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Background

Achieving precise implant alignment is crucial for producing good outcomes after total knee arthroplasty (TKA). We introduce a simple method for confirming the accuracy of tibial osteotomy during TKA.

Findings

Two metallic markers were placed on the skin 20 cm apart, one on the tibial tuberosity and other on the tibial crest, points that are easily identified and palpated intraoperatively. Anteroposterior radiographs of the legs were obtained. We defined the line along the markers as the tuberosity line. The osteotomy line is perpendicular to the anatomical axis of the tibia. We then calculated the angle between these two lines and designated it the osteotomy angle. We set the osteotomy angle of the protractor, and cut the bone parallel to the osteotomy line of the protractor. Postoperatively, we analyzed the varus angle of the tibial osteotomy in 35 TKAs using the protractor. The average of the varus angle of the tibial osteotomy was 89.4° ± 1.6° (95% confidence interval of −1.0976, 0.0119). There was no significant difference from the target angle of 90° (p = 0.055). The varus angles of 90° and 90° ± 2° for the tibial osteotomy were 42.9% and 82.9%, respectively.

Conclusions

We determined the accuracy of the tibial osteotomy in the coronal plane using the protractor to be satisfactory.

A 40 year old welder who underwent opening-wedge high tibial osteotomy for correction of alignment in a varus knee developed persistent pain with loss of knee extension. The posterior tibial slope increased from 9 degrees to 20 degrees after the osteotomy and caused the anteromedial knee pain and limited extension. The patient then underwent a revision osteotomy using a closing wedge technique to correct tibial slope. The osteotomy was performed, first from the medial cortex in the lateral direction, and second in the anteroposterior direction to remove the tibial bone in wedge shape and obtain full extension of the knee. The posterior tibial slope decreased to 8 degrees after the revision osteotomy and the patients returned to pain-free daily life. We reviewed this unique technique for correction of sagittal malalignment using a closing-wedge osteotomy for revision after opening-wedge osteotomy.

Background

Intra-articular hardware penetration can occur during osteosynthesis of ankle fractures, jeopardizing patients' outcomes. The intraoperative recognition of misplaced screws may be difficult due to the challenge of adequate interpretation of specific radiographic views. The present study was designed to investigate the diagnostic accuracy of standardized radiographic ankle views to determine the accuracy of diagnosis for intra-articular hardware placement of medial malleolar screws in a cadaveric model.

Methods

Nine preserved human cadaveric lower extremity specimens were used. Under direct visualization, two 4.0 mm cancellous screws were inserted into the medial malleolus. Each specimen was analyzed radiographically using antero-posterior (AP) and mortise views. The X-rays were randomly uploaded on a CD-ROM and included in a survey submitted to ten selected orthopaedic surgeons. The "Standards for Reporting of Diagnostic Accuracy" (STARD) questionnaire was used to determine the surgeons' perception of accuracy of screw placement in the medial malleolus. The selection of items was based on evidence whenever possible, therefore the "inconclusive" category was added. Inter and intraobserver variations were analyzed by kappa statistics to measure the amount of agreement.

Results

There was a poor level of agreement (kappa 0.4) both in the AP and in the mortise view among all the examiners. Associating the two x-rays, the agreement remained poor (kappa 0.4). In the cases in which there was a diagnosis of articular penetration, there was a poor agreement related to which of the screws was intra-articular. The number of "inconclusive" responses was low and constant, without a statistically significant difference between the subspecialists

Conclusion

The routine intraoperative radiographic imaging of the ankle is difficult to interpret and unreliable for detection of intra-articular hardware penetration. We therefore recommend to reposition medial malleolar screws intraoperatively if there is any doubt regarding inadequate screw placement.

High tibial osteotomy (HTO) is commonly used for genu varum deformity in young and active patients. Corrective valgus osteotomy may however lead to an oblique joint line in cases of associated femur varum or absence of tibia vara. The over-correction, needed to obtain good long-term clinical results, may increase the obliquity even more. To avoid this drawback, the authors suggest use of an accurate and reproducible radiological protocol including at least a standing AP long-leg X-ray to measure not only the hip–knee–ankle (HKA) angle but also the medial distal femoral mechanical angle (MDFMA) and the medial proximal tibial mechanical angle (MPTMA). These measures will guide the surgeon to choose the best indication, including HTO, double level osteotomy (DLO) and distal femoral osteotomy (DFO). Computer-navigation of the osteotomies is the best choice to achieve the preoperative goal. This paper will present the pre- and perioperative protocols of HTO and DLO and the rationale behind this way of thinking.

Neuropathic arthropathy (Charcot’s joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged.

Neuropathic arthropathy (Charcot’s joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged.

While options for operative treatment of leg axis varus malalignment in patients with medial gonarthrosis include several established procedures, such as unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) or high tibial osteotomy (HTO), there has been little focus on a less invasive option introduced more recently: the UniSpacer™ implant, a self-centering, metallic interpositional device for the knee. This study evaluates clinical and radiological results of the UniSpacer™, whether alignment correction can be achieved by UniSpacer™ arthroplasty and alignment change in the first five postoperative years. Anteroposterior long leg stance radiographs of 20 legs were digitally analysed to assess alignment change: two relevant angles and the deviation of the mechanical axis of the leg were analysed before and after surgery. Additionally, the change of the postoperative alignment was determined one and five years postoperatively. Analysing the mechanical tibiofemoral angle, a significant leg axis correction was achieved, with a mean valgus change of 4.7 ± 1.9°; a varus change occurred in the first postoperative year, while there was no significant further change of alignment seen five years after surgery. The UniSpacer™ corrects malalignment in patients with medial gonarthrosis; however, a likely postoperative change in alignment due to implant adaptation to the joint must be considered before implantation. Our results show that good clinical and functional results can be achieved after UniSpacer™ arthroplasty. However, four of 19 knees had to be revised to a TKA or UKA due to persistent pain, which is an unacceptably high revision rate when looking at the alternative treatment options of medial osteoarthritis of the knee.

Background:

Medial proximal tibial angle (MPTA) is the commonly used angle, which is simply measured from the knee radiographs. It can determine the correction angle in medial opening wedge high tibial osteotomy (MOWHTO). The hypothesis of our study is that post-osteotomy MPTA can predict the change in correction angle, and we aimed to determine the optimal MPTA with which to prevent recurrent varus deformity after MOWHTO.

Materials and Methods:

Between January 2002 and April 2010, radiographs of 59 patients, who underwent 71 MOWHTOs using the locking-compression osteotomy plates without bone grafts, were evaluated for the change of the MPTA. The MPTA was measured preoperatively and one and twelve months postoperatively. The changes of MPTA between one and twelve months were classified into valgus, stable, and varus change. The predicting factors were analyzed using analysis of variance (ANOVA) and Bonferroni multiple comparisons. The receiver operating characteristic (ROC) curve was used to find out the cut off point for preventing the recurrent varus deformity.

Results:

The overall preoperative, and one and twelve month postoperative MPTA values were 84.4 ± 2.4°, 97.2 ± 4.1°, and 96.3 ± 3.6°, respectively. Between one and twelve months, 39 knees displayed reduced varus change (–2.8 ± 2.1°), 18 knees displayed no change, and 14 knees displayed a greater valgus change (+2.9 ± 2.1°). The best factor for predicting these changes was the one month MPTA value (P = 0.006). By using the ROC curve, a one month MPTA of 95° was analyzed as the cut off point for preventing the recurrent varus deformity. With MPTA ≥95°, 92.3% of the osteotomies exhibited stable or varus change and 7.7% exhibited valgus change. However, with MPTA <95°, 47.4% exhibited stable or varus change and 52.6% exhibited valgus change (P < 0.001, odds ratio = 13.3).

Conclusion:

The postoperative MPTA can be used to predict the change in correction angle and an MPTA of at least 95° is the crucial angle with which to prevent recurrent varus deformity.

Background

The association between knee alignment and knee pain in knee osteoarthritis (OA) is unclear. High tibial osteotomy, a treatment option in knee OA, alters load from the affected to the unaffected compartment of the knee by correcting malalignment. This surgical procedure thus offers the possibility to study the cross-sectional and longitudinal association of alignment to pain. The aims were to study 1) the preoperative association of knee alignment to preoperative knee pain and 2) the association of change in knee alignment with surgery to change in knee pain over time in patients operated on for knee OA by high tibial osteotomy.

Methods

182 patients (68% men) mean age 53 years (34 - 69) with varus alignment having tibial osteotomy by the hemicallotasis technique for medial knee OA were consecutively included. Knee alignment was assessed by the Hip-Knee-Ankle (HKA) angle from radiographs including the hip and ankle joints. Knee pain was measured by the subscale pain (0 - 100, worst to best scale) of the Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at one year follow-up. To estimate the association between knee alignment and knee pain multivariate regression analyses were used.

Results

Mean preoperative varus alignment was 170 degrees (153 - 178) and mean preoperative KOOS pain was 42 points (3 - 86). There was no association between preoperative varus alignment and preoperative KOOS pain, crude analysis 0.02 points (95% CI -0.6 - 0.7) change in pain with every degree of HKA angle, adjusted analysis 0.3 points (95% CI -1.3 - 0.6).

The mean postoperative knee alignment was 184 degrees (171 - 185). The mean change in knee alignment was 13 degrees (0 - 30). The mean change in KOOS pain was 32 (-16 - 83). There was neither any association between change in knee alignment and change in KOOS pain over time, crude analysis 0.3 point (95% CI -0.6 - 1.2), adjusted analysis 0.4 points (95% CI 0.6 - 1.4).

Conclusion

We found no association between knee alignment and knee pain in patients with knee OA indicating that alignment and pain are separate entities, and that the degree of preoperative malalignment is not a predictor of knee pain after high tibial osteotomy.

We report on a 46-year-old athletic patient, previously treated with anterior cruciate ligament reconstruction, with large degenerative chondral lesions of the medial femoral condyle, trochlea and patella, which was successfully treated with a closing-wedge high tibial osteotomy and the implant of a newly developed biomimetic nanostructured osteochondral bioactive scaffold. After 1 year of follow-up the patient was pain-free, had full knee range of motion, and had returned to his pre-operation level of athletic activity. MRI evaluation at 6 months showed that the implant gave a hyaline-like signal as well as a good restoration of the articular surface, with minimal subchondral bone oedema. Subchondral oedema was almost non-visible at 12 months.

Context:

Medial impingement syndrome of the ankle is common in the athletic population. A marginal osteophyte on the leading edge of the medial talar facet and a corresponding “kissing” osteophyte on the tibia, in front of the medial malleolus, may abut and cause pain and limited dorsiflexion.

Background:

Palpation of the talar osteophyte and standard imaging—especially, the oblique view of the foot—are useful in making the diagnosis. Surgical removal of the osteophyte may be necessary.

Conclusions:

Ankle impingement is commonly seen in running and jumping sports, especially if the athlete has a subtle cavus foot. It may be associated with ankle instability, osteochondritis dissecans of the talus, and stress fractures of the foot.

Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.

Background:

Ankle arthrodesis is still a gold standard salvage procedure for the management of ankle arthritis. There are several functional and mechanical benefits of ankle arthrodesis, which make it a viable surgical procedure in the management of ankle arthritis. The functional outcomes following ankle arthrodesis are not very well known. The purpose of this study was to perform a clinical and radiographic evaluation of ankle arthrodesis in posttraumatic arthritis performed using Charnley's compression device.

Materials and Methods:

Between January 2006 and December 2009 a functional assessment of 15 patients (10 males and 5 females) who had undergone ankle arthrodesis for posttraumatic arthritis and/or avascular necrosis (AVN) talus (n=6), malunited bimalleolar fracture (n=4), distal tibial plafond fractures (n=3), medial malleoli nonunion (n=2). All the patients were assessed clinically and radiologically after an average followup of 2 years 8 months (range 1–5.7 years).

Results:

All patients had sound ankylosis and no complications related to the surgery. Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that 11 of the 15 had excellent results, two had good, and two showed fair results. They were all returned to their preinjury activities.

Conclusion:

We conclude that, the ankle arthrodesis can still be considered as a standard procedure in ankle arthritis. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function. Still, one should keep in mind that it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of subtalar arthritis.

The high frequency with which medial compartment osteoarthritis is associated with patellofemoral osteoarthritis makes the addition of tibial tuberosity anteriorisation to high tibial osteotomy an appealing solution, despite the discouraging previously reported long-term results when tubercle anteriorisation was combined with a Coventry closed wedge technique. We conducted a prospective study of a new osteotomy combination: “the dual osteotomy”. An open wedge high tibial osteotomy was combined with 1- to 1.5-cm Maquet-like tibial tuberosity anteriorisation. Thirty-four knees in 30 patients underwent surgery, including ten knees in nine male patients and 24 knees in 21 female patients with a mean age of 45 years (age range 34−58 years). All patients had varus medial compartment osteoarthritis and patellofemoral osteoarthritis with preoperative anatomical tibiofemoral angle exceeding 5°. Twenty-four months after surgery, final evaluation detected improvement in the Knee Society clinical rating system function score from a mean of 61.3 (range 30−80) preoperatively to a mean of 87.3 (range 50−100) postoperatively and in the knee pain score from 27.3 (range 10−30) to 47 (range 30−50) postoperatively. Based on the rating system, at final follow-up, 70% of patients experienced no pain, 13% had mild or occasional pain, 10% had pain on stairs only, and 7% had pain during walking and on stairs. Anatomical tibiofemoral angles from 0 to 10° valgus were achieved in 91% of operated knees, and union was achieved in all cases within six to twelve weeks after surgery. The dual osteotomy was effective in the short term in cases of medial compartment osteoarthritis associated with patellofemoral osteoarthritis.

Objective

Tibial spiking (i.e., spurring of tibial spines), eburnation, and osteophytes are considered features of osteoarthritis. This investigation employed direct inspection of the medial and lateral tibial plateaus in paleopathological specimens to analyze the frequency and morphological features of osteoarthritis and to define any relationship between the size of osteophytes and that of the intercondylar tibial spines.

Materials and Methods

A total of 35 tibial bone specimens were evaluated for the degree of osteoarthritis and presence of eburnation. Each plateau was also divided into four quadrants and the presence and size of bone outgrowths were recorded in each quadrant. The “medial/lateral tibial intercondylar spine index” for each specimen was calculated as follows: (medial/lateral intercondylar tibial spine height)/(anteroposterior width of the superior tibial surface). The relationships between medial and lateral tibial height indexes with the degree of osteoarthritis were then tested.

Results

Osteophytes were observed more frequently in the anterior quadrants of both tibial plateaus than in the posterior quadrants (29 vs 16 for the medial tibial plateau [p = 0.01] and 28 vs 20 for the lateral tibial plateau [p = 0.04]). Eburnation was seen more frequently in the posterior regions of both tibial plateaus than in the anterior regions (17 vs 5, p < 0.01). In specimens with no signs of osteoarthritis the lateral intercondylar tibial index was significantly lower than that in specimens with some degree of osteoarthritis (p = 0.02). The medial intercondylar tibial index of the specimens with no signs of osteoarthritis was not significantly different from that of the specimens with some degree of osteoarthritis (p = 0.45). There was a positive correlation between the lateral spine height index and the overall grading of osteoarthritis, (r = 0.6, p < 0.01). In the anteromedial and posteromedial quadrants of the lateral tibial plateau, the association between the lateral intercondylar tibial spine index and the grade of osteophytes was 0.5 (p < 0.01) and 0.7 (p < 0.01) respectively.

Conclusion

Spiking of the lateral tibial intercondylar spine is associated with osteophyte formation and osteoarthritis. Eburnation occurs mainly in the posterior parts of the tibial plateaus while osteophytes arise mainly in the anterior parts. These findings suggest that stresses occurring in the flexed knee may contribute to many of the morphological abnormalities of osteoarthritis.

A 23-year-old recreational male athlete presented with intermittent pain of three weeks duration, localized to the left ankle. Pain was aggravated by walking, although his symptoms had not affected the patient’s jogging activity which was performed three times per week. Past history revealed an inversion sprain of the left ankle, sustained fifteen months previously. Examination showed mild swelling anterior to the ankle mortise joint while other tests including range of motion, strength and motion palpation of specific joints of the ankle were noted to be unremarkable. Radiographic findings revealed a defect in the medial aspect of the talus. An orthopaedic referral was made for further evaluation. Tomography revealed a Grade III osteochondral lesion of the talus.

It was determined that follow-up views be taken in three months to demonstrate if the lesion was progressing or healing. Within the three month period, activity modifications and modalities for pain control were indicated. Surgery was considered a reasonable option should conservative measures fail.

The present case illustrates an osteochondral lesion of the talus, a condition which has not previously been reported in the chiropractic literature. A review of the pertinent orthopaedic literature has indicated an average delay of three years in diagnosing the existence of this lesion.

Although considered rare, the diagnostic frequency of the condition appears to be on the rise due to increased awareness and the use of bone and CT scans. The osteochondral lesion of the talus deserves particular consideration by practitioners working with athletes due to its higher incidence within this group. This diagnosis should be considered in patients presenting with chronic ankle pain particularly when a history of an inversion sprain exists.

The purpose of this report is to increase awareness of this condition, and review diagnosis and management strategies.

Images

Introduction

Surgical planning of high tibial osteotomy (HTO) typically requires the measurement of lower limb alignment from standing anteroposterior radiographs. Although every effort is made to maintain a standardized patient position, factors such as pain or anatomic constraints may necessitate acquiring the radiograph in a less than optimal patient position. One such constraint is natural rotation of the feet with respect to the tibia. The purpose of the present study was to investigate the magnitude of the effect of foot rotation on radiographic measures of lower limb alignment.

Methods

We analyzed 19 lower limbs from radiographs obtained from 10 people who reported to an orthopedic injuries clinic. Each patient was radiographed in 3 positions: 15° of internal foot rotation, no foot rotation and 15° of external foot rotation. We measured and compared the mechanical axis angle (hip–knee–ankle) and the mechanical axis deviation from each position.

Results

Compared with the position with no foot rotation, internal foot rotation resulted in less measured varus alignment and less mechanical axis deviation from the knee joint centre, whereas external foot rotation produced greater measured varus alignment and increased mechanical axis deviation from the knee joint centre.

Conclusions

These results indicate that patient positioning is an important factor when measuring lower limb alignment from radiographs. As a result, special care must be taken when acquiring these radiographs for use in planning surgical procedures such as HTO.

An eight year old girl presented with a progressively increasing deformity of the left proximal tibia since last 2 years. She had no history of trauma, fever and swelling of left knee. There were no obvious signs of rickets/muscular dystrophy. She had 25 degrees of tibia vara clinically with lateral thrust and a prominent fibular head. The radiograph of left knee revealed tibia vara with medial beaking and a significant depression of the medial tibial epiphysis and metaphysis. A computed tomography (CT) scan revealed significant depression of the medial tibial epiphysis but no bony bar in the physis or fusion of the medical tibial epiphysis. There was a posterior slope in addition to the medial one. She was treated with elevation of the medial tibial hemiplateau with subtuberosity valgus derotation dome osteotomy. She also underwent a lateral proximal tibial hemiphysiodesis (temporary stapling). A prophylactic subcutaneons anterolateral compartment fasciotomy was also performed. All osteotomies united in 2 months. All deformities were corrected and she regained a knee range of 0 to 130 degrees. At final followup (4 years), there was no recurrence of varus deformity, knee was stable, with 1cm of leg length discrepancy. In Langenskiold stage IV tibia vara, elevation of medial tibial plateau, a subtuberosity valgus derotation osteotomy and a concomitant lateral hemiephiphysiodesis has given good results.

Protrusio acetabuli is identified on anteroposterior (AP) radiographs of the pelvis with an acetabular line projecting medial to the ilioischial line. We documented this radiographic sign and additional radiographic parameters in 19 patients (29 hips) with protrusio and compared the parameters to those of 29 older patients (29 hips) with advanced primary osteoarthritis (OA) but no protrusio and 12 younger patients (22 hips) with protrusio but no advanced OA. A negative acetabular roof angle and particularly large acetabular fossa were more apparent in younger patients; these hips suggest the destruction of a protrusio hip begins less in the medial joint area and more in the posteroinferior joint, and the mechanism is driven less by excessive medially directed forces but by a pincer impingement. While the indication for joint-preserving surgery currently consists primarily of a valgus femoral osteotomy based on AP radiographs and patient age, modern decision making also relies on cartilage evaluation and requires advanced surgical techniques. We conclude joint-preservation surgery must be tailored to the individual hip morphology.

Level of Evidence: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Purpose

Severe Blount’s disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity.

Methods

Four patients were treated for severe Blount’s disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest.

Results

Mechanical axis was corrected from a mean 23° (13°–30°) to 0° in three patients and 6° valgus in 1. Tibias were lengthened by 1–4 cm. At follow-up, the mechanical axis was 0° in two patients and 7° varus in two. The overlengthening was diminishing as planned.

Conclusions

The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount’s disease.

Background

High tibial osteotomy (HTO) is used to treat medial compartment osteoarthritis of the knee in active patients with varus alignment. In this study we review the clinical and radiographic outcomes associated with the Taylor Spatial Frame (Smith & Nephew), and its use in HTOs, and we include an illustrative case report.

Methods

In 7 patients with medial compartment osteoarthritis of the knee and varus alignment, the Taylor Spatial Frame was applied to the tibia in the operating room and a proximal tibial osteotomy was performed. Patients followed a computer-generated turning schedule until the desired correction was achieved. The frame was removed when the osteotomy site had healed. The lower extremity measure (LEM) was used to assess physical function. Clinical outcome measures relating to the Taylor Spatial Frame included latency, time to correction, time in the frame, number of residual corrections and complications. Radiographic outcomes included preoperative Resnick grades of osteoarthritis, pre-and post-correction limb alignment and tibial slope measurements.

Results

Average (and standard deviation) LEM grade at a mean 41 (14) months follow-up after correction was 94% (5%). Average latency was 8 days, time to correction was 15 days, time in the frame was 23 weeks and number of residual corrections was 1.3. Complications were similar to those for external fixators. Radiographic correction goals were met in all patients.

Conclusion

The Taylor Spatial Frame is a valuable asset when using HTO to treat medial compartment osteoarthritis of the knee.

Twenty-five cases of advanced tibia vara occurring in adolescent Nigerians treated at the University College Hospital, Ibadan, are reported. They were aged from 11 to 14 years. The severity of the condition was assessed by measuring the intercondylar distance of the knees, radiological appearance, and measurement of the femorotibial angles. The condition is characterized by failure of growth of the posteromedial part of the proximal part of tibial epiphysis, the deformity producing acute varus at the upper end of the tibia with medial torsion and ultimately with flexion of the diaphysis on epiphysis. The deformity leads to early degenerative changes in the knee.

The decision to correct the deformity by tibial osteotomy was not only for cosmetic reasons but also to prevent knee osteoarthritis at a later date. The operation in experienced hands gives satisfactory cosmetic appearance with few complications except for the tendency of the scars to be keloidal, broad, and conspicuous.

Images

This study assessed medial translation of the hip joint achieved by the Bernese periacetabular osteotomy (PAO) in correcting residual acetabular dysplasia deformities. 86 hips in 75 patients with an average age of 25 years (range, 12-50) were treated for symptomatic acetabular dysplasia with a periacetabular osteotomy. Radiographic analysis was performed to assess correction of the acetabular deformity with specific attention to the horizontal position of the hip joint center. All hips were followed until bony union of the iliac osteotomy and the average follow-up was 28 months. The lateral center edge angle improved an average 31.6° (-0.4° preoperative, 31.2° at follow-up). Anterior center edge angle improved 39.3° (-4.5° to 34.8°). The acetabular roof obliquity improved an average 21.8° (25.1° to 3.3°). Preoperatively, the average distance from the medial aspect of the femoral head to the ilioischial line was 17.6 mm. This distance was decreased to an average 7.8 mm postoperatively. This change resulted in an average medial translation of the hip joint center of 9.8 mm, (range -6 to 31mm). Overall, some degree of medial translation of the hip joint center was obtained in 79 (92%) of the hips. 4 (5%) were maintained in the same horizontal position, and 3 (3%) had slight lateral repositioning. For the hips translated medially, the average change was 10.0 mm, and 72% of all hips had an optimal correction with the distance between the medial aspect of the femoral head and the ilioischial line being between 0 and 10 mm. This study demonstrates that in addition to optimizing femoral head coverage, a major and distinct advantage of the periacetabular osteotomy is reproducible and consistent medial translation of the hip joint center.

The posterior inclination of the tibial plateau, which is referred to as posterior tibial slope, is determined routinely on lateral radiographs. However, radiographically, it is not always possible to reliably recognize the lateral plateau, making a separate assessment of the medial and lateral plateaus difficult. We propose a technique to measure the plateaus separately by defining a tibial longitudinal axis on a conventional MRI. The medial plateau posterior tibial slope obtained from radiographs was compared with MR images in 100 consecutive patients with knee pain when ligament or meniscal injury was assumed. The posterior tibial slope on MRI correlated with those on radiographs. The mean posterior tibial slope was 3.4° smaller on MRI compared with radiographs (4.8° ± 2.4° versus 8.2° ± 2.8°, respectively). The reproducibility was slightly better on radiographs than MRI (± 0.9° versus ± 1.4°). Twenty-one of the 100 cases had more than a 5° difference (range, −8.7° to 8.9°) between the medial and lateral plateaus. The proposed technique allows measurement of the posterior tibial slope of the medial and lateral plateaus on a standard knee MRI. By using this novel measurement technique, a reliable assessment of the medial and lateral tibial plateaus is possible.

Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.