Search Results (99)

Background: Osteotomies around the knee aim to correct varus or valgus malalignment and improve biomechanics. However, little is known about their effect on knee phenotypes, as defined by the Coronal-Plane-Alignment-of-the-Knee (CPAK) and Hirschmann’s functional classification. This study evaluated pre- and postoperative phenotypes in patients undergoing high-tibial-osteotomy (HTO) or distal-femoral-osteotomy (DFO). Methods: We retrospectively analysed 214 osteotomies around the knee (HTO: 145; DFO: 69) of 188 patients from our institutional registry. Radiographic parameters were measured using a validated artificial intelligence software, with phenotypes classified by CPAK and Hirschmann classification. Preoperative osteotomy planning was compared to postoperative alignment. Regression was used to assess the influence of demographic and radiographic factors. Results: CPAK types changed in 95.3% of cases. Medial opening HTOs most frequently shifted from CPAK type I (73.8%) to VI (42.3%), while medial closing DFOs transitioned from type III (81.5%) to V (24.1%). Concordance between planned and achieved CPAK types was highest for types III, IV, and V. Postoperative angles were generally smaller than planned for joint-line-obliquity (JLO), lateral-distal-femur-angle, and medial-proximal-tibial-angle (p < 0.001). Neutral JLO was restored in only 48.1%. Preoperative phenotypes NEUmLDFA0° (40.1%) and VARmMPTA3° (32.3%) were most common, while postoperative phenotypes included VALmLDFA3° (52.4%) and VALmMPTA3° (37.7%). Age, sex, and BMI significantly influenced alignment outcomes. Conclusions: Postoperative CPAK classifications shifted significantly across all osteotomy types, with minimal retention of preoperative types. Although most procedures achieved correction within the target HKA range, restoration of a neutral JLO was observed in only half of the cases, emphasizing the importance of phenotype-specific planning and highlight potential limitations of CPAK classification. Full article

Hip joint reconstruction is often necessary for children and adolescents with conditions like developmental dysplasia of the hip (DDH), neurogenic dislocation of the hip (NDH), or Legg–Calvé–Perthes disease (LCPD) when non-surgical treatments are ineffective. Background: Post-operative immobilization after hip reconstruction in children is crucial to promote proper healing and reduce the risk of complications. While spica casting has been the traditional method, it can lead to various issues. Foam splinting has emerged as an alternative approach. This study aimed to compare the effectiveness and satisfaction of the patient and the caregivers of spica casting and foam splinting after pelvic osteotomies in young patients with DDH, NDH, and LCPD. Methods: A prospective randomized clinical trial included patients aged 3 to 16 undergoing pelvic reconstruction (iliac and proximal femoral osteotomy, open reduction, and soft tissue procedures). Participants were randomized into two groups: one receiving spica casts and the other foam splints, both for a six-week period post-surgery. Quality of life (QOL) assessments like CPCHILD, SF-36, and EQ-5D were conducted using various scores to measure patient and caregiver satisfaction preoperative and at six and twelve weeks postoperative. The surgical techniques were consistent across both groups. Results: The study included 34 patients, with one excluded due to non-adherence. The spica cast group experienced statistically significant declines in QOL scores, while the foam splint group showed decreases that were not statistically significant. Complications were reported in 11 patients, with a higher prevalence in the spica cast group. Conclusions: The foam splint group demonstrated superior satisfaction levels and fewer complications, which leads to the conclusion that foam splinting should be the preferred option to spica casting for post-operative immobilization in these cases. Full article

Background: Total hip arthroplasty (THA) in adult patients with developmental dysplasia of the hip (DDH) presents unique surgical challenges due to altered hip anatomy and biomechanics. One of the most critical factors influencing surgical success is correcting femoral anteversion. This study evaluates the effects of different anteversion corrections (increased, unchanged, and decreased) during THA on clinical outcomes in adult Crowe type 3-4 DDH patients. Methods: A retrospective analysis was conducted on 130 patients who underwent THA with anteversion correction between 2008 and 2017 at a tertiary university hospital. Patients were divided into three groups: Group 1 (increased anteversion), Group 2 (unchanged anteversion), and Group 3 (decreased anteversion). Clinical outcomes were assessed using AOFAS and Lysholm scores, Q-angle measurements, and physical examinations, while radiological evaluations were performed to determine implant stability and complications. Results: Postoperative assessments show that increased anteversion is associated with higher rates of instability, knee dysfunction, and pain. Group 1 had significantly lower AOFAS scores (p < 0.001) and fell due to rotational deformity (25.6%). Group 2 exhibited the best clinical outcomes, with the lowest rates of instability and the highest functional scores. Group 3 had moderate functional improvements but a higher dislocation rate (17.1%) than Group 2. Conclusions: Our findings suggest that excessive changes in femoral anteversion during THA, remarkably increasing it, may negatively impact clinical outcomes by causing instability and pain. Preserving the anteversion angle as much as possible is the most favorable approach for optimizing functional recovery and implant stability. Further large-scale, long-term studies are required to confirm these findings and refine surgical strategies for DDH patients undergoing THA. Full article

Background: The anatomic pathways of the lateral femoral cutaneous nerve (LFCN) have primarily been reported in adult in vitro populations with limited branching patterns. Children with hip disorders may require surgical treatment with an anterior approach, and the LFCN is a structure at risk. The aim of our study was to photographically verify the initial six-centimeter pathway of the LFCN in children measured from its appearance at the anterior superior iliac spine (ASIS). Method: A total of 31 children underwent pelvic osteotomy, including three bilateral. The nerve was identified and isolated in the subcutaneous layer. Standardized photographs were obtained. Our outcome parameters were type of pelvic exit, branching pattern, distance from the pelvic exit to the ASIS, and nerve thickness and appearance, categorized as straight or curved. Results: 91.3% of nerves passed medially to the ASIS. A total of 74% of the nerves showed a splitting branching pattern, and 9% had a branching pattern of more than four. The mean distance from pelvic exit to the ASIS was 17 mm, and the mean nerve thickness was 2.7 mm. Conclusions: In contrast to adult anatomy, our study shows that the LFCN has two or more branches in 74% of patients. Thus, based on our observations, surgeons should carefully dissect the subcutaneous tissue around the LCFN due to the numerous anatomical variations to avoid iatrogenic damage to the nerve. Full article

Background/Objectives: Medial open wedge high tibial osteotomy (MOWHTO) has led to favorable clinical results since the introduction of locking plates. Surgical indications, techniques, and postoperative alignment are crucial for achieving favorable clinical outcomes. This study analyzed the clinical outcomes of patients after >5 years of post-MOWHTO follow-up to identify the influential factors. Methods: Thirty-nine patients (48 knees) underwent MOWHTO for medial compartment knee osteoarthritis or -necrosis and were followed up for >5 years. The targeted postoperative % mechanical axis (%MA) was 62.5% (Fujisawa point). The Japanese Orthopaedic Association (JOA) Knee Disease Outcome Criteria score; Kellgren–Lawrence classification; hip-knee-ankle, medial proximal tibial, mechanical lateral distal femoral, and joint line convergence angles (JLCA); and %MA were evaluated preoperatively, at implant removal, and at the final follow-up. Total knee arthroplasty (TKA) was the survival endpoint. Uni- and multivariate analyses were performed to identify the factors influencing survival rates. Results: The mean JOA score improved from preoperative to implant removal and was sustained at 102 months. Four of the 48 knees required TKA, resulting in a 10-year survival rate of 82%. Body mass index, preoperative JLCA, and Δ%MA influenced the post-MOWHTO survival rate. The Δ%MA was significantly greater in the group with a %MA < 62.5% at implant removal. Conclusions: MOWHTO with a target %MA of 62.5% yielded favorable long-term outcomes. Additionally, preoperative obesity and high joint instability negatively influenced post-MOWHTO survival. Furthermore, a postoperative %MA of < 62.5% is associated with difficulty maintaining stable alignment and an increased risk of conversion to TKA. Full article

Limb-sparing techniques for appendicular primary bone tumors are still associated with a high rate of complications. Three-dimensional (3D)-printed patient-specific instruments could reduce these complications. The aim of this study is to describe a limb-sparing surgery using 3D-printed patient-specific guides (PSGs) and an endoprosthesis (PSE) to treat femoral chondrosarcoma in a dog. An eight-year-old female Golden Retriever presented with persistent lameness of the right hind limb, reluctance to move and difficulty in maintaining a standing position. Palpation of the right femur revealed an approximately 4 cm painful lesion. Cytological analysis of the needle aspiration supported the clinical and radiological suggestion of a cartilaginous bone neoplasm. Computed tomography (CT) scans suggested the presence of an aggressive lesion on the right distal femur. CT scans of the femur and tibia were then reconstructed using a bone tissue algorithm and processed with computer-aided design (CAD) software, which allowed for performing virtual surgical planning (VSP) and the fabrication of both the PSG and the PSE. Anti-inflammatory drugs and monoclonal antibodies were used for pain management while waiting for surgery. Adjuvant chemotherapy was also administered. An ostectomy of the distal third of the femur to completely remove the tumor was performed with the designed PSG, while the bone defect was filled with the designed PSE. Histopathological examination of the osteotomized bone segment confirmed a grade 2 central chondrosarcoma. There was no excessive tumor growth during the 28 days between the CT scans and surgery. Both PSG and PSE fitted perfectly to the bone surfaces. PSG eliminated the need for intraoperative imaging and ensured a faster and more accurate osteotomy. PSE optimized load sharing and eliminated the complications of the commercial endoprosthesis, such as incongruity and the need for manual intraoperative adjustment. Overall, the use of VSP, 3D-printed PSG and PSE significantly reduced surgical time, risk of infection and intra- and postoperative complications. Full article

Subtrochanteric nonunion is especially challenging. Extramedullary fixation using fixed-angle devices with a closing lateral wedge osteotomy is the standard surgical procedure for restoring the hip’s normal alignment and achieving bone union. However, this procedure is technically demanding and relies on devices that facilitate bone union in a non-dynamic manner, along with the limitations that this type of fixation entails, especially in this highly biomechanically stressed area. This paper aims to describe a novel surgical technique to heal subtrochanteric nonunion based on dynamic fixation performed through an over-valgus correction of the hip and fixed with a dynamic hip screw (DHS). Between March 2022 and July 2023, five patients diagnosed with nonunion of a subtrochanteric fracture were operated on by a single surgeon and followed prospectively. The average age of the patients was 64 (range: 34–85). The mean duration of surgery was 112 min (range: 63–153). The femoral neck angle before surgery was 120° (range: 110°–122°) and 147° (range: 142°–150°) after surgery. The mean leg length increased by 8 mm (range: 6–12). The Harris hip score improved from 38 points (range: 30–44) to 90 points (range: 88–96), corresponding to excellent or good results. All patients healed without major complications and were asymptomatic after 12 months of follow-up. In conclusion, over-valgus correction using a DHS is a novel technique that seems helpful for subtrochanteric nonunion. It allows for dynamic fixation, offering the advantages of dynamic fixation, especially in this high-stress area. It is also performed without osteotomy, making it a less demanding technique than the current methods described. Full article

Introduction: Popliteal cysts (PCs) are occasionally accompanied by knee osteoarthritis (OA) and varus malalignment. However, whether concomitant arthroscopic excision of PCs with medial open-wedge high tibial osteotomy (MOWHTO) improves the osteoarthritic environment remains unclear. Therefore, this study assessed serial changes in C-size, medial meniscus extrusion (MME), and cartilage status for up to 2 years following an MOWHTO. Methods: This study retrospectively used serial magnetic resonance imaging (MRI) evaluations to assess 26 consecutive patients who underwent MOWHTO. Of the 26 patients, six with preoperative PCs were included. Based on the arthroscopic findings at the time of the MOWHTO, concomitant meniscal and chondral lesions, and whether or not partial meniscectomy was performed, were evaluated. All patients underwent second-look arthroscopy with plate removal 2 years postoperatively. The PC size, MME, and cartilage sub-scores in the medial compartment of the whole-organ MRI score (WORMS) were assessed by serial MRI preoperatively and at 3, 6, 18, and 24 months postoperatively. The recurrence of PCs and clinical outcomes, including the Rauschning–Lindgren grade, were also evaluated when serial MRI was performed. Moreover, changes in cartilage status were assessed using two-stage arthroscopy. Results: All patients underwent concomitant partial meniscectomy for medial meniscal tears in the posterior horn. A significant decrease in the mean size of preoperative PCs (27.4 ± 22.3 mm) was noted from 3 months postoperatively (8.7 ± 7.6 mm, p = 0.018), and thereafter. The mean size of PCs further decreased with time until 2 years (1.5 ± 4.0 mm, p = 0.018) following an MOWHTO with partial meniscectomy. Moreover, significant improvements in the MME and WORMS values were noted from 3 to 24 months postoperatively. Meanwhile, no PC recurrence occurred during the follow-up period and the preoperative Rauschning–Lindgren grade improved significantly with time after MOWHTO (p = 0.026). Furthermore, the two-stage arthroscopic assessments showed significant improvements in ICRS grade in the medial femoral condyle (p = 0.038). Conclusions: After an MOWHTO with partial meniscectomy, PCs decreased with time up to 2 years postoperatively; no recurrence occurred during the follow-up period, although cyst excision was not concomitantly performed. Furthermore, the reduction in PCs corresponded with improvements in MME and chondral lesions in the knee joint following the MOWHTO. Full article

Background/Objectives: The aim of the study is to present middle-term results of tailored bone and soft-tissue surgeries in subluxated and dislocated hips in children affected by cerebral palsy. Methods: A total of 87 medical records belonging to 73 children affected by CP, treated with combined soft-tissue releases, VDO, and pelvic osteotomy, were reviewed retrospectively. Radiological measurements of AI, RI, and NSA were obtained before surgery, postoperatively, at 12 and 24 months after surgery. Results were assessed globally and by GMFCS, age, and Robin score. Results: Postoperative results are not statistically influenced by age and GMFCS levels at surgery. All three radiographic parameters showed persistent statistically significant improvement after surgery and at follow-up, respectively. Conclusions: Obtaining the best possible concentric reduction of the femoral head in the acetabulum, with simultaneous multilevel soft-tissue rebalancing, creates the best mechanical and biological environment to allow the reshaping of both articular surfaces, obtaining physiological internal joint pressure. The anatomical best congruency is protective from recurrence. Full article

Background and Objectives: The study aimed to evaluate a newly designed semicircular implant for the fixation of Vancouver Type B1 periprosthetic femoral fractures (PFFs) in total hip arthroplasty (THA) patients. To determine its strength and clinical applicability, the new implant was compared biomechanically with conventional fixation methods, such as lateral locking plate fixation and a plate combined with cerclage wires. Materials and Methods: Fifteen synthetic femur models were used in this biomechanical study. A Vancouver Type B1 periprosthetic fracture was simulated by osteotomy 5 mm distal to the femoral stem. The models were divided into three groups: Group I (lateral locking plate fixation), Group II (lateral locking plate with cerclage wires), and Group III (new semicircular implant system). All fixation methods were subjected to axial loading, lateral bending, and torsional force testing using an MTS biomechanical testing device. Failure load and displacement were measured to assess stability. Results: The semicircular implant (Group III) demonstrated a significantly higher failure load (778.8 ± 74.089 N) compared to the lateral plate (Group I: 467 ± 68.165 N) and plate with cerclage wires (Group II: 652.4 ± 65.474 N; p < 0.001). The new implant also exhibited superior stability under axial, lateral bending, and torsional forces. The failure load for Group III was more robust, with fractures occurring at the screw level rather than plate or screw detachment. Conclusions: Compared to traditional fixation methods, the newly designed semicircular implant demonstrated superior biomechanical performance in stabilizing Vancouver Type B1 periprosthetic femoral fractures. It withstood higher physiological loads, offered better structural stability, and could be an alternative to existing fixation systems in clinical practice. Further studies, including cadaveric and in vivo trials, are recommended to confirm these results and assess the long-term clinical outcomes. Full article

Background/Objectives: Legg–Calvé–Perthes disease (LCPD) presents challenges in treatment due to its varied course and unclear etiology. This study aimed to evaluate the efficacy of combining proximal femoral varus osteotomy (PFVO) with a modified trochanteric flip osteotomy to address biomechanical consequences and improve hip abductor muscle strength. Methods: We present a modified approach combining PFVO with a trochanteric flip osteotomy. In this technique, the greater trochanter in compound with its muscular insertions is separated from the femur and attached distally using a varization blade plate. Nine patients (ten hips, mean age 8 years) with LCPD were treated using this technique. Clinical examination findings and radiographic evaluations were retrospectively analyzed. The median follow-up was 33 months. Results: At the last follow-up, two patients exhibited Trendelenburg gait, but hip abduction was improved in all patients. Radiographically, consolidation at the osteotomy site was observed in all cases with no delayed union or non-union. The median CE angle improved by 7°, while the median CCD decreased by 18°. The median MPFA decreased by 13°, resulting in a median of 82°. Conclusions: Combining PFVO with a modified trochanteric flip osteotomy addresses biomechanical issues associated with PFVO, potentially improving hip containment and abductor muscle strength. This approach may offer advantages over traditional osteotomy techniques in treating LCPD, and it appears to produce a superior functional outcome in particular in regard to limping when compared to conventional PFVO. Despite satisfactory radiological outcomes in most cases, further research is needed to assess long-term effectiveness and address challenges such as femoral head enlargement and persistent gait abnormalities. Full article

Background: Femoral neck fractures are rare but serious injuries in children and adolescents, often resulting from high-energy trauma and prone to complications like avascular necrosis (AVN) and nonunion. Even rarer is the development of slipped capital femoral epiphysis (SCFE) following femoral neck fracture, which presents unique diagnostic and treatment challenges. SCFE can destabilize the femoral head, with severe cases requiring complex surgical interventions. Case presentation: This report details a case of a 15-year-old male with autism spectrum disorder (ASD) who developed severe SCFE one month after treatment for a Delbet type III femoral neck fracture. The condition was managed with an Imhäuser intertrochanteric osteotomy (ITO), in situ fixation (ISF), and osteochondroplasty (OChP), supported by virtual surgical planning (VSP) and 3D-printed patient-specific instruments (PSIs) for precise correction and fixation. Discussion: The surgery was completed without complications. Six months after the operation, the patient exhibited a pain-free, mobile hip with radiographic evidence of fracture healing and no signs of AVN. Functional outcomes were favorable despite rehabilitation challenges due to ASD. Conclusions: The Imhäuser ITO, combined with ISF and OChP, effectively addressed severe SCFE after femoral neck fracture, minimizing AVN risk. VSP and PSIs enhanced surgical accuracy and efficiency, demonstrating their value in treating rare and complex pediatric orthopedic conditions. Full article

Background/Objectives: The redirection or reshaping of the acetabulum might be warranted to attain a concentric and stable hip in children with developmental dysplasia of the hip (DDH). The aim of this study is to assess the late clinical and radiological results, and to determine the number of patients requiring secondary surgery or a total hip arthroplasty at a long-term follow-up. Methods: Our institution performed 99 Salter osteotomies on 76 patients without underlying neuromuscular conditions over a 21-year period, from 1981 to 2002. These procedures were carried out by three different surgeons. Patients underwent a comprehensive evaluation at the review visit, including a physical examination, clinical assessments using the Harris hip score (HHS), Oxford score (OHS) and Visual Analogue Scale (VAS) pain score, as well as pelvic radiographs. Results: At a median follow-up of 22 years, total hip arthroplasty was performed in 6 out of 77 hips (8%). Patients who underwent a Salter osteotomy with an open reduction had a higher rate of avascular necrosis (AVN) of the femoral head compared to those who only underwent a Salter pelvic osteotomy (p < 0.001). There were statistically significant differences in the group with and without AVN in terms of HHS (p = 0.006, 95%CI 0.003 to 0.006), OHS (p = 0.016, 95%CI 0.012 to 0.017), a modified OHS (p = 0.018, 95% CI 0.012 to 0.016), a VAS score in activity (p = 0.046, 95%CI 0.042 to 0.050) and VAS score satisfaction (p = 0.005, 95%CI 0.003 to 0.006). Conclusions: The rate of THA was 8% at a mean of follow-up of 22 years. Secondary results suggest that AVN occurs more frequently when a Salter osteotomy is combined with an open reduction. The occurrence of AVN is associated with significantly lower clinical outcome scores and patient satisfaction, as well as significantly higher pain scores. In the absence of AVN, good clinical results can be expected at long-term follow-up. Full article

Background: Femoral torsional malalignment is a common cause of in-toeing and out-toeing in children, often leading to gait disturbances, functional limitations, and increased risk of falls. Traditionally, osteotomy was the only surgical option for correction. A minimally invasive technique known as rotational guided growth (RGG) has recently been introduced to address these malalignments. This study aims to assess the effectiveness of rotational femoral malalignment correction by rotational epiphysiodesis with tension band 8-plates (Orthofix, Verona, Italy). Methods: Eleven patients with in-toeing and out-toeing (19 femurs) were treated using RGG with 8-plates. The 8-plates were applied laterally and medially, with screws placed above and below the growth plate of the distal femur, angled obliquely to the long axis of the bone in opposite directions. Changes in foot progression angle (FPA), femoral version, the alteration in the angle between the 8-plates, and the rate of correction were recorded. Results: All patients reported functional gait improvement. The FPA was corrected from a mean of 32 degrees to 7 degrees, the femoral version improved from a mean of 60 degrees to 22 degrees. The angle between the 8-plates changed from a mean of 75 degrees to 28 degrees, with a correction rate of 4.1 degrees per month. The average time for correction was 11 months. No complications were observed during the treatment. Conclusions: RGG using 8-plates is a novel, minimally invasive surgical technique that effectively corrects rotational femoral deformities and may serve as a preferred alternative to derotational osteotomy in growing patients. Full article

Background: Fibrous dysplasia (FD) is a rare condition in which normal spongy and cortical bone is replaced by non-neoplastic fibrous tissue, leading to weakened bone matrix and increased risk of pathological fractures and deformities. Treating these deformities poses a significant challenge for surgeons. While various cases of surgical stabilization and limb lengthening using intramedullary nails have been reported, there is limited evidence on the use of Motorized Intramedullary Limb-Lengthening Nails (MILLNs) in FD patients. This case report presents the clinical history of a patient with FD who underwent multiple surgical interventions to address severe lower limb length discrepancy (LLD) and angular deformity caused by multiple fractures. Case presentation: A sixteen-year-old Caucasian girl with polyostotic FD developed a severe post-traumatic LLD of 10 cm on the right side, associated with coxa vara, valgus knee, and patellar instability. The deformity of the proximal femur was addressed with a valgus and derotational femoral osteotomy. However, this procedure exacerbated the knee’s valgus deformity and only partially corrected the LLD, leading to the decision to proceed with femoral lengthening. A retrograde magnetic intramedullary nail (PRECICE, NuVasive) was utilized for this purpose. Approximately three months postoperatively, radiographs revealed the loosening of the proximal anchoring screw, while the nail had reached maximum distraction. We then proposed reactivating the previously implanted nail. Nine months after the final surgery, standing long-leg radiographs showed a residual shortening of 1 cm, with excellent healing at the fracture sites and the nail and screws remaining securely in place. The patient was monitored regularly, with the latest follow-up occurring four years and five months after the conclusion of the last lengthening procedure. Conclusions: This case report describes the reactivation of a MILLN in a patient with polyostotic fibrous dysplasia. While nail reactivation has been previously described in the literature, to our knowledge, it has not been reported for treating complications arising from FD. In cases of mechanical complications, this approach can equalize leg length discrepancies and correct deformities, avoiding additional invasive surgeries and reducing healthcare costs. As this is an off-label treatment, preoperative consent from both the patient and the parents is required. Full article