15° (7–33°).
Unicompartmental knee replacement (UKR) is an established and effective treatment for early unicondylar osteoarthritis of the knee. However good results will only be achieved with a UKR if appropriate implants, indications and surgical techniques are used. There are now many UKR available. The majority have been introduced recently and have no published clinical results, as a result it is not clear how well they will function. Wear is a potential problem with UKR because of thin polyethylene and small contact areas. To minimise wear we use a device with a fully congruous unconstrained mobile bearing, the Oxford UKR. The indications for UKR are confusing. The Oxford UKR is recommended for medial compartment osteoarthritis with full thickness cartilage loss and a functionally intact Anterior Cruciate Ligament. The
Introduction. Proper rotational alignment of the tibial component in total knee arthroplasty (TKA) could be achieved using several techniques. The self adjustment methodology allows the alignment of the tibial component under the femoral component after several flexion-extension movements. Our hypothesis was that this technique allowed a posterior tibial component alignment parallel to the femoral component posterior bicondylar axis. The aim of this study was to access this hypothesis using a post-operative CT-scan study. Materials and Methods. This prospective CT-scan study involved 94 TKA. Theses TKA were divided in two groups: group1: 50 knees with a pre-operative genu
Objective: To study deformities in tibial fractures that are treated orthopedically. Material and Methods: A prospective study of 42 tibial fractures treated orthopedically (1996–2003), Average age was 8.9 years, Nineteen (45.2%) were male and 23 (54.3%) were female. Average follow-up was 59.6 months. Nineteen of the fractures (45.2%) were medial third and 23 (54.8%) were distal. The fracture line was spiral in 26 cases (61.9%), oblique in 10 cases (23.8%) and transverse in 6 (4.8%). In 18 cases (42.9%), there was a facture of the fibula and in 24 cases there was not (57.1%). Exclusion criteria: previous fractures, angular deformities less than 5 and surgical treatment. At one year post-concolidation, antero-posterior and lateral X-rays were taken and if the angular deformity was greater than 5 a tibial CT was done to measure axial rotation. Descriptive statistical and non-parametrical studies was done with signification p <
0.05. Results:
Unicompartmental knee replacements (UKR) have many advantages over total replacements (TKR), including better function and less morbidity. However, in general, they have a higher failure rate. To minimise the UKR failure rate it is essential that the implant should not wear out, and that the appropriate indications and surgical techniques are used. The Oxford UKR has a fully congruent mobile bearing and has been shown in a retrieval study to have minimal wear. The indications for the use of Oxford UKR are clearly defined. It is recommended for medial compartment osteoarthritis, with a functionally intact Anterior Cruciate Ligament. The
The purpose of this study was to compare the clinical and radiographic
outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively
moderate and severe arthritic varus ankles to those achieved for
patients with neutral ankles. A total of 105 patients (105 ankles), matched for age, gender,
body mass index, and follow-up duration, were divided into three
groups by pre-operative coronal plane tibiotalar angle; neutral
(<
5°), moderate (5° to 15°) and severe (>
15°) varus deformity.
American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot
score, a visual analogue scale (VAS), and Short Form (SF)-36 score
were used to compare the clinical outcomes after a mean follow-up period
of 51 months (24 to 147).Aims
Patients and Methods
Little is known about the long-term outcome of
mobile-bearing total ankle replacement (TAR) in the treatment of end-stage
arthritis of the ankle, and in particular for patients with inflammatory
joint disease. The aim of this study was to assess the minimum ten-year
outcome of TAR in this group of patients. We prospectively followed 76 patients (93 TARs) who underwent
surgery between 1988 and 1999. No patients were lost to follow-up.
At latest follow-up at a mean of 14.8 years (10.7 to 22.8), 30 patients
(39 TARs) had died and the original TAR remained Cite this article:
In patients undergoing medial opening wedge high tibial osteotomy
(MOWHTO), soft tissue opening on the medial side of the knee is
difficult to predict. When the load bearing axis is corrected beyond
a certain point, the knee joint tilts open on the medial side. We
therefore hypothesised that there is a tipping point and defined
this as the coronal hypomochlion. In this prospective study of 150 navigated MOWHTOs (144 consecutive
patients), data were collected before surgery and at three months
post-operatively. In order to calculate the hypomochlion, we compared
the respective changes to the joint line convergence angle (JLCA)
with the post-operative axis of the leg. The change to the medial proximal
tibial angle accounts for only about 80% of the change to the femorotibial
angle; 20% of the correction can therefore be attributed to non-osseous,
soft-tissue changes.Aims
Patients and Methods
Bone defects are occasionally encountered during
primary total knee replacement (TKR) and cause difficulty in establishing
a stable well-aligned bone-implant interface. Between March 1999
and November 2005, 59 knees in 43 patients underwent primary TKR
with a metal block augmentation for tibial bone deficiency. In all,
six patients (eight knees) died less than four years post-operatively,
and four patients (five knees) were lost to follow-up leaving 46 knees
in 33 patients available for review at a mean of 78.6 months (62
to 129). The clinical results obtained, including range of movement,
American Knee Society and Oxford knee scores, and the Western Ontario
and McMaster Universities osteoarthritis index, were good to excellent,
with no failures. Radiolucent lines at the block-cement-bone interface
were noted in five knees (11%) during the first post-operative year,
but these did not progress. Modular rectangular metal augmentation for tibial bone deficiency
is a useful option. No deterioration of the block-prosthesis or
block-cement-bone interface was seen at minimum of five years follow-up.
The purpose of this prospective, randomised study
was to evaluate the clinical and radiological results comparing the
identical cemented or cementless NexGen total knee prostheses implanted
bilaterally in the same patient. Sequential simultaneous bilateral
total knee replacements were performed in 50 patients (100 knees).
There were 39 women and 11 men with a mean age of 58.4 years (51
to 67) who received a cemented prosthesis in one knee and a cementless
prosthesis in the other. The mean follow-up was 13.6 years (13 to
14). At final review, the mean Knee Society scores (96.2 (82 to
100)
Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.
It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate.
In 1937 Blount described a series of 28 patients with ‘Tibia vara’. Since then, a number of deformities in the tibia and the femur have been described in association with this condition. We analysed 14 children with Blount’s disease who were entered into a cross-sectional study. Their mean age was 10 (2 to 18). They underwent a clinical assessment of the rotational profile of their legs and a CT assessment of the angle of anteversion of their hips (femoral version). We compared our results to previously published controls. A statistically significant increase in femoral anteversion was noted in the affected legs, with on average the femurs in patients with Blount’s disease being 26° more anteverted than those in previously published controls. We believe this to be a previously unrecognised component of Blount’s disease, and that the marked intoeing seen in the disease may be partly caused by internal femoral version, in addition to the well-recognised internal tibial version.
Genu varum in the achondroplastic patient has a complex and multifactorial aetiology. There is little mention in the literature of the role of fibular overgrowth. Using the ratio of fibular to tibial length as a measurement of possible fibular overgrowth, we have related it to the development of genu varum. Full-length standing anteroposterior radiographs of 53 patients with achondroplasia were analysed. There were 30 skeletally-immature and 23 skeletally-mature patients. Regression analysis was performed in order to determine if there was a causal relationship between fibular overgrowth and the various indices of alignment of the lower limb. Analysis showed that the fibular to tibial length ratio had a significant correlation with the medial proximal tibial angle and the mechanical axial deviation in the skeletally-immature group. We conclude that there is a significant relationship between fibular overgrowth and the development of genu varum in the skeletally-immature achondroplastic patient.
Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities.
