Aims. The impact of a diaphyseal femoral deformity on knee alignment varies according to its severity and localization. The aims of this study were to determine a method of assessing the impact of diaphyseal femoral deformities on knee alignment for the varus knee, and to evaluate the reliability and the reproducibility of this method in a large cohort of osteoarthritic patients. Methods. All patients who underwent a knee arthroplasty from 2019 to 2021 were included. Exclusion criteria were genu valgus, flexion contracture (> 5°), previous femoral osteotomy or fracture, total hip arthroplasty, and femoral rotational disorder. A total of 205 patients met the inclusion criteria. The mean age was 62.2 years (SD 8.4). The mean BMI was 33.1 kg/m. 2. (SD 5.5). The radiological measurements were performed twice by two independent reviewers, and included hip knee ankle (HKA) angle, mechanical medial distal femoral angle (mMDFA), anatomical medial distal femoral angle (aMDFA), femoral neck shaft angle (NSA), femoral bowing angle (FBow), the distance between the knee centre and the top of the FBow (DK), and the angle representing the FBow impact on the knee (C’KS angle). Results. The FBow impact on the mMDFA can be measured by the C’KS angle. The C’KS angle took the localization (length DK) and the importance (FBow angle) of the FBow into consideration. The mean FBow angle was 4.4° (SD 2.4; 0 to 12.5). The mean C’KS angle was 1.8° (SD 1.1; 0 to 5.8). Overall, 84 knees (41%) had a severe FBow (> 5°). The radiological measurements showed very good to excellent intraobserver and interobserver agreements. The C’KS increased significantly when the length DK decreased and the FBow angle increased (p < 0.001). Conclusion. The impact of the diaphyseal femoral deformity on the mechanical femoral axis is measured by the C’KS angle, a reliable and reproducible measurement. Cite this article: Bone Jt Open 2023;4(4):262–272

Aims. The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group). Methods. This was a case-control study of consecutive patients receiving a posterior-stabilized TKA for OA between 1996 and 2010 with previous HTO. A total of 73 TKAs after HTO with minimum ten years’ follow-up were included. Cases were matched with a TKA without previous HTO for age at the time of the HTO. All revisions were recorded. Kaplan-Meier survivorship analysis was performed using revision of metal component as the endpoint. The Knee Society Score, range of motion, and patient satisfaction were assessed. Results. Mean follow-up was 13 years (SD 3) after TKA in both groups. The 20-year Kaplan-Meier survival estimate was 98.6% in TKA post-HTO group (HTO as timing reference) and 81.4% in control group (TKA as timing reference) (p = 0.030). There was no significant difference in clinical outcomes, radiological outcomes, and complications at the last follow-up. Conclusion. At the same delay from index surgery (HTO or TKA), a strategy of HTO followed by TKA had superior knee survivorship compared to early TKA at long term in young patients. Level of evidence: III. Cite this article: Bone Jt Open 2023;4(2):62–71

Aims. To present our experience of using a combination of intra-articular osteotomy and external fixation to treat different deformities of the knee. Patients and Methods. A total of six patients with a mean age of 26.5 years (15 to 50) with an abnormal hemi-joint line convergence angle (HJLCA) and mechanical axis deviation (MAD) were included. Elevation of a tibial hemiplateau or femoral condylar advancement was performed and limb lengthening with correction of residual deformity using a circular or monolateral Ilizarov frame. Results. At a mean follow-up of 2.8 years (1.5 to 4.1), the mean HJLCA improved from 15.6° (10° to 23°) pre-operatively to 0.4° (0° to 2°). The mean MAD improved from 70.0 mm (20.1 to 118.5) pre-operatively to 9.1 mm (3 to 15). The mean tibiofemoral angle improved from 31.0° (8° to 54°) pre-operatively to 4.9° (2° to 8°). The mean limb-length discrepancy decreased from 6.3 cm (2.9 to 13.6) pre-operatively to 1.1 cm (0 to 5). All osteotomies and distraction zones healed without complications. Conclusion. The use of intra-articular corrective osteotomies combined with the Ilizarov technique allowed correction of deformities of the knee joint with satisfactory HJLCA and overall mechanical axis in six patients with a good functional and cosmetic outcome in the short term. Cite this article: Bone Joint J 2017;99-B:204–10

Fixed flexion deformities are common in osteoarthritic knees that are indicated for total knee arthroplasty. The lack of full extension at the knee results in a greater force of quadriceps contracture and energy expenditure. It also results in slower walking velocity and abnormal gait mechanics, overloading the contralateral limb. Residual flexion contractures after TKA have been associated with poorer functional scores and outcomes. Although some flexion contractures may resolve with time after surgery, a substantial percentage will become permanent. Therefore, it is essential to correct fixed flexion deformities at the time of TKA, and be vigilant in the post-operative course to maintain the correction. Surgical techniques to address pre-operative flexion contractures include: adequate bone resection, ligament releases, removal of posterior osteophytes, and posterior capsular releases. Post-operatively, extension can be maintained with focused physiotherapy, a specially modified continuous passive motion machine, a contralateral heel lift, and splinting

Introduction. The objective of this study was to assess the effect of PCL resection on flexion-extension gaps, mediolateral soft tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilised total knee arthroplasty (TKA). Methods. This prospective study included 110 patients with symptomatic knee osteoarthritis undergoing primary robotic-arm assisted posterior-stabilised TKA. All operative procedures were performed by a single surgeon using a standard medial parapatellar approach. Optical motion capture technology with fixed femoral and tibial registration pins was used to assess gaps pre- and post-PCL resection in knee extension and 90 degrees knee flexion. This study included 54 males (49.1%) and 56 females (50.9%) with a mean age of 68 ± 6.2 years at time of surgery. Mean preoperative hip-knee-ankle deformity was 6.1 ± 4.4 degrees varus. Results. PCL resection increased the flexion gap more than the extension gap in the medial (2.4 ± 1.5mm vs 1.3 ± 1.0mm respectively, p<0.001) and lateral (3.3 ± 1.6mm vs 1.2 ± 0.9mm respectively, p<0.01) compartments. The gap differences following PCL resection created mediolateral laxity in flexion (gap difference: 1.1 ± 2.5mm, p<0.001) but not in extension (gap difference: 0.1 ± 2.1mm, p=0.51). PCL resection improved overall FFD (6.3 ± 4.4° preoperatively vs 3.1 ± 1.5° postoperatively, p<0.001). There was a strong positive correlation between preoperative FFD and change in FFD following PCL release (Pearson correlation coefficient = 0.81, p<0.001). PCL resection did not affect overall limb alignment (change in alignment: 0.2 ± 1.2 degrees valgus, p=0.60). Conclusion. PCL resection creates flexion-extension mismatch by increasing the flexion gap proportionally more than the extension gap. The increase in the lateral flexion gap is greater than the increase in medial flexion gap, which creates mediolateral laxity in flexion. Improvements in FFD following PCL resection are dependent on the degree of deformity prior to PCL resection. Bone resection, implant positioning, and periarticular soft tissue balancing should account for these changes in flexion-extension gaps, mediolateral laxity, and fixed flexion deformity following PCL resection in PS TKA. For figures, tables, or references, please contact authors directly

We retrospectively reviewed the records of 1150 computer-assisted total knee replacements and analysed the clinical and radiological outcomes of 45 knees that had arthritis with a pre-operative recurvatum deformity. The mean pre-operative hyperextension deformity of 11° (6° to 15°), as measured by navigation at the start of the operation, improved to a mean flexion deformity of 3.1° (0° to 7°) post-operatively. A total of 41 knees (91%) were managed using inserts ≤ 12.5 mm thick, and none had mediolateral laxity > 2 mm from a mechanical axis of 0° at the end of the surgery. At a mean follow-up of 26.4 months (13 to 48) there was significant improvement in the mean Knee Society, Oxford knee and Western Ontario and McMaster Universities Osteoarthritis Index scores compared with the pre-operative values. The mean knee flexion improved from 105° (80° to 125°) pre-operatively to 131° (120° to 145°), and none of the limbs had recurrent recurvatum. These early results show that total knee replacement using computer navigation and an algorithmic approach for arthritic knees with a recurvatum deformity can give excellent radiological and functional outcomes without recurrent deformity

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

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).

A prospective study of 276 TKA's performed in patients with valgus knee deformity ≥ 10° using a Modified Surgical Technique. MATERIALS AND METHODS. Bone cuts were used to balance the valgus knee and soft tissue release was confined to the postero-lateral capsule in severe deformity. The aim was to restore a “functional mechanical axis” as opposed to a “neutral” mechanical axis. All surgeries were performed between Jan2003 and Apr2007, under the care of a single surgeon using an LCS rotating platform. All patients had full length radiographs and outcome scores collected prospectively. RESULTS. The mean coronal alignment of the lower limb was corrected from 15.9°(10-45°) to 3.8°. 94% patients had their coronal alignment restored to = 7°. Sixteen knees with postoperative valgus ≥8° were analysed as a separate group. The mechanical axis deviation was corrected from 52.3mm to 8.8mm. The distal femoral cut was made at 5° valgus in 131 knees(47.5%), 6° in 111 knees(40.2%) and 7° in 24 knees(8.7%).78 knees(28%) were balanced only with bone cuts. 198 knees(72%) had release of posterolateral capsule. 16 knees(5.8%) also had release of IT band. Lateral patellar release was performed in 39 knees (14%) and 23 knees had patella contouring. 93%knees had central patello-femoral alignment postoperatively. One spinout was managed by closed reduction and a second patient had revision of tibial tray for collapse. Patellar subluxation occurred in two patients. The oxford knee score and the American Knee Society clinical score improved from 48.5 to 26 and 21.04 to 86.03 respectively. CONCLUSION. Adequate correction of valgus knee deformity was successfully achieved using our modified technique with satisfactory short term outcome. It is our opinion that the extensive release of soft tissues is not only unnecessary but also fraught with the potential for instability

We investigated fixed flexion deformity (FFD) after total knee replacement (TKR). Data relating to 369 cruciate-retaining unilateral TKRs performed at a single institution were collected prospectively. Fixed flexion was measured pre-operatively and at one week, six months, 18 months, three years and five years after surgery. Using binary logistic regression, pre-operative FFD was a predictor of post-operative FFD > 10° at one week (p = 0.006) and six months (p = 0.003) following surgery. Gender was a predictor at one week (p = 0.0073) with 24% of women showing a FFD > 10° compared with 37% of men. We have shown that a gradual improvement in knee extension can be expected up to three years after surgery in knees with FFD. By this time residual FFD is mild or absent in the majority of patients, including those who had a severe pre-operative FFD

Aims. Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity. Methods. A systematic literature search was performed in the databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of “total knee arthroplasty/replacement” combined with “hindfoot/ankle alignment”. Inclusion criteria were all English language studies analyzing the association between TKA and the alignment of the hindfoot, including the clinical or radiological outcomes. Exclusion criteria consisted of TKA performed with a concomitant extra-articular osteotomy and case reports or expert opinions. An assessment of quality was conducted using the modified Methodological Index for Non-Randomized Studies (MINORS). The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42019106980). Results. A total of 17 studies were found to be eligible for review. They included six prospective and ten retrospective studies, and one case-control study. The effects of TKA showed a clinical improvement in the hindfoot deformity in three studies, but did not if there was osteoarthritis (OA) of the ankle (one study) or a persistent deformity of the knee (one study). The radiological alignment of the hindfoot corrected in 11 studies, but did not in the presence of a rigid hindfoot varus deformity (in two studies). The effects of a hindfoot deformity on TKA included a clinical association with instability of the knee in one study, and a shift in the radiological weightbearing axis in two studies. The mean MINORS score was 9.4 out of 16 (7 to 12). Conclusion. TKA improves both the function and alignment of the hindfoot in patients with a preoperative deformity of the hindfoot. This may not apply if there is a persistent deformity of the knee, a rigid hindfoot varus deformity, or OA of the ankle. Moreover, a persistent deformity of the hindfoot may adversely affect the stability and longevity of a TKA. These findings should be interpreted with caution due to the moderate methodological quality of the studies which were included. Therefore, further prospective studies are needed in order to determine at which stage correction of a hindfoot deformity is required to optimize the outcome of a TKA. Cite this article: Bone Joint J 2021;103-B(1):87–97

Aims. Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment. Methods. A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019. Results. Mean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group. Conclusion. With the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59–66

Aims. An algorithm to determine the constitutional alignment of the lower limb once arthritic deformity has occurred would be of value when undertaking kinematically aligned total knee arthroplasty (TKA). The purpose of this study was to determine if the arithmetic hip-knee-ankle angle (aHKA) algorithm could estimate the constitutional alignment of the lower limb following development of significant arthritis. Methods. A matched-pairs radiological study was undertaken comparing the aHKA of an osteoarthritic knee (aHKA-OA) with the mechanical HKA of the contralateral normal knee (mHKA-N). Patients with Grade 3 or 4 Kellgren-Lawrence tibiofemoral osteoarthritis in an arthritic knee undergoing TKA and Grade 0 or 1 osteoarthritis in the contralateral normal knee were included. The aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA) measured on standing long leg radiographs. The primary outcome was the mean of the paired differences in the aHKA-OA and mHKA-N. Secondary outcomes included comparison of sex-based differences and capacity of the aHKA to determine the constitutional alignment based on degree of deformity. Results. A total of 51 radiographs met the inclusion criteria. There was no significant difference between aHKA-OA and mHKA-N, with a mean angular difference of −0.4° (95% SE −0.8° to 0.1°; p = 0.16). There was no significant sex-based difference when comparing aHKA-OA and mHKA-N (mean difference 0.8°; p = 0.11). Knees with deformities of more than 8° had a greater mean difference between aHKA-OA and mHKA-N (1.3°) than those with lesser deformities (-0.1°; p = 0.009). Conclusion. This study supports the arithmetic HKA algorithm for prediction of the constitutional alignment once arthritis has developed. The algorithm has similar accuracy between sexes and greater accuracy with lesser degrees of deformity. Cite this article: Bone Joint Open 2020;1-7:339–345

Aims. Once knee arthritis and deformity have occurred, it is currently not known how to determine a patient’s constitutional (pre-arthritic) limb alignment. The purpose of this study was to describe and validate the arithmetic hip-knee-ankle (aHKA) algorithm as a straightforward method for preoperative planning and intraoperative restoration of the constitutional limb alignment in total knee arthroplasty (TKA). Methods. A comparative cross-sectional, radiological study was undertaken of 500 normal knees and 500 arthritic knees undergoing TKA. By definition, the aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA). The mechanical HKA (mHKA) of the normal group was compared to the mHKA of the arthritic group to examine the difference, specifically related to deformity in the latter. The mHKA and aHKA were then compared in the normal group to assess for differences related to joint line convergence. Lastly, the aHKA of both the normal and arthritic groups were compared to test the hypothesis that the aHKA can estimate the constitutional alignment of the limb by sharing a similar centrality and distribution with the normal population. Results. There was a significant difference in means and distributions of the mHKA of the normal group compared to the arthritic group (mean -1.33° (SD 2.34°) vs mean -2.88° (SD 7.39°) respectively; p < 0.001). However, there was no significant difference between normal and arthritic groups using the aHKA (mean -0.87° (SD 2.54°) vs mean -0.77° (SD 2.84°) respectively; p = 0.550). There was no significant difference in the MPTA and LDFA between the normal and arthritic groups. Conclusion. The arithmetic HKA effectively estimated the constitutional alignment of the lower limb after the onset of arthritis in this cross-sectional population-based analysis. This finding is of significant importance to surgeons aiming to restore the constitutional alignment of the lower limb during TKA. Cite this article: Bone Jt Open 2021;2(5):351–358

Abstract. Introduction. This study compared biomechanical and functional parameters of a total knee arthroplasty (TKA) implant (Cemented Zimmer Hi-Flex) against healthy older adults to determine whether knee biomechanics was restored in this patient population. Methodology. Patients with a primary TKA and healthy adults >55 years old with no musculoskeletal deficits or arthritis participated. Bilateral knee range of motion (RoM) was assessed with a goniometer, then gait patterns were analysed with a 3D motion-capture system. An arthrometer then quantified anterior-posterior laxity of each knee. Statistical analyses were performed in SPSS (α=0.05; required sample size: n=21 per group). Results. 25 knees were replaced in 21 patients. Nine presented with fixed flexion deformities (FFD) (13.3±5.6°). FFDs were abolished intraoperatively, and the average flexion increased from 124.8±9.1° to 130.9±5.8°. At 9.6±3.2 years postoperatively, the patients achieved poorer RoM than healthy controls (n=23); p<0.0001. These differences were due to limited flexion in the knee. Patients also failed to achieve the same degree of flexion as controls bilaterally during gait. No differences were observed during mid-flexion; a state that has been associated with instability (p=0.614). There were no differences between groups in knee laxity. Conclusion. Patients in this study had similar gait patterns to healthy older adults during mid-flexion, and were no more likely to exhibit anterior-posterior translation of the knee >7mm; a known risk factor of instability. However, the flexion range was poorer. This led to bilateral pathological knee flexion patterns during gait. Further research should identify the cause of these limitations

Abstract. INTRODUCTION. The anatomic distal femoral locking plate (DF-LCP) has simplified the management of supracondylar femoral fractures with stable knee prostheses. Osteoporosis and comminution seem manageable, but at times, the construct does not permit early mobilization. Considerable soft tissue stripping during open reduction and internal fixation (ORIF) may delay union. Biological plating offsets this disadvantage, minimizing morbidity. Materials. Thirty comminuted periprosthetic supracondylar fractures were operated from October 2010 to August 2016. Fifteen (group A) were treated with ORIF, and fifteen (group B) with closed (biological) plating using the anatomical DF-LCP. Post-operatively, standard rehabilitation protocol was followed in all, with hinged-knee-brace supported physiotherapy. Clinico-radiological follow-up was done at 3 months, 6 months, and then yearly (average duration, 30 months), and time to union, complications, failure rates and function were evaluated. Results. Average time to union was 4.5 months (range, 3–6 months) in group A, and 3.5 months (range, 2.5–5 months) in group B. Primary bone grafting was done in twelve patients (all group A). At final follow-up, all fractures had healed, and all (but two) patients were walking unsupported, with no pain or deformity, with average knee range of motion (ROM) of 90° (range, 55 to 100°). Two patients had superficial infection (group A), two had knee stiffness (group A), one had shortening of 1.5cm (group B) and one had valgus malalignment of 10 degrees (group B). Conclusion. Biological plating in comminuted supracondylar fractures about stable TKA prostheses is an excellent option, may obviate need for bone grafting, and reducing complications

Abstract. Introduction. Total knee replacement (TKR) in patients with skeletal dysplasia is technically challenging surgery due to deformity, joint contracture, and associated co-morbidities. The aim of this study is to follow up patients with skeletal dysplasia following a TKR. Methodology. We retrospectively reviewed 22 patients with skeletal dysplasia who underwent 31 TKRs at our institution between 2006 and 2022. Clinical notes, operative records and radiographic data were reviewed. Results. Achondroplasia was the most common skeletal dysplasia (8), followed by Chondrodysplasia punctata (7) and Spondyloepiphyseal dysplasia (5). There were fourteen men and eight women with mean age of 51 years (28 to 73). The average height of patients was 1.4 metres (1.16–1.75) and the mean weight was 64.8 Kg (34.3–100). The mean follow up duration was 68.32 months (1–161). Three patients died during follow up. Custom implants were required in twelve patients (38.71%). Custom jigs were utilised in six patients and two patients underwent robotic assisted surgery. Hinged TKR was used in seventeen patients (54.84%), posterior stabilised TKR in nine patients (29.03%), and cruciate retaining TKR in five patients (16.13%). One patient underwent a patella resurfacing for persistent anterior knee pain and another had an intra-operative medial tibial plateau fracture which was managed with fixation. No revisions occurred during the follow up period. Conclusion. Despite the technical challenges and complexity of TKR within this unique patient group, we demonstrate good implant survivorship during the study period. Cross sectional imaging is recommended preoperatively for precise planning and templating

Abstract. Introduction. Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield significantly tilted joint line obliquity (JLO). Methods. A single-centre, retrospective analysis of prospectively collected data for 26 patients, who underwent DLO by PSCGs for valgus malaligned knees. Post-operative alignment was evaluated and the delta for different lower limb alignment parameters were calculated; HKA, MPTA, and LDFA. At the two-year follow-up, changes in KOOS sub-scores, UCLA scores, lower limb discrepancy, and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. Results. The postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p > 0.05). All KOOS subscores’ mean values were improved to an extent two-fold superior to the reported MCID (all with p < 0.0001). There was a significant increase in the UCLA score at the final follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1 months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3+/−2cm) to postoperative measures (LLD= 0.3 +/− 0.4 cm) p=0.02. Conclusion. DLO is effective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO

Aims. The purpose of this study was to explore the correlation between femoral torsion and morphology of the distal femoral condyle in patients with trochlear dysplasia and lateral patellar instability. Methods. A total of 90 patients (64 female, 26 male; mean age 22.1 years (SD 7.2)) with lateral patellar dislocation and trochlear dysplasia who were awaiting surgical treatment between January 2015 and June 2019 were retrospectively analyzed. All patients underwent CT scans of the lower limb to assess the femoral torsion and morphology of the distal femur. The femoral torsion at various levels was assessed using the a) femoral anteversion angle (FAA), b) proximal and distal anteversion angle, c) angle of the proximal femoral axis-anatomical epicondylar axis (PFA-AEA), and d) angle of the AEA–posterior condylar line (AEA-PCL). Representative measurements of distal condylar length were taken and parameters using the ratios of the bianterior condyle, biposterior condyle, bicondyle, anterolateral condyle, and anteromedial condyle were calculated and correlated with reference to the AEA, using the Pearson Correlation coefficient. Results. The femoral torsion had a strong correlation with distal condylar morphology. The FAA was significantly correlated with the ratio of the bianterior condyle (r = 0.355; p = 0.009), the AEA-PCL angle (r = 0.340; p = 0.001) and the ratio of the anterolateral condyle and lateral condyle (ALC-LC) (r = 0.309; p = 0.014). The PFA-AEA angle was also significantly correlated with the ratio of the bianterior condyle (r = 0.319; p = 0.008), the AEA-PCL angle (r = 0.231; p = 0.031), and the ratio of ALC-LC (r = 0.261; p = 0.034). In addition, the bianterior condyle ratio showed a significant correlation with the biposterior condyle ratio (r = -0.324; p = 0.027) and the AEA-PCL angle (r = 0.342; p = 0.021). Conclusion. Increased femoral torsion correlated with a prominent anterolateral condyle and a shorter posterolateral condyle compared with the medial condyle. The deformities of the anterior and posterior condyles are combined deformities rather than being isolated and individual deformities in patients with trochlear dysplasia and patella instability. Cite this article: Bone Joint J 2020;102-B(7):868–873

Abstract. Aim. End-stage arthropathy is a well-known complication of haemophilia, with recurrent haemarthroses leading to joint destruction, deformity, pain, and stiffness. In the knee, this is often treated with total knee arthroplasty (TKA), which can be more challenging in patients with haemophilia (PwH) and associated with poorer outcomes. We conducted a systematic literature review and meta-analysis to determine implant survivorship, functional outcomes and complication rates. Method. A systematic review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting TKA outcomes with Kaplan-Meier survivorship in PwH (PROSPERO registered). Meta-analysis was performed for survivorship and outcomes, and the results were compared to outcomes from the National Joint Registry (NJR). Results. 19 studies, totalling 1187 TKAs (average age 39 years) were reviewed. In PwH, implant survivorship at 5, 10, and 15 years was 94%, 86%, and 76% respectively, whereas NJR reported survivorship for males <55 years was 94%, 90%, and 86%. Survivorship generally improved over the time period studied (1973–2017), but was inversely correlated with HIV infection (common in PwH). Range of motion improved by 10–20° post-operatively, and there were large improvements in Patient Reported Outcome Measures (PROMS). The prosthetic joint infection rate (PJI) was 6% compared to 0.5-1% in non-PwH, but the reporting of other complications, especially haematological, was inconsistent. Conclusions. TKA in PwH has similar 5-year survivorship to non-PwH, but a six-fold higher infection rate. There were marked improvements in range of motion and PROMS, but complications were poorly reported. There remains a need for larger, long-term studies with standardised reporting