Hinterwimmer, Stefan; Beitzel, Knut; Paul, Jochen; Kirchhoff, Chlodwig; Sauerschnig, Martin; von Eisenhart-Rothe, Rüdiger; Imhoff, Andreas B
Valgus-producing open-wedge high tibial osteotomy is an established treatment for varus malalignment and medial osteoarthritis, with reproducible results in the frontal plane. However, an undesirable but often accepted increase in posterior tibial slope and decrease in patellar height are still routinely seen. To evaluate the influence of valgus open-wedge high tibial osteotomy on posterior tibial slope and patellar height when special techniques are used to minimize unwanted changes. Case series; Level of evidence, 4. Twenty-five patients, 3 women and 22 men (mean age, 40.2 years), underwent valgus open-wedge high tibial osteotomy. Several technical steps were taken to prevent an increase in posterior tibial slope during the osteotomy. To minimize patellar height changes, the tibial tuberosity was left on either the proximal or distal fragment, depending on the desired patellofemoral effect. The medial and lateral posterior slope was measured using the proximal posterior cortex as a reference; the patellar height was assessed with the Caton-Deschamps Index and compared on preoperative and postoperative radiographs. No significant posterior tibial slope changes were observed. Patellar height increased with both types of tibial tuberosity osteotomy. With the proximal osteotomy, the Caton-Deschamps Index increased from 0.95 to 0.97; with the distal osteotomy, it increased from 0.89 to 0.95. The change was not significant with either osteotomy. The posterior tibial slope did not change on the medial side, measuring 4.2 preoperatively and postoperatively. The lateral slope decreased from 5.4 to 5.1. There was no correlation between the correction in the coronal plane and the changes in the sagittal plane. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. Analysis and control of sagittal changes in valgus open-wedge high
Sylvester, Adam D
Although the hominid knee has been heavily scrutinized, shape variation of the medial tibial condyle has yet to be described. Humans, chimpanzees, and gorillas differ in the shape of their medial femoral condyles and in their capacity for external and internal rotation of the tibia relative to the femur. I hypothesize that these differences should be reflected in the shape of the medial tibial condyle of these hominids. Here I use geometric morphometric techniques to uncover shape differences between the medial tibial condyles of humans, chimpanzees, and gorillas. Humans are distinguished from the other two species by having a much more oval-shaped medial tibial condyle, while those of chimpanzees and gorillas are more triangular in outline. Gorillas (especially males) are distinguished by having more concavely-curved condyles (mediolateral direction), which is interpreted as an effect of heavy loading through the medial compartment of the knee in conjunction with differences in the degree of arboreality. Copyright © 2013 Wiley Periodicals, Inc.
Park, Hoon; Ryu, Keun Jung; Kim, Hyun Woo; Hwang, Jin Ho; Han, Joon Woo; Lee, Dong Hoon
During tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone. The purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique. Between June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26-71 months). The mean age of the patients was 25 years (range, 18-40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient's BMI. During the period studied, the blocking screw was to maintain the
Cinotti, G; Sessa, P; Ripani, F R; Postacchini, R; Masciangelo, R; Giannicola, G
The aim of this study was to address, in normal knees, the variability of posterior offset of femoral condyles and tibial slope, and the presence of any correlation between the two that might be needed to achieve an adequate joint motion in flexion. Magnetic resonance images of normal knees of 80 subjects, 45 males and 35 females, with a mean age of 38.9 years, were analysed. Measurements were performed by two independent observers using an imaging visualization software. The tibial slope averaged 8 and 7.7 °, on the medial and lateral sides, respectively (P = 0.2); the mean posterior offset of femoral condyles was 27.4 and 25.2 mm on the two sides, respectively (P = 0.0001). The variation coefficient of the condylar offset and tibial slope was 11.5 and 38%, respectively. In the medial compartment, a significant correlation was found between the femoral condylar offset and the tibial slope, while the same was not observed in the lateral compartment of the knee. Magnetic resonance imaging allows the assessment of tibial slope and femoral condylar offset in the medial and lateral side separately, taking into account any difference between the two compartments. The sagittal tibial slope exhibits a greater variability compared with the posterior offset of femoral condyles. The correlation found, in the medial compartment, between the tibial slope and femoral condylar offset suggests that the reconstitution of the proper morphology of the posterior part of the knee joint may be necessary to obtain a full range of motion in flexion after total knee replacement.
Cinotti, G; Sessa, P; Ripani, F R; Postacchini, R; Masciangelo, R; Giannicola, G
The aim of this study was to address, in normal knees, the variability of posterior offset of femoral condyles and tibial slope, and the presence of any correlation between the two that might be needed to achieve an adequate joint motion in flexion. Magnetic resonance images of normal knees of 80 subjects, 45 males and 35 females, with a mean age of 38.9 years, were analysed. Measurements were performed by two independent observers using an imaging visualization software. The tibial slope averaged 8 and 7.7 °, on the medial and lateral sides, respectively (P = 0.2); the mean posterior offset of femoral condyles was 27.4 and 25.2 mm on the two sides, respectively (P = 0.0001). The variation coefficient of the condylar offset and tibial slope was 11.5 and 38%, respectively. In the medial compartment, a significant correlation was found between the femoral condylar offset and the tibial slope, while the same was not observed in the lateral compartment of the knee. Magnetic resonance imaging allows the assessment of tibial slope and femoral condylar offset in the medial and lateral side separately, taking into account any difference between the two compartments. The sagittal tibial slope exhibits a greater variability compared with the posterior offset of femoral condyles. The correlation found, in the medial compartment, between the tibial slope and femoral condylar offset suggests that the reconstitution of the proper morphology of the posterior part of the knee joint may be necessary to obtain a full range of motion in flexion after total knee replacement. PMID:22946518
Bonilla, Alvaro G; Bertone, Alicia L; Brokken, Matthew T; Santschi, Elizabeth M
CASE DESCRIPTION 4 horses were examined because of signs of chronic hind limb lameness. CLINICAL FINDINGS 3 horses had a history of lameness for > 6 months; specific duration was unknown for 1 horse. On initial evaluation, grade 3 to 4 (on a scale from 1 to 5) hind limb lameness was present in all 4 horses. Radiography of the stifle joint of the affected limb revealed medial femoral condyle subchondral lucencies or subchondral cystic lesions (SCLs) in all 4 horses, medial femorotibial osteoarthritis in 3 horses, and medial tibial condyle SCLs in 3 horses. TREATMENT AND OUTCOME 2 horses were treated medically (stall rest and oral NSAID administration), and 2 horses were treated surgically by means of medial femoral transcondylar lag screw placement through the medial femoral condyle SCLs. The 2 horses treated medically did not improve and were euthanized. Necropsy confirmed the presence of medial femoral condyle and medial tibial condyle SCLs. Surgical treatment did not resolve the lameness in 1 horse with SCLs in the medial tibial condyle and medial femoral condyle, and euthanasia was performed 150 days after surgery. In the second horse, a medial tibial condyle SCL was evident on radiographs obtained 3 months after surgery; however, this was not addressed surgically, and signs of lameness resolved 11 months after surgery. CLINICAL RELEVANCE Results of this small case series suggested that SCLs in the medial tibial condyle can occur in association with SCLs of the medial femoral condyle, with a poor prognosis for return to athletic function in affected horses. Further investigation is indicated.
Domzalski, Marcin; Mackenzie, William
Two cases of asymmetrical closure of the proximal tibial epiphysis without a clear aetiological factor were presented. In both cases premature closure of the growth plate resulted in progressive recurvatum and valgus deformity of the knee with leg length discrepancy. The correction of deformity was obtained using Taylor Spatial frame with excellent results at 2 years follow-up. We hypothesize that repetitive trauma or chronic overloading during sports activities might be a factor of growth arrest in reported cases. Orthopedic surgeons should be aware of the possibility of subtle physeal injuries, causing angular deformities, in the cases of even minor knee trauma in skeletally immature population.
Baillon, B; Salvia, P; Feipel, V; Rooze, M
Analysis of the correction or over-correction of high valgus and varus tibial osteotomies is generally limited to the frontal plane. Most likely however, the deformation observed radiographically in the frontal plane is simply a one-dimensional expression of a more complex three-dimensional deformation. This might be one of the causes for certain failures after surgery and recurrent problems which are difficult to solve. We proposed using 3D electrogoniometric to measure of the effect of a "dome" osteotomy on patellar and femoro-tibial kinematics and the changes in the moment arms of the knee muscles. We used five lower limbs harvested from non-fixed cadavers. A "dome" osteotomy was stabilized by external fixation. Three-dimensional analysis of the femoro-tibial and femoro-patellar kinematics was performed using two electrogoniometers with six degrees of freedom. Changes in the lengths of the hamstrings and quadriceps was measured using four LVDT linear variable differential transformers. The muscles lever arms were measured with the tendon excursion method. At 90 degrees flexion, varus osteotomy induced internal rotation while valgus osteotomy induced the opposite effect. Beyond 40 degrees flexion, there was a clear internal rotation of the patella for varus and neutral corrections. Valgus corrections however induced external rotation. The peak lever arm of the quadriceps increased with valgus, while the angle of the peak was higher for varus correction. Valgus appeared to increase the lever arm of the semitendinous. Our study demonstrated that the effect of tibial osteotomy is not limited to the frontal plane. Tibial rotations are observed systematically for all corrections in the frontal plane. Varus correction tends to create internal rotation while valgus correction tends to have the opposite effect. Axial correction also affects patellar kinematics. Interanal rotation is induced by varus correction and external rotation by valgus correction. This patellar
Jung, Kwang Am; Lee, Su Chan; Hwang, Seung Hyun; Kim, Duk Su; Kim, Taek Keun
Spontaneous osteonecrosis of the knee (SPONK) usually involves a single condyle or plateau. The medial femoral condyle (MFC) is most often involved and spontaneous osteonecrosis of the medial tibial plateau (MTP) is a rare condition, representing only 2% of all necroses reported in the knee. SPONK involving both the MFC and the MTP is extremely rare. SPONK occurring in either the MFC or the MTP individually might extend to the corresponding side of the knee in the advanced end-stage; however, in that situation, significant degenerative changes would exist and it might be difficult to differentiate end-stage SPONK form severe osteoarthritis. SPONK affecting both the MFC and the MTP without significant secondary osteoarthritic changes has not been reported, even though it is difficult to know which occurs first. We have cared for three patients with histologically proven osteonecrosis of the MFC and MTP and report their radiologic features.
Lesiak, Alex C; Esposito, Paul W
The fibula is an important stabilizer of the lateral ankle. Discontinuity of the fibular shaft can lead to progressive pain and shortening of the fibula, ultimately causing loss of lateral support to the ankle. Two children, who sustained segmental bone loss of the shaft of the fibula, developed progressive symptomatic valgus of the ankle with widening of the mortice and lateral subluxation of the talus. Both patients were treated with fibular plating and grafting with tricalcium sulfate with acute reconstitution of fibular length. Distal medial tibial hemiepiphysiodesis was simultaneously performed. One patient required revision plating and grafting 14 months after the index surgery because of plate failure. The valgus angulation and the widened medial mortice were corrected in the ankles of both patients, who returned to full activities. The patients were followed to maturity; the correction has been maintained, and they remain asymptomatic. The technique used in these cases can correct valgus angulation secondary to loss of fibular congruity rather than only halting progression of the deformity.
Fujita, Shinya; Arai, Yuji; Honjo, Kuniaki; Nakagawa, Shuji; Kubo, Toshikazu
Spontaneous osteonecrosis of the knee (SPONK) usually involves a single condyle, most often the medial femoral condyle (MFC). Involvement of the medial tibial plateau (MTP) is less common, occurring in about 2% of knees with SPONK. Early onset SPONK on the ipsilateral side of the medial compartment is very rare, with, to our knowledge, only four cases reported to date. We describe a very rare case of SPONK with early simultaneous development in the MFC and MTP. Serial plain radiographs and magnetic resonance imaging showed that SPONK in both condyles followed a similar progressive course. The pathological findings in these lesions were similar to those observed in subchondral insufficiency fractures. PMID:27242941
Fujita, Shinya; Arai, Yuji; Honjo, Kuniaki; Nakagawa, Shuji; Kubo, Toshikazu
Spontaneous osteonecrosis of the knee (SPONK) usually involves a single condyle, most often the medial femoral condyle (MFC). Involvement of the medial tibial plateau (MTP) is less common, occurring in about 2% of knees with SPONK. Early onset SPONK on the ipsilateral side of the medial compartment is very rare, with, to our knowledge, only four cases reported to date. We describe a very rare case of SPONK with early simultaneous development in the MFC and MTP. Serial plain radiographs and magnetic resonance imaging showed that SPONK in both condyles followed a similar progressive course. The pathological findings in these lesions were similar to those observed in subchondral insufficiency fractures.
Katsuragawa, Y; Fukui, N; Nakamura, K
We assessed the clinical knee score and bone mineral density of the proximal tibia in an attempt to evaluate the efficacy of valgus knee bracing. The knee score improved after 3 months, and increases in bone mineral density were seen more in the lateral tibial condyle than in the medial. These results suggest that the brace acts by transferring the forces across the knee joint from the medial to the lateral side.
Kaewpornsawan, Kamolporn; Tangsataporn, Suksan; Jatunarapit, Ratiporn
To find the effectiveness of the early surgery (2-3 years of age)as a very important prognostic factor affecting the outcomes in Thai children with infantile tibia vara and all the prognostic factors including the usefulness of arthrographic study in correcting the deformity. From 1994 to 2004, sixteen children aged average 3.61 years old (2.08-7.0) were treated in Siriraj Hospital and diagnosed as infantile tibia vara by Langenskiold radiographic staging were included in the present study and retrospectively reviewed with an average of 6.4 years follow up (range 6 month - 11.1 years). All cases were initially treated by surgery because of low compliance for brace or brace failure. They consisted of 3 boys and 13 girls. There were 24 legs including the bilateral involvement in 8 cases (2 boy and 6 girls). After arihrography, the midshaft fibular osteotomy was performed then the proximal tibial dome-shaped valgus osteotomy was done and fixed with 2 pins. The desired position was 12 degree knee valgus . The patients were divided in two groups, 1)group A,the successful group with the knee becoming normal without any deformity after single osteotomy, 2)group B,the recurrent group with recurrence of the varus deformity required further corrective osteotomies to make normal axis of the knee. All variables were analyzed and compared between group A and group B. The general characteristics and radiographic findings were recorded in 1)age, 2)sex, 3)side, 4)weight in kilogram and in percentage of normal or overweight(obesity) compared with the standard Thai weight chart, 5)tibiofemoral angle (TFA) pre and postoperative treatment, 6) metaphyseal diaphyseal angle (MDA), 7)the medial physeal slope angle (MPS, 8)The preoperative arthrographic articulo-diaphyseal angle (ADA), 9.arthrographic articulo-medial physeal angle (AMPA). There were 14 legs in group A and the remaining 10 legs were in group B (average 2.4 operations). All cases healed in good alignment of the legs without
González Maza, Carlos; Moscoso López, Luis; Magaña García, Ignacio; Mejía Vargas, Gildardo; López Segundo, José Román
The purpose of the present study is to report sixty six high tibial lateral osteotomies (HTO) make on patients with osteoarthrosis of the medial compartment, using modified semi invasive technique. With this technique the incision is 5-6 mm, fibular head is not resect, biceps femoris tendon is not cut, no internal fixation is place; the median follow-up was 6.4 years. The status of the patient at the final follow-up was analyzed using Knee Society Score (KSS), and Visual Analogue Scale (VAS). An average of 85 points was achieved after HTO compared to 55 points preoperative and 83 points after HTO compared to 51 points preoperative, was obtained at the evaluation with KSS. The only complication was superficial infections (4%). Serious complications did not appear. There was not pseudoarthrosis.
Toksvig-Larsen, S; Ryd, L
A methodologic study with which the cut surface could be quantified was performed on cadaveric tibial bone prepared for endoprosthetic components. Using sterilized, dental-imprint material and measuring with a Zeiss UMC 850, the characteristics of the cut surface were defined. A clinically flat surface was found to be uneven, with a maximum roughness between the uppermost and lowermost points of 1.0 and 2.4 mm for the bone surface and between 1.2 and 2.3 mm for the imprint. The flatness, defined as the standard deviation of the measuring points, was between 0.15 and 0.40 mm for the bone and 0.20 and 0.42 mm for the imprint. This lack of flatness creates gaps between the prosthesis and the bone.
Boss, A; Stutz, G; Oursin, C; Gächter, A
We assessed the patients who were operated on in a combined procedure from 1980 to 1992 with anterior cruciate ligament (ACL) insufficiency, cartilaginous lesions of the medial compartment, lesion of medial meniscus and varus malalignment. The combined operative procedure was autologous intra-articular ACL reconstruction with the middle third of the patellar ligament--partially augmented with Kennedy-ligament augmentation device (LAD) in hot dog technique--and high tibial osteotomy. The patients were examined according to the criteria of IKDC including testing of anterior stability with the KT-1000 arthrometer. Radiographically we checked axis and arthritis according to a modified score of Kannus. Twenty-seven of 34 patients who fulfilled the inclusion criteria could be followed up in three categories (2-5 years post-operatively, 5-10 years postoperatively, over 10 years post-operatively). Total qualification was good in 37%; there were no perioperative complications. Rehabilitation was not prolonged. Eighty-nine percent practised their preoperative job, over 50% had a higher level of sports activities than preoperatively, and more than 25% regained their pretraumatic sports capacity. Two-thirds had no giving way and less than 3 mm translation difference in comparison to the contralateral knee. Seventy-five percent of patients would accept the operation again. Radiological findings had no correlation to overall qualification. The encouraging results with respect to many of the criteria suggest using the combined procedure in a young patient with ACL insufficiency, varus malalignment and medial compartment damage including medial meniscus lesion.
Bové, J C
The aim of this work was to study the behavior of an inert porous alumina ceramic spacer used with a plate fixation for open-wedge tibial valgus osteotomy in patients with osteoarthritis of the knee and genu varum. The population included 50 patients who underwent surgery between October 1994 and December 2000. There were 31 women and 19 men, mean age 55 years at surgery (26 right knees and 24 left knees). Patients were reviewed at 3 weeks, 6 weeks, 3 months, 6 months, and one year, then every 2 years. Clinical and radiological data were available for all patients. Mean follow-up was 16 months. Two patients were lost to follow-up at 5 and 6 months. The results of the open-wedge tibial osteotomy were in agreement with the usual outcome reported in the literature concerning pain relief, functional recovery, joint motion, angle correction, and good preservation of the clinical and radiological result. Three fracture lines were observed on the lateral tibial plateau but did not affect final outcome or angle correction. There was however one case with loss of correction due to fracture of the screws. Radiographically, at 6 months, there were 9 thin lucent lines around the spacer (24%) which did not affect final outcome. Bone healing was achieved at 3 months on the average in all cases except 2 (4%) where healing was achieved at 8 and 13 months. The porous alumine spacer is a reliable biocompatible and mechanically stable element helpful for achieving bone healing. Integration into bone tissue was radiographically satisfactory. There were no specific complications related to use of the spacer.
Cotic, Matthias; Vogt, Stephan; Hinterwimmer, Stefan; Feucht, Matthias J; Slotta-Huspenina, Julia; Schuster, Tibor; Imhoff, Andreas B
The first purpose of this study was to compare the clinical and radiographic outcome of two different locking plates used for valgus-producing medial open-wedge high tibial osteotomy (HTO). The second purpose was to histologically evaluate peek-carbon wear for biocompatibility. Twenty-six consecutive patients undergoing open-wedge HTO using the first-generation PEEKPower HTO-Plate® (Group I) were matched with 26 patients after open-wedge HTO with the TomoFix™ plate (Group II). Clinical scores (visual analogue scale for pain, WOMAC, Lysholm score) were obtained preoperatively and at a minimum follow-up of 24 months postoperatively. Fixation stability was evaluated radiographically by comparing the medial proximal tibial angle (MPTA) and tibial slope 2 days after open-wedge HTO and after implant removal. Tissue samples of Group I were collected at the time of implant removal for histologic evaluation. Implant-related complications occurred in 15 % (n = 4) of Group I and 0 % of Group II. Out of them, 3 implant replacements were excluded from statistical analyses. After a final median follow-up of 25 months (range 24-31), the clinical scores in both groups showed significant improvements compared to preoperatively (visual analogue scale, WOMAC, Lysholm score; p < 0.001), without significant group differences (visual analogue scale, n.s.; WOMAC, n.s.; Lysholm score, n.s.). No significant differences between baseline and follow-up measurements for MPTA and tibial slope were observed within each group (MPTA: Gr. I, n.s.; Gr. II, n.s.; tibial slope: Gr. I, n.s.; Gr. II, n.s.) or between the two groups (MPTA, n.s.; tibial slope, n.s.). In histologic samples, CF PEEK abrasion did not induce inflammation or tissue necrosis. The first-generation PEEKPower HTO-Plate® provided a higher rate of implant-related complications compared to the TomoFix™ plate at a minimum follow-up of 24 months after valgus-producing open-wedge HTO. Therefore, it is not recommended to use the
Kiapour, Ata M.; Kiapour, Ali; Goel, Vijay K.; Quatman, Carmen E.; Wordeman, Samuel C.; Hewett, Timothy E.; Demetropoulos, Contantine K.
Despite general agreement on the effects of knee valgus and internal tibial rotation on anterior cruciate (ACL) loading, compelling debate persists on the interrelationship between these rotations and how they contribute to the multi-planar ACL injury mechanism. This study investigates coupling between knee valgus and internal tibial rotation and their effects on ACL strain as a quantifiable measure of injury risk. Nineteen instrumented cadaveric legs were imaged and tested under a range of knee valgus and internal tibial torques. Posterior tibial slope and the medial tibial depth, along with changes in tibiofemoral kinematics and ACL strain, were quantified. Valgus torque significantly increased knee valgus rotation and ACL strain (p<0.02), yet generated minimal coupled internal tibial rotation (p=0.537). Applied internal tibial torque significantly increased internal tibial rotation and ACL strain and generated significant coupled knee valgus rotation (p<0.001 for all comparisons). Similar knee valgus rotations (7.3° vs 7.4°) and ACL strain levels (4.4% vs 4.9%) were observed under 50 N-m of valgus and 20 N-m of internal tibial torques, respectively. Coupled knee valgus rotation under 20 N-m of internal tibial torque was significantly correlated with internal tibial rotation, lateral and medial tibial slopes, and medial tibial depth (R2>0.30; p<0.020). These findings demonstrate uni-directional coupling between knee valgus and internal tibial rotation in a cadaveric model. Although both knee valgus and internal tibial torques contribute to increased ACL strain, knee valgus rotation has the ultimate impact on ACL strain regardless of loading mode. PMID:26070647
Koudela, K; Koudela, K; Koudelová, J
The authors present the results of total knee replacement in a 66-year-old woman with achondroplasia. The condition was diagnosed on the basis of clinical and radiographic findings; molecular genetic examination confirmed that the patient was heterozygous for the G1138A mutation responsible for substitution of an arginine for a glycine residue at position 380 (G380R). The patient presented with an unusual finding of severe fixed 20-degree valgus deformity, so far not published, which did not conform with the clinical features of achondroplasia. The authors presumed that the deformity had developed due to asymmetric growth of the distal femoral diaphysis resulting in a hypoplastic lateral femoral condyle and, consequently, valgus deformity. They put emphasis on thorough pre-operative radiography in order to define the size of components according to the templates, and on measurement of the valgus angle and femoral mechanical axis. They also drew attention to the problem of an extra-articular tibial alignment guide and recommended the use of its alternative or computer navigation. The surgery restored the mechanical axis, range of motion and stability of the knee, relieved pain and improved walking, which afforded a better quality of life for the patient.
Hecht, Paul J; Lin, Timothy J
Hallux valgus is a common foot problem whose cause and progression is multifactorial, complex, and poorly known. Hallux valgus shows a predilection toward women. It is a progressive disorder with no treatment known to slow or stop progression. Surgery is indicated in healthy individuals when nonoperative measures fail. Adverse effects of surgery include infection and recurrence. Many procedures have been described, including soft tissue and bony reconstruction of the first ray. The procedure that is indicated depends on the severity of the deformity. Published by Elsevier Inc.
Schopler, S A; Menelaus, M B
A previously undescribed anomaly of the distal femur occurred in a 3-month-old child with arthrogryposis multiplex congenita. There was a large boss of bone superior and posterior to the true lateral femoral condyle with which the lateral tibial femoral condyle articulated. To obtain full extension of the knee, it was necessary to perform a full posterior release and to replace the tibial condyle distally onto the true lateral condyle. The etiology of the anomaly remains conjectural, but the lesion should be sought for in patients with resistant flexion contracture requiring surgical release.
Stijak, Lazar; Blagojević, Zoran; Kadija, Marko; Stanković, Gordana; Djulejić, Vuk; Milovanović, Darko; Filipović, Branislav
Posterior tibial slope is one of the most citated factors wich cause rupture of the anterior cruciate ligament (ACL). The aim of this study was to determine the association of a greather posterior tibial slope on the lateral condyle, that is a lesser posterior tibial slope on the medial condyle, with ACL rupture. The patients were divided into two groups. The study group included the patients with chronic instability of the knee besause of a previous rupture of ACL. The control group included the patients with knee lesion, but without ACL rupture. Posterior tibial slope measuring was performed by sagittal MR slices supported by lateral radiograph of the knee. We measured posterior tibial slope on lateral and medial condyles of the tibia. Using these values we calculated an average posterior tibial slope as well as the difference between slopes on lateral and medial condyles. Patients with ACL rupture have highly statistically significantly greather posterior tibial slope (p < 0.01) on lateral tibial condyle (7.1 degrees : 4.5 degrees) as well as statistically significantly lesser posterior tibial slope (p < 0.05) on medial tibial condyle (5.9 degrees : 6.6 degrees) than patients with intact ACL. Great posterior tibial slope on lateral tibial condyle associated with the small posterior tibial slope on the medial tibial condyle, that is a positive differentce between lateral and medial tibial condyles are factors wich may cause ACL rupture.
Rudan, John; Harrison, Mark; Simurda, Michael A
Objective To study factors that affect femorotibial (F-T) alignment after valgus closing wedge tibial osteotomy. Study design A review of standardized standing radiographs. Femorotibial alignment was measured 1 year postoperatively for over- and under-correction. Changes in F–T alignment and in tibial plateau angle were measured. Setting An urban hospital and orthopedic clinic. Patients Eighty-two patients with osteoarthritis and varus femorotibial alignment underwent valgus closing wedge tibial osteotomy. Patients having a diagnosis of inflammatory arthritis or a prior osteotomy about the knee were excluded. Results A 1° wedge removed from the tibia resulted in an average correction of F–T alignment of 1.2°. A knee that had increased valgus orientation of the distal femur had a greater degree of correction, averaging 1.46° in F–T alignment per degree of tibial wedge. This resulted in excessive postoperative valgus alignment for some patients who had increased valgus tilt of the distal femur. Optimal F–T alignment of 6° to 14° of valgus occurred when the postoperative tibial inclination was 4° to 8° of valgus. Conclusions There was a trend for knees with increased valgus orientation of the distal femur to have greater correction in F–T alignment after tibial osteotomy, likely because of a greater opening up of the medial joint space during stance. Surgeons need to account for this in their preoperative planning. PMID:10526522
Cipolla, Massimo; Cerullo, Guglielmo; Franco, Vittorio; Giannì, Enrico
A valgus knee is a disabling condition that can affect patients of all ages. Antivalgus osteotomy of the knee is the treatment of choice to correct the valgus, to eliminate pain in the young or middle age patient, and to avoid or delay a total knee replacement. A distal femoral lateral opening wedge procedure appears to be one of the choices for medium or large corrections and is particularly easy and precise if compared to the medial femoral closing wedge osteotomy. However, if the deformity is minimal, a tibial medial closing wedge osteotomy can be done with a faster healing and a short recovery time. PMID:19547972
Ishida, Tomoya; Yamanaka, Masanori; Takeda, Naoki; Aoki, Yoshimitsu
Dynamic knee valgus contributes to injuries of the anterior cruciate ligament (ACL). However, it is unclear how the knee rotates during dynamic knee valgus. Knee rotation significantly affects ACL strain. To understand knee rotation during dynamic knee valgus should help the clinician evaluate dynamic alignment. The purpose of this study was to determine how the knee rotates during dynamic knee valgus and whether the knee rotation is affected by toe direction (foot rotation). Sixteen females performed dynamic knee valgus in three toe directions (neutral, toe-out, and toe-in) while maintaining the knee flexion angle at 30°. The knee rotation angle was evaluated using a 7-camera motion analysis system. Knee rotation was compared between the start position and the dynamic knee valgus position, as well as among the three toe directions, using repeated measures ANOVA models. The knee significantly rotated externally in the dynamic knee valgus position compared with the start position in two toe directions (neutral and toe-out). A similar tendency was observed with the toe-in condition. Toe direction significantly affected the knee rotation angle. For toe-out and toe-in conditions, external and internal shifts of knee rotation compared with neutral were observed. The knee rotates externally during dynamic knee valgus, and the knee rotation is affected by toe direction. Because of knee abduction and external rotation, the ACL may impinge on the femoral condyle in the case of dynamic valgus, especially in the toe-out position. Copyright © 2012 Elsevier B.V. All rights reserved.
Perillo-Marcone, A; Barrett, D S; Taylor, M
The influence of the tibial plateau orientation on cancellous bone stress was examined by finite element analysis for a cemented device. The objectives of the study were i) to examine the effect of the plateau-ankle angle on the cancellous bone stress, ii) to analyze the significance of the anteroposterior angles of the tibial component on these stresses, and iii) to compare the finite element predictions with clinical data. In general, positioning the tibial plateau in valgus resulted in lower cancellous bone stresses. These results support previous clinical studies, which suggest that overall alignment in valgus results in lower migration rates and lower incidence of loosening.
A discussion of the essential deformity in calcaneo-valgus feet develops a theme originally put forward in 1961 on the relapsed club foot (Evans 1961). Whereas in the normal foot the medial and lateral columns are about equal in length, in talipes equino-varus the lateral column is longer and in calcaneo-valgus shorter than the medial column. The suggestion is that in the treatment of both deformities the length of the columns be made equal. A method is described of treating calcaneo-valgus deformity by inserting cortical bone grafts taken from the tibia to elongate the anterior end of the calcaneus.
Introduction Hallux valgus (bunions) are prominent and often inflamed metatarsal heads and overlying bursae. They are associated with valgus deviation of the great toe which moves towards the second toe. Hallux valgus is found in at least 2% of children aged 9 to 10 years, and almost half of adults, with greater prevalence in women. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of conservative treatments for hallux valgus (bunions)? What are the effects of osteotomy for hallux valgus (bunions)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 15 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: chevron osteotomy plus adductor tenotomy; distal metatarsal osteotomy; minimally invasive surgery (percutaneous distal metatarsal osteotomy, SERI [Simple, Effective, Rapid, Inexpensive] distal metatarsal osteotomy); phalangeal (Akin) osteotomy plus distal chevron osteotomy; proximal osteotomy; night splints; and orthoses (including antipronatory orthoses in children).
Shin, Choongsoo S.; Chaudhari, Ajit M.; Andriacchi, Thomas P.
Valgus moments on the knee joint during single-leg landing have been suggested as a risk factor for anterior cruciate ligament (ACL) injury. The purpose of this study was to test the influence of isolated valgus moment on ACL strain during single-leg landing. Physiologic levels of valgus moments from an in vivo study of single-leg landing were applied to a three-dimensional dynamic knee model, previously developed and tested for ACL strain measurement during simulated landing. The ACL strain, knee valgus angle, tibial rotation, and medial collateral ligament (MCL) strain were calculated and analyzed. The study shows that the peak ACL strain increased nonlinearly with increasing peak valgus moment. Subjects with naturally high valgus moments showed greater sensitivity for increased ACL strain with increased valgus moment, but ACL strain plateaus below reported ACL failure levels when the applied isolated valgus moment rises above the maximum values observed during normal cutting activities. In addition, the tibia was observed to rotate externally as the peak valgus moment increased due to bony and soft-tissue constraints. In conclusion, knee valgus moment increases peak ACL strain during single-leg landing. However, valgus moment alone may not be sufficient to induce an isolated ACL tear without concomitant damage to the MCL, because coupled tibial external rotation and increasing strain in the MCL prevent proportional increases in ACL strain at higher levels of valgus moment. Training that reduces the external valgus moment, however, can reduce the ACL strain and thus may help athletes reduce their overall ACL injury risk. PMID:19100550
Optimizing the value of the posterior condylar offset, proximal tibial resection and slope in order to achieve the right balance of the posterior cruciate ligament - clinical application of the molding function of the two parts of the PCL
Bogojevski, Ljubomir; Doksevska, Milena Bogojevska
Introduction: In order to achieve the right balance of the posterior cruciate ligament using the skeletal method is very difficult, almost impossible (Mahoney). Our hypothesis for the right balance of the PCL by using the skeletal method is based on several defined facts: - PCL is a union based of two anatomically independent, but functionally synergic parts, posteromedial and anterolateral part. - The length of the posteromedial part of the PCL is determined by the belonging of the medial compartment and is shortest in varus and longest in valgus deformation. - The length of the anterolateral part of the PCL, placed centrally is unchangeable (cca 38 mm) in every knee and is independent from the anatomical appearance (deformation). - The cylindrical shape of the distal posterior part of the femur (Ficat) depends of the molding function of the PCL (Kapandji) and is a result of the proportion of the both parts of the PCL that is consisted of: shorter posteromedial part, less bone stock on the medial and more bone stock on the lateral condyle (varus knee) and vice versa, longer posteromedial part, more bone stock on the medial condyle and less on the lateral (valgus knee). According to that, the neutral bone stock is achieved by equalization of the lengths of the two parts (common radius of the cylinder) of the PCL, that is basis for the interligamentary balance of the posterior cruciate ligament. Methods: The basic characteristics of the interligamentary balance of the PCL that we started in 2008 are the following: 1. Posterior condylar offset is equal to the even length of the both part of the PCL. 2. Decrease of the values of proximal tibial resection from 10 in varus to 4-6 in valgus. 3. Femoral valgus cut from 6 in excessive varus deformity to 4 in valgus. Results: The clinical evaluation of the cases divided in groups excessive varus, mean varus, valgus type 1, 2 (Krakow) showed right distribution in the groups of the postoperative ROM and intraoperative
...) Classification. Class II. ...) translation in one or more planes. It has no linkage across-the-joint. This prosthesis is made of alloys, such as cobalt-chromium-molybdenum, and is intended to resurface one tibial condyle. The generic type...
Kołodziej, Łukasz; Napiontek, Marek; Kazimierczak, Arkadiusz
Posterior tibial tendon dysfunction (PTTD) ranks among the most common causes of adult acquired flatfoot deformity. The deformity develops gradually through characteristic stages and its early manifestations are often ignored or mis-diagnosed. The aim of the study was to gain an insight into what the participants of the 5th Polish Foot and Ankle Society Congress knew about the diagnosis and treatment of flatfoot. An anonymous survey described the clinical presentation of a hypothetical patient with fixed stage III (according to the Johnson and Strom classification) acquired flatfoot deformity in PTTD. A total of 65 questionnaires were distributed and 51 (78%) were completed and returned. The respondents included 40 orthopaedics consultants and 11 orthopaedics and traumatology resident doctors. The mean time of work experience of the specialists was 17.5 years and that of resident doctors, 3.5 years. The deformity was properly diagnosed by 36 respondents (71%), including 29 specialists (73%) and 7 resident doctors (63%). Proper operative treatment was selected by 28 respondents (52%): 24 specialists (60%) and 4 residents (36%). Overall, appropriate comprehensive diagnostic work-up and treatment was planned only by 19 respondents (35%), including 17 specialists (32%) and 2 residents (4%). Appropriate diagnostic work-up and treatment of acquired flatfoot deformity in PTTD was planned by less than half of the respondents and their work experience did not have any relation with the management they suggested. 1. There is a significant lack of knowledge about PTTD among residents. 2. The majority of PFAS members surveyed selected the correct method of diagnostic work-up and treatment, but the differences with respect to non-PFAS respondents were not statistically significant.
Sun, Jun; Yan, Songhua; Jiang, Yan; Wong, Duo Wai-Chi; Zhang, Ming; Zeng, Jizhou; Zhang, Kuan
Knee valgus and varus morbidity is at the second top place in children lower limb deformity diseases. It may cause abnormal stress distribution. The magnitude and location of contact forces on tibia plateau during gait cycle have been indicated as markers for risk of osteoarthritis. So far, few studies reported the contact stress and force distribution on tibial plateau of valgus knee of children. To estimate the contact stresses and forces on tibial plateau of an 8-year old obese boy with valgus knee and a 7-year old healthy boy, three-dimensional (3D) finite element (FE) models of their left knee joints were developed. The valgus knee model has 36,897 nodes and 1,65,106 elements, and the normal knee model has 78,278 nodes and 1,18,756 elements. Paired t test was used for the comparison between the results from the 3D FE analysis method and the results from traditional kinematic measurement methods. The p value of paired t test is 0.12. Maximum stresses shifted to lateral plateau in knee valgus children while maximum stresses were on medial plateau in normal knee child at the first peak of vertical GRF of stance phase. The locations of contact centers on medial plateau changed 3.38 mm more than that on lateral plateau, while the locations of contact centers on medial plateau changed 1.22 mm less than that on lateral plateau for healthy child from the first peak to second peak of vertical GRF of stance phase. The paired t test result shows that there is no significant difference between the two methods. The results of FE analysis method suggest that knee valgus malalignment could be the reason for abnormal knee load that may cause knee problems in obese children with valgus knee in the long-term. This study may help to understand biomechanical mechanism of valgus knees of obese children.
Ristić, Vladimir; Maljanović, Mirsad C; Pericin, Branislav; Harhaji, Vladimir; Milankov, Miroslav
The aim of this study was to identify an increased posterior tibial slope as a possible risk factor for anterior cruciate ligament injury. Sixty patients were divided into two groups (with and without anterior cruciate ligament rupture). The posterior tibial slope on the lateral and medial condyles was measured by sagittal magnetic resonance imaging slices by means of computerized method using circles to determine tibial axis. The patients with anterior cruciate ligament rupture had a statistically significantly (p = 0.06) greater posterior tibial slope on the lateral tibial condyle than the control group (6.68 degrees:5.64 degrees), and a greater slope on the medial condyle (5.49 degrees:4.67 degrees) in comparison to the patients with the intact anterior cruciate ligament. No significant difference in the average values of angles was observed between males and females with anterior cruciate ligament rupture, the average value being 6.23 degrees in men and 5.84 degrees in women on the lateral condyle, and 4.53 degrees in men and 4.53 degrees in women on the medial condyle. A statistically significant difference between the values of posterior tibial slope was observed between the groups with and without anterior cruciate ligament rupture, the sex having no affect on the value of the posterior tibial slope. The method of measuring angles should be unique.
Yang, Dejin; Shao, Hongyi; Zhou, Yixin; Tang, Hao; Guo, Shengjie
Lateral soft-tissue release can jeopardize the common peroneal nerve (CPN) in total knee arthroplasty for valgus knees. Previous studies reporting safe zones to protect the CPN were based on well-aligned knees. We conducted this study to compare the localization of the CPN in well-aligned knees and in valgus knees. We conducted a consecutive 3-dimensional radiographic study on magnetic resonance images of 58 well-aligned knees and 39 valgus knees. We measured the distance between the CPN and the tibia, as well as the mediolateral, anteroposterior, and angular location of the CPN. We compared the results between well-aligned knees and valgus knees. We found that there is an increased distance between the CPN and the tibia at the level of the tibial cut, but not at the joint line in valgus knees. It is safer to release the posterolateral capsule at the tibial side than at the level above this. The angular location and the mediolateral or anteroposterior location of the CPN in valgus knees are similar to those of well-aligned knees. The location of the CPN in valgus knees is similar to that in well-aligned knees. The previously reported safe zone in well-aligned knees is applicable in valgus knees to protect the CPN. Copyright © 2017 Elsevier Inc. All rights reserved.
Wang, Bin; Wang, Pengfei; Wang, Yupeng; Jia, Song; Yang, Huanyou; Yin, Jiali; Jiang, Wenping; Zhao, Gang
To provide the anatomical basis for the selection of osteotomy site in leg lengthening or tibial slip. Between August 2010 and July 2014, 10 adult fresh amputated leg specimens were collected. The pressure perfusion of red latex was performed by the popliteal artery. The anterior tibial artery and its main branches were separated and exposed, and the periosteal branch of anterior tibial artery was adequately exposed; the posterior tibial artery and its main branches were exposed; the peroneal artery was separated and exposed. The tibial and peroneal artery and its branches were observed and measured. When measuring the proximal end, the medial tibial plateau bone margin, the most prominent part of the tibial tuberosity, and the fibular head edge were used as a reference; when measuring the distal end, distal medial condyle of tibia malleolus tip, tibial lateral malleolus lateral tip, and distal tibial articular surface were used as a reference; the vertical distance between tibia proximal and distal main arteries and bone end reference was measured to determine the optimal osteotomy position of upper and lower tibia. The osteotomy index was calculated which was used to represent the relative position of osteotomy site in the whole tibia. The proximal tibial osteotomy site located at (78.2 ± 19.5) mm from medial tibial plateau margin, (41.8 ± 16.0) mm from the tibial tuberosity pole, and (66.7 ± 16.4) mm from the fibular head edge. The distal tibial osteotomy site located at (70.8 ± 12.1) mm above the inferior margin of tibial medial malleolus, (83.3 ± 13.0) mm above the inferior margin of lateral malleolus tip, and (59.1 ± 11.7) mm from distal tibial articular surface. The proximal tibial osteotomy index was 18.45-23.35 (mean, 20.46); the distal tibial osteotomy index was 14.36-23.05 (mean, 18.81). The metaphyseal-diaphyseal connection shold be selected in the proximal and distal tibia osteotomy, the lower one third of the tibia is not suitable for ostetomy.
Maheshwari, Jitendra; Pandey, Vinay Kumar; Mhaskar, Vikram Arun
In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling "anterior tibial condyle fracture". These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone. Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months. All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability. This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction.
Maheshwari, Jitendra; Pandey, Vinay Kumar; Mhaskar, Vikram Arun
Background: In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling “anterior tibial condyle fracture”. These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone. Materials and Methods: Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months. Results: All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability. Conclusion: This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction. PMID:25298560
Ducat, A; Sariali, E; Lebel, B; Mertl, P; Hernigou, P; Flecher, X; Zayni, R; Bonnin, M; Jalil, R; Amzallag, J; Rosset, P; Servien, E; Gaudot, F; Judet, T; Catonné, Y
Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias
Utturkar, G. M.; Irribarra, L. A.; Taylor, K. A.; Spritzer, C. E.; Taylor, D. C.; Garrett, W. E.; DeFrate, Louis E.
There are conflicting data regarding what motions increase ACL injury risk. More specifically, the mechanical role of valgus collapse positions during ACL injury remains controversial. Our objective was to evaluate ACL elongation in a model that mimics knee movements thought to occur during ACL injury. Eight healthy male subjects were imaged using MR and biplanar fluoroscopy to measure the in vivo elongation of the ACL and its functional bundles during three static knee positions: full extension, 30° of flexion, and a position intended to mimic a valgus collapse position described in the literature. For this study, the valgus collapse position consisted of 30° of knee flexion, internal rotation of the hip, and 10° of external tibial rotation. ACL length decreased significantly from full extension (30.2 ± 2.6 mm) to 30° of flexion (27.1 ± 2.2 mm). ACL length further decreased in the valgus collapse position (25.6 ± 2.4 mm). Both functional bundles of the ACL followed similar trends with regards to decreases in length in each of the three positions. Since strain would follow patterns of ACL length, landing on an extended knee may be a more relevant risk factor for ACL injuries than the valgus collapse position in males. Future studies should evaluate the effects of dynamic motion patterns on in vivo ACL strains. PMID:22855117
Utturkar, G M; Irribarra, L A; Taylor, K A; Spritzer, C E; Taylor, D C; Garrett, W E; Defrate, Louis E
There are conflicting data regarding what motions increase ACL injury risk. More specifically, the mechanical role of valgus collapse positions during ACL injury remains controversial. Our objective was to evaluate ACL elongation in a model that mimics knee movements thought to occur during ACL injury. Eight healthy male subjects were imaged using MR and biplanar fluoroscopy to measure the in vivo elongation of the ACL and its functional bundles during three static knee positions: full extension, 30° of flexion, and a position intended to mimic a valgus collapse position described in the literature. For this study, the valgus collapse position consisted of 30° of knee flexion, internal rotation of the hip, and 10° of external tibial rotation. ACL length decreased significantly from full extension (30.2 ± 2.6 mm) to 30° of flexion (27.1 ± 2.2 mm). ACL length further decreased in the valgus collapse position (25.6 ± 2.4 mm). Both functional bundles of the ACL followed similar trends with regards to decreases in length in each of the three positions. Since strain would follow patterns of ACL length, landing on an extended knee may be a more relevant risk factor for ACL injuries than the valgus collapse position in males. Future studies should evaluate the effects of dynamic motion patterns on in vivo ACL strains.
da Silva, Robson Rocha; Matos, Marcos Almeida; Pimentel, Maurício; Martins, Bruno Jacomeli; Oliveira, Rafael Valadares
Varus supracondylar osteotomy of the femur is the established procedure for treating painful knees that present lateral arthrosis and valgus deformity. In descriptions of the conventional surgical techniques, there are divergences regarding the location, access route, correction level, fixation type and area for synthesis insertion. This is most evident in cases of severe valgus with angles greater than 30° and distal femoral deformation, in association with hypoplasia of the lateral condyle. The authors describe a new surgical technique for distal femoral osteotomy, based on anatomical and geometrical criteria, which was developed in their clinic for treating severe valgus cases, and they present one of the cases treated. In the new technique, the wedge to be surgically resected has an oblique direction and the format of an isosceles triangle. This new proposal thus seeks to resolve problems that have been presented in such cases, through enabling valgus correction without causing any new deformity of the distal femur. Good cortical bone contact is promoted, and application of a stable synthesis system is made easier. However, the age limits for such patients and the degree of knee arthrosis that might contraindicate this procedure remain unknown. Hence, a larger sample and longer follow-up for operated cases are required. PMID:27042630
Ouchi, Kazuo; Hakozaki, Michiyuki; Kikuchi, Shin-Ichi; Yabuki, Shoji; Konno, Shin-Ichi
Osteochondroma, one of the most common benign bone tumors, frequently occurs in the metaphysis of the long bones. We report an extremely rare case of osteochondroma that occurred in the tibial sesamoid. The patient was a 62-year-old Japanese male. He presented with a 1-year history of pain and a hard mass on the plantar aspect of the right forefoot sole. The osteochondroma protruded toward the sole from the tibial sesamoid, leading to pain on weightbearing. After tibial sesamoidectomy, the patient's symptoms were eliminated, and no pain or complications such as hallux valgus occurred after the surgery. Although a potential risk exists of postoperative hallux valgus deformity, tibial sesamoidectomy seems to be an appropriate surgical option for both osteochondroma and bizarre parosteal osteochondromatous proliferation to avoid residual pain or local recurrence.
Segal, Kira; Ilizarov, Svetlana; Fragomen, Austin T.; Ilizarov, Gabriel
Background Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) and the Ilizarov method enable gradual realignment of angulation and translation in the coronal, sagittal, and axial planes, therefore, the term six-axis correction. Questions/purposes We asked whether this approach would allow precise correction of tibial deformities. Methods We retrospectively reviewed 102 patients (122 tibiae) with tibial deformities treated with percutaneous osteotomy and gradual correction with the TSF. The proximal osteotomy group was subdivided into two subgroups to distinguish those with an intentional overcorrection of the mechanical axis deviation (MAD). The minimum followup after frame removal was 10 months (average, 48 months; range, 10–98 months). Results In the proximal osteotomy group, patients with varus and valgus deformities for whom the goal of alignment was neutral or overcorrection experienced accurate correction of MAD. In the proximal tibia, the medial proximal tibial angle improved from 80° to 89° in patients with a varus deformity and from 96° to 85° in patients with a valgus deformity. In the middle osteotomy group, all patients had less than 5° coronal plane deformity and 15 of 17 patients had less that 5° sagittal plane deformity. In the distal osteotomy group, the lateral distal tibial angle improved from 77° to 86° in patients with a valgus deformity and from 101° to 90° for patients with a varus deformity. Conclusions Gradual correction of all tibial deformities with the TSF was accurate and with few complications. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:19911244
Sabzevari, Soheil; Rahnemai-Azar, Amir Ata; Shaikh, Humza S; Arner, Justin W; Irrgang, James J; Fu, Freddie H
The purpose of the study was to determine the influence of femoral and tibial bone morphology on the amount of femoral and tibial tunnel widening after primary anatomic ACL reconstruction. It was hypothesized that tibial and femoral bone morphology would be significantly correlated with tunnel widening after anatomic ACL reconstruction. Forty-nine consecutive patients (mean age 21.8 ± 8.1 years) who underwent primary single-bundle anatomic ACL reconstruction with hamstring autograft were enrolled. Two blinded observers measured the bone morphology of tibia and femur including, medial and lateral tibial posterior slope, medial and lateral tibial plateau width, medial and lateral femoral condyle width, femoral notch width, and bicondylar width on preoperative magnetic resonance imaging (MRI) scans. Tibial and femoral tunnel width at three points (aperture, mid-section, and exit) were measured on standard anteroposterior radiograph from 1 week and 1 year postoperatively (mean 12.5 ± 2 months). Tunnel width measurements at each point were compared between 1 week and 1 year to calculate percent of tunnel widening over time. Multivariable linear regression was used to analyze correlations between bone morphology and tunnel widening. Increase in lateral tibial posterior slope was the only independent bony morphology characteristics that was significantly correlated with an increased tibial tunnel exit widening (R = 0.58). For every degree increase in lateral tibial posterior slope, a 3.2% increase in tibial tunnel exit width was predicted (p = 0.003). Excellent inter-observer and intra-observer reliability were determined for the measurements (ICC = 0.91 and 0.88, respectively). Increased lateral tibial posterior slope is an important preoperative anatomic factor that may predict tunnel widening at the tibial tunnel exit. In regard to clinical relevance, the results of this study suggest that lateral tibial posterior slope be measured
Wang, Joon Ho; Bae, Ji Hoon; Lim, Hong Chul; Shon, Won Yong; Kim, Cheol Woong; Cho, Jae Woo
High tibial osteotomy can affect the posterior tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia. However, the effect of the location of cortical hinge on posterior tibial slope has not been previously described. Posterolateral location of the cortical hinge will increase posterior tibial slope after medial open wedge osteotomy, and lateral location of the cortical hinge will not affect the change of the posterior tibial slope. Controlled laboratory study. We performed incomplete valgus open wedge osteotomy on 12 paired knees of 6 fresh-frozen human cadavers (age, 63.4 + or - 7.5 years) using an OrthoPilot navigation system. The left and right legs of each specimen were randomly assigned to a posterolateral (group A) or a lateral (group B) cortical hinge group. Changes in mean medial proximal tibial angle, posterior tibial slope, and opening wedge angle were measured and compared after surgery. In group A, mean medial proximal tibial angle changed from 84.37 degrees + or - 2.8 degrees to 93.48 degrees + or - 3.06 degrees (P = .028); mean posterior tibial slope increased significantly from 8.71 degrees + or - 0.81 degrees to 12.16 degrees + or - 0.84 degrees (P = .031); and mean wedge angle was 1.92 degrees + or - 0.46 degrees . In group B, mean medial proximal tibial angle changed from 82.98 degrees + or - 2.53 degrees to 90.89 degrees + or - 3.25 degrees (P = .027); mean posterior tibial slope changed from 9.19 degrees + or - 1.11 degrees to 9.78 degrees + or - 1.27 degrees (P = .029); and mean wedge angle was 7.25 degrees + or - 0.72 degrees . The location of the intact cortical hinge affects the posterior tibia slope. During medial open wedge osteotomy, the change of posterior tibial slope was larger in the posterolateral than in the lateral cortical hinge group. To prevent the unintentional increase of the posterior tibial slope, special attention should be paid to locate the intact cortical hinge on the lateral
Wülker, Nikolaus; Mittag, Falk
Hallux valgus is the commonest forefoot deformity, with an estimated prevalence of 23% to 35%. It causes symptoms on the medial edge of the foot, the sole, and the small toes. Non-operative treatment may alleviate symptoms but does not correct the deformity of the big toe. Surgery is indicated if the pain persists. The correct operation must be selected from a wide variety of available techniques. In this article, we selectively review the pertinent literature, including the recommendations of medical societies in Germany and abroad, in the light of our own clinical experience. There have been many clinical trials of various treatments for hallux valgus, but very few of these were randomized, and the case numbers were generally small. Mild deformities are best treated by distal first metatarsal osteotomies, e.g. the Chevron osteotomy. Severe deformities require a soft-tissue procedure at the first metatarsophalangeal joint and a proximal first metatarsal osteotomy. In case of osteoarthritis, and in elderly patients, a resection arthroplasty is preferred; arthrodesis is performed in physically active patients. After correction of hallux valgus, patients can usually bear their full weight on the treated foot while wearing a flat surgical shoe. Proper surgical treatment results in a good or very good outcome in 85% of patients and a satisfactory result in a further 10%. The clinical outcome of present treatments seems to be good in most cases, but large-scale randomized trials are still needed to verify the efficacy of the wide variety of operations and fixation techniques that are currently being offered.
LaPorta, Guido A; Susek, Mehgan M
Guided growth is useful in correcting pediatric angular deformities. Ankle valgus is a coronal plane deformity and is often seen in skeletally immature patients with congenital or acquired lower extremity pathologic features. Temporary hemiepiphysiodesis with a percutaneous transphyseal medial malleolar screw is a surgical treatment capable of correcting the angular deformity and can offer effective correction. In the present case study, a 12-year-old male with dorsal-lateral peritalar subluxation and ankle valgus underwent a reconstructive procedure and temporary hemiepiphysiodesis with a percutaneous medial malleolar screw. After removal of the screw, reduction of his peritalar subluxation was achieved, improving his lateral-distal tibial angle from 81° preoperatively to 89° at the final follow-up examination. The patient returned to his preoperative sporting activities and ambulated comfortably and pain free in sneakers with orthotics. In conclusion, temporary hemiepiphysiodesis with a transphyseal medial malleolar screw is an effective treatment option for ankle valgus in a skeletally immature individual.
Shin, Young-Soo; Han, Seung-Beom; Hwang, Yeok-Ku; Suh, Dong-Won; Lee, Dae-Hee
We aimed to compare posterior cruciate ligament (PCL) tibial tunnel location after tibial guide insertion medial (between the PCL remnant and the medial femoral condyle) and lateral (between the PCL remnant and the anterior cruciate ligament) to the PCL stump as determined by in vivo 3-dimensional computed tomography (3D-CT). Tibial tunnel aperture location was analyzed by immediate postoperative in vivo CT in 66 patients who underwent single-bundle PCL reconstruction, 31 by over-the-PCL and 35 by under-the-PCL tibial guide insertion techniques. Tibial tunnel positions were measured in the medial to lateral and proximal to distal directions of the posterior proximal tibia. The center of the tibial tunnel aperture was located more laterally (by 2.7 mm) in the over-the-PCL group than in the under-the-PCL group (P = .040) and by a relative percentage (absolute value/tibial width) of 3.2% (P = .031). Tibial tunnel positions in the proximal to distal direction, determined by absolute value and relative percentage, were similar in the 2 groups. Tibial tunnel apertures were located more laterally after lateral-to-the-PCL tibial guide insertion than after medial-to-the-PCL tibial guide insertion. There was, however, no significant difference between these techniques in distance from the joint line to the tibial tunnel aperture. Insertion lateral to the PCL stump may result in better placement of the PCL in its anatomic footprint. Level III, retrospective comparative study. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Choi, Jun Young; Yoon, Hyeong Hwa; Suh, Yu Min; Suh, Jin Soo
To investigate the efficiency of simultaneous correction of moderate to severe hallux valgus deformity and adult-type pes planus. Twenty cases of moderate to severe hallux valgus complicated with adult-type pes planus in 19 consecutive patients (15 (79%) women, 4 (11%) men; mean age: 44.50 ± 17.13 years, mean follow-up duration: 31.30 ± 17.02 months) were included. Medial calcaneal sliding osteotomy was performed to correct hindfoot valgus, whereas treatments of hallux valgus were case dependent. The mean postoperative hallux valgus angle, intermetatarsal angle, hindfoot alignment angle, and hindfoot alignment ratio were 8.40 ± 5.29°, 4.20 ± 2.54°, 3.09 ± 2.92º and 0.41 ± 0.17, respectively. Although a hallux varus deformity occurred as a postoperative complication in one case (5%), there were no cases of postoperative recurrence. Simultaneous correction of hallux valgus and pes plano-valgus using medial calcaneal sliding osteotomy is an effective technique that reduces recurrence of hallux valgus and increases satisfaction in patients with moderate to severe hallux valgus deformity complicated with adult-type pes planus accompanying hindfoot valgus.
Gupta, Rajan T; Vankoski, Stephen; Novak, Robert A; Dias, Luciano S
Historically, trunk movement has been thought to be reactionary to lower body motions. The excessive trunk movement in patients with myelomeningocele may be a primary mechanism during ambulation. The purpose of this study was to quantify three-dimensional trunk movement in patients with myelomeningocele. Patients walked with ankle-foot orthoses (AFOs), both with and without crutches. Data were collected in reference to global and pelvic coordinates. Patients who walked with AFOs and crutches showed less trunk dynamic range of motion than patients without crutches. Between the two patient groups, there was a significant difference in trunk obliquity but not in trunk tilt or rotation. There is a good correlation between maximum trunk obliquity and coronal plane valgus knee stress. Overall, coronal plane valgus knee stress is multifactorial and trunk motion and external tibial torsion are major contributors. However, when using trunk kinematics to describe dynamic motion, both global and pelvic coordinate systems are important reference frames.
Rupprecht, Martin; Spiro, Alexander S; Breyer, Sandra; Vettorazzi, Eik; Ridderbusch, Karsten; Stücker, Ralf
Background and purpose Growth modulation with a medial malleolar screw is used to correct ankle valgus deformity in children with a wide spectrum of underlying etiologies. It is unclear whether the etiology of the deformity affects the angular correction rate with this procedure. Patients and methods 79 children (20 girls) with ankle valgus deformity had growth modulation by a medial malleolar screw (125 ankles). To be included, patients had to have undergone screw removal at the time of skeletal maturity or deformity correction, or a minimum follow-up of 18 months, and consistent radiographs preoperatively and at the time of screw removal and/or follow-up. The patients were assigned to 1 of 7 groups according to their underlying diagnoses. The lateral distal tibial angle (LDTA) was analyzed preoperatively, at screw removal, and at follow-up. Results Mean age at operation was 11.7 (7.4–16.5) years. The average lateral distal tibial angle normalized from 80° (67–85) preoperatively to 89° (73–97) at screw removal. The screws were removed after an average time of 18 (6–46) months, according to an average rate of correction of 0.65° (0.1–2.2) per month. No significant differences in the correction rate per month were found between the groups (p = 0.3). Interpretation Growth modulation with a medial malleolar screw is effective for the treatment of ankle valgus deformity in patients with a wide spectrum of underlying diagnoses. The individual etiology of the ankle valgus does not appear to affect the correction rate after growth modulation. Thus, the optimal timing of growth modulation mainly depends on the remaining individual growth and on the extent of the deformity. PMID:25909385
Torry, Michael R.; Shelburne, Kevin B.; Myers, Casey; Giphart, J. Erik; Pennington, W. Wesley; Krong, Jacob P.; Peterson, Daniel S.; Steadman, J. Richard; Woo, Savio L-Y.
The goal of this study was to determine the effects of peak knee valgus angle and peak knee abductor moment on the anterior, medial, and lateral tibial translations (ATT, MTT, LTT) in the ‘at risk’ female knee during drop landing. Fifteen female subjects performed drop landings from 40 cm. 3D knee motion was simultaneously recorded using a high speed, biplane fluoroscopy system and a video-based motion analysis system. Valgus knee angles and knee abduction moments were stratified into low, intermediate and high groups and peak ATT, MTT and LTT were compared between these groups with ANOVA (α = .05). Significant differences were observed between stratified groups in peak knee valgus angle (p < .0001) and peak knee abduction moment (p < .0001). However, no corresponding differences in peak ATT, LTT and MTT between groups exhibiting low to high peak knee valgus angles (ATT: p = .80; LTT: p = .25; MTT: p = .72); or, in peak ATT (p = .61), LTT (p = .26) and MTT (p = .96) translations when stratified according to low to high knee abduction moments, were found. We conclude that the healthy female knee is tightly regulated with regard to translations even when motion analysis derived knee valgus angles and abduction moments are high. PMID:22968826
Torry, Michael R; Shelburne, Kevin B; Myers, Casey; Giphart, J Erik; Pennington, W Wesley; Krong, Jacob P; Peterson, Daniel S; Steadman, J Richard; Woo, Savio L-Y
The goal of this study was to determine the effects of peak knee valgus angle and peak knee abductor moment on the anterior, medial, and lateral tibial translations (ATT, MTT, LTT) in the "at risk" female knee during drop landing. Fifteen female subjects performed drop landings from 40 cm. Three-dimension knee motion was simultaneously recorded using a high speed, biplane fluoroscopy system, and a video-based motion analysis system. Valgus knee angles and knee abduction moments were stratified into low, intermediate, and high groups and peak ATT, MTT, and LTT were compared between these groups with ANOVA (α = 0.05). Significant differences were observed between stratified groups in peak knee valgus angle (p < 0.0001) and peak knee abduction moment (p < 0.0001). However, no corresponding differences in peak ATT, LTT, and MTT between groups exhibiting low to high-peak knee valgus angles (ATT: p = 0.80; LTT: p = 0.25; MTT: p = 0.72); or, in peak ATT (p = 0.61), LTT (p = 0.26) and MTT (p = 0.96) translations when stratified according to low to high knee abduction moments, were found. We conclude that the healthy female knee is tightly regulated with regard to translations even when motion analysis derived knee valgus angles and abduction moments are high.
de Gheldere, Antoine; Eastwood, Deborah M
Failure of the enlarged and deformed anterolateral portion of the femoral head to roll into the acetabulum during abduction alters hip joint mechanics. The resultant hinge abduction is associated with pain, and the patient often has restricted movement. A valgus osteotomy removes the deformed portion of the femoral head away from the weight-bearing area and ensures there is pain-free congruent range of movement around the weight-bearing position. The concomitant improvement in lever arm function and leg length results in a better gait pattern. In immature patients, abolition of hinge abduction allows the lateral acetabular ossification center to grow more normally. Copyright © 2011 Elsevier Inc. All rights reserved.
Schmerbach, Kay Ingo; Boeltzig, Christian Konrad Matthias; Reif, Ullrich; Wieser, Jan Carsten; Keller, Thomas; Grevel, Vera
To evaluate the influence of a tibial plateau leveling jig on osteotomy orientation, fragment reduction, and postoperative tibial plateau angle (TPA) during tibial plateau leveling osteotomy (TPLO). In vitro experimental study. Large-breed canine cadavers (n=20). TPLO was performed on 40 hindlimbs using 4 methods. Group 1: Jig; dogs in dorsal recumbency with the osteotomy parallel to the distal jig pin. Groups 2-4: No jig; dogs in lateral recumbency with the osteotomy in a vertical orientation (group 2: tibia parallel to the table top; group 3: controlled superimposition of the femoral condyles; group 4: internal rotation of the tibia). Postoperative TPA, fragment reduction, and osteotomy orientation relative to the tibial plateau were compared. Positive or negative values denoted deviation from parallel relative to the tibial plateau. Postoperative TPA, fragment reduction, and proximodistal osteotomy orientation were not significantly different between groups. Craniocaudal osteotomy orientation was significantly different (P<.005) from the tibial plateau. Median deviations were -4.0 degrees (group 1), 11.8 degrees (group 2), 11.2 degrees (group 3), and 0.2 degrees (group 4). Group 1 was not significantly different from group 4. A jig is not essential for osteotomy orientation, tibial plateau rotation, or fragment reduction. Comparable results were achieved performing a vertical osteotomy with the tibia slightly internally rotated (10 degrees -15 degrees) and parallel to the table surface. TPLO without use of a jig reduces surgical trauma, is less time consuming, and reduces cost.
Xu, Hailin; Jin, Kaiji; Fu, Zhongguo; Ma, Mingtai; Liu, Zhongdi; An, Shuai; Jiang, Baoguo
Background: There are no unified theories as to the anatomical changes that occur with hallux valgus, we investigated the radiological characteristics and anatomical risk factors for hallux valgus deformity in Chinese adults. Methods: We reviewed 141 patients with hallux valgus (206 feet; 15 males, 126 females; mean age, 58.5 years). These patients attended Peking University People's Hospital from April 2008 to March 2014. All feet had intact radiological data, obtained using the Centricity RIS/PACS system. We measured hallux valgus angle (HVA), 1–2 intermetatarsal angle (IMA), proximal articular set angle (PASA), distal articular set angle, hallux interphalangeal angle, metatarsocuneiform angle, size of the medial eminence of the distal first metatarsal, tibial sesamoid position, and joint congruity of the first metatarsophalangeal joint (MTPJ). Results: We found positive correlations between the HVA and IMA (r = 0.279, P < 0.01) and HVA and PASA (r = 0.358, P < 0.01), but not for IMA and PASA (P > 0.05). Feet were divided into three groups based on HVA severity. IMA (P < 0.05) and PASA (P < 0.05) in the mild group were significantly lower than that in the moderate and severe groups, with no significant difference determined for IMA or PASA between the moderate and severe groups (P > 0.05). Feet were then grouped based on the shape of the first metatarsal head. Using this grouping, HVA was significant higher in the rounded shape (19.92°) than in a flat shape (17.66°). The size of the medial eminence of the distal first metatarsal was positively correlated with HVA (r = 0.185, P < 0.01). The medial eminence in the moderate and severe groups was significantly larger than that in the mild group; moderate and severe groups were not significantly different. Conclusions: PASA enlargement is an adaptive change during early hallux valgus formation, and decompensation leads to subdislocation in the first MTPJ. A rounded first metatarsal head would thus predispose a
Lonner, J H; Lotke, P A
Spontaneous osteonecrosis of the tibial plateau involves a continuum of change observed in the subchondral zone that is commonly associated with early and mid stages of osteoarthritis. The typical patient is an elderly woman who experiences a sudden onset of pain in the medial aspect of the knee. The diagnosis of this under-appreciated clinical entity may be difficult, but careful examination and judicious use of imaging studies, as well as a high index of suspicion, may facilitate the accurate diagnosis. Although the radiographs may initially be normal (with the exception of mild arthrosis), radionuclide scans and MRI can be of great value. The MRI studies usually show a decreased signal intensity on a T1-weighted image, but may be normal in the early course of the disease. The T2-weighted images and fat suppression views are helpful in establishing a diagnosis and determining the extent of involvement. Recognition of this problem may help to avoid unnecessary intra-articular surgery. Many of these patients have complete or partial resolution of symptoms by 1 year, after a period of protected weight bearing. Nonetheless, surgery may be necessary for more advanced lesions and in those patients with progressive arthrosis.
Salem, Khaled Hamed
Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial. In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised. Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases). Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.
Della Sala, S W; Recla, M; Campolongo, F; Bortot, G; Bauer, M; Peterlongo, P
The authors report a case of giant cell tumour of the mandibular condyle, which is a rare finding. This tumour, studied using the main three radiological modalities (plain radiography, CT and MRI) showed characteristic radiological features of "giant cell tumour".
Shibuya, Naohiro; Thorud, Jakob C; Martin, Lanster R; Plemmons, Britton S; Jupiter, Daniel C
Although the efficacy of Akin proximal phalanx closing wedge osteotomy as a sole procedure for correction of hallux valgus deformity is questionable, when used in combination with other osseous corrective procedures, the procedure has been believed to be efficacious. However, a limited number of comparative studies have confirmed the value of this additional procedure. We identified patients who had undergone osseous hallux valgus correction with first metatarsal osteotomy or first tarsometatarsal joint arthrodesis with (n = 73) and without (n = 81) Akin osteotomy and evaluated their radiographic measurements at 3 points (preoperatively, within 3 months after surgery, and ≥6 months after surgery). We found that those people who had undergone the Akin procedure tended to have a larger hallux abduction angle and a more laterally deviated tibial sesamoid position preoperatively. Although the radiographic correction of the deformity was promising immediately after corrective surgery with the Akin osteotomy, maintenance of the correction was questionable in our cohort. The value of additional Akin osteotomy for correction of hallux valgus deformity is uncertain.
Bilateral bifid mandibular condyle is a rarely seen malformation. The aetiology of bifid condyle is not completely understood, although developmental anomaly, traumas, condylar fracture, teratogenic embryopathy and surgical condylectomy may all be causative factors. Although a few studies on human dried skulls tried to shed light on this entity it remains obscure. As most bifid condyle subjects have no complaint related to temporamandibular joint(TMJ), the cases are generally diagnosed through incidental radiographic findings. The case of a 54-year-old female is presented. In a panoramic radiograph obtained after a clinical examination, bilateral bifid mandibular condyle was observed. The open-closed lateral radiograph of the TMJ (obtained using the TMJ-specific program of the panoramic device) demonstrated duplication of the right and left condyles. In order to better evaluate the TMJ morphology and to eliminate pathologies such as fractures that might be missed with conventional radiographs, a computed tomography scan was also obtained. The joint head orientation was observed in the mediolateral direction. The case is discussed in the context of the relevant literature. Until large population-based studies are undertaken and further experimental studies are performed, bifid condyle will remain an incidental finding of anatomic variation rather than a clinically informative observation.
Zhu, Guang-Duo; Guo, Wan-Shou; Zhang, Qi-Dong; Liu, Zhao-Hui; Cheng, Li-Ming
Background: Controversies about the rational positioning of the tibial component in unicompartmental knee arthroplasty (UKA) still exist. Previous finite element (FE) studies were rare, and the results varied. This FE study aimed to analyze the influence of the tibial component coronal alignment on knee biomechanics in mobile-bearing UKA and find a ration range of inclination angles. Methods: A three-dimensional FE model of the intact knee was constructed from image data of one normal subject. A 1000 N compressive load was applied to the intact knee model for validating. Then a set of eleven UKA FE models was developed with the coronal inclination angles of the tibial tray ranging from 10° valgus to 10° varus. Tibial bone stresses and strains, contact pressures and load distribution in all UKA models were calculated and analyzed under the unified loading and boundary conditions. Results: Load distribution, contact pressures, and contact areas in intact knee model were validated. In UKA models, von Mises stress and compressive strain at proximal medial cortical bone increased significantly as the tibial tray was in valgus inclination >4°, which may increase the risk of residual pain. Compressive strains at tibial keel slot were above the high threshold with varus inclination >4°, which may result in greater risk of component migration. Tibial bone resection corner acted as a strain-raiser regardless of the inclination angles. Compressive strains at the resected surface slightly changed with the varying inclinations and were not supposed to induce bone resorption and component loosening. Contact pressures and load percentage in lateral compartment increased with the more varus inclination, which may lead to osteoarthritis progression. Conclusions: Static knee biomechanics after UKA can be greatly affected by tibial component coronal alignment. A range from 4° valgus to 4° varus inclination of tibial component can be recommended in mobile-bearing UKA. PMID
... All Site Content AOFAS / FootCareMD / Treatments Proximal Tibial Bone Graft Page Content What is a bone graft? Bone grafts may be needed for various ... the proximal tibia. What is a proximal tibial bone graft? Proximal tibial bone graft (PTBG) is a ...
Sung, Ki Hyuk; Ahn, Soyeon; Chung, Chin Youb; Lee, Kyoung Min; Kim, Tae Won; Han, Ho Sung; Kim, Dae Ha; Choi, In Ho; Cho, Tae-Joon; Yoo, Won Joon; Park, Moon Seok
This study was performed to estimate the rate of angular correction after asymmetrical physeal suppression and analyze the factors that influence the rate of correction by using a linear mixed model application. A total of 175 physes (72 distal femoral, 70 proximal tibial, and 33 distal tibial) from 78 consecutive patients with valgus angular deformity of the lower limb who underwent asymmetrical physeal suppression were included. The anatomic lateral distal femoral angle, the anatomic lateral proximal tibial angle, and the anatomic lateral distal tibial angle were measured from the teleroentgenograms of the patients' preoperative visit and periodic follow-ups. The rate of angular correction was adjusted by multiple factors by using a linear mixed model with age, sex, and surgical method as the fixed effects and each subject as the random effect. The final model included the age-specific and surgical method-specific rate and sex-specific and surgical method-specific intercept. Multivariate analysis was performed for this model. In younger children (boys 14 y or younger and girls 12 y or younger), the rate of correction of valgus deformity at the distal femur, proximal tibia, and distal tibia was 0.71 degrees/month (8.5 degrees/y), 0.40 degrees/month (4.8 degrees/y), and 0.48 degrees/month (5.8 degrees/y), respectively. In older children, the rate of correction of valgus deformity at the distal femur, proximal tibia, and distal tibia was 0.39 degrees/month (4.7 degrees/y), 0.29 degrees/month (3.5 degrees/y), and 0.48 degrees/month (5.8 degrees/y), respectively. The rate of correction at the distal femur was significantly lower in older children (P = 0.025). The rate of angular correction at the proximal tibia was significantly faster in the screw group than in the staple group (P = 0.046). Asymmetrical physeal suppression with staples, percutaneous transphyseal screws, and permanent method all are effective methods for treating valgus deformity in growing children
Dwyer, Amitabh Jitendra; John, Bobby; Krishen, Maharaj; Hora, Rajeev
Forty-eight children with an average age of 7.2 years (range: 3-12 years) were examined clinically and radiographically at an average 4-year follow-up (range: 2-10 years), between 1989 and 2000 to analyze correction of deformities following tibial shaft fractures. An inconsistent alteration in the length of the fractured tibia was observed. Anterior angular deformity realigned maximally (52.7%) followed by varus (40.9%) and valgus (23.9%) deformities. Posterior deformity corrected the least (18.5%). In the sagittal plane, acceptable critical anterior and posterior angular deformities that corrected completely were 12 degrees and 6 degrees respectively. In the coronal plane, acceptable critical angular deformities were 10 degrees varus and 8 degrees valgus.
Zirngibl, B; Grifka, J; Baier, C; Götz, J
Hallux valgus-the most common forefoot deformity-can cause both pain and decreased mobility. The development and progress of the hallux valgus is a multifactorial process. Different intrinsic and extrinsic causes are responsible. Various conservative and operative treatment options exist and have to been chosen regarding the stage of the disease. Conservative orthopedic measures may prevent a deterioration of hallux valgus only at an early stage of the disease. Concerning operative techniques, more than 150 different surgical procedures are described in the literature, which can be reduced to some common procedures. These are dependent on the manifestation of the bunion as well as on associated foot and ankle pathologies. Patients should be informed that postoperative follow-up treatment until complete recovery is time-consuming.
Medial tibial stress syndrome is characterised by complaints along the posteromedial tibia. Runners and athletes involved in jumping activities may develop this syndrome. Increased stress to stabilize the foot especially when excessive pronation is present explain the occurrence this lesion.
Shenoy K, Vandana; Kengagsubbiah, Srivatsa; V, Sathyabhama; Priya, Vishnu
Condylar fracture is the second most common site in the mandibular fractures. Motor vehicle accident and fall are the major causes of such fractures. Because of the anatomical weakness of the condyle and the shape of the condylar head the antero-medial dislocation of the condyle is common. Open reduction and closed reduction is always debatable. The open reduction will bring back the normal function much earlier than closed reduction. Medially dislocated condylar fracture fragments are always managed with open method. In superior or high condylar fractures,exact reduction with conventional open reduction can be difficult due to the limited surgical and visual fields. In such cases extracorporeal fixation of condyle using vertical ramus osteotomy may be better choice to achieve perfect alignment and absolute maintaince of vertical height of the ramus and facial symmetry. We here present a case of extracorporeal fixation of unilateral left high condylar fracture. PMID:25386546
Tubbs, R Shane; Lingo, Patrick Ryan; Mortazavi, Martin M; Cohen-Gadol, Aaron A
Disruption or embryologic derailment of the normal bony architecture of the craniovertebral junction (CVJ) may result in symptoms. As studies of the embryology and pathology of hypoplasia of the occipital condyles and third occipital condyles are lacking in the literature, the present review was performed. Standard search engines were accessed and queried for publications regarding hypoplastic occipital condyles and third occipital condyles. The literature supports the notion that occipital condyle hypoplasia and a third occipital condyle are due to malformation or persistence of the proatlas, respectively. The Pax-1 gene is most likely involved in this process. Clinically, condylar hypoplasia may narrow the foramen magnum and lead to lateral medullary compression. Additionally, this maldevelopment can result in transient vertebral artery compression secondary to posterior subluxation of the occiput. Third occipital condyles have been associated with cervical canal stenosis, hypoplasia of the dens, transverse ligament laxity, and atlanto-axial instability causing acute and chronic spinal cord compression. Treatment goals are focused on craniovertebral stability. A better understanding of the embryology and pathology related to CVJ anomalies is useful to the clinician treating patients presenting with these entities.
Rapaport, Benjamin H. J.; Heggie, Andrew A. C.
Simple bone cysts (SBCs) are benign lesions often found in the long bones of children between their first and second decades. They occasionally occur in the mandible but rarely in the mandibular condyle. A case of a 7-year-old female child with an increasing enlargement of the left mandibular condyle is presented. A 2 cm × 3 cm lytic lesion was explored and curetted through an intraoral vestibular incision and proved to be an SBC. Postoperative recovery was uncomplicated with remodeling of the condylar observed at 3 years follow-up.
...) Identification. A mandibular condyle prosthesis is a device that is intended to be implanted in the human jaw to... jaw for temporary reconstruction of the mandibular condyle in patients who have undergone resective...
Mammi, G I; Rocchi, R; Cadossi, R; Massari, L; Traina, G C
The effect of electromagnetic field stimulation was investigated in a group of 40 consecutive patients treated with valgus tibial osteotomy for degenerative arthrosis of the knee. All patients were operated on by the same author and followed the same postoperative program. After surgery, patients were randomly assigned to a control group (dummy stimulators) or to a stimulated one (active stimulators). Four orthopedic surgeons, unaware of the experimental conditions, were asked to evaluate the roentgenograms taken 60 days postoperatively and to rate the osteotomy healing according to four categories (the fourth category being the most advanced stage of healing). In the control group, 73.6% of the patients were included in the first and second category. In the stimulated group, 72.2% of the patients were included in the third and fourth category. On a homogeneous group of patients, electromagnetic field stimulation had positive effects on the healing of tibial osteotomies.
Yim, Ji Hyeon; Seon, Jong Keun; Song, Eun Kyoo
Although opening-wedge high tibial osteotomy (HTO) is used to correct deformities, it can simultaneously alter tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia, and this undesired change in tibial slope can influence knee kinematics, stability, and joint contact pressure. Therefore, medial opening-wedge HTO is a technically demanding procedure despite the use of 2-dimensional (2-D) navigation. The authors evaluated the posterior tibial slope pre- and postoperatively in patients who underwent navigation-assisted opening-wedge HTO and compared posterior slope changes for 2-D and 3-dimensional (3-D) navigation versions. Patients were randomly divided into 2 groups based on the navigation system used: group A (2-D guidance for coronal alignment; 17 patients) and group B (3-D guidance for coronal and sagittal alignments; 17 patients). Postoperatively, the mechanical axis was corrected to a mean valgus of 2.81° (range, 1°-5.4°) in group A and 3.15° (range, 1.5°-5.6°) in group B. A significant intergroup difference existed for the amount of posterior tibial slope change (Δ slope) pre- and postoperatively (P=.04).Opening-wedge HTO using navigation offers accurate alignment of the lower limb. In particular, the use of 3-D navigation results in significantly less change in the posterior tibial slope postoperatively than does the use of 2-D navigation. Accordingly, the authors recommend the use of 3-D navigation systems because they provide real-time intraoperative information about coronal, sagittal, and transverse axes and guide the maintenance of the native posterior tibial slope. Copyright 2012, SLACK Incorporated.
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Mandibular condyle prosthesis. 872.3960 Section... (CONTINUED) MEDICAL DEVICES DENTAL DEVICES Prosthetic Devices § 872.3960 Mandibular condyle prosthesis. (a) Identification. A mandibular condyle prosthesis is a device that is intended to be implanted in the human jaw...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Mandibular condyle prosthesis. 872.3960 Section... (CONTINUED) MEDICAL DEVICES DENTAL DEVICES Prosthetic Devices § 872.3960 Mandibular condyle prosthesis. (a) Identification. A mandibular condyle prosthesis is a device that is intended to be implanted in the human jaw...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Mandibular condyle prosthesis. 872.3960 Section... (CONTINUED) MEDICAL DEVICES DENTAL DEVICES Prosthetic Devices § 872.3960 Mandibular condyle prosthesis. (a) Identification. A mandibular condyle prosthesis is a device that is intended to be implanted in the human jaw...
... (CONTINUED) MEDICAL DEVICES DENTAL DEVICES Prosthetic Devices § 872.3960 Mandibular condyle prosthesis. (a) Identification. A mandibular condyle prosthesis is a device that is intended to be implanted in the human jaw to... requirement for premarket approval for any mandibular condyle prosthesis intended to be implanted in the human...
Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature.
Dayton, Paul; Feilmeier, Mindi; Kauwe, Merrell; Hirschi, Jordan
Rotation of the first metatarsal, as a component of hallux abducto valgus, is rarely discussed and is not addressed as a component of most hallux valgus corrective procedures. We believe frontal plane rotation of the first metatarsal to be an integral component of hallux abducto valgus deformity (the "third plane of deformity") and believe de-rotation is necessary for complete deformity correction. We observed the change in angular measurements commonly used in the evaluation of hallux valgus deformity in patients who underwent a modified lapidus procedure. We measured the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position on weightbearing radiographs of 25 feet in 24 patients who had undergone tarsal metatarsal corrective arthrodesis and lateral capsular release. Specific attention was given to reduction of the frontal plane rotation of the first metatarsal during correction. Our results showed a change in the angular measurements observed by 4 investigators as follows. The mean change in the intermetatarsal angle was 10.1° (p < .0001). The mean change in the hallux abductus angle was 17.8° (p < .0001). The mean change in the proximal articular set angle was 18.7° (p < .0001). The mean change in the tibial sesamoid position was 3.8 (p < .0001). Also, a consistent valgus, or everted position of the first metatarsal, was noted as a component of the hallux abducto valgus deformity in our patient population and was corrected by varus rotation or inversion of the metatarsal. We also reviewed the current literature related to anatomic changes in the first ray in the patient with hallux valgus deformity and reviewed our hypothesis regarding the reduction in the proximal articular set angle, which we believe to be related to frontal plane rotation of the first metatarsal, resulting in a radiographic artifact. Copyright © 2013. Published by Elsevier Inc.
Abraham, E; Lubicky, J P; Songer, M N; Millar, E A
Fifty-five supramalleolar osteotomies were performed in 35 patients for progressive hindfoot valgus in myelomeningocele. All patients were ambulatory. The most common motor level of innervation was L3 in 42 limbs. The average age at surgery was 12 years. The average follow-up was 8 years. Preoperatively, all patients experienced progressive difficulty with brace use, and anteroposterior weight-bearing ankle radiographs showed a valgus tilt of the talotibial angle (TTA) of > or = 10 degrees with an average of 18 degrees. The average postoperative correction of TTA was 17 degrees. The results were graded as follows: excellent, 42 limbs; good, eight limbs; fair, three limbs; and poor, two limbs. The fair and poor limb results were the result of loss of correction or nonunion. The best results were seen when the TTA was corrected to 5 degrees of varus.
Background and purpose Complications related to the fibula during distraction osteogenesis could cause malalignment. Most published studies have analyzed only migration of the fibula during lengthening, with few studies examining the effects of fibular complications. Patients and methods We retrospectively reviewed 120 segments (in 60 patients) between 2002 and 2009. All patients underwent bilateral tibial lengthening of more than 5 cm. The mean follow-up time was 4.9 (2.5–6.9) years. Results The average lengthening percentage was 34% (21–65). The ratio of mean fibular length to tibial length was 1.05 (0.91–1.11) preoperatively and 0.83 (0.65–0.95) postoperatively. The mean proximal fibular migration (PFM) was 15 (4–31) mm and mean distal fibular migration (DFM) was 9.7 (0–24) mm. Premature consolidation occurred in 10 segments, nonunion occurred in 12, and angulation of fibula occurred in 8 segments after lengthening. Valgus deformities of the knee occurred in 10 segments. Interpretation PFM induced valgus deformity of the knee, and premature consolidation of the fibula was associated with the distal migration of the proximal fibula. These mechanical malalignments could sometimes be serious enough to warrant surgical correction. Thus, during lengthening repeated radiographic examinations of the fibula are necessary to avoid complications. PMID:22329670
Jaroma, Antti; Soininvaara, Tarja; Kröger, Heikki
Background and purpose Total knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA. Patients and methods 86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score. Results The baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred. Interpretation Tibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3–6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up. PMID:27120266
Jaroma, Antti; Soininvaara, Tarja; Kröger, Heikki
Background and purpose - Total knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA. Patients and methods - 86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score. Results - The baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred. Interpretation - Tibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3-6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up.
Bettega, G; Leitner, F
Computer aided surgery has become a standard in many fields. It is rarely used in orthognathic surgery. Twenty years ago, we developed a navigation system adapted to this surgery, especially for mandibular condyle repositioning. The system has been improved along with technological progress. The authors of several clinical studies have validated this system. It is now routinely used in our department, because of its educational virtues among other assets. Copyright © 2013. Published by Elsevier Masson SAS.
Goulart, D R; Muñoz, P; Olate, S; de Moraes, M; Fariña, R
The aim of this research was to compare the condylar morphology of patients with unilateral condylar hyperplasia (UCH) and patients with a class III skeletal relationship using cone beam computed tomography (CBCT). A prospective study was conducted on patients with facial asymmetry attending the division of oral and maxillofacial surgery of the study university in Chile. Fifteen patients with UCH and 15 with a class III skeletal relationship were selected. Linear measurements of the condylar processes were obtained at a scale of 1:1 using the software Ez3D Viewer Plus. Analysis of variance (ANOVA) and the paired t-test were used, considering P<0.05. Patients with UCH presented statistical differences between the hyperplastic condyle and non-hyperplastic condyle for anteroposterior and mediolateral diameters, condylar neck length, and ramus height. Patients with a class III skeletal relationship showed no differences between the right and left sides; the morphology of their condyles was similar to the condyles with hyperplasia and presented statistical differences when compared with the non-hyperplastic condyles (one-way ANOVA, P<0.05). The condylar morphology of UCH patients could be related to the development of a class III skeletal relationship. These findings provide an insight into the possibility of some class III patients presenting bilateral condylar hyperplasia.
Sales, Jafar Ganjpour; Soleymaopour, Jafar; Ansari, Maroof; Afaghi, Farhad; Goldust, Mohamad
Tibial condyle fractures affect knee stability and motion. Treatment of bicondylar type of tibial plateau fracture is a challenging problem. This study aimed at evaluating the application of hybrid external fixators with minimum deformation in these patients and the resulted outcomes. In this descriptive analytical study, 28 patients with bicondylar tibial plateau fractures treated by HEF device were evaluated. The surgeon used a semicircular and one circular wire instead of the one or two loop of conventional HEF device for a better range of motion of the knee joint. Treatment outcomes including quality of walking, union condition, knee range of motion, complications and the final outcome according to the knee score (rusmussen) were checked. Twenty-eight male patients, with the mean age of 40.54 +/- 13.83 years were enrolled in the study. Complications occurred in 8 (28.6%) patients; 7 cases with superficial infection and 1 patient with deep vein thrombosis. All complications were managed medically with no significant consequences left. All the patients were able to walk with no aid except in one case. In 96.4% and 89.3% of the cases, the clinical and radiological outcomes were good to excellent, respectively according to the knee score. In 85.7% of the patients, the knee range of motion was in normal limits. Application of hybrid external fixator using one and half ring instead of one or two fixator rings in treating bicondylar tibial fractures was associated with desired clinical and radiological results.
Ribeiro, Fabiano Rebouças; Takesian, Fernando Hovaguim; Bezerra, Luiz Eduardo Pimentel; Filho, Rômulo Brasil; Júnior, Antonio Carlos Tenor; da Costa, Miguel Pereira
Impacted valgus fractures of the proximal humerus are considered to be a special type fracture, since impaction of the humeral head on the metaphysis with maintenance of the posteromedial periosteum improves the prognosis regarding occurrences of avascular necrosis. This characteristic can also facilitate the reduction maneuver and increase the consolidation rate of these fractures, even in more complex cases. The studies included were obtained by searching the Bireme, Medline, PubMed, Cochrane Library and Google Scholar databases for those published between 1991 and 2013. The objective of this study was to identify the most common definitions, classifications and treatment methods used for these fractures in the orthopedic medical literature.
Ribeiro, Fabiano Rebouças; Takesian, Fernando Hovaguim; Bezerra, Luiz Eduardo Pimentel; Filho, Rômulo Brasil; Júnior, Antonio Carlos Tenor; da Costa, Miguel Pereira
Impacted valgus fractures of the proximal humerus are considered to be a special type fracture, since impaction of the humeral head on the metaphysis with maintenance of the posteromedial periosteum improves the prognosis regarding occurrences of avascular necrosis. This characteristic can also facilitate the reduction maneuver and increase the consolidation rate of these fractures, even in more complex cases. The studies included were obtained by searching the Bireme, Medline, PubMed, Cochrane Library and Google Scholar databases for those published between 1991 and 2013. The objective of this study was to identify the most common definitions, classifications and treatment methods used for these fractures in the orthopedic medical literature. PMID:27069878
Frame, Kevin R; Bridges, Janis P; Worth, Andrew J
To evaluate the use of a temporary calcaneo-tibial screw for stabilization of the tarsocrural joint in dogs with surgically treated collateral ligament injury. The degree of varus and valgus laxity of the tarsocrural joint in various states of injury and stabilization was measured in paired cadaveric limbs of Greyhound dogs. The angle of varus or valgus laxity was calculated following simulated collateral ligament injury (long collateral ligament only, long and short collateral ligaments, and bilateral long and short collateral ligaments) and stabilization with a calcaneo-tibial screw. The joint was significantly more stable after placement of a calcaneo-tibial screw compared to limbs with any combination of injured collateral ligaments. There was not a significant difference between stability of the intact limb compared to the injured limb with calcaneo-tibial screw fixation. Calcaneo-tibial screw fixation appears to be an adequate method of stabilizing the tarsocrural joint following collateral ligament injury, and warrants clinical evaluation as a less expensive alternative to external skeletal fixation application. It is likely that this method would need to be supplemented with a cranial half cast to prevent screw failure during weight bearing.
Vaidya, Sandeep V; Song, Hae-Ryong; Lee, Seok-Hyun; Suh, Seung-Woo; Keny, Swapnil M; Telang, Shailendra S
The results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplastic patients were analyzed. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at fixator removal, and at last follow-up. Of these parameters, statistically significant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 +/- 7.05 degrees, 103.2 +/- 11.8 degrees, 25.1 +/- 14.6 mm (medial), and 22.7 +/- 10 degrees (internal) preoperatively to 87.3 +/- 6.3 degrees, 90.9 +/- 5.4 degrees, 5.3 +/- 10 cm (medial), and 15.8 +/- 4.2 degrees (external), respectively, at the time of fixator removal; and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84 +/- 1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy. This procedure is safe and efficacious if performed with strict adherence to prescribed technique.
Nedopil, Alexander J; Howell, Stephen M; Hull, Maury L
Eight patients treated with kinematically-aligned (KA) total knee arthroplasty (TKA) presented with tibial component failure. We determined whether radiographic measurements and clinical characteristics are different between patients with and without tibial component failure to identify mechanisms of failure and strategies to reduce the risk. Out of 3,212 primary TKAs (2,725 TKAs with a two-year minimum follow up), of which all were performed with KA, eight patients presented with tibial component failure. Radiographic measurements, clinical characteristics (e.g. age, gender, BMI, etc.), revision surgical records, and Oxford knee scores were compared to control cohort patients matched 1:3. Tibial component failure presented at an average of 28 ± 15 months after primary TKA. Patients with tibial component failure had a 6 kg/m(2) greater body mass index (p = 0.034) and 5° greater posterior slope of the tibia component (p = 0.002) than controls. Final follow-up averaged 56 ± 19 months after the primary TKA and 28 ± 24 months after the revision TKA. The final Oxford knee score was 39 ± 4.6 for patients with tibial component failure and 44 ± 6.5 for the controls (p = 0.005). The incidence of tibial component failure after KA TKA was 0.3% and was caused by posterior subsidence or posterior edge wear and not varus subsidence. The strategy for lowering the risk of tibial component failure when performing KA is to set the tibial component parallel to the flexion-extension plane (slope) and varus-valgus plane of the native joint line.
Lim, R; Dias, L; Vankoski, S; Moore, C; Marinello, M; Sarwark, J
Twenty-five independent community-ambulating patients with lumbosacral-level myelomeningocele (N = 50 limbs) underwent gait analysis. The limbs of these patients were divided into two groups based on thigh-foot angle (TFA): Group I (n = 20) had marked external tibial torsion, TFA > or = 20 degrees, and group II had TFA between 10 and 20 degrees. Ten limbs were excluded because of neutral or internal alignment. Twenty normal limbs with TFA = 10 degrees served as controls. An abnormal internal varus knee stress during stance was identified in all group I limbs and 12 (70%) of 20 limbs group II limbs compared with controls, which demonstrated an internal valgus stress. This internal varus moment was greater in group I limbs than in the abnormal limbs in group II (p < 0.05). Knee flexion was the only other parameter found to correlate with this stress and only in group I limbs. We conclude that (a) in this patient group, increased external tibial torsion is likely to result in an abnormal internal varus knee stress; (b) TFA > 20 degrees appears significantly to increase this stress; and (c) knee flexion is an important related parameter, but only in limbs with TFA between 10 and 20 degrees. We believe that this abnormal stress may predispose the knee to late arthrosis and that derotational osteotomies to normalize the TFA may prove to have a favorable long-term effect.
Kim, Tae Won; Kim, Byung Kag; Kim, Dong Whan; Sim, Jae Ang; Lee, Beom Koo; Lee, Yong Seuk
Purpose The purpose of this study was to evaluate compartmental changes using combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT) after open wedge high tibial osteotomy (OWHTO) for providing clinical guidance for proper correction. Materials and Methods Analysis was performed using SPECT/CT from around 1 year after surgery on 22 patients who underwent OWHTO. Postoperative mechanical axis was measured and classified into 3 groups: group I (varus), group II (0°–3° valgus), and group III (>3° valgus). Patella location was evaluated using Blackburne-Peel (BP) ratio. On SPECT/CT, the knee joint was divided into medial, lateral, and patellofemoral compartments and the brighter signal was marked as a positive signal. Results Increased signal activity in the medial compartment was observed in 12 cases. No correlation was observed between postoperative mechanical axis and medial signal increase. Lateral increased signal activity was observed in 3 cases, and as valgus degree increased, lateral compartment’s signal activity increased. Increased signal activity of the patellofemoral joint was observed in 7 cases, and significant correlation was observed between changes in BP ratio and increased signal activity. Conclusions For the treatment of medial osteoarthritis, OWHTO requires overcorrection that does not exceed 3 valgus. In addition, the possibility of a patellofemoral joint problem after OWHTO should be kept in mind. PMID:27894172
El-Azab, Hosam; Glabgly, Parpakorn; Paul, Jochen; Imhoff, Andreas B; Hinterwimmer, Stefan
Valgus high tibial osteotomy (HTO) may be associated with changes in the patellar height and posterior tibial slope. Patellar height increases and posterior tibial slope decreases after closed-wedge HTO, whereas patellar height decreases and tibial slope increases after open-wedge osteotomy. Cohort study; Level of evidence, 3. Lateral radiographs of 100 knees were assessed for patellar height (PH) (Insall-Salvati index [ISI], Caton-De Champ index [CDI], and Blackburne-Peel index [BPI]) as well as posterior tibial slope. Measurements were done before HTO (50 closed wedge [CW], 50 open wedge [OW]), direct postoperatively, and before removal of the hardware. In the CW group, all 3 PH indices were increased direct postoperatively and at removal of the hardware, with changes in CDI and BPI being significant (P<.05). The effect size (ES) for the direct postoperative PH increase was medium (ES = 0.48) according to CDI. In the OW group, all 3 indices showed a significant (P <.05) PH decrease direct postoperatively and at hardware removal. The ES for the direct postoperative PH decrease was large according to CDI (ES = 0.92) and BPI (ES = 0.80). There were no significant changes between the 2 follow-up measurements (P > .05) with a small ES each. Posterior tibial slope showed a significant (P <.05) decrease of 3.1 degrees +/- 3.4 degrees after CW HTO and a significant (P <.05) increase of 2.1 degrees +/- 3.6 degrees after OW HTO direct postoperatively. These changes did not change at the second follow-up. In CW HTO, the correlations between frontal plane correction and PH changes were moderate (CDI: r = .57; BPI: r = .64). In OW HTO, these correlations were weak (CDI: r = .44; BPI: r = .46). According to ISI, there was no correlation (CW: r = .11; OW: r = .16). There was no correlation between PH changes and slope changes (CDI) and no correlation between frontal plane HTO correction and slope changes in both CW and OW HTO. The results confirm our hypothesis for PH and
Heyse, Thomas J; Tibesku, Carsten O
Patient-specific instrumentation (PSI) was introduced in an attempt to reduce positional outliers of components in total knee arthroplasty (TKA). It was hypothesized that PSI could help with the positioning of tibial components in optimal rotational alignment. A magnetic resonance imaging (MRI) analysis of 58 patients following TKA was conducted. Of these, 30 operations were performed using PSI and 28 using conventional instrumentation. The rotation of the tibial components was determined in MRI using three different reference lines: a tangent to the dorsal tibial condyles, the tibial epicondylar line, and the tibial tubercle. Deviations >9° were considered outliers. Also internal rotation >1° was considered an outlier. Data were analyzed statistically for positional outliers using the Chi-squared test. There was excellent inter- and intraobserver reliability with low standard deviations for the determination of tibial component rotation using the tangent to the dorsal condyles and the tibial epicondylar line as reference. Using the dorsal tangent as reference, there were eight components in excessive external rotation (28.6 %) and one component being in relative internal rotation (5.4°) in the conventional group, while there were two components in excessive external rotation in the PSI group (6.7 %). Using the tibial epicondyles as reference, there were seven components in excessive external rotation (21.4 %) and one component being in relative internal rotation (4.4°) in the conventional group; while there were two components in excessive external rotation in the PSI group (6.7 %). These differences were statistically significant (p < 0.05). Measurements based on the tibial tubercle showed poor reproducibility in terms of intra- and interobserver reliability and was of little use in the context of the research question. In this setup, PSI was effective in significantly reducing outliers of optimal rotational tibial component alignment during TKA. Anatomy of
Lloyd, Timothy E; Sivarajasingam, Vaseekaran
We report an unusual case of a 20-year-old man who presented with a superolateral dislocation of the left condyle with intracranial penetration following a road traffic accident. Management included open reduction of the condyle, rigid intermaxillary fixation (IMF), and intensive jaw physiotherapy. One year after operation he had good functional outcome with an interincisal opening of 30mm.
Papadopoulos, H; Edwards, R S
Anterior dislocation of the mandibular condyle is commonly seen in patients with chronic dislocation of their temporomandibular joints. Posterior, superior and lateral dislocation is rare. Superolateral dislocation of an intact condyle, let alone intact mandible is uncommon, usually occurring after a traumatic insult to the mandible. The authors report on such a case, and its management.
Morris, Jason; Ryan, Michael
Proximal first metatarsal osteotomies have historically been associated with and limited to treatment of severe hallux valgus deformities. These procedures are powerful in deformity correction and overall realignment of first ray function because of their ability to correct closer to the deformity's origin. When considering all factors in bunion correction, they are good options for correction of a wide range of hallux abducto valgus deformities. This article discusses the use of proximal metatarsal osteotomies for correction of hallux valgus deformity, techniques to facilitate optimal outcome, and common complications of these osteotomies. Copyright © 2014 Elsevier Inc. All rights reserved.
Aglietti, P; Rinonapoli, E; Stringa, G; Taviani, A
High tibial osteotomy is a reliable method for relieving pain in the varus osteoarthritic knee. In a review of 139 osteotomies, excellent and good results were noted in 64% of the knees after a follow-up period of at least ten years. The ideal candidate for this operation has Grade I or II osteoarthritis; less than 10 degrees of varus deformity, as measured by a single leg standing roentgenogram; no lateral subluxation; and no instability. The lateral closed wedge osteotomy without internal fixation is the preferred technique, and correction beyond the normal anatomic position, to 5 degrees of valgus, is advised. Protected weight-bearing after the second postoperative day is allowed. Complications have been infrequent and minor. Forty-seven knees were managed in this manner, and 88% had an excellent or good result at a four-year follow-up evaluation. In the majority of the well corrected knees, the alignment did not change with time, and the osteoarthritis did not progress. No failures in this series were attributable to the associated patellofemoral osteoarthritis; the reaction of the patellofemoral joint to osteotomy is obscure.
Schweitzer, M E; Maheshwari, S; Shabshin, N
The purpose of this article is to describe the MR findings of Hallux Valgus (HV) and Hallux Rigidus (HR). Twenty-four patients (11 with HV, 4 with HR, and 9 with both HV and HR) were studied at 1.5 Tesla MRI. Two separate observers evaluated the first ray blindly for the following signs: sesamoid position, sesamoid proliferation, hypertrophy of the median eminence, presence of a lateral facet, presence of an adventitial bursa, shape of the first metatarsal head, relative length of the first metatarsal, joint space loss, osteophytes (dorsalor lateral), marrow edema, geodes, subchondral sclerosis, intra-articular ossicle, and pes planus. The most common findings observed in HV were a hypertrophic medial eminence (95%), sesamoid proliferation (90%) and adventitial bursitis (70%). The most common findings observed in HR were osteophytes (77% and 69%), geodes, and marrow edema. We conclude that traditional routine radiograph signs of HV and HR may be applied to MR images.
Palmu, Sauli A; Auro, Sampo; Lohman, Martina; Paukku, Reijo T; Peltonen, Jari I; Nietosvaara, Yrjänä
Background Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. Methods 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980–89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23–32) years after the fracture. Results 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1–26) days. Primary complications were recorded in 5 children. The childrens’ memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0–10) for function appearance was 9. Leg-length discrepancy (5–10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. Interpretation The long-term outcome of tibial fractures in children treated non-operatively is generally good. PMID:24786903
Nikolopoulos, Dimitrios; Michos, Ioannis; Safos, George; Safos, Petros
The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees. PMID:26191494
Cianforlini, Marco; Rosini, Cristina; Marinelli, Mario; de Palma, Luigi
Objective: Treatment of mild and moderate hallux valgus deformities. Discussion: Minimally invasive technique enables surgeons to treat mild and moderate hallux valgus deformities with excellent and good results in the majority of patients. Nonunion of first metatarsal, moreover, has only rarely been reported. Summary: We describe the essential steps of a surgical technique for the treatment of nonunions after miniinvasive subcapital first metatarsal osteotomy reconstructed using a tricortical iliac crest bone graft. PMID:25013553
He, Y.; Zhang, M.; Huang, A. Y.; Cui, Y.; Bai, D.; Warman, M. L.
Mice are commonly used to study the temporomandibular joint (TMJ) and to model human TMJ disease. However, evaluating TMJ pathology in mice using standard histologic methods is time consuming, labor intensive, and dependent upon investigators’ expertise at consistently orienting and sectioning across tiny specimens. We describe a method that uses confocal microscopy to rapidly and reliably assess indicators of mandibular condyle cartilage pathology in mice. We demonstrate the utility of this method for detecting abnormalities in chondrocyte distribution in mice lacking lubricin (Prg4), the major boundary lubricant of articular cartilage. We further show that the method can provide information about recombination sites and efficiency in mandibular cartilage for Cre-driver strains. Because specimen preparation and data acquisition with confocal microscopy are simple and fast, the method can serve as a primary screening tool for TMJ pathology, before proceeding to complicated, time consuming, secondary analyses. PMID:28266618
King, G J; Zarzour, Z D; Rath, D A; Dunning, C E; Patterson, S D; Johnson, J A
The stabilizing influence of radial head arthroplasty was studied in eight medial collateral ligament deficient anatomic specimen elbows. An elbow testing apparatus, which used computer controlled pneumatic actuators to apply tendon loading, was used to simulate active elbow flexion. The motion pathways of the elbow were measured using an electromagnetic tracking device, with the forearm in supination and pronation. As a measure of stability, the maximum varus to valgus laxity over the range of elbow flexion was determined from the difference between varus and valgus gravity loaded motion pathways. After transection of the medial collateral ligament, the radial head was excised and replaced with either a silicone or one of three metallic radial head prostheses. Medial collateral ligament transection caused a significant increase in the maximum varus to valgus laxity to 18.0 degrees +/- 3.2 degrees. After radial head excision, this laxity increased to 35.6 degrees +/- 10.3 degrees. The silicone implant conferred no increase in elbow stability, with a maximum varus to valgus laxity of 32.5 degrees +/- 15.5 degrees. All three metallic implants improved the valgus stability of the medial collateral ligament deficient elbow, providing stability similar to the intact radial head. The use of silicone arthroplasty to replace the radial head in the medial collateral ligament deficient elbow must be questioned. Metallic radial head arthroplasty provides improved valgus stability, approaching that of an intact radial head.
Anglin, Carolyn; Masri, Bassam A; Tonetti, Jérôme; Hodgson, Antony J; Greidanus, Nelson V
Femoral neck fracture is the most common short-term concern after hip resurfacing arthroplasty. Currently, there is little basis to decide between neutral and valgus placement. We loaded 10 notched cadaveric femur pairs to failure; one side was implanted at 0 degrees relative to the femoral neck and the other at 10 degrees valgus. All 20 were dual-energy X-ray absorptiometry-scanned. Failure load correlated with bone mineral density. Valgus placement increased the fracture load by an average of 28% over neutral for specimens with normal bone mineral density but had no effect on fracture load in specimens with low bone mineral density. For specimens with normal bone mineral density (typical of patients undergoing resurfacing arthroplasty), neutral-valgus placement had a greater effect than bone mineral density, explaining 54% of the fracture load variance. Component placement greater than 10 degrees valgus is likely undesirable because this can lead to an increase in component size and a greater likelihood of notching. To reduce fracture risk, we recommend placing the femoral component in valgus and selecting patients with higher bone mineral density.
Ozturk, Hasan; Agus, Haluk; Altay, Taskin; Hancerli, Ozgur
Background Hallux valgus is a common disorder affecting mostly women population. Distal soft tissue procedure in the treatment of hallux valgus is one of the main operative techniques described. The aim of this study is to evaluate the outcomes of McBride’s distal soft tissue procedure in hallux valgus cases. Materials and methods This study includes 30 patients (27 women) having 31 hallux valgus, who were treated between 1999 and 2004. Modified McBride’s distal soft tissue procedure was carried out in all cases. Pain status of the cases was recorded by using VAS, clinical assessment described by Bonney and Macnab, and American Orthopaedic Foot and Ankle Society’s (AOFAS) score at the last follow up. Results The mean hallux valgus and intermetatarsal angles decreased from 31.4° and 13.8° to 13.5° and 10.5°, respectively, with an average follow-up period of 54.4 months. AOFAS’s score displayed significant improvement from 57 to 87. The mean VAS showed a significant decrease from 8.75 preoperatively to 2.1 at the last follow-up. According to Bonney and Macnab criteria, only one case was accepted as poor result due to 5° hallux varus. Conclusions McBride’s distal soft tissue procedure yields high rate of satisfaction for mild to moderate hallux valgus with no bony complications related to osteotomy. PMID:19384606
Schwartz, Adam J; Ravi, Bheeshma; Kransdorf, Mark J; Clarke, Henry D
A standing anteroposterior (AP) radiograph is commonly used to evaluate coronal alignment following total knee arthroplasty (TKA). The impact of coronal alignment on TKA outcomes is controversial, perhaps due to variability in imaging and/or measurement technique. We sought to quantify the effect of image rotation and tibial slope on coronal alignment. Using a standard extramedullary tibial alignment guide, 3 cadaver legs were cut to accept a tibial tray at 0°, 3°, and 7° of slope. A computed tomography scan of the entire tibia was obtained for each specimen to confirm neutral coronal alignment. Images were then obtained at progressive 10° intervals of internal and external rotation up to 40° maximum in each direction. Images were then randomized and 5 blinded TKA surgeons were asked to determine coronal alignment. Continuous data values were transformed to categorical data (neutral , valgus [L], and varus [R]). Each 10° interval of external rotation of a 7° sloped tibial cut (or relative internal rotation of a tibial component viewed in the AP plane) resulted in perception of an additional 0.75° of varus. The slope of the proximal tibia bone cut should be taken into account when measuring coronal alignment on a standing AP radiograph. Copyright © 2017 Elsevier Inc. All rights reserved.
Giagounidis, E M; Sell, S
In 94 patients 112 knees were examined after high tibial osteotomy for varus and valgus gonarthrosis. Preoperatively, there were 71 varus and 23 valgus deformities. The mean follow-up period was 9.0 years (range 2-21 years). Concerning the pain on walking and the pain at rest, we noted good and excellent results in 73% and 65%, respectively. The radiological evaluation showed an improvement or a persistence of the stage of arthrosis in 69.5% of the reviewed cases. The results according to the HSS score as an objective parameter showed in over 50% an improvement of the patients' situation. The data were subjected to multivariate statistical analysis in which three of four evaluated risk factors were found to be associated with the duration of pain-free survival: certain preoperative injuries, preoperative meniscopathies and a deterioration of the stage of arthrosis (P < 0.05). There was no significance for weight in excess of 10% above the normal body mass index (BMI) limits. However, in a Kaplan-Meier survival analysis this parameter could be determined as a significant factor for a reduced pain-free survival interval (P < 0.05): patients with a BMI of more than 10% above normal limits had a pain-free period of 5.07 years, whereas those with a BMI of less than 10% had a pain-free period of 7.80 years.
Bible, Jesse E; Choxi, Ankeet A; Dhulipala, Sravan C; Evans, Jason M; Mir, Hassan R
Limited information exists to define standard tibial radiographs. The purpose of this study was to define new landmarks on the proximal tibia for standard anteroposterior and lateral radiographs. In 10 cadaveric knees, fibular head bisection was considered the anteroposterior image, and femoral condyle overlap the lateral image. In another 10 knees, a "twin peaks" anteroposterior view, showing the sharpest profile of the tibial spines, was used. The "flat plateau" lateral image was obtained by aligning the femoral condyles then applying a varus adjustment with overlap of the tibial plateaus. Medial peritendinous approaches were performed, and an entry reamer used to open the medullary canal. A priori analysis showed good to excellent intra-/inter-observer reliability with the new technique (intra-class correlation coefficient ICC 0.61-0.90). The "twin peaks" anteroposterior radiograph was externally rotated 2.7±2.1° compared to the standard radiograph with fibular head bisection. Portal position and incidence of damage to intra-articular structures did not significantly differ between groups (P>.05). The "twin peaks" anteroposterior view and "flat plateau" lateral view can safely be used for nail entry portal creation in the anatomic safe zone. Tibia-based radiographic referencing is useful for intramedullary nailing cases in which knee or proximal tibiofibular joint anatomy is altered.
Suganthy, J; Rassau, Marina; Koshi, Rachel; Battacharjee, Suranjan
Congenital absence of tibia is a rare anomaly. We report a case of bilateral tibial hemimelia born to phenotypically normal parents. The two amputated legs with tibial dysplasia obtained from a 3-year-old boy were studied by radiography and anatomical dissection. The radiological evaluation revealed a normal hip joint. The lower end of femur was normal without any bifurcation, shortening or bowing. Fibula was present on both legs and there was no sign of bowing or doubling. Both right and left tibiae were absent. In addition, on the right side, five tarsal bones, two metatarsals and the corresponding digital rays were absent. On the left side, three tarsal bones were absent. Dissection of the amputated segments showed the presence of extensor digitorum longus, peroneus tertius, peroneus longus and brevis, gastrocnemius, and soleus. Following bilateral knee disarticulation the patient was fitted with prosthesis and is doing well.
Makhdom, Asim M; Sinno, Hani; Aldebeyan, Sultan; Cota, Adam; Hamdy, Reggie Charles; Alzahrani, Mohammad; Janelle, Chantal
Hallux valgus is the most common forefoot problem in adults. Although it can cause considerable disability and affect the quality of life of those affected, many patients seek medical attention because of cosmetic concerns. Our aim was to objectively measure the perceived health burden of living with bilateral hallux valgus. Previously validated utility outcome measures, including the visual analog scale, time trade-off, and standard gamble tests, were used to quantify the health burden for single-eye blindness, double-eye blindness, and bilateral hallux valgus in 103 healthy subjects using an online survey. The Student t test and linear regression analysis were used for statistical analysis. The mean visual analog scale, time trade-off, and standard gamble scores for bilateral hallux valgus were 0.86 ± 1.6, 0.95 ± 0.5, and 0.95 ± 0.14, respectively. These were significantly greater than the utility scores for single-eye and double-eye blindness (p < .05). Age, gender, race, income, and education were not statistically significant independent predictors of the utility scores for hallux valgus. In conclusion, we have objectively demonstrated the effect of living with bilateral hallux valgus deformities. Our sample population reported being willing to undergo a procedure with a 5% mortality rate and sacrifice 1.8 years of life to attain perfect health and avoid the bilateral hallux valgus health state. Our findings will guide us in counseling our patients and understanding how they perceive their foot deformity. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Dombroski, Derek; Garino, Jonathan; Lee, Gwo-Chin
Despite recent advances in cartilage regeneration and restoration procedures, isolated, large, full-thickness cartilage lesions in young patients continue to pose significant challenges to patients and orthopedic surgeons. Treatment options for this difficult problem have traditionally included arthrodesis, osteotomy, osteochondral allograft, and prosthetic reconstruction. We present a case of an adolescent patient with isolated idiopathic lateral tibial chondrolysis treated with a custom ceramic hemi-unicondylar hemiarthroplasty. Preoperatively, a 3-dimensional computed tomography scan of the patient's knee was obtained to begin manufacturing a conforming custom ceramic insert that would articulate between the tibial base plate and the patient's native lateral femoral cartilage. Through a lateral parapatellar approach, the tibial preparation was carried out using the Zimmer M/G unicompartmental knee system (Warsaw, Indiana), and the tibial base plate was cemented into position in the standard fashion. A custom, conforming, prefabricated ceramic insert (CeramTec, Memphis, Tennessee) was then inserted onto the tibial base plate. At 5-year follow-up, this salvage procedure was successful in relieving pain and restoring function in this young patient. There were no signs of implant loosening or lysis. Magnetic resonance imaging of the knee at last follow-up revealed that the cartilage thickness of the patient's lateral femoral condyle remained unchanged. Unicondylar hemiarthroplasty performed in patients with large unipolar lesions in the knee can provide durable and reliable pain relief. Ceramic is a viable material that can be considered for articulation with native cartilage.
... device that is intended to stabilize mandibular bone and provide for temporary reconstruction of the... surgical procedures requiring removal of the mandibular condyle and mandibular bone. This device is not...
Chung, Jun Young; Song, Hyung Keun; Jung, Myung Kuk; Oh, Hyeong Tak; Kim, Joon Ho; Yoon, Ji-Sang; Min, Byoung-Hyun
The major meniscal functions are load bearing, load distribution, and shock absorption by increasing the tibiofemoral joint (TFJ) contact area and dissipating axial loads by conversion into hoop stresses. The increased hoop strain stretches the meniscus in outward direction towards radius, causing extrusion, which is associated with the root tear and resultant degenerative osteoarthritis. Since the larger contact area of medial TFJ may increase the hoop stresses, we hypothesized that the larger medial femoral to tibial condylar dimension would contribute to the development of medial meniscus posterior root tear (MMPRT). Thus, the purpose of the study was to assess the relationship between MMPRT and medial femoral to tibial condylar dimension. A case-control study was conducted to compare medial femoral to tibial condylar dimensions of patients with complete MMPRT (n = 59) with those of demography-matched controls (n = 59) during the period from 2010 to 2013. In each patient, MRIs were reviewed and several parameters were measured including articulation width of medial femoral condyle (MFC) at 0°, 30°, 60°, and 90°, medial tibial condyle (MTC) width, degree of meniscal extrusion, and medial femoral to tibial condylar width ratio (MFC/MTC) at 0°, 30°, 60°, and 90°, respectively. Demographic and radiographic data were assessed. A larger medial femoral to tibial condylar dimension was associated with MMPRT at 0° and 30° knee angles. Patients with MFC/MTC greater than 0.9 at 0° also showed about 2.5-fold increase in the chance of MMPRT. Those with meniscal extrusion greater than 3 mm also had about 17.1 times greater chance for the presence of MMPRT accordingly. A larger medial femoral to tibial condylar dimension may be considered as one of the regional contributors to the outbreak of MMPRT, and medial femoral to tibial condylar width ratio greater than 0.9 at 0° knee angle may be considered as a significant risk factor for MMPRT. III.
van Haeff, M J; Sauter, A J
Eight weeks after transposition of the tibial tubercle for recurrent subluxation of the patella, the patient sustained a tibial fracture during rope jumping. In spite of consolidation of the osteotomy in the frontal plane, there remained a small gap in the anterior cortex in the transverse plane through which the tibia failed during bending stress.
Shah, Krupa; Shah, Hitesh
Tibial hemimelia is a rare congenital limb deficiency which is characterised by a hypoplastic/aplastic tibia. It actually represents a spectrum of anomalies, ranging from mild hypoplasia of the tibia to total absence of the tibia. Several classifications based on radiological description exist in the literature. The tibial hemimelia is usually described with preaxial mirror polydactyly, split hand/foot syndrome-ectrodactyly, polydactyly-triphalangeal thumb syndrome (Werner syndrome) and micromelia-trigonal brachycephaly syndrome. We describe a child with unclassified tibial hemimelia. The child had right incomplete tibial hemimelia with bifid tibia, left complete tibial hemimelia, bilateral split hands and left split foot. This is the first report of the bifid tibia in the literature.
Muminagić, Sahib; Drljevic, Sanja; Granić, Amela; Kapidzić, Tarik; Kovacević, Mehmed; Hodzić, Faruk
In 1973. J. Kramer published his own technique for the cure of hallux valgus (Orthopädische Praxis Heft 8/1982, 636-645). He corrects bad position of the first bone of the metatarsus with all the consequences which lie in the basis of the deformation. By osteotomy of the first bone of the metatarsus and re-instates functional equipise of the first foot instep in all the components. Having the experience of 550 operated patients he considered that this method has advantages over numerous described method, indicative range is practically wide, respecting the technique it is simply performed, post-operative cure does not require immobilisation, and in comparison with other methods, complications and bad results are practically unknown. On our ward, in the period between 1984 and 1988, we applied Kramer's osteotomy in 98 cases of hallux valgus. The results were satisfying, considerably better than after other methods of hallux valgus treatment.
Kim, S J; Lee, Y T; Kim, H J
We present a case of foreign body synovitis in the knee joint caused by a fragment of stainless steel imbedded in the tibial plateau for 10 years, which was extracted successfully using an arthroscope. The cause of synovitis was the long-standing release of small stainless steel particles resulting from the abrasion of the steel against the opposing lateral femoral condyle. For an articular foreign body, arthroscopy is by far the best treatment. Arthroscopy allows the surgeon to localize as well as to extract even the smallest foreign body fragment, and also provides for washing out of the joint cavity.
A, Joshi; Kc, B R; Basnet, S B; Panth, R; Shrestha, R L; Chand, P; Thapa, B B
Adamantinoma is an extremely rare primary bony neoplasm. Because of its malignant nature, accurate and early diagnosis is very important. On the other hand adamantinoma mimics many benign conditions, so it is doubly important to establish correct tissue diagnosis to avoid radical surgery with morbidities. Because of its rarity, diagnosing adamantinoma still remains difficult, even if when it occurs in classical sites. We report a case of adamantinoma of tibial shaft diaphysis in a 23 year male. In this case, because of classic clinic-radiological features, we were suspecting adamantinoma from very beginning but final diagnosis was delayed for nine months.
Wall, C E
The Megaladapidae have a posterior expansion of the articular surface of the mandibular condyle. Several other strepsirhine species exhibit a similar condylar surface. In this study, I propose two behavioral scenarios in which the posterior articular expansion might function: 1) contact with the postglenoid process and resistance to joint stress during browsing, and 2) movement against the postglenoid process during the fast closing and power strokes of mastication, as a consequence of large transverse jaw movements and associated with a strong mandibular symphysis. These models are evaluated through dissection of the TMJ in Lepilemur and from comparative anatomical observations on strepsirhines and ungulates. In Lepilemur the mandibular symphysis is unfused, but compared to the unfused symphyses of other strepsirhines is strengthened by interlocking bony projections (Beecher  Am. J. Phys. Anthropol. 47:325-336). An accessory articular meniscus is found between the posterior articular expansion and the postglenoid process in Lepilemur, suggesting that significant movement occurs in this part of the TMJ. The symphysis is fused in adult specimens of Megaladapis. A posterior articular expansion is common among ungulates, and its presence is associated not with browsing but with symphyseal fusion. This supports the second model and suggests that the posterior articular expansion functions as a movement surface during mastication. Schwartz and Tattersall ( J. Hum. Evol. 16:23-40) cite the posterior articular expansion as a synapomorphy uniting an Adapis-Leptadapis clade with a Megaladapidae-Daubentonia-Indridae clade. The comparative evidence suggests that the posterior articular expansion has evolved convergently in adapines, notharctines, megaladapids, hapalemurids, and indrids as part of a functional complex related to herbivory. However, close morphological similarity of the posterior articular expansion among genera within these strepsirhine subfamilies
Luo, Cong-Feng; Sun, Hui; Zhang, Bo; Zeng, Bing-Fang
1) To introduce a computed tomography-based "three-column fixation" concept; and 2) to evaluate clinical outcomes (by using a column-specific fixation technique) for complex tibial plateau fractures (Schatzker classification Types V and VI). Prospective cohort study. Level 1 trauma center. Twenty-nine cases of complex tibial plateau fractures were included. Based on routine x-ray and computed tomography images, all the fractures were classified as a "three-column fracture," which means at least one separate fragment was found in lateral, medial, and posterior columns in the proximal tibia (Schatzker classification Types V and VI). The patients were operated on in a "floating position" with a combined approach, an inverted L-shaped posterior approach combined with an anterior-lateral approach. All three columns of fractures were fixed. Operative time, blood loss, quality of reduction and alignment, fracture healing, complications, and functional outcomes based on Hospital for Special Surgery score and lower-extremity measure were recorded. All the cases were followed for average 27.3 months (range, 24-36 months). All the cases had satisfactory reduction except one case, which had a 4-mm stepoff at the anterior ridge of the tibial plateau postoperatively. No case of secondary articular depression was found. One case had secondary varus deformity, one case had secondary valgus deformity, and two cases of screw loosening occurred postoperatively. No revision surgery was performed. Two cases had culture-negative wound drainage. No infection was noted. The average radiographic bony union time and full weightbearing time were 13.1 weeks (range, 11-16 weeks) and 16.7 weeks (range, 12-24 weeks), respectively. The mean Short Form 36, Hospital for Special Surgery score, and lower-extremity measure at 24 months postoperatively were 89 (range, 80-98), 90 (range, 84-98), and 87 (range, 80-95), respectively. The average range of motion of the affected knee was 2.7° to 123.4° at
Durst, A; Clibbon, J; Davis, B
The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication. PMID:26274757
Sahin, Namık; Atıcı, Teoman; Kurtoğlu, Ünal; Turgut, Ali; Ozkaya, Güven; Ozkan, Yüksel
The purpose of the present study was to determine whether the axes aligned with the sulcus between the tibial spines and the middle of the posterior cruciate ligament at the knee and with the tibialis anterior tendon at the ankle provide a neutral rotational and coronal alignment of the tibial component in total knee arthroplasty (TKA). In a cohort of 45 TKA patients, CT scans were taken to quantify coronal and rotational positioning of the components. All patients received a posterior stabilised total knee replacement with a fixed insert (PFC Sigma; DePuy Orthopaedics, Inc; Warsaw, IN, USA). The tibial guide was aligned with the sulcus between the tibial spines and the middle of the posterior cruciate ligament at the knee and with the tibialis anterior tendon at the ankle. The average post-operative coronal mechanical alignment was 1° varus (range 4.5° varus-1.5° valgus; SD ±1.51). The average post-operative rotational deviation from the transepicondylar axes (TEA) was 0.78° of internal rotation (1.50° of internal rotation - 3.5° of external rotation) for the tibial component. The whole-extremity mechanical axis deviation was outside the tolerance range of 3° in 4 patients (8.9 %). Deviation of the tibial component rotational position relative to the TEA was 3° or less in 94.5 % of the patients. When the tibial component is aligned using the axis drawn from the centre of the PCL to the sulcus between the tibial spines on the proximal tibia and to the tibialis anterior tendon at the ankle, good alignment will be achieved in both the coronal and axial planes. IV.
Hirano, Takaaki; McCullough, Matthew B A; Kitaoka, Harold B; Ikoma, Kazuya; Kaufman, Kenton R
Posterior tibial tendon dysfunction is a significant contributor to flatfeet. Non-operative treatments, like in-shoe orthoses, have varying degrees of success. This study examined changes to the work of friction of the posterior tibial tendon under three conditions: intact, simulated flatfoot, and flatfoot with an orthosis. It was hypothesized that work of friction of the posterior tibial tendon would significantly increase in the flatfoot, yet return to normal with an orthosis. Changes to bone orientation were also expected. Six lower limb cadavers were mounted in a foot simulator, that applied axial and a posterior tibial tendon load. Posterior tibial tendon excursion, gliding resistance, and foot kinematics were monitored, and work of friction calculated. Each specimen moved through a range of motion in the coronal, transverse, and sagittal planes. Mean work of friction during motion in the coronal plane were 0.17 N cm (SD 0.07 N cm), 0.25 N cm (SD 0.09 N cm), and 0.23 N cm (SD 0.09 N cm) for the intact, flatfoot, and orthosis conditions, respectively. Motion in the transverse plane yielded average WoF of 0.36 N cm (SD 0.28 N cm), 0.64 N cm (SD 0.25 N cm), and 0.57 N cm (SD 0.38 N cm) in the same three conditions, respectively. The average tibio-calcaneal and tibio-metatarsal valgus angles significantly increased in the flatfoot condition (5.8 degrees and 9 degrees , respectively). However, the orthosis did slightly correct this angle. The prefabricated orthosis did not consistently restore normal work of friction, though it did correct the flatfoot visually. This implies that patients with flatfeet may be predisposed to developing posterior tibial tendon dysfunction due to abnormal gliding resistance, though bone orientations are restored.
Isidro, Albert; Malgosa, Assumpció
Hallux valgus is the most common orthopedic problem of the adult foot. The etiology can be congenital, associated with the occurrence of metatarsus primus varus, or acquired, which is closely related to wearing ill-fitting shoes. Hallux valgus occurs almost exclusively in shod societies and, therefore, is a very uncommon finding in archaeological remains. We present a partial first ray of the left foot belonging to a dismembered Egyptian mummy recovered in the necropolis of Sharuna (Middle Egypt) and dated to the end of the Old Kingdom (circa 2100 BC). The mummification process led to a metatarsophalangeal joint in connection by means of soft tissues. The alignment of this joint could be diagnosed as a hallux valgus. Further examination showed a metatarsophalangeal angle of 28°. After a comprehensive literature search and noting that all of the previous cases were described by indirect factors, such as mounting the joint in dry bones, we can state with certainty that the piece we present herein is the oldest case of mummified hallux valgus.
Choi, Gi Won; Kim, Tae Wan; Lee, Ji Wun; Park, Sung Bum; Kim, Jin Kak
Purpose With differences between the sexes in foot bone anatomy and ligamentous laxity, there is the possibility that the results of hallux valgus surgery may also differ between the sexes. We aimed to compare the results of hallux valgus surgery between the sexes. Materials and Methods The authors retrospectively reviewed 60 males (66 feet) and 70 females (82 feet) who underwent distal or proximal chevron osteotomy for the treatment of hallux valgus deformity between June 2005 and December 2011. We compared the clinical and radiologic outcomes between the sexes. Results There were no statistically significant differences in demographics between the sexes. The mean American Orthopedic Foot and Ankle Society score, visual analogue scale for pain, and patient satisfaction at the last follow-up did not differ significantly between the sexes. The mean preoperative hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were not significantly different between the sexes. At the last follow-up, the mean HVA was significantly greater in females (p=0.003) than in males; mean IMA was not significantly different between the sexes. The mean correction of HVA in males was significantly greater than that in females (p=0.014). Conclusion There were no significant differences between the sexes regarding clinical outcomes after distal and proximal chevron osteotomy. However, male patients achieved greater correction of HVA than female patients. There is a possibility that sexual dimorphism of the foot may affect postoperative HVA. PMID:25683997
The aim of the study was to determine the risk factors of unusual, lateral direction of epiphyseal displacement in primarily unilateral slipped capital femoral epiphysis (SCFE) patients with a special focus on radiological parameters of an unaffected hip. A total of 115 patients (75 boys, 40 girls), mean age 13.2 years (8.4-18.6), were analyzed. The mean follow-up time was 11 years (2-29). The proportion of valgus slip among SCFE patients was 11 of 115 cases (9.6%). The patients with valgus slip compared with the classic ones were predominantly females (55 vs. 33%), were younger (11.1 vs. 13.4 years), had a greater epiphyseal-shaft angle (67.4 vs. 59.1°), smaller displacement in the frontal plane (absolute value 6.7 vs. 15°), and a lower risk of contralateral slip (27 vs. 65%). There was no difference in the neck-shaft angle and epiphyseal-neck angle value. A more horizontal orientation of the subcapital growth plate, assessed by epiphyseal-shaft angle, can be considered a conducive factor in the valgus direction of epiphyseal slip in SCFE. In valgus SCFE cases, there is a smaller degree of epiphyseal displacement in both the sagittal and the coronal plane and a lower risk of consecutive contralateral slip.
Fujiwara, Yasuhiro; Hayashida, Tatsuro; Murakami, Koji; Makio, Satoshi; Shimizu, Yuichi; Oka, Yoshinobu; Kim, Wook-Choel; Ogura, Taku; Kubo, Toshikazu
Slipped capital femoral epiphysis (SCFE) is a common disease of adolescent and the epiphysis is positioned more posteromedially in relation to the femoral neck shaft with varus SCFE; however, posterolateral displacement of the capital epiphysis, valgus SCFE, occurs less frequently. We report a case of valgus SCFE in a 17-year-old boy with hypopituitarism. After falling down, he experienced difficulty in walking. The radiographs were inconclusive; however three-dimensional computed tomography images showed lateral displacement of the epiphysis on the right femoral head. Valgus SCFE was diagnosed. The patient underwent in situ pinning of both sides. In situ pinning on the left side was performed as a prophylactic pinning because of endocrine abnormalities. At the 1-year follow-up, he could walk without any difficulty and there were no signs of pain. The epiphysis is commonly positioned more posteromedially in relation to the femoral neck shaft with most SCFE, but, in this case, the epiphysis slipped laterally. Differential diagnosis included femoral neck fracture (Delbet-Colonna type 1); however, this was less likely due to the absence of other clinical signs. Therefore, we diagnosed the patient as SCFE. When children complain of leg pain and limp, valgus SCFE that may not be visualized on anteroposterior radiographs needs to be considered. PMID:28154765
Oh, Kwang-Jun; Ko, Young Bong; Bae, Ji Hoon; Yoon, Suk Tae; Kim, Jae Gyoon
The aim of this study was to evaluate which lower extremity alignment (knee and ankle joint) parameters affect knee joint line obliquity (KJLO) in the coronal plane after open wedge high tibial osteotomy (OWHTO). Overall, 69 knees of patients that underwent OWHTO were evaluated using radiographs obtained preoperatively and from 6 weeks to 3 months postoperatively. We measured multiple parameters of knee and ankle joint alignment (hip-knee-ankle angle [HKA], joint line height [JLH], posterior tibial slope [PS], femoral condyle-tibial plateau angle [FCTP], medial proximal tibial angle [MPTA], mechanical lateral distal femoral angle [mLDFA], KJLO, talar tilt angle [TTA], ankle joint obliquity [AJO], and the lateral distal tibial ground surface angle [LDTGA]; preoperative [-pre], postoperative [-post], and the difference between -pre and -post values [-Δ]). We categorized patients into two groups according to the KJLO-post value (the normal group [within ± 4 degrees, 56 knees] and the abnormal group [greater than ± 4 degrees, 13 knees]), and compared their -pre parameters. Multiple logistic regression analysis was used to examine the contribution of the -pre parameters to abnormal KJLO-post. The mean HKA-Δ (-9.4 ± 4.7 degrees) was larger than the mean KJLO-Δ (-2.1 ± 3.2 degrees). The knee joint alignment parameters (the HKA-pre, FCTP-pre) differed significantly between the two groups (p < 0.05). In addition, the HKA-pre (odds ratio [OR] = 1.27, p = 0.006) and FCTP-pre (OR = 2.13, p = 0.006) were significant predictors of abnormal KJLO-post. However, -pre ankle joint parameters (TTA, AJO, and LDTGA) did not differ significantly between the two groups and were not significantly associated with the abnormal KJLO-post. The -pre knee joint alignment and knee joint convergence angle evaluated by HKA-pre and FCTP-pre angle, respectively, were significant predictors of abnormal KJLO after OWHTO. However, -pre ankle joint parameters
Hennig, Alex C; Incavo, Stephen J; Beynnon, Bruce D; Abate, Joseph A; Urse, John S; Kelly, Stephen
Twenty opening wedge tibial osteotomies were performed using the Osteotrac plate, which consists of a two-piece plate with a one-way ratcheting mechanism with two degrees of freedom. A variety of concomitant procedures were performed including osteochondral transfer, tibial tubercle medialization, and anterior cruciate ligament reconstruction. The change in tibiofemoral alignment in the coronal plane and the shift in lower extremity mechanical axis were determined. The average lateral shift in the lower extremity mechanical axis was 24% of the tibial plateau width. The average change in the mechanical tibiofemoral angle was 7 degrees of valgus. Union rate at the osteotomy site was 95%. No deep infections, clinical deep venous thrombosis, or device failures occurred. The Osteotrac plate provides safe and effective fixation and intraoperative adjustability to achieve and maintain a lateral shift of the lower extremity mechanical axis and valgus correction of the tibiofemoral alignment in patients with varus knees undergoing proximal tibial opening wedge osteotomy and associated meniscal and chondral procedures.
Cao, Hong-Hui; Tang, Kang-Lai; Lu, Wei-Zhong; Xu, Jian-Zhong
We investigated the clinical outcomes after medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular, in patients with flexible flatfoot with accessory navicular symptoms. From December 2008 to July 2011, 16 patients (21 feet) with a flexible flatfoot, symptomatic accessory navicular, and obvious heel valgus underwent medial displacement calcaneal osteotomy and reconstruction with posterior tibial tendon insertion on the navicular bone. The patients were evaluated preoperatively, 6 weeks and 3, 6, and 12 months postoperatively, and every 6 months thereafter. The clinical examination was undertaken using the American Orthopaedic Foot and Ankle Society ankle and midfoot scores. The radiologic assessments included the arch height, calcaneus inclination angle, talocalcaneal angle, and talar first metatarsal angle on the lateral weightbearing radiograph. The talocalcaneal angle and talar first metatarsal angle was assessed on the anteroposterior view of the weightbearing foot. Heel valgus alignment was assessed on the axial hindfoot radiographs. The mean follow-up duration was 28.5 months (range 18 to 48). All patients were satisfied with the clinical results and were pain free 6 months postoperatively. No cases of wound infection or nerve injury developed. The mean American Orthopaedic Foot and Ankle Society score improved from 53.3 ± 6.5 to 90.8 ± 1.4 at the last follow-up visit (p < .01). The improvements in all radiographic parameters were statistically significant between the preoperative and last follow-up examinations (p < .01). The heel valgus of all patients was corrected. Our results have shown that medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular bone is an effective treatment of flexible flatfoot with symptomatic accessory navicular, associated with excellent clinical outcomes and correction of the deformity. Copyright © 2014
Aguinaldo, Arnel L; Chambers, Henry
Studies have shown that various biomechanical factors affect valgus extension overload during baseball pitching; yet, their relationships are not clearly defined, and factors such as trunk rotation and arm slot have not been investigated. The onset of trunk rotation, with other biomechanical variables that define sequential body motion, will significantly predict elbow valgus loading. Descriptive laboratory study. Sixty-nine adult baseball players pitched off an indoor mound during 3-dimensional motion analysis to measure whole body kinematics and kinetics at 240 Hz. Thirteen biomechanical variables were calculated and extracted for regression analysis to investigate their associations with elbow valgus load. A 2-way analysis of variance compared valgus torques between pitchers with 2 onsets of trunk rotation (before and after front-foot contact) and 2 arm slot positions (overhand and sidearm). Six biomechanical variables had significant correlations (P < .02) with elbow valgus torque-with maximum shoulder external rotation, elbow flexion at peak valgus torque, and elbow valgus loading rate accounting for 68% of its variance. Reduced elbow valgus torques were associated with increased elbow flexion (P < .01). Players who initiated trunk rotation before front-foot contact had significantly higher elbow valgus torques than did those who rotated afterward (P = .02). Fourteen pitchers displayed a sidearm delivery and had significantly higher elbow valgus torques than did those with an overhand arm slot position. Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion. A condition of late trunk rotation, reduced shoulder external rotation, and increased elbow flexion appeared to be most closely related to valgus torque. Sidearm pitchers appeared to be more susceptible than overhand pitchers to reduced elbow valgus torque. The biomechanical findings of this study offer scientific feedback for developing
Kamble, Vijaya; Kulkarni, Ameya; Pajnigara, Nilufer; Dhok, Avinash
Osteochondroma (OC) is a common slow growing tumour of bone. This lesion is frequently seen in the axial skeleton and is relatively uncommon in oral and maxillofacial region. In facial bones, it usually affects the mandibular condyle followed by coronoid process. Very few cases of condylar osteocondroma have been reported in the literature. The aim of this article was to present an atypical case of osteochondroma of bilateral mandibular condyle in an asymptomatic patient and facilitate making an exact diagnosis of it. To the best of our knowledge this is the 2nd case of this type reported in literature. PMID:27656529
Lim, William; Weng, Lye Kok; Tin, Goh Bee
Osteochondromas are common tumors of the long bones, but are rare in the craniofacial region. We detailed two different management of osteochondroma of the mandibular condyle treated utilizing three-dimensional (3D) imaging and computer-assisted planning. Simultaneous open temporomandibular joint and orthognathic surgeries were done to treat both the pathology and secondary facial asymmetry. An osteochondroma that presented as a bony mass at the lateral aspect of the left mandibular condyle of a 24-year-old Chinese female was treated with simultaneous orthognathic surgery and conservative excision. No recurrence was detected 7 months postsurgery. An osteochondroma that presented as a generalized enlargement of the right mandibular condyle of a 25-year-old Chinese male was treated with simultaneous orthognathic surgery and condylectomy. There were no significant issues 3 years postsurgery. Simultaneous orthognathic and temporomandibular joint surgeries are a viable option for the management of osteochondroma of the mandibular condyle. The availability of 3D imaging enabled better presurgical examination of the lesion, which directed treatment toward condylectomy or conservative excision. PMID:25593879
Kim, Moon-Hwan; Yi, Chung-Hwi; Weon, Jong-Hyuck; Cynn, Heon-Seock; Jung, Do-Young; Kwon, Oh-Yun
[Purpose] This study investigated whether the toe-spread-out exercise affects the hallux valgus angle, the cross-sectional area of the abductor hallucis muscle, and the hallux valgus angle during active abduction. [Subjects and Methods] Twenty-four subjects with hallux valgus were randomly assigned to orthosis and orthosis plus toe-spread-out exercise groups. The orthosis group wore the orthosis for 8 weeks, while the orthosis plus toe-spread-out group also performed the toe-spread-out exercise. The hallux valgus angle, the cross-sectional area of the abductor hallucis muscle, and the hallux valgus angle during active abduction were measured initially and after 8 weeks by radiography and ultrasonography. [Results] While there were no significant changes in the three parameters in the orthosis group, there were significant differences in the orthosis plus toe-spread-out exercise group after 8 weeks. In addition there were significant differences in the three measures between the two groups. [Conclusion] The toe-spread-out exercise reduces the hallux valgus angle and hallux valgus angle during active abduction, and increases the cross-sectional area of the abductor hallucis muscle. The toe-spread-out exercise is recommended for patients with mild to moderate hallux valgus. PMID:25995546
Bae, Dae Kyung; Lee, Jong Whan; Cho, Seong Jin; Song, Sang Jun
To compare navigation and weight bearing radiographic measurements of mechanical axis (MA) before and after closed wedge high tibial osteotomy (HTO) and to evaluate post-osteotomy changes in MA assessed during application of external varus or valgus force. Data from 30 consecutive patients (30 knees) who underwent computer-assisted closed-wedge HTO were prospectively analyzed. Pre- and postoperative weight bearing radiographic evaluation of MA was performed. Under navigation guidance, pre- and post-osteotomy MA values were measured in an unloaded position. Any change in the post-osteotomy MA in response to external varus or valgus force, which was named as dynamic range, was evaluated with the navigation system. The navigation and weight bearing radiographic measurements were compared. Although there was a positive correlation between navigation and radiographic measurements, the reliability of navigation measurements of coronal alignment was reduced after osteotomy and wedge closing. The mean post-osteotomy MA value measured with the navigation was 3.5°±0.8° valgus in an unloaded position. It was 1.3°±0.8° valgus under varus force and 5.8°±1.1° valgus under valgus force. The average dynamic range was >±2°. Potential differences between the postoperative MAs assessed by weight bearing radiographs and the navigation system in unloaded position should be considered during computer-assisted closed wedge HTO. Care should be taken to keep the dynamic range within the permissible range of alignment goal in HTO.
Miller, Emily J; Pagnano, Mark W; Kaufman, Kenton R
For total knee arthroplasty (TKA), neutral mechanical alignment produces balanced static knee loading. Dynamically, knee loading is affected by more than limb static alignment. We compared static and dynamic knee loading following TKA. Fifteen TKA patients were evaluated pre-operatively and 2 months and 2 years post-operatively. Tibiofemoral angles and medial tibial plateau loading were calculated. Pre-operatively, static medial load was greater for varus than valgus knees. Post-operatively, no relationship existed between tibiofemoral angle and static medial plateau load. Pre-operatively and post-operatively, dynamic medial load was not dependent on tibiofemoral angle. While all patients achieved equal static plateau load distributions at 2 years, only 47% had dynamic medial load distributions of 50 ± 10%. Static tibiofemoral alignment alone does not predict dynamic tibial loading.
Pinzur, M S; Cox, W; Kaiser, J; Morris, T; Patwardhan, A; Vrbos, L
The prosthetic sockets of 14 independent persons with unilateral trans-tibial (BK) amputation were mounted on an adjustable alignment pylon. Vertical ground reaction forces were recorded in neutral prosthetic alignment and in 10 degrees of prosthetic socket varus, valgus, flexion, and extension. Stance phase time, peak vertical ground reaction force, and impulse were all found to be increased on the sound limb when compared to the amputated residual limb. Significant differences were found in stance phase time and peak vertical ground reaction force when comparing malaligned with neutrally aligned prosthetic limbs. Significant differences were also seen in impulse between neutrally aligned and malaligned prosthetic limbs. The results suggest that prosthetic malalignment in persons with trans-tibial amputation leads to increased loading of the contralateral limb.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures. PMID:27026999
Reshef, Noam; Guelich, David R
MTSS is a benign, though painful, condition, and a common problem in the running athlete. It is prevalent among military personnel, runners, and dancers, showing an incidence of 4% to 35%. Common names for this problem include shin splints, soleus syndrome, tibial stress syndrome, and periostitis. The exact cause of this condition is unknown. Previous theories included an inflammatory response of the periosteum or periosteal traction reaction. More recent evidence suggests a painful stress reaction of bone. The most proven risk factors are hyperpronation of the foot, female sex, and history of previous MTSS. Patient evaluation is based on meticulous history taking and physical examination. Even though the diagnosis remains clinical, imaging studies, such as plain radiographs and bone scans are usually sufficient, although MRI is useful in borderline cases to rule out more significant pathology. Conservative treatment is almost always successful and includes several options; though none has proven more superior to rest. Prevention programs do not seem to influence the rate of MTSS, though shock-absorbing insoles have reduced MTSS rates in military personnel, and ESWT has shortened the duration of symptoms. Surgery is rarely indicated but has shown some promising results in patients who have not responded to all conservative options.
Zheng, Keke; Scholes, Corey J; Chen, Junning; Parker, David; Li, Qing
Medial opening wedge high tibial osteotomy (MOWHTO) is a surgical procedure to treat knee osteoarthritis associated with varus deformity. However, the ideal final alignment of the Hip-Knee-Ankle (HKA) angle in the frontal plane, that maximizes procedural success and post-operative knee function, remains controversial. Therefore, the purpose of this study was to introduce a subject-specific modeling procedure in determining the biomechanical effects of MOWHTO alignment on tibiofemoral cartilage stress distribution. A 3D finite element knee model derived from magnetic resonance imaging of a healthy participant was manipulated in-silico to simulate a range of final HKA angles (i.e. 0.2°, 2.7°, 3.9° and 6.6° valgus). Loading and boundary conditions were assigned based on subject-specific kinematic and kinetic data from gait analysis. Multiobjective optimization was used to identify the final alignment that balanced compressive and shear forces between medial and lateral knee compartments. Peak stresses decreased in the medial and increased in the lateral compartment as the HKA was shifted into valgus, with balanced loading occurring at angles of 4.3° and 2.9° valgus for the femoral and tibial cartilage respectively. The concept introduced here provides a platform for non-invasive, patient-specific preoperative planning of the osteotomy for medial compartment knee osteoarthritis.
Sigward, Susan M; Powers, Christopher M
Excessive knee valgus moments are considered a risk factor for non-contact anterior cruciate ligament injuries in female athletes, however, little is known about the biomechanical factors that contribute to this loading pattern. The purpose of this study was to compare lower extremity kinematics, foot position and ground reaction forces between female soccer players who demonstrate normal frontal plane moments at the knee with those who demonstrate excessive frontal plane moments at the knee during a cutting maneuver. Sixty-one female soccer players, 16 (2) years, participated. Three dimensional kinematics and ground reaction forces were recorded during a side-step cutting maneuver. Knee frontal plane moments were calculated with inverse dynamics equations and were used to classify subjects into normal (N=38) and excessive valgus moment (N=23) groups. Data revealed that the subjects with excessive valgus moments demonstrated an initial loading pattern that included greater laterally directed ground reaction forces (P<0.001, effect size 1.51), increased hip abduction (P=0.002, effect size 0.79), increased hip internal rotation (P=0.008, effect size 0.71) and a more internally rotated foot progression angle (P=0.04, effect size 0.55). Taken together, these variables explained 49% of the variance in peak knee valgus moment (R=.698, P<0.001). These results provide insight into potentially injurious loading strategies and support the premise that interventions designed to encourage loading of the lower extremity in a more neutral alignment may work to decrease frontal plane loading at the knee.
Waizy, H; Stukenborg-Colsman, C; Abbara-Czardybon, M; Emmerich, J; Windhagen, H; Frank, D
Maintaining the corrected position of the first metatasophalangeal axis. Reducing postoperative stiffness by forgoing a medial capsular shift. Hallux valgus deformities or recurrent hallux valgus deformities. Existing osteoarthritis, joint stiffness, large bone defects, osteonecrosis. General medical contraindications to surgical interventions and anesthesiological procedures. Operation under regional anesthesia (foot block) or general anesthesia. Tourniquet. Longitudinal skin incision medial over the pseudexostosis of the first metatarsal bone. Preparing the tendon of the Musculus abductor hallucis. Detaching the tendon from the capsule. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle in an L-wise manner. Osteotomy of the first metatarsal bone. Lax sutures of the capsule in correct position and reattachment of the Musculus abductor hallucis tendon shifted toward distal and dorsal, regarding the rotation of the hallux. Postoperative elevation of the operated foot. Analgesia with nonsteroidal antiinflammatory drugs. Postoperative weight-bearing according to the osteotomy. Passive mobilization of the metatarsophalangeal joint. Dressing for 4 weeks postoperatively in the corrected position. Radiologic control after 6 weeks. Hallux valgus orthosis at night and a toe spreader for a further 6 weeks. A total of 30 isolated hallux valgus deformities with a mean preoperative intermetatarsal (IMA) angle of 12.9° (range 11-15°) were operated with a chevron osteotomy. The mean follow-up was 14.4 (range 8-17) months. The mean dorsiflexion at the last follow-up was 44° (range 20-60°). Only 2 patients had a dorsiflexion <40°. The mean reduction of the IM angle was 5.6° (range 3-7°). One patient required wound revision. There was no infection or avascular necrosis of the metatarsal head observed in the patients. At follow-up, 20 (67%) patients were completely satisfied, 9 (30%) satisfied, and 1 (3
Jung, Woon-Hwa; Takeuchi, Ryohei; Chun, Chung-Woo; Lee, Jung-Su; Ha, Jae-Hun; Kim, Ji-Hyae; Jeong, Jae-Heon
The purposes of this study were to evaluate regeneration of the articular cartilage after medial opening-wedge high tibial osteotomy for knees with medial-compartment osteoarthritis and to assess the clinical outcome and cartilage regeneration according to the postoperative limb alignment at 2 years postoperatively. The study involved 159 knees in 159 patients. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of cartilage regeneration, the articular cartilage was classified into 2 stages as no regenerative change (grade 1) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade 2) on second-look arthroscopy. Maturation of the cartilage regeneration was defined as even coverage with fibrocartilage. "Immaturation" of the cartilage regeneration was defined as white scattering with fibrocartilage or partial coverage with fibrocartilage. Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. We divided the knees into 3 groups according to the postoperative limb alignment. Group A comprised knees with a mechanical tibiofemoral angle of 0° or less. Group B comprised knees with a mechanical tibiofemoral angle greater than 0° and less than 6°. Group C comprised knees with a mechanical tibiofemoral angle of 6° or greater. Grade 2 regeneration was achieved in the medial femoral condyle articular cartilage in 92% of knees and in the medial tibial plateau articular cartilage in 69% of knees. Maturation of the cartilage regeneration was found in the medial femoral condyle articular cartilage in 4% of knees and in the medial
Yoo, Ju-Hyung; Park, Byoung-Kyu; Han, Chang-Dong; Oh, Hyun-Cheol
Purpose To evaluate the minimum 5-year mid-term clinical and radiological results of minimally invasive surgery total knee arthroplasty (MIS-TKA) using a mini-keel modular tibia component. Materials and Methods We retrospectively evaluated 254 patients (361 cases) who underwent MIS-TKA between 2005 and 2006. The latest clinical and radiological assessments were done in 168 cases that had been followed on an outpatient basis for more than 5 postoperative years. Clinical results were assessed using the Hospital for Special Surgery (HSS) score and Knee Society score. Radiological evaluation included measurements of knee alignment. Results The average postoperative knee range of motion and HSS score were 134.3°±12.4° and 92.7°±7.0°, respectively. The average postoperative femorotibial angle and tibial component alignment angle were 5.2°±1.7° valgus and 90.2°±1.6°, respectively. The average tibial component posterior inclination was 4.8°±2.1°. The percentage of cases with tibial component alignment angle of 90°±3° was 96.1%, and that with the femorotibial angle of 6°±3° valgus was 94.0%. Radiolucent lines were observed in 20 cases (12.0%): around the femur, tibia, and patella in 14 cases, 10 cases, and 1 case, respectively. However, they were less than 2 mm and non-progressive in all cases. The survival rate was 99.4% and there was no implant-related revision. Conclusions MIS-TKA using a mini-keel modular tibial plate showed satisfactory results, a high survival rate, and excellent clinical and radiological results in the mid-term follow-up. PMID:25229044
Varghese, Viju Daniel; Livingston, Abel; Boopalan, P R; Jepegnanam, Thilak S
Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure. PMID:27190758
Okuda, R; Kinoshita, M; Morikawa, J; Jotoku, T; Abe, M
We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989-1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.
Varghese, Viju Daniel; Livingston, Abel; Boopalan, P R; Jepegnanam, Thilak S
Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.
Kazemi, Seyed Morteza; Qoreishi, Mohamad; Behboudi, Ehsan; Manafi, Alireza; Kazemi, Seyed Kamyar
There are limited studies regarding the effects of high tibial osteotomy (HTO) on other areas of lower extremity. In current study, we investigated the changes of tibiotalar joint following HTO. A total of 39 patients with genu varum requiring HTO were enrolled in this before and after study. The genu varus, joint diversion (JDA), lateral distal tibial (LDTA) and lateral distal tibial-ground surface (LDT-GSA) angles were measured before the operation and compared with 6 months after the surgery. Twenty threeout of39 patients (59%) were females. The genu varus angle decreased significantly (13°±1.7° versus 0.6°±1°). No significant changes were seen in JDA (P=0.45) and LDTA (P=0.071). LDT-GSA changed significantly (P=0.011) from 8.1°±1° in varus to -0.3°±0.5° in valgus. Although HTO did not change the JDA and LDTA, however, significant change in LDT-GSAindicates that HTO can significantly decrease the shearing forces exerted on the ankle joint.
Wong, Benjamin L.; Sah, Robert L.
During knee movement, femoral cartilage articulates against cartilage from the tibial plateau, and the resulting mechanical behavior has yet to be fully characterized. The objectives of this study were to determine 1) the overall and depth-varying axial and shear strains, and 2) the associated moduli, of femoral and tibial cartilage during the compression and shearing of apposing tibial and femoral samples. Osteochondral blocks from human femoral condyles (FC) characterized as normal and donor-matched lateral tibial plateau (TP) were apposed, compressed 13%, and subjected to relative lateral motion. When surfaces began to slide, axial (−Ezz) and shear (Exz) strains and compressive (E) and shear (G) modulus, overall and as a function of depth, were determined for femoral and tibial cartilage. Tibial −Ezz was ~2-fold greater than FC −Ezz near the surface (0.38 versus 0.22) and overall (0.16 versus 0.07). Near the surface, Exz of TP was 8-fold higher than that of FC (0.41 versus 0.05), while overall Exz was 4-fold higher (0.09 versus 0.02). For TP and FC, −Ezz and Exz were greatest near the surface and decreased monotonically with depth. E for FC was 1.7-fold greater than TP, both near the surface (0.40 versus 0.24MPa) and overall (0.76 versus 0.47MPa). Similarly, G was 7-fold greater for FC (0.22MPa) than TP near the surface (0.03MPa) and 3-fold higher for FC (0.38MPa) than TP (0.13MPa) overall. These results indicate that tibial cartilage deforms and strains more axially and in shear than the apposing femoral cartilage during tibio-femoral articulation, reflecting their respective moduli. PMID:20394929
Jacobi, Matthias; Villa, Vincent; Reischl, Nikolaus; Demey, Guillaume; Goy, Damien; Neyret, Philippe; Gautier, Emanuel; Magnussen, Robert A
Opening wedge high tibial osteotomy (HTO) is an accepted treatment option for medial compartment knee osteoarthritis with associated varus lower limb axis in younger, more active patients. A concern with the use of this technique is that posterior tibial slope (PTS) and tibial rotation can be altered. We hypothesized that there is a tendency to increase the PTS and internal rotation of the distal tibia during the procedure and that certain intra-operative parameters may influence the amount of change that can be expected. A cadaveric model and surgical navigation system were used to evaluate the influence of certain intra-operative factors of the degree of PTS and tibial rotation change observed during medial opening HTO. Parameters evaluated included: degree of osteotomy opening, knee flexion angle, location of limb support (thigh versus foot), performance of a posteromedial release, the status of the lateral cortical hinge, and the degree of osteoarthritis present in the knee. Combining measurements of all specimens and parameters, a mean PTS increase of 2.7° ± 3.9° and a mean tibial internal rotation of 1.5° ± 2.9° were observed. Clinically, significant changes in tibial slope (>2°) occurred in 50.4 % of corrections, while significant changes in tibial rotation (>5°) occurred in only 11.9 % of corrections. Patients with significant osteoarthritis and concomitant flexion contracture, cases where large corrections were required, and procedures in which the lateral cortical hinge was disrupted were associated with increased PTS change. The other factors evaluated did not exert a significant influence of the degree of PTS change observed. Surgeons should be vigilant for possible PTS change, particularly in high-risk situations as outlined above. Routine use of an intra-operative measure of PTS is recommended to avoid inadvertent slope change.
Objective This work aimed to assess tibial rotations, meniscal movements, and morphological changes during knee flexion and extension using kinematic magnetic resonance imaging (MRI). Methods Thirty volunteers with healthy knees were examined using kinematic MRI. The knees were imaged in the transverse plane with flexion and extension angles from 0° to 40° and 40° to 0°, respectively. The tibial interior and exterior rotation angles were measured, and the meniscal movement range, height change, and side movements were detected. Results The tibia rotated internally (11.55° ± 3.20°) during knee flexion and rotated externally (11.40° ± 3.0°) during knee extension. No significant differences were observed between the internal and external tibial rotation angles (P > 0.05), between males and females (P > 0.05), or between the left and right knee joints (P > 0.05). The tibial rotation angle with a flexion angle of 0° to 24° differed significantly from that with a flexion angle of 24° to 40° (P < 0.01). With knee flexion, the medial and lateral menisci moved backward and the height of the meniscus increased. The movement range was greater in the anterior horn than in the posterior horn and greater in the lateral meniscus than in the medial meniscus (P < 0.01). During backward movements of the menisci, the distance between the anterior and posterior horns decreased, with the decrease more apparent in the lateral meniscus (P < 0.01). The side movements of the medial and lateral menisci were not obvious, and a smaller movement range was found than that of the forward and backward movements. Conclusion Knee flexion and extension facilitated internal and external tibial rotations, which may be related to the ligament and joint capsule structure and femoral condyle geometry. PMID:25142267
Lin, K-C; Tarng, Y-W; Lin, G-Y; Yang, S-W; Hsu, C-J; Renn, J-H
The three-column fixation concept is becoming popular in orthopedic practice. Posterior column fracture is an uncommon type of tibial plateau fracture. The supine position for the surgical approach is familiar to most surgeons; however, it is difficult to achieve good reduction and fixation in posterior column fracture. The prone position and direct posterior approach can achieve proper reduction and fixation for posterior column tibial plateau fracture, yielding good functional outcome. Between January 2010 and January 2012, 184 tibial plateau fractures were diagnosed and operated on in our institution. Sixteen posterior column tibial plateau fractures (10 male and 6 female patients, with a mean age of 41.5 ± 14.3 years) were diagnosed by preoperative plain films and CT scans. Ten patients presented with fracture-dislocation of the knee joint. A direct posterior approach in prone position was used to reduce the tibial condyle and fix it with an anti-glide buttress plate. Radiographic evaluation included reduction quality and bone union. Functional evaluation included Lysholm score and Tegner activity score. All fractures healed within 6 months, without secondary displacement. Ten knees had postoperative anatomic reduction (0mm step-off) and 6 had acceptable reduction (< 2mm step-off). At 34.4 ± 9.6 months, median extension was 3 (5-10) and flexion 135 (100-145). The mean Lysholm score was 95 (75-100) and the mean Tegner activity score was 6 (5-8). All patients were satisfied with the operation. No cases of post-traumatic osteoarthritis of the knee occurred during follow-up. The prone position and direct posterior approach has great advantages in terms of reduction and stable fixation, yielding good results. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Bae, Dae Kyung; Ko, Young Wan; Kim, Sang Jun; Baek, Jong Hun; Song, Sang Jun
The purpose of the present study was to compare the change in tibial posterior slope angle (PSA) between patients treated via computer-assisted and conventional closed-wedge high tibial osteotomy (CWHTO). It was hypothesized that a decrease in the PSA would be less in the computer-assisted group than in the conventional group. Data on a total of 75 computer-assisted CWHTOs (60 patients) and 75 conventional CWHTOs (49 patients) were retrospectively compared using matched pair analysis. The pre- and postoperative mechanical axis (MA) and the PSA were radiographically evaluated. The parallel angle was defined as the angle between the joint line and the osteotomy surface. The data were compared between the two groups. The postoperative radiographic MA averaged 1.3° ± 2.6° valgus in the computer-assisted group and 0.3° ± 3.1° varus in the conventional group. The change in PSA averaged -0.8° ± 0.9° in the computer-assisted group and -4.0° ± 2.2° in the conventional group. The parallel angle averaged 0.2° ± 3.0° in the computer-assisted group and 6.2° ± 5.3° in the conventional group. Computer-assisted CWHTO using four guide pins could avoid inadvertent change in the PSA. The navigation can be used in anticipation of decreasing the risk of change in the PSA in CWHTO, especially in patients whose preoperative PSA is small. The special attention should be paid to locate the hinge axis acutely and to make the parallel proximal and distal osteotomy surfaces during CWHTO. III.
Brazier, J; Migaud, H; Gougeon, F; Cotten, A; Fontaine, C; Duquennoy, A
We compared on lateral X-rays of 83 healthy knees, 6 methods measuring the tibial sagittal slope. Each method determined the tibial slope according to an independent anatomical axis. The goals of the study were to: 1) detect the differences between the 6 methods; 2) determine if any mathematical relation could be observed between the 6 methods; 3) compare accuracy of proximal anatomical axis versus long anatomical axis to evaluate the tibial slope. 50 healthy patients (83 knees) knees were included in the study. The patients (26 male and 24 females) were 39.3 +/- 15.8 years old. We obtained true lateral X-rays orientated with an image intensifier in order to obtain the exact superposition of the femoral condyles. The measurements were carried out by an observer according to two procedures: 1) by manual goniometric measurements twice; the mean value between both lectures was recorded; 2) with a digitizer (Orthographics TM, Salt Lake City, Ut). We measured the angle between the tangent to the medial tibial plateau and the perpendicular direction to each of the studied anatomical axis: tibial proximal anatomical axis (TPAA); tibial shaft anatomical axis (TSAA); posterior tibial cortex (PTC); fibular proximal anatomical axis (FPAA); fibular shaft axis (FSA); anterior tibial cortex (ATC). The values obtained with the digitizer were used to compare the six methods. The values obtained with the TSAA were considered as reference. Tibial slope values were different with the 6 methods. ATC gave the higher values and PTC the smaller. The difference could be 5 degrees between two methods measuring the same posterior tibial slope. However different, the values obtained with the 6 methods were strongly correlated (R > 0.85; p = 0.0001). We determined mathematical relationships between the values obtained with the 6 methods according to the regression analysis. The correlation with the values obtained with TSAA (reference values) was stronger for TPAA and TPC (respectively R = 0
Crevoisier, Xavier; Assal, Mathieu; Stanekova, Katarina
The pathogenesis of hallux valgus deformity is multifactorial. Conservative treatment can alleviate pain but is unable to correct the deformity. Surgical treatment must be adapted to the type and severity of the deformity. Success of surgical treatment ranges from 80% to 95%, and complication rates range from 10% to 30%. Ankle osteoarthrosis most commonly occurs as a consequence of trauma. Ankle arthrodesis and total ankle replacement are the most common surgical treatments of end stage ankle osteoarthrosis. Both types of surgery result in similar clinical improvement at midterm; however, gait analysis has demonstrated the superiority of total ankle replacement over arthrodesis. More recently, conservative surgery (extraarticular alignment osteotomies) around the ankle has gained popularity in treating early- to mid-stage ankle osteoarthrosis. Adult acquired flatfoot deformity is a consequence of posterior tibial tendon dysfunction in 80% of cases. Classification is based upon the function of the tibialis posterior tendon, the reducibility of the deformity, and the condition of the ankle joint. Conservative treatment includes orthotics and eccentric muscle training. Functional surgery is indicated for treatment in the early stages. In case of fixed deformity, corrective and stabilising surgery is performed. Cite this article: Crevoisier X, Assal M, Stanekova K. Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments. EFORT Open Rev 2016;1:58–64. DOI: 10.1302/2058-5241.1.000015. PMID:28461929
Kwon, Young-Eun; Choi, Karp-Shik; An, Chang-Hyeon; Choi, So-Young; Lee, Jae-Seo
A 21-year-old woman presented with facial asymmetry. Crepitus and clicking of the temporomandibular joint were noted. The midline deviated 5.5 mm to the left, and secondary malocclusion was observed. Panoramic and cone-beam computed tomographic images showed an irregular and exophytic bony mass on the anteromedial surface of the right mandibular condyle. A 3-phase bone scan revealed increased tracer uptake on the affected side. The lesion was treated with excision and reshaping under the diagnosis of osteochondroma confirmed by a histopathological examination. The lesion recurred after 3 years, and the patient underwent condylectomy. Mandibular condylar osteochondroma is often resected because it causes functional and aesthetic problems, but it rarely recurs. To the best of our knowledge, only 2 cases of recurrent osteochondromas of the mandibular condyle have been reported previously. Surgical treatment of the osteochondroma should be performed considering the possibility of recurrence, and long-term follow-up is recommended. PMID:28361031
Boyd, R L; Gibbs, C H; Mahan, P E; Richmond, A F; Laskin, J L
Forces were measured at the articular surface of the temporomandibular joint (TMJ) condyle in two stump-tail monkeys (Macaca arctoides) during chewing, incisal biting, and drinking and also during aggressive behaviors. Force was measured with a thin piezoelectric foil transducer, which was cemented over the anterior and superior surfaces of the condyle. Wires from the upper and lower surfaces of the foil were insulated between two layers of Teflon tape and run subcutaneously to a telemetry unit, which was implanted in the upper back. Force applied across the foil by the condyle was detected by the telemetry unit and transmitted to an FM radio receiver outside the animal. The FM signals were received and demodulated, and a signal proportional to the force applied between the condyle and the TMJ fossa was displayed on a chart recorder. Data were collected over an 8-day period. The animals were not constrained. The TMJ was found to be load bearing. The greatest force of 39.0 lb (17.7 kg) was measured during feisty vocal aggression. Forces ranged as high as 34.5 lb (15.7 kg) during chewing and 28.5 lb (13.0 kg) during incisal biting. Forces were greater on the working (food) side than on the nonworking (balancing) side by average ratios of 1.4 to 2.6. A large unilateral interference at the most distal molar greatly disturbed chewing. It reduced TMJ forces by 50% or more, and the monkey refused to chew on the side opposite the interference.
Marruecos, J; Conill, C; Valduvieco, I; Vargas, M; Berenguer, J; Maurel, J
Skull-base metastases are very unfrequent. Occipital condyle syndrome (OCS) is usually underdiagnosed. Until now few cases have been reported in the literature. We present a 71-year-old woman with metastatic rectum adenocarcinoma, with right occipital headache and ipsilateral hypoglossal palsy, diagnosed by computed tomography and magnetic resonance imaging of OCS due to a skull-base metastasis and treated with radiation therapy.
Cambell, R L; Moore, R F
A 3-month-old infant sustained trauma to the mandibular symphysis resulting in radiographic evidence of a fracture of the right condylar head. This presented the diffculty of performing a clinical examination and total reliance on history of a trauma and subsequent swelling. Multiple radiographs of the condyles were used to establish the diagnosis and rule out a film artifact. No definitive treatment was required other than muscle exercises and parental instruction as to potential problems.
Ramos-Murguialday, Mikel; Lasa-Menéndez, Victor; Ignacio Iriarte-Ortabe, Jose; Couce, Marta
Chondrosarcomas (CHSs) are malignant tumors of cartilaginous origin rarely found in the jawbone. Only 5% to 10% of CHSs occur in the head and neck region. These tumors have strong tendency to recur locally after surgical removal. Here, we present the case of a 45-year-old man with a CHS of the mandible. We describe the removal of the mandibular condyle, which requires the reconstruction of the temporomandibular joint. This raises the difficulty of reconstruction because of the location of the tumor in a region of great aesthetic and functional impact. In our case, the patient with computed tomography scan had a mandibular osteolytic and expansive multilocular lesion located in the mandibular branch and left mandibular angle involving the condyle. A biopsy revealed a moderately differentiated CHS (World Health Organization grade II). We decided to perform a wide surgical excision of the lesion without neck dissection because of the infrequent lymphatic spread. It was carried out with a left mandibulectomy, including the mandibular condyle. The reconstruction was performed by using a microsurgical fibula flap and fixing it to the meniscus and articular capsule with a Mitek anchor. The patient has no clinical signs of recurrence or aesthetic or functional limitations 3 years after surgery. This case has brought us to review a very uncommon matter in this location, which emphasizes the importance of a wide resection crucial in the disease prognosis.
Sheikh, S; Pallagatti, S; Gupta, D; Mittal, A
The incidence of tuberculosis (TB) is increasing worldwide and so are its consequences. Its oral manifestations are infrequent, occurring in approximately 3% of all cases. Although the primary lesion occurs as a pulmonary infection, the extrapulmonary infections have also shown an increase over the past few years. These infections generally involve the head and neck through haematogenous or lymphatic routes. The clinical presentation may be as an ulcer, granuloma, orofacial TB, TB of the salivary glands or tuberculous lymphadenitis. Rarely, secondary oral manifestations associated with pulmonary infection are seen, which can appear as lesions on the gingiva, palate, lips, tongue, buccal mucosa, frenulum and in the jaw bones. Owing to the rarity of orofacial TB, it seldom arouses clinical suspicion, especially when a positive history of a systemic infection or therapy is denied. Tuberculous involvement of the mandibular condyle is even rarer, and only two such cases are reported so far, both in English-language literature. Further, the diagnosis of such a case is extremely difficult as there are no specific signs pathogonomic of infection. The only manifestation may be a localized painful swelling of the jaw. The presented case is of osteomyelitis of the mandibular condyle in a 20-year-old male patient in whom TB was later suspected. In this case report the role of diagnostic techniques is emphasized as the osteomyelitis of the condyle has the risk of being easily missed owing to its atypical signs and symptoms and atypical radiographic appearance.
Schwartsmann, Carlos Roberto; Spinelli, Leandro de Freitas; Yépez, Anthony Kerbes; Boschin, Leonardo Carbonera; Silva, Marcelo Faria
ABSTRACT OBJECTIVE : The purpose of this study was to evaluate the performance of valgus intertrochanteric osteotomy in femoral neck non-union. METHODS : Forty-two patients with femoral neck fractures with non-union treated using Pauwels' intertrochanteric osteotomy were reviewed. Demographics, time elapsed between fracture and surgery, follow--up, osteosynthesis used, Garden's classification, limb shortening, and x-rays were evaluated. RESULTS : Twenty-two men and 20 women were reviewed. The youngest patient was 18 years old and the oldest 65 years old, with a mean age of 42.4 years (±11.2). The minimum follow-up was 2 years, with a mean of 10.2 years. The average time elapsed between initial fracture and osteotomy was 6.5 months. Twel-ve cases were neglected femoral neck fractures. Nineteen patients were classified as Garden III, and 23 patients as Garden IV. After valgus osteotomy, non-union healing was observed in 38 patients (38/42; 90.4%). Healing of thirty-seven cases of pseudoarthrosis were obtained after the first-attempt osteotomy, and one case required two operations for healing. The osteotomy failed in four cases. Conside-ring the healed osteotomies, good to excellent functional results were achieved in 80.9% (34/42) of the patients. Total hip replacement was subsequently performed in 14.2% (6/42) of the patients for unfavoura-ble outcomes (two for cutting out, two for osteonecrosis, and two for osteoarthritis). CONCLUSIONS : Valgus intertrochanteric osteotomy has a high success rate in archiving healing in femoral neck non-union with good functional results. It is a biological and effective method. Level of Evidence IV, Therapeutic Study. PMID:27057146
Aronson, Patricia A.; Gieck, Joe H.; Hertel, Jay; Rijke, Arie M.; Ingersoll, Christopher D.
Abstract Context: Recommendations on the positioning of the tibiofemoral joint during a valgus stress test to optimize isolation of the medial collateral ligament (MCL) from other medial joint structures vary in the literature. If a specific amount of flexion could be identified as optimally isolating the MCL, teaching and using the technique would be more consistent in clinical application. Objective: To determine the angle of tibiofemoral joint flexion between 0° and 20° that causes a difference in the slope of the force-strain line when measuring the resistance to a valgus force applied to the joint. Design: Cross-sectional study. Setting: University research laboratory. Patients or Other Participants: Twelve healthy volunteers (6 men, 6 women: age = 26.4 ± 5.6 years, height = 170.9 ± 8.4 cm, mass = 75.01 ± 14.6 kg). Intervention(s): Using an arthrometer, we applied a valgus force, over a range of 60 N, to the tibiofemoral joint in 0°, 5°, 10°, 15°, and 20° of flexion. Main Outcome Measure(s): Force-strain measurements were obtained for 5 positions of tibiofemoral joint flexion. Results: As knee flexion angle increased, slope values decreased (F4,44 = 17.6, P < .001). The slope at full extension was not different from that at 5° of flexion, but it was different from the slopes at angles greater than 10° of flexion. Similarly, the slope at 5° of flexion was not different from that at 10° of flexion, but it was different from the slopes at 15° and 20° of flexion. Further, the slope at 10° of flexion was not different from that at 15° or 20° of flexion. Finally, the slope at 15° of flexion was not different from that at 20° of flexion. Conclusions: When performing the manual valgus stress test, the clinician should fully extend the tibiofemoral joint or flex it to 5° to assess all resisting medial tibiofemoral joint structures and again at 15° to 20° of joint flexion to further assess the MCL. PMID:20617910
PIPINO, GENNARO; INDELLI, PIER FRANCESCO; TIGANI, DOMENICO; MAFFEI, GIUSEPPE; VACCARISI, DAVIDE
Purpose medial opening-wedge osteotomy is a widely performed procedure used to treat moderate isolated medial knee osteoarthritis. Historically, the literature has contained reports showing satisfactory mid-term results when accurate patient selection and precise surgical techniques were applied. This study was conducted to investigate the clinical and radiographic seven- to twelve-year results of opening-wedge high tibial osteotomy in a consecutive series of patients affected by varus knee malalignment with isolated medial compartment degenerative joint disease. Methods we reviewed a case series of 147 medial opening-wedge high tibial osteotomies at an average follow-up of 9.5 years. Endpoints for evaluation included the reporting of adverse effects, radiographic evidence of bone union, radiographic changes in the correction angle during union, and clinical and functional final outcomes. Results good or excellent results were obtained in 94% of the cases: the patients reported no major complications related to the opening-wedge high tibial osteotomy surgical technique, bone graft resorption, implant choice or postoperative rehabilitation protocol. At final follow-up, the average hip-knee angle was 4° of valgus without major loss of correction during the healing process. A statistically significant change in the patellar height was detected postoperatively, with a trend towards patella infera. Conclusions medial opening-wedge high tibial osteotomy is still a reliable method for correcting varus deformity while producing stable fixation, thus allowing satisfactory stability, adequate bone healing and satisfactory mid- to long-term results. Level of evidence Level IV, therapeutic cases series. PMID:27386441
Bytyqi, Dafina; Shabani, Bujar; Cheze, Laurence; Neyret, Philippe; Lustig, Sebastien
Patients with knee osteoarthritis tend to modify spatial and temporal parameters during walking to reduce the pain. Total knee arthroplasty (TKA) is considered the gold standard treatment for end-stage knee osteoarthritis. However, reduced physical function of the knee is partly, but apparently not fully, remedied by surgery. The purpose of this study was to investigate the in vivo, three dimensional knee kinematics during gait at the patients with knee osteoarthritis and the influence of "third condyle" psoterior stabilized (PS) total knee arthroplasty on restoration of normal kinematics. Twenty patients with medial knee osteoarthritis and a control group with age-matched subjects were prospectively collected for this study. The same group of 20 patients were re-assessed 10 months after total knee arthroplasty with "third condyle" PS prosthesis. All subjects were assessed with a 3D, optoelectric knee assessement device, while walking on a treadmill at a self-selected speed. For each participant, knee flexion-extension, abduction-adduction, internal-external rotation and anterior-posterior displacement, were calculated. The range of flexion/extension was improved significantly (39.9° ± 5.5° vs 44.8° ± 5.1°, p < 0.05) after TKA but it still remained lower than control group (6.9° ± 5.5° vs 2.2° ± 3.9°, p < 0.05). The range of motion in internal-external rotation did not change pre- and post-arthroplasty, but remained lower than the matched control group (6.7° ± 2.4° vs 9.3° ± 2.4, p < 0.05). The maximum posterior displacement during swing phase was significantly higher at post-arthroplasty group comparing with control group (-9.5 ± 2.2 vs -5.7 ± 3 mm, p < 0.05). Following "third condyle" PS-TKA, patients had better clinical, spatiotemporal and kinematic parameters. Despite improvements, the knee kinematics during gait in TKA group differed from healthy control group. TKA group had a lower extension lower range
Inui, Hiroshi; Taketomi, Shuji; Yamagami, Ryota; Sanada, Takaki; Shirakawa, Nobuyuki; Tanaka, Sakae
Tilting of the mobile bearing relative to the tibial tray in the flexion position may result from the implantation of femoral components more laterally relative to tibial components during unicompartmental knee arthroplasty (UKA) using the Oxford Knee. The purpose of the present study was to compare femoral component positions after UKA using the phase 3 device and a novel device. We further evaluated the placement of the femoral components with the new device in the flexion position to determine the association with short-term prognosis. The location of femoral and tibial components in the flexion position of 38 knees implanted using the phase 3 device and 49 knees using a novel device was assessed at 1 year postoperatively using radiography of the proximal tibia and distal femur in the flexion position. The femoral component was implanted more laterally using the new device than using the phase 3 device in the flexion position (P = .012), which caused the impingement of the mobile bearing against the lateral wall of the tibial tray. After UKA using the new device, 10% of patients exhibited the tilting phenomenon of the mobile bearing because of the lateral implantation of the femoral implant. To prevent implantation of the femoral component too laterally using the new device during UKA, knee surgeons should set the drill guide more medially such that the center of the drill is aligned with the middle of the medial femoral condyle. Copyright © 2016 Elsevier Inc. All rights reserved.
Davenport, Kathleen L; Simmel, Liane; Kadel, Nancy
Hallux valgus is a common deformity of the forefoot. There is no doubt that some dancers develop hallux valgus, but the question remains as to whether dancers are at greater risk than the general population for developing this deformity. Review of the literature reveals on-going debate regarding risk factors for hallux valgus, which may include increasing age, female gender, genetic predisposition, constrictive shoe wear, first ray hypermobility, foot architecture, tight Achilles tendon, and first metatarsal length. There is insufficient evidence to demonstrate conclusively that dancing, specifically pointe work, increases the prevalence or severity of hallux valgus; more research is needed. Treatment of hallux valgus in dancers should be conservative, with delay of surgical correction until retirement if possible.
Sener, Sevgi; Akgunlu, Faruk
Objectives: To investigate the relationship between different clinical findings and condyle position. Methods: Tenderness on masseter (MM), temporal (TM), lateral pyterigoid (LPM), medial pyterigoid (MPM) and posterior cervical (PSM) muscles, limitation, deviation and deflection in opening of mouth, clicking, crepitating, tenderness on lateral palpation of temporomandibular joint (TMJ) area for each side of 85 patients were evaluated. Each side of patients was categorized into the clinical findings: no sign and/or symptom of temporomandibular dysfunctions (TMDs), only extraarticular findings and only intraarticular findings, extra and intraarticular findings. Condyle positions of 170 TMJs were determined the narrowest anterior (a) and posterior interarticular distance (p) on mid-sagittal MRIs of condyles and expressed as p/a ratio and these ratio were transformed into logarithmic base e. Spearman’s Correlation was used to investigate the relationship between the condyle position and the clinical findings. The difference between the condyle positions of different groups was tested by T test. Reliability statistic was used to determine intra-observer concordance of two measurements of condylar position. Results: A significant relationship was found between the condyle position and tenderness of PSM. There was no significant difference between the groups in aspect of the condyle position. Occlusion and condyle position correlated with significantly. Conclusions: The inclination of the upper cervical spine and craniocervical angulations can cause the signs and symptoms of TMD and condyle position is not main cause of TMDs alone but it may be effective together with other possible etiological factors synergistically. PMID:21769281
Dempsey, Alasdair R; Lloyd, David G; Elliott, Bruce C; Steele, Julie R; Munro, Bridget J
Common lower limb postures have been found when noncontact anterior cruciate ligament (ACL) injuries occur during sidestep cutting tasks. These same postures have been linked to knee loadings known to stress the ACL. Whole body technique modification would reduce knee loading. Controlled laboratory study. Experienced team sport athletes were recruited for whole body sidestep cutting technique modification. Before and after a 6-week technique modification training, participants performed sidestep cutting tasks while ground-reaction force and motion data were collected. A kinematic and inverse dynamics model was used to calculate 3-dimensional knee loading during sidestep cutting. At initial foot contact, the participants placed their stance foot closer to the body's midline and held their torso more upright, in line with the aims of the technique modification training. This was accompanied by significantly lower peak valgus moments in the weight acceptance phase of stance. Both postural changes were correlated with the change in peak valgus moment. Whole body sidestep cutting technique modification resulted in reduced knee loading. Implementation of whole body technique modification may produce effective ACL injury prevention programs in sports involving sidestep cutting.
Wagner, Emilio; Ortiz, Cristian; Torres, Karen; Contesse, Ivan; Vela, Omar; Zanolli, Diego
Different surgical techniques are available to correct each type of Hallux Valgus (HV) deformity, and all present similar good results. No information is available relative to the cost of each technique compared to their individual success. To determine the cost-effectiveness-ratio (CER) of five different techniques for HV. We included 245HV surgeries performed in 179 patients. The severity was defined according to radiological parameters. For mild to moderate HV we included the Chevron, Modified-Scarf and Ludloff techniques; for severe HV: either Poscow-osteotomy or Lapidus-arthrodesis fixed with plates or screws. Weighted costs were estimated. CER was expressed in $US dollars per AOFAS-point. The lowest weighted cost was observed for the Chevron-group, and the highest weighted cost was observed in the Poscow-osteotomy and Lapidus-arthrodesis fixed with plate groups. The AOFAS-score improvement was higher in the Chevron and Modified-Scarf groups. The CER found for Chevron and Modified-Scarf techniques were significantly less than for Poscow and Lapidus-techniques. Cost-Effectiveness-Ratio was lower, and therefore better, in the groups with mild to moderate deformities operated with Chevron or Modified-Scarf techniques. In severe HV, the three techniques investigated presented similar CER. CER analysis is an additional factor that can be included in the decision making analysis in hallux valgus surgery. Level of Evidence Level IV, Retrospective Study. Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Walker, Peter S; Parakh, Dhiraj S; Chaudhary, Miriam E; Wei, Chih-Shing
There are several types of designs used for unicompartmental tibial components. The all-plastic inlay component is recessed and it preserves bone around the outer edge of the tibia. For an onlay component, the entire condyle is resected, and the plastic bearing is usually metal-backed, although all-plastic components are also available. The purpose of this study was to investigate the hypothesis that while 6-mm inlay components require less bone removal, the peak stresses and strains at the surface of the bone will be much greater when compared with 8-mm metal-backed onlay components, and that all-plastic onlays will be only a slight advantage over inlays. Tibial models were generated using computed tomography (CT) scans, while typical inlay and onlay components were modeled. Finite element analyses of bones and components were completed by assigning material properties based on the CT scans and applying loads. Results indicated that plastic inlays generated 6 times more peak stress at the tibial surface when compared with metal-backed onlays. Moreover, models using inlay components produced strain values exceeding onlay components by a factor of 13.5 due to areas of softer bone at the interface. Off-center loading toward the anterior or posterior of the components produced similar results. The stresses and strains for the 8-mm all-plastic onlay were reduced compared with the inlay but still much higher than for the metal-backed onlay. These findings indicated that metal-backed onlays may be a better option when considering load distribution on the tibial surface.
Popkov, D A; Kononovich, N A; Shutov, R B
Transphyseal reinforcement of right intact tibia performed with thin steel rods in six mongrel dogs at the age of six months. Contralateral segment served as control. The leg growth and blood supply studied under the created conditions for the next six months. Radiographic, physiologic (surface thermometry, photoplethysmography), and statistical methods used for studying. The significant effect of transphyseally inserted rods on the leg longitudinal growth and blood supply has not been revealed. The changes in natural shape-formation oftibial proximal and distal meta-epiphyses observed influenced by the transphyseal rods in the experiment. In order to evaluate the tissue response and the degree of the functional activity of leg bone meta-epiphyseal zones the most informative areas considered to be the following: the area of medial malleolus in the early period of physiological growth completion, and the area of the tibial lateral condyle--at the late stage.
Increased knee valgus angles have been associated with an increased risk of a variety of knee injuries. It has yet to be established if knee valgus angles during jump landing tasks differ between jumping sports with relatively higher and lower knee injury rates-namely, basketball and volleyball. Any difference in knee angles on landing may be related to sport-specific differences, which may in turn relate to the different injury risk rates. Fifteen elite female basketball and volleyball players had their knee valgus angles assessed during 2 landing tasks: 1 bilateral (drop jump landing) and 1 unilateral (step landing task). During the drop jump task knee valgus angle was significantly greater in the basketball group (p = 0.017) in the right knee, but there was no significant difference in performance between sports in the left knee (p = 0.67). During the step landing task volleyball players had significantly greater knee valgus angles than basketball players for both the left (p = 0.018) and right (p = 0.025) knees. The basketball group showed superior control of knee valgus during the unilateral task, which may be related to sport-specific skills. The basketball players showed significant asymmetry in knee valgus angle during bilateral drop jump landings; this finding reflects those of previous studies and may be related to the relative increased knee injury risk reported for this population group.
Frey, Steven; Hosalkar, Harish; Cameron, Danielle B; Heath, Aaron; David Horn, B; Ganley, Theodore J
Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm. We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria. There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively. Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open
Background Many novel approaches to mandibular condyle fracture have been reported, but there is a relative lack of reports on the Risdon approach. In this study, the feasibility of the Risdon approach for condylar neck and subcondylar fractures of the mandible is demonstrated. Methods A review of patients with mandibular condylar neck and subcondylar fractures was performed from March 2008 to June 2012. A total of 25 patients, 19 males and 6 females, had 14 condylar neck fractures and 11 subcondylar fractures. Results All of the cases were reduced using the Risdon approach. For subcondylar fractures, reduction and fixation with plates was done under direct vision. For condylar neck fractures, reduction and fixation was done with the aid of a trochar in adults and a percutaneous threaded Kirschner wire in children. There were no malunions or nonunions revealed in follow-up care. Mild transient neuropraxia of the marginal mandibular nerve was seen in 4 patients, which was resolved within 1–2 months. Conclusions The Risdon approach is a technique for reducing the condylar neck and subcondylar fractures that is easy to perform and easy to learn. Its value in the reduction of mandibular condyle fractures should be emphasized. PMID:23829537
Caroli, Emanuela; Rocchi, Giovanni; Orlando, Epimenio Ramundo; Delfini, Roberto
Occipital condyle fractures (OCFs) are uncommon and potentially fatal lesions. After the advent of CT, prompt diagnosis can be readily made and consequently better prognosis of these patients is expected. Early recognition of some types of OCF is imperative to avoid fatal results. We analyzed 121 cases of OCF (116 from the literature and five of our own). Rarely patients with a deficit of the lower cranial nerves make a complete recovery. However, quoad vitam prognosis of patients with "pure OCFs" remains good. Immobilization provides good recovery of most OCFs, but delay of treatment can lead to serious morbidity. We want to emphasize that not only an OCF with instability of O-C1-C2 can be a fatal injury unless prompt surgical intervention, but a displacement and migration of the fractured condylar fragment can also result in a fatal outcome. A high level of suspicion is fundamental for the early diagnosis of these fractures, so that when a posterior basal cranial or occipital squama fracture occurs, a CT study of the occipital condyles becomes imperative.
Ulu, Mustafa Onur; Albayram, Sait; Aydin, Sabri; Ulusoy, Levent; Hanci, Murat
With the routine use of multi-slice high resolution computed tomography, increasing number of occipital condyle fractures have been reported in the last decade. The authors report a very rare case of bilateral occipital condyle fracture complicated by the fracture of the inferior clivus and discuss the possible mechanisms of injury. PMID:17180399
... HUMAN SERVICES Food and Drug Administration 21 CFR Part 872 Dental Devices; Reclassification of Temporary Mandibular Condyle Prosthesis AGENCY: Food and Drug Administration, HHS. ACTION: Final order... mandibular condyle prosthesis, a preamendments class III device, into class II (special controls), and rename...
Zhu, Jun-Yi; Zou, Hai-Xiao; Li, Hui-Min; Wang, Wei; Jia, Jun
Due to the anatomic and functional complexity, reconstruction of the condylar process after mandibular tumor extirpation remains a surgical challenge. The aim of this study was to present the results and experience of condyle head reimplantation combined with vascularized free flap for mandibular reconstruction in our institution. In the current study, the authors evaluated the clinical features of condyle head reimplantation combined with vascularized free flap for mandibular reconstruction in 5 patients with benign mandibular intraosseous lesions from December 2013 to March 2015 in our institution. All patients showed nearly normal mouth opening, with minimal mandibular deviation and joint symptoms. The radiograph data showed that 4 patients had no obvious bone resorption of condyles while only 1 patient had prominent condyle resorption. All the condyles were cut above the condylar neck, with the biggest remaining condyle height being 2.8 cm and the smallest one being 1.1 cm. Moreover, the original vertical height of mandibular ramus was decreased by 2 to 3 mm during the surgery. In conclusion, this study revealed that combining the condyle reimplantation with vascularized free flap constitutes a reliable method in condylar reconstruction and a slight reduction of the vertical height of condyles may help to diminish unfavorable outcomes.
Iriuchishima, Takanori; Ryu, Keinosuke; Aizawa, Shin; Fu, Freddie H
The purpose of this study was to reveal the correlation between the size of the native anterior cruciate ligament (ACL) footprint and the size of the tibia plateau. Twenty-four non-paired human cadaver knees were used. All soft tissues around the knee were resected except the ACL. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the femoral and tibial sides. An accurate lateral view of the femoral condyle and the tibial plateau was photographed with a digital camera, and the images were downloaded to a personal computer. The size of the femoral and tibial ACL footprints, and anterior-posterior (AP) and medial-lateral (ML), lengths of the tibia plateau and area of tibia plateau were measured with Image J software (National Institution of Health). The sizes of the native femoral and tibial ACL footprints were 72.3 ± 24.4 and 134.1 ± 32.4 mm(2), respectively. The AP lengths of the whole, medial and lateral facet of the tibia plateau were as follows: 44.5 ± 4.1, 40.8 ± 4.1 and 36.8 ± 4 mm, respectively. The ML length of the tibia plateau was 68.3 ± 5.5 mm. Total area of tibia plateau was 2,282.9 ± 378.7 mm(2). The AP length of the lateral facet of the tibia plateau (Pearson's correlation coefficient = 0.508, p = 0.011) and the total area of tibia plateau (Pearson's correlation coefficient = 0.442, p = 0.031) were significantly correlated with the size of the tibial ACL footprint. For clinical relevance, the AP length of lateral facet of the tibia plateau and total area of tibia plateau are significantly correlated with the size of the tibial ACL footprint. It might be possible to predict the size of the ACL measuring these parameters.
Yoon, Seong-Dae; Zhang, GuoFeng; Kim, Hee-June; Lee, Byoung-Joo; Kyung, Hee-Soo
The purpose was to compare the accuracy of Miniaci method using picture archiving and communication system (PACS) with a cable method in high tibial osteotomy (HTO). This study analyzed 47 patients (52 knees) with varus deformity and medial osteoarthritis. From 2007 to 2013, patients underwent HTO using either a cable method (20 knees) or Miniaci method based on a PACS image (32 knees). In the cable method, the 62.5% point of the mediolateral tibial plateau width was located using an electrocautery cord under fluoroscopy (cable group). The Miniaci method used preoperative radiographs to shift the weight bearing axis (PACS group). Full-length lower limb radiographs obtained preoperatively and at the sixth postoperative week were used to compare the percentage of crossing point of the weight bearing line on the tibial plateau with respect to the medial border. The weight bearing line on the tibial plateau was corrected from a preoperative 11.0±7.0% to a postoperative 47.2±7.4% in the cable group and from 12.7±4.9% to 59.5±5.3% in the PACS group. The mechanical femorotibial angle was corrected from varus 8.9±3.7° to valgus 0.3±4.0° in the cable group and from varus 9.0±3.3° to valgus 2.9±2.6° in the PACS group. In HTO, correction based on the Miniaci method using a PACS was more accurate than correction using the cable method.
Yoon, Seong-Dae; Zhang, GuoFeng; Kim, Hee-June; Lee, Byoung-Joo; Kyung, Hee-Soo
Purpose The purpose was to compare the accuracy of Miniaci method using picture archiving and communication system (PACS) with a cable method in high tibial osteotomy (HTO). Materials and Methods This study analyzed 47 patients (52 knees) with varus deformity and medial osteoarthritis. From 2007 to 2013, patients underwent HTO using either a cable method (20 knees) or Miniaci method based on a PACS image (32 knees). In the cable method, the 62.5% point of the mediolateral tibial plateau width was located using an electrocautery cord under fluoroscopy (cable group). The Miniaci method used preoperative radiographs to shift the weight bearing axis (PACS group). Full-length lower limb radiographs obtained preoperatively and at the sixth postoperative week were used to compare the percentage of crossing point of the weight bearing line on the tibial plateau with respect to the medial border. Results The weight bearing line on the tibial plateau was corrected from a preoperative 11.0±7.0% to a postoperative 47.2±7.4% in the cable group and from 12.7±4.9% to 59.5±5.3% in the PACS group. The mechanical femorotibial angle was corrected from varus 8.9±3.7° to valgus 0.3±4.0° in the cable group and from varus 9.0±3.3° to valgus 2.9±2.6° in the PACS group. Conclusions In HTO, correction based on the Miniaci method using a PACS was more accurate than correction using the cable method. PMID:27894175
Feuerstein, Catherine; Weil, Lowell; Weil, Lowell Scott; Klein, Erin E; Argerakis, Nicholas; Fleischer, Adam E
Arthrofibrosis is a known complication of hallux valgus surgery. Joint manipulation under anesthesia has been studied for adhesive capsulitis of the shoulder; however, a paucity of published data exists on the use of this modality in the foot and ankle. The purpose of the present study was to investigate the outcomes of first metatarsophalangeal joint manipulation for arthrofibrosis that occurred as a complication of bunion surgery. The study population consisted of patients attending a single foot and ankle specialty clinic who were evaluated for arthrofibrosis after bunion surgery. Patients who underwent joint manipulation under anesthesia were asked to complete a research visit in which a clinical examination was performed and the presence and severity of joint pain were assessed. A total of 38 patients (34 females, 4 males, 53 feet), with a mean age of 55.7 ± 11.8 (range 30 to 83) years, agreed to participate. The mean follow-up period was 6.5 ± 3.4 (range 1 to 17) years. The visual analog scale scores improved significantly from baseline to the final follow-up visit (baseline 6.5 ± 1.5, range 2 to 10; final follow-up visit 2.3 ± 1.5, range 0 to 6; p < .001). Furthermore, joint motion had increased significantly (p < .001) for both dorsiflexion and plantarflexion at the final follow-up examination. The final range of motion (dorsiflexion, r = -0.431, p = .002; plantarflexion, r = -0.494, p < .001) correlated highly with patient self-reported pain in the first metatarsophalangeal joint. Our findings suggest that joint manipulation could be a useful modality for increasing first metatarsophalangeal joint mobility and alleviating pain in patients who experience arthrofibrosis after surgical correction of hallux valgus. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Kernen, Rolf; Mueller, Sebastian Andreas
Grade III valgus deformity (tibiofemoral alignment > 20°) is present in only 0.5% of patients receiving total knee arthroplasty. Furthermore, cases with a valgus deformity exceeding 40° are even rarer. Since they mostly affect elderly, polymorbid patients, successful outcome means a great challenge. We report on a case of a 90-year-old patient with a valgus deformity of 47°. The patient was preoperatively restricted to a wheel chair, unable to walk, and only able to stand for a few seconds. The maximal knee flexion was 100°, and there was an extension deficit of 15°. The WOMAC score was 91; the EQ-5D-5L Index was 0.048. She was treated with a constrained hinged prosthesis. Postoperatively, the axis was 6° valgus. After 3 months of rehabilitation, she was independent using a wheeled walker. The maximal flexion of the knee was 110° and there was no extension deficit. The WOMAC score was 45; the EQ-5D-5L Index was 0.813. This case demonstrates the possibility of a satisfactory result and an improvement in quality of life and mobility with a plausible timetable and with reasonable use of resources even in advanced age and severe valgus deformity. PMID:28386499
Nazem, Khalilollah; Fouladi, Arash; Chinigarzadeh, Mozhdeh
Background: High tibia osteotomy (HTO) is a common surgical operation for correction of genu varum deformity. In some patients, there are concurrent tibia vara and genu varum (bow leg). This study aimed to consider the possibility of better correction of bow leg deformity after double level tibial osteotomy (DLTO). Materials and Methods: A case series of 10 patients of genu varum in addition to tibia vara (bow leg) deformity who were referred to orthopedic ward of an academic hospital of Isfahan- Iran during 2009–2011 were included in the study. The mean age was 17.3 ± 3.1 years and all of them underwent DLTO. The results of treatment have been assessed based on clinical and radiological parameters before and after surgery. Results: The mean pre- and post operative values for Tibia-Femoral Angle, Medial Proximal of Tibia Angle (MPTA), and Lateral Distal of Tibia Angle (LDTA) were 18.13 ± 3.05° vs. 3.93 ± 0.66°, 79.13 ± 3.4° vs. 89.7 ± 1.8° and 96.40 ± 1.8° vs. 88.73 ± 3.0° respectively (P < 0.05). Improvement of all radiological parameters was meaningful. Seventy three percent of patients had normal mechanical axis of limb after surgery. The remaining cases had varus deformity in distal femur that was corrected by valgus supracondylar osteotomy in an additional operation. Limited range of motion (ROM) near knee and ankle was not observed. Conclusion: DLTO correct bow leg deformity in the point of alignment of limb and paralleling of knee and ankle joint more effectively. This method can be used in metabolic and congenital bow leg which deformities are present in throughout of the lower limb. We described this technique for the first time. PMID:24523802
Lui, Tun Hing
The underlying reason for recurrence of hallux valgus deformity after bunion surgery is multifactorial and includes surgeon-based and patient-based factors as well as original components of deformity initially unaddressed at the index procedure. Surgical treatment of a recurred hallux valgus deformity should be undertaken using the same guidelines for correction of a primary hallux valgus deformity. It requires correction of bony alignment, restoration of joint congruity, and achievement of soft tissue balance. The purpose of this Technical Note is to describe the details of endoscopic soft tissue procedure to correct a recurred hallux valgus deformity. To successfully complete this procedure, adequate lateral release to achieve soft tissue balance around the first metatarsophalangeal joint with reduction of the sesamoid bones is mandatory.
Mihata, Teruhisa; Safran, Marc R; McGarry, Michelle H; Abe, Muneaki; Lee, Thay Q
The contributions of the scapulothoracic articulation and spine when measuring shoulder range of motion have been well described; however, the effect of elbow valgus laxity has not. Increased elbow valgus laxity affects the assessment of shoulder external rotation measured during physical examination at 90 degrees of elbow flexion. Controlled laboratory study. Seven cadaveric upper extremities were tested with an elbow valgus laxity-testing device. Shoulder external rotation was assessed with 2.8 N . m of external torque by measuring a change in the angle of the forearm axis at 90 degrees of elbow flexion. Elbow valgus laxity was measured in degrees of valgus angulation with 1.5 N . m of valgus torque with the humerus fixed. Shoulder external rotation and elbow valgus laxity were recorded at each of the following conditions: (1) intact, (2) after splitting the pronator muscles and venting the capsule, (3) after cutting the posterior band of the anterior oblique ligament of the ulnar collateral ligament, and (4) after cutting the anterior oblique ligament completely. After the posterior band of the anterior oblique ligament of the ulnar collateral ligament was cut, apparent shoulder external rotation and elbow valgus laxity were increased by 4.1 degrees +/- 1.7 degrees (P < .01) and 3.1 degrees +/- 1.3 degrees (P < .001), respectively, when compared with the intact condition. Complete cutting of the anterior oblique ligament resulted in an apparent increased shoulder external rotation and an increased elbow valgus laxity of 11.0 degrees +/- 1.1 degrees (P < .001) and 9.1 degrees +/- 1.2 degrees (P < .001), respectively, when compared with the intact condition. Shoulder external rotation as assessed by physical examination, which was defined as the angle of the forearm axis, as well as elbow valgus laxity, was significantly increased after the anterior oblique ligament of the ulnar collateral ligament was cut, although the glenohumeral joint condition was not changed
Heggelman, Ben; Gaasbeek, Robert; Nix, Maarten
The incidence of fabella fractures is considered to be extremely low. This report presents two patients with femorotibial osteoarthritis and considerable preoperative valgus malalignment, who developed a fracture of the fabella (as demonstrated by radiography) after total knee arthroplasty with intraoperative correction of the valgus malalignment. Special attention should be paid to the fabella for not missing a fabella fracture in these patients. PMID:27340579
Cassard, X; Beaufils, P; Blin, J L; Hardy, P
Arthroscopic treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery. But bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical results. Twenty-six patients (mean age 42 years, range 18 to 70 years, 17 men, 9 women) were arthroscopically treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 2 type I, 17 type II, 6 type III and 1 type IV. No type V or VI were treated in this series. The fixation device was: percutaneous cannulated screw in 23 cases, Kirchner wire in 2 cases, and bone cement filing of the fracture site in 1 case. We did not use cancellous bone graft but we used a hydroxyapatite plug in one case. There were 8 meniscal injuries: 2 underwent arthroscopic suture, 1 had partial meniscectomy and 5 were left in place. Twenty-six cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Knee Society scoring system) and radiographical examination were done with an average follow-up of 32.7 months. There were no complications except one immediate postoperative septic osteoarthritis (case with hydroxyapatite plug) and one bony depression of the lateral tibial plateau at the fourth month. Passive motion of the knee started at 1.8 days postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 94.1 for the knee, 94.7 for the function. In two cases we found early signs of osteoarthrosis. There were no secondary bony depression or significant valgus deformity on X-rays. Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with
Saluja, Sandeep; Das, Sushant Swaroop; Vasudeva, Neelam
The Occipital Condyle (OC) is an integral component of craniovertebral region which is predisposed to a wide array of traumatic, degenerative and neoplastic diseases. Frequent surgical interventions of OC are required for successful management of these conditions. Hence a meticulous anatomical knowledge of the OC is vital but variability in morphometric dimensions exist amongst different races and hinder the standardization of measurements. The aim of this study was to present a morphometric reference database for OC of the Indian population and enable comparisons with other populations. The study was performed on 228 OC of 114 adult human skulls. Linear measurements of the OC were taken with the help of digital Vernier's Calliper and angular measurements were determined with software Image J. Mean and standard deviation of the morphometric parameters taken into account were analysed. The comparison of morphometric dimensions of the right and left sides was carried out using Student's t-test and p-value was calculated. The morphometric analysis of the OC established that mean width was larger (12.97 mm) in Indians population when compared to other races. The anterior and posterior intercondylar distances as well as the distances between the tips of OC and opisthion and basion were observed to be shorter in Indians. We found a significant difference (p=0.01) among the distance between Posterior tip of Occipital Condyle (POC) and basion of the right and left sides. The sagittal condylar angle and sagittal intercondylar angle were found to be greater in our study when compared to other researchers. There existed a highly significant difference (p=0.001) between the sagittal condylar angles of the right and left sides. The present morphometric study would be valuable for the successful instrumentation of the OC as wider and ventrally oriented OC as well as smaller intercondylar distances may pose challenge to the surgeons during condylectomy. The data of present study
Küçükdurmaz, Fatih; Ağır, Ismail; Saygı, Baransel; Bezer, Murat
Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft. Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50-108 months). The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction. Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5° and 31.9°, respectively, which decreased to 38.5° and 29.1°, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements (P<0.05). Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients.
Küçükdurmaz, Fatih; Ağır, İsmail; Saygı, Baransel; Bezer, Murat
Background: Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft. Materials and Methods: Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50–108 months). Results: The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction. Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5° and 31.9°, respectively, which decreased to 38.5° and 29.1°, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements (P<0.05). Conclusion: Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients. PMID:22719122
Pathare, Neil P.; Nicholas, Stephen J.; Colbrunn, Rob; McHugh, Malachy P.
Objectives: Despite a trend toward lowering the femoral tunnel and thus positioning ACL grafts partially within the indirect insertion of the ACL attachment, the biomechanical role of the indirect insertion has not been described. The purpose of this study was to determine the effect of debridement of the indirect femoral ACL insertion on tibiofemoral translation and rotation. It was hypothesized that debridement would have a negligible affect on tibiofemoral kinematics. Methods: Knee kinematics in six degrees of freedom were measured on a robotic device in nine cadaveric knees. Measurements were made with the ACL intact, following debridement of the indirect insertion, and following complete sectioning of the ACL. Three loading conditions were used: (1) a 134 N anterior tibial load, (2) a combined 10 Nm valgus and 5 Nm internal rotation torque, and (3) a simulated, robotic pivot shift. Debridement involved exposing 5-6 mm of bone from the central, inferior aspect of the direct ACL attachment to the inferior cartilage margin. Anterior tibial translation (ATT) was recorded in response to an anterior tibial load and combined rotatory loads at 0°, 15°, 30°, 45°, 60°, and 90° of knee flexion. Additionally, posterior tibial translation and external tibial rotation were recorded during a simulated, robotic pivot shift. Based on pilot data, it was estimated that 9 specimens would be required to detect a 1.4 mm difference in ATT between different experimental conditions with 80% power at an alpha level of 0.05. Data were analyzed using repeated measures ANOVA. Results: For the anterior tibial loading condition, debridement of the indirect insertion increased tibial translation by 0.37±0.24 mm at 0º (P<.01) and by 0.16±0.19 mm at 15º (P<.05; increases were < 1 mm in all specimens). ACL deficiency increased ATT in response to an anterior tibial load (P<.0001) with maximum effect at 15º (11.26±1.15 mm vs. ACL intact; 11.04±1.08 mm vs. indirect insertion
Background Currently, the metatarsophalangeal angle (hallux valgus angle) is measured based on radiographic images. However, using X-ray examinations for epidemiological or screening purposes would be unethical, especially in children. For this reason it is discussed to measure the hallux valgus angle of the margo medialis pedis (medial border of the foot) documented on foot outline drawings or foot scans. As a first step on the way to prove the validity of those approaches this study assesses the hallux valgus angle measured on the margo medialis pedis based on the same x-ray pictures as the metatarsophalangeal hallux valgus. Methods Radiographic images of the foot were obtained from patients with symptomatic hallux valgus malformation. Twelve sets of contact copies of the 63 originals were made, and were marked and measured according to three different methods, each one performed by two observers and with two repeated measurements. Thus, data sets from 756 individual assessments were entered into the multifactorial statistical analysis. Comparisons were made between the angle of the margo medialis pedis and the metatarsophalangeal angle, which was determined by two different methods. To determine the inter- and intraobserver reliability of the different methods, each assessment was conducted by two independent experts and repeated after a period of several weeks. Results The correlations between the hallux valgus angles determined by the three different methods were all above r = 0.89 (p < 0.001) and thus highly significant. The values obtained by measuring the margo medialis pedis angle, however, were on average 4.8 degrees smaller than the metatarsophalangeal angles. No significant differences were found between the observers. No systematic deviations for any observer between repeated measurements were detected. Conclusions Measurements of the radiographic hallux angle of the margo medialis pedis are reliable and show high correlation with the
Mathai, Naveen Joseph; Amaravathi, Rajkumar S; Pavan, KV; Sekaran, Padmanabhan; Sharma, Gaurav; Codanda, Belliappa
Background: An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP. Materials and Methods: 41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year. Results: The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically
Cheng, Pen-Gang; Chang, Wei-Ning; Wang, Matthew N
Posteromedial dislocation of the elbow with lateral condyle fracture is a rare injury, and only a few cases have been reported in the literature. We report 3 children who had posteromedial dislocation of the elbow with Milch type II lateral condylar fracture of the distal humerus. Major complications included malunion, nonunion of the fracture, heterotophic calcification and elbow subluxation. From our experience and a review of the literature, open anatomical reduction and internal fixation of the lateral condyle fracture is the mainstay of treatment for these children. Poor reduction of the lateral condyle fracture results in incongruity of the joint surface and leads to poor results.
Hakki, Sam; El-Othmani, Mouhanad M; Gabriel, Christian; Mihalko, William M; Saleh, Khaled J
Tibial anatomical landmarks for transverse plane rotation of the tibial tray have not been validated. The current authors propose aligning the tibial tray with both the anterior tibial center point of rotation (ATCPR) and the femoral trochlear groove (FTG) to establish the ideal tibial tray rotation in total knee arthroplasty (TKA). When the tibial tray centerline was aligned with ATCPR and FTG lines, the mean range of motion (ROM) was 144.3° (preoperatively 145°) and tibial rotation range was 22.8 mm (preoperatively, 24.9 mm). When the tibial component was rotated 5 mm medially to the ATCPR, the knee ROM decreased in flexion with patellar subluxation, while it decreased in extension when rotated 5 mm laterally. This method identifies the ideal tibial tray rotation in TKA, at which maximal range of tibial rotation and knee ROM are achieved without obvious overriding of components. [Orthopedics, 2016; 39(3):S67-S71.]. Copyright 2016, SLACK Incorporated.
Pitta, Guilherme Benjamin Brandão; Dos Santos, Thays Fernanda Avelino; Dos Santos, Fernanda Thaysa Avelino; da Costa Filho, Edelson Moreira
Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures. The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers large numbers of traumas, not only fractures, but also crush injuries and severe bruising, among others, which at any given moment, could lead compartment syndrome in the patient. The case is reported of a 58-year-old patient who, following a tibial plateau fracture, presented compartment syndrome of the leg and was submitted to decompressive fasciotomy of the four right compartments. After osteosynthesis with internal fixation of the tibial plateau using an L-plate, the patient again developed compartment syndrome.
Burghardt, Rolf D.; Yoshino, Koichi; Kashiwagi, Naoya; Yoshino, Shigeo; Bhave, Anil; Paley, Dror; Herzenberg, John E.
Purpose Outcome assessment after double level tibial lengthening in patients with dwarfism. Methods Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. Results Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm. Conclusion Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying. PMID:26566326
Shibuya, Naohiro; Roukis, Thomas S; Jupiter, Daniel C
The hypermobility theory of the first ray is the reason for the popularization of procedures such as the modified Lapidus procedure involving arthrodesis of the first tarsal-metatarsal joint for correction of hallux valgus deformity. Although many studies have involved motion of the first ray in hallux valgus patients, the presence and clinical significance of hypermobility in the first ray remains controversial. We performed a systematic review and meta-analysis to evaluate the difference in the first ray range of motion between patients with or without hallux valgus deformity. The databases used for the present review included Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that had evaluated the motion of the first ray in patients with or without hallux valgus. After screening for inclusion and exclusion criteria, we identified 3 studies that were relevant to our study question. All 3 studies showed more first ray motion in the hallux valgus group. Our quantitative synthesis showed a mean difference in the range of motion of the first ray of 3.62 mm (95% confidence interval 2.26 to 4.98) between those with and without hallux valgus deformity. Thus, we found statistically significantly increased first ray motion in patients with hallux valgus deformity compared with those without hallux valgus deformity. However, the clinical significance of this small amount of increased sagittal plane motion as a response to or a cause of hallux valgus remains unanswered. Published by Elsevier Inc.
Feller, Julian Ashley
Although tibial tuberosity (TT) transfer has for many years been the basis of many protocols for the management of patellar instability, the role of pure medial transfer in particular appears to be declining. In contrast, the greater recognition of the importance of patella alta as a predisposing factor to recurrent patellar dislocation has resulted in a resurgence in the popularity of distal TT transfer. When TT transfer is performed, the direction and amount of transfer is based on the patellar height and the lateralization of the TT relative to the trochlear groove. Patellar height is best assessed on a lateral radiograph with the knee in flexion using a ratio that uses the articular surface of the patella in relation to the height above the tibia. Assessment of lateralization of the TT relative to the trochlear groove can be made using either computed tomography or magnetic resonance imaging scans.
Ni, Yulong; Gao, Shunhong; Zhang, Jingyu; Dong, Huishuang; Zhang, Yunpeng; Fu, Jiansong
To investigate the effectiveness of tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft in the treatment of tibial bone defects. Between January 2007 and December 2013, 19 cases of traumatic tibia bone and soft tissue defects were treated. There were 14 males and 5 females, aged from 18 to 49 years (mean, 28 years). The tibial fracture site located at the middle tibia in 6 cases and at the distal tibia in 13 cases. According to Gustilo type, 4 cases were rated as type III A, 14 cases as type III B, and 1 case as type III C (injury of anterior tibial artery). The length of bone defect ranged from 4.3 to 8.5 cm (mean, 6.3 cm). The soft tissue defects ranged from 8 cm x 5 cm to 17 cm x 9 cm. The time from injury to operation was 3 to 8 hours (mean, 4 hours). One-stage operation included debridement, external fixation, and vacuum sealing drainage. After formation of granulation tissue, the fresh wound was repaired with sural neurovascular flap or posterior tibial artery perforator flap. The flap size ranged from 10 cmx6 cm to 19 cm x 11 cm. In two-stage operation, tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft was used to repair tibial defect. The periosteal flap ranged from 6.5 cm x 4.0 cm to 9.0 cm x 5.0 cm; bone graft ranged from 4.5 to 9.0 cm in length. External fixation was changed to internal fixation. All flaps survived with soft texture, and no ulcer and infection occurred. All incisions healed by the first intention. All patients were followed up 18-40 months (mean, between normal and affected sides.The function of the knee an ankle joint was good without infection, malunion, and equinus. According to the Johner standard at last follow-up, the results were excellent in 15 cases, good in 3 cases, and fair in 1 case, with an excellent and good rate of 94.7%. Tibial periosteal flap pedicled with intermuscular branch of
Lee, Keun-Bae; Park, Ju-Kwon; Park, Young-Hoon; Seo, Hyung-Yeon; Kim, Myung-Sun
Painful plantar callosities under lesser metatarsal heads are commonly associated with hallux valgus. The purpose of the present study was to evaluate the prognosis of painful plantar callosities after hallux valgus correction without lesser metatarsal osteotomy in hallux valgus deformity. Between September 2004 and June 2007, 31 patients (40 feet) underwent proximal chevron first metatarsal osteotomy with a distal soft tissue procedure, with preoperatively painful plantar callosities under lesser metatarsal heads. Clinical results were evaluated using a visual analogue scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal interphalangeal scales, and a modified 70-point clinical scale. Radiographic evaluations included hallux valgus angle and intermetatarsal angle. Thirty-two (80%) of the 40 feet had no pain and callosity and 5 (12.5%) had no pain but residual plantar callosities, and 3 (7.5%) were not improved at final evaluation. The mean VAS and AOFAS scores were improved from 7.8 +/- 1.6 to 1.9 +/- 1.5 points and from 53.8 +/- 14.2 to 92.6 +/- 15.3 points, respectively. In terms of the 70-point clinical scale, overall clinical results were good in 34 feet and fair in 6. The mean hallux valgus and intermetatarsal angles were improved from 36.6 +/- 6.2 to 12.5 +/- 5.9 degrees and from 17.5 +/- 3.9 to 8.6 +/- 3.5 degrees, respectively. Painful plantar callosities under the lesser metatarsals in patients with hallux valgus deformity can be improved by hallux valgus correction alone without lesser metatarsal osteotomy.
Gladnick, Brian P; Boorman-Padgett, James; Stone, Kyle; Kent, Robert N; Cross, Michael B; Mayman, David J; Pearle, Andrew D; Imhauser, Carl W
Knowledge of the complex kinematics of the native knee is a prerequisite for a successful reconstructive procedure. The aim of this study is to describe the primary and coupled motions of the native knee throughout the range of knee flexion, in response to applied varus and valgus loads. Twenty fresh-frozen cadaver knees were affixed to a six degree of freedom robotic arm with a universal force-moment sensor, and loaded with a 4Nm moment in varus and valgus at 0, 15, 30, 45, and 90° of knee flexion. The resulting tibiofemoral angulation, displacement, and rotation were recorded. For each parameter investigated, the knee joint demonstrated more laxity at higher flexion angles. Varus angulation increased progressively from zero (2.0° varus) to 90 (5.2° varus) degrees of knee flexion (p<0.001). Valgus angulation also increased progressively, from zero (1.5° valgus) to 90 (3.9° valgus) degrees of knee flexion (p<0.001). At all flexion angles, the magnitude of tibiofemoral angle deviation was larger with varus than with valgus loading (p<0.05). We conclude that the native knee exhibits small increases in coronal plane laxity as the flexion angle increases, and that the knee has generally more laxity under varus load than with valgus load throughout the Range of Motion (ROM). Larger differences in laxity of more than 2 to 3°, or peak laxity specifically during the range of mid-flexion, were not found in our cadaver model and are not likely to represent normal coronal plane kinematics. Level V, biomechanical cadaveric study. Copyright © 2016 Elsevier B.V. All rights reserved.
Yoshioka, Tomokazu; Kubota, Shigeki; Sugaya, Hisashi; Hyodo, Kojiro; Ogawa, Kaishi; Taniguchi, Yu; Kanamori, Akihiro; Sankai, Yoshiyuki; Yamazaki, Masashi
Maintenance or restoration of a good range of motion of the knee is one of the most important outcomes following knee surgery. According to previous studies, opening wedge high tibial osteotomy enables better recovery of range of motion in knee flexion than that achievable after total knee arthroplasty or unicompartmental knee arthroplasty. However, few reports provide a detailed description of the postoperative recovery of knee extension range of motion after opening wedge high tibial osteotomy. We describe our experience with a knee extension training program using a single-joint hybrid assistive limb device (HAL-SJ; Cyberdyne Inc., Tsukuba, Japan) during the acute recovery phase after opening wedge high tibial osteotomy. The HAL-SJ is a wearable robotic device that facilitates voluntary control of knee joint motion. A 67-year-old Japanese woman who underwent opening wedge high tibial osteotomy for spontaneous osteonecrosis of the left medial femoral condyle received HAL-SJ-based knee extension training postoperatively. Our experience with this patient revealed that knee extension training with the HAL-SJ during the acute phase following opening wedge high tibial osteotomy is feasible. Furthermore, the patient's knee extension range of motion improved to values similar to those seen during the preoperative stage, and her flexion range of motion was improved at 3 months after the surgery. HAL-SJ-based knee extension training could be used as a novel post-opening wedge high tibial osteotomy rehabilitation modality. Further exploration of individualized optimal settings of the HAL-SJ is required to improve its safety and efficacy.
Lateral humeral condyle fracture is the second most common fracture around the elbow in pediatric age group. Acute neurological deficit as a consequence of nerve injury associated with lateral humeral condyle fractures is very uncommon. We report a rare presentation of a case of lateral humeral condyle fracture in a 13-year-old boy with acute radial nerve palsy. Patient was operated through a modified anterolateral approach to the elbow with, exploration of the radial nerve and internal fixation of the fracture. Complete fracture union at 6 weeks with good range of movements and full neurological recovery at 12 weeks was seen. We report this case due to rare combination of radial nerve injury and lateral humeral condyle fracture. Importance should be given to a thorough neurological examination during initial clinical examination and proper pre-operative planning. PMID:27891411
Das, Sushant Swaroop; Vasudeva, Neelam
Introduction The Occipital Condyle (OC) is an integral component of craniovertebral region which is predisposed to a wide array of traumatic, degenerative and neoplastic diseases. Frequent surgical interventions of OC are required for successful management of these conditions. Hence a meticulous anatomical knowledge of the OC is vital but variability in morphometric dimensions exist amongst different races and hinder the standardization of measurements. Aim The aim of this study was to present a morphometric reference database for OC of the Indian population and enable comparisons with other populations. Materials and Methods The study was performed on 228 OC of 114 adult human skulls. Linear measurements of the OC were taken with the help of digital Vernier’s Calliper and angular measurements were determined with software Image J. Statistical Analysis Mean and standard deviation of the morphometric parameters taken into account were analysed. The comparison of morphometric dimensions of the right and left sides was carried out using Student’s t-test and p-value was calculated. Results The morphometric analysis of the OC established that mean width was larger (12.97 mm) in Indians population when compared to other races. The anterior and posterior intercondylar distances as well as the distances between the tips of OC and opisthion and basion were observed to be shorter in Indians. We found a significant difference (p=0.01) among the distance between Posterior tip of Occipital Condyle (POC) and basion of the right and left sides. The sagittal condylar angle and sagittal intercondylar angle were found to be greater in our study when compared to other researchers. There existed a highly significant difference (p=0.001) between the sagittal condylar angles of the right and left sides. Conclusion The present morphometric study would be valuable for the successful instrumentation of the OC as wider and ventrally oriented OC as well as smaller intercondylar distances
... more common in particular ethnic groups? Genetic Changes Mutations in the TTN gene cause tibial muscular dystrophy . ... in chemical signaling and in assembling new sarcomeres. Mutations in the TTN gene alter the structure and ...
Valls-Mellado, M; Martí-Garín, D; Fillat-Gomà, F; Marcano-Fernández, F A; González-Vargas, J A
We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.
Mah, Deuk-Hyun; Moon, Seong-Yong; Oh, Ji-Su; You, Jae-Seek
Objectives We retrospectively evaluated the impact of mandibular third molars on the occurrence of angle and condyle fractures. Materials and Methods This was a retrospective investigation using patient records and radiographs. The sample set consisted of 440 patients with mandibular fractures. Eruption space, depth and angulation of the third molar were measured. Results Of the 144 angle fracture patients, 130 patients had third molars and 14 patients did not. The ratio of angle fractures when a third molar was present (1.26 : 1) was greater than when no third molar was present (0.19 : 1; odds ratio, 6.58; P<0.001). Of the 141 condyle fractures patients, the third molar was present in 84 patients and absent in 57 patients. The ratio of condyle fractures when a third molar was present (0.56 : 1) was lower than when no third molar was present (1.90 : 1; odds ratio, 0.30; P<0.001). Conclusion The increased ratio of angle fractures with third molars and the ratio of condyle fractures without a third molar were statistically significant. The occurrence of angle and condyle fractures was more affected by the continuity of the cortical bone at the angle than by the depth of a third molar. These results demonstrate that a third molar can be a determining factor in angle and condyle fractures. PMID:25741462
Rafferty, Katherine L.; Sun, Zongyang; Egbert, Mark; Bakko, Daniel W.; Herring, Susan W.
Objective: Loading of temporomandibular tissues during mandibular distraction may cause changes in condylar growth and cartilage thickness. This study examines the effects of distraction on the condyle in a large animal model by explicitly measuring growth and in vivo loading. Design: Unilateral mandibular distraction was carried out on twenty growing minipigs divided into three groups. One group underwent distraction but not consolidation, whereas the other two groups were allowed a period of consolidation of either one or two weeks. Animals received fluorochrome and 5-bromo-2'-deoxyuridine (BrdU) labeling and masticatory strain was measured from the condylar neck. Condylar strain was also recorded in an age-matched sample of eight animals that received no distraction surgery. Immunohistochemical procedures were used to identify dividing prechondroblasts and histological analysis was used to measure mineral apposition rate, count dividing cells, and measure the thickness of condylar cartilage. Results: Strain magnitude, particularly compressive strain, was much larger on the non-distraction side compared to the distraction side condyle. Compared to normal loading levels, the distraction side condyle was underloaded whereas the condyle on the intact side was overloaded. Mineral apposition and cartilage thickness were greater on the distraction side condyle compared to the opposite side. Differences between the sides were most pronounced in the group with no consolidation and became progressively reduced with consolidation time. Conclusions: Increased mineralization and cartilage thickness on the distraction side condyle is associated with reduced, not increased loading, perhaps because of disruption of the distraction side masseter muscle. PMID:17573035
The Effect of a Single Treatment of the Protonics System on Lower Extremity Kinematics during Gait and the Lateral Step Up Exercise . (in review) Gait...section in a comparison with a matched control group of subjects who have not sustained a fracture. Due to the low number of tibial stress fractures...fractures must be confirmed by x-rays, bone scans or MRIs. Tibial stress reactions have been operationally defined as bony pain specifically along the
Jalgaonkar, Azal A; Dachepalli, Sunil; Al-Wattar, Zaid; Rao, Sudhir; Kochhar, Tony
Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.
Three-Dimensional Reconstruction Computed Tomography Evaluation of Tunnel Location during Single-Bundle Anterior Cruciate Ligament Reconstruction: A Comparison of Transtibial and 2-Incision Tibial Tunnel-Independent Techniques
Ahn, Jin Hwan; Ko, Chun-Suk; Ko, Taeg Su; Kim, Jang Hwan
Background Anatomic tunnel positioning is important in anterior cruciate ligament (ACL) reconstructive surgery. Recent studies have suggested the limitations of a traditional transtibial technique to place the ACL graft within the anatomic tunnel position of the ACL on the femur. The purpose of this study is to determine if the 2-incision tibial tunnel-independent technique can place femoral tunnel to native ACL center when compared with the transtibial technique, as the placement with the tibial tunnel-independent technique is unconstrained by tibial tunnel. Methods In sixty-nine patients, single-bundle ACL reconstruction with preservation of remnant bundle using hamstring tendon autograft was performed. Femoral tunnel locations were measured with quadrant methods on the medial to lateral view of the lateral femoral condyle. Tibial tunnel locations were measured in the anatomical coordinates axis on the top view of the proximal tibia. These measurements were compared with reference data on anatomical tunnel position. Results With the quadrant method, the femoral tunnel centers of the transtibial technique and tibial tunnel-independent technique were located. The mean (± standard deviation) was 36.49% ± 7.65% and 24.71% ± 4.90%, respectively, from the over-the-top, along the notch roof (parallel to the Blumensaat line); and at 7.71% ± 7.25% and 27.08% ± 7.05%, from the notch roof (perpendicular to the Blumensaat line). The tibial tunnel centers of the transtibial technique and tibial tunnel-independent technique were located at 39.83% ± 8.20% and 36.32% ± 8.10%, respectively, of the anterior to posterior tibial plateau depth; and at 49.13% ± 4.02% and 47.75% ± 4.04%, of the medial to lateral tibial plateau width. There was no statistical difference between the two techniques in tibial tunnel position. The tibial tunnel-independent technique used in this study placed femoral tunnel closer to the anatomical ACL anteromedial bundle center. In contrast, the
Mortka, Kamila; Lisiński, Przemysław
[Purpose] Hallux valgus is one of the most common deformations of the human foot, and it causes great difficulties for the patients. The aim of this paper was to review available medical literature in search of evidence which would justify implementation of physiotherapy, based on its effectiveness for patients with hallux valgus. [Subjects and Methods] The following databases were searched for applicable papers: PubMed, Google Scholar, Clinical Key and UpToDate. Full-text articles from the last 15 years were subjected to a review, which ultimately selected seven papers about hallux valgus therapy published over the past 12 years. These studies were grouped according to their design and level of evidence and classified depending on whether they concerned physiotherapy as postoperative therapy or as the only treatment. [Results] The studies included in the present analysis used the following interventions for patients with hallux valgus: exercise, manual therapy, gait training, taping and orthosis. All the studies showed beneficial effects and the most frequently observed results were reductions in pain and improvements in function. [Conclusion] The evidence found in the reviewed materials clearly indicates that patients with hallux valgus should not only be subject to surgical procedures but also undergo physiotherapeutic treatment.
Koo, Kenneth Kin-Hoo; Tse, Lung Fung; Cheng, Hi Shan; Ho, Kevin Ki Wai
Hallux valgus is the lateral deviation of the great toe at the MTPJ that has many attributing aetiologies. This study will aim to identify whether hallux valgus progresses over time in the oriental Chinese population in Hong Kong. Patients with acquired symptomatic hallux valgus who presented to clinic between 2008 and 2013 were included. The deformities were analysed radiologically at presentation and pre-operative and angles were measured. These angles were analysed in relation to the waiting time from presentation to surgery. A sample of 43 cases from 38 patients (Mean age 63 years, range 48-80 years) were included. Forty-one cases had a hallux valgus angle (HVA) >24° at presentation (Mean 40.4°) and all had an intermetatarsal angle (IMA) >9°. A significant difference is seen with HVA (p=0.040, t=-2.128) at presentation and pre-op but not IMA (p=0.281, t=-1.095). The average wait for surgery was 705.7days which had shown significant correlation with progression in HVA (p=0.031). No significant difference was seen between IMA and waiting time to surgery (p=0.195). The findings suggests severe hallux valgus deformity does progress over time in Hong Kong. Shorter waiting times for surgery could be beneficial to this population. Level III, retrospective comparative series. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
Rodriguez, Jose A; Bas, Marcel A; Orishimo, Karl F; Robinson, Jonathan; Nicholas, Stephen J
Total knee arthroplasty and its relation to gait abduction or adduction moment has not been fully described. Gait analysis was performed on 25 patients (27 knees) preoperatively, 6 months and 1 year after total knee arthroplasty. Reflective markers were placed on the lower extremity, and motion data were collected at 60 Hz using 6 infrared cameras. Ground reaction forces were recorded at 960 Hz with a force plate. Stance phase was divided into braking and propulsive phases. Coronal knee angles and moments were calculated. Repeated-measures analysis of variance was used to compare frontal plane knee impulse over time and between the braking and propulsive phases of stance. In varus knees, static alignment was corrected from 2.2° varus to 3.3° valgus and in valgus knees from 15.2° valgus to 2.7° valgus (P < .010). Braking phase adduction impulse decreased from 0.145 to 0.111 at 6 months but increased to 0.126 Nm/kg s (P > .05) at 1 year. Propulsive phase impulse changed from 0.129 to 0.085 and persisted at 1 year. Impulse changed from 0.01 (abduction) to 0.11 Nm/kg s (adduction) at 6 months and persisted (P = .01). Restoration of anatomic alignment and soft tissue balancing changes the lateral loading conditions of valgus knees. Both cases, between 6 months and 1 year, increased peak moment. Copyright © 2016 Elsevier Inc. All rights reserved.
Lee, Sun-Min; Lee, Jung-Hoon
Abstract Background: Hallux valgus, an increased angle of lateral deviation in the big toe, can cause pain and difficulties in balancing and walking. This study aimed to investigate the effects of balance taping using elastic therapeutic tape on moderate hallux valgus. Methods: When she walked with shoes, she complained of pain over the medial eminence of the hallux metatarsophalangeal (MTP) joint. Balance taping using kinesiology tape was applied for 3 months (average, 16hours/d) to both big toes of a 26-year-old woman with moderate hallux valgus. Results: On the right side, the hallux valgus angle (HVA) decreased from 21° to 14° and the intermetatarsal angle (IMA) decreased from 15° to 14.5°. On the left side, the HVA decreased from 22° to 11° and the IMA decreased from 15° to 12°. Furthermore, the patient was able to walk long distances in shoes without pain in the medial eminence of the hallux metatarsophalangeal joint. Conclusion: This study suggested that repeated balance taping with kinesiology tape could be used as a complementary treatment method for moderate hallux valgus. PMID:27861365
Piqué-Vidal, Carlos; Solé, María T; Antich, Jaume
Our objective was to construct 3-generation pedigree charts from 350 patients with hallux valgus. During a 1-year period, all consecutive patients (n = 1174) with a painful bunion deformity evaluated roentgenographically were asked to complete a detailed 3-generation family history questionnaire. We studied 350 probands (22 men, 328 women; male/female ratio, 1:14.9; mean age, 47.8 years). Juvenile hallux valgus was diagnosed in 15 patients. Three or more affected members were observed in pedigrees from 244 probands, 2 affected members in 71, and 1 affected member in 35 (proband) (affected subjects per pedigree ranged from 1 to 16). Ninety percent of probands had at least 1 family member affected. The hallux valgus penetrance according to pedigrees from all probands was 56%. The female sex predominated with regard to the gender of parents with hallux valgus, affected branch of the family, and gender of relatives with bunion deformity. Severity of hallux valgus was not significantly influenced by gender, the affected branch of the family, or gender of the affected relatives. Family history of bunion deformity was present in 90% of probands, with vertical transmission affecting some family members across 3 generations, which is compatible with autosomal dominant inheritance with incomplete penetrance.
Muñoz, Gonzalo; Olate, Sergio; Cantín, Mario; Vásquez, Bélgica; Del Sol, Mariano; Fariña, Rodrigo
The aim of this study was to ascertain the joint space present in the TMJ of subjects diagnosed with Class III dentofacial deformity with an indication for orthognathic surgery. Fourteen subjects were recruited from the Division of Oral and Maxillofacial Surgery at the Universidad de La Frontera, Chile. All subjects were admitted to the study after signing an informed consent and undergoing cephalometric analyses to define the severity of the deformity. Then, the joint space was analyzed, studying a cone beam CT image of the TMJ, which was evaluated in the coronal and sagittal views, defining the most anterior, median and posterior joint space (sagittal view), as well as the lateral, median and medial joint space (coronal view). The data were recorded in millimeters by an observer and data were analyzed after measuring the same parameter at three different times. A student's t-test was used for the analyses. Differences observed in both joints were not greater than 0.2 mm with spaces between 2 mm and 1.5 mm, thereby establishing the homogeneity of the sample, which presented no significant differences between the two joint spaces (right and left). It can be concluded that the joint space is symmetrical in both condyles and that no important changes are present compared to the results indicated in the international literature.
Muñoz, Gonzalo; Olate, Sergio; Cantín, Mario; Vásquez, Bélgica; del Sol, Mariano; Fariña, Rodrigo
The aim of this study was to ascertain the joint space present in the TMJ of subjects diagnosed with Class III dentofacial deformity with an indication for orthognathic surgery. Fourteen subjects were recruited from the Division of Oral and Maxillofacial Surgery at the Universidad de La Frontera, Chile. All subjects were admitted to the study after signing an informed consent and undergoing cephalometric analyses to define the severity of the deformity. Then, the joint space was analyzed, studying a cone beam CT image of the TMJ, which was evaluated in the coronal and sagittal views, defining the most anterior, median and posterior joint space (sagittal view), as well as the lateral, median and medial joint space (coronal view). The data were recorded in millimeters by an observer and data were analyzed after measuring the same parameter at three different times. A student’s t-test was used for the analyses. Differences observed in both joints were not greater than 0.2 mm with spaces between 2 mm and 1.5 mm, thereby establishing the homogeneity of the sample, which presented no significant differences between the two joint spaces (right and left). It can be concluded that the joint space is symmetrical in both condyles and that no important changes are present compared to the results indicated in the international literature. PMID:25356133
Lemière, E; Sicre, A; Vereecke, F; Brygo, A; Nicola, J; Ferri, J
Physical therapy greatly contributes to improved function of the injured temporomandibular joint, particularly after trauma. In our unit, we use the Delaire rehabilitation method for patients presenting a fracture of the mandibular condyles. This method involves active mobilization, first with assistance, then with facilitation, and finally against resistance. A rehabilitation session starts with a preparation of the teguments and muscles associated with relaxation exercises. The joint is first mobilized by assisted movements if needed. When unassisted motion becomes possible, propulsion, diduction and open-close exercises are then performed with neuromuscular facilitation. When sufficient amplitudes have been achieved, the program proceeds with opposed exercises. By inducing propulsion and diduction (lateral pterygoid muscle) movements, physical therapy stimulates regeneration of the condylar unit, thus facilitating optimal functional rehabilitation. Posture and passive motion methods, which in our opinion are poorly adapted to the temporomandibular joint, are used little in our unit. Since condylar regeneration is controlled by functional factors, the lateral pterygoid muscle is an important element. Good functional outcome, and the absence of ankylosis, depends directly on the quality of active rehabilitation.
Nelitz, Manfred; Seitz, Andreas M; Bauer, Jasmin; Reichel, Heiko; Ignatius, Anita; Dürselen, Lutz
It was investigated whether the strain of the anterior cruciate ligament and tibial kinematics are affected by increasing posterior tibial slope. 9 human cadaveric knee joints were passively moved between full extension and 120° flexion in a motion and loading simulator under various loading conditions and at 0°, 5°, 10° and 15° posterior tibial slope angles. The anterior cruciate ligament strain and the tibial rotation angle were registered. To assess the influence of posterior tibial slope on the anterior cruciate ligament strain at a fixed flexion angle the anterior cruciate ligament strain was recorded at three different flexion angles of 0°, 30° and 90° while continuously increasing the osteotomy angle from 5° to 15°. The anterior cruciate ligament strain was either not affected by the posterior tibial slope angle or, in some load cases, was decreased for increasing posterior tibial slope (P<0.05). There was a significant decrease of tibial rotation when the posterior tibial slope was increased to 15° for many of the load cases tested (P<0.05). The mean maximum decrease was from 17.4° (SD 5.7°) to 11.2° (SD 4.7°) observed for flexion-extension motion under 30N axial load in combination with an internal rotation moment. The hypothesis that increasing posterior tibial slope results in higher anterior cruciate ligament strain was not confirmed. However, knee kinematics were affected in terms of a reduced tibial rotation. From a biomechanical point of view the data do not support the efficacy of sagittal osteotomies as performed to stabilize anterior cruciate ligament deficient knees. Copyright © 2013 Elsevier Ltd. All rights reserved.
Murawski, Christopher D; Egan, Christopher J; Kennedy, John G
The traditional scarf osteotomy has been associated with complication rates between 1.1% and 45%. We have modified the traditional technique with a rotational osteotomy to reduce these complications. We determined whether a modified rotational scarf osteotomy improves functional outcome scores, allows correction of a wide degree of an intermetatarsal (IM) angle deformity, has a low incidence of troughing, and maintains normal ROM postoperatively in the treatment of symptomatic hallux valgus (HV). We retrospectively reviewed 140 patients: 38 men and 102 women with a mean age of 54 years (range, 35-66 years) who underwent surgery for HV and had a minimum followup of 24 months (mean, 41 months; range, 24-68 months). All patients had preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot and Short Form (SF)-36 V2 outcome scores recorded. The mean AOFAS score improved from 52 points preoperatively to 92 points (range, 71-96 points) at followup. The mean SF-36 V2 score improved from 69 points preoperatively to 94 points (range, 67-98 points) at followup. The IM angle improved from a preoperative mean of 18° (range, 9°-23°) to a mean of 8° (range, 6°-12°). Eleven patients experienced a complication. The modified rotational scarf osteotomy has a low complication rate (9%) and apparently reduces the risk of troughing. This procedure can reduce a high degree of IM angle deformity while restoring function to the forefoot. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
Munteanu, Shannon E; Menz, Hylton B; Wark, John D; Christie, Jemma J; Scurrah, Katrina J; Bui, Minh; Erbas, Bircan; Hopper, John L; Wluka, Anita E
To evaluate the contributions of shared but unmeasured genetic and environmental factors to hallux valgus (HV). Between 2011 and 2012, 74 monozygotic (MZ) and 56 dizygotic (DZ) female twin pairs self-reported HV and putative risk factors, including footwear use across their lifespan. Estimates of casewise concordance (PC ), correlation (ρ), and odds ratios (ORs) were calculated, adjusting for age and other risk factors, and compared between MZ and DZ pairs using logistic regression, generalized estimating equations, and a maximum likelihood-based method, respectively. A total of 70 participants (27%) reported HV, with 12 MZ and 7 DZ pairs being concordant. After adjusting for age, twins were correlated (ρ = 0.27 [95% confidence interval (95% CI) 0.08, 0.46]) and concordant (PC = 0.45 [95% CI 0.29, 0.61]; mean age 58 years), with no difference between MZ and DZ pairs (P = 0.7). HV was associated with regularly wearing footwear with a constrictive toe-box during the fourth decade (adjusted OR 2.73 [95% CI 1.12, 6.67]). This risk factor was correlated in MZ (ρ = 0.38 [95% CI 0.15, 0.60]) but not DZ (ρ = -0.20 [95% CI -0.43, 0.03]) pairs. These correlations were significantly different (P = 0.002). Twins are correlated for HV, but we found no evidence that correlation was due to shared genetic factors. We identified an environmental risk factor, footwear with a constrictive toe-box, that is not shared to the same extent by MZ and DZ pairs, contrary to the assumption of the classic twin model. Footwear, and possibly genetic factors and unknown shared environmental factors, could contribute to developing HV. © 2016, American College of Rheumatology.
Khan, M T
To assess the effectiveness of marigold therapy using Tagetes patula preparations, a double-blind placebo-controlled trial was designed to be carried out over a period of eight weeks. Sixty patients were entered in the trial. Twenty patients with bilateral hallux abducto valgus and its associated condition, bunion, were randomly selected from 37 subjects for group A. For group B, 40 patients with unilateral hallux abducto valgus and bunion were randomly selected from 69 subjects and subdivided into groups Ba and Bb. Patients with ulcerated conditions, those on medication and those who had undergone surgery for the condition were excluded. The results obtained were highly significant (P < 0.001), suggesting that T. patula preparations, plus protective pad, were effective in reducing the width of the lesion and level of pain of hallux abducto valgus.
Toth-Tascau, Mirela; Pasca, Oana; Vigaru, Cosmina; Rusu, Lucian
The general purpose of this study was to assess the gait symmetry for Talus Valgus deformity based on experimental kinematic analysis. As this foot condition generally occurs in children, the study is focused on two children having five years old, one being healthy, as control subject, and the second one having bilateral Talus Valgus deformity. Kinematic experimental analysis was conducted using Zebris CMS-HS Measuring System. The bilateral symmetry was analyzed using two methods: index of symmetry (SI) calculated for spatio-temporal parameters (stance phase, swing phase, and step length) and kinematic parameter (maximum value of dorsiflexion - plantar flexion angle in the ankle joint), and an unpaired t-test to compare the variation of means values of dorsiflexion - plantar flexion angle in ankle joint for both left and right side. The study evidenced a good bilateral symmetry in case of the control subject and quantified the asymmetry in case of subject with Talus Valgus deformity.
Liu, Tong; Wang, Chen-yu; Xiao, Jian-lin; Zhu, Lan-yu; Li, Xue-zhou; Qin, Yan-guo; Gao, Zhong-li
The purpose of this study was to establish a method for measuring the knee valgus angle from the anatomical and mechanical axes on three-dimensional reconstruction imaging models, and to use this method for estimating an average knee valgus angle value for northern Chinese adults. Computed tomographic angiography data in DICOM format for 128 normal femurs from 64 adult subjects were chosen for analysis. After the femur images were subjected to three-dimensional reconstruction, the deepest point in the intercondylar notch (point A), the midpoint of the medullary cavity 20 cm above the knee-joint line (point B), and the landmark of the femoral head rotation center (point C) were identified on each three-dimensional model. The knee valgus angle was defined as the angle enclosed by the distal femoral anatomical axis (line AB) and the femoral mechanical axis (line AC). The average (mean±SD) of knee valgus angle for the 128 femurs was 6.20°±1.20° (range, 3.05° to 10.64°). Significant positive correlations were found between the knee valgus angles of the right and left sides and between the knee valgus angle and age. During total knee arthroplasty, choosing a valgus cut angle of approximately 6° may achieve a good result in reestablishing the natural mechanical alignment of the lower extremity for patients of northern Chinese ethnicity. Larger valgus cut angles should be chosen for older patients. PMID:25091990
Baba, Asif Nazir; Bhat, Javid Ahmed; Paljor, SD; Mir, Naseer Ahmed; Majid, Suhail
Background: Hallux valgus is a common condition that affects the forefoot. A large number of procedures are described for managing this condition. Mitchell's osteotomy and its modifications are being widely used for treating hallux valgus. However, most of the studies describe the results from the developed world. We present results of the classic Mitchell's osteotomy in hallux valgus in Indian subcontinent. Materials and Methods: Forty eight adult patients (including 12 bilateral ones) in the age range of 18–60 years with hallux valgus were managed with the classic Mitchell's osteotomy. Pain over the bunion was the reason for surgery in 53 of 60 feet and cosmesis in the remaining 7 feet. Patients with hallux valgus angle more than 20° and not responding to a trial of conservative treatment were included. Patients having metatarsophalangeal (MTP) joint osteoarthritis (Grade II and higher), hallux rigidus, rheumatoid arthritis, and with subluxation of MTP joint were excluded from the study. Further, patients with first metatarsal more than 3 mm shorter than second metatarsal were also excluded. Results: The average follow-up period is 3 yrs (range 18months – 6yrs). About 55 feet (83%) were painless after surgery. Forty-two (70%) patients were happy with the cosmetic results of the surgery. Metatarsalgia was the reason for dissatisfaction with the procedure in five patients. The average correction of hallux valgus and the intermetatarsal angles achieved was 19.7° and 6.9°, respectively. Using the Broughton and Winson scoring system, 37 (61.7%) feet had excellent results, 18 (30%) had good, and five (8.3%) feet had a poor results. Conclusion: The classic Mitchell's procedure is a simple procedure and gives good cosmetic and radiological results. PMID:19753185
Märdian, S; Schwabe, P; Schaser, K-D
The tibia shaft is the most often fractured long bone of human beings. Among others traffic accidents (37.5 %), falls (17.8 %), sport accidents (30.9 %) and assaults (4.5 %) are typical mechanisms. A brief clinical examination including the correct classification of the fracture pattern and even more important the degree of the soft tissue damage are the most crucial factors for the following therapeutic cascade. This follows a defined algorithm based on the degree of soft tissue damage. As biplanar X-ray diagnostics are obligatory, CT scans are subject to complex fracture patterns and accompanying intraarticular pathologies.The treatment of tibial shaft fractures is the preserve of operative stabilization, which should be done primarily depending on the degree of the soft tissue injury. Here intramedullary methods - especially intramedullary nailing - are the golden standard.The most serious complication of these fractures is the development of a compartment syndrome. This requires rapid diagnosis and an adequate surgical management in order to avoid extensive muscle necrosis with ischaemic contractures and irreversible neurovascular deficits. Apart from postoperative infections, which are the predominant complication especially in open injuries, non union provide typical and late complications which are partly difficult to treat. These should, depending on their type, follow a dedicated treatment algorithm.
Kim, Deog-Im; Kim, Yi-Suk
Most of foot pain occurs by the entrapment of the tibial nerve and its branches. Some studies have reported the location of the tibial nerve; however, textbooks and researches have not described the posterior tibial artery and the relationship between the tibal nerve and the posterior tibial artery in detail. The purpose of this study was to analyze the location of neurovascular structures and bifurcations of the nerve and artery in the ankle region based on the anatomical landmarks. Ninety feet of embalmed human cadavers were examined. All measurements were evaluated based on a reference line. Neurovascular structures were classified based on the relationship between the tibial nerve and the posterior tibial artery. The bifurcation of arteries and nerves were expressed by X- and Y-coordinates. Based on the reference line, 9 measurements were examined. The most common type I (55.6%), was the posterior tibial artery located medial to the tibial nerve. Neurovascular structures were located less than 50% of the distance between M and C from M at the reference line. The bifurcation of the posterior tibial artery was 41% in X-coordinate, -38% in Y-coordinate, and that of the tibial nerve was 48%, and -10%, respectively. Thirteen measurements and classification showed statistically significant differences between both sexes (P<0.05). It is determined the average position of neurovascular structures in the human ankle region and recorded the differences between the sexes and amongst the populations. These results would be helpful for the diagnosis and treatment of foot pain. PMID:26140224
Hunter, Barbara; Duesterdieck-Zellmer, Katja F.; Huber, Michael J.; Parker, Jill E.; Semevolos, Stacy A.
This study evaluated outcomes of surgical treatment for carpal valgus in New World camelids and correlated successful outcome (absence of carpal valgus determined by a veterinarian) with patient characteristics and radiographic features. Univariable and multivariable analyses of retrospective case data in 19 camelids (33 limbs) treated for carpal valgus between 1987 and 2010 revealed that procedures incorporating a distal radial transphyseal bridge were more likely (P = 0.03) to result in success after a single surgical procedure. A greater degree of angulation (> 19°, P = 0.02) and younger age at surgery (< 4 months, P = 0.03) were associated with unsuccessful outcome. Overall, 74% of limbs straightened, 15% overcorrected, and 11% had persistent valgus following surgical intervention. To straighten, 22% of limbs required multiple procedures, not including implant removal. According to owners, valgus returned following implant removal in 4 limbs that had straightened after surgery. PMID:25477542
Hunter, Barbara; Duesterdieck-Zellmer, Katja F; Huber, Michael J; Parker, Jill E; Semevolos, Stacy A
This study evaluated outcomes of surgical treatment for carpal valgus in New World camelids and correlated successful outcome (absence of carpal valgus determined by a veterinarian) with patient characteristics and radiographic features. Univariable and multivariable analyses of retrospective case data in 19 camelids (33 limbs) treated for carpal valgus between 1987 and 2010 revealed that procedures incorporating a distal radial transphyseal bridge were more likely (P = 0.03) to result in success after a single surgical procedure. A greater degree of angulation (> 19°, P = 0.02) and younger age at surgery (< 4 months, P = 0.03) were associated with unsuccessful outcome. Overall, 74% of limbs straightened, 15% overcorrected, and 11% had persistent valgus following surgical intervention. To straighten, 22% of limbs required multiple procedures, not including implant removal. According to owners, valgus returned following implant removal in 4 limbs that had straightened after surgery.
Tsukamoto, Riichiro; Williams, Paul A; Clarke, Ian C; Pezzotti, Giuseppe; Shoji, Hiromu; Akagi, Masao; Yamamoto, Kengo
Zirconia (ZrO(2)) ceramics combined with highly cross-linked polyethylene appears to be a promising approach to minimize wear in artificial knee joints. The wear performance of yttria-stabilized zirconia (YZr) femoral condyles on 7-Mrad tibial inserts was compared in a knee simulator to CoCr bearing on 3.5-Mrad inserts. The knee design was the Bi-Surface type with a 9-year clinical history in Japan (JMM, Japan). A displacement-controlled knee simulator was used with kinematics that included 20 degrees flexion, +/-5 degrees rotation, and 6 mm anterior/posterior translation. Lubricant was alpha-calf serum, test duration was 10 million cycles (10 Mc), and wear was measured by weight-loss techniques. The wear zones were studied by laser interferometry, scanning electron microscopy, and Raman microprobe spectroscopy. At 10 Mc the wear rates of the CoCr controls averaged 4.5 mm(3)/Mc. This was within 7% of the prior estimate at 5-Mc duration and comparable to Bi-Surface wear data from another laboratory. The CoCr condyles increased in roughness (R(a)) from <50 nm to average R(a) = 250 nm due to linear scratching. The ceramic condyles remained pristine throughout the wear study (R(a) <7 nm). With the YZr/7-Mrad combination, the weight change had a positive slope over at 10 Mc, which meant that the actual polyethylene wear was unmeasurable. Microscopic examinations at 10 Mc showed that the zirconia surfaces were intact and there was no detectable change from tetragonal to monoclinic phase. Our laboratory knee wear simulation appeared very supportive of the 9-year YZr/PE clinical results with Bi-Surface total knee replacements in Japan. 2007 Wiley Periodicals, Inc.
Aims The aim was to assess how the stress shielding can influence the integrity and resistance of bones in presence of a misalignment. Methods Three finite elements models have been developed: a normal one, and two varus and valgus knee ones. Results The obtained results reveal interesting consequences deriving by a wrong disposition of parts which compose the skeletal chain of the leg. Conclusion The most dangerous conditions occur in the contact interface between pelvis and hip of the femur, for the valgus knee configuration, and for the varus one, at the contact interface around the knee zone. PMID:25972702
Rahnemai-Azar, Ata A; Abebe, Ermias S; Johnson, Paul; Labrum, Joseph; Fu, Freddie H; Irrgang, James J; Samuelsson, Kristian; Musahl, Volker
To determine the influence of anatomical features of both the tibia and femur on quantitative pivot shift of anterior cruciate ligament (ACL)-injured patients. Fifty-three consecutive ACL-injured patients (mean age 26 ± 10.1 years, 36 males) who underwent ACL reconstruction were prospectively enrolled. Two blinded observers measured the parameters of medial and lateral tibial slope, femoral condyle width, notch width, bicondylar width and tibial plateau width on magnetic resonance imaging. The same examiner performed pivot shift under anaesthesia, while a previously validated image analysis technique was used to quantify knee kinematics during examination. The median lateral compartment translation detected during pivot shift testing (2.8 mm) was used to classify patients into "low-grade rotatory laxity" (≤2.8 mm) and "high-grade rotatory laxity" (>2.8 mm) groups. Twenty-nine subjects were grouped as "low-grade rotatory laxity", and 24 subjects were grouped as "high-grade rotatory laxity". Of the tested bone morphologic parameters, lateral tibial plateau slope was significantly greater in "high-grade rotatory laxity" group (9.3° ± 3.4°) compared to "low-grade rotatory laxity" group (6.1° ± 3.7°) (p < 0.05). Lateral tibial plateau slope was a significant predictor of "high-grade rotatory laxity" (odds ratio 1.27, p < 0.05). A tibial slope of 9° and greater predicted "high-grade rotatory laxity" (sensitivity 63 %; specificity 72 %). Increased slope of the lateral tibial plateau might be an important anatomical variable predicting high-grade rotatory laxity in patients with ACL injury. The finding can be useful in the clinical setting in predicting potential non-copers to conservative therapy and aid in the individualization of the reconstructive procedures of patients. Prospective diagnostic study, Level II.
Lee, Yong Seuk; Ra, Ho Jong; Ahn, Jin Hwan; Ha, Jeong Ku; Kim, Jin Goo
The purposes of this study were (1) to predict the tibial insertion of the posterior cruciate ligament (PCL) and posterior cortex that aligned with the tibial tunnel (PCTT) by use of 2-dimensional plain radiographs by evaluating the relation between plain radiograph and computed tomography (CT) images and (2) to determine the safe angle of the tibial guide for preventing breakage of the posterior cortex. In 10 fresh cadaveric tibias, the soft tissues were dissected and the tibial footprint of the PCL was identified. The insertion of the PCL, the longest distance from the PCTT to the posterior cortex that aligned with the tibial plateau (PCTP), and the possible maximum angle of the tibial guide to the most posteriorly positioned cortical line were measured from simple anteroposterior (AP) and lateral radiographs, as well as CT. The mean tibial insertion of the PCL from the joint line was located between 5.9 ± 1.1 and 17.4 ± 2.4 mm on the simple AP radiographs and between 2.2 ± 1.2 and 12.3 ± 1.5 mm on the simple lateral radiographs (P = .005). The PCL insertion was from the posterior 48% of the area of the posterior intercondylar fossa to the posterior cortex. The longest distance from the PCTT to the PCTP was 10.8 ± 2.2 mm. The maximum angle of the tibial guide to the PCTT possible on CT and the PCTP on lateral radiographs was 52° ± 5° and 62° ± 4.5°, respectively (P = .005). The mean tibial insertion of the PCL from the joint line was located higher on the lateral radiographs than on the AP radiographs, and the PCL insertion was in the posterior 48% of the area of the PCL fovea to the posterior cortex. The maximum possible angle of the tibial guide to the PCTT based on CT was 52°. Therefore the angle of the tibial guide pin must be limited for tibial footprint reconstruction to prevent posterior wall breakage. Increasing the tibial guide angle may have some advantages, but there is a limit because of posterior wall breakage. Copyright Â© 2011
Blumenfeld, Thomas J; Scott, Richard D
Use of an all-polyethylene tibial component in primary total knee arthroplasty remains an attractive option considering the reported durability of the construct, the lowered cost compared to modular metal-backed tibia, and the elimination of backside wear. The two major intra-operative disadvantages include the inability to alter the tibial component thickness after permanent implant placement and the inability to use varus-valgus constrained designs. The long-term disadvantage is the inability to perform a modular insert exchange should this be required. We report the 30-year outcome of a single patient using the duopatellar total knee replacement system. Based on a critical review of the literature we would recommend use in patients 80 years of age or older, consideration in patients 75 to 79 years, and possibly in younger yet less active patients. These three groups would be the least likely to require a modular tibial liner exchange in their lifetime. Copyright © 2009 Elsevier B.V. All rights reserved.
Bachhal, V; Sankhala, S S; Jindal, N; Dhillon, M S
We report the outcome of 32 patients (37 knees) who underwent hemicallostasis with a dynamic external fixator for osteoarthritis of the medial compartment of the knee. There were 16 men (19 knees) and 16 women (18 knees) with a mean age at operation of 54.6 years (27 to 72). The aim was to achieve a valgus overcorrection of 2° to 8° or mechanical axis at 62.5% (± 12.5%). At a mean follow-up of 62.8 months (51 to 81) there was no change in the mean range of movement, and no statistically significant difference in the Insall-Salvati index or tibial slope (p = 0.11 and p = 0.15, respectively). The mean hip-knee-ankle angle changed from 190.6 (183° to 197°) to 176.0° (171° to 181°), with a mean final position of the mechanical axis of 58.5% (35.1% to 71.2%). The desired alignment was attained in 31 of 37 (84%) knees. There were 21 excellent, 13 good, two fair and one poor result according to the Oxford knee score with no correlation between age and final score. This score was at its best at one year with a statistically significant deterioration at two years (p = 0.001) followed by a small but not statistically significant deterioration until the final follow-up (p = 0.17). All the knees with Ahlback grade 1 osteoarthritis had excellent or good results. Complications included pin tract infections involving 16.4% of all pins used, delayed union in two, knee stiffness in four, fracture of the lateral cortex in one and ring sequestrum in one. In conclusion, hemicallostasis provides precision in attaining the desired alignment without interfering with tibial slope or patellar height, and is relatively free of serious complications.
Coury, John G; Lum, Zachary C; O'Neill, Nicholas P; Gerardi, Joseph A
There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.
Kim, Deog-Im; Kwak, Dai-Soon; Han, Seung-Ho
The proximal and distal parts of the femur show the differences between the sexes. Head diameter and the breadth of the epicondyle of the femur are known to distinguish males from females. The proximal end of the femur is studied to determine sex using discriminant analysis but; its distal end is not done. This study aims to develop an equation specific to Koreans by using the medial and lateral condyles of the femur, and to demonstrate the usefulness of equations for specific population groups. We used three-dimensional images from 202 Korean femurs. Twelve variables were measured with a computer program after the femurs were in alignment. Eleven variables showed a statistically significant difference between the sexes (P<0.01). The most accurate equation used width of the medial and lateral condyles (WDC), with of the medial condyle (WMC), depth of the lateral condyle (DLC), and depth of the intercondylar notch (DIN) (94.1%), and is as follows: D = 0.336 × WDC + (-0.097) × WMC + (-0.153) × DLC + 0.372 × DIN - 20.912. The second highest accuracy was 90.1% for the width dimensional group and WDC. This study shows that the medial and lateral condyles of the femur should be helpful for sex determination in situations where the skull and pelvis are missing and part of the femur is available. The study also demonstrates the need for different equations for different population groups.
Rysz, Maciej; Grabczan, Wojciech; Mazurek, Maciej Jan; Krajewski, Romuald; Grzelecki, Dariusz; Ciszek, Bogdan
A small size and difficulties with shaping a medial femoral condyle corticocancellous bone flap are factors limiting its use. The goal of this study was to evaluate range of vascular supply to a medial femoral condyle corticocancellous bone flap to determine whether harvesting of larger flaps and performing a flap osteotomy would compromise the vasculature of a flap's bone. Twenty-four limbs were dissected and medial femoral condyle corticocancellous bone flaps were harvested with skin paddles. Thirteen of 24 flaps had subperiosteal osteotomies simulating shaping a bone for reconstruction. A pedicle artery was perfused with red latex. Medial femoral condyle corticocancellous bone flap vascularization was evaluated by cutting the bone into 1-cm blocks and assessing the number of Haversian canals filled with red latex. Length of harvested flaps was 7 to 13 cm, thickness was 0.5 to 3 cm, and width was 1 to 3 cm. Pedicle length was between 3.5 and 9 cm (mean ± SD, 6.6 ± 1.6 cm). Red latex filled bone vessels at a distance of 6 to 11.5 cm from the distal end of a flap (8.2 ± 1.4 cm). Skin paddles were filled with latex in all cases. A medial femoral condyle corticocancellous bone flap had sufficient blood supply, allowing for harvesting flaps up to 11 cm long, and subperiosteal osteotomy did not compromise the vasculature of the flap's bone.
Pugliese, L C; Pike, F S; Aiken, S W
Medial patellar luxation frequently occurs in dogs resulting in lameness with increasing incidence in large breed dogs. Patella alta has been defined as a patellar ligament length to patellar length ratio that is greater than two and may predispose to patellar luxation. To describe the surgical technique for stabilization of the distal translation of the tibial tuberosity using tibial tuberosity advancement plates and the clinical outcomes with follow-up for clinical cases of dogs. Dogs that were presented with the complaint of patellar luxation and that were concurrently diagnosed with patella alta and were greater than 20 kg in body weight underwent surgery using a tibial tuberosity advancement plate to stabilize the osteotomy. Radiographic assessment of A:PL distance (the ratio of the proximal aspect of the patella to the femoral condyle [A] to the patellar length [PL]), L:P ratio (ratio of the length of the patellar ligament to the diagonal length of the patella), and owner assessment were obtained. Eleven stifles in nine dogs underwent surgical correction with a mean preoperative L:P ratio of 2.47. There were no complications and the lameness resolved clinically. The mean A:PL ratios preoperatively (2.6 ± 0.22) and postoperatively (2.1 ± 0.25) were significantly different (p = 0.0003). All owners were satisfied with the outcome and all dogs had a resolution of lameness with no recurrence of patellar luxation. Stabilization of distal translation of the tibial tuberosity using tibial tuberosity advancement implants to correct patella alta in large breed dogs was feasible and resulted in good clinical outcome.
Pitta, Guilherme Benjamin Brandão; dos Santos, Thays Fernanda Avelino; dos Santos, Fernanda Thaysa Avelino; da Costa Filho, Edelson Moreira
Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures. The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers large numbers of traumas, not only fractures, but also crush injuries and severe bruising, among others, which at any given moment, could lead compartment syndrome in the patient. The case is reported of a 58-year-old patient who, following a tibial plateau fracture, presented compartment syndrome of the leg and was submitted to decompressive fasciotomy of the four right compartments. After osteosynthesis with internal fixation of the tibial plateau using an L-plate, the patient again developed compartment syndrome. PMID:26229779
EL Hajj, Firass; Sebaaly, Amer; Kharrat, Khalil; Ghanem, Ismat
Osteochondritis of the distal tibial epiphysis is a very rare entity. 9 cases have been described in 7 articles and 8 other cases have been mentioned in textbooks. This paper describes the 10th case of osteochondritis of the distal tibial epiphysis and summarizes the clinical and radiological presentations of the 9 other cases. The etiology of this entity is well debated in the literature. We believe that it results from a vascular abnormality in the distal tibial epiphysis associated with a mechanical stress (trauma, excessive overload, etc.). Since it is a self-limited disease, the prognosis is good and the younger the patient is the better the prognosis will be. In general, this entity responds well to conservative treatment. PMID:23193412
Kim, Sang Bum; Lim, Jin Woo; Seo, Jeong Gook
Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case. PMID:26929808
Couture, Christopher J.; Karlson, Kristine A.
Tibial stress injuries, commonly called shin splints, often result when bone remodeling processes adopt inadequately to repetitive stress. Physicians who are caring for athletic patients must have a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are…
Couture, Christopher J.; Karlson, Kristine A.
Tibial stress injuries, commonly called shin splints, often result when bone remodeling processes adopt inadequately to repetitive stress. Physicians who are caring for athletic patients must have a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are…
Pintar, Frank A; Yoganandan, Narayan; Baisden, Jamie
Because of the need to evaluate anthropomorphic test device (ATD) biofidelity under high-head angular accelerations, the purpose of the present investigation was to develop appropriate instrumentation for intact post mortem human subject (PMHS) testing, validate the instrumentation, and obtain information to characterize the response of the head-neck complex under this loading scenario. A series of rigid-arm pendulum, inertially loaded ATD tests was conducted. Head and neck ATD hydraulic piston chin pull tests were conducted. Subsequently, a series of PMHS tests was conducted to derive the response of the human head-neck under high-rate chin loading. Finally, Hybrid III and THOR-NT ATD head-neck systems were evaluated under the same scenario as the PMHS. A parametric analysis for center of gravity (CG) location and accelerometer orientation determined that even small errors (+/- 3 mm or 2 degrees), produced errors in the force and moment calculations by as much as 17 %. If the moment of inertia (MOI) term was varied by 5 %, resulting moment calculations were affected by as much as 8 %. If the 5 % error in MOI was used to compute occipital condyle moments, and results compared to upper load cell derived moments, peaks differed by as much as 24 %. The head CG and mass MOI should be directly measured for each preparation to obtain accurate results. The injury run on each specimen resulted in predominantly C1-C2 separations or partial separations. The 50(th) percentile probability of AIS=2+ neck injury using tensile force was about 2400 N; for AIS=3+ neck injury the 50(th) percentile risk was about 3180 N. When inserting extension moment as the criteria, the 50(th) percentile probability of an AIS=2+ injury was 51 Nm. The AIS=3+ extension moment at the 50(th) percentile probability was 75 Nm. The new THOR-NT ATD head-neck produced more biofidelic responses with an alternate head-neck junction design compared to the Hybrid III ATD.
van Raaij, Tom M; Bakker, Wouter; Reijman, Max; Verhaar, Jan AN
Background We performed a matched case control study to assess the effect of prior high tibia valgus producing osteotomy on results and complications of total knee arthroplasty (TKA). Methods From 1996 until 2003 356 patients underwent all cemented primary total knee replacement in our institution. Twelve patients with a history of 14 HTO were identified and matched to a control group of 12 patients with 14 primary TKA without previous HTO. The match was made for gender, age, date of surgery, body mass index, aetiology and type of prosthesis. Clinical and radiographic outcome were evaluated after a median duration of follow-up of 3.7 years (minimum, 2.3 years). The SPSS program was used for statistical analyses. Results The index group had more perioperative blood loss and exposure difficulties with one tibial tuberosity osteotomy and three patients with lateral retinacular releases. No such procedures were needed in the control group. Mid-term HSS, KSS and WOMAC scores were less favourable for the index group, but these differences were not significant. The tibial slope of patients with prior HTO was significantly decreased after this procedure. The tibial posterior inclination angle was corrected during knee replacement but posterior inclination was significantly less compared to the control group. No deep infection or knee component loosening were seen in the group with prior HTO. Conclusion We conclude that TKA after HTO seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no HTO previously. PMID:17683549
Paulos, L E; France, E P; Rosenberg, T D; Jayaraman, G; Abbott, P J; Jaen, J
To better understand the role of preventive knee braces in injury prevention, a biomechanical study using fresh frozen cadaveric knees (N = 18) was conducted. Ligament tensions and joint displacements were measured at static, nondestructive valgus forces as well as low-rate destructive forces. After quantifying and establishing individual ligament contributions to valgus restraining function, knees were then braced with two different laterally applied preventive braces, the McDavid Knee Guard and the Omni Anderson Knee Stabler. The effects of lateral bracing were analyzed according to valgus force, joint line opening, and ligament tensions. Valgus applied forces, with or without braces, consistently produced medial collateral ligament (MCL) disruptions at ligament tensions surprisingly higher than the anterior cruciate ligament (ACL) and higher than or equal to the posterior cruciate ligament (PCL). Although large joint displacements were necessary for complete ligament failure, bundle disruption in the MCL, ACL, and PCL was noted at much smaller joint openings. In Part I of this study, no significant protection could be documented with the two preventive braces used. Also, four potentially adverse effects were noted: MCL preload, center axis shift, premature joint line contact, and brace slippage.
LaPorta, Guido A; Nasser, Ellianne M; Mulhern, Jennifer L; Malay, D Scot
The present report describes a new method of hallux abducto valgus deformity correction planning using the mechanical axis of the medial column (mechanical axis planning). This method of radiographic evaluation identifies an ideal position for the first metatarsal after correction and is useful regardless of the surgical procedure chosen. We retrospectively reviewed 200 radiographs to identify a "normal" value for the mechanical axis angle. We reviewed 100 radiographs of patients with hallux abducto valgus deformity (deformity group) and 100 radiographs of patients without hallux abducto valgus deformity (control group). The deformity group revealed an M1-M2 anatomic axis angle of 13.5° ± 2.83° and an M1-M2 mechanical axis angle of 11.58° ± 1°. The control group revealed an M1-M2 anatomic axis angle of 7.5° ± 1.76° and an M1-M2 mechanical axis angle of 11.19° ± 0.9°. The differences in the M1-M2 anatomic axis angle and M1-M2 mechanical axis angle were statistically significant between the control and deformity groups. We sought to provide a reliable method for planning hallux abducto valgus deformity correction by aligning the mechanical axis of the medial column and the mechanical axis of the first ray to the "normal" value of 11° to reduce the deformity.
Lara, Luiz Carlos Ribeiro; de Araujo, Bruno Vierno; Franco, Nelson; Hita, Roberto Minoru
OBJECTIVE: To clinically and radiographically compare the results of treatment of hallux valgus, by two addition osteotomy techniques: one using resected exostosis, and the other using a plate fixation for addition wedge. METHODS: We evaluated 24 feet of 19 patients, mean age 51.3 years, affected by hallux valgus, with a mean follow-up of 50.1 months. 13 feet underwent addition osteotomy with resected exostosis (AORE) and 11 patients (11 feet) underwent addition osteotomy with plate (AOP). The AOFAS score, intermetatarsal 1 and 2 angles, and hallux valgus angle were evaluated before and after surgery. RESULTS: In the AORE technique, the mean preoperative AOFAS was 46.6, with IMA 14o and HVA 32o, while in the postoperative AOFAS it was 81.3, with IMA 9o and HVA 25o, and 92.3% satisfactory results. In the AOP technique, the mean preoperative AOFAS was 42.1, with IMA 15o and HVA 29o while in the postoperative AOFAS it was 77.4, with IMA 11o and HVA 23o and 81.8% of satisfactory results. CONCLUSIONS: Both techniques proved to be effective in the treatment of hallux valgus, both clinically and radiografically, with no statistical difference between them. Level of evidence III, Retrospective comparative study. PMID:24453631
Kuyucu, E; Ceylan, H H; Surucu, S; Erdil, I; Kara, A; Gulenc, B G; Bulbul, M; Erdil, M
PURPOSE OF THE STUDY Accurate radiographic measurements are crucial in treating hallux valgus (HV). This three-dimensional deformity should not be evaluated from one joint on one plane. However, in practice, surgeons measure the deformity only on transverse dorsoplantar radiographs. We determined the amount of error associated with positioning the foot incorrectly on radiographs. MATERIAL AND METHODS To simulate incorrect positions of the foot in radiographic evaluation, we designed an angled device that can move in transverse and frontal plane. In four patients with symptomatic HV, we took weight-bearing radiographs of the involved foot in seven different positions. These 28 radiographs were given identifying but meaningless labels. On each radiograph, six surgeons blinded to the position of the radiograph measured the HV angle (HVA) and the inter-metatarsal angle (IMA) and state the treatment plan according to five treatment options were given to participants. RESULTS Inter-observer agreement was high for measurements of HVA and IMA in all positions (interclass correlation coefficients, 0.96 and 0.88, respectively). However, intra-observer agreement was poor for HVA (intra-observer agreement, 0.17) but good for IMA (intra-observer agreement, 0.64). According to the measurements in different positions, intra-observer treatment choices revealed moderate results (ICC: 0.524). Clinical Relevance Radiographic measurements are very important on the treatment decisions of hallux valgus. The foot position can influence the measurement accuracy and can cause incorrect decisions. In this study, we evaluated the impact of foot positions on measurements of hallux valgus angle and inter-metatarsal angle. Additionally, we evaluated the incorrect foot positioning on treatment decisions. Moreover, we analyzed intra-observer and inter-observer agreements of these angles in various positions. CONCLUSIONS We recommend that measurements of IMA are more reliable than those of HVA for
Manco, L.G.; Schneider, R.; Pavlov, H.
An insufficiency fracture of the tibial plateau may be the cause of knee pain in patients with osteoporosis. The diagnosis is usually not suspected until a bone scan is done, as initial radiographs are often negative or inconclusive and clinical findings are nonspecific and may simulate osteoarthritis or spontaneous osteonecrosis. In five of 165 patients referred for bone scans due to nontraumatic knee pain, a characteristic pattern of intense augmented uptake of radionuclide confined to the tibial plateau led to a presumptive diagnosis of insufficiency fracture, later confirmed on radiographs.
Albuquerque, Rodrigo Pires e; Campos, André Siqueira; de Araújo, Gabriel Costa Serrão; Gameiro, Vinícius Schott
The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. We describe a case in an adult who suffered a left knee injury due to a fall from height. No risk factors were identified. The lesion was treated with surgical reduction and internal fixation. The rehabilitation method was successful, resulting in excellent function and rage of motion of the knee. The aim of this study was to present an unusual case of direct trauma of the tibial tuberosity in an adult and the therapy performed. PMID:24293543
Jiwanlal, Aneel; Jeray, Kyle James
Isolated posterior tibial plateau fractures are rare injuries that encompass a wide variety of fracture patterns. Based on the variation in fracture pattern, the surgical approach varies, with both anterior and posterior approaches described for surgical fixation. Postoperative protocol also varies among studies. The aim of this article is to summarize the outcomes related to posterior column tibial plateau fractures. The papers reviewed, primarily small retrospective case series, showed functional knee range of motion is preserved, a low incidence of wound complications, and patient outcome scores comparable to other reported lower extremity injury outcome scores. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Kiseri, Burim; Dayan, Süleyman Çağatay; Yıldız, Melih; Sülün, Tonguç
The direction and amount of retrusive movement may be correlated with the amount of joint space and the maximum intercuspal position of the condyle. The aim of this study was to identify any such correlation using an ultrasonic jaw motion analyzer and digital volumetric tomographic (DVT) scans. Thirty-five dental students were selected as subjects. DVT scans were obtained using a next-generation i-CAT CBCT unit, and the direction and amount of retrusive movement were measured with a 3-D analyzer. Spearman Rho correlation tests showed no correlation between the amount of retrusive movement and the condyle position and joint space on either the right or left side. There is sufficient reason to suggest that retrusive movement of the condyle does not occur in isolation but is influenced by glenoid fossa bone morphology.
Dong, Zhiwei; Li, Qihong; Bai, Shizhu; Zhang, Li
Condyle fractures are common in children and are increasingly treated with open reduction. Three-dimensional printing has developed into an important method of assisting surgical treatment. This report describes the case of a 14-year-old patient treated for a right condyle fracture at the authors' hospital. Preoperatively, the authors designed a surgical guide using 3-dimensional printing and virtual surgery. The 3-dimensional surgical guide allowed accurate alignment of the fracture using Kirschner wire without additional dissection and tissue injury. Kirschner wire fixation augmented by 3-dimensional printing technology produced a good outcome in this adolescent condyle fracture. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Park, Young-Wook; Lee, Woo-Young; Kwon, Kwang-Jun; Kim, Seong-Gon; Lee, Suk-Keun
Osteochondroma is rarely reported in the maxillofacial region; however, it is prevalent in the mandibular condyle. This slowly growing tumor may lead to malocclusion and facial asymmetry. A 39-year-old woman complained of gradual development of anterior and posterior unilateral crossbite, which resulted in facial asymmetry. A radiological study disclosed a large tumor mass on the top of the left mandibular condyle. This bony tumor was surgically removed through condylectomy and the remaining condyle head was secured. Subsequently, bimaxillary orthognathic surgery was performed to correct facial asymmetry and malocclusion. Pathological diagnosis was osteochondroma; immunohistochemistry showed that the tumor exhibited a conspicuous expression of BMP-4 and BMP-2 but rarely expression of PCNA. There was no recurrence at least for 1 year after the operation. Patient's functional and esthetic rehabilitation was uneventful.
Deng, Zhenhan; Li, Yusheng; Liu, Hong; Li, Kanghua; Lei, Guanghua; Lu, Bangbao
BACKGROUND The aim of this study was to investigate bone mineral density (BMD) and the biomechanical and histological effects of posterior cruciate ligament (PCL) rupture on the lateral femoral condyle. MATERIAL AND METHODS Strain on different parts of the lateral femoral condyle from specimens of normal adult knee joints, including 12 intact PCLs, 6 ruptures of the anterolateral bundle, 6 ruptures of the postmedial bundle, and 12 complete ruptures, was tested when loaded with different loads on the knee at various flexion angles. Lateral femoral condyles were also collected randomly from both the experimental side in which the PCLs were transected and the control side from 4 sets of 12 matched-mode pairs of rabbits at 4, 8, 16, and 24 weeks after surgery, and their BMD and morphological and histological changes were observed. RESULTS Partial and complete rupture of the PCL may cause an abnormal load on all parts of the lateral femoral condyle with any axial loading at all positions. Noticeable time-dependent degenerative histological changes of the lateral femoral condyle were observed in the rabbit model of PCL rupture. All of the PCL rupture groups had a higher expression of matrix metalloproteinase-7 (MMP-7) and collagen type II than the control group at all time points (P<0.05), but no significant difference in BMD (P>0.05). CONCLUSIONS Rupture of the PCL may trigger a coordinated response of lateral femoral condyle degeneration in a time-dependent manner, to which the high level of expression of MMP-7 and collagen type II could contribute.
Deng, Zhenhan; Li, Yusheng; Liu, Hong; Li, Kanghua; Lei, Guanghua; Lu, Bangbao
Background The aim of this study was to investigate bone mineral density (BMD) and the biomechanical and histological effects of posterior cruciate ligament (PCL) rupture on the lateral femoral condyle. Material/Methods Strain on different parts of the lateral femoral condyle from specimens of normal adult knee joints, including 12 intact PCLs, 6 ruptures of the anterolateral bundle, 6 ruptures of the postmedial bundle, and 12 complete ruptures, was tested when loaded with different loads on the knee at various flexion angles. Lateral femoral condyles were also collected randomly from both the experimental side in which the PCLs were transected and the control side from 4 sets of 12 matched-mode pairs of rabbits at 4, 8, 16, and 24 weeks after surgery, and their BMD and morphological and histological changes were observed. Results Partial and complete rupture of the PCL may cause an abnormal load on all parts of the lateral femoral condyle with any axial loading at all positions. Noticeable time-dependent degenerative histological changes of the lateral femoral condyle were observed in the rabbit model of PCL rupture. All of the PCL rupture groups had a higher expression of matrix metalloproteinase-7 (MMP-7) and collagen type II than the control group at all time points (P<0.05), but no significant difference in BMD (P>0.05). Conclusions Rupture of the PCL may trigger a coordinated response of lateral femoral condyle degeneration in a time-dependent manner, to which the high level of expression of MMP-7 and collagen type II could contribute. PMID:27843134
Kutzner, Ines; Küther, Steffen; Heinlein, Bernd; Dymke, Jörn; Bender, Alwina; Halder, Andreas M; Bergmann, Georg
Knee osteoarthritis occurs predominately at the medial compartment. To unload the affected compartment, valgus braces are used which induce an additional valgus moment in order to shift the load more laterally. Until now the biomechanical effect of braces was mainly evaluated by measuring changes in external knee adduction moments. The aim of this study was to investigate if and to which extent the medial compartment load is reduced in vivo when wearing valgus braces. Six components of joint contact load were measured in vivo in three subjects, using instrumented, telemeterized knee implants. From the forces and moments the medio-lateral force distribution was calculated. Two braces, MOS Genu (Bauerfeind AG) and Genu Arthro (Otto Bock) were investigated in neutral, 4° and 8° valgus adjustment during walking, stair ascending and descending. During walking with the MOS brace in 4°/8° valgus adjustment, medial forces were reduced by 24%/30% on average at terminal stance. During walking with the GA in the 8° valgus position, medial forces were reduced by only 7%. During stair ascending/descending significant reductions of 26%/24% were only observed with the MOS (8°). The load reducing ability of the two investigated valgus braces was confirmed in three subjects. However, the load reduction depends on the brace stiffness and its valgus adjustment and varies strongly inter-individually. Valgus adjustments of 8° might, especially with the MOS brace, not be tolerated by patients for a long time. Medial load reductions of more than 25% can therefore probably not be expected in clinical practise. Copyright © 2011 Elsevier Ltd. All rights reserved.
Sundaram, R O; Cohen, D; Barton-Hanson, N
Tibial plateau fractures following anterior cruciate ligament (ACL) reconstruction are extremely rare. This is the first reported case of a tibial plateau fracture following four-strand gracilis-semitendinosus autograft ACL reconstruction. The tibial tunnel alone may behave as a stress riser which can significantly reduce bone strength.
Coughlin, M J; Freund, E
The purpose of this study was to determine the intraobserver and inter-observer reliability of physicians on a repetitive basis in making angular measurements of hallux valgus deformities. The hallux valgus angle, the 1-2 intermetatarsal angle, and the distal metatarsal articular angle and the assessment of congruency/subluxation of the first MTP joint were evaluated on a repetitive basis. Physicians were provided with a series of black and white photographs of radiographs with a hallux valgus deformity. Three different sets of photographs randomly ordered were sent at a minimum interval of six weeks to the participants. Participating physicians were extremely reliable in the measurement of the 1-2 metatarsal angle. 96.7% of the photographs were repeatedly measured within a range of 5 degrees or less. The angular measurements to determine the hallux valgus angle were slightly less reliable, but 86.2% of photos were repeatedly measured within a range of 5 degrees or less. In the measurement of the distal metatarsal articular angle, 58.9% of photographs were repeatedly measured within a range of 5 degrees or less. There was a wide range within physician evaluators who recognized very few congruent joints (2 of 21) and those who recognized several congruent joints (11 of 21). Most physicians appeared to be internally consistent in the assessment of MTP congruency; however, some photographs were much more difficult to assess than others. This study validates the reliability of the measurement of the hallux valgus and the 1-2 metatarsal angle. The interobserver reliability in the measurement of the distal metatarsal articular angle is questioned.
Affatato, S.; Spinelli, M.; Zavalloni, M.; Carmignato, S.; Lopomo, N.; Marcacci, M.; Viceconti, M.
Knee osteoarthritis is a complex clinical scenario where many biological and mechanical factors influence the severity of articular degenerative changes. Minimally invasive knee prosthetic surgery, with only a compartment replacement (unicompartmental knee replacement), might be a good compromise between osteotomy and total knee prosthesis. The focus of this study was to develop and validate a protocol to assess the fixation method of the femoral components in mechanical simulation, for pre-clinical validation; the wear behaviour of two different fixation frames was quantified and compared. In particular, two different wear tests were conducted using the same knee simulator, the same load profiles and the same kinematics; two different fixation methods were applied to the femoral sleds (synthetic femur and metal block). Surface characterization on both articulating bearings was performed by a roughness measuring machine and coordinate measuring machine. The wear produced by the tibial inserts using the synthetic femur was considerably higher than the wear registered by the metal-block holder. Roughness measurements on femoral sleds showed a limited number of scratches with high Rt values for the metal-block set-up; the damaged surface broadened in the case of femoral condyles and tibial inserts mounted on composite bone, but lower Rt and linear penetration values were measured. The two holding frames showed different wear activities as a consequence of dissimilar dynamic performance. Further observations should be made in vivo to prove the actual importance of synthetic bone simulations and specific material behaviour.
Lorbach, O; Anagnostakos, K; Kohn, D
The present article summarizes the different osteotomy techniques for an extension of standard surgical approaches to the knee joint in selected patients. The aim is to achieve satisfactory exposure and reduce potential postoperative complications compared to alternative techniques, such as the V-Y plasty or the quadriceps snip procedures. Osteotomy of the tibial tubercle is a reasonable extension of the anteromedial or the anterolateral surgical approach in selected patients undergoing revision total knee replacement. This osteotomy will provide excellent surgical exposure of the knee without the risk of avulsion of the patellar tendon and will preserve the blood supply of the patella and the surrounding soft tissue. Moreover, functional clinical outcome will be improved by minimizing damage to the extensor mechanism. Osteotomy of the lateral femoral condyle gives excellent exposure of the posterolateral aspect of the knee joint which might be necessary in some patients with fractures of the posterolateral tibial plateau as well as patients undergoing open allograft transplantation of the lateral meniscus. An alternative option for an extended exposure to the posterolateral knee joint is accomplished by osteotomy or partial resection of the fibular head which is also described as having good clinical results and a low complication rate.
Affatato, S; Spinelli, M; Zavalloni, M; Carmignato, S; Lopomo, N; Marcacci, M; Viceconti, M
Knee osteoarthritis is a complex clinical scenario where many biological and mechanical factors influence the severity of articular degenerative changes. Minimally invasive knee prosthetic surgery, with only a compartment replacement (unicompartmental knee replacement), might be a good compromise between osteotomy and total knee prosthesis. The focus of this study was to develop and validate a protocol to assess the fixation method of the femoral components in mechanical simulation, for pre-clinical validation; the wear behaviour of two different fixation frames was quantified and compared. In particular, two different wear tests were conducted using the same knee simulator, the same load profiles and the same kinematics; two different fixation methods were applied to the femoral sleds (synthetic femur and metal block). Surface characterization on both articulating bearings was performed by a roughness measuring machine and coordinate measuring machine. The wear produced by the tibial inserts using the synthetic femur was considerably higher than the wear registered by the metal-block holder. Roughness measurements on femoral sleds showed a limited number of scratches with high R(t) values for the metal-block set-up; the damaged surface broadened in the case of femoral condyles and tibial inserts mounted on composite bone, but lower R(t) and linear penetration values were measured. The two holding frames showed different wear activities as a consequence of dissimilar dynamic performance. Further observations should be made in vivo to prove the actual importance of synthetic bone simulations and specific material behaviour.
Harms, Christoph; Helms, Kai; Taschner, Tibor; Stratos, Ioannis; Ignatius, Anita; Gerber, Thomas; Lenz, Solvig; Rammelt, Stefan; Vollmar, Brigitte; Mittlmeier, Thomas
The synthetic material Nanobone® (hydroxyapatite nanocrystallines embedded in a porous silica gel matrix) was examined in vivo using a standardized bone defect model in the ovine tibial metaphysis. A standardized 6 × 12 × 24-mm bone defect was created below the articular surface of the medial tibia condyles on both hind legs of 18 adult sheep. The defect on the right side was filled with Nanobone®, while the defect on the contralateral side was left empty. The tibial heads of six sheep were analyzed after 6, 12, and 26 weeks each. The histological and radiological analysis of the defect on the control side did not reveal any bone formation after the total of 26 weeks. In contrast, the microcomputed tomography analysis of the defect filled with Nanobone® showed a 55%, 72%, and 74% volume fraction of structures with bone density after 6, 12, and 26 weeks, respectively. Quantitative histomorphological analysis after 6, and 12 weeks revealed an osteoneogenesis of 22%, and 36%, respectively. Hematoxylin and eosin sections demonstrated multinucleated giant cells on the surface of the biomaterial and resorption lacunae, indicating osteoclastic resorptive activity. Nanobone® appears to be a highly potent bone substitute material with osteoconductive properties in a loaded large animal defect model, supporting the potential use of Nanobone® also in humans. PMID:22745551
Mirouse, G; Corcos, P; Casabianca, L; Guillon, P
We report the occurrence of a rare injury in a teenager not yet described in the literature: the association of posteromedial elbow dislocation, lateral condyle and coronoid process fractures. The treatment required fixation of lateral condyle and coronoid process thanks to lateral and medial approaches and capsular fixation. This lesion is unstable, such as the terrible triad described in adults. It requires external and anterior stabilization of the elbow. The management of such injuries of the elbow is complex. It must consider both bone and ligament instability, and risk of injury to growth plates.
Carranza, Miriam L; Carda, Carmen; Simbrón, Alicia; Quevedo, María C Sánchez; Celaya, Gabriela; de Ferraris, Maria Elsa Gómez
The lateral pterygoid muscle (LPM) inserts at the condyle and the articular disc and plays a central role in mandibular movement via the Temporomandibular Articular Complex. The aim of this study was to examine the association between the morphology of LPM muscular fascicles and the degree of mineralization of the mandibular condyle in the prenatal stage employing structural, ultrastructural and microanalytical evaluation. Sixteen human fetuses at 11-37 weeks of gestation, with no apparent pathology and resulting from spontaneous abortions, were included in the study. Samples from lateral pterygoid muscle and the mandibular condyle were processed for light microscopy and electron microscopy and microanalysis. Desmin immunolabeling (dilution 1: 25 Dako) and alpha sarcomeric actin immunolabeling (dilution 1:50 Dako) employing the avidin-biotin system were used in paraffin embedded samples. Contralateral samples were examine by transmission electron microscopy. Four condyles (at 17-21 weeks of gestation) were used to measure the relative content of calcium and phosphorous employing the X-ray diffraction microanalytical technique. At 11-16 weeks of gestation, the LPM was composed of secondary myotubes associated to satellite cells and nerve fibers. At 18 weeks, the muscle exhibited multiple compact fascicles and the condyle showed a thin, external, subperiostal mineralized layer with few central bone spicules. At 20 weeks, at the site of insertion of the LPM, the bone trabeculae of the condyle contained an electrondense matrix with abundant mineralization nuclei. At 17-21 weeks of gestation no significant variations in the contents of phosphorous and calcium were observed. At 24 weeks, transmission electron calcium and microscopy studies revealed a marked increase in the functional units of the muscle fascicles. Also, at this age muscle fibers exhibited differences in the expression of desmin and alpha sarcomeric actin. At 37 weeks the muscle became multipennate in
Kapapa, Thomas; Tschan, Christoph A; König, Kathrin; Schlesinger, Arkadius; Haubitz, Bernd; Becker, Hartmut; Zumkeller, Matthias; Eckhard, Rickels
We report a case of fractured occipital condyle caused by minor trauma accompanied by light pain on palpation at the lateral cervical trigonum. A 15-year-old boy complained of nuchal pain, particularly pain on palpation at the left lateral cervical trigonum in the absence of neurologic deficits after head deceleration trauma. Computed tomography demonstrated a unilateral nonluxated fracture of the occipital condyle. Owing to consequent immobilization by means of cervical orthosis, pain disappeared after the first 48 hours. Follow-up examination 4 weeks later showed no neurologic deficits. The boy had no severe impairment of movements at the cervical spine.
Woo, Min-Ho; Yoon, Kyu-Ho; Park, Jae-An
Bifid mandibular condyle (BMC) is an uncommon morphological variant of the mandibular condyle. Although authors have proposed various etiologies for BMC, no consensus has emerged. In addition, varying findings have been reported regarding the epidemiological parameters of BMC (e.g., prevalence, gender ratio, and age), possibly due to its low incidence. BMC is occasionally associated with symptoms of the temporomandibular joint, such as ankylosis, pain, and trismus; however, it is difficult to detect this condition on conventional radiographs. This study reports a case of BMC with radiographic findings, and reviews the literature on the epidemiology of BMC. PMID:27672618
Osterwalder, A; Maestretti, G
The procedure known as the Metatarsus Primus Double Osteotomy ("L'ostéotomie métatarsienne bipolaire" of Schnepp-Carret) for the treatment of the hallux valgus is a logical, efficient and non-mutilating procedure. The technique consists in reducing the hallux valgus deformity by a subcapital bone wedge resection of the metatarsus primus. The bone wedge is then pinched into a second proximal osteotomy of the metatarsus primus, correcting the varus deformity in a valgus direction. This procedure is little known and is not even mentioned in the classic orthopedic literature of German and English language.
Roth, Joshua D; Howell, Stephen M; Hull, Maury L
Following total knee arthroplasty (TKA), high tibial forces, large differences in tibial forces between the medial and lateral compartments, and anterior translation of the contact locations of the femoral component on the tibial component during passive flexion indicate abnormal knee function. Because the goal of kinematically aligned TKA is to restore native knee function without soft tissue release, the objectives were to determine how well kinematically aligned TKA limits high tibial forces, differences in tibial forces between compartments, and anterior translation of the contact locations of the femoral component on the tibial component during passive flexion. Using cruciate retaining components, kinematically aligned TKA was performed on thirteen human cadaveric knee specimens with use of manual instruments without soft tissue release. The tibial forces and tibial contact locations were measured in both the medial and lateral compartments from 0° to 120° of passive flexion using a custom tibial force sensor. The average total tibial force (i.e. sum of medial + lateral) ranged from 5 to 116 N. The only significant average differences in tibial force between compartments occurred at 0° of flexion (29 N, p = 0.0008). The contact locations in both compartments translated posteriorly in all thirteen kinematically aligned TKAs by an average of 14 mm (p < 0.0001) and 18 mm (p < 0.0001) in the medial and lateral compartments, respectively, from 0° to 120° of flexion. After kinematically aligned TKA, average total tibial forces due to the soft tissue restraints were limited to 116 N, average differences in tibial forces between compartments were limited to 29 N, and a net posterior translation of the tibial contact locations was observed in all kinematically aligned TKAs during passive flexion from 0° to 120°, which are similar to what has been measured previously in native knees. While confirmation in vivo is warranted, these findings give
Gluteal strain/ tendinitis Greater trochanteritis TOTAL Groin sfrain/ tendinitis Hip/ groin injury other Pelvic sfress fracture 32 19 Thigh...Medial collateral sfrain 79 28 27 Medial plica syndrome 1 Patellar tendinitis 7 Patellofemoral pain syndrome 16 Pes Anserinus tendinitis 1...Knee other 24 Lower leg TOTAL 127 Achilles tendinitis 19 Acute fibular fracture 3 Acute tibial fracture 1 Anterior compartment syndrome 7
Faulí, A; Anglada, M T; Gomar, C; Sala, X; López, A; Pons, M; Gambús, P; Fábregas, N
To compare 3 combinations of 0.5% levobupivacaine (L) and 1% mepivacaine (M) for popliteal block for hallux valgus surgery. Prospective, double blind study of 120 patients undergoing unilateral hallux valgus outpatient surgery with posterior popliteal block with ultrasound-guided single injection. Patients were randomly allocated into three groups: G1: 20mL L+10mL M; G2: 10mL L+20mL M; and G3: 15mL L+15mL M. Recorded variables were: time of block, onset and reversal times for tibial and peroneal nerves block; postoperative pain until the 7(th) day by means of visual analogue scale (VAS), simple descriptive scale and the quality of nocturnal rest, complications, and patient satisfaction. ANOVA and chi2 were applied in the statistical analysis, with a P<0.05 considered significant. Groups were homogeneous for demographic and surgical characteristics. None of the patients required intraoperative complementary analgesia or anaesthesia. Block onset was significantly longer in G1 than in G2 and G3 (39.4±14.7 versus 32.2±16.5 and 33.2±12minutes). Recovery time from sensory and motor block was significantly longer in G1 than in G2 and G3 (29.5±9.3 versus 22.2±8.2 and 24.8±7.9hours). Postoperative pain level was below VAS 30 (1-100) in the three groups; none of the patients experienced severe pain. Maximum pain level appeared at 24h postoperatively. Patient satisfaction was high and there were no complications. Block onset time and anaesthetic efficacy was adequate in the three groups. The combination of 20mL levobupivacaine 0.5% with 10mL mepivacaine 1% provide a good alternative for a lasting postoperative analgesia. Copyright © 2011 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.
Wang, Ching-Jen; Cheng, Jai-Hong; Huang, Chien-Yiu; Hsu, Shan-Ling; Lee, Fan-Yen; Yip, Hon-Kan
Extracorporeal shockwave therapy (ESWT) is a new non-invasive method to induce tissue regeneration and repair the damaged osteoarthritis (OA) of knee. Previous studies suggested subchondral bone as the key target for OA treatment. However, the relationship of the effect and different locations of subchondral bone is unknown. The purpose of the study was to investigate whether the subchondral bone of medial tibia as the target for ESWT in early OA knee treatment and compared with various locations on lateral tibia and femur condyles. Application of ESWT on the medial tibial subchondral bone ameliorated 38% in gross pathological OA changes (compared to OA, P < 0.001), 94 % in OARSI score (compared to OA, P < 0.001) and 45% in cartilage defect (compared to OA, P < 0.001), 17% in bone mineral density (compared to OA, P < 0.001) than lateral tibia and femur. In micro-CT analysis, ESWT on medial tibial subchondral bone increased bone volume (61% vs 44% in tibia and 62% vs 53% in femur, P < 0.05), yield stress (6 MPa vs 4 MPa in tibia and 4 MPa vs 2 MPa in femur, P < 0.05) and decreased bone porosity (38% vs 53% in tibia and 37% vs 46% in femur, P < 0.05) than OA. The TUNEL, PCNA and osteocalcin significantly influenced the levels of molecular expression in different locations of ESWT application. Our results confirm that application of ESWT to the medial tibial subchondral bone has more effective therapy for OA knee than lateral locations of joint knee. PMID:28469777
Schatka, Imke; Weiler, Andreas; Jung, Tobias M; Walter, Thula C; Gwinner, Clemens
Notwithstanding the importance of the tibial slope (TS) for anterior tibial translation, little information is available regarding the implications on posterior laxity, particularly in healthy subjects. It was hypothesized that increased TS is associated with decreased posterior tibial translation (PTT) in healthy knees. A total of 124 stress radiographs of healthy knees were enrolled in this study. Tibial slope and the posterior tibial translation were evaluated using a Telos device with a 150-N force at 90° of knee flexion. Two blinded observers reviewed independently on two different occasions. One hundred and twenty-four patients [35 females and 89 males; 41 (range 18-75) years] were enrolled in this study, with a mean PTT of 2.8 mm (±1.9 mm; range 0-8 mm) and a mean TS of 8.6° (±2.6°; range 1°-14°). Pearson correlation showed a significant correlation between the PTT and TS in the overall patient cohort (P < 0.0001) with r = 0.76 and R (2) = 0.58. There was no statistical difference between female and male patients regarding the PTT or the TS. Subgrouping of the patient cohort (four groups with n = 31) according to their TS (groups I < 7°; II = 7°-8.5°; III = 9°-10.5°; IV ≥ 11°) revealed significant differences between each subgroup, respectively. Furthermore, there was a weak but significant correlation between age and PTT (P = 0.004, r = 0.26). In addition to the substantial variance in tibial slope and posterior laxity among healthy knees, high tibial slope significantly correlates with increased posterior tibial translation. Increasing age is further associated with a greater magnitude of posterior tibial translation. Consequently, knowledge of the tibial slope facilitates simple estimation of posterior knee laxity, which is mandatory for PCL reconstruction and knee arthroplasty.
González-Otero, Sergio; Navarro-Cuéllar, Carlos; Escrig-de Teigeiro, Margarita; Fernández-Alba-Luengo, Javier; Navarro-Vila, Carlos
Osteochondroma is one of the most common benign bone tumours, although not in the craniofacial region. More than half of these appear in the coronoid process. It can appear on the mandibular condyle, especially in its medial half, and mainly affects women aged around forty years. We present the case of a 51-year-old woman with pain of several months' duration in the right temporomandibular joint (TMJ) and no other symptoms. Panoramic radiography showed an enlarged condyle with no subchondral cysts. Computed tomography showed a bony proliferation with benign signs and a scintigraphy revealed an increased uptake in the condyle. Due to the painful clinical symptoms, a surgical procedure using preauricular and retromandibular approaches was performed to excise the condyle. The resulting defect, which was 9 mm high, was reconstructed by means of a vertical sliding osteotomy of the mandibular ramus and two miniplates for osteosynthesis. Almost two years later, the patient is symptom-free and has a normal opening with no malocclusion or deviation in the opening pattern. We present and discuss different reconstruction options after condylectomy.
Iglesias-Martin, Fernando; Torres-Carranza, Eusebio; Prats-Golczer, Victoria-Eugenia; Garcia-Perla-Garcia, Alberto
Objectives: To evaluate the etiopathogenesis, clinical features, therapeutic options, and surgical approaches for removal of ectopic third molars in the mandibular condyle. Study design: MEDLINE search of articles published on ectopic third molars in the mandibular condyle from 1980 to 2011. 14 well-documented clinical cases from the literature were evaluated together with a new clinical case provided by the authors, representing a sample of 15 patients. Results: We found a mean age at diagnosis of 48.6 years and a higher prevalence in women. In 14 patients, associated radiolucent lesions were diagnosed on radiographic studies and confirmed histopathologically as odontogenic cysts. Clinical symptoms were pain and swelling in the jaw or preauricular region, trismus, difficulty chewing, cutaneous fistula and temporomandibular joint dysfunction. Treatment included conservative management in one case and in the other cases, surgical removal by intra- or extraoral approaches, the latter being the most common approach carried out. In most reported cases, serious complications were not outlined. Conclusions: The etiopathogenic theory involving odontogenic cysts in the displacement of third molars to the mandibular condyle seems to be the most relevant. They must be removed if they cause symptoms or are associated with cystic pathology. The surgical route must be planned according to the location and position of the ectopic third molar, and the possible morbidity associated with surgery. Key words:Third molar, ectopic tooth, condyle, mandible. PMID:22926463
Fernandes, Paulo R B; de Vasconsellos, Henrique A; Okeson, Jeffrey P; Bastos, Ricardo L; Maia, Mey L T
Head, neck, face, and ear pains are commonly associated with disorders of the temporomandibular joint (TMJ). Several theories have been proposed regarding the functional relationship of the TMJ and the associated structures, and how they might contribute to certain painful conditions. This study was conducted to determine the anatomic relationship of the auriculotemporal nerve to the middle meningeal artery and the mandibular condyle. Forty human cadaver temporomandibular joints were dissected to locate the precise position of the auriculotemporal nerve to the mandibular condyle. The study findings revealed a significant variation in the relationship of the auriculotemporal nerve to the middle meningeal artery. The auriculotemporal nerve was found to be between 10-13 mm inferior to the superior surface of the condyle and 1-2 mm posterior to the neck of the condyle. The nerve was not found to be in a position that would likely create an entrapment with adjacent tissues. These findings may assist the clinician to locate the most appropriate injection site for an auriculotemporal nerve block.
Ramos, António; Mesnard, Michel
The purpose of this article is to present and evaluate an innovative intramedullary implant concept developed for total alloplastic reconstruction in bone resorption cases. The main goal of this innovative concept is to avoid the main problems experienced with temporomandibular (TMJ) devices on the market, associated with bone fixation and changes in kinematics. A three-dimensional finite element model was developed based on computed tomography (CT) scan images, before and after implantation of the innovative implant concept. To validate the numerical model, a clean cadaveric condyle was instrumented with four rosettes and loaded before and after implantation with the innovative concept TMJ implant. The experimental results validate the numerical models comparing the intact and implanted condyles, as they present good correlation. They show that the most critical region is around rosette #1, with an increase in strains in the proximal region of the condyle of 140%. The maximum principal strain and stress generated with the implant is less than 2200 με and 75 MPa in the posterior region of the cortical bone. Shortly after insertion of this press-fit implant, stress and strain results appear to be within the normal limits and show some similarities with the intact condyle. If these responses do not change over time, the screw fixation used at present could be avoided or replaced. This solution reduces bone resection and lessens surgical damage to the muscles.
Ford, Kevin R; Nguyen, Anh-Dung; Dischiavi, Steven L; Hegedus, Eric J; Zuk, Emma F; Taylor, Jeffrey B
Deficits in proximal hip strength or neuromuscular control may lead to dynamic lower extremity valgus. Measures of dynamic lower extremity valgus have been previously shown to relate to increased risk of several knee pathologies, specifically anterior cruciate ligament ruptures and patellofemoral pain. Therefore, hip-focused interventions have gained considerable attention and been successful in addressing these knee pathologies. The purpose of the review was to identify and discuss hip-focused exercise interventions that aim to address dynamic lower extremity valgus. Previous electromyography, kinematics, and kinetics research support the use of targeted hip exercises with non-weight-bearing, controlled weight-bearing, functional exercise, and, to a lesser extent, dynamic exercises in reducing dynamic lower extremity valgus. Further studies should be developed to identify and understand the mechanistic relationship between optimized biomechanics during sports and hip-focused neuromuscular exercise interventions. PMID:26346471
Collier, Matthew B; Engh, C Anderson; McAuley, James P; Engh, Gerard A
Wear of the polyethylene tibial bearing is a leading cause of failure of knee replacements done prior to the current decade. The objective of this study was to determine how patient-related factors, implant-related factors, and limb or tibial component alignment influenced the amount of thickness loss in polyethylene tibial bearings that were retrieved at the time of revision surgery or after the death of the patient. We retrieved polyethylene tibial bearings from eighty-one unicondylar and eighty-nine total knee replacements that had been performed because of osteoarthritis with varus deformity from 1984 to 1998. All of the polyethylene bearings had been sterilized with gamma radiation in air. Polyethylene loss was quantified as the change in the minimum bearing thickness per years in vivo (the mean time in vivo [and standard deviation] was 8 +/- 4 years). Multiple linear regression was used to assess whether polyethylene loss was associated with age, weight, gender, varus angle of the tibial component, postoperative hip-knee-ankle angle, initial thickness of the polyethylene, shelf age of the polyethylene, and either the type of polyethylene (for total knee replacements, which were of one posterior cruciate ligament-retaining design) or the manufacturer (for unicondylar knee replacements), and to determine the magnitude by which polyethylene loss would change if any of the significant risk factors were changed. The mean loss (and standard deviation) of polyethylene thickness in the medial compartment of total knee replacements (0.33 +/- 0.28 mm/yr) and that in medial unicompartmental knee replacements (0.49 +/- 0.40 mm/yr) were significantly (p < 0.05) associated with the same three variables: patient age, postoperative hip-knee-ankle angle, and shelf age of the polyethylene. A total knee bearing with a one-year increase in shelf age, a unicondylar knee bearing with a six-month increase in shelf age, a patient who was ten years younger at the time of operation
Aronson, J; Nguyen, L L; Aronson, E A
Adolescent hallux valgus has a high recurrence rate after conventional surgical corrections. Excellent results have been reported with a double osteotomy of the first metatarsal fixed with a 3/16" transarticular pin. The present study reports the early results of using a medial plate and screws with an osteoperiosteal distally based flap to correct metatarsophalangeal joint subluxation, decrease recurrence from laxity in the medial capsular repair, and avoid intra-articular damage. The study included 18 feet in 16 patients (8 males, 8 females). All osteotomies healed primarily without complications, though there was recurrence in 3 undercorrected feet (2 patients). The average preoperative hallux valgus angle of 34 degrees was reduced to 16 degrees at a minimum 1-year follow-up. The average intermetatarsal angle improved from 14 degrees (before operation) to 6 degrees. No patient has requested plate removal.
Clouthier, Allison L; Hassan, Elizabeth A; Brandon, Scott C E; Campbell, Aaron; Rainbow, Michael J; Deluzio, Kevin J
Valgus unloader braces are a conservative treatment option for medial compartment knee osteoarthritis that aim to unload the damaged medial compartment through application of an external abduction moment. Patient response to bracing is highly variable, however. While some experience improvements in pain, function, and joint loading, others receive little to no benefit. The objective of this work was to analyze clinical measures and biomechanical characteristics of unbraced walking to identify variables that are associated with the mechanical effectiveness of valgus unloader bracing. Seventeen patients with medial knee osteoarthritis walked overground with and without a valgus unloader brace. A musculoskeletal model was used to estimate the contact forces in the medial compartment of the tibiofemoral joint and brace effectiveness was defined as the decrease in peak medial contact force between unbraced and braced conditions. Stepwise linear regression was used to identify clinical and biomechanical measures that predicted brace effectiveness. The final regression model explained 77% of the variance in brace effectiveness using two variables. Bracing was more effective for those with greater peak external hip adduction moments and for those with higher Kellgren-Lawrence grades, indicating more severe radiographic osteoarthritis. The hip adduction moment was the best predictor of brace effectiveness and was well correlated with several other measures indicating that it may be functioning as a "biomarker" for good bracing candidates. The ability to predict good candidates for valgus bracing may improve issues of patient compliance and could enable the ability to train patients to respond better to bracing. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Moyer, R F; Birmingham, T B; Bryant, D M; Giffin, J R; Marriott, K A; Leitch, K M
To review and synthesize the biomechanical effects of valgus knee bracing for patients with medial knee osteoarthritis (OA). Electronic databases were searched from their inception to May 2014. Two reviewers independently determined study eligibility, rated study quality and extracted data. Where possible, data were combined into meta-analyses and pooled estimates with 95% confidence intervals (CI) for standardized mean differences (SMD) were calculated. Thirty studies were included with 478 subjects tested while using a valgus knee brace. Various biomechanical methods suggested valgus braces can decrease direct measures of medial knee compressive force, indirect measures representing the mediolateral distribution of load across the knee, quadriceps/hamstring and quadriceps/gastrocnemius co-contraction ratios, and increase medial joint space during gait. Meta-analysis from 17 studies suggested a statistically significant decrease in the external knee adduction moment (KAM) during walking, with a moderate-to-high effect size (SMD = 0.61; 95% CI: 0.39, 0.83; P < 0.001). Meta-regression identified a near-significant association for the KAM effect size and duration of brace use only (β, -0.01; 95% CI: -0.03, 0.0001; P = 0.06); with longer durations of brace use associated with smaller treatment effects. Minor complications were commonly reported during brace use and included slipping, discomfort and poor fit, blisters and skin irritation. Systematic review and meta-analysis suggests valgus knee braces can alter knee joint loads through a combination of mechanisms, with moderate-to-high effect sizes in biomechanical outcomes.
Ege, Tolga; Kose, Ozkan; Koca, Kenan; Demiralp, Bahtiyar; Basbozkurt, Mustafa
The purpose of this study was to compare the measurements made using a smartphone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients. Two observers used an iPhone to measure the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (of anteroposterior foot radiographs in 32 patients with symptomatic hallux valgus on a computer screen. Digital angular measurements on the computer were set as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements, and the difference between the first and second iPhone measurements for each observer were calculated. Inter- and intraobserver reliability of the smartphone measurement method was also tested. The variability of all measurements was similar for the iPhone and the computer-assisted techniques. The concordance between iPhone and computer-assisted angular measurements was excellent for the HVA, IMA, and DMAA. The maximum mean difference between the two techniques was 1.25 ± 1.02° for HVA, 0.92 ± 0.92° for IMA, and 1.10 ± 0.82° for DMAA. The interobserver reliability was excellent for HVA, IMA, and DMAA. The maximum mean difference between observers was 1.31 ± 0.89° for HVA, 0.90 ± 0.92° for IMA, and 0.78 ± 0.87° for DMAA. The intraobserver reliability was excellent for HVA, IMA, and DMAA. We conclude that the Hallux Angles software for the iPhone can be used for measurement of hallux valgus angles in clinical practice and even for research purposes. It is an accurate and reproducible method.
Chang, Alison H.; Lee, Song Joo; Zhao, Heng; Ren, Yupeng; Zhang, Li-Qun
Impaired proprioception and poor muscular stabilization in the frontal plane may lead to knee instability during functional activities, a common complaint in persons with knee osteoarthritis (KOA). Understanding these frontal plane neuromechanical properties in KOA will help elucidate the factors contributing to knee instability and aid in the development of targeted intervention strategies. The study objectives were to compare knee varus-valgus proprioception, isometric muscle strength, and active muscular contribution to stability between persons with medial KOA and healthy controls. We evaluated knee frontal plane neuromechanical parameters in 14 participants with medial KOA and 14 age- and gender-matched controls, using a joint driving device (JDD) with a customized motor and a 6-axis force sensor. Analysis of covariance with BMI as a covariate was used to test the differences in varus-valgus neuromechanical parameters between these two groups. The KOA group had impaired varus proprioception acuity (1.08 ± 0.59° vs. 0.69 ± 0.49°, p < 0.05), decreased normalized varus muscle strength (1.31 ± 0.75% vs. 1.79 ± 0.84% body weight, p < 0.05), a trend toward decreased valgus strength (1.29 ± 0.67% vs. 1.88 ± 0.99%, p = 0.054), and impaired ability to actively stabilize the knee in the frontal plane during external perturbation (4.67 ± 2.86 vs. 8.26 ± 5.95 Nm/degree, p < 0.05). The knee frontal plane sensorimotor control system is compromised in persons with medial KOA. Our findings suggest varus-valgus control deficits in both the afferent input (proprioceptive acuity) and muscular effectors (muscle strength and capacity to stabilize the joint). PMID:24321442
Chang, Alison H; Lee, Song Joo; Zhao, Heng; Ren, Yupeng; Zhang, Li-Qun
Impaired proprioception and poor muscular stabilization in the frontal plane may lead to knee instability during functional activities, a common complaint in persons with knee osteoarthritis (KOA). Understanding these frontal plane neuromechanical properties in KOA will help elucidate the factors contributing to knee instability and aid in the development of targeted intervention strategies. The objectives of the study were to compare knee varus-valgus proprioception, isometric muscle strength, and active muscular contribution to stability between persons with medial KOA and healthy controls. We evaluated knee frontal plane neuromechanical parameters in 14 participants with medial KOA and 14 age- and gender-matched controls, using a joint driving device (JDD) with a customized motor and a 6-axis force sensor. Analysis of covariance with BMI as a covariate was used to test the differences in varus-valgus neuromechanical parameters between these two groups. The KOA group had impaired varus proprioception acuity (1.08±0.59° vs. 0.69±0.49°, p<0.05), decreased normalized varus muscle strength (1.31±0.75% vs. 1.79±0.84% body weight, p<0.05), a trend toward decreased valgus strength (1.29±0.67% vs. 1.88±0.99%, p=0.054), and impaired ability to actively stabilize the knee in the frontal plane during external perturbation (4.67±2.86 vs. 8.26±5.95 Nm/degree, p<0.05). The knee frontal plane sensorimotor control system is compromised in persons with medial KOA. Our findings suggest varus-valgus control deficits in both the afferent input (proprioceptive acuity) and muscular effectors (muscle strength and capacity to stabilize the joint). © 2013 Published by Elsevier Ltd.
De Salazar, Alvaro Ortiz; Muñoz, Fernando; Antoñana, Mirel; Aramendi, José I.; Castellanos, Enrique; Loizate, Alberto; Calderon, Antonio; Llorente, Alberto; Serrano, Alberto
We present a clinical case of chronic dissection of the anterior tibial artery leading to acute aneurysmal dilatation. Our patient, a 22-year-old man, had a history of trauma at the middle third of his left leg. Because of impending ischemia, he was diagnosed by emergency arteriography. We ligated the proximal and distal ends of the dissection and used a reversed saphenous vein for a short end-to-end bypass. Although the evolution of this dilatation had been silent, its clinical presentation was spectacular. The case is worthy of attention because of its extreme rarity, both as a dissection of a peripheral artery caused by trauma and as an aneurysmal dilatation at tibial level. (Texas Heart Institute Journal 1991;18:223-5) Images PMID:15227485
Adn, M; Hamlat, A; Morandi, X; Guegan, Y
Intraneural ganglion cyst of the tibial nerve is very rare. To date, only 5 cases of this entity in the popliteal fossa have been reported. We report a new case and review the previously reported cases. A 40-year-old man experienced a mild vague pain in the medial half of his right foot for 3 years. Magnetic resonance imaging scan demonstrated a soft-tissue mass along the right tibial nerve. At surgery, an intraneural ganglion cyst was evacuated. After 12 months, the patient was pain-free with no signs of recurrence. Trauma might be a contributing factor to the development of intraneural ganglion cysts. Application of microsurgical techniques is encouraged.
Meyer, X; Boscagli, G; Tavernier, T; Aczel, F; Weber, F; Legros, R; Charlopain, P; Martin, J P
Tibial periostitis frequently occurs in athletes. We present our experience with MRI in a series of 7 patients (11 legs) with this condition. The clinical presentation and scintigraphic scanning suggested the diagnosis. MRI exploration of 11 legs demonstrated a high band-like juxta-osseous signal enhancement of SE and IR T2 weighted sequences in 6 cases, a signal enhancement after i.v. contrast administration in 4. Tibial periostitis is a clinical diagnosis and MRI and scintigraphic findings can be used to assure the differential diagnosis in difficult cases with stress fracture. MRI can visualize juxta-osseous edematous and inflammatory reactions and an increased signal would appear to be characteristic when the band-like image is fixed to the periosteum.
Yeow, C H; Gan, W L; Lee, P V S; Goh, J C H
Anterior tibial translation and axial tibial rotation are major biomechanical factors involved in anterior cruciate ligament injuries. This study sought to evaluate a brace prototype designed with an anterior-sloped joint, in terms of its efficacy in attenuating anterior tibial translation and axial tibial rotation during landing, using a motion analysis approach. Ten healthy male subjects performed single-leg landing tasks from a 0.6-m height with and without the brace prototype. Ground reaction force and kinematics data were obtained using a motion-capture system and force-plates. Anterior tibial translation and axial tibial rotation were determined based on tibial and femoral marker reference frames. Vertical and anterior-posterior ground reaction forces, hip, knee and ankle joint range-of-motions and angular velocities, anterior tibial translation and axial tibial rotation were compared between unbraced and braced conditions using Wilcoxon signed-rank test. We found no significant difference in peak vertical and anterior-posterior ground reaction forces (p=0.770 and p=0.332 respectively) between unbraced and braced conditions. Knee joint range-of-motion and angular velocity were lower (p=0.037 and p=0.038 respectively) for braced condition than unbraced condition. Anterior tibial translation and axial tibial rotation were reduced (p=0.027 and p=0.006 respectively) in braced condition, compared to unbraced condition. The anterior-sloped brace joint helps to attenuate anterior tibial translation and axial tibial rotation present in the knee joint during landing. It is necessary to test the brace prototype in a sporting population with realistic sports landing situations in order to assess its effectiveness in lowering anterior cruciate ligament injury risk. Copyright © 2010 Elsevier Ltd. All rights reserved.
Jo, Ho-Seung; Park, Jin-Sung; Byun, June-Ho; Lee, Young-Bok; Choi, Young-Lac; Cho, Seong-Hee; Moon, Dong-Kyu; Lee, Sang-Hyuk; Hwang, Sun-Chul
The purpose of this study was to determine the standard hinge position to minimize effects from medial open-wedge high tibial osteotomy (HTO) on the posterior tibial slope. Sixteen cadaveric knees underwent medial open-wedge osteotomy using either the standard or the low hinge position. To define the standard hinge position, a line 3 cm inferior to the medial tibial plateau towards the fibular head and located its intersection with a longitudinal line 1 cm medial to the fibular shaft was drawn. Low hinge position was defined as the point 1 cm inferior to the standard position. After tibial osteotomy, computed tomography scans of each knee were taken and three-dimensional models were constructed to characterize hinge position orientation and measure the osteotomy site effects on posterior tibial slope, medial proximal tibial angle, and gap ratio (the ratio of the anterior to posterior gap in the opened wedge). In two low hinge position specimens, the tibial lateral cortex hinge fracture occurred. Osteotomy through the low hinge position resulted in significantly greater posterior tibial slope compared to the standard hinge position (mean ± standard deviation) (11.2 ± 3.0° and 5.6 ± 2.5°, respectively; p < 0.001). Medial proximal tibial angle was also significantly greater for low compared to standard hinge position (95.4 ± 3.5° and 88.0 ± 3.5°, respectively; p < 0.001). Gap ratio was not significantly different between the two groups. Hinge position significantly affects the posterior tibial slope and medial proximal tibial angle following medial open-wedge HTO. Accurate hinge position is crucial to prevent complications from changes in posterior tibial slope and medial proximal tibial angle after surgery.
Faber, F W; Kleinrensink, G J; Mulder, P G; Verhaar, J A
Hypermobility of the first tarsometatarsal (TMT 1) joint in the sagittal plane plays a role in the etiology and treatment of the hallux valgus complex. However, objective quantification of this mobility is still a problem. We performed a radiographic analysis of TMT 1 mobility in the sagittal plane in 94 hallux valgus patients aged 15 to 65 years. We examined 94 feet with symptomatic hallux valgus deformity requiring operative correction. Excluded were patients with osteoarthritis, inflammatory diseases or previous operations on the foot. The TMT 1 mobility was tested with a clinical test and by radiographic measurement using the modified Coleman block test. The mean mobility of the TMT 1 joint in the sagittal plane in the patient group was 12.9 degrees (SD 4.80). In addition, there was a statistically significant difference between two subgroups: patients with and without clinical TMT 1 hypermobility. No correlation of TMT 1 (hyper)mobility and radiographic second ray hypertrophy was found. This simple method can produce additional information to the clinical TMT 1 hypermobility test in the sagittal plane.
Abdalbary, Sahar Ahmed; Elshaarawy, Ehab A.A.; Khalid, Bahaa E.A.
Abstract The deep transverse metatarsal ligament (DTML) connects the neighboring 2 metatarsal heads and is one of the stabilizers connecting the lateral sesamoid and second metatarsal head. In this study, we aimed to determine the tensile properties of the DTML in normal specimens and to compare these results with hallux valgus specimens. We hypothesized that the tensile properties of the DTML would be different between the 2 groups of specimens. The DTML in the first interspace was dissected from 12 fresh frozen human cadaveric specimens. Six cadavers had bilateral hallux valgus and the other 6 cadavers had normal feet. The initial length (L0) and cross-sectional area (A0) of the DTML were measured using a digital caliper, and tensile tests with load failure were performed using a material testing machine. There were significant between-groups differences in the initial length (L0) P = 0.009 and cross-sectional area (A0) of the DTML P = 0.007. There were also significant between-groups differences for maximum force (N) P = 0.004, maximum distance (mm) P = 0.005, maximum stress (N/mm2) P = 0.003, and maximum strain (%) P = 0.006. The DTML is an anatomical structure for which the tensile properties differ in hallux valgus. PMID:26937914
Meng, Hong-Zheng; Zhang, Wei-Lin; Li, Xiu-Cheng; Yang, Mao-Wei
Radiographic angles are used to assess the severity of hallux valgus deformity, make preoperative plans, evaluate outcomes after surgery, and compare results between different methods. Traditionally, hallux valgus angle (HVA) has been measured by using a protractor and a marker pen with hardcopy radiographs. The main objective of this study is to compare HVA measurements performed using a smartphone and a traditional protractor. The secondary objective was to compare the time taken between those two methods. Six observers measured major HVA on 20 radiographs of hallux valgus deformity with both a standard protractor and an Apple iPhone. Four of the observers repeated the measurements at least a week after the original measurements. The mean absolute difference between pairs of protractor and smartphone measurements was 3.2°. The 95% confidence intervals for intra-observer variability were ±3.1° for the smartphone measurement and ±3.2° for the protractor method. The 95% confidence intervals for inter-observer variability were ±9.1° for the smartphone measurement and ±9.6° for the protractor measurement. We conclude that the smartphone is equivalent to the protractor for the accuracy of HVA measurement. But, the time taken in smartphone measurement was also reduced.
Berruto, M; Bianchi, M; Laurà, G
Twenty-two of the 24 patients operated on with femoral supracondylar osteotomy for arthritic valgus knee between 1978 and 1987 were evaluated, comparing the results with those obtained in a similar group of 10 patients with the same disorder treated with knee replacement during the same period. From a functional viewpoint and according to the Hospital for Special Surgery rating scale, the results of the osteotomy were not significantly different from the extremely positive outcome of the knee replacement. However, as far as pain is concerned, only 50% of the osteotomy patients were completely asymptomatic after the operation. In the 50% of the osteotomy patients with post-operative under or over correction of the mechanical axis of the knee, the results were unsatisfactory. Finally, there was only one case of delayed union. In the light of these results, in contrast to what has been said by other authors, femoral osteotomy may be considered a valid alternative to knee replacement in the treatment of arthritic valgus knee in active subjects, less than 65 years old, with a valgus angulation of no more than 15 degrees and Ahlback stage 2 beta arthritis of the lateral compartment. It is, however, a technique which requires extreme precision both in planning and performing the operation.
Dhaher, Y Y; Tsoumanis, A D; Rymer, W Z
Experimental evidence on the reflex responses of thigh muscles to valgus mechanical perturbations at the human knee are presented. Random step positional deflections, ranging from 5 degrees to 12 degrees at 60 degrees /s, were applied to the fully extended knees of seven healthy subjects. Subjects were instructed to maintain a constant background co-activation ( approximately 2-11% MVC) of the quadriceps and hamstring muscles prior to and during the mechanical stimulus. We found that the reflex response to sustained valgus joint deflection in the vasti muscles had longer onset latencies (range: 83-92ms) than did the stretch reflex in the same muscles (latencies: 29-31ms). This reflex EMG response consisted typically of a peak followed by sustained muscle activity throughout the step perturbation. The sustained EMG activity was dependent on the amplitude of the perturbing stimulus, but in a nonlinear manner. The long latency of the valgus response suggests that the reflex originates in nonmuscular sensory pathways, potentially from mechanoreceptors lying in periarticular tissues such as joint ligaments and capsule. Analysis of the spatial distribution of reflex responses showed an asymmetrical pattern with preferential activation of medial vs. lateral muscles of the knee. We assess whether these asymmetric reflex contractions could promote joint stability, either by inducing generalized joint stiffening, or by preferential activation of those muscles that are best suited to resist induced ligament strain.
Crespo Romero, E; Peñuela Candel, R; Gómez Gómez, S; Arias Arias, A; Arcas Ordoño, A; Gálvez González, J; Crespo Romero, R
This study aims to illustrate the results of percutaneous forefoot surgery (PFS) for correction of hallux valgus. A prospective study of 108 patients, with hallux valgus deformity, who underwent PFS was conducted. The minimum clinical and radiological follow-up was two years (mean 57.3 months, range 22-112). Preoperative mean visual analog scale was 6.3 ± 1.5 points, and AOFAS scores were 50.6 ± 11 points. At the last follow-up, both scores improved to 1.9 ± 2.4 points and 85.9 ± 1.83 points, respectively. Mean hallux valgus angle changed from 34.3° ± 9.3° preoperatively to 22.5° ± 11.1° at follow-up. At follow-up, 76.5% of the subjects were satisfied or very satisfied. Recurrence of medial 1st MT head pain happened in 22 cases (16.7%). PFS, in our study, does not improve the radiological and patient satisfaction rate results compared with conventional procedures. The main advantage is a low postoperative pain level, but with an insufficient HVA correction. II, prospective study.
Cammarata, Martha L.; Dhaher, Yasin Y.
Gender differences in neuromuscular control of the lower extremity may contribute to increased injury risk in females, but the neurophysiological mechanisms underlying these differences remain unclear. In this study, we sought to explore the effect of gender on volitional and reflex neuromuscular responses to a rapid valgus perturbation at the knee applied under “intervene” and “do not intervene” conditions. Multiple 7° ramp-and-hold valgus perturbations were applied at the neutrally extended knee of 12 male and 12 female healthy subjects, while surface electromyography over the quadriceps and hamstrings recorded the neuromuscular response. Volitional responses did not vary between groups, perhaps reflecting the relative novelty of the loading direction. However, reflex responses observed under the “do not intervene” paradigm did vary by gender. Males demonstrated much more frequent and consistent reflex muscle activation than females. Moreover, muscle activation patterns were gender-specific. Diminished responses in female subjects may indicate that the position-based valgus perturbation did not produce the necessary mechanical stimulus to elicit reflexes. These gender differences in reflex control of the knee provide new insight into the control of frontal-plane knee joint movement and loading and may elucidate the neuromechanical underpinnings associated with neuromuscular control. PMID:19918763
Guo, Jun-Chao; Wang, Li-Zhen; Chen, Wei; Du, Cheng-Fei; Mo, Zhong-Jun; Fan, Yu-Bo
Orthopedic insole was important for partial foot amputation (PFA) to achieve foot balance and avoid foot deformity. The inapposite insole orthosis was thought to be one of the risk factors of reamputation for foot valgus patient, but biomechanical effects of internal tissues on valgus foot had not been clearly addressed. In this study, plantar pressure on heel and metatarsal regions of PFA was measured using F-Scan. The three-dimensional finite element (FE) model of partial foot evaluated different medial wedge angles (MWAs) (0.0°-10.0°) of orthopedic insole on valgus foot. The effect of orthopedic insole on the internal bone stress, the medial ligament tension of ankle, plantar fascia tension, and plantar pressure was investigated. Plantar pressure on medial heel region was about 2.5 times higher than that of lateral region based on the F-Scan measurements. FE-predicted results showed that the tension of medial ankle ligaments was the lowest, and the plantar pressure was redistributed around the heel, the first metatarsal, and the lateral longitudinal arch regions when MWA of orthopedic insole ranged from 7.5° to 8.0°. The plantar fascias maintained about 3.5% of the total load bearing on foot. However, the internal stresses from foot bones increased. The simulation in this study would provide the suggestion of guiding optimal design of orthopedic insole and therapeutic planning to pedorthist.
patellofemoral joint pain during running. Medicine and Science in Sports and Exercise , 36, S56. Dierks, T.A., Davis, I.S. & Hamill, J. (2004). Lower extremity...knee flexion / extension , and knee internal/external rotation were assessed. Timing difference values of 0% stance indicated synchronous coupling. CRP...and continuous excursion ratios. Differences were primarily observed between the tibial internal/external rotation with knee flexion / extension
D'Lima, Darryl D; Patil, Shantanu; Steklov, Nikolai; Slamin, John E; Colwell, Clifford W
An instrumented tibial prosthesis was developed to measure forces in vivo after total tibial arthroplasty. This prosthesis was implanted in a 67-kg, 80-year-old man. The prosthesis measured forces at the 4 quadrants of the tibial tray. Tibial forces were measured postoperatively during rehabilitation, rising from a chair, standing, walking, and climbing stairs. By the sixth postoperative week, the peak tibial forces during walking averaged 2.2 times body weight (BW). Stair climbing increased from 1.9 times BW on day 6 to 2.5 times BW at 6 weeks. This represents the first direct in vivo measurement of tibial forces, which should lead to refined surgical techniques and enhanced prosthetic designs. Technical design improvements will enhance function, quality of life, and longevity of total knee arthroplasty.
Bernstein, Derek T; O'Neill, Craig A; Kim, Ryan S; Jones, Hugh L; Noble, Philip C; Harris, Joshua D; McCulloch, Patrick C
Conventional osteochondral allograft (OCA) matching, requiring orthotopic, size-matched condyles, and narrow surgical time windows often prohibit timely transplantation. The femoral condyle radius of curvature (RoC) is an appropriate, isolated criterion for donor-host matching in fresh OCAs, potentially enhancing matching efficiency when compared with conventional matching techniques. Descriptive laboratory study. In part 1 of this study, 3-dimensional digital reconstructions of 14 randomly selected, cadaveric distal femoral hemicondyles were performed. Each condyle was divided into anterior, middle, and posterior zones. A virtual best-fit grid was applied to each, and each zone's sagittal- and coronal-plane RoCs were determined. Seven nonorthotopic OCA transplantations were performed based on RoC matching with 1-mm tolerance, and the preoperative and postoperative surface geometry were quantified to assess the accuracy of articular surface restoration. Of note, each donor-host pair did not match by the conventional method. In part 2 of this study, 12 cadaveric distal femora were categorized by size and digitized in the aforementioned manner. Simulated circular defects measuring 20, 25, and 30 mm in diameter were introduced into each zone. OCA matches were determined based on donor and host RoCs, and the total number of potential matches (of 71 total comparisons) was recorded as a percentage for each simulated defect. Finally, the results of RoC matching were compared with the conventional method for simulated defects in all zones of both the medial and lateral femoral condyles. Part 1: The mean surface deviation after OCA transplantation was -0.09 mm, with a mean maximum protrusion at any point of 0.59 mm. Part 2: Using the RoC, 20-mm defects had a 100% chance of being matched. Defects of 25 and 30 mm had a 91% and 64% chance of being matched, respectively. Compared with the conventional method, the RoC method yielded a 3.2-fold greater match rate for lesions of
Vergara-Amador, E; Davalos Herrera, D; Moreno, L Á
Few studies have evaluated the radiologic characteristics of the development of the anterior tibial tuberosity. This study aimed to evaluate the radiologic characteristics of the anterior tibial tuberosity in a pediatric population broken down into age groups. We assessed 210 plain-film X-rays of the knee from patients aged from 10 to 17 years, divided into groups according to age and sex, for the presence of ossification of the anterior tibial tuberosity, the distance between the anterior tibial tuberosity and the metaphysis, and fusion with the epiphysis. At 10 years of age, the anterior tibial tuberosity was ossified in 50% of the girls but in only 25% of the boys. In all the girls, the anterior tibial tuberosity was ossified at 11 years, fusion of the anterior tibial tuberosity with the epiphysis had started at 12 years, and fusion was complete by 17 years. In boys, the process is delayed by one year compared to girls. A single center of ossification was found in all cases. The ossification of the anterior tibial tuberosity starts distally, then the proximal part fuses with the rest of the epiphysis, and finally the distal part fuses with the tibia. The results of this study help enable a better analysis of the anterior tibial tuberosity in cases of knee pain. Copyright © 2016 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.
Ortiz, Cristian; Wagner, Pablo; Vela, Omar; Fischman, Daniel; Cavada, Gabriel; Wagner, Emilio
The most common methods for assessing severity of hallux valgus deformity and the effects of an operative procedure are the angular measurements in weightbearing radiographs, specifically the hallux valgus angle and intermetatarsal angle (IMA). Our objective was to analyze the interobserver variability in hallux valgus patients of a new angle called the "angle to be corrected" (ATC), and to compare its capacity to differentiate between different deformities against IMA. We included 28 symptomatic hallux valgus patients with 48 weightbearing foot x-rays. Three trained observers measured the 1 to 2 IMA and the ATC. We then identified retrospectively 45 hallux valgus patients, which were divided into 3 operative technique groups having used the ATC as reference, and analyzed the capacity of the IMA to differentiate between them. The IMA average value was 13.6 degrees, and there was a significant difference between observer 3 and observer 1 (P = .001). The average value for the ATC was 8.9 degrees, and there was no difference between observers. Both angles showed a high intraclass correlation. Regarding the capacity to differentiate between operative technique groups, the ATC was different between the 3 operative technique groups analyzed, but the IMA showed differences only between 2. The ATC was at least as reliable as the intermetatarsal angle for hallux valgus angular measurements, showing a high intraclass correlation with no interobserver difference. It can be suggested that the ATC was better than the IMA to stratify hallux valgus patients when deciding between different operative treatments. Level III, comparative study. © The Author(s) 2015.
Tajika, Tsuyoshi; Kobayashi, Tsutomu; Yamamoto, Atsushi; Shitara, Hitoshi; Ichinose, Tsuyoshi; Shimoyama, Daisuke; Oya, Noboru; Sasaki, Tsuyoshi; Takagishi, Kenji
There are few literatures describing the association between glenohumeral internal rotation deficits (GIRD) and valgus laxity of the elbow on the throwing side of high school pitchers with and without a history of elbow symptom. The passive range of motion of glenohumeral internal and external rotation on bilateral side shoulders was measured in 75 high-school baseball pitchers during the preseason. Using ultrasonography, the width of the ulnohumeral joint of the elbow was measured at 30° of flexion, both at rest and with valgus stress in the pitching side. Comparisons of glenohumeral internal rotation deficits and the difference between the width of ulnohumeral joint space with and without valgus stress on the throwing side were made between 75 high-school pitchers with and without a history of elbow symptom. Participants with a history of elbow symptom exhibited a greater difference between the width of ulnohumeral joint with and without valgus stress in the throwing side than participants with no history of elbow symptom (P<0.05). No difference in glenohumeral internal rotation deficits was found in participants with and without a history of elbow symptom. In all participants, significant association was found between glenohumeral internal rotation deficits on the pitching side and the difference from the width of the ulnohumeral joint with and without valgus stress (P=0.04, r=0.23). Elbow valgus instability was associated with elbow joint pain in high-school pitchers. Although GIRD was not significantly different between the two groups, GIRD and elbow valgus instability might be related to the throwing side in high-school pitchers.
Limchaichana, Napat; Nilsson, Håkan; Petersson, Arne; Ekberg, EwaCarin
The aim of this research was to study if changes in condyle position in temporomandibular disorders (TMD) patients could be a factor that is affected by resilient appliance therapy and if it influences the treatment outcome. The study investigated 48 patients randomly assigned to a treatment group (T group = 21 patients, using resilient appliance) or a control group (C group = 27 patients, using nonoccluding appliance). Changes in the condyle-fossa relationship (with and without the appliance) were determined in an MRI examination. Ten weeks after treatment, the treatment outcome was measured. The results showed that with the appliance, change in condyle position occurred in 76% of the T group and 22% of the C group (p < 0.001). Sixty-seven percent (67%) of the T group and 44% of the C group experienced a successful treatment outcome. Treatment outcome was not related to changes in condyle position in patients with TMD pain.
Martin, J Ryan; Watts, Chad D; Levy, Daniel L; Miner, Todd M; Springer, Bryan D; Kim, Raymond H
Stress shielding is an uncommon complication associated with primary total knee arthroplasty. Patients are frequently identified radiographically with minimal clinical symptoms. Very few studies have evaluated risk factors for postoperative medial tibial bone loss. We hypothesized that thicker cobalt-chromium tibial trays are associated with increased bone loss. We performed a retrospective review of 100 posterior stabilized, fixed-bearing total knee arthroplasty where 50 patients had a 4-mm-thick tibial tray (thick tray cohort) and 50 patients had a 2.7-mm-thick tibial tray (thin tray cohort). A clinical evaluation and a radiographic assessment of medial tibial bone loss were performed on both cohorts at a minimum of 2 years postoperatively. Mean medial tibial bone loss was significantly higher in the thick tray cohort (1.07 vs 0.16 mm; P = .0001). In addition, there were significantly more patients with medial tibial bone loss in the thick tray group compared with the thin tray group (44% vs 10%, P = .0002). Despite these differences, there were no statistically significant differences in range of motion, knee society score, complications, or revision surgeries performed. A thicker cobalt-chromium tray was associated with significantly more medial tibial bone loss. Despite these radiographic findings, we found no discernable differences in clinical outcomes in our patient cohort. Further study and longer follow-up are needed to understand the effects and clinical significance of medial tibial bone loss. Copyright © 2016 Elsevier Inc. All rights reserved.
Chan, Yuen; Selvaratnam, Veenesh; Garg, Neeraj
Use of Kirschner wires (K-wires) is the most common method of fracture stabilisation in lateral condyle fracture fixation in children. We report a case of toxic shock syndrome (TSS) following an open reduction and internal fixation using K-wires for a humeral lateral condyle fracture in a 5-year-old girl. TSS is a toxin-mediated multisystem illness. It typically presents with shock and it is most often attributed to toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes. It can lead to multiorgan failure and, ultimately, death. It is important to be aware of TSS, as it can present within any setting. Patients often have non-specific symptoms and their condition can worsen rapidly. TSS postorthopaedic surgery is rare; however, due to the serious nature of this disease, it is important to promptly recognise and diagnose TSS, and to ensure appropriate treatment is started without delay. PMID:26264942
Grzelak, Piotr; Podgórski, Michał Tomasz; Stefańczyk, Ludomir; Krochmalski, Marek; Domżalski, Marcin
Although subchondral impaction fractures have already been reported in the non-weight-bearing portion of the lateral femoral condyle, this study reveals the presence of an intra-articular impaction fracture of the postero-superior region of the non-weight-bearing portion of the medial femoral condyle recognized in 5 of a group of 22 representatives of the Polish national Olympic weightlifting team, who underwent 1.5T magnetic resonance imaging examination. Articular cartilage lesions varied with regard to the type of injury and its severity ranging from healed or subchronic injuries to acute trauma. All described individuals had no clinical history of acute knee trauma and only 3 of them had minor pain symptoms. The accumulation of microtraumas occurring during participation in particular activities associated with weightlifting training seems to be responsible for the development of this type of contusion. This is the first description of impaction fracture observed in this location in professional weightlifters.
Giesen, E B W; Ding, M; Dalstra, M; van Eijden, T M G J
Since edentate subjects have a reduced masticatory function, it can be expected that the morphology of the cancellous bone of their mandibular condyles has changed according to the altered mechanical environment. In the present study, the morphology of cylindrical cancellous bone specimens of the mandibular condyles of edentate subjects (n = 25) was compared with that of dentate subjects (n = 24) by means of micro-computed tomography and by the application of Archimedes' principle. Stiffness and strength were determined by destructive mechanical testing. Compared with dentate subjects, it appeared that, in edentate subjects, the bone was less dense and the trabecular structure was less plate-like. The regression models of stiffness and strength built from bone volume fraction and the trabecular orientation relative to the axis of the specimen were similar for both dentate and edentate subjects. This indicates that, under reduced mechanical load, the fundamental relationship between bone morphology and mechanical properties does not change.
Sabharwal, Sanjeev; Henry, Patrick; Behrens, Fred
Coronal plane fractures of the lateral femoral condyle can be difficult to diagnose, especially in children with open physis. Two adolescents who sustained this uncommon Salter-Harris III fracture of the knee were misdiagnosed after initial clinical examination and standard x-rays. Oblique x-rays, computed tomography, and magnetic resonance imaging were valuable in arriving at the correct diagnosis and in decision making.
Seok, Hyun; Kim, Seong-Gon
Proliferative periostitis is a rare form of osteomyelitis that is characterized by new bone formation with periosteal reaction common causes of proliferative periostitis are dental caries, periodontitis, cysts, and trauma. While proliferative periostitis typically presents as a localized lesion, in this study, we describe an extensive form of proliferative periostitis involving the whole mandibular ramus and condyle. Because the radiographic findings were similar to osteogenic sarcoma, an accurate differential diagnosis was important for proper treatment. PMID:26339579
Wang, R; Cai, Y; Zhao, Y F; Zhao, J H
In this study, we report a very unusual case of a patient with osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. The patient was treated by removal of the impacted third molar, opening of the drainage, combined with systemic application of antibiotics for two weeks. This treatment option did not lead to any functional defects or facial asymmetry. The patient fully recovered and the disease did not recur. © 2014 Australian Dental Association.
Yatabe, M; Zwijnenburg, A; Megens, C C; Naeije, M
Little is known about the detailed kinematics of the human temporomandibular condyle during jaw opening and closing. According to the rotate and swing model by Osborn (1989), the condyle is kept in close contact with the articular eminence during opening. Whether the condyle is in closer contact with the articular eminence during opening than during closing is unknown. Another consequence of the model is that the opening condylar movements are less variable than the closing movements. In this study, the hypothesis that the opening condylar path is closer to the articular eminence and also less variable than the closing condylar path is tested. Twenty subjects (10 males and 10 females with a mean age of 22) without signs or symptoms of a craniomandibular disorder performed 2 series of 4 protrusive movements and 2 series of 4 empty opening-closing movements. The movements were recorded by a six-degrees-of-freedom opto-electronic jaw movement recording system (OKAS-3D). The kinematic center of the condyle was used as a reference point for the reconstruction of condylar movement paths. Characteristics of the opening and closing paths were investigated by means of a displacement index (DI). This index is the quotient between the three-dimensional path length and the three-dimensional path distance between the start and the end point of an opening or closing movement of the kinematic center. The DI was smaller (p < 0.0001) and also less variable (p < 0.0001) during opening than during closing. The smaller DI value, in combination with the concave nature of the movement path, indicates that the opening path of the kinematic center lies above the closing path and thus closer to the articular eminence.
Proper anatomic reduction of the fracture and accelerated complete recovery are desirable goals after trauma reconstruction. Over the recent decades, significant headway in craniomaxillofacial trauma care has been achieved and advancements in the management for the injuries of the mandibular condyle have also proved to be no exception. A trend in operative and reconstructive options for proper anatomic reduction and internal fixation has become notable as a result of newly introduced technology, surgical techniques, and operative expertise.
Oka, Shinya; Schuhmacher, Peter; Brehmer, Axel; Traut, Ulrike; Kirsch, Joachim; Siebold, Rainer
This study was performed to investigate the morphology of the tibial anterior cruciate ligament (ACL) by histological assessment. The native (undissected) tibial ACL insertion of six fresh-frozen cadaveric knees was cut into four sagittal sections parallel to the long axis of the medial tibial spine. For histological evaluation, the slices were stained with haematoxylin and eosin, Safranin O and Russell-Movat pentachrome. All slices were digitalized and analysed at a magnification of 20×. The anterior tibial ACL insertion was bordered by a bony anterior ridge. The most medial ACL fibres inserted from the medial tibial spine and were adjacent to the articular cartilage of the medial tibial plateau. Parts of the bony insertions of the anterior and posterior horns of the lateral meniscus were in close contact with the lateral part of the tibial ACL insertion. A small fat pad was located just posterior to the functional ACL fibres. The anterior-posterior length of the medial ACL insertion was an average of 10.8 ± 1.1 mm compared with the lateral, which was only 6.2 ± 1.1 mm (p < 0.001). There were no central or posterolateral inserting ACL fibres. The shape of the bony tibial ACL insertion was 'duck-foot-like'. In contrast to previous findings, the functional mid-substance fibres arose from the most posterior part of the 'duck-foot' in a flat and 'c-shaped' way. The most anterior part of the tibial ACL insertion was bordered by a bony anterior ridge and the most medial by the medial tibial spine. No posterolateral fibres nor ACL bundles have been found histologically. This histological investigation may improve our understanding of the tibial ACL insertion and may provide important information for anatomical ACL reconstruction.
Huizinga, M R; Gorter, J; Demmer, A; Bierma-Zeinstra, S M A; Brouwer, R W
The primary purpose of this study is to investigate the progression of medial osteoarthritis (OA) following lateral closing-wedge high tibial osteotomy (HTO). Secondary outcomes included functional and pain scores. This prospective cohort study analysed 298 patients treated with lateral closing-wedge HTO surgery for medial compartmental OA. OA progression was measured by comparing the minimum joint space width (mJSW) and Kellgren-Lawrence (KL) score on radiographs preoperatively and postoperatively. The WOMAC score and NRS score for pain were obtained preoperatively and postoperatively to assess secondary outcomes. Failure was defined as revision surgery; survival was estimated. Mean follow-up was 5.2 ± 1.8 years (range 2-8.5). Mean preoperative mJSW was 3.4 ± 1.6 mm, which changed nonsignificantly (p = 0.51) to 3.4 ± 1.7 mm postoperatively. Mean annual joint space narrowing was 0.02 ± 0.34 mm/year. Progression to 1 KL grade or more was seen in 132 (44 %) patients, and annual risk of KL progression was 8.6 %. No KL progression was seen in 56 % of patients. Mean NRS decreased from 7.3 ± 1.5 to 3.5 ± 2.5 (p < 0.001). WOMAC scores decreased from 48.0 ± 17.2 to 23.6 ± 19.7 (p < 0.001). Failure was seen in 21 patients. Compared to demographic data in the literature, valgus high tibial osteotomy seems to reduce the progression of OA, reduces pain and improves knee function in patients with medial compartment OA and a varus alignment. III.
Silva, Amanda Pagliotto da; Sassi, Fernanda Chiarion; Andrade, Claudia Regina Furquim de
To characterize the oral-motor system of adults with mandibular condyle facture comparing the performance of individuals submitted to open reduction with internal fixation (ORIF) and closed reduction with mandibulomaxillary fixation (CRMMF). Study participants were 26 adults divided into three groups: G1 - eight individuals submitted to ORIF for correction of condyle fracture; G2 - nine individuals submitted to CRMMF for correction of condyle fracture; CG - nine healthy volunteers with no alterations of the orofacial myofunctional system. All participants underwent the same clinical protocol: assessment of the orofacial myofunctional system; evaluation of the mandibular range of motion; and surface electromyography (sEMG) of the masticatory muscles. Results indicated that patients with condyle fractures from both groups presented significant differences compared with those from the control group in terms of mobility of the oral-motor organs, mastication, and deglutition. Regarding the measures obtained for mandibular movements, participants with facial fractures from both groups showed significant differences compared with those from the control group, indicating greater restrictions in mandibular motion. As for the analysis of sEMG results, G1 patients presented more symmetrical masseter activation during the task of maximal voluntary teeth clenching. Patients with mandibular condyle fractures present significant deficits in posture, mobility, and function of the oral-motor system. The type of medical treatment does not influence the results of muscle function during the first six months after fracture reduction. Individuals submitted to ORIF of the condyle fracture present more symmetrical activation of the masseter muscle.
Chang, Zhong-Fu; Chen, Jie
Subjects with normal occlusion, Angle Class Ⅲ malocclusion and Angle Class Ⅲ malocclusion with temporomandibular dysfunctions(TMD) were included, and their protraction and retraction, opening and closing mouth were recorded and compared to determine the condyle movement characteristics of Angle Class Ⅲ malocclusion patients with TMD. Thirty cases of Angle Class Ⅲ malocclusion with TMD (experimental group), 30 cases of simple Angle Class Ⅲ malocclusion (control group 1) and 30 cases of normal occlusion (control group 2) were chosen, the condyle movement of mouth opening and closing, protraction and retraction were recorded and analyzed by computer aided axiography (CADIAX Ⅲ) , the measurements were compared and qualitative analysis was performed. SPSS 10.0 software package was used for statistical analysis. The indexes of opening and closing mouth, forward, backward and lateral movement were higher in experimental group and control group 1 than in the control group 2, especially in the vertical direction. The maximum variation was on the Y axis between the experimental group and the control group 2, the lateral movement of working side was significantly higher than that of the normal group, while the movement ranges at other directions were significantly smaller than that of control group 2, especially in opening and closing mouth horizontally upward and the maximum space displacement at right, upward direction (P<0.01). The tracking of condyle movements has its own characteristics in three dimensions in the experimental group ,compared with control group 1 and 2.
Arastu, M H; Kokke, M C; Duffy, P J; Korley, R E C; Buckley, R E
Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.
Hu, Y; Yang, H-f; Li, S; Chen, J-z; Luo, Y-w; Yang, C
Unilateral fracture of the condylar neck in immature subjects might lead to mandible asymmetry and condyle remodelling. A rat model was used to investigate mandibular deviation and condylar remodelling associated with condyle fracture. 72 4-week-old male rats were randomly divided into three groups: an experimental group (unilateral transverse condylar fracture induced surgically), a sham operation group (surgical exposure but no fracture), and a non-operative control group (no operation). The rats were killed at intervals up to 9weeks after surgery, and outcomes were assessed using various measures of mandible deviation, histological and X-ray observation, and immunohistochemical measures of expression levels of connective tissue growth factor (CTGF) and type II collagen (Col II). The fracture led to the degeneration of mandibular size, associated with atrophy of fractured condylar process. Progressive remodelling of cartilage and increasing expression levels of CTGF and Col II were found. The authors conclude that condylar fracture can lead to asymmetries in mandible and condyle remodelling and expression of CTGF and Col II in condylar cartilage on both the ipsilateral and the contralateral sides.
Ciocca, Leonardo; Donati, Davide; Fantini, Massimiliano; Landi, Elena; Piattelli, Adriano; Iezzi, Giovanna; Tampieri, Anna; Spadari, Alessandro; Romagnoli, Noemi; Scotti, Roberto
In this study, rapid CAD-CAM prototyping of pure hydroxyapatite to replace temporomandibular joint condyles was tested in sheep. Three adult animals were implanted with CAD-CAM-designed porous hydroxyapatite scaffolds as condyle substitutes. The desired scaffold shape was achieved by subtractive automated milling machining (block reduction). Custom-made surgical guides were created by direct metal laser sintering and were used to export the virtual planning of the bone cut lines into the surgical environment. Using the same technique, fixation plates were created and applied to the scaffold pre-operatively to firmly secure the condyles to the bone and to assure primary stability of the hydroxyapatite scaffolds during masticatory function. Four months post-surgery, the sheep were sacrificed. The hydroxyapatite scaffolds were explanted, and histological specimens were prepared. Different histological tissues penetrating the scaffold macropores, the sequence of bone remodeling, new apposition of bone and/or cartilage as a consequence of the different functional anatomic role, and osseointegration at the interface between the scaffold and bone were documented. This animal model was found to be appropriate for testing CAD-CAM customization and the biomechanical properties of porous, pure hydroxyapatite scaffolds used as joint prostheses.
Giesen, E B; Ding, M; Dalstra, M; van Eijden, T M
The objective of the present study was (1) to test the hypothesis that the elastic and failure properties of the cancellous bone of the mandibular condyle depend on the loading direction, and (2) to relate these properties to bone density parameters. Uniaxial compression tests were performed on cylindrical specimens (n=47) obtained from the condyles of 24 embalmed cadavers. Two loading directions were examined, i.e., a direction coinciding with the predominant orientation of the plate-like trabeculae (axial loading) and a direction perpendicular to the plate-like trabeculae (transverse loading). Archimedes' principle was applied to determine bone density parameters. The cancellous bone was in axial loading 3.4 times stiffer and 2.8 times stronger upon failure than in transverse loading. High coefficients of correlation were found among the various mechanical properties and between them and the apparent density and volume fraction. The anisotropic mechanical properties can possibly be considered as a mechanical adaptation to the loading of the condyle in vivo.
Giesen, E B W; Ding, M; Dalstra, M; van Eijden, T M G J
To investigate the influence of decreased mechanical loading on the density and mechanical properties of the cancellous bone of the human mandibular condyle. Destructive compressive mechanical tests were performed on cancellous bone specimens.Background. Reduced masticatory function in edentate people leads to a reduction of forces acting on the mandible. As bone reacts to its mechanical environment a change in its material properties can be expected. Cylindrical bone specimens were obtained from dentate and edentate embalmed cadavers. Mechanical parameters were determined in the axial and in the transverse directions. Subsequently, density parameters were determined according to a method based on Archimedes' principle. The apparent density and volume fraction of the bone were about 18% lower in the edentate group; no age-related effect on density was found. The decrease of bone in the edentate group was associated with a lower stiffness and strength (about 22% and 28%, respectively). The ultimate strain, however, did not differ between the two groups. Both groups had similar mechanical anisotropy; in axial loading the bone was stiffer and stronger than in transverse loading. Reduced mechanical load had affected the density and herewith the mechanical properties of condylar cancellous bone, but not its anisotropy. The change in material properties of the cancellous bone after loss of teeth indicate that the mandibular condyle is sensitive for changes in its mechanical environment. Therefore, changes in mechanical loading of the condyle have to be accounted for in surgical procedures of the mandible.
Ren, Yupeng; Jacobs, Benjamin J; Nuber, Gordon W; Koh, Jason L; Zhang, Li-Qun
Anterior cruciate ligament (ACL) injuries have become more common in recent years as more young people participate in risky sporting activities . Most ACL injuries occur as a result of noncontact mechanisms. Previous in vitro studies of ACL strain have found significant increases in ACL strain primarily with anterior directed force on the tibia relative to the femur and with internal rotation and often with valgus torque [2,3]. However, there remains significant controversy over the mechanisms of ACL failure and the forces on the knee that lead to injury. Some studies have also shown that isolated valgus loading may not load the ACL strongly. The goal of this study was to investigate the mechanism underlying valgus-related ACL injuries. An improved understanding of ACL failure may lead to improved ACL injury prevention programs. A novel 6 degrees of freedom (DOF) knee driving robot was developed in this study with a unique multi-axis simultaneous torque/position control. It was found that pure valgus torque caused a torque that internally rotated the tibia and thus increased ACL strain markedly, which may be an important mechanism underlying the rather common seemingly valgus-related ACL injuries.
Mok, Kam-Ming; Kristianslund, Eirik; Krosshaug, Tron
Knee valgus angles measured in sidestep cutting and vertical drop jumps are key variables in research on anterior cruciate ligament (ACL) injury causation. These variables are also used to quantify knee neuromuscular control and ACL injury risk. The aims of the current study were to (1) quantify the differences in the calculated knee valgus angles between 6 different thigh marker clusters, (2) investigate the trial ranking based on their knee valgus angles, and (3) investigate the influence of marker clusters on the cross-talk effect. Elite female handball and football players (n = 41) performed sidestep cutting and vertical drop jumping motions. We found systematic differences up to almost 15° of peak valgus between the marker sets in the drop jump test. The Spearman's rank correlation coefficient varied from .505 to .974 among the 6 marker sets. In addition, the cross-talk effect varied considerably between the marker clusters. The results of the current study indicate that the choice of thigh marker cluster can have a substantial impact on the magnitude of knee valgus angle, as well as the trial ranking. A standardized thigh marker cluster, including nonanatomical landmark, is needed to minimize the variation of the measurement.
Lee, Sun-Min; Lee, Jung-Hoon
Hallux valgus, an increased angle of lateral deviation in the big toe, can cause pain and difficulties in balancing and walking. This study aimed to investigate the effects of balance taping using elastic therapeutic tape on moderate hallux valgus. When she walked with shoes, she complained of pain over the medial eminence of the hallux metatarsophalangeal (MTP) joint. Balance taping using kinesiology tape was applied for 3 months (average, 16hours/d) to both big toes of a 26-year-old woman with moderate hallux valgus. On the right side, the hallux valgus angle (HVA) decreased from 21° to 14° and the intermetatarsal angle (IMA) decreased from 15° to 14.5°. On the left side, the HVA decreased from 22° to 11° and the IMA decreased from 15° to 12°. Furthermore, the patient was able to walk long distances in shoes without pain in the medial eminence of the hallux metatarsophalangeal joint. This study suggested that repeated balance taping with kinesiology tape could be used as a complementary treatment method for moderate hallux valgus.
Gouin, F; Yaouanc, F; Waast, D; Melchior, B; Delecrin, J; Passuti, N
Valgus tibial osteotomy (VTO) is a well-known procedure for the treatment of medial compartment femoro-tibial osteoarthritis. Good and very good results have been reported with calcium phosphate wedges, which avoid the inconveniences of autologous grafts use. The hypothesis of this study is that with equivalent results in the treatment of osteoarthritis of the knee, the use of calcium phosphate wedges (BMCaPh) to fill the bone defect created by osteotomy would result in fewer specific complications and less pain associated with autologous grafts (AUTO) harvesting. This prospective, controlled, randomised study included one arm that received a macroporous, biphasic calcium phosphate wedge (BMCaPh group) and one arm that received an autologous tricortical graft (AUTO group) for filling. The same plate with locked screws was used for fixation in all cases. All patients underwent at least two years of clinical and radiographic post-operative follow-up. Forty patients were included. Loss of correction occurred in six of the twenty-two patients in the BMCaPh group (27%), resulting in three early surgical revisions, compared to one loss of correction in the AUTO group. Lateral cortical hinge tears were a risk factor for loss of correction for the entire cohort and in the BMCaPh group. (relative risk 13.3 [1.9-92]. Moreover, union took significantly longer and pain lasted significantly longer in the BMCaPh group, although results were comparable at 6 months. A significant number of undesirable events (loss of correction) occurred in this study, limiting the number of included patients. Nevertheless, the results show that although there was no difference in the two groups for overall complications, number of revisions all causes combined, or clinical results, filling with BMCaPh was less tolerated and increased the risk of loss of correction when local mechanical conditions of the knee were unfavourable (lateral cortical hinge tears). Moreover, although it is not possible
Moen, Maarten H; Tol, Johannes L; Weir, Adam; Steunebrink, Miriam; De Winter, Theodorus C
Medial tibial stress syndrome (MTSS) is one of the most common leg injuries in athletes and soldiers. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. The name given to this condition refers to pain on the posteromedial tibial border during exercise, with pain on palpation of the tibia over a length of at least 5 cm. Histological studies fail to provide evidence that MTSS is caused by periostitis as a result of traction. It is caused by bony resorption that outpaces bone formation of the tibial cortex. Evidence for this overloaded adaptation of the cortex is found in several studies describing MTSS findings on bone scan, magnetic resonance imaging (MRI), high-resolution computed tomography (CT) scan and dual energy x-ray absorptiometry. The diagnosis is made based on physical examination, although only one study has been conducted on this subject. Additional imaging such as bone, CT and MRI scans has been well studied but is of limited value. The prevalence of abnormal findings in asymptomatic subjects means that results should be interpreted with caution. Excessive pronation of the foot while standing and female sex were found to be intrinsic risk factors in multiple prospective studies. Other intrinsic risk factors found in single prospective studies are higher body mass index, greater internal and external ranges of hip motion, and calf girth. Previous history of MTSS was shown to be an extrinsic risk factor. The treatment of MTSS has been examined in three randomized controlled studies. In these studies rest is equal to any intervention. The use of neoprene or semi-rigid orthotics may help prevent MTSS, as evidenced by two large prospective studies.
van der Woude, J A D; Wiegant, K; van Heerwaarden, R J; Spruijt, S; van Roermund, P M; Custers, R J H; Mastbergen, S C; Lafeber, F P J G
Both, knee joint distraction as a relatively new approach and valgus-producing opening-wedge high tibial osteotomy (HTO), are knee-preserving treatments for knee osteoarthritis (OA). The efficacy of knee joint distraction compared to HTO has not been reported. Sixty-nine patients with medial knee joint OA with a varus axis deviation of <10° were randomized to either knee joint distraction (n = 23) or HTO (n = 46). Questionnaires were assessed at baseline and 3, 6, and 12 months. Joint space width (JSW) as a surrogate measure for cartilage thickness was determined on standardized semi-flexed radiographs at baseline and 1-year follow-up. All patient-reported outcome measures (PROMS) improved significantly over 1 year (at 1 year p < 0.02) in both groups. At 1 year, the HTO group showed slightly greater improvement in 4 of the 16 PROMS (p < 0.05). The minimum medial compartment JSW increased 0.8 ± 1.0 mm in the knee joint distraction group (p = 0.001) and 0.4 ± 0.5 mm in the HTO group (p < 0.001), with minimum JSW improvement in favour of knee joint distraction (p = 0.05). The lateral compartment showed a small increase in the knee joint distraction group and a small decrease in the HTO group, leading to a significant increase in mean JSW for knee joint distraction only (p < 0.02). Cartilaginous repair activity, as indicated by JSW, and clinical outcome improvement occurred with both, knee joint distraction and HTO. These findings suggest that knee joint distraction may be an alternative therapy for medial compartmental OA with a limited mechanical leg malalignment. Randomized controlled trial, Level I.
Beytemür, Ozan; Albay, Cem; Adanır, Oktay; Yüksel, Serdar; Güleç, Mehmet Akif
This study aims to evaluate the functional and radiographic results and treatment complications of AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) type 43C1 and C2 fractures treated with intramedullary nailing. We retrospectively evaluated 35 AO/OTA type 43C1 and C2 patients (26 males, 9 females; mean age 39.8±16.9 years; range 19 to 82 years) treated with intramedullary nailing. Two interfragmentary screws out of nail were applied in 10 patients (29%), while one interfragmentary screw out of nail was applied in 17 patients (49%). Intramedullary nailing was applied in eight patients (23%) without external screws. Fracture union, union time, alignment problems, and complications were evaluated. Clinical evaluation of patients was conducted using the Olerud and Molander score and by measuring the ankle joint range of motion. Union was achieved in all 35 patients. Mean union time was 16.5±2.8 weeks (range 12 to 24 weeks) and mean Olerud and Molander score was 88±8.24. Varus deformity was detected in one patient, valgus deformity was detected in two patients, and rotation deformity was detected in one patient. Superficial infection was detected in three patients (9%). Deep infection was not detected in any patient. Intramedullary nailing is not contraindicated for simple intra-articular distal tibial fractures. In these fractures, intramedullary nailing performed in accordance with its technique, with an additional percutaneous screw if necessary, is a successful treatment option with high fracture union rates, high functional results, and low complication rates.
Clark, Ross A; Bartold, Simon; Bryant, Adam L
The relationship between the phases of the menstrual cycle and injury risk remains unclear. Neuromuscular function may be compromised during menstruation, which could result in reduced cyclicality of movement patterns. We hypothesize that mediolateral (varus/valgus) knee acceleration during running gait will possess increased variability during menstruation when compared to approximately ovulation in women who do not take the monophasic oral contraceptive pill (MOCP). Thirty-six women (18 MOCP users: MOCP group and 18 non-pill users: NP group) performed six-minute treadmill running trials at 10 km h(-1) with an accelerometer fixed to the proximal tibia. Trials were performed at menstruation and approximately equal ovulation (for the MOCP group at a similar stage of the cycle) in a randomized order. The cyclicality of gross mediolateral tibial acceleration during 15 consecutive strides was assessed using combined wavelet and autocorrelation analysis. Longitudinal and anteroposterior accelerations were also examined. Repeated measures analysis of variance (ANOVA) tests were performed to assess differences at each stage of the menstrual cycle (alpha=0.05). Gross mediolateral acceleration in the NP group had significantly (P=0.022) increased variability at the time of menstruation compared to approximately equal ovulation, and was also significantly (P=0.011) more variable than the MOCP group at the corresponding time point. No significant difference was observed for any measure in the MOCP group. Increased variability in the NP users at menstruation may be a result of compromised motor control strategies. This provides further evidence of variability in performance and motor control during menstruation, and may have implications for a female athlete's risk of injury. Copyright (c) 2010 Elsevier Ltd. All rights reserved.
Schröter, Steffen; Ihle, Christoph; Mueller, Johannes; Lobenhoffer, Philipp; Stöckle, Ulrich; van Heerwaarden, Ronald
The purpose of the study was to determine the interrater reliability as well as the correlation of mediCAD(®) and PreOPlan(®) in deformity analysis and digital planning of osteotomies. Digital radiographs were obtained from 81 patients planned to undergo an open wedge high tibial osteotomy. The JPEG files of the radiographs were imported to landmark-based software. Deformity analysis and planning of correction were performed by 1 experienced and 2 unexperienced observers. Osteotomy planning was aimed at correction to the predefined mechanical tibiofemoral angle of 3° valgus leg alignment. The interrater reliability of measurements was assessed using intraclass correlation coefficients (ICCs) and the confidence interval. The ICC of PreOPlan(®) was from 0.841 (mechanical lateral distal femur angle) to 0.993 (wedge-angle) and from 0.896 (joint line convergence angle) to 0.995 (mechanical tibiofemoral angle) of mediCAD(®). The ICC of height of wedge-base was 0.979 with PreOPlan(®) and 0.969 with mediCAD(®). Comparing PreOPlan(®) and mediCAD(®), the ICC of the height of wedge-base of the observers was 0.966, 0.956 and 0.969, respectively. The results show a high interrater reliability of digital planning software. Experience of the observer had no influence on results. Furthermore, a high interrater reliability and correlation of digital planning specific parameters was found. Surgeons need to master limb geometry measurements and osteotomy planning on digital radiographs as digital planning reports are used for intercolleagual correspondence, teaching purposes and as medicolegal documents. The digital planning software tested agrees with the actual demands and could be recommended for deformity analysis and planning of osteotomies. Diagnostic studies, Level I.
Lu, Daifeng; Xiao, Mochao; Lian, Yongyun; Zhou, Yong; Liu, Xuefeng
Objective: To perform dual-bundle reconstruction of posterior cruciate ligament using full arthroscopic tibial inlay technology with self-designed tibia tunnel drilling system and to compare the effect of arthroscopic tibial inlay versus traditional technique for posterior cruciate ligament reconstruction. Material and methods: 32 patients were randomly divided into experiment group (improved tibial inlay, n = 17) and control group (traditional tibial inlay, n = 15). Self-designed tibia tunnel drill system was used to produce intraoperative deep-limited bone tunnel. During follow-up, the location of the bone block and the healing situation were checked by knee X-ray and spiral CT scan. Blood loss, operation time and nerve vascular injuries were evaluated. Results: Mean intraoperative blood loss was 123.53 ± 74.05 ml in the improved tibial inlay group compared with 332 ± 114.26 ml in the traditional tibial inlay group (t = 6.12, P < 0.05). Mean operation time was 235.27 ± 58.88 min in the improved tibial inlay group compared with 346.37 ± 59.67 min in the traditional tibial inlay group (t = 5.19, P < 0.05). Posterior drawer test were negative in 15 cases, slight positive in 2 with improved tibial inlay technique compared with 14 negative cases and 2 positive cases of traditional tibial Inlay technique. The X-ray and spiral CT scan showed the location of the bone block were perfect and healed well with the patent who received improved tibial inlay technology after 12 weeks postoperatively. Conclusion: Accurate depth-limited bone tunnel can be produced by the tibia tunnel drill system with minor trauma, less bleeding and reducing of nerves or vessels and the recent clinical effects of PCL reconstruction were pretty good. PMID:25419349
Westerman, Richard W
Aseptic loosening of the tibial component continues to be a significant mode of failure in total knee arthroplasty surgery. Surface cemented components preserve tibial bone stock, but are reliant on a strong bone-cement interface. This study compares standard surface cemented tibial component design to a tibial component with the addition of an undersurface cement containment skirt. The hypothesis was that the addition of a 2-mm underside skirt would allow cement containment and pressurization during implantation, which might improve the overall survival. Two identical tibial components were used, out of which one had the 2-mm underside skirt removed for the purposes of this study. Overall, 12 tibial Sawbones were prepared identically and transducers placed in the medial and lateral plateau. Each component was implanted six times, according to the manufacturer's operative technique. The series of implantation experiments showed no difference in cement pressurization (p = 0.86) regardless of the tibial component design used, with a wide variation in pressure measurements occurring in both groups. The tibial component skirt has not demonstrated any enhancement in cement pressurization. The cement containment skirt might still be advantageous by increasing the cement mantle thickness without causing excessive bone penetration; however, the biological effects cannot be predicted without further clinical evaluation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Robin, Jonathan G.; Neyret, Philippe
Patients with unstable, malaligned knees often present a challenging management scenario, and careful attention must be paid to the clinical history and examination to determine the priorities of treatment. Isolated knee instability treated with ligament reconstruction and isolated knee malalignment treated with periarticular osteotomy have both been well studied in the past. More recently, the effects of high tibial osteotomy on knee instability have been studied. Lateral closing-wedge high tibial osteotomy tends to reduce the posterior tibial slope, which has a stabilising effect on anterior tibial instability that occurs with ACL deficiency. Medial opening-wedge high tibial osteotomy tends to increase the posterior tibia slope, which has a stabilising effect in posterior tibial instability that occurs with PCL deficiency. Overall results from recent studies indicate that there is a role for combined ligament reconstruction and periarticular knee osteotomy. The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction which, when combined, may ultimately halt the evolution of arthritis and preserve their natural knee joint for a longer period of time. Cite this article: Robin JG, Neyret P. High tibial osteotomy in knee laxities: Concepts review and results. EFORT Open Rev 2016;1:3-11. doi: 10.1302/2058-5241.1.000001. PMID:28461908
Levine, A H; Pais, M J; Berinson, H; Amenta, P S
An unusually prominent soleal line (a normal anatomic variant) may mimic periosteal reaction along the posterior margin of the proximal tibial shaft. This area of pseudoperiostitis is differentiated from hyperostoses arising from the anterior tibial tubercle and the interosseous membrane. It is always associated with normal, undisturbed architecture of the underlying bone.
Park, Joo-Hee; Kang, Sun-Young; Choung, Sung-Dae; Jeon, Hye-Seon; Kwon, Oh-Yun
The purpose of this study was to investigate the effects of tibial position on ITB flexibility and patellar position. A total of 31 asymptomatic subjects (21 males, 10 females) were recruited for this investigation. Adduction angle was measured by Ober's test, and PCD was measured by ultrasonography in three different tibial rotation conditions: N, IR, and ER. Repeated measures ANOVA revealed a significant difference in adduction angle and PCD among three different tibial positions (P<0.05). Adduction angle was significantly greater in the N tibial position than in ER (P<0.05). The PCD was significantly greater in N position than in IR (P<0.05). However, the PCD was significantly smaller in IR compared with the N position (P<0.05). These findings support that tibial rotation influences the flexibility of ITB and patellar positions. Therefore, excessive tibial rotation can cause inappropriate patellar positions that eventually lead to knee injury. Therapists should consider tibial rotation when measuring adduction angles because tibial rotation can change Ober's test results and contribute to the consistency of ITB length measurements. Level IV. Copyright © 2015 Elsevier B.V. All rights reserved.
Nadorf, Jan; Kinkel, Stefan; Gantz, Simone; Jakubowitz, Eike; Kretzer, J. Philippe
Introduction Revision total knee arthoplasty often requires modular implants to treat bone defects of varying severity. In some cases, it may not be clear which module size and implant combination (e.g. sleeve and stem) should be chosen for a specific defect. When balancing implant stability and osseointegration against stress-shielding, it is important to choose an appropriate implant combination in order to match the given level of bone loss. Therefore, the necessity of stems in less extensive tibial defects and the advantage of different stems (lengths and stiffnesses) in combination with large metaphyseal sleeves on implant fixation and bone flexibility using a modular tibial revision knee system, were analyzed. Materials and methods Four different stem combinations for a tibial revision implant (Sigma TC3, DePuy) were compared to an intact bone. Standardized implantation with n = 4 synthetic tibial bones was performed after generating an Anderson Orthopaedic Research Institute (AORI) Type T1 bone defect. Axial torques around the longitudinal stem axis and varus-valgus torques were separately applied to the implant. Micromotions of bone and implant were tracked using a digital image correlation system to calculate relative micromotions at the implant-bone-interface and bone deformation. Results Overall, using stems reduced the proximal micromotions of tray and sleeve compared to no stem, while reducing bone deformation proximally at the same time, indicating some potential for proximal stress-shielding compared to no stem. The potential for increased proximal stress-shield due to reduced proximal deformation appeared to be greater when using the longer stems. The location of lowest relative micromotions was also more distal when using long stems as opposed to short stems. A short stem (especially a smaller diameter short stem which still achieves diaphyseal fixation) displayed less potential for stress-shielding, but greater bone deformation distal to the tip
Seagrave, Richard A.; Sojka, John; Goodyear, Adam; Munns, Stephen W.
INTRODUCTION The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes’ double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft. PRESENTATION OF CASE We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up. DISCUSSION Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft. CONCLUSION All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee. PMID:24412805
Cao, Honghui; Tang, Kanglai; Deng, Yinshuan; Tan, Xiaokang; Zhou, Binghua; Tao, Xu; Chen, Lei; Chen, Qianbo
To analyze the excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular for the treatment of flatfoot related with accessory navicular and to evaluate its effectiveness. Between May 2006 and June 2011, 33 patients (40 feet) with flatfoot related with accessory navicular were treated. There were 14 males (17 feet) and 19 females (23 feet) with an average age of 30.1 years (range, 16-56 years). All patients had bilateral accessory navicular; 26 had unilateral flatfoot and 7 had bilateral flatfeet. The disease duration ranged from 7 months to 9 years (median, 24 months). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-midfoot score was 47.9 +/- 7.3. The X-ray films showed type II accessory navicular, the arch height loss, and heel valgus in all patients. All of them received excision of accessory navicular and reconstruction of posterior tibial tendon insertion on navicular with anchor. All patients got primary wound healing without any complication. Thirty patients (36 feet) were followed up 6-54 months with an average of 23 months. All patients achieved complete pain relief at 6 months after surgery and had good appearance of the feet. The AOFAS ankle-midfoot score was 90.4 +/- 2.0 at last follow-up, showing significant difference when compared with preoperative score (t=29.73, P=0.00). X-ray films showed that no screw loosening or breakage was observed. There were significant differences in the arch height, calcaneus inclination angle, talocalcaneal angle, and talar-first metatarsal angle between pre-operation and last follow-up (P < 0.01). The excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular is a good choice for the treatment of flatfoot related with accessory navicular, with correction of deformity, excellent effectiveness, and less complications.
Zahradnik, David; Uchytil, Jaroslav; Farana, Roman; Jandacka, Daniel
A non-contact anterior cruciate ligament (ACL) injury is both a serious and very common problem in volleyball. The aim of the study was to determine the association between stick, step-back, and run-back landings after a block and select risk factors of ACL injuries for female professional volleyball players. The research sample involved fourteen female professional volleyball players. Two force plates were used to determine ground reaction forces. Eight infrared cameras were employed to collect the kinematic data. The one-factor repeated-measures analysis of variance, where the landing type was the factor, was used for comparing the valgus moment and ground reaction force on the right lower limb. ANOVA showed that the type of landing has a main effect on the valgus moment on the right lower limb (F) = 5.96, p = 0.019df = 1.18, partial η(2) = 0.239 and SP = 0.693). Furthermore, it did not show a main effect on the vertical reaction force on the right lower limb ((F)=2.77, p=0.090, df=1.55, partial η(2)= 0.128 and SP=0.448). The highest valgus moment occurred during the run-back landing. This moment, however, did not have any effect within the first 100 ms after initial contact with the ground, but rather upon the subsequent motion carried out when stepping back off the net. A comparison between a run-back landing and a step-back landing showed relevant higher values of vertical ground reaction forces during the run-back landing.
Quatman, CE; Hewett, TE
Background Anterior cruciate ligament (ACL) injury is a devastating injury that puts an athlete at high risk of future osteoarthritis. Identification of risk factors and development of ACL prevention programmes likely decrease injury risk. Although studies indicate that sagittal plane biomechanical factors contribute to ACL loading mechanisms, it is unlikely that non-contact ACL injuries occur solely in a sagittal plane. Some authors attempt to ascribe the solely sagittal plane injury mechanism to both female and male ACL injuries and rebuff the concept that knee “valgus” is associated with isolated ACL injury. Prospective studies that utilise coupled biomechanical and epidemiological approaches demonstrated that frontal knee motions and torques are strong predictors of future non-contact ACL injury risk in female athletes. Video analysis studies also indicate a frontal plane “valgus collapse” mechanism of injury in women. As load sharing between knee ligaments is complex, frontal as well as sagittal and transverse plane loading mechanisms likely contribute to non-contact ACL injury. The purpose of this review is to summarise existing evidence regarding ACL injury mechanisms and to propose that sex-specific mechanisms of ACL injury may occur, with women sustaining injuries by a predominantly “valgus collapse” mechanism. Conclusion Prevention programmes and interventions that only target high-risk sagittal plane landing mechanics, especially in the female athlete, are likely to be less effective in ameliorating important frontal and transverse plane contributions to ACL injury mechanisms and could seriously hamper ACL injury prevention efforts. Programmes that target the reduction of high-risk valgus and sagittal plane movements will probably prove to be superior for ACL injury prevention. PMID:19372087
Zahradnik, David; Uchytil, Jaroslav; Farana, Roman; Jandacka, Daniel
A non-contact anterior cruciate ligament (ACL) injury is both a serious and very common problem in volleyball. The aim of the study was to determine the association between stick, step-back, and run-back landings after a block and select risk factors of ACL injuries for female professional volleyball players. The research sample involved fourteen female professional volleyball players. Two force plates were used to determine ground reaction forces. Eight infrared cameras were employed to collect the kinematic data. The one-factor repeated-measures analysis of variance, where the landing type was the factor, was used for comparing the valgus moment and ground reaction force on the right lower limb. ANOVA showed that the type of landing has a main effect on the valgus moment on the right lower limb (F) = 5.96, p = 0.019df = 1.18, partial η2 = 0.239 and SP = 0.693). Furthermore, it did not show a main effect on the vertical reaction force on the right lower limb ((F)=2.77, p=0.090, df=1.55, partial η2= 0.128 and SP=0.448). The highest valgus moment occurred during the run-back landing. This moment, however, did not have any effect within the first 100 ms after initial contact with the ground, but rather upon the subsequent motion carried out when stepping back off the net. A comparison between a run-back landing and a step-back landing showed relevant higher values of vertical ground reaction forces during the run-back landing. PMID:25031674
Silva, Paulo; Coelho, Danilo Lopes; Curi, Calim; de Oliveira, Leandro Alves; de Moraes, Frederico Barra; do Amaral, Rogério Andrade; Rebello, Percival Rosa
Objectives: To evaluate valgus subtrochanteric osteotomy for the treatment of trochanteric non-union. Methods: A retrospective study of cases series. From 1998 September to 2009 January, seventeen (17) cases with a diagnosis of non-union of trochanteric fracture were re-operated by the hip group of the Ortophaedic And Traumatology service of the Hospital Geral de Goiania (HGG). The patients presented pain at the fracture site, a femoral varus angle of less than 120°, and non-union of the fracture in the 3rd months after the initial surgery. Results: Patients with ages ranging from 30 to 73 years, with a maximum follow-up of 09 years and minimum of 09 years. The mean time from first surgery to osteotomy was six months. Bone union was observed in 16 patients, with a mean union time of 12 weeks after surgery. The mean hip varus angle was 1050 (1200 to 900). After surgery, the mean hip valgus angle was 1440 (1550 to 1350). We had one unsuccessful case; a 78-year old patient who had osteogtomy, fixed with DHS of 1500, with valgization to 1540. After six months of follow-up without union of the fracture, it was decided to perform total cemented hip artroplasthy, without complications. Conclusion: Valgus subtrochanteric osteotomies can be indicated for the treatment of trochanteric treatment of pseudoarthroses, with good final results for bone union, avoiding the need for total hip artroplasthy and maintaining biological fixation, as well as reestablishing the mechanical and anatomical axis of the affected limb. PMID:27027080
Adam, Stephanie P; Choung, Steven C; Gu, Yang; O'Malley, Martin J
Many procedures have been developed to correct hallux valgus deformity using distal soft tissue realignment, metatarsal osteotomy, and periodically, a proximal phalanx osteotomy (Akin). The ideal metatarsal osteotomy allows for varying degrees of correction with reliable improvement in deformity and patient satisfaction. We evaluated the results after scarf osteotomy with respect to American Orthopaedic Foot and Ankle Society (AOFAS) scores, patient satisfaction, radiographic results, and complications. We evaluated 29 patients (34 feet) during an 18-month period who underwent a unilateral scarf osteotomy combined with distal soft tissue realignment. Preoperative and postoperative AOFAS scores, patient satisfaction, and radiographic data were used to evaluate the effectiveness of the procedure. Complications were recorded. Minimal followup was 12 months (average, 26.4 months; range, 12-48 months). The mean AOFAS scores improved from 61.5 to 90.3. At final followup, 94% of patients were satisfied with the surgery. The hallux valgus angle improved from 34.6° to 14.9° and the intermetatarsal angle improved from 15.8° to 7.2° postoperatively. A combined Akin osteotomy was performed in only four cases. Complications included superficial wound infection (one), recurrence (two), and troughing (three). Our results suggest the scarf osteotomy produces improved AOFAS scores, high percentage of patient satisfaction, and effective correction of hallux valgus deformities. Using our scarf technique of rotation combined with translation minimizes the need for an Akin osteotomy while still obtaining good correction and avoids associated complications described in the literature. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Masala, Salvatore; Fiori, Roberto; Calabria, Eros; Raguso, Mario; de Vivo, Dominique; Cuzzolino, Alessandro; Simonetti, Giovanni
The purpose of our study was to investigate the role of intra-articular pulse-dose radiofrequency in management of painful hallux valgus refractory to conservative therapies. Between November 2010 and April 2012, 51 patients (15 male, 36 female) with a median age of 71.4 years were included in our clinical trial. Under fluoroscopic guidance we introduced a 22 gauge 10 cm length cannula by a percutaneous access in the first metatarsophalangeal joint and its tip was placed intra-articularly. After removing the spindle, a radiofrequency needle with a 5 mm active tip was introduced. The following parameters were used: 1200 pulses at high voltage (45 V) with 20 msec duration followed by 480 msec silent phases. A great reduction in pain intensity was documented at 1 week, 1 month and 3 months after procedures. Pain intensity increased between 5 and 8 months after treatments, so we performed a second procedure in all patients between 7 months and 9 months since the first treatment. Also in this case we obtained a great reduction of pain intensity in the first 3 months after the procedure. Pain intensity returned at preprocedural values after 9 months after second procedure. No complications were observed. Our experience shows pulse-dose radiofrequency is a safe, repeatable and effective technique for managing patients with symptomatic hallux valgus in the short and medium term. Pulse-dose radiofrequency may improve pain control and quality of life in patients with hallux valgus refractory to conservative therapies. © 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.
Lee, Moses; Walsh, James; Smith, Margaret M; Ling, Jeff; Wines, Andrew; Lam, Peter
Minimally invasive surgery is being used increasingly, including for hallux valgus surgery. Despite the growing interest in minimally invasive procedures, there have been few publications on percutaneous chevron/akin (PECA) procedures, and no studies have been published comparing PECA to open scarf/akin osteotomies (SA). This was a prospective, randomized study of 50 patients undergoing operative correction of hallux valgus using one of 2 techniques (PECA vs open SA). Data were collected preoperatively and on 1 day, 2 weeks, 6 weeks, and 6 months postoperatively. Outcome measures include the American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal (AOFAS-HMI) Score, visual analog pain score, hallux valgus angle (HVA), and 1-2 intermetatarsal angle (IMA). Twenty-five patients underwent PECA procedures and 25 patients received SA procedures. Both groups showed significantly improved AOFAS-HMI scores after surgery (PECA group: 61.8 to 88.9, SA group: 57.3 to 84.1, P = .560) with comparable final scores. HVA and IMA also presented similar outcomes at final follow-up ( P = .520 and P = .270, respectively). However, the PECA group showed significantly lower pain level (VAS) in the early postoperative phase (postoperative day 1 to postoperative week 6, P < .001 and P = .004, respectively). No serious complications were observed in either group. Both groups showed comparable good to excellent clinical and radiologic outcomes at final follow-up. However, the PECA group had significantly less pain in the first 6 weeks following surgery. Level of Evidence Level II, prospective comparative study.
Takeuchi, Ryohei; Ishikawa, Hiroyuki; Miyasaka, Yasuyuki; Sasaki, Yohei; Kuniya, Takashi; Tsukahara, So
High tibial valgus osteotomy (HTO) is an established treatment for medial-compartment osteoarthritis of the knee. We have combined medial open and lateral closed-wedge HTO (hybrid closed-wedge HTO) to overcome the limitations of traditional closed-wedge HTO. Our new hybrid procedure has the following advantages: (1) the bone block removed is smaller in size; (2) the procedure yields optimal geometric characteristics for bone healing; (3) there is no step-off at the lateral osteotomy site; (4) the lateral cortex of the proximal and distal fragments is attached firmly by the oblique osteotomy; and (5) early full weight-bearing walking is possible. This procedure is effective in treating medial-compartment osteoarthritis accompanied by patellofemoral osteoarthritis. The indications for this procedure include a willingness and ability to comply with the postoperative rehabilitation program; a diagnosis of either medial-compartment osteoarthritis or complicated patellofemoral osteoarthritis; and preferably, an age of 70 years or younger, although this is not a strict constraint. Patients are permitted to stand using both legs on the day after surgery and walk with full weight bearing within 2 weeks of undergoing our novel HTO procedure. We describe the details of this surgical technique and the postoperative rehabilitation program for the patients who undergo this treatment. PMID:25264504
Feibel, Robert J; Uhthoff, Hans K
Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external
Choi, Woo Jin; Yoon, Hang Seob; Lee, Jin Woo
The ultimate goal of primary total ankle replacement is to provide a well-balanced soft-tissue envelope around a well-aligned, well-fixated implant. Some surgeons have emphasized that good outcomes in total ankle replacement are more dependent on ligament balancing, along with the procedure itself, than the extent of preoperative coronal deformity in the ankle. Thus, it is imperative that the surgeon be familiar with additional procedures to address the varus, valgus, and other associated deformities commonly encountered in primary total ankle replacement.
Rizk, Ahmed Shawkat
Coxa vara is a radiological term describing a decrease in the neck-shaft angle to 120° or less. Coxa vara is associated with pathomechanical changes that can manifest clinically. If left untreated, coxa vara can affect the normal development of the pediatric hip. Valgus osteotomy is the standard surgical treatment for coxa vara, but there is no consensus regarding the optimal osteotomy technique and fixation method. The work reported here aimed to highlight transfixing wires as a fixation method for valgus osteotomy applied as treatment for various types of pediatric coxa vara. This study included 16 cases of pediatric coxa vara with different etiologies in 9 patients with a mean age of 39.9 ± 15.2 months. Radiological and clinical evaluations and scoring of the condition of each patient according to the Iowa Hip Score were performed pre- and postoperatively. Transfixing wires and a protective spica were used for the fixation of a V-shaped, laterally based, closing-wedge valgus osteotomy in all cases. The postoperative follow-up period ranged from 14 to 102 months, with a mean duration of 33.3 ± 27.7 months. The mean Hilgenreiner epiphyseal angle (HEA) was corrected from 81.7 ± 2.2° to 24.3 ± 3.5° and the mean femoral neck-shaft angle (FNSA) was improved from 86.9 ± 4.2° to 138.6 ± 3.5°. No recurrence of the deformity was observed during the follow-up periods considered here. The osteotomy site united after an average of 11.7 ± 2.2 weeks with no secondary displacement, and in cases of developmental coxa vara there was progressive ossification of the neck defect with no surgery-related complications. Clinical results were markedly improved by the osteotomy, with a mean postoperative Iowa Hip Score at last follow-up of 95.06 ± 2.6, compared to a mean preoperative score of 57.4 ± 3.6. Transfixing wires protected in a hip spica cast represent a simple, easy, and reliable fixation method for valgus osteotomies performed to correct
Spruce, Michelle C; Bowling, Frank L; Metcalfe, Stuart A
Hallux valgus is a common chronic condition affecting up to a third of the population. Progressive disruption to the complex anatomy of the first ray involving metatarsal, sesamoids and hallux impose both structural and functional alteration to the foot which underpin the secondary pathologies associated with this condition. It is common for patients to seek correction of the deformity in order to alleviate pain and improve footwear tolerance. Surgical intervention remains the only viable means to restore osseous alignments. To date there remains no universally accepted standards for procedure selection. A total of 179 consecutive participants were recruited into the study. Ethical approval was obtained and all participants consented to participate in the study, in accordance with the Helsinki Declaration. All patients attending the Department of Podiatric Surgery, between July 2004 and October 2007 for the surgical management of hallux valgus were invited to complete a Foot Health Status Questionnaire. Pre-operative data collection on all participants was undertaken on the day of admission, using the validated Foot Health Status Questionnaire measurement tool as with previous studies. A total of 179 complete data sets were recorded in this longitudinal study with an average participant age of 49.4 years (SD 14.5). The group comprised 164 females and 15 males. The mean days for administration of the Foot Health Status Questionnaire post operative follow up was 1045 days (149 weeks or 2.9 years). The results demonstrated that within all four foot specific domains, the minimal important differences were achieved by the majority of the group. Meanwhile, in domains relating to general health, physical activity, vigour and social capacity, the majority of participants failed to attain the calculated minimal important difference (94 [53%], 96 [54%], 93 [52%], 93 [52%], respectively). The authors have presented for the first time minimal important difference for all eight
McKean, R Matthew; Bergin, Patrick F; Watson, Geoffrey; Mehta, Siddhant K; Tarquinio, Thom A
Arthrodesis is a standard operative treatment for symptomatic arthritis of the first metatarsophalangeal (MTP) joint. Patients with degenerative joint disease (DJD), severe hallux valgus, and metatarsus primus varus may also require fusion of the first MTP joint. An important question in the latter group of patients is whether a proximal first metatarsal osteotomy is required, in addition to the first MTP joint fusion. Our hypothesis was that patients with severe hallux valgus and metatarsus primus varus, treated with first MTP joint arthrodesis alone, would have correction of the first-to-second intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) to near population norms, without the addition of a proximal first metatarsal osteotomy. Preoperative and postoperative radiographs of 19 feet, in 17 patients, with preoperative IMA greater than 15 were analyzed. Weight-bearing radiographs were divided into pre- and postoperative cohorts. Three independent reviewers measured these radiographs and mean 1-2 IMA and HVA were calculated. Mean follow-up was 10 months. The mean preoperative 1-2 IMA was 19.2 degrees (15.6-24.3). The mean preoperative HVA was 48.5 (36-56.6). The mean postoperative values for 1-2 IMA and HVA were 10.8 and 12.3 degrees, respectively. The mean change in IMA was 8.3 degrees and in the hallux valgus angle was 36.4 degrees. The differences between pre- and postoperative measurement for both angles were statistically significant (P < .001). Seven of 19 (37%) feet were corrected to an IMA of less than 9 degrees (normal), whereas in 15/19 feet the postoperative IMA was 12.3 degrees or less. The postoperative HVA was less than 15 degrees in 15/19 (79%) feet. This pre- and postoperative radiographic analysis of patients with severe bunion deformity demonstrated that HVA and 1-2 IMA were acceptably corrected without the addition of a proximal first metatarsal osteotomy. Level III, retrospective comparative series. © The Author(s) 2016.
Khairy, Hosam Mohamed
Background Although the valgus subtrochanteric osteotomy is considered as a standard surgical treatment for coxa vara, there is no consensus on the optimal method of fixation and osteotomy technique. Fixation of the osteotomy has been achieved by various methods including external fixation and internal fixation with pins and cerclage and a variety of plates. The aim of this study is the evaluation of the results of developmental coxa treated by Y intertrochanteric valgus osteotomy fixed with a T-buttress plate compared with other methods of fixation in the literature. Methods Eighteen corrective valgus intertrochanteric femoral osteotomies were performed in 18 patients (18 hips) for treatment of unilateral developmental coxa vara deformity and fixed with a T plate. There were 12 males and 6 females. The right hip was affected in 10 patients and the left hip in 8 patients. Clinically, patients were evaluated by Larson hip score. Radiographically, anteroposterior view of the pelvis and frog leg lateral views of the affected hip were taken preoperatively and compared with the findings at the final follow-up. Results The average follow-up was 29 months (range, 24 to 36 months). Clinical results showed improvement of the mean Larson hip score from 57.8 to 97.0 (p < 0.001). Radiological results showed that all osteotomies were completely united in 2.4 months (range, 2 to 3 months) with the achievement of the planned correction angle. The average correction of Hilgenreiner's epiphyseal angle improved from 78.2° to 27.8° (p < 0.001) at the final follow-up. The femoral neck shaft angle was improved from 93.7° to 129.9° (p < 0.001) at the final follow-up. Shortening of the affected limb was corrected from 2.8 cm to 1.3 cm (p < 0.001) at the last follow-up. No major serious complications were recorded in the present study. Conclusions Intertrochanteric valgus osteotomy of the proximal femur fixed with a T plate may be efficient for treatment of developmental coxa vara
Robinson, Cal; Bhosale, Abhijit; Pillai, Anand
AIM: To define footwear outcomes following hallux valgus surgery, focusing on patient return to comfortable and heeled footwear and patterns of post-operative footwear selection. METHODS: Surgical intervention is indicated for symptomatic cases of hallux valgus unresponsive to conservative methods, with favourable reported outcomes. The return to various types of footwear post-operatively is reflective of the degree of correction achieved, and corresponds to patient satisfaction. Patients are expected to return to comfortable footwear post-operatively without significant residual symptoms. Many female patients will additionally attempt to return to high-heeled, narrow toe box shoes. However, minimal evidence exists to guide their expectations. Sixty-five female hallux valgus patients that had undergone primary surgery between 2011 and 2013 were retrospectively identified using our hospital surgical database. Patients were reviewed using a footwear-specific outcome questionnaire at a mean 18.5 mo follow-up. RESULTS: Eighty-six percent of patients were able to return to comfortable footwear post-operatively with minimal discomfort. Of those intending to resume wearing heeled footwear, 62% were able to do so, with 77% of these patients wearing these as or more frequently than pre-operatively. No significant difference was observed between pre- and post-operative heel size. Mean time to return to heeled footwear was 21.4 wk post-operation. Cosmetic outcomes were very high and did not adversely impact footwear selection. CONCLUSION: We report high rates of return to both comfortable and heeled shoes in female patients following primary hallux valgus surgery. We observed an “all-or-none phenomenon” where patients rejected a return to heeled footwear unless able to tolerate them at the same frequency and heel size as pre-operatively. A minority of patients were unable to return to comfortable footwear post-operatively, which had adverse ramifications on their quality
Bose, Dipan; Bhalla, Kavi S; Untaroiu, Costin D; Ivarsson, B Johan; Crandall, Jeff R; Hurwitz, Shepard
Valgus bending and shearing of the knee have been identified as primary mechanisms of injuries in a lateral loading environment applicable to pedestrian-car collisions. Previous studies have reported on the structural response of the knee joint to pure valgus bending and lateral shearing, as well as the estimated injury thresholds for the knee bending angle and shear displacement based on experimental tests. However, epidemiological studies indicate that most knee injuries are due to the combined effects of bending and shear loading. Therefore, characterization of knee stiffness for combined loading and the associated injury tolerances is necessary for developing vehicle countermeasures to mitigate pedestrian injuries. Isolated knee joint specimens (n=40) from postmortem human subjects were tested in valgus bending at a loading rate representative of a pedestrian-car impact. The effect of lateral shear force combined with the bending moment on the stiffness response and the injury tolerances of the knee was concurrently evaluated. In addition to the knee moment-angle response, the bending angle and shear displacement corresponding to the first instance of primary ligament failure were determined in each test. The failure displacements were subsequently used to estimate an injury threshold function based on a simplified analytical model of the knee. The validity of the determined injury threshold function was subsequently verified using a finite element model. Post-test necropsy of the knees indicated medial collateral ligament injury consistent with the clinical injuries observed in pedestrian victims. The moment-angle response in valgus bending was determined at quasistatic and dynamic loading rates and compared to previously published test data. The peak bending moment values scaled to an average adult male showed no significant change with variation in the superimposed shear load. An injury threshold function for the knee in terms of bending angle and shear
Chen, Daoyun; Chen, Jianmin; Jiang, Yao; Liu, Fanggang
Leg discrepancy is common after poliomyelitis. Tibial lengthening is an effective way to solve this problem. It is believed lengthening over a tibial intramedullary nail can provide a more comfortable lengthening process than by the conventional technique. However, patients with sequelae of poliomyelitis typically have narrow intramedullary canals allowing limited space for inserting a tibial intramedullary nail and Kirschner wires. To overcome this problem, we tried using humeral nails instead of tibial nails in the lengthening procedure. In this study, we used humeral nails in 20 tibial lengthening procedures and compared the results with another group of patients who were treated with tibial lengthening over tibial intramedullary nails. The mean consolidation index, percentage of increase and external fixation index did not show significant differences between the two groups. However, less blood loss and shorter operating time were noted in the humeral nail group. More patients encountered difficulty with the inserted intramedullary nail in the tibial nail group procedure. The complications did not show a statistically significant difference between the two techniques on follow-up. In conclusion, we found the humeral nail lengthening technique was more suitable in leg discrepancy patients with sequelae of poliomyelitis.
Berson, L; Davidson, R S; Dormans, J P; Drummond, D S; Gregg, J R
Twenty-four patients with distal tibial growth disturbance were reviewed. Disturbances were classified as physeal bar (prior to deformity), angular, linear or combined deformities. Treatment consisted of osteotomy in fourteen, epiphyseodesis in seven, excision of bony bar in two, and observation in one patient. Follow up was an average 36.6 months (range 4-129 months) after treatment of growth disturbance. The age at time of injury was 10.4 years of age average (range 3-15 years). There were 12 SH2, 2 SH3, 7 SH4, and 3 SH5 distal tibial physeal fractures. Thirteen of 15 fractures considered high energy and only 1 of 9 fractures considered low energy resulted in angular deformity. Angular and linear deformities presented an average 46 months (range 12-120 months) and physeal bars at an average 14 months (range 6-25 months) after injury. Patients with a delay in presentation of growth disturbance greater than 24 months had angular deformities in 92% compared with 33% in children presenting less than or at 24 months. Treatment based on type of deformity, age at time of injury, and growth remaining was considered successful in 83%. Patients with angular or linear deformities were more likely to present late, have high energy injuries, be male patients and have Salter-Harris types IV and V. Early diagnosis and treatment of growth disturbance can prevent severe deformity.
Hamahashi, Kosuke; Mitani, Genya; Takagaki, Tomonori; Serigano, Kenji; Mochida, Joji; Sato, Masato; Watanabe, Masahiko
Objective: The purpose of this study was to compare the clinical outcomes between patients with a valgus or varus deformity undergoing minimally invasive total knee arthroplasty through the medial approach. Methods: The patients were classified into 2 groups according to the preoperative femorotibial angle measured on an anteroposterior long leg roentgenogram. The valgus group comprised of 26 knees in 21 patients with a femorotibial angle <170° (163.5 ± 5.7), and the varus group comprised of 24 knees in 21 patients with a femorotibial angle >190° (195.9 ± 5.5). The following background variables were compared between the groups: age at the time of the operation, sex, causative disease, preoperative femoral mechanical–anatomical angle, and postoperative knee range of motion, Knee Society score, femorotibial angle, and implant position. Results: There were significant differences between the valgus and varus groups in the age (68.0 ± 6.9 vs 75.8 ± 6.2 years), percentage of males (23.8% vs 0%), percentage with rheumatoid arthritis (61.9% vs 4.8%), and preoperative femoral mechanical–anatomical angle (6.2 ± 1.0° vs 7.4 ± 2.1°). Clinical outcome variables of postoperative femorotibial angle (173.1 ± 3.9° vs 175.2 ± 1.6°) and α angle (96.6 ± 3.1° vs 95.0 ± 1.9°) also differed. Conclusion: It was assumed that over-valgus resection of the femur is a contributory factor to residual valgus alignment. However, knee range of motion and Knee Society score did not differ between the groups. We suggest that minimally invasive total knee arthroplasty through the medial approach is one of the treatment options for patients with valgus deformity. PMID:28144381
Haddad, Behrooz; Konan, Sujith; Mannan, Ken; Scott, Gareth
We measured the posterior tibial slope for the medial and lateral tibial plateau separately in MR images of 143 knees (71 women, 72 men) and compared the measurements between genders and different ethnic groups. For the whole population the mean medial slope was 5.7 degrees and the mean lateral slope 5.6 degrees. There was a significant difference between the medial and lateral posterior tibial slope in the Asian patients compared with other ethnic groups (p < 0.001). We have shown that measurement of the posterior tibial slope (PTS) could be reliably performed on MR images, revealing a gender difference. These findings might have clinical relevance when performing reconstructive surgery at the knee in determining ideal placement of the tibial component.
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. PMID:19941664
Hogan, Macalus V; Dare, David M; Deland, Jonathan T
Varus and valgus ankle deformities represent a challenge to the foot and ankle surgeons. The presence of degenerative changes of the tibiotalar joint articular surfaces introduces an additional layer of complexity. Reconstruction of such deformities requires a customized approach to each patient. Surgical intervention often requires joint-sparing realignment, arthroplasty, and/or arthrodesis, depending on the severity of deformity and the joint surface integrity. The ligamentous stability of the ankle plays an essential role in the preservation and optimization of function. This article reviews the role of deltoid and lateral ligament reconstruction in the treatment of varus and valgus ankle osteoarthritis.
Baykal, Barbaros; Kirdemir, Vecihi; Ateşalp, A Sabri; Bek, Dogan; Tercan, Volkan
The results of a modified crescentic proximal metatarsal osteotomy and distal soft tissue procedures for patients with symptomatic, incongruent, metatarsophalangeal joint, hallux valgus deformity were reviewed. Forty-nine feet of 41 patients were evaluated. All of the patients were male military personnel of different ranks, and their mean age was 23 years (range, 20-43 years). The mean follow-up period was 25 months (range, 10-60 months). The patients were evaluated according to the American Orthopedic Foot and Ankle Society forefoot scoring system. The mean preoperative score was 54.4, and the mean postoperative score was 95.4. The mean hallux valgus angle was 39.4 degrees before surgery and 12.8 degrees after surgery (26.6 degrees correction); the mean intermetatarsal angle was 15.9 degrees before surgery and 7.1 after surgery (8.8 degrees correction). A total of 93.8% of the patients were satisfied with the results of the procedure. Complications included delayed union in one case and superficial wound infections in two cases. We also emphasize small modifications performed while shifting the metatarsal shaft laterally and compare the results of our study with those of similar studies.
Radl, Roman; Leithner, Andreas; Zacherl, Maximilian; Lackner, Ursula; Egger, Josef; Windhager, Reinhard
We studied prospectively the influence of personality traits on the subjective outcome of a chevron osteotomy in 42 patients with hallux valgus. The mean age of patients was 48.3 (20-70) years. Personality traits were evaluated by the means of the Freiburg Personality Inventory (FPI-R). Three months postoperatively 37 patients were satisfied, and five patients not satisfied with the operative procedure. The preoperative AOFAS Score improved from an average of 48.7 (30-65) points to 87.9 (50-100) points. A comparison of satisfied and dissatisfied patients revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angle was 12.2+/-7.8 degrees and 13.4+/-8.3 degrees (p=0.74) among satisfied and not satisfied patients, respectively, and the intermetatarsal angle (I-II) was 7.4+/-2.5 degrees and 7.6+/-4 degrees (p=0.89), respectively. The results suggest that the patient's subjective result after the operative correction may be influenced by some individual, personality profiles.
Andrade, Marco Antônio Percope de; Gomes, Davi Coutinho Fonseca Fernandes; Portugal, André Lopes; Silva, Guilherme Moreira de Abreu e
Objective: Assess the long-term results of distal femoral varusing osteotomy and try to establish predictive criteria that could help on selecting patients to be submitted to this technique. Methods: Fifteen patients with lateral compartment osteoarthritis and valgus deformity of the knee were submitted to distal femoral “V” varusing osteotomy fixated with lateral plate, pursuing knee alignment at 0° on the anatomical axis. The mean follow-up period was 81.4 months, ranging from 43 to 132 months. The Knee Society Rating System protocol was employed. Additional assessed variables were the following: patient age, follow-up time, and postoperative anatomical angle. Results: 11 results were regarded as excellent or good (73%) and four as fair or poor (27%). Conclusion: Distal femoral “V” varusing osteotomy constitutes a good treatment alternative for patients with lateral compartment osteoarthritis and valgus knee. The following variables have not been confirmed: patient age at the time of surgery, follow-up time, and postoperative anatomical angle as predictive factors for the results. PMID:27022518
Panchbhavi, Vinod K; Trevino, Saul
The aim of this study was to determine if there are intraobserver and interobserver differences in reliability when measuring hallux valgus angles (HVA), 1-2 intermetatarsal angles (IMA), and distal metatarsal articular angles (DMAA) manually compared to computer-assisted means. Our hypothesis was that the measurements taken by computer-assisted methods of these three forefoot angles would be superior in consistency and accuracy compared to manual measurements. Four examiners studied 20 weightbearing anteroposterior radiographs of patients with hallux valgus. Manual measurements were taken on photographic prints using a goniometer and a fine point pen. Computer-assisted measurements were taken on digitized images using computer software. Three sets of measurements by both of these methods were taken 1 week apart. There was no statistically significant difference between digital and manual measurements for any of the three angles measured (p .05). However, the reliability of measurements within a range of 5 degrees for both methods was 70.6% for HVA, 84% for 1-2 IMA, and 59% for DMAA. There were no significant differences in interobserver and intraobserver reliability in measuring 1-2 IMA and HVA, regardless of the method of measurement; however, there was a significant difference in interobserver reliability when measuring the DMAA either on computer or manually (p = <.05).
Srivastava, Subodh; Chockalingam, Nachiappan; El Fakhri, Tarek
Radiographic angles are used to assess the severity of hallux valgus deformity, in preoperative planning, assessing postoperative outcomes, and in comparing results between interventions. The manual method to measure these angles has been shown to be prone to errors and to be time consuming. Computer programs are now available to assist in angular measurements. This study was undertaken to compare the reliability and time taken between the 2 methods. A total of 30 radiographs were used from a population of patients with hallux valgus deformity. The radiographs were digitized for computer-assisted measurements. The technical error of measurement (TEM) was calculated for intra- and interobserver data to assess the error in angular measurement with both methods. The technical error of measurement was lower with the computer-assisted method, suggesting that this method is more reliable. Furthermore, the time taken was also reduced with this method. Copyright © 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Svartman, Celso; Santili, Cláudio; De Assumpção, Rodrigo MontezumaC.; de Almeida Leite, Leonardo Felicissimo; Quialheiro, Leonardo Silva; de Carvalho Fabricio, Sidney
Between 1988 and 2003, 23 patients with paralytic calcaneus-valgus feet were submitted to the Westin procedure and 17 patients (25 feet) were re-evaluated. Nine patients were male and eight were female. The mean age at the surgical procedure was 8±5 years. The aetiology of paralysis was sequelae of poliomyelitis in 6 patients (8 feet) and of myelomeningocele in 11 patients (17 feet). The mean follow-up period was 6±6 years. The results were analysed clinically and radiographically considering the decrease of the retropulsion, the patient’s satisfaction, and the increase of the lateral tibiocalcaneal angle. Results were considered satisfactory when the patients showed a decrease of the retropulsion during gait, improvement of the gait pattern, and an increase of the tibiocalcaneal angle. As an overall result, 16 patients (94.2%) were satisfied and 1 patient (two feet) dissatisfied with the outcome. The increase of the tibiocalcaneal angle was significant for the myelomeningocele patients (P=0.001), but not for poliomyelitis (P=0.053). No statistical relation between the follow-up period and the increase of the tibiocalcaneal angle was found (r=0.04). The authors concluded that the Westin procedure is a good technique for the treatment of paralytic calcaneus valgus feet with myelomeningocele. PMID:16933136
Tsukeoka, Tadashi; Tsuneizumi, Yoshikazu
Retrospective studies demonstrated inadequate soft tissue balance is associated with the long-term outcome of total knee arthroplasty (TKA). However, most of these studies have evaluated the joint laxity only postoperatively without anesthesia. Therefore information about the effect of anesthesia on knee laxity is important for soft tissue balancing at the time of surgery. This study was conducted to determine how anesthesia affects the varus and valgus stress tests after TKA. A consecutive series of 26 patients undergoing staged bilateral TKA was evaluated. Varus and valgus laxity of the knee with the TKA implant was measured a few days before the contralateral TKA without anesthesia and again immediately after the contralateral TKA under spinal anesthesia. The laxity was significantly increased from 3.0° to 3.6° (p = 0.005) and from 4.7° to 5.7° (p = 0.007) in medial and lateral side, respectively, when the stress tests were performed under anesthesia in comparison to the laxity measured without anesthesia. The major change in laxity (≥3°) was measured in 6 (23%) patients tested without anesthesia. Anesthesia significantly influenced knee joint laxity after TKA. The findings of this study suggest that muscular forces impart a stabilizing force across the joint.
Fucs, Patrícia M de Moraes Barros; Svartman, Celso; Santili, Cláudio; De Assumpção, Rodrigo Montezuma C; de Almeida Leite, Leonardo Felicissimo; Quialheiro, Leonardo Silva; de Carvalho Fabricio, Sidney
Between 1988 and 2003, 23 patients with paralytic calcaneus-valgus feet were submitted to the Westin procedure and 17 patients (25 feet) were re-evaluated. Nine patients were male and eight were female. The mean age at the surgical procedure was 8+/-5 years. The aetiology of paralysis was sequelae of poliomyelitis in 6 patients (8 feet) and of myelomeningocele in 11 patients (17 feet). The mean follow-up period was 6+/-6 years. The results were analysed clinically and radiographically considering the decrease of the retropulsion, the patient's satisfaction, and the increase of the lateral tibiocalcaneal angle. Results were considered satisfactory when the patients showed a decrease of the retropulsion during gait, improvement of the gait pattern, and an increase of the tibiocalcaneal angle. As an overall result, 16 patients (94.2%) were satisfied and 1 patient (two feet) dissatisfied with the outcome. The increase of the tibiocalcaneal angle was significant for the myelomeningocele patients (P=0.001), but not for poliomyelitis (P=0.053). No statistical relation between the follow-up period and the increase of the tibiocalcaneal angle was found (r=0.04). The authors concluded that the Westin procedure is a good technique for the treatment of paralytic calcaneus valgus feet with myelomeningocele.
Rodríguez-Reyes, Gerardo; López-Gavito, Eduardo; Pérez-Sanpablo, Alberto Isaac; Galván Duque-Gastélum, Carlos; Alvarez-Camacho, Michelín; Mendoza-Cruz, Felipe; Parra-Téllez, Patricia; Vázquez-Escamilla, Jesús; Quiñones-Urióstegui, Ivett
Percutaneous surgical techniques are suitable for the correction of the hallux valgus deformity. Satisfactory aesthetic and functional results obtained with the Reverdin- Isham osteotomy have been reported. The aim of this study was to describe dynamic plantar pressure redistribution after the correction of the deformity using this technique. A sample of 20 feet with mild or moderate hallux valgus was conformed and surgically treated using the Reverdin-Isham osteotomy. Clinical, radiological, surface and pressure assessments were performed pre and postoperatively. Postoperative mean (± SD) values of the American Orthopaedic Foot and Ankle Society (AOFAS) score, metatarsophalangeal, first intermetatarsal and proximal articular sect angles were 95.7 (3.3), 15.5° (5.4), 9.5° (1.5) y 5.3° (3.0), respectively. A significant decrease was observed in surface values of both lateral (P = 0.003) and medial (P = 0.001) masks of the forefoot. Mean pressure values of the lateral forefoot region denoted a significant increase (P < 0.001) while the medial forefoot region showed no change (P = 0.137). There is evidence that this particular surgical technique promotes a new plantar pressure pattern in the foot that might significantly favour the increase of the pressure observed under the lesser metatarsal heads and might not induce meaningful changes in the mean pressure registered under the first metatarsal head and hallux.
Galasso, Olimpio; Jenny, Jean-Yves; Saragaglia, Dominique; Miehlke, Rolf K
The use of a keel in the tibial component during modern primary total knee arthroplasty (TKA) has become common, and its cementation may affect the future performance of the prosthesis. Although proponents of cementing the entire tibial component argue that this technique provides better initial fixation and may prevent aseptic loosening, reasons exist to apply cement only to the tibial baseplate. In this study, 232 patients who underwent TKA using full or surface cementation of the tibial baseplate were evaluated at an average 5.6-year follow-up to assess survivorship and clinical results. The cumulative survival rate at 8 years was 97.1%. With revision of either component for any reason considered the endpoint, no significant difference was noted between full and surface cemented groups. Knee Society Score, range of motion, and femoro-tibial mechanical angle significantly increased postoperatively. Multivariate analysis revealed that good preoperative range of motion and Knee Society Scores were related to good postoperative range of motion and Knee Society Scores. Follow-up length was a negative predictor of postoperative Knee Society Score. The use of full or surface cementation of the baseplate was unrelated to the postoperative clinical outcomes. Clinical outcomes did not differ according to the tibial component cementation technique. The results of this study suggest that cementing the keel of the tibial component during primary TKA has no advantage for patients. Longer-term follow-up and proper patient randomization are required to confirm these findings.
Henricson, Anders; Nilsson, Kjell G
Background and purpose - Total knee replacement (TKR) in younger patients using cemented components has shown inferior results, mainly due to aseptic loosening. Excellent clinical results have been reported with components made of trabecular metal (TM). In a previous report, we have shown stabilization of the TM tibial implants for up to 5 years. In this study, we compared the clinical and RSA results of these uncemented implants with those of cemented implants. Patients and methods - 41 patients (47 knees) aged ≤ 60 years underwent TKR. 22 patients (26 knees) received an uncemented monoblock cruciate-retaining (CR) tibial component (TM) and 19 patients (21 knees) received a cemented NexGen Option CR tibial component. Follow-up examination was done at 10 years, and 16 patients (19 knees) with TM tibial components and 17 patients (18 knees) with cemented tibial components remained for analysis. Results - 1 of 19 TM implants was revised for infection, 2 of 18 cemented components were revised for knee instability, and no revisions were done for loosening. Both types of tibial components migrated in the first 3 months, the TM group to a greater extent than the cemented group. After 3 months, both groups were stable during the next 10 years. Interpretation - The patterns of migration for uncemented TM implants and cemented tibial implants over the first 10 years indicate that they have a good long-term prognosis regarding fixation.
Henricson, Anders; Nilsson, Kjell G
Background and purpose Total knee replacement (TKR) in younger patients using cemented components has shown inferior results, mainly due to aseptic loosening. Excellent clinical results have been reported with components made of trabecular metal (TM). In a previous report, we have shown stabilization of the TM tibial implants for up to 5 years. In this study, we compared the clinical and RSA results of these uncemented implants with those of cemented implants. Patients and methods 41 patients (47 knees) aged ≤ 60 years underwent TKR. 22 patients (26 knees) received an uncemented monoblock cruciate-retaining (CR) tibial component (TM) and 19 patients (21 knees) received a cemented NexGen Option CR tibial component. Follow-up examination was done at 10 years, and 16 patients (19 knees) with TM tibial components and 17 patients (18 knees) with cemented tibial components remained for analysis. Results 1 of 19 TM implants was revised for infection, 2 of 18 cemented components were revised for knee instability, and no revisions were done for loosening. Both types of tibial components migrated in the first 3 months, the TM group to a greater extent than the cemented group. After 3 months, both groups were stable during the next 10 years. Interpretation The patterns of migration for uncemented TM implants and cemented tibial implants over the first 10 years indicate that they have a good long-term prognosis regarding fixation PMID:27357222
Chmielnicki, M; Prokop, A
Tibial shaft fractures are among the most common long bone fractures in humans. The incidence is 1-2 per 100,000. The gold standard of treatment for AO type 42 A-C fractures is a locking intramedullary nail. The development of new implants has extended the indications for this minimally invasive technique, so that now AO types 41 and 43 can also be treated with special nails. Fixed-angle screw anchors increase primary stability and supplemental locking devices located proximally and distally extend the spectrum of use to metaphyseal fractures. The cannulated Targon TX titanium nail can be introduced, either with or without reaming. Using an operative video, the treatment of a tibial fracture with an intramedullary nail is demonstrated in stages and the operative steps further illustrated on artificial bone. Georg Thieme Verlag KG Stuttgart · New York.
McKeon, Kathleen E; Gelberman, Richard H; Calfee, Ryan P
The clinical diagnosis of thumb ulnar collateral ligament disruption has been based on joint angulation during valgus stress testing. This report describes a definitive method of distinguishing between complete and partial ulnar collateral ligament injuries by quantifying translation of the proximal phalanx on the metacarpal head during valgus stress testing. Sixty-two cadaveric thumbs underwent standardized valgus stress testing under fluoroscopy with the ulnar collateral ligament intact, following an isolated release of the proper ulnar collateral ligament, and following a combined release of both the proper and the accessory ulnar collateral ligament (complete ulnar collateral ligament release). Following complete ulnar collateral ligament release, the final thirty-seven thumbs were also analyzed after the application of a valgus force sufficient to cause 45° of valgus angulation at the metacarpophalangeal joint to model more severe soft-tissue injury. Two independent reviewers measured coronal plane joint angulation (in degrees), ulnar joint line gap formation (in millimeters), and radial translation of the proximal phalanx on the metacarpal head (in millimeters) on digital fluoroscopic images that had been randomized. Coronal angulation across the stressed metacarpophalangeal joint progressively increased through the stages of the testing protocol: ulnar collateral ligament intact (average [and standard deviation], 20° ± 8.1°), release of the proper ulnar collateral ligament (average, 23° ± 8.3°), and complete ulnar collateral ligament release (average, 30° ± 8.9°) (p < 0.01 for each comparison). Similarly, gap formation increased from the measurement in the intact state (5.1 ± 1.3 mm), to that following proper ulnar collateral ligament release (5.7 ± 1.5 mm), to that following complete ulnar collateral ligament release (7.2 ± 1.5 mm) (p < 0.01 for each comparison). Radial translation of the proximal phalanx on the metacarpal head did not increase
Haller, Justin M; Marchand, Lucas; Rothberg, David L; Kubiak, Erik N; Higgins, Thomas F
The purpose of the study was to compare the inflammatory cytokine and matrix metalloproteinase (MMP) concentrations in synovial fluid after acute plafond fracture with acute tibial plateau fracture. Between December 2011 and August 2014, we prospectively enrolled patients with acute tibial plateau and plafond fractures. Synovial fluid aspirations were obtained from injured and uninjured joints. The concentrations of IL-1β, IL-1RA, IL-6, IL-8, IL-10, MCP-1, TNF-α, MMP-1, -3, -9, -10, -12, and -13 were quantified using multiplex assays. A Bonferroni correction was used so that the adjusted alpha level for significance was p < 0.004. We enrolled 45 tibial plateau fractures and 19 plafond fractures. Mean patient age was 42 years (range, 20-60) and 64% were male patients. There were 24 low-energy (OTA 41B) plateau fractures and eight low-energy (OTA 43B) plafond fractures. There were 21 high-energy (6 OTA 41B3 and 15 OTA 41C) plateau fractures and 11 high-energy (OTA43C) plafond fractures. All cytokines and MMPs except MMP-13 were significantly elevated in plafond fractures compared to uninjured ankles. When comparing acutely injured joints, IL-8 (p < 0.001), IL-1β (p = 0.002), and MMP-12 (p = 0.001) were significantly higher in plafond fractures compared to plateau fractures. Concentrations of IL-1RA (p = 0.008) and MCP-1 (p = 0.005) were higher in plafond fractures, and MMP-10 (p = 0.01) was higher in plateau fractures, but these differences did not reach significance. In conclusion, several cytokines and MMPs were significantly elevated in acute plafond fractures as compared to acute tibial plateau fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Liu, Siying; Tian, Lei; Ding, Mingchao; Liu, Yanpu; Li, Guiyu; Chen, Jinwu; Ding, Yin
To investigate the effects of condylar extracapsular injuries on the development of the mandibular condyle and try to find a way to treat condylar hyperplasia by electively using such injuries to restrict the overdeveloped mandibular condyle. Sixty 6-month-old beagle puppies were divided randomly into five groups: blank control; unilateral fracture to the condylar neck; unilateral fracture to the condylar neck treated with rigid internal fixation; unilateral periosteum injury; unilateral decortication of the condylar neck. Computed tomography, (99 m)Tc single-photon emission computed tomography, and tetracycline-calcein double-labeling were performed after surgery. The puppies were sacrificed 12 and 24 weeks after surgery. Morphologic analyses and examination of growth activity were done. Unilateral fracture of the condylar neck without fixation caused local morphologic changes during the early postoperative period, but compensatory growth of the condyle altered such changes after healing. The other types of injury failed to inhibit the growth of the condyle and the mandible, whereas functional deviation of the chin was found after unilateral fracture of the condylar neck with or without fixation. The four types of extracapsular injury described here failed to inhibit the growth of the mandibular condyle and could not be selected as alternatives to treat condylar hyperplasia. Copyright © 2016 Elsevier Inc. All rights reserved.
Background Osteoarthritis (OA) is a destructive joint disease and there are no known biomarkers available for an early diagnosis. To identify potential disease biomarkers and gain further insight into the disease mechanisms of OA we applied quantitative proteomics with SILAC technology on the secretomes from chondrocytes of OA knees, designated as high Mankin (HM) scored secretome. A quantitative comparison was made between the secretomes of the medial and lateral femur condyle chondrocytes in the same knee since the medial femur condyle is usually more affected in OA than the lateral condyle, which was confirmed by Mankin scoring. The medial/lateral comparison was also made on the secretomes from chondrocytes taken from one individual with no clinically apparent joint-disease, designated as low Mankin (LM) scored secretome. Results We identified 825 proteins in the HM secretome and 69 of these showed differential expression when comparing the medial and lateral femoral compartment. The LM scored femoral condyle showed early signs of OA in the medial compartment as assessed by Mankin score. We here report the identification and relative quantification of several proteins of interest for the OA disease mechanism e.g. CYTL1, DMD and STAB1 together with putative early disease markers e.g. TIMP1, PPP2CA and B2M. Conclusions The present study reveals differences in protein abundance between medial/lateral femur condyles in OA patients. These regulatory differences expand the knowledge regarding OA disease markers and mechanisms. PMID:24090399
Kim, Ji-Hye; Lee, Dong-Eun; Gunawardhana, K S Niluka Darshani; Choi, Seong-Ho; Woo, Gye-Hyeong; Cha, Jeong-Heon; Bak, Eun-Jung; Yoo, Yun-Jung
This study examined the effect of the interaction between periodontitis and type 1 diabetes mellitus on alveolar bone, mandibular condyle and tibia in animal models. Rats were divided into normal, periodontitis, diabetic and diabetic with periodontitis groups. After injection of streptozotocin to induce diabetes, periodontitis was induced by ligation of both lower-side first molars for 30 days. Alveolar bone loss and trabecular bone volume fraction (BVF) of the mandibular condyle and tibia were estimated via hematoxylin and eosin staining and micro-computed tomography, respectively. Osteoclastogenesis of bone marrow cells isolated from tibia and femur was assayed using tartrate-resistant acid phosphatase staining. The cemento-enamel junction to the alveolar bone crest distance and ratio of periodontal ligament area in the diabetic with periodontitis group were significantly increased compared to those of the periodontitis group. Mandibular condyle BVF did not differ among groups. The BVF of tibia in the diabetic and diabetic with periodontitis groups was lower than that of the normal and periodontitis groups. Osteoclastogenesis of bone marrow cells in the diabetic groups was higher than that in the non-diabetic groups. However, the BVF of tibia and osteoclastogenesis in the diabetic with periodontitis group were not significantly different than those in the diabetic group. Type 1 diabetes mellitus aggravates alveolar bone loss induced by periodontitis, but periodontitis does not alter the mandibular condyle and tibia bone loss induced by diabetes. Alveolar bone, mandibular condyle and tibia may have different responses to bone loss stimuli in the diabetic environment.
McGonagle, L; Elamin, S; Wright, DM
INTRODUCTION Lateral humeral condyle fractures typically require a longer period of internal fixation than other distal humeral fractures due to the increased risk of non-union. K-wires can be buried and left in situ until union or they can be left unburied and require removal after four weeks, with plaster immobilisation until union. There is no consensus as to whether wire burial is preferable or not. The aim of this study was to determine whether K-wire burial is associated with more complications than non-buried wires in treating lateral condyle fractures of the elbow. METHODS All patients with lateral humeral condyle fractures treated with K-wire fixation at our institution from May 2008 to August 2011 were included in the study. Fracture configuration, mode of reduction, wire burial and complications were assessed. RESULTS Sixty-seven patients (19 girls and 48 boys, mean age: 6.5 years, range: 1–17 years) were included in the study. All had closed injuries and were treated with open reduction and K-wire fixation. K-wires were buried in 55 patients. Thirteen cases of buried wires eroded through skin and were removed on average 45 days (range: 30–58 days) post-operatively. Of the wire erosion cases, three developed microbiologically proven infections, one of which was a deep infection. There were a further three superficial wound infections in the absence of wire erosion through the skin. There were complications in 2 of the 12 cases in the unburied wires group: 1 microbiologically proven superficial wire site infection and 1 wire backed out after 11 days, requiring refixation. CONCLUSIONS Wire erosion through the skin is the most common complication of K-wire burial. This may be due to the decrease in swelling after fracture fixation, making the wires more prominent under the skin. Skin integrity should be monitored closely if wires are buried. PMID:23031772
McGonagle, L; Elamin, S; Wright, D M
Lateral humeral condyle fractures typically require a longer period of internal fixation than other distal humeral fractures due to the increased risk of non-union. K-wires can be buried and left in situ until union or they can be left unburied and require removal after four weeks, with plaster immobilisation until union. There is no consensus as to whether wire burial is preferable or not. The aim of this study was to determine whether K-wire burial is associated with more complications than non-buried wires in treating lateral condyle fractures of the elbow. All patients with lateral humeral condyle fractures treated with K-wire fixation at our institution from May 2008 to August 2011 were included in the study. Fracture configuration, mode of reduction, wire burial and complications were assessed. Sixty-seven patients (19 girls and 48 boys, mean age: 6.5 years, range: 1-17 years) were included in the study. All had closed injuries and were treated with open reduction and K-wire fixation. K-wires were buried in 55 patients. Thirteen cases of buried wires eroded through skin and were removed on average 45 days (range: 30-58 days) post-operatively. Of the wire erosion cases, three developed microbiologically proven infections, one of which was a deep infection. There were a further three superficial wound infections in the absence of wire erosion through the skin. There were complications in 2 of the 12 cases in the unburied wires group: 1 microbiologically proven superficial wire site infection and 1 wire backed out after 11 days, requiring refixation. Wire erosion through the skin is the most common complication of K-wire burial. This may be due to the decrease in swelling after fracture fixation, making the wires more prominent under the skin. Skin integrity should be monitored closely if wires are buried.
Guo, Zhimin; Gong, Xingxing; Li, Yanwei; Qiu, Xiaochun; Zhang, Meng; Shangguan, Tiancheng; Ao, Qingfang; Liu, Qiang
To summarize the effectiveness of anatomical plate combined with cortical bone plate allografts in the treatment of comminuted fractures of the femoral condyles. Between January 2008 and December 2012, 18 patients with comminuted fractures of the femoral condyles were treated, including 13 males and 5 females with an average age of 45 years (range, 23-65 years). Fractures were caused by traffic accident in 11 cases, by falling from height in 4 cases, and by the other in 3 cases. The locations were the left side in 7 cases and the right side in 11 cases. Of 18 fractures, 12 were open fractures and 6 were closed fractures. The mean time from injury to operation was 6 days (range, 4-15 days). The fixation was performed by anatomical plate combined with cortical bone plate allografts, and autograft bone or allogeneic bone grafting were used. Superficial local skin necrosis occurred in 1 case, and was cured after skin graft, and other incisions achieved primary healing. All patients were followed up 12-36 months (mean, 23 months). X-ray films showed that bone union was achieved within 3-12 months (5.6 months on average). No related complication occurred, such as fixation loosening, refracture, infection, or immunological rejection. According to Merchan et al. criteria for knee joint function evaluation, the results were excellent in 7 cases, good in 9 cases, fair in 1 case, and poor in 1 case at last follow-up; the excellent and good rate was 88.9%. Anatomical plate combined with cortical bone plate allograft fixation is a good method to treat comminuted fractures of the femoral condyles. This method can effectively achieve complete cortical bone on the inside of the femur as well as provide rigid fixation.
Pinto, M A G S; Harris, W W
The purpose of this paper is to present an alternative method of achieving a synostosis between tibia and fibula in trans-tibial amputations by means of a fibular segment in place of tibial osteoperiosteal flaps as described by Ertl, in 1949. From May 1997 through to February 2003, 15 patients were submitted to the proposed procedure. As a result, all patients produced a solid synostosis between tibia and fibula and were rehabilitated with the use of prostheses. The capacity of these patients for distal weight-bearing on the stump was remarkable when compared to patients submitted to the conventional trans-tibial amputation technique.
Woyski, Dustin; Emerson, Jason
Fractures of the tibial shaft in patients with ipsilateral total knee arthroplasty are rare but difficult to treat. Nonoperative treatment of these fractures with casting or bracing limits weight bearing for an extended period and can result in unacceptable malalignment. Operative fixation with plate and screws also limits early weight bearing and requires healing of soft tissue that is of poor quality. The authors present a method of internal fixation that uses a standard intramedullary tibial nail and suprapatellar instrumentation. This method can easily be performed, avoids the tibial baseplate, and does not require alteration of the instrumentation or intramedullary nail.
Park, Jae Hyun; Tai, Kiyoshi; Sato, Yasumori
A 15-year-old girl who had a unilateral condylar fracture with severe crowding in both arches was treated with 4 premolar extractions followed by orthodontic therapy with a temporary skeletal anchorage device in the maxillary arch. The total active treatment time was 21 months. Her occlusion was significantly improved by orthodontic treatment, and the range of condylar movement was also improved. Posttreatment records after 30 months showed excellent results with a good stable occlusion. The remodeling process of the condyle was confirmed with cone-beam computed tomography images.
de Fernández, M I; Negroni, R; Arechavala, A
Disseminated histoplasmosis is the most serious form of the disease produced by the fungus Histoplasma capsulatum. Histoplasmosis was first described by Darling in 1906, and it is endemic in certain areas of Central and Southeastern regions of USA, and most Latin America countries, including the Pampa húmeda and Mesopotamia regions in Argentina, but in other continents it has a limited regional distribution. Lung involvement predominates in 90% of cases, but H. capsulatum may involve bone and soft tissues. Bone lesions without other signs of infection are very rare, and are often misdiagnosed as cancer. We report a case of disseminated histoplasmosis in a man with a myelodysplasia who presented a left tibial abscess, without any clinical evidence of pulmonary involvement. The patient was successfully treated with itraconazole.
Cugat, Ramon; Ares, Oscar; Cuscó, Xavier; Garcia, Montserrat; Samitier, Gonzalo; Seijas, Roberto
Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.
Landis, Emily K.; Karnick, Pushpak
This study uses new three-dimensional imaging techniques to compare the articular curvature of the proximal tibial articular surface of hominoids. It has been hypothesized that the curvature of the anteroposterior contour of the lateral condyle in particular can be used to differentiate humans and apes and reflect locomotor function. This study draws from a large comparative sample of extant hominoids to obtain quantitative curvature data. Three-dimensional models of the proximal tibiae of 26 human, 15 chimpanzee, 15 gorilla, 17 orangutan, 16 gibbon and four Australopithecus fossil casts (AL 129-1b, AL 288-1aq, AL 333x-26, KNM-KP 29285A) were acquired with a Cyberware Model 15 laser digitizer. Curvature analysis was accomplished using a software program developed at Arizona State University's Partnership for Research In Stereo Modeling (PRISM) lab, which enables the user to extract curvature profiles and compute the difference between analogous curves from different specimens. Results indicate that the curvature of chimpanzee, gorilla and orangutan tibiae is significantly different from the curvature of human tibiae, thus supporting the hypothesized dichotomy between humans and great apes. The non-significant difference between gibbons and all other taxa indicates that gibbons have an intermediate pattern of articular curvature. All four Australopithecus tibia were aligned with the great apes.
Moon, Sang Won; Park, Sin Hyung; Lee, Byung Hoon; Oh, Minkyung; Chang, Minho; Ahn, Jin Hwan; Wang, Joon Ho
To evaluate whether hinge position affects the change in posterior tibial slope in medial open-wedge high tibial osteotomy (HTO). We retrospectively evaluated 19 knees from 17 patients who underwent medial open-wedge HTO by 3-dimensional computed tomography scan before and after surgery. A 3-dimensional image model was constructed by applying reverse-engineering software to the computed tomography DICOM (Digital Imaging and Communications in Medicine) files. The hinge axis (i.e., the position of the hinge compared with the anteroposterior axis on an axial view), posterior tibial slope, medial-proximal tibial angle, and gap ratio (i.e., the ratio of anterior gap to posterior gap in the opened wedge) were measured. The mean hinge axis was 4.92° ± 3.86°. Posterior tibial slope increased from 7.29° ± 2.56° preoperatively to 10.48° ± 3.01° postoperatively (P = .001). The mean medial-proximal tibial angle was 85.96° ± 1.97° preoperatively and 93.13° ± 3.17° postoperatively (P = .001). The mean gap ratio was 62.48% ± 7.26%. Linear regression analysis determined that the hinge axis (P = .0001) was a significant factor changing posterior tibial slope. Hinge position affected the change in posterior tibial slope in medial open-wedge HTO; in particular, a posterolateral hinge position led to an increase in posterior tibial slope. Level IV, therapeutic study. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Ozel, Omer; Yucel, Bulent; Mutlu, Serhat; Orman, Osman; Mutlu, Harun
In this study, postoperative changes in the posterior tibial slope angle and clinical outcomes following open-wedge high tibial osteotomy were evaluated. This study included 39 knees (18 left, 21 right) of 35 patients (three male, 32 female; median age, 53 years; age range 37-64 years) with symptomatic isolated medial joint osteoarthritis who underwent open-wedge high tibial osteotomy and fixation with a Puddu plate. The patients were clinically assessed according to the Lysholm knee score, a visual analogue pain scale, and a patient satisfaction questionnaire. Radiological assessment was made according to the changes in the posterior tibial slope angle and the correlation between these changes and clinical signs. The median follow-up period was 11 years (range 7-14 years). Significant improvements were observed in the preoperative and postoperative clinical scores of the Lysholm knee scale, visual analogue pain scale, and patient satisfaction questionnaire (p < 0.05). Radiological assessment showed that the posterior tibial slope angle was significantly higher during the postoperative and follow-up periods (p 0.05). There was no correlation between the postoperative Lysholm scores and the increase in the posterior tibial slope angle (p = n.s.). We conclude that both the conventional Puddu plate design and its anteromedial plate placement are what increase the tibial slope after an opening-wedge proximal tibial osteotomy. Therefore, current new plate design may help preserve the posterior tibial slope angle. IV.
Paredes-Carnero, X; Fernández-Cortiñas, A B; Escobar, J; Galdo, J M; Babé, J G
To evaluate the use of unconstrained implants in the correction of large valgus deformities using total knee arthroplasty (TKA). A total of 817 primary TKA operated between 1998 and 2006 were retrospectively assessed. 50 TKA were selected (group A) in 49 patients, with a minimum deformity of 15° of valgus, 41 cases were included. Another 50 ATR were selected (group B), with a maximum deformity of 15° of varus, finally including 44 cases in 42 patients. The same surgeon performed every operation. The minimum follow-up time was 10 years. The Knee Society Score (KS and FS), the Oxford Knee Score (OKS) and the Range of Mobility (ROM), both preoperative and postoperative at 1,.5 and 10 years, as well as radiographic evolution and complications were evaluated. Preoperative values of KS, FS and OKS were lower in group A (P<.0001, P<.01 and P<.05, respectively), but not ROM. Postoperatively, KS, FS, OKS and ROM were not different between the groups, neither year, nor 5, nor 10 years. There were also no radiological or complications between the two groups. The use of non-constricted implants in severe valgus was not inferior to the mild varus, implying, in addition, a saving in economic terms, with excellent postoperative results. Correction of severe valgus deformities can be performed with non-constrained primary implants, without obtaining worse results than those obtained in mild deformities. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Nha, Kyung-Wook; Kim, Hyun-Jung; Ahn, Hyeong-Sik; Lee, Dae-Hee
It is unclear whether open- or closed-wedge high tibial osteotomy (HTO) results in significant changes in posterior tibial slope, with no consensus on the magnitude of such changes. Furthermore, methods of measuring posterior tibial slope differ among studies. This meta-analysis was therefore designed to evaluate whether posterior tibial slope increases after open-wedge HTO and decreases after closed-wedge HTO and to quantify the magnitudes of the slope changes after open- and closed-wedge HTO using various methods of measuring posterior tibial slope. Posterior tibial slope increases after open-wedge and decreases after closed-wedge HTO. The magnitude of change is similar for the 2 methods, and the value obtained for posterior tibial slope change is affected by the method of measurement. Meta-analysis. Multiple comprehensive databases, including MEDLINE, EMBASE, the Cochrane Library, and KoreaMed, were searched for studies that evaluated the posterior slope of the proximal tibia in patients who had undergone open- and/or closed-wedge HTO. Studies were included that compared pre- and postoperative posterior tibial slopes, regardless of measurement method, including anterior and posterior tibial cortex or tibial shaft axis as a reference line, in patients who underwent open- or closed-wedge HTO. The quality of each included study was appraised with the Newcastle-Ottawa Scale. Twenty-seven studies were included in the meta-analysis. Pooled data, which included subgroups of 3 methods, showed that posterior tibial slope increased 2.02° (95% CI, 2.66° to 1.38°; P = .005) after open-wedge HTO and decreased 2.35° (95% CI, 1.38° to 3.32°; P < .001) after closed-wedge HTO. This meta-analysis confirmed that posterior tibial slope increased after open-wedge HTO and decreased after closed-wedge HTO when the results of a variety of measurement methods were pooled. The magnitude of change after open- and closed-wedge HTO was similar and small (approximately 2°), suggesting
Bekelis, Kimon; Duhaime, Ann-Christine; Missios, Symeon; Belden, Clifford; Simmons, Nathan
In cadaveric studies and recently in one adult patient the occipital condyle has been studied as an option to allow bone purchase by fixation devices. In the current case the authors describe the use of occipital condyle screws in a child undergoing occipitocervical fixation. To the best of the authors' knowledge this case is the first reported instance of this technique in a pediatric patient. This girl had a history of posterior fossa decompression for Chiari malformation Type I when she was 22 months of age. When she was 6 years old she presented with neck pain on flexion and extension of her head. Magnetic resonance imaging in flexion and extension revealed occipitocervical instability. She underwent an occiput to C-2 posterior arthrodesis with bilateral screw placement in the occipital condyles, C-2 lamina, and C-1 lateral masses. Postoperatively, she was neurologically intact. Computed tomography demonstrated a stable construct, and her cervical pain had resolved on follow-up.
Three different human femoro-tibial characters are selected as functionally relevant and derived hominid characters: femoral bicondylar angle, shape of the femoral distal epiphysis, and the tibial insertion of the lateral meniscus. The timing and mode of formation of these characters are investigated during human ontogeny and are shown to differ considerably. The available hominid fossils (Australopithecus afarensis and early Homo) are interpreted in the light of this ontogenetic analysis with the conclusion that, during hominid evolution, different modes of selection of these features must have occurred. In modern humans, the femoral bicondylar angle proves to be an epigenetic functional feature, which develops during early childhood growth. It is present in all australopithecines and we suggest that it developed following a change in their locomotor behavior and not upon a genomic change: the early practice of bipedal walking, with adducted knee joints, in the locomotor repertoire of infant australopithecines, was sufficient to promote this angle. Later in hominid evolution, the knee joint evolved from having a single insertion of the lateral meniscus on the tibia to a double one. While Australopithecus afarensis exhibits a single insertion, early Homo clearly exhibits a double insertion of the lateral meniscus on the tibia. The double insertion restricts the mobility of the meniscus on the tibial plateau, indicating a habitual practice of full extension movements of the knee joint. Among modern humans, the posterior insertion of the lateral meniscus appears early in fetal life. Consequently in early Homo, this new selected feature developed directly as a result of a genomic change. The derived shape of human distal femoral epiphysis includes a prominence of the lateral lip of the femoral trochlea, an elliptical profile of the lateral condyle, and an anteroposterior lengthening of the epiphysis. Analysis of human fetal and neonatal distal epiphyses shows that the
Zelle, Boris A; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.
Softness, Kenneth A; Murray, Ryan S; Evans, Brian G
Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation (ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty (TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed. PMID:28251061
Graceffa, Angelo; Marcucci, Massimiliano; Baldini, Andrea
Many surgical techniques, correlated to different anatomical landmarks, have been proposed to allow a satisfactory rotational alignment of the tibial component in primary total knee arthroplasty (TKA). Unfortunately, an accurate landmark has not yet been established although many computer models using CT reconstructions and standard radiologic studies have been performed. In this review article, the authors propose a new anatomical rotational reference for a correct positioning of the tibial component during primary TKA; the authors compared the results of their studies with the current literature on rotational alignment references and previously proposed surgical techniques. The authors also analyzed the correlation between classic and newer tibial baseplate designs and different tibial rotational landmarks. PMID:26855939
Hall, Matthew J; Mandalia, Vipul I
Tibial tubercle osteotomy has a long history in the management of patella instability and patello-femoral arthritis. This review aims to provide a comprehensive review of the literature describing the biomechanics of the patello-femoral joint and the rationale behind the use of the tibial tubercle osteotomy in modern day practice. Several different tibial tubercle osteotomies are available and we aim to detail the concepts behind their use and the subsequent clinical results. With continued developments of chondrocyte implantation techniques, the potential to fill defects on the chondral surface of either the patella or trochlea in conjunction with a tibial tubercle osteotomy may well become more commonplace in a group that is commonly young and difficult to manage. Level of evidence III.
Venesky, Kandy; Docherty, Carrie L; Dapena, Jesus; Schrader, John
Context: Although prophylactic ankle bracing has been shown to be effective in reducing the incidence of ankle sprains, how these ankle braces might affect the other joints of the lower extremity is not clearly understood. Objective: To determine the effects of a prophylactic ankle brace on knee joint varus-valgus and internal-external rotation torque during a drop landing onto a slanted surface. Design: A repeated-measures design. Setting: Biomechanics research laboratory. Patients or Other Participants: Twenty-four physically active college students. Intervention(s): Participants were tested in a brace and no-brace condition. Main Outcome Measure(s): We measured 3 dependent variables: (1) peak ankle inversion-eversion torque, (2) peak knee varus-valgus torque, and (3) peak knee internal-external rotation torque. A forceplate was used to collect ground reaction force data, and 6 motion analysis cameras collected kinematic data during the unilateral drop landing. An adjustable bar was hung from the ceiling, and a slant board was positioned over the center of the forceplate, so that the ankle of the participant's dominant leg would invert upon landing. Peak torque was measured in both the brace and no-brace conditions. The average of the peak values in 3 trials for both conditions was used for the statistical analysis. Results: Ankle eversion torque was significantly greater in the brace condition (F1,23 = 19.75, P < .01). Knee external rotation torque was significantly greater in the brace condition (F1,23 = 4.33,P < .05). Valgus knee torque was smaller in the brace condition, but the difference was not statistically significant (F1,23 = 3.45,P = .08). Conclusions: This study provides an important first step in understanding the effects of prophylactic ankle bracing on other joints of the lower extremity. We found that prophylactic ankle bracing did have an effect on knee torque when the subject was landing on a slanted surface. Specifically, knee external rotation
Suda, Daisuke; Ohazama, Atsushi; Maeda, Takeyasu; Kobayashi, Tadaharu
Mandibular distraction surgery is a critical treatment for jaw deformity. However, abnormal mandibular condylar bone resorption is often seen as complication after surgery. Our previous study using a rat mandibular distraction model suggested that overloading leads to mandibular condylar resorption. Host factors are also believed to influence the resorption. To understand the relationship between host factors and resorption, we investigated the effect of changing bone mass and architecture on the mandibular condyle using FK506. FK506, an immunosuppressant, was used to compromise bone mass and architecture in this study. Animals were divided into 4 groups: distraction surgery (Dist), FK506 administration (FK), distraction surgery with FK506 administration (FK + Dist), and no surgery or FK506 administration (Cont). The FK group showed reduced bone mass and impaired bone architecture. The Dist group exhibited abnormal bone resorption on the surface of the condyles, which was slightly exacerbated in the FK + Dist group. Bone defect length decreased over time as a result of bone apposition in the Dist group. However, in the FK + Dist group, the bone defect length remained the same. These results suggest that bone mass and architecture strongly affect the tolerance to the overloading and adaptation with bone apposition in condylar resorption site. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.
Han, Pei; Tan, Moyan; Zhang, Shaoxiang; Ji, Weiping; Li, Jianan; Zhang, Xiaonong; Zhao, Changli; Zheng, Yufeng; Chai, Yimin
A type of specially designed pin model of Mg-Zn alloy was implanted into the full thickness of lesions of New Zealand rabbits’ femoral condyles. The recovery progress, outer surface healing and in vivo degradation were characterized by various methods including radiographs, Micro-CT scan with surface rendering, SEM (scanning electron microscope) with EDX (Energy Dispersive X-ray analysis) and so on. The in vivo results suggested that a few but not sufficient bridges for holding force were formed between the bone and the implant if there was a preexisting gap between them. The rapid degradation of the implantation in the condyle would result in the appearance of cavities. Morphological evaluation of the specially designed pins indicated that the cusp was the most vulnerable part during degradation. Furthermore, different implantation sites with distinct components and biological functions can lead to different degradation rates of Mg-Zn alloy. The rate of Mg-Zn alloy decreases in the following order: implantation into soft tissue, less trabecular bone, more trabecular bone, and cortical bone. Because of the complexities of in vivo degradation, it is necessary for the design of biomedical Mg-Zn devices to take into consideration the implantation sites used in clinics. PMID:24566138
Touraine, Sébastien; Lagadec, Matthieu; Petrover, David; Genah, Idan; Parlier-Cuau, Caroline; Bousson, Valérie; Laredo, Jean-Denis
Intratendinous ganglia are rare. We report the case of a sedentary woman with chronic mechanical anterolateral pain of the knee and an extensive ganglion of the patellar tendon as indicated on magnetic resonance (MR) and ultrasound (US) examinations. There was evidence of a high-riding patella, patellar malalignment and patellar tendon-lateral femoral condyle friction syndrome with significantly close contact between the patellar tendon and the lateral facet of the femoral trochlea. The ultrasound-guided aspiration of the ganglion enabled a localized injection of an anti-inflammatory drug (cortivazol) and the cytopathological examination of the fluid, which confirmed the diagnosis. Clinical improvement was maintained with knee rehabilitation and was satisfactory at follow-up after 1 year. To our knowledge, we report the first case of a ganglion of the patellar tendon subsequent to patellar tendon-lateral femoral condyle friction syndrome. We found that this case was illustrative of mucoid degeneration in connective tissue due to chronic repetitive microtraumas. Additionally, this case provided the opportunity to discuss the management of this condition in a sedentary individual with a high-riding patella and patellar malalignment.
Fracture-dislocation of the humeral condyle is exceptional in adults. The purpose was to analyze the results of surgical treatment by open reduction and internal fixation without ligamentous repair. There were six men with an average age of 31 years. According to the AO classification, five fractures were classified as AO type B1 and one as B2. Dislocation was reduced in emergency before osteosynthesis. Postoperatively, the joint was held immobile with a brace for 25.40 days. Five patients were reviewed after a mean follow-up of 52.96 months. The median arc of flexion/extension was 104.80° and 157.8° for pronation-supination. All elbows were stable and all fractures were consolidated. Two elbows were painful. The results were satisfactory in five patients. The elbow stability can be ensured only by the synthesis of bone structures. Surgical treatment should restore exact anatomy between the condyle and trochlea. This protocol may provide a joint stability and satisfactory results.
Andrey, Véronique; Tercier, Stéphane; Vauclair, Frédéric; Bregou-Bourgeois, Aline; Lutz, Nicolas; Zambelli, Pierre-Yves
The aim of this study was to compare clinical and radiological outcome of lateral condyle fracture of the elbow in children treated with bioabsorbable or metallic material. From January 2008 to December 2009, 16 children with similar fractures and ages were grouped according to the fixation material used. Children were seen at 3, 6, and 12 months and more than 4 years (mean 51.8 months) postoperatively. The clinical results were compared using the Mayo Elbow Performance Score (MEPS). Radiographic studies of the fractured and opposite elbow were assessed at last follow-up control. Twelve children had a sufficient followup and could be included in the study. Seven could be included in the traditional group and 5 in the bioabsorbable group. At 12 months, the MEPS was 100 for every child in both groups. Asymptomatic bony radiolucent visible tracks and heterotopic ossifications were noted in both groups. There were no significant differences in terms of clinical and radiological outcome between the two groups. The use of bioabsorbable pins or screws is a reasonable alternative to the traditional use of metallic materials for the treatment of lateral condyle fracture of the elbow in children.
Bibb, C A; Pullinger, A G; Baldioceda, F
Histological variation was studied in serial sections, in contrast to previous studies which have generalized from representative sections. The sample consisted of consecutive serial sagittal sections from the central third of nine condyles, plus an accompanying stone cast showing the intact articular surface before sectioning. The thickness of the articular soft tissue and its fibrous connective tissue and cartilage components was measured, and the presence of undifferentiated mesenchymal (UM) cells was assessed by low-power light microscopy. Components of variance analysis showed that section-to-section variation in thickness was of the same order as differences between joints, each explaining approx. 50% of the variance in both connective tissue and cartilage thickness. The fibrous connective tissue contributed as much to the overall variation in soft tissue thickness as did the cartilage component (SD 0.0946 versus 0.0909 mm for the superior sector). Serial UM cell variability was common, and the UM cells were often distributed in islands rather than uniformly across the articular tissue. Condyles with the greatest surface irregularity were characterized by greater serial variability in fibrous connective tissue thickness, more frequent absence of cartilage, and more areas of UM cell depletion. These results suggest that serial variation in histological character may be more important than mean values in the description of surface contours and articular tissue relations in the temporomandibular joint. This should influence the design of future investigations.
Giesen, E B W; Ding, M; Dalstra, M; van Eijden, T M G J
As several morphological parameters of cancellous bone express more or less the same architectural measure, we applied principal components analysis to group these measures and correlated these to the mechanical properties. Cylindrical specimens (n = 24) were obtained in different orientations from embalmed mandibular condyles; the angle of the first principal direction and the axis of the specimen, expressing the orientation of the trabeculae, ranged from 10 degrees to 87 degrees. Morphological parameters were determined by a method based on Archimedes' principle and by micro-CT scanning, and the mechanical properties were obtained by mechanical testing. The principal components analysis was used to obtain a set of independent components to describe the morphology. This set was entered into linear regression analyses for explaining the variance in mechanical properties. The principal components analysis revealed four components: amount of bone, number of trabeculae, trabecular orientation, and miscellaneous. They accounted for about 90% of the variance in the morphological variables. The component loadings indicated that a higher amount of bone was primarily associated with more plate-like trabeculae, and not with more or thicker trabeculae. The trabecular orientation was most determinative (about 50%) in explaining stiffness, strength, and failure energy. The amount of bone was second most determinative and increased the explained variance to about 72%. These results suggest that trabecular orientation and amount of bone are important in explaining the anisotropic mechanical properties of the cancellous bone of the mandibular condyle.
Struewer, Johannes; Kiriazidis, Ilias; Figiel, Jens; Dukatz, Thomas; Frangen, Thomas; Ziring, Ewgeni
Dislocation of the mandibular condyle into the middle cranial fossa is a rare complication of mandibular trauma due to anatomical and biomechanical factors. Owing to the proximity of the temporal glenoid fossa to the middle meningeal artery, there is the risk of serious sequelae in case of trauma. The authors report the case of a 36-year-old male patient, who was beaten up in a family dispute and presented with complex mandibular and maxillofacial fractures, including mandibular condyle intrusion into the middle cranial fossa causing extensive meningeal bleeding. The patient underwent immediate surgery, with evacuation of the epidural haematoma via a temporal approach. In addition open reduction and reconstruction of the temporal glenoid fossa via anatomic reduction of the fragments was performed. A functional occlusion was re-established via miniplate reconstruction of the complex mandibular body and ramus fractures. Prompt diagnosis and a multidisciplinary approach are essential to minimize the complications. Advanced imaging modalities of computed tomography are indicated. Treatment options should be individualized in particular in case of suspected neurological injury.
Guzzini, Matteo; Guidi, Marco; Civitenga, Carolina; Ferri, Germano; Ferretti, Andrea
Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion. PMID:27064589
Matthys, Tori; Ho Dang, Hong An; Rafferty, Katherine L.; Herring, Susan W.
Introduction Temporary paralysis of the masseter muscle using botulinum toxin is a common treatment for temporomandibular disorders, bruxism, and muscle hypertrophy. Loss of masseter force is associated with decreased mandibular mineral density. Our objectives were (1) to establish whether bone loss at the mandibular condyle is regionally specific, and (2) to ascertain whether the treatment affects the condylar cartilage. Methods Young adult female rabbits received a unilateral masseter injection of botulinum neurotoxin serotype A (BoNT/A, n=31), saline (n=19) or no injection (n=3) and were also injected with bromodeoxyuridine (BrdU), a replication marker. Termination occurred 4 or 12 weeks following treatment. Condyles were processed by paraffin histology. Cortical thickness, cartilage thickness and trabecular bone areal density were measured, and replicating cells were counted after BrdU reaction. Results BoNT/A rabbits exhibited a high frequency of defects in the condylar bone surface, occurring equally on injected and uninjected sides. Bone loss was seen only on the side of the BoNT/A injection. Cortical as well as trabecular bone was severely affected. The midcondylar region lost the most bone. Recovery at 12 weeks was insignificant. Condylar cartilage thickness showed no treatment effect but did increase with time. Numbers of proliferating cells were similar in treatment groups, but BoNT/A animals showed more side asymmetry in association with the condylar defects. Conclusion Bone loss may be a risk factor for the use of botulinum toxin in jaw muscles. PMID:26672706
Teng, P S P; Kong, P W; Leong, K F
Non-contact anterior cruciate ligament (ACL) injuries commonly occur when athletes land in high risk positions such as knee valgus. The position of the foot at landing may influence the transmission of forces from the ankle to the knee. Using an experimental approach to manipulate foot rotation positions, this study aimed to provide new insights on how knee valgus during single-leg landing may be influenced by foot positions. Eleven male recreational basketball players performed single-leg drop landings from a 30-cm high platform in three foot rotation positions (toe-in, toe-forward and toe-out) at initial contact. A motion capture system and a force plate were used to measure lower extremity kinematics and kinetics. Knee valgus angles at initial contact (KVA) and maximum knee valgus moments (KVM), which were known risk factors associated with ACL injury, were measured. A one-way repeated measures Analysis of Variance was conducted (α=0.05) to compare among the three foot positions. Foot rotation positions were found to have a significant effect on KVA (p<0.001, η(2)=0.66) but the difference between conditions (about 1°) was small and not clinically meaningful. There was a significant effect of foot position on KVM (p<0.001, η(2)=0.55), with increased moment observed in the toe-out position as compared to toe-forward (p=0.012) or toe-in positions (p=0.002). When landing with one leg, athletes should avoid extreme toe-out foot rotation positions to minimise undesirable knee valgus loading associated with non-contact ACL injury risks. Copyright © 2017 Elsevier B.V. All rights reserved.
Roddy, Edward; Marshall, Michelle; Thomas, Martin J.; Rathod, Trishna; Peat, George M.; Croft, Peter R.
Background: Foot problems are prevalent in older women and are thought to be associated with footwear. This study examined women’s shoe wearing patterns over time and evaluated associations between footwear characteristics and foot pain and hallux valgus. Methods: Women aged 50–89 years (n = 2,627) completed a survey that included drawings of four toe-box shapes and four heel heights. For each life decade, participants indicated which footwear style they wore most of the time. Foot pain in the past 12 months and hallux valgus were documented by self-report. Logistic regression examined associations between heel height, toe-box shape, foot pain and hallux valgus. Results: Wearing shoes with a high heel and very narrow toe box between the ages of 20 and 29 was common, but decreased to less than 10% by the age of 40. Compared with women who had worn shoes with a very wide toe box, the likelihood of hallux valgus increased in those who had worn shoes with a wide (odds ratio [OR] 1.96, 95% CI 1.03–3.71), narrow (2.39, 1.29–4.42) and very narrow (2.70, 1.46–5.00) toe box between the ages of 20 and 29 and those who wore shoes with a very narrow toe box (1.93, 1.10–3.39) between the ages of 30 and 39. Conclusions: Women wear shoes with a lower heel and broader toe box as they age. Wearing constrictive footwear between the ages of 20 and 39 may be critical for developing hallux valgus in later life. PMID:26834078
Background and purpose Bilateral tibial lengthening has become one of the standard treatments for upper segment-lower segment disproportion and to improve quality of life in achondroplasia. We determined the effect of tibial lengthening on the tibial physis and compared tibial growth that occurred at the physis with that in non-operated patients with acondroplasia. Methods We performed a retrospective analysis of serial radiographs until skeletal maturity in 23 achondroplasia patients who underwent bilateral tibial lengthening before skeletal maturity (lengthening group L) and 12 achondroplasia patients of similar height and age who did not undergo tibial lengthening (control group C). The mean amount of lengthening of tibia in group L was 9.2 cm (lengthening percentage: 60%) and the mean age at the time of lengthening was 8.2 years. The mean duration of follow-up was 9.8 years. Results Skeletal maturity (fusion of physis) occurred at 15.2 years in group L and at 16.0 years in group C. The actual length of tibia (without distraction) at skeletal maturity was 238 mm in group L and 277 mm in group C (p = 0.03). The mean growth rates showed a decrease in group L relative to group C from about 2 years after surgery. Physeal closure was most pronounced on the anterolateral proximal tibial physis, with relative preservation of the distal physis. Interpretation Our findings indicate that physeal growth rate can be disturbed after tibial lengthening in achondroplasia, and a close watch should be kept for such an occurrence—especially when lengthening of more than 50% is attempted. PMID:22489887
observed in 5% of children with neurofibromatosis type 1 ( NF1 ), typically identified in infancy. The majority of NF1 individuals with tibial bowing...will sustain a fracture that will not heal (i.e. pseudarthrosis) resulting in multiple surgeries, poor limb function, and amputation. Some NF1 ...pseudarthrosis and better understand its pathophysiology. We have begun recruitment and assessed many individuals with NF1 with and with tibial bowing. QUS
Matoković, Damir; Šimić-Klarić, Andrea; Rajić, Marijana Tomić; Crnković, Helena Tesari; Jurinić, Mislav; Jovanović, Savo
Tibial tuberosity fractures are rare in childhood, most frequently due to excessive quadriceps muscle contraction. On performing long jump, a 15-year-old boy sustained tibial tuberosity avulsion fracture type II according to Watson-Jones. The patient was treated operatively with fragment repositioning and screw fixation. Ten months after the injury and rehabilitation, he resumed his sports activities with full range knee motion.
anterolateral bowing of the lower leg prior to fracture in neurofibromatosis type 1. J Pediatr Orthop 2009;29:385-92. 3. Stevenson DA, Yan J, He Y, Li H...neurofibromatosis type 1 (NF1), typically identified in infancy. The majority of NF1 individuals with tibial bowing will sustain a fracture that will not...not fracture and the bowing improves over time. Clinical predictors to help drive management are lacking, and the pathophysiology of tibial bowing
Mubarak, S J; Gould, R N; Lee, Y F; Schmidt, D A; Hargens, A R
The medial tibial stress syndrome is a symptom complex seen in athletes who complain of exercise-induced pain along the distal posterior-medial aspect of the tibia. Intramuscular pressures within the posterior compartments of the leg were measured in 12 patients with this disorder. These pressures were not elevated and therefore this syndrome is a not a compartment syndrome. Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.
Silva, Alcindo; Sampaio, Ricardo; Pinto, Elisabete
To compare the femoral and tibial components rotational alignment in total knee arthroplasty (TKA) performed either with conventional or with patient-specific instrumentation. Forty-five patients underwent primary TKA and were prospectively randomized into two groups: 22 patients into the conventional instrumentation group (group A) and 23 patients into the Signature™ patient-specific instrumentation group (group B). All patients underwent computed tomography of the operated knee in the first week after surgery to measure the components rotation. The femoral component rotation was 0.0° (-0.25, 1.0) in group A, and 0.0° (0.0, 1.0) in group B. The tibial component rotation was -16.0° (-18.5, 11.8) in group A, and -16.0° (-19.0, -14.0) in group B. There were no significant differences between the two groups in tibial and femoral components rotation. The difference between the tibial component rotation and the neutral tibial rotation was similar in both groups [2.0° (-0.5, 6.3) in group A and 2.0° (-1.0, 4.0) in group B], but the dispersion around the median was different between the two groups. The amplitude of the difference between tibial rotation and neutral position was 27° (-13, 14) in group A and 9° (-3, 6) in group B. There is a smaller chance of internal malrotation of the tibial component with the Signature™ patient-specific instrumentation system, with less dispersion and amplitude of the tibial component rotation around the neutral position. II.
Hiraba, K; Hibino, K; Hiranuma, K; Negoro, T
Electromyographic (EMG) activities of the superior (SUP) and inferior heads (INF) of the lateral pterygoid muscle (LPT) were recorded in humans during voluntary stepwise changes in biting force and jaw position that were adopted to exclude the effects of acceleration and velocity of jaw movements on the muscle activity. The SUP behaved like a jaw-closing muscle and showed characteristic activity in relation to the biting force. It showed a considerable amount of background activity (5-32% of the maximum) even in the intercuspal position without teeth clenching and reached a nearly maximum activity at relatively lower biting-force levels than the jaw-closing muscles during increment of the biting force. Stretch reflexes were found in the SUP, the function of which could be to stabilize the condyle against the biting force that pulls the condyle posteriorly. This notion was verified by examining the biomechanics on the temporomandibular joint. The complex movements of the mandibular condyle in a sagittal plane were decomposed into displacement in the anteroposterior direction (Ac) and angle of rotation (RAc) around a kinesiological specific point on the condyle. In relation to Ac, each head of the LPT showed quite a similar behavior to each other in all types of jaw movements across all subjects. Working ranges of the muscle activities were almost constant (Ac <3 mm for the SUP and Ac >3 mm for the INF). The amount of EMG activity of the SUP changed in inverse proportion to Ac showing a hyperbola-like relation, whereas that of the INF changed rather linearly. The EMG amplitude of the SUP showed a quasilinear inverse relation with RAc in the hinge movement during which the condyle rotated with no movement in the anteroposterior direction. This finding suggests that the SUP controls the angular relationship between the articular disk and the condyle. On the other hand, the position of the disk in relation to the maxilla, not to the condyle, is controlled indirectly by
Milgrom, Charles; Burr, David B; Finestone, Aharon S; Voloshin, Arkady
Previous human in vivo tibial strain measurements from surface strain gauges during vigorous activities were found to be below the threshold value of repetitive cyclical loading at 2500 microstrain in tension necessary to reduce the fatigue life of bone, based on ex vivo studies. Therefore it has been hypothesized that an intermediate bone remodeling response might play a role in the development of tibial stress fractures. In young adults tibial stress fractures are usually oblique, suggesting that they are the result of failure under shear strain. Strains were measured using surface mounted unstacked 45° rosette strain gauges on the posterior aspect of the flat medial cortex just below the tibial midshaft, in a 48year old male subject while performing vertical jumps, staircase jumps and running up and down stadium stairs. Shear strains approaching 5000 microstrain were recorded during stair jumping and vertical standing jumps. Shear strains above 1250 microstrain were recorded during runs up and down stadium steps. Based on predictions from ex vivo studies, stair and vertical jumping tibial shear strain in the test subject was high enough to potentially produce tibial stress fracture subsequent to repetitive cyclic loading without necessarily requiring an intermediate remodeling response to microdamage.
Chaudhary, M E; Walker, P S
Tibial component loosening is an important failure mode in unicompartmental knee arthroplasty (UKA) which may be due to the 6-8 mm of bone resection required. To address component loosening and fixation, a new early intervention (EI) design is proposed which reverses the traditional material scheme between femoral and tibial components. The EI design consists of a plastic inlay for the distal femur and a thin metal plate for the proximal tibia. With this reversed materials scheme, the EI design requires minimal tibial bone resection compared with traditional UKA. This study investigated, by means of finite element (FE) simulations, the advantages of a thin metal tibial component compared with traditional UKA tibial components, such as an all-plastic inlay or a metal-backed onlay. We hypothesized that an EI tibial component would produce comparable stress, strain, and strain energy density (SED) characteristics to an intact knee and more favorable values than UKA components, due primarily to the preservation of dense cancellous bone near the surface. Indeed, FE results showed that stresses in the supporting bone for an EI design were close to intact, while stresses, strains, and strain energy densities were reduced compared with an all-plastic UKA component. Analyzed parameters were similar for an EI and a metal-backed onlay, but the EI component had the advantage of minimal resection of the stiffest bone.
Silva, Carlos Francisco Bittencourt; Camara, Eduardo Kastrup Bittencourt; Vieira, Luiz Antonio; Adolphsson, Fernando; Rodarte, Rodrigo Ribeiro Pinho
Objective: To radiographically evaluate individuals who underwent opening wedge proximal tibial osteotomy, with the aim of analyzing the proximal tibial slope in the frontal and sagittal planes, and the patellar height. Method: The study included 22 individuals who were operated at the National Traumatology and Orthopedics Institute (INTO) for correction of varus angular tibial deviation using the opening wedge osteotomy (OWO) technique with the Orthofix monolateral external fixator. Patients with OWO whose treatment was completed between January 2000 and December 2006 were analyzed. The measurement technique consisted of using anteroposterior radiographs with loading and lateral views with the operated knees flexed at 30°. Results: There were no statistically significant differences between the pre and postoperative tibial slope and patellar height values in the patients evaluated. Conclusion: Opening wedge proximal tibial osteotomy is a technique that avoids the problems presented by high proximal tibial osteotomy, since it is done without causing changes to the extensor mechanism, ligament imbalance or distortions in the proximal tibia. PMID:27022577
Soulier, Robert; Fallat, Lawrence
Pediatric distal tibial fractures generally occur without significant long-term sequelae, and patients are commonly able to return to their preinjury activities after proper management. The literature reports excellent outcomes after anatomical reduction of distal tibial and ankle physeal fractures with closed or open treatment. Treatment options include simple immobilization of nondisplaced fractures, and closed or open reduction for restoration of anatomic alignment of displaced fractures. Soft tissue interposition within the fracture can threaten successful closed reduction, and may warrant open management if closed reduction fails to produce a satisfactory result. Despite the documented possibility of soft tissue interposition preventing closed reduction of pediatric ankle fractures, there is a paucity of literature reporting this complication. We report a unique case of an irreducible Salter-Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon. Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Julian, R. J.
A lateral or medial angulation of the shaft of the distal tibiotarsal bone resulting in deviation of the lower part of the leg and frequently with bending of the proximal shaft of the tarsometatarsus is the most common leg deformity in broiler chickens. This lateral or medial deviation of the legs in broiler chickens, which has been described by many workers, deserves a specific name such as angular bone deformity or valgus-varus deformity of intertarsal joint, so that it may be separated from other varieties of lameness in broilers. ImagesFigure 1.Figure 2A.Figure 2B.Figure 3.Figure 4.Figures 5A and 5B.Figures 5A and 5B.Figures 6A and 6B.Figures 6A and 6B.Figures 7A and 7B.Figures 7A and 7B.Figure 8. PMID:17422417
Bell, Katherine M; van Zyl, Malan; Ugarte, Claudia E; Hartman, Angela
Four hand-reared cheetah cubs (Acinonyx jubatus) exhibited progressively severe bilateral valgus deformity of the carpi (CV) during the weaning period. Radiographs of the thoracic limbs suggested normal bone ossification, and serum chemistry was unremarkable. All affected cubs developed CV shortly after the onset of gastroenteritis, which was treated medically, and included use of a prescription diet. A sudden decrease in growth rate was associated with gastrointestinal disease. Before gastroenteritis and CV, affected cubs had higher growth rates than unaffected cubs, despite similar mean daily energy intake. Return to normal thoracic limb conformation was consequent to dietary manipulation (including a reduction in energy intake and vitamin and mineral supplementation), as well as decreased growth rates and recovery from gastroenteritis. The cause of the CV is likely to have been multi-factorial with potentially complex physiological interactions involved. © 2010 Wiley-Liss, Inc.
Smith, Kathryn E.; Dupont, Kenneth M.; Safranski, David L.; Blair, Jeremy; Buratti, Dawn; Zeetser, Vladimir; Callahan, Ryan; Lin, Jason; Gall, Ken
Three-dimensional (3-D) printing offers many potential advantages in designing and manufacturing plating systems for foot and ankle procedures that involve small, geometrically complex bony anatomy. Here, we describe the design and clinical use of a Ti-6Al-4V ELI bone plate (FastForward™ Bone Tether Plate, MedShape, Inc., Atlanta, GA) manufactured through 3-D printing processes. The plate protects the second metatarsal when tethering suture tape between the first and second metatarsals and is a part of a new procedure that corrects hallux valgus (bunion) deformities without relying on doing an osteotomy or fusion procedure. The surgical technique and two clinical cases describing the use of this procedure with the 3-D printed bone plate are presented within. PMID:28337049
Xarchas, Konstantinos C; Mavrolias, Dimitrios; Kyriakopoulos, Georgios
We introduce a new set of modifications and present the results from 48 patients (a total of 60 feet operated), who underwent this modified Wilson’s osteotomy for the correction of Hallux Valgus. Patients were of an average age of 52 years old (from 21 to 75 years of age) and were followed up for a mean of 12 months post-operatively. Patient evaluation was made with the symptom scoring system as presented by Kataraglis et al., with the final outcome being satisfactory in all of the cases. This set of modifications introduced to the original Wilson’s osteotomy, proved to offer a stable, predictable and satisfactory outcome in all cases and we strongly recommend it. PMID:25352929
Inderhaug, Eivind; Raknes, Sveinung; Østvold, Thomas; Solheim, Eirik; Strand, Torbjørn
To map knee morphology radiographically in a population with a torn ACL and to investigate whether anatomic factors could be related to outcomes after ACL reconstruction at mid- to long-term follow-up. Further, we wanted to assess tibial tunnel placement after using the 70-degree "anti-impingement" tibial tunnel guide and investigate any relation between tunnel placement and revision surgery. Patients undergoing ACL reconstruction involving the 70-degree tibial guide from 2003 to 2008 were included. Two independent investigators analysed pre- and post-operative radiographs. Demographic data and information on revision surgery were collected from an internal database. Anatomic factors and post-operative tibial tunnel placements were investigated as predictors of revision. Three-hundred and seventy-seven patients were included in the study. A large anatomic variation with significant differences between men and women was seen. None of the anatomic factors could be related to a significant increase in revision rate. Patients with a posterior tibial tunnel placement, defined as 50 % or more posterior on the Amis and Jakob line, did, however, have a higher risk of revision surgery compared to patients with an anterior tunnel placement (P = 0.03). Use of the 70-degree tibial guide did result in a high incidence (47 %) of posterior tibial tunnel placements associated with an increased rate of revision surgery. The current study was, however, not able to identify any anatomic variation that could be related to a higher risk of revision surgery. Avoiding graft impingement from the femoral roof in anterior tibial tunnel placements is important, but the insight that overly posterior tunnel placement can lead to inferior outcome should also be kept in mind when performing ACL surgery. IV.
Thorning, Maria; Thorlund, Jonas B; Roos, Ewa M; Wrigley, Tim V; Hall, Michelle
Patients undergoing medial arthroscopic partial meniscectomy are at increased risk of developing and/or progressing knee osteoarthritis, with increased medial compartment load being a potential contributor. The aim of this study was to evaluate the immediate effect of a valgus unloader knee brace on knee joint moments in patients following medial arthroscopic partial meniscectomy. Within-participant design. Twenty-two patients (age 35-55 years) who had undergone medial arthroscopic partial meniscectomy within the previous 8-15 months completed three-dimensional analysis of gait, forward lunge and one-leg rise during two conditions: with and without a valgus unloader knee brace. Outcome measures included the peak and impulse of the knee adduction moment and the peak knee flexion moment. The peak knee flexion moment increased during brace condition for forward lunge (mean difference [95% CI]) 0.54 [0.27-0.82] (Nm/(BW×HT)%), p<0.001 and one-leg rise (mean difference 0.45 [95% CI 0.08-0.82] (Nm/(BW×HT)%), p=0.022). No other significant differences were found between conditions in any of the included tasks. A significant effect of the knee brace was detected in terms of an increase in peak knee flexion moment during the more demanding tasks such as forward lunge and one-leg rise. This increase implies enhanced stability of the knee provided by the brace, which may induce increased knee function and knee-related confidence during strenuous tasks. Future research is required to explore the structural implications. Copyright Â© 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Gur, Gozde; Ozkal, Ozden; Dilek, Burcu; Aksoy, Songul; Bek, Nilgun; Yakut, Yavuz
Taping is an effective temporary therapy for improving hallux valgus (HV) in adults. Although HV has been demonstrated to impair postural balance, there is a lack of information about how corrective taping affects balance and gait patterns in adults with HV deformity. Eighteen middle-aged female patients (average age, 53.5 years) with HV were included. Corrective tape was applied to correct HV angulation. A series of balance and gait stability tests were performed before applying tape and 1 hour after the tape was applied with a Balance Master computerized posturography device. The study involved the following tests: modified clinical test of sensory interaction and balance (mCTSIB), unilateral stance (US), limit of stability (LoS), step up/over (SUO), and walk across (WA) tests. No significant difference was found between the no-tape and taped condition in the static balance mCTSIB and US tests ( P > .05). The taping intervention resulted in significant improvement in the dynamic balance measures for the LoS test's backward reaction time and left maximum excursion ( P < .05), a significantly higher impact index bilaterally in the SUO assessment ( P < .05), and an increase in step width mean and variability in the WA test ( P < .05). Taping for correcting HV angulation had negative acute effects on dynamic balance in the SUO and WA tests and positive effects in the LoS test. Corrective taping, although a form of conservative treatment for hallux valgus, has been insufficiently studied in terms of effects on balance. Our results show that taping, as an acute effect, may impair balance in middle-aged adults when walking or ascending and descending stairs.
Seo, Jeong-Ho; Boedijono, Dimas
Purpose The aim of this study was to investigate new point-connecting measurements for the hallux valgus angle (HVA) and the first intermetatarsal angle (IMA), which can reflect the degree of subluxation of the first metatarsophalangeal joint (MTPJ). Also, this study attempted to compare the validity of midline measurements and the new point-connecting measurements for the determination of HVA and IMA values. Materials and Methods Sixty feet of hallux valgus patients who underwent surgery between 2007 and 2011 were classified in terms of the severity of HVA, congruency of the first MTPJ, and type of chevron metatarsal osteotomy. On weight-bearing dorsal-plantar radiographs, HVA and IMA values were measured and compared preoperatively and postoperatively using both the conventional and new methods. Results Compared with midline measurements, point-connecting measurements showed higher inter- and intra-observer reliability for preoperative HVA/IMA and similar or higher inter- and intra-observer reliability for postoperative HVA/IMA. Patients who underwent distal chevron metatarsal osteotomy (DCMO) had higher intraclass correlation coefficient for inter- and intra-observer reliability for pre- and post-operative HVA and IMA measured by the point-connecting method compared with the midline method. All differences in the preoperative HVAs and IMAs determined by both the midline method and point-connecting methods were significant between the deviated group and subluxated groups (p=0.001). Conclusion The point-connecting method for measuring HVA and IMA in the subluxated first MTPJ may better reflect the severity of a HV deformity with higher reliability than the midline method, and is more useful in patients with DCMO than in patients with proximal chevron metatarsal osteotomy. PMID:26996576
Bek, Nilgün; Coşkun, Gürsoy; Kınıklı, Gizem İrem; Karahan, Sevilay
The aim of this study was to develop a disease-specific multidimensional hallux valgus (HV) scale, as well as to establish the validity and reliability thereof. The 14-item Multidimensional Nil Hallux Valgus Scale was developed. The scale has a score range of 0-60, with higher score indicating increased HV symptoms, complaints, and functional disorder. Among the patients referred to our clinic with HV diagnosis based on anterior-posterior non-weight-bearing radiography of the affected foot, 129 feet of 66 patients (63 bilateral, 3 unilateral) were included in the study. In clinical evaluations of these HV patients, American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal Joints Scale (AOFAS-MTF-IF), Manchester Scale, and Short Form 36 Health Survey (SF-36) were used to test the validity and reliability of the new scale. From factor analyses, it was observed that the items clustered in 5 factors, which explained 73.2% of the variance. Floor and ceiling effects were observed to be within normal limits (floor effect: 3.1%; ceiling effect: 0.8%). The Cronbach's alpha level related with the overall internal consistency of the scale was estimated as 83.3%, and the Cronbach's alpha for the subheadings of the scale varied between 33.9% and 74.2%. High correlation was observed regarding test-retest reliability of the scale. This newly developed scale allows for the holistic evaluation of HV including the condition-specific parameters and is a valid and reliable scale that can be conveniently used by health care professionals.
Lee, Kyoung Min; Kang, Jong Yeol; Chung, Chin Youb; Kwon, Dae Gyu; Lee, Sang Hyeong; Choi, In Ho; Cho, Tae-Joon; Yoo, Won Joon; Park, Moon Seok
Proximal femoral deformity related to physis has not been studied in patients with cerebral palsy (CP). This study was performed to investigate the clinical relevance of neck shaft angle (NSA), head shaft angle (HSA), and proximal femoral epiphyseal shape in patients with CP, which represent the deformities of metaphysis, physis, and epiphysis, respectively. Three hundred eighty-four patients with CP (mean age 9.1 y, 249 males and 135 females) were included. Extent of involvement and functional states [Gross Motor Function Classification System (GMFCS) level] were obtained. Radiographic measurements including NSA, HSA, and qualitative shape of the proximal femoral epiphysis were evaluated and analyzed according to extent of involvement and GMFCS level. Reliability and correlation with each measurement were assessed. Multiple regression test was performed to examine the significant contributing factors to migration percentage (MP) that represents hip instability. NSA showed excellent interobserver reliability with intraclass correlation coefficients of 0.976. Correlation with the MP was higher in the NSA (r=0.419, P<0.001) than in the HSA (r=0.256, P<0.001). NSA, HSA, and MP tended to increase with increasing GMFCS level, and proportion of valgus deformed proximal femoral epiphysis also increased with increasing GMFCS level, which means valgus deformity and unstable hips in the less favorable functional states. Multiple regression analysis revealed NSA, GMFCS level, and shape of the proximal femoral epiphysis to be significant factors affecting MP. NSA appeared to be more clinically relevant than HSA in evaluating proximal femoral deformity in patients with CP. Shape of proximal femoral epiphysis is believed to have clinical implications in terms of hip instability. Diagnostic level II.
Martinez de Albornoz, Pilar; Leyes, Manuel; Forriol, Francisco; Del Buono, Angelo; Maffulli, Nicola
To ascertain whether changing position and size of the spacer may modify the load and displacement of the tibial plateau when performing an opening wedge high tibial osteotomy. Fifteen sawbones tibia models were used. In the axial plane, the anterior, medial, and posterior thirds of the tibial plateau were marked, and the medial and posterior thirds were called "point 1" and "point 2", respectively. A 7.5-mm-stainless steel indenter was used to apply the load over these two points: the load applied to point 1 simulated the load to that site when the knee was extended, and the load to point 2 simulated the load to the same area when the knee was flexed. Maximum load (N) and displacement (mm) were calculated. The system was shown to withstand higher loads with less displacement when the plate was posterior than it could do with the plate in the middle position. Significant differences were also found when comparing the anterior and middle position of the plate with the greatest displacement when the plate was anterior. The differences were increased when comparing the anterior and posterior positions of the plate. No statistical differences (n.s.) were found when using different spacers. The maximum stiffness was achieved if the plate was posterior and in point 1 indenter position, in which the force vector stands on the points of the lateral and medial supports (Fμ = 198.8 ± 61.5 N). The lowest stiffness was observed when the plate was anterior, and the force was applied to point 2 (Fμ = 29.7 ± 5.1 N). Application of the plate in a more posterior position provides greater stability.
Ponnada, Swaroopa Rani; Gaddam, Kranthi Praveen Raju; Perumalla, Kiran; Khan, Imran; Mohammed, Naqeed Abdul
Introduction The relationship of the condyle and the mandibular fossa differs in shape with type of malocclusion and skeletal pattern. A review of literature shows till date there are no studies on Temporomandibular Joint (TMJ) condyle-fossa relation to the type of malocclusion based on growth pattern. Computed Tomography (CT) provides optimal imaging of the osseous components of the TMJ. Aim The purpose of this study was to investigate the condyle-fossa relationship and the dimensional and positional symmetries between the right and left condyles in subjects with normal occlusion and malocclusion in different growth patterns utilizing the CT scans of the TMJ. Materials and Methods Sixty subjects with age group of 18-30 years were selected for the study. The sample was divided into three groups based on overbite and growth pattern. The groups included 20 subjects with normal occlusion and average growth pattern, 20 patients with horizontal growth pattern and deep bite, 20 patients with vertical growth pattern and deep bite. The depth of the mandibular fossa, the condyle-fossa relationship, and the concentric position of the condyles were evaluated by the images obtained from the sagittal slices. ANOVA was performed to assess the significance. If it was found significant, post-hoc Tukey’s test was performed to see which two groups were statistically significant. Results No statistically significant difference was found in the anterior joint space and the superior joint space in horizontal and vertical growers with deep bite. Statistically significant (p <0.05) posterior positioning of the condyles was observed (nonconcentric positioning) in vertical growers with deep bite. Conclusion There is a significant change in the position of the condyle in vertical growers compared to average and horizontal growers. Left condyle is more anteriorly placed than the right condyle in all the three groups. There is no significant change in the vertical depth of the mandibular
Bek, Doğan; Ege, Tolga; Yıldız, Cemil; Tunay, Servet; Başbozkurt, Mustafa
This study aims to evaluate the effectiveness of two different external tibial cutting guides with and without a spike anchoring to the intercondylar eminentia to achieve a desired posterior tibial slope. Between January 2008 and December 2011, 120 posterior cruciate ligament protecting total knee arthroplasty (TKA) surgeries of 83 patients in which two different external tibial cutting guides used were included. Fifty-nine knees were included into the spiked and 61 knees were included into the spikeless cutting guide group. Posterior tibial slope angles were measured using the postoperative X-rays. There was no significant difference between two groups in terms of age, sex, and body mass indexes (p<0.05). While the mean postoperative slope angle was 2.66°±2.001°(range 0°-7°) in spiked group, it was 2.46°±2.277° (range 0°-7°) in spikeless group. Both systems had identical accuracy, indicating a low rate. The comparison of variances of two groups showed that both cutting guides had similar precision (p=0.234). There was no effect of body mass index on the results in both groups. Although different extra-medullary tibial cutting guides with and without a spike can reproducibly impart a desired posterior tibial slope in TKA, we concluded that a spiked guide was considered user-friendly.
Crookshank, Meghan; Coquim, Jason; Olsen, Michael; Schemitsch, Emil H; Bougherara, Habiba; Zdero, Rad
Few studies have evaluated the 'bulk' mechanical properties of human longbones and even fewer have compared human tissue to the synthetic longbones increasingly being used by researchers. Distal femur fractures, for example, comprise about 6% of all femur fractures, but the mechanical properties of the distal condyles of intact human and synthetic femurs have not been well quantified in the literature. To this end, the distal portions of a series of 16 human fresh-frozen femurs and six synthetic femurs were prepared identically for mechanical testing. Using a flat metal plate, an axial 'crush' force was applied in-line with the long axis of the femurs. The two femur groups were statistically compared and values correlated to age, size, and bone quality. Results yielded the following: crush stiffness (human, 1545 +/- 728 N/mm; synthetic, 3063 +/- 1243 N/mm; p = 0.002); crush strength (human, 10.3 +/- 3.1 kN; synthetic, 12.9 < or = 1.7 kN; p = 0.074); crush displacement (human, 6.1 +/- 1.8 mm; synthetic, 2.8 +/- 0.3 mm; p = 0.000); and crush energy (human, 34.8 +/- 15.9J; synthetic, 18.1 +/- 5.7J; p = 0.023). For the human femurs, there were poor correlations between mechanical properties versus age, size, and bone quality (R2 < or = 0.18), with the exception of crush strength versus bone mineral density (R2 = 0.33) and T-score (R2 = 0.25). Human femurs failed mostly by condyle 'roll back' buckling (15 of 16 cases) and/or unicondylar or bicondylar fracture (7 of 16 cases), while synthetic femurs all failed by wedging apart of the condyles resulting in either fully or partially displaced condylar fractures (6 of 6 cases). These findings have practical implications on the use of a flat plate load applicator to reproduce real-life clinical failure modes of human femurs and the appropriate use of synthetic femurs. To the authors' knowledge, this is the first study to have done such an assessment on human and synthetic femurs.
Saravanos, D. A.; Mraz, P. J.; Davy, D. T.
NASA technology and optimal design methodologies originally developed for the optimization of composite structures (engine blades) are adapted and applied to the optimization of orthopaedic knee implants. A method is developed enabling the shape tailoring of the tibial components of a total knee replacement implant for optimal interaction within the environment of the tibia. The shape of the implant components are optimized such that the stresses in the bone are favorably controlled to minimize bone degradation, to improve the mechanical integrity of the implant/interface/bone system, and to prevent failures of the implant components. A pilot tailoring system is developed and the feasibility of the concept is demonstrated and evaluated. The methodology and evolution of the existing aerospace technology from which this pilot optimization code was developed is also presented and discussed. Both symmetric and unsymmetric in-plane loading conditions are investigated. The results of the optimization process indicate a trend toward wider and tapered posts as well as thicker backing trays. Unique component geometries were obtained for the different load cases.
Numata, Hitoaki; Nakase, Junsuke; Kitaoka, Katsuhiko; Shima, Yosuke; Oshima, Takeshi; Takata, Yasushi; Shimozaki, Kengo; Tsuchiya, Hiroyuki
Female athletes are at greater risk of non-contact ACL injury. Three-dimensional kinematic analyses have shown that at-risk female athletes have a greater knee valgus angle during drop jumping. The purpose of this study was to evaluate the relationship between knee valgus angle and non-contact ACL injury in young female athletes using coronal-plane two-dimensional (2D) kinematic analyses of single-leg landing. Two hundred ninety-one female high school athletes newly enrolled in basketball and handball clubs were assessed. Dynamic knee valgus was analysed during single-leg drop jumps using 2D coronal images at hallux-ground contact and at maximal knee valgus. All subjects were followed up for 3 years for ACL injury. Twenty-eight (9.6%) of 291 athletes had ACL rupture, including 27 non-contact ACL injuries. The injured group of 27 knees with non-contact ACL injury was compared with a control group of 27 randomly selected uninjured knees. The relationship between initial 2D movement analysis results and subsequent ACL injury was investigated. Dynamic knee valgus was significantly greater in the injured group compared to the control group at hallux-ground contact (2.1 ± 2.4 vs. 0.4 ± 2.2 cm, P = 0.006) and at maximal knee valgus (8.3 ± 4.3 vs. 5.1 ± 4.1 cm, P = 0.007). The results of this study confirm that dynamic knee valgus is a potential risk factor for non-contact ACL injury in female high school athletes. Fully understanding the risk factors that increase dynamic knee valgus will help in designing more appropriate training and interventional strategies to prevent injuries in at-risk athletes. Prognostic studies, Level II.
Investigating the relationship between internal tibial torsion and medial collateral ligament injury in patients undergoing knee arthroscopy due to tears in the posterior one third of the medial meniscus.
Guler, Olcay; Isyar, Mehmet; Karataş, Dilek; Ormeci, Tugrul; Cerci, Halis; Mahirogulları, Mahir
To evaluate the relationship between medial collateral ligament (MCL) injury and degree of internal tibial torsion in patients who had undergone arthroscopic resection due to tears in the posterior one third of the medial meniscus. Seventy-one patients were allocated into two groups with respect to foot femur angle (FFA) and transmalleolar angle (TMA) (Group 1 31 patients with FFA<8° and Group 2 40 patients with FFA≥8°). The groups were compared in terms of valgus instability, Lysholm score, magnetic resonance view, FFA, and TMA, both before and after the operation. Lysholm scores were higher in Group 2 at both postoperative week 1 (p<0.001) and month 1 (p=0.045) relative to Group 1. Preoperative cartilage injury was encountered more frequently in Group 1 (p=0.037) than in Group 2. MCL injury was detected more frequently in Group 1 compared to Group 2 postoperatively at week 1 (p=0.001). We conclude that FFA and TFA, indicators of internal tibial torsion, may serve as markers for foreseeing clinical improvement and complications following arthroscopic surgery. level III retrospective comparative study. Copyright © 2015 Elsevier B.V. All rights reserved.
Aquilina, Peter; Parr, William C H; Chamoli, Uphar; Wroe, Stephen
Various patterns of internal fixation of mandibular condyle fractures have been proposed in the literature. This study investigates the stability of two patient-specific implants (PSIs) for the open reduction and internal fixation of a subcondylar fracture of the mandible. A subcondylar fracture of a mandible was simulated by a series of finite element models. These models contained approximately 1.2 million elements, were heterogeneous in bone material properties, and also modeled the muscles of mastication. Models were run assuming linear elasticity and isotropic material properties for bone. The stability and von Mises stresses of the simulated condylar fracture reduced with each of the PSIs were compared. The most stable of the plate configurations examined was PSI 1, which had comparable mechanical performance to a single 2.0 mm straight four-hole plate.
Wassouf, A; Eyrich, G; Lebeda, R; Grätz, K W
Migration of dislocated lower third molar into the condylar region is quite rare. Attention should be taken to avoid condyle fracture. 49-year-old patient had an ectopic lower left third molal in the condylar region, suffered from a submandibular and masseter space abscess. Removal of the molar via intraoral approach was chosen avoiding facial nerve branches and unnecessary scar formation. Coronoid process is removed, the tooth is separated and removed. The defect is filled with iliac cancellous bone. The coronoid process was fixed as a cover with a resorbable plate and screws (BIONX). Removal via intraoral approach is possible. Hypesthesia existed postoperatively, became normal later. Annual observation is strongly recommended. Intraoral approach is superior to the extraoral approach. Removal of the coronoid process minimizes the masticator forces. Separation of the tooth is essential. Filling the defect with cancellous bone accelerates the healing.
Barna, M; Štulík, J; Kryl, J; Vyskočil, T; Nesnídal, P
The case of a 63-year-old man diagnosed with Collet-Sicard syndrome due to a fracture of the right occipital condyle is presented. The cause of injury was falling off a bicycle. Dysphonia and dysphagia were present from the moment of injury, with the gradual development of light atrophy of the tongue muscles and right trapezius muscle. The diagnosis was based on examination by CT and MRI methods, the act of swallowing and physical examination by an otorhinolaryngology specialist and a neurologist who confirmed the diagnosis of injury to cranial nerves IX, X and XI on the right side. The patient was treated conservatively with application of a Philadelphia collar. Dysphagia required PEG tube insertion. Skull fracture healing was evident on a CT scan at 3-month follow-up. However, dysphonia with dysphagia and muscle atrophy remained persistent.
Klasser, Gary D; Echandi, Luisana; Shannon, Michael
Metastatic tumor invasion of the condyle from the liver is rare. It is important for dental practitioners to differentiate tumor involvement from musculoskeletal disorders such as temporomandibular disorders. The authors present a case report of a patient with temporomandibular joint pain and dysfunction consistent with musculoskeletal disorders. Because of the patient's medical history, comprehensive examination results and findings of imaging studies performed, the dental practitioners referred him to other health care providers for further and more in-depth investigation. This resulted in the establishment of an accurate diagnosis, with treatment directed at the primary source. A thorough medical history, comprehensive clinical examination and adjunctive testing, when necessary, are paramount in establishing a definitive diagnosis for patients with orofacial pain, thereby enabling the delivery of appropriate treatment.
de Jesus, G P; Vaz, L G; Gabrielli, M F R; Passeri, L A; V Oliveira, T; Noritomi, P Y; Jürgens, P
The surgical treatment of mandibular condyle fractures currently offers several possibilities for stable internal fixation. In this study, a finite element model evaluation was performed of three different methods for osteosynthesis of low subcondylar fractures: (1) two four-hole straight plates, (2) one seven-hole lambda plate, and (3) one four-hole trapezoidal plate. The finite element model evaluation considered a load applied to the first molar on the contralateral side to the fracture. Results showed that, although the three methods are capable of withstanding functional loading, the lambda plate displayed a more homogeneous stress distribution for both osteosynthesis material and bone and may be a better method when single-plate fixation is the option.
Maheshwari, Jitendra; Mhaskar, Vikram; Mhaskar, Parul Maheshwari
We describe for the first time a case of lateral femoral condyle fracture following a fall in a 13-year-old child that was reduced arthroscopically using a probe. It was definitively fixed with 0 vicryl sutures in a cruciate pattern after being initially stabilised with 1.5-mm Kirschner wires. Four beath pins carrying sutures were drilled at four opposing quadrants through the reduced fragment into the femur. The sutures were then tied on the lateral cortex of the femur. After fixation, the child was kept non-weight bearing for 6 weeks, partial weight bearing from 6 weeks to 12 weeks and then full weight bearing thereafter. Range of motion (ROM) exercises were commenced on the first postoperative day. At one-year follow-up, the ROM was from −5° to 130°, all symptoms disappeared, and complete resumption of all sports activities was allowed. PMID:28231653
Maheshwari, Jitendra; Mhaskar, Vikram; Mhaskar, Parul Maheshwari
We describe for the first time a case of lateral femoral condyle fracture following a fall in a 13-year-old child that was reduced arthroscopically using a probe. It was definitively fixed with 0 vicryl sutures in a cruciate pattern after being initially stabilised with 1.5-mm Kirschner wires. Four beath pins carrying sutures were drilled at four opposing quadrants through the reduced fragment into the femur. The sutures were then tied on the lateral cortex of the femur. After fixation, the child was kept non-weight bearing for 6 weeks, partial weight bearing from 6 weeks to 12 weeks and then full weight bearing thereafter. Range of motion (ROM) exercises were commenced on the first postoperative day. At one-year follow-up, the ROM was from -5° to 130°, all symptoms disappeared, and complete resumption of all sports activities was allowed.
Aquilina, Peter; Parr, William C. H.; Chamoli, Uphar; Wroe, Stephen
Various patterns of internal fixation of mandibular condyle fractures have been proposed in the literature. This study investigates the stability of two patient-specific implants (PSIs) for the open reduction and internal fixation of a subcondylar fracture of the mandible. A subcondylar fracture of a mandible was simulated by a series of finite element models. These models contained approximately 1.2 million elements, were heterogeneous in bone material properties, and also modeled the muscles of mastication. Models were run assuming linear elasticity and isotropic material properties for bone. The stability and von Mises stresses of the simulated condylar fracture reduced with each of the PSIs were compared. The most stable of the plate configurations examined was PSI 1, which had comparable mechanical performance to a single 2.0 mm straight four-hole plate. PMID:26000081
Schlitz, Ryne S; Schwertz, Joseph M; Eberhardt, Alan W; Gilbert, Shawn R
Good outcomes have been described for pediatric lateral condyle fractures treated by open reduction and fixation using either screws or Kirschner wires (K-wires). No studies have compared the biomechanical properties of the 2 fixation methods. We hypothesized that screw fixation would be more biomechanically stable than K-wire fixation. Synthetic humerus models were used for biomechanical testing, following a previously published protocol. A miter saw was used to make an oblique cut to simulate a Milch type II fracture. Fractures were anatomically reduced and fixed with either 2 divergent 0.062-inch K-wires placed bicortically or a 4.0-mm lag screw placed obliquely (perpendicular to the fracture line). Specimens were then embedded in polymethyl methacrylate bone cement for testing. Mechanical testing using displacement control was performed applying compression or distraction from 0 to 1.5 mm at a rate of 0.5 mm/s for 10 cycles. The maximum force was calculated based on the maximum force averaged over the 10 cycles. Stiffness was calculated based on the slope of the force-displacement curve of the 10th cycle. A 2-sample t test was used to determine significant differences between the stiffness and maximum force comparing the K-wire and screw groups. A P-value of <0.05 was considered statistically significant. Stiffness and maximum force in tension testing were significantly greater with screw fixation compared with K-wire fixation. Testing in compression revealed statistically significant increased maximum force and a trend towards increased stiffness. Screw fixation in a synthetic bone model of pediatric lateral condyle fractures (Milch type II) provides increased biomechanical stability of the construct as compared with K-wires. If similar effects were seen in vivo, increased biomechanical stability with screw fixation could decrease the occurrence of complications such as loss of reduction and nonunion.
Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions. Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student' s t-test, with p < 0.05. All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8). With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.
A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.
Voudouris, John C; Woodside, Donald G; Altuna, Gurkan; Kuftinec, Mladen M; Angelopoulos, Gerassimos; Bourque, Paul J
Changes in the condyle, the glenoid fossa, and the muscles of mastication were investigated in subjects undergoing continuous orthopedic advancement of the mandible with a Herbst-block appliance. The total sample consisted of 56 subjects and included 15 nonhuman primates (in the middle mixed, early permanent, and permanent dentitions), 17 human Herbst patients in the early permanent dentition, and 24 human controls from the Burlington Growth Center. The 8 nonhuman primates in the middle mixed dentition were the focus of this study. Mandibular advancement was obtained progressively in 5 animals by adding stops to the telescopic arms of fixed functional Herbst appliances with occlusal coverage; activations of 5.0 mm, 7.0 mm, and 8.0 mm were achieved. Two primates served as controls, and the third was a sham control. Two experimental animals and the 2 controls also wore surgically implanted electromyographic electrodes in the superior and inferior heads of the lateral pterygoid muscles and in the superficial masseter and anterior digastric muscles. Changes in condylar growth direction and amount were assessed with the Björk method from measurements made on serial cephalometric tracings superimposed on metallic implants. Undecalcified sections, treated with intravenous tetracycline vital staining, were viewed with fluorescence microscopy to examine histologic changes in the condyle and the glenoid fossa. New bone formation in the fossa associated with continuous mandibular protrusion was quantified by using computerized histomorphometric analysis of decalcified histological sections and polarized light. The unique combination of permanently implanted electromyographic electrodes, tetracycline vital staining, and histomorphometry represents a significant technological advancement in methods and materials. Together, they demonstrated different muscle-bone interaction results for functional appliances than those reported in previous studies. In Part 1 of this study, we
Gali, Rajasekhar; Devireddy, Sathya Kumar; Venkata, Kishore Kumar Rayadurgam; Kanubaddy, Sridhar Reddy; Nemaly, Chaithanyaa; Dasari, Mallikarjuna
Introduction: Free grafting or extracorporeal fixation of traumatically displaced mandibular condyles is sometimes required in patients with severe anteromedial displacement of condylar head. Majority of the published studies report the use of a submandibular, retromandibular or preauricular incisions for the access which have demerits of limited visibility, access and potential to cause damage to facial nerve and other parotid gland related complications. Purpose: This retrospective clinical case record study was done to evaluate the preauricular transmasseteric anteroparotid (P-TMAP) approach for open reduction and extracorporeal fixation of displaced and dislocated high condylar fractures of the mandible. Patients and Methods: This retrospective study involved search of clinical case records of seven patients with displaced and dislocated high condylar fractures treated by open reduction and extracorporeal fixation over a 3-year period. The parameters assessed were as follows: a) the ease of access for retrieval, reimplantation and fixation of the proximal segment; b) the postoperative approach related complications; c) the adequacy of anatomical reduction and stability of fixation; d) the occlusal changes; and the e) TMJ function and radiological changes. Results: Accessibility and visibility were good. Accurate anatomical reduction and fixation were achieved in all the patients. The recorded complications were minimal and transient. Facial nerve (buccal branch) palsy was noted in one patient with spontaneous resolution within 3 months. No cases of sialocele or Frey's syndrome were seen. Conclusion: The P-TMAP approach provides good access for open reduction and extracorporeal fixation of severely displaced condylar fractures. It facilitates retrieval, transplantation, repositioning, fixing the condyle and also reduces the chances of requirement of a vertical ramus osteotomy. It gives straight-line access to condylar head and ramus thereby permitting
Dibbern, Kevin; Kempton, Laurence B; Higgins, Thomas F; Morshed, Saam; McKinley, Todd O; Marsh, J Lawrence; Anderson, Donald D
Patients with tibial pilon fractures have a higher incidence of post-traumatic osteoarthritis than those with fractures of the tibial plateau. This may indicate that pilon fractures present a greater mechanical insult to the joint than do plateau fractures. We tested the hypothesis that fracture energy and articular fracture edge length, two independent indicators of severity, are higher in pilon than plateau fractures. We also evaluated whether clinical fracture classification systems accurately reflect severity. Seventy-five tibial plateau fractures and 52 tibial pilon fractures from a multi-institutional study were selected to span the spectrum of severity. Fracture severity measures were calculated using objective CT-based image analysis methods. The ranges of fracture energies measured for tibial plateau and pilon fractures were 3.2-33.2 Joules (J) and 3.6-32.2 J, respectively, and articular fracture edge lengths were 68.0-493.0 mm and 56.1-288.6 mm, respectively. There were no differences in the fracture energies between the two fracture types, but plateau fractures had greater articular fracture edge lengths (p < 0.001). The clinical fracture classifications generally reflected severity, but there was substantial overlap of fracture severity measures between different classes. Similar fracture energies with different degrees of articular surface involvement suggest a possible explanation for dissimilar rates of post-traumatic osteoarthritis for fractures of the tibial plateau compared to the tibial pilon. The substantial overlap of severity measures between different fracture classes may well have confounded prior clinical studies relying on fracture classification as a surrogate for severity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:618-624, 2017.
Giannetti, Silvio; Bizzotto, Nicola; Stancati, Andrea; Santucci, Attilio
The purpose of our study was to compare the outcome after minimally invasive reconstruction and internal fixation with and without the use of pre- and intra-operative real size 3D printing for patients with displaced tibial plateau fractures (TPFs). We prospectively followed up 40 consecutive adult patients with closed TPF who underwent surgical treatment of reconstruction of the tibial plateau with the use of minimally invasive fixation. Sixteen patients (group 1) were operated using a pre-operative and intra-operative real size 3D-model, while 24 patients (group 2) were operated without 3D-model printing, but using only pre-operative and intra-operative 3D Tc-scan images. The mean operating time was 148.2±15.9min for group 1 and 174.5±22.2min for group 2 (p=0.041). In addition, the mean intraoperative blood loss was less in group 1 (520mL) than in group 2 (546mL) (p=0.534). After discharge, all patients were followed up at 6 weeks, 12 weeks, 6 months, 1year and then every year post surgically and radiographic evaluation was carried out each time using clinical and radiological Rasmussen's score, with no significant differences between the two groups. Two patients (group 2) developed infection which resolved within 3 weeks after usage of antibiotics. Neither superficial nor deep infections were present in group 1. In all patients, no non-union occurred. No intraoperative, perioperative, or postoperative complications, such as loss of valgus correction, bone fractures, or metallic plate failures were detected at follow-up. In patients operated with the use of 3D-model printing, we found a significant reduction in surgical time. Moreover, the technique without a 3D-model increased the patient's and the surgeon's exposure to radiation.
Yoshino, Kazunori; Koga, Yoshio; Segawa, Hiroyuki; Ueno, Yuichi; Tanabe, Yuji; Endo, Naoto; Omori, Go
Load transmission through knee prostheses was examined to clarify how the tibial component behaves under dynamic loading conditions. We did Genesis II total knee arthroplasty using sawbones and measured impact load transmission ratios using the split-Hopkinson pressure bar technique. We also measured the polyethylene strain when an impact load was applied using a strain gauge bonded to the anterior surface of the polyethylene. The impact load transmission ratios of metal-backed and all-polyethylene tibial components were less than 4%. Greater load transmission was observed with metal-backed components, which suggests that some of the applied dynamic load is transferred directly to the tibial cortical bone. Increasing polyethylene thickness decreased impact load transmission ratios in both components, which might lower the cancellous bone stresses beneath tibial implants. Greater strain in the tibial component was observed in all-polyethylene components. Increased polyethylene thickness did not significantly decrease the polyethylene strain, probably because of the nonlinear elastic behavior of the polyethylene material. The distant positioning of the strain gauge may, however, have prevented the detection of local contact strains. Recent clinical studies did not confirm our theoretical predictions, suggesting that other factors contribute more significantly to the clinical outcome in current total knee arthroplasty.
Aoki, Stephen K; Curtis, Stuart H
This study evaluates the initial fixation strength of tibial eminence fracture repair using 1, 2, 3, and 4 sutures to determine the optimal number of sutures required to adequately secure the avulsed fragment to the tibia. Sixteen skeletally immature porcine knees were stripped of all soft tissues, isolating the femur-anterior cruciate ligament (ACL)-tibia complex. Type III tibial eminence fractures were simulated in the specimens, and each specimen was randomly assigned to a repair group using 1, 2, 3, or 4 #2 FiberWire sutures (Arthrex, Inc, Naples, Florida). Initial fixation strength of the repair was measured by single cycle pull to failure testing using a materials testing machine (Instron, Norwood, Massachusetts). The mean ultimate failure force during anterior tibial translation was 389±128, 627±66, 703±77, and 802±29 N for 1, 2, 3, and 4 sutures, respectively. The lower limit of the 95% confidence interval was >500 N (estimated force of native ACL during activities of daily living) for each group with ≥2 sutures. In this study, at least 2 high-strength sutures were needed for tibial eminence fracture repairs to withstand potential forces seen across the ACL in the postoperative period. Suture fixation of tibial eminence fractures is a reproducible method requiring a minimum of 2 high-strength polyester sutures to resist forces seen during early rehabilitation.
Inoue, Hiroaki; Atsumi, Satoru; Ichimaru, Shohei; Fujiwara, Hiroyoshi; Kubo, Toshikazu
Complications of patellar dislocation include osteochondral injury of the lateral femoral condyle and patella. Most cases of osteochondral injury occur in the anterior region, which is the non-weight-bearing portion of the lateral femoral condyle. We describe two patients with osteochondral injury of the weight-bearing surface of the lateral femoral condyle associated with lateral dislocation of the patella. The patients were 18- and 11-year-old females. Osteochondral injury occurred on the weight-bearing surface distal to the lateral femoral condyle. The presence of a free osteochondral fragment and osteochondral injury of the lateral femoral condyle was confirmed on MRI and reconstruction CT scan. Treatment consisted of osteochondral fragment fixation or microfracture, as well as patellar stabilization. Osteochondral injury was present in the weight-bearing portion of the lateral femoral condyle in both patients, suggesting that the injury was caused by friction between the patella and lateral femoral condyle when the patella was dislocated or reduced at about 90° flexion of the knee joint. These findings indicate that patellar dislocation may occur and osteochondral injury may extend to the weight-bearing portion of the femur even in deep flexion, when the patella is stabilized on the bones of the femoral groove. PMID:25506015
Shahid, Muhammad Saleem; Lee, Paul; Evans, Sam; Thomas, Rhys
The aim of this study was to assess bone loss and thickness of the cut with the use of a burr in percutaneous hallux valgus surgery. Twelve blocks of saw bone were used. Cuts of same depth were made in each block with two different saw blades and a burr. Each block was assessed for bone loss and thickness of the cut. There was statistically significant (p<0.05) increased bone loss and thickness of the cuts with the use of a burr as compared to use of two different saw blades. The use of a burr resulted in threefold increased loss of bone material and fourfold increase in the thickness of the cut as compare to use of two different saw blades. The metatarsal shortening is a risk factor in percutaneous hallux valgus surgery with the use of a burr. Copyright © 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Today, bunion surgery is still very controversial. Considering that a bunion deformity is actually a result of multiple possible causes, the rationale of the currently applied techniques has not been conclusively demonstrated. Multiple techniques are still applied with uncertain outcome, as shown by the not insignificant recurrence rate. The tarsometatarsal reorientation arthrodesis addresses the deficient anteromedial buttress which is due to the most often concomittent hypermobile first ray. This is an important aspect of treating hallux