Aims. Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°. Methods. A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded. Results. At mean 5.1 years follow-up (SD 2.6) (valgus) and 6.6 years (SD 3.3) (controls), mean AOS scores decreased and SF-36 scores increased significantly in both groups. Improvements in scores were similar for both groups – AOS pain: valgus, mean 26.2 points (SD 24.2), controls, mean 22.3 points (SD 26.4); AOS disability: valgus, mean 41.2 points (SD 25.6); controls, mean 34.6 points (SD 24.3); and SF-36 PCS: valgus, mean 9.1 points (SD 14.1), controls, mean 7.4 points (SD 9.8). Valgus ankles underwent more ancillary procedures during TAA (40 (80%) vs 13 (26%)) and more secondary procedures postoperatively (18 (36%) vs 7 (14%)) than controls. Tibiotalar deformity improved significantly (p < 0.001) towards a normal weightbearing axis in valgus ankles. Three valgus and four control ankles required subsequent fusion, including two for deep infections (one in each group). Conclusion. Satisfactory mid-term results were achieved in patients with preoperative valgus malalignment ≥ 15°, but they required more adjunctive procedures during and after TAA. Valgus coronal-plane deformity ≥ 15° is not an absolute contraindication for TAA if associated deformities are addressed. Cite this article: Bone Joint J 2020;102-B(12):1689–1696

Valgus knee deformity can present a number of unique surgical challenges for the total knee arthroplasty (TKA) surgeon. Understanding the typical patterns of bone and soft-tissue pathology in the valgus arthritic knee is critical for appropriate surgical planning. This review aims to provide the knee arthroplasty surgeon with an understanding of surgical management strategies for the treatment of valgus knee arthritis. Lateral femoral and tibial deficiencies, contracted lateral soft tissues, attenuated medial soft tissues, and multiplanar deformities may all be present in the valgus arthritic knee. A number of classifications have been reported in order to guide surgical management, and a variety of surgical strategies have been described with satisfactory clinical results. Depending on the severity of the deformity, a variety of TKA implant designs may be appropriate for use. Regardless of an operating surgeon’s preferred surgical strategy, adherence to a step-wise approach to deformity correction is advised. Cite this article: Bone Joint J 2017;99-B(1 Supple A):60–4

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8° (45° to 66°) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6° (7° to 23°). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities

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

Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from −18.7° (−10° to −30°) to 6.1° (2° to 10°) in patients with cubitus varus and from 36.5° (25° to 45°) to 9.4° (4° to 15°) in patients with cubitus valgus. There were 18 excellent and six good results. The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition

Total knee arthroplasty (TKR) using a medial capsular approach gives worse results in arthritic knees with valgus deformity than in those in varus, usually because of swelling, poor wound healing and stiffness, instability, recurrent valgus deformity and poor patellar tracking. A technique for replacement TKR of valgus knees using a lateral capsular approach was described several years ago, but was not routinely adopted because of the difficulties with and complexity of the procedure which included deliberate elevation of the tibial tubercle. In order to avoid this we have modified and simplified the procedure. Our preliminary results suggest that this lateral approach is safe and may give a better outcome than that through the medial capsule for the replacement of valgus knees

We describe the mid-term results of a prospective study of total knee replacement in severe valgus knees using an osteotomy of the lateral femoral condyle and computer navigation. There were 15 knees with a mean valgus deformity of 21° (17° to 27°) and a mean follow-up of 28 months (24 to 60). A cemented, non-constrained fixed bearing, posterior-cruciate-retaining knee prosthesis of the same design was used in all cases (Columbus-B. Braun; Aesculap, Tuttlingen, Germany). All the knees were corrected to a mean of 0.5° of valgus (0° to 2°). Flexion of the knee had been limited to a mean of 85° (75° to 110°) pre-operatively and improved to a mean of 105° (90° to 130°) after operation. The mean Knee Society score improved from 37 (30 to 44) to 90 points (86 to 94). Osteotomy of the lateral femoral condyle combined with computer-assisted surgery gave an excellent mid-term outcome in patients undergoing total knee replacement in the presence of severe valgus deformity

The aim of our study was to investigate whether placing of the femoral component of a hip resurfacing in valgus protected against spontaneous fracture of the femoral neck. We performed a hip resurfacing in 20 pairs of embalmed femora. The femoral component was implanted at the natural neck-shaft angle in the left femur and with a 10° valgus angle on the right. The bone mineral density of each femur was measured and CT was performed. Each femur was evaluated in a materials testing machine using increasing cyclical loads. In specimens with good bone quality, the 10° valgus placement of the femoral component had a protective effect against fractures of the femoral neck. An adverse effect was detected in osteoporotic specimens. When resurfacing the hip a valgus position of the femoral component should be achieved in order to prevent fracture of the femoral neck. Patient selection remains absolutely imperative. In borderline cases, measurement of bone mineral density may be indicated

Aims. The aims of this study were to determine the proportion of patients with outlier varus or valgus alignment in kinematically aligned total knee arthroplasty (TKA), whether those with outlier varus or valgus alignment have higher forces in the medial or lateral compartments of the knee than those with in-range alignment and whether measurements of the alignment of the limb, knee and components predict compartment forces. Patients and Methods. The intra-operative forces in the medial and lateral compartments were measured with an instrumented tibial insert in 67 patients who underwent a kinematically aligned TKA during passive movement. The mean of the forces at full extension, 45° and 90° of flexion determined the force in the medial and lateral compartments. Measurements of the alignment of the limb and the components included the hip-knee-ankle (HKA) angle, proximal medial tibial angle (PMTA), and distal lateral femoral angle (DLFA). Measurements of the alignment of the knee and the components included the tibiofemoral angle (TFA), tibial component angle (TCA) and femoral component angle (FCA). Alignment was measured on post-operative, non-weight-bearing anteroposterior (AP) scanograms and categorised as varus or valgus outlier or in-range in relation to mechanically aligned criteria. Results. The proportion of patients with outlier varus or valgus alignment was 16%/24% for the HKA angle, 55%/0% for the PMTA, 0%/57% for the DLFA, 25%/12% for the TFA, 100%/0% for the TCA, and 0%/64% for the FCA. In general, the forces in the medial and lateral compartments of those with outlier alignment were not different from those with in-range alignment except for the TFA, in which patients with outlier varus alignment had a mean paradoxical force which was 6 lb higher in the lateral compartment than those with in-range alignment. None of the measurements of alignment of the limb, knee and components predicted the force in the medial or lateral compartment. Conclusion. Although kinematically aligned TKA has a high proportion of varus or valgus outliers using mechanically aligned criteria, the intra-operative forces in the medial and lateral compartments of patients with outlier alignment were comparable with those with in-range alignment, with no evidence of overload of the medial or lateral compartment of the knee. Cite this article: Bone Joint J 2017;99-B:1319–28

We present a series of 30 uncemented total hip replacements performed between June 1985 and January 2002 with a mean follow-up of seven years (5 to 20) in 27 patients who had previously undergone a valgus intertrochanteric osteotomy. No further osteotomy was undertaken to enable hip replacement. We used a number of uncemented modular or monoblock femoral components, acetabular components and bearings. The patients were followed up clinically and radiologically. We report 100% survival of the femoral component. One acetabular component was revised at five years post-implantation for aseptic loosening. We noted cortical hypertrophy around the tip of the monoblock stems in six patients. We believe that modular femoral components should be used when undertaking total hip replacement in patients who have previously undergone valgus femoral osteotomy

We report a prospective case-controlled study which compared the outcome of knee replacement in seriously deformed and slightly deformed knees. There were 51 knees with varus or valgus deformity greater than 20 degrees matched for age, gender, disease, type of prosthesis and time of operation with a control group in which the alignment of the leg was within 5 degrees of normal. The clinical outcome at a mean 5.5 years was similar in the two groups. Some deformity persisted in 14 patients in the first group, 13 of whom were initially in valgus. These patients had a significantly poorer mean clinical outcome. Lateral dislocation or subluxation of the patella was found in four knees, all of which had had valgus deformity of 30 degrees or more

Aims. This study aimed to evaluate if total knee arthroplasty (TKA) femoral components aligned in either mechanical alignment (MA) or kinematic alignment (KA) are more biomimetic concerning trochlear sulcus orientation and restoration of trochlear height. Methods. Bone surfaces from 1,012 CT scans of non-arthritic femora were segmented using a modelling and analytics system. TKA femoral components (Triathlon; Stryker) were virtually implanted in both MA and KA. Trochlear sulcus orientation was assessed by measuring the distal trochlear sulcus angle (DTSA) in native femora and in KA and MA prosthetic femoral components. Trochlear anatomy restoration was evaluated by measuring the differences in medial, lateral, and sulcus trochlear height between native femora and KA and MA prosthetic femoral components. Results. Femoral components in both MA and KA alignments exhibited a more valgus DTSA compared to native femora. However, DTSA deviation from native was significantly less in KA than in MA (4.8° (SD 2.2°) vs 8.8° (SD 1.8°); p < 0.001). DTSA deviation from native orientation correlated positively with the mechanical lateral distal femoral angle (mLDFA) in KA and negatively in MA (r = 0.53, p < 0.001; r = -0.18, p < 0.001). Medial trochlear height was not restored with either MA or KA, with MA resulting in lower medial trochlear height than KA in the proximal 20% of the trochlea. Lateral and sulcus trochlear height was not restored with either alignment in the proximal 80% of the trochlea. At the terminal arc point, KA replicated sulcus and lateral trochlear height, while MA led to over-restoration. Conclusion. Femoral components aligned in KA demonstrated greater biomimetic qualities than those in MA regarding trochlear sulcus orientation and trochlear height restoration, particularly in valgus femora. Variability across knees was observed, warranting further research to evaluate the clinical implications of these findings. Cite this article: Bone Joint J 2024;106-B(8):817–825

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing’s sarcoma

The use of a valgus brace can effectively relieve the symptoms of unicompartmental osteoarthritis of the knee. This study provides an objective measurement of function by analysis of gait symmetry. This was measured in 30 patients on four separate occasions: immediately before and after initial fitting and then again at three months with the brace on and off. All patients reported immediate symptomatic improvement with less pain on walking. After fitting the brace, symmetry indices of stance and the swing phase of gait showed a consistent and immediate improvement at 0 and 3 months, respectively, of 3.92% (p = 0.030) and 3.40% (p = 0.025) in the stance phase and 11.78% (p = 0.020) and 9.58% (p = 0.005) in the swing phase. This was confirmed by a significant improvement at three months in the mean Hospital for Special Surgery (HSS) knee score from 69.9 to 82.0 (p < 0.001). Thus, wearing a valgus brace gives a significant and immediate improvement in the function of patients with unicompartmental osteoarthritis of the knee, as measured by analysis of gait symmetry

Aims. The primary aim of this trial was to compare the subsidence of two similar hydroxyapatite-coated titanium femoral components from different manufacturers. Secondary aims were to compare rotational migration (anteversion/retroversion and varus/valgus tilt) and patient-reported outcome measures between both femoral components. Methods. Patients were randomized to receive one of the two femoral components (Avenir or Corail) during their primary total hip arthroplasty between August 2018 and September 2020. Radiostereometric analysis examinations at six, 12, and 24 months were used to assess the migration of each implanted femoral component compared to a baseline assessment. Patient-reported outcome measures were also recorded for these same timepoints. Overall, 50 patients were enrolled (62% male (n = 31), with a mean age of 65.7 years (SD 7.3), and mean BMI of 30.2 kg/m. 2. (SD 5.2)). Results. The two-year subsidence was similar for Avenir (-0.018 mm (95% confidence interval (CI) -0.053 to 0.018) and Corail (0.000 mm (95% CI -0.027 to 0.026; p = 0.428). Both anteversion/retroversion (Avenir 0.139° (95% CI -0.204 to 0.481°); Corail -0.196° (95% CI -0.445 to 0.053°; p = 0.110) and varus/valgus tilt (Avenir -0.024° (95% CI -0.077 to 0.028); Corail -0.049° (95% CI -0.098 to 0.000°; p = 0.473) were not statistically significantly different. After two years, patients reported similar improvements in EuroQol five-dimension five-level health questionnaire (Avenir 0.22 (SD 0.2); Corail 0.22 (SD 0.18); p = 0.965) and other outcomes scores. Patient satisfaction on a five-point Likert scale was also similar between both groups after two years (Avenir 1.38 (SD 0.88); Corail 1.33 (SD 0.57); p = 0.846). Conclusion. The performance of both femoral components was similar in terms of stability and patient outcomes. Cite this article: Bone Joint J 2023;105-B(10):1045–1051

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion

Congenital convex pes valgus (congenital vertical talus) is a rare condition. We reviewed ten feet in seven patients who had had surgical correction. All had been operated on by the senior author (JF) and the same surgical technique was used throughout, incorporating transfer of the tibialis anterior to the neck of the talus. The mean age at surgery was 31 months and the mean follow-up was nine years (6 to 14). All patients completed a questionnaire and had clinical, radiological and photographic evaluation performed by an independent examiner. None had required further surgery. All but one were satisfied with the result, and had no functional limitations. They all wore normal shoes. The mean ankle dorsiflexion was 17° and plantar flexion 21°. The mean arc of subtalar motion was 27°. All radiological parameters measured were within the normal range, although irregularity of the talonavicular joint was common. No avascular necrosis of the body of the talus was seen. We conclude that the medium-term results of this procedure are very satisfactory

Our study describes the mid-term clinical results of the use of transtrochanteric valgus osteotomy (TVO) for the treatment of osteoarthritis of the hip secondary to acetabular dysplasia. The operation included valgus displacement at the level of the lesser trochanter, and lateral displacement of the greater trochanter by inserting a wedge of bone. We reviewed 70 hips. The mean age of the patients at operation was 44 years (14 to 59). Most (90%) had advanced osteoarthritis. The scores for pain and gait had improved significantly at a mean follow-up of 9.4 years. The rate of survival until an endpoint of a further operation during a follow-up of ten years was 82%. The survival rate was 95% in patients with unilateral involvement who were less than 50 years of age at operation. TVO is a useful form of treatment for advanced osteoarthritis of the hip, particularly in young patients with unilateral disease

Aims. The Coronal Plane Alignment of the Knee (CPAK) classification has been developed to predict individual variations in inherent knee alignment. The impact of preoperative and postoperative CPAK classification phenotype on the postoperative clinical outcomes of total knee arthroplasty (TKA) remains elusive. This study aimed to examine the effect of postoperative CPAK classification phenotypes (I to IX), and their pre- to postoperative changes on patient-reported outcome measures (PROMs). Methods. A questionnaire was administered to 340 patients (422 knees) who underwent primary TKA for osteoarthritis (OA) between September 2013 and June 2019. A total of 231 patients (284 knees) responded. The ­Knee Society Score 2011 (KSS 2011), Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), and Forgotten Joint Score-12 (FJS-12) were used to assess clinical outcomes. Using preoperative and postoperative anteroposterior full-leg radiographs, the arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated and classified based on the CPAK classification. To investigate the impact on PROMs, multivariable regression analyses using stepwise selection were conducted, considering factors such as age at surgery, time since surgery, BMI, sex, implant use, postoperative aHKA classification, JLO classification, and changes in aHKA and JLO classifications from preoperative to postoperative. Results. The preoperative and postoperative CPAK classifications were predominantly phenotype I (155 knees; 55%) and phenotype V (73 knees; 26%), respectively. The change in the preoperative to postoperative aHKA classification was a significant negative predictive factor for KOOS-12 and FJS-12, while postoperative apex proximal JLO was a significant negative predictive factor for KSS 2011 and KOOS-12. Conclusion. In primary TKA for OA, preoperative and postoperative CPAK phenotypes were associated with PROMs. Alteration in varus/valgus alignment from preoperative to postoperative was recognized as a negative predictive factor for both KOOS-12 and FJS-12. Moreover, the postoperative apex proximal JLO was identified as a negative factor for KSS 2011 and KOOS-12. Determining the target alignment for each preoperative phenotype with reproducibility could improve PROMs. Cite this article: Bone Joint J 2024;106-B(10):1059–1066

There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury