Limb deformity is common in patients presenting for knee arthroplasty, either related to asymmetrical wear patterns from the underlying arthritic process (intra-articular malalignment) or less often major extra-articular deformity due to prior fracture malunion, childhood physical injury, old osteotomy, or developmental or metabolic disorders such as Blount's disease or hypophosphatemic rickets. Angular deformity that is above the epicondyles or below the fibular neck may not be easily correctable by adjusted bone cuts as the amount of bone resection may make soft tissue balancing impossible or may disrupt completely the collateral ligament attachments. Development of a treatment plan begins with careful assessment of the malalignment which may be mainly coronal, sagittal, rotational or some combination. Translation can also complicate the reconstruction as this has effects directly on location of the mechanical axis. Most intra-articular deformities are due to the arthritic process alone, but may occasionally be the result of intra-articular fracture, periarticular osteotomy or from prior revision surgery effects. While intra-articular deformity can almost always be managed with adjusted bone cuts it is important to have available revision type implants to enhance fixation (stems) or increase constraint when ligament balancing or ligament laxity is a problem. Extra-articular deformities may be correctable with adjusted bone cuts and altered implant positioning when the deformity is smaller, or located a longer distance from the joint. The effect of a deformity is proportional to its distance from the joint. The closer the deformity is to the joint, the greater the impact the same degree angular deformity will have. In general deformities in the plane of knee are better tolerated than sagittal plane (varus/valgus) deformity. Careful pre-operative planning is required for cases with significant extra-articular deformity with a focus on location and plane of the apex of the deformity, identification of the mechanical axis location relative to the deformed limb, distance of the deformity from the joint, and determination of the intra-articular effect on bone cuts and implant position absent osteotomy. In the course of pre-operative planning, osteotomy is suggested when there is inability to correct the mechanical axis to neutral without excessive bone cuts which compromise ligament or patellar tendon attachment sites, or alternatively when adequate adjustment of cuts will likely lead to excessive joint line obliquity which can compromise ability to balance the soft tissues. When chosen, adjunctive osteotomy can be done in one-stage at the time of TKA or the procedures can be done separately in two stages. When simultaneous with TKA, osteotomy fixation options include long stems added to the femoral (or tibial) component for intramedullary fixation, adjunctive plate and screw fixation, and antegrade (usually locked) nailing for some femoral osteotomies. Choice of fixation method is often influenced by specific deformity size location, bone quality and amount, and surgeon preference. Surgical navigation, or intra-operative x-ray imaging methods (or both) have both been used to facilitate accurate correction of deformity in these complex cases. When faced with major deformity of the femur or tibia, with careful planning combined osteotomy and TKA can result in excellent outcomes and durable implant fixation with less constraint, less bone loss, and better joint kinematics than is possible with modified TKA alone

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI

We undertook a retrospective analysis of 306 procedures on 233 patients, with a mean age of 12 years (1 to 21), in order to evaluate the use of somatosensory evoked potential (SSEP) monitoring for the early detection of nerve compromise during external fixation procedures for limb lengthening and correction of deformity. Significant SSEP changes were identified during 58 procedures (19%). In 32 instances (10.5%) the changes were transient, and resolved once the surgical cause had been removed. The remaining 26 (8.5%) were analysed in two groups, depending on whether or not corrective action had been performed in response to critical changes in the SSEP recordings. In 16 cases in which no corrective action was taken, 13 (81.2%, 4.2% overall) developed a post-operative neurological deficit, six of which were permanent and seven temporary, persisting for five to 18 months. In the ten procedures in which corrective action was taken, four patients (40%, 1.3% overall) had a temporary (one to eight months) post-operative neuropathy and six had no deficit. After appropriate intervention in response to SSEP changes, the incidence and severity of neurological deficits were significantly reduced, with no cases of permanent neuropathy. SSEP monitoring showed 100% sensitivity and 91% specificity for the detection of nerve injury during external fixation. It is an excellent diagnostic technique for identifying nerve lesions when they are still highly reversible.

We have reviewed the long-term results of 22 patients (23 fusions) with fractures of the os calcis, who had subtalar arthrodesis with correction of the deformity between 1975 and 1991. The mean follow-up was nine years (5 to 20). All patients were evaluated according to a modified foot score. A radiological assessment was used in which linear and angular variables were measured including the fibulocalcaneal abutment, the height of the heel and fat pad, the angle of the arch and the lateral talocalcaneal and the lateral talar declination angles. The technique used restores the normal relationship between the hindfoot and midfoot and corrects the height of the heel. This leads to better biomechanical balance of the neighbouring joints and gives a favourable clinical outcome. The modified foot score showed a good or excellent result in 51% of the feet. Residual complaints were mostly due to problems with the soft tissues. Subjectively, an excellent or good score was achieved in 78% of the cases. After statistical analysis, except for the height of the heel and the degenerative changes in the calcaneocuboid joint, no significant difference was found in the measured variables between the operated and the contralateral side

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice.

Preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain free motion, and stability without necessarily using more constrained implants.

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice. Certain myths in deformity correction will be presented.

Technical tips with regard to preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Technique of performing TKA with concomitant extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants.

The treatment of patients with osteoarthritis of the knee and associated extra-articular deformity of the leg is challenging. Current teaching recognises two possible approaches: (1) a total knee replacement (TKR) with intra-articular bone resections to correct the malalignment or (2) an extra-articular osteotomy to correct the malalignment together with a TKR (either simultaneously or staged).

However, a number of these patients only have unicompartmental knee osteoarthritis and, in the absence of an extra-articular deformity would be ideal candidates for joint preserving surgery such as unicompartmental knee replacement (UKR) given its superior functional outcome and lower cost relative to a TKR [1).

We report four cases of medial unicondylar knee replacement, with a simultaneous extra-articular osteotomy to correct deformity, using novel 3D printed patient-specific guides (Embody, UK) (see Figure 1). The procedure was successful in all four patients, and there were no complications. A mean increase in the Oxford knee score of 9.5, and in the EQ5D VAS of 15 was observed.

To our knowledge this is the first report of combined osteotomy and unicompartmental knee replacement for the treatment of extra-articular deformity and knee osteoarthritis. This technically challenging procedure is made possible by a novel 3D printed patient-specific guide which controls osteotomy position, degree of deformity correction (multi-plane if required), and orientates the saw-cuts for the unicompartmental prosthesis according to the corrected leg alignment.

Using 3D printed surgical guides to perform operations not previously possible represents a paradigm shift in knee surgery. We suggest that this joint preserving approach should be considered the preferred treatment option for suitable patients.

Aims. The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (. sd. 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications. Patients and Methods. We prospectively collected the data of 70 consecutive patients with AIS treated with MIS using three incisions and a muscle-splitting approach by a single surgeon between June 2013 and February 2016 and these were retrospectively reviewed. There were eight male and 62 female patients with a mean age of 15 years (. sd. 4.5 ) with a mean body mass index of 19.8 kg/m. 2. (. sd. 5.4). The curves were classified according to Lenke; 40 curves were type 1, 15 were type 2, three were type 3, two were type 4, eight were type 5 and two were type 6. Results. The mean primary Cobb angle was corrected from 58.9° (. sd. 12.6°) pre-operatively to 17.7° (. sd.  10.2°) post-operatively with a mean correction of 69% (. sd. 20%, p < 0.001). The mean kyphosis at T5 to T12 increased from 24.2° (. sd. 12.2°) pre-operatively to 30.1° (. sd. 9.6°, p < 0.001) post-operatively. Peri-operative (30 days) complications occurred in three patients(4.2%): one subcutaneous haematoma, one deep venous thrombosis and one pulmonary complication. Five additional complications occurred in five patients (7.1%): one superficial wound infection, one suture granuloma and three delayed deep surgical site infections. The mean ORT was 337.1 mins (. sd. 121.3); the mean EBL was 345.7 ml (. sd. 175.1) and the mean LOS was 4.6 days (. sd. 0.8). Conclusion. The use of MIS for patients with AIS results in a significant correction of spinal deformity in both the frontal and sagittal planes, with a low EBL and a short LOS. The rate of peri-operative complications compares well with that following a routine open technique. The longer term safety and benefit of MIS in these patients needs to be evaluated with further follow-up of a larger cohort of patients. Cite this article: Bone Joint J 2017;99-B:1651–7

Introduction. The most challenging aspect in rotational deformity correction is translating the pre-operative plan to an accurate intra-operative correction. Landmarks away from the osteotomy site are typically employed at pre-operative planning and this can render inadequate correction. Our proposed technique of pre-operative planning using CT scan and leg length radiographs can translate to accurate intra-operative correction. Materials and Methods. A circle was superimposed at osteotomy site with its centre serving as the centre of correction of rotation. Medio-lateral distance at osteotomy site measured and used as diameter of the circle. Circumference of the circle was calculated by multiplying diameter with Pi and used in the below formula to obtain accurate de-rotation distance;. Derotation distance = (Circumference/360) × correction value for desired ante-version. The exact site of osteotomy was measured in theatre under C-arm and exposed. Derotation distance was marked on the surface of bone as point A and point B with a flexible ruler. Osteotomy performed with saw and derotation was done till point A and point B were co-linear. Derotation distance obtained using this technique is specific for the site of chosen osteotomy and implies a specific degree of correction for every millimeter derotated. Distal femur was the chosen site of osteotomy if there was associated patellar instability and proximal femur if there was no patellar instability. Results. We have used the above technique to successfully correct rotational malalignment of femur and tibia in three patients thus far. The foot progression angle improved in all patients following surgery. One patient had post-operative CT scan of the hips which showed accurate reduction of ante-version. Conclusions. Our new technique of rotational deformity correction is simple and reproducible using commonly available tools as CT scan and leg length radiographs. This technique effectively translates the pre-operative plan to accurate intra-operative correction of rotational deformity

Aims: To correct cubitus varus deformity by wedge resection and compression by external þxator for rapid osteogenesis. Methods: We treated 6patients with cubitus varus deformity secondary to malunited supra-condylar fracture of humerus. 4:M, 2:F aged between 8–14years. Duration between injury and surgery averaged 20months (1.4–2.4years). Preoperative humeroulna angle on x-ray averaged Ð18.5¡ (−12¡ to −28¡) and on contralateral limb averaged 12.4¡ (8¡−18¡). All patients had full elbow movements preoperatively. 2x2mm k-wires passed in lower humeral metaphysis parallel to joint line and 2x2mm k-wires passed in lower diaphysis perpendicular to humeral shaft. Laterally based bone wedge equivalent to preoperatively calculated template including 5¡ of over-correction was removed in between the wires. A compression distraction rod was applied to close the wedge by compression. Elbow was mobilized after postoperative pain relief in þrst week with dynamic elastic sling. Fixator was removed at 6weeks. Results: All patients achieved full elbow movements and complete cosmetic correction. Osteotomy united faster under compression. No neurovascular complication was seen. One patient had minor pin tract infection, subsided on treatment. Conclusions: Any residual corrections postoperatively are fully adjustable. Literature reports poor results of up to 30% due to loss off or inadequate correction. Stability achieved by þxator allowed early postoperative elbow mobilization. Extremely reliable, ßexible and fully controlled method.

Material-Methods: At 18 patients with Seronegative Chronic Polyarthritis(16 women, 2men, M.A 64,5 y) we made 24 Hoffmann-Tillmann procedures at the forefoot (6 right,6 left,6 both).At 2 patients we repeated the operation due to pseudarthrosis, at 2 patients we applied a corrective operation at the 2nd toe and at 1 patient we removed the osteosynthesis materials.

The postoperative and Radiologic control of 15 patients(20 foots) was continued for 1,5–7,5 y(M.3,5y).We had phone contact with 2 patients and for 1 patient, who died, we used the latest evaluation.

All the patients were satisfied with the postoperative results. Walking and shoe use were incompliant. At 2 patients we mentioned slight hyperextension of the 1st MP joint and at 2 patients asymptomatic pseuthasrthrosis of the 1st MP joint.

The M.V. of the HV angle was 17° and the inclination angle between Metatarsals and toes was 20°.The Phalanges showed mild to major degree Osteoporosis. The Hallux AOFAS Score was 83 (49–90) and for the remain toes 89,5(79–97).The results according to Mielke Score were very good at 15 foots and good at 5 foots.

Conclusions: Arthrodesis of the 1st MP joint in combination with head resection of the II-V Metatarsals is a very effective method for the treatment of the Rheumatoid foot.

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone

Aim: To review our experience with hemi-epiphysiodesis using different methods for the correction of angular deformity about the knee. Method: This was a retrospective review of 73 patients (101 knees) who underwent hemi-epiphysiodesis from 1999 to 2008. Assessment looked at the type and degree of deformity, implants used, average operating time and hospital stay, complications, degree of correction and the average time to correction. Results: There were 50 boys and 23 girls with bilateral deformity in 28 cases. There were 88 valgus and 13 varus knees. Average follow-up was 17 months. Staples were used in 28 cases, “8” Plates in 24, Screws in 16 and Drilling in 5 cases. The distal femoral physis was involved in 46 knees, the proximal tibial physis in 21 and both physes in 34 knees (total 135 physes). Average operation time and hospital stay were similar for all methods. There were 6 minor and 3 major complications with staples with an average correction time of 14 months, 3 minor complications with an average correction time of 11 months with “8” plates, 3 minor and 1 major complication with an average correction time of 14 months with screws and 1 minor complication with drilling with an average correction time of 13 months. The outcome was considered as resolved in 47 and pending in 26 cases, with all showing progressive correction of deformity. Conclusions: Hemi-epiphysiodesis by any method is an effective way to correct angular deformities about the knee in skeletally immature individuals within a reasonable time limit and with minimal morbidity when compared to a corrective osteotomy. Our experience suggests that “8” plates achieve faster correction with the least complications when compared to other methods. Valgus knee deformities corrected faster than varus ones

The exact prevalence of scoliosis remains unknown however it appears to be stable over time. In contrast the surgical management of spinal deformity has evolved considerably. In the UK this can be observed by examining recorded hospital statistics. Specifically the volume of procedures undertaken and preferred technique to correct deformity can be analysed and trends captured providing a comprehensive picture of changing UK practice. Annual data tables from 2000 to 2013 were downloaded from the health information and social care UK website which contains Hospital Episode Statistics (HES) data online. Numbers of completed consultant episodes for the four character primary procedure codes V41.1 (posterior attachment of correctional instrument to spine), V41.2 (anterior attachment of correctional instrument to spine), V41.4 (Anterior and posterior attachment of correctional instrument to spine), V41.8 and V41.9 (other specified and other non-specified instrumental correction of spinal deformity respectively) as main procedure where recorded. The total number of attachment of correctional instrument procedures listed as main procedure has increased significantly. The increase consists of higher numbers of posterior attachment procedures over this time from 352 in 2011–2012 to 1967 in 2012–2013 with data demonstrating a year on year increase to 2009–2010 before plateauing. Unspecified and other specified instrumental correctional spinal procedures have also contributed to the overall rise increasing from 206 in 2000–2001 to 447 in 2012–2013. Anterior attachment procedures listed as the main procedure are currently declining in number from a peak of 230 in 2005–2006 to 89 in 2012–2013. Combined posterior and anterior attachment procedures have also decreased marginally from 27 in 2009–2010 to 19 in 2012–2013. Unfortunately combined anterior and posterior procedures were not uniquely coded until 2009–2010. There is also some inherent variability in accuracy of coding which may distort HES data. Despite these limitations these results are likely to represent genuine changes in practice for the surgical correction of spinal deformity over the time period examined

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture

The purpose of this paper was to evaluate the early results of a new technique for correction of angular deformity in adolescents. A retrospective review of all patients and radiographs undergoing an open wedge technique of corrective osteotomy employing a special plate designed to keep the osteotomy open at a precise amount was carried out. From 2000–2005, eleven patients have been treated by the author using this technique. Indications for surgery included adolescent Blount’s disease or Tibia Vara in eight cases, growth arrest after fracture of the proximal tibia in one case, distal tibia in one case and developmental genu valgum in one case. The mechanical axis was restored to normal in ten of the eleven cases. One patient with adolescent Blount’s disease remained in slight varus despite the maximum available correction of 22.5 degrees. All patients healed radiographically in eight to ten weeks. Two patients have had their plates and screws removed after union of the osteotomy because of the high profile construct. Excellent results can be achieved for correction of angular deformity in adolescents with use of a special plate designed for an open wedge technique. Attention to preserving the opposite cortex at the time of the osteotomy is critical to the success of the procedure. A maximum of approximately 20 degrees of correction is possible with this technique. Early union of the osteotomy and restoration of function give this technique specific advantages over other methods

Twenty complex tibial deformities due to anterior poliomyelitis in 18 patients were corrected by a modified O’Donoghue osteotomy. This technique allowed correction of the deformity in three planes. This was achieved by widening the rectangular window distally to correct both rotation and valgus and by trimming the anterior edges of the step cuts to correct flexion deformity. An above-knee cast was applied for eight to 13 weeks and the patients followed up for a mean of 3.2 years. One of the 18 patients developed delayed union because of fracture of the medial limb of the step cut. The results showed excellent correction of the three-plane deformity and there was no recurrence. This method of osteotomy is a safe and simple procedure which does not require internal fixation and allows correction of torsional and angular deformity

The correction of angular deformities of long bones by incomplete osteotomy, followed three weeks later by manual osteoclasis, overcomes the problem of secondary displacement sometimes seen after correction by complete osteotomy and makes internal fixation unnecessary. This paper presents an experience of twenty-six operations in eighteen patients. In all cases the deformity was corrected with excellent cosmetic and functional results. Complete bony union was achieved and there were no problems with displacement at the osteotomy site. Four cases are described in detail to illustrate use of the technique in different clinical situations

Aims

The aims of this 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).

Aims

The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children.