Change in angle of depressed medial tibial plateau following extra-articular mechanical realignment surgery in children with Blount's disease who presented late for treatment

Introduction: The aim of this study was to determine whether any change in degree of medial tibia plateau depression after extra-articular mechanical realignment surgery was observed in children with Blount’s disease who presented late for treatment in their adolescent and young adulthood. Methods: We retrospectively reviewed the radiographic parameters of 22 patients (32 lower limbs) with Blount’s disease who underwent gradual correction of deformity surgery using ring external fixator without surgical elevation of the depressed medial tibial plateau at a mean age of 15 (10–37) years. Preoperative and postoperative angles of depressed medial tibia plateau (ADMTP) of the same patient were compared for any significant change. Normally distributed data were analysed using Student’s t-test when comparing two groups or one-way ANOVA when comparing more than two groups. Skewed data were analysed using Mann-Whitney test. Results: After extra-articular mechanical alignment surgery, statistically significant improvements in medial tibial plateau depression were seen in the Infantile (p = 0.03) and Juvenile (p = 0.04) Blount’s subgroups. Change of ADMTP was greater in patients who were operated on at age < 17 years, before skeletal maturity (p = 0.001). The improvement was likely due to ossification of unossified cartilage at the posteromedial proximal tibia and remodelling potential of proximal tibia physis after mechanical realignment. Conclusion: Improvement of medial tibia plateau depression is possible after mechanical realignment without surgical hemiplateau elevation in cases of Infantile and Juvenile Blount’s disease that present late for treatment, especially when the operation is performed before age 17 years old.

Effect of the Osteotomy Inclination Angle in the Sagittal Plane on the Posterior Tibial Slope of the Tibiofemoral Joint in Medial Open-Wedge High Tibial Osteotomy: Three-Dimensional Computed Tomography Analysis

The posterior tibial slope of the tibiofemoral joint changes after medial open wedge high tibial osteotomy (MOWHTO), but little is known about the effect of the sagittal osteotomy inclination angle on the change in the posterior tibial slope of the tibiofemoral joint. The purpose of this study was to investigate the effect of the osteotomy inclination angle in the sagittal plane on changes in the posterior tibial slope after MOWHTO by comparing how anterior and posterior inclination affect the posterior tibial slope of the tibiofemoral joint. The correlation between the osteotomy inclination angle and the postoperative posterior tibial slope angle was also assessed. Between May 2011 and November 2017, 80 patients with medial compartment osteoarthritis who underwent MOWHTO were included. The patients were divided into two groups according to the sagittal osteotomy inclination angle on the 3D reconstructed model. Patients with an osteotomy line inclined anteriorly to the medial tibial plateau line were classified into group A (58 patients). Patients with posteriorly inclined osteotomy line were classified as group P (22 patients). In the 3D reconstructed model, the preoperative and postoperative posterior tibial slope, osteotomy inclination angle relative to medial tibial plateau line in sagittal plane, and gap distance and ratio of the anterior and posterior osteotomy openings were measured. The preoperative and postoperative hip-knee-ankle angle, weight-bearing line ratio, and posterior tibial slope were also measured using plain radiographs. In the 3D reconstructed model, the postoperative posterior tibial slope significantly increased in group A (preoperative value = 9.7 ± 2.9°, postoperative value = 10.7 ± 3.0°, p < 0.001) and decreased in group P (preoperative value = 8.7 ± 2.7°, postoperative value = 7.7 ± 2.7°, p < 0.001). The postoperative posterior tibial slope (group A = 10.7 ± 3.0°, group P = 7.7 ± 2.7°, p < 0.001) and posterior tibial slope change before and after surgery (group A = 1.0 ± 0.8°, group P = −0.9 ± 0.8°, p < 0.001) also differed significantly between the groups. The Pearson correlation coefficient was 0.875 (p < 0.001) for the osteotomy inclination angle, and multivariate regression analysis showed that the only significant factor among the variables was the sagittal osteotomy inclination angle (β coefficient = 0.216, p < 0.001). The posterior tibial slope changed according to the osteotomy inclination angle in the sagittal plane after MOWHTO. The postoperative posterior tibial slope tended to increase when the osteotomy line was inclined anteriorly with respect to the medial tibial plateau line but decreased when the osteotomy line was inclined posteriorly. To avoid inadvertent change of posterior tibial slope, close attention needs to be paid to maintaining the sagittal osteotomy line parallel to the medial joint line during MOWHTO.

Severe bicompartmental bone bruise is associated with rotatory instability in anterior cruciate ligament injury

Purpose The presence and severity of bone bruise is more and more investigated in the non-contact anterior cruciate ligament (ACL) injury context. Recent studies have advocated a correlation between bone bruise and preoperative knee laxity. The aim of the present study was to investigate the correlation between bone bruise and preoperative rotatory knee laxity. Methods Twenty-nine patients (29.1 ± 9.8 years) with MRI images at a maximum of 3 months after ACL injury (1.6 ± 0.8 months) were included. The bone bruise severity was evaluated according to the International Cartilage Repair Society (ICRS) scale for lateral femoral condyle, lateral tibial plateau, medial femoral condyle, and medial tibial plateau. The intraoperative rotational knee laxity was evaluated through a surgical navigation system in terms of internal–external rotation at 30° and 90° of knee flexion (IE30, IE90) and internal–external rotation and acceleration during pivot-shift test (PS IE, PS ACC). The KOOS score was also collected. The association between ICRS grade of bone bruise and rotational laxity or KOOS was investigated. Results Significant correlation (p < 0.05) was found between the bone bruise severity on the medial tibial plateau and rotational laxity (IE90, PS IE, and PS ACC) and between the severity of bone bruise on femoral lateral condyle and KOOS-Symptoms sub-score. The presence of bone bruise on the medial tibial plateau was significantly associated with a lateral femoral notch sign > 2 mm (very strong odds ratio). No kinematical differences were found between none-to-deep and extensive-generalized lateral bone bruise, while higher IE30 and IE90 were found in extensive-generalized bicompartmental bone bruise than isolated extensive-generalized lateral bone bruise. Conclusion A severe bicompartmental bone bruise was related to higher rotatory instability in the intraoperative evaluation of ACL deficient knees. The severity of edema on the medial tibial plateau was directly correlated with higher intraoperative pivot shift, and the size of edema on the lateral femoral condyle was associated with lower preoperative clinical scores. Level of evidence Level II.

Salvage of severe knee osteoarthritis: efficacy of tibial condylar valgus osteotomy versus open wedge high tibial osteotomy

Introduction To compare the clinical outcomes and the radiographic features between tibial condylar valgus osteotomy (TCVO) and open wedge high tibial osteotomy (OWHTO). New insight into the indication criteria for TCVO was also clarified for achieving satisfactory results. Materials and methods Sixty-three knees with medial-compartment osteoarthritis were retrospectively studied. Thirty-four knees with subluxated lateral joint and depression of the medial tibial plateau underwent TCVO and the rest underwent OWHTO. Among the 63 knees included, 27 knees with a pre-operative femorotibial angle (FTA) ≥ 185° were defined as severe varus (subgroup S, 15 in STCVO group and 12 in SHTO group). Lower limb alignment, intra-, and extra-articular congruency were evaluated according to the radiograph obtained before and 24 months after surgery. The visual analog scale (VAS) score and Hospital for Special Surgery (HSS) score were obtained to assess the clinical results. Opening angle and distance of the opening gap in each group were measured by intra-operative fluoroscopy. Results During the 2-year follow-up period, the mean HSS score increased from 70.3 to 81.4 in HTO group and 65.9 to 87.3 in TCVO group (p < 0.05). The mean VAS score decreased from 5.9 to 2.6 and 6.0 to 2.1, respectively (p < 0.01). Pre-operative FTA was restored to 172.9° in HTO group and 171.3° in TCVO group, and percentage of mechanical axis (%MA) was improved to 59.7% and 61.2%, respectively. Joint line convergence angle (JLCA) was slightly restored and medial tibial plateau depression (MTPD) was relatively the same before and after OWHTO, while these parameters improved greatly (from 6.4° to 1.2° and − 8.0° to 5.9°, p < 0.01) in TCVO group. More undercorrected knees were observed in SHTO group than STCVO group (58.3% and 13.3%, p < 0.05). Opening angle and distance of the opening gap were larger in TCVO group (19.1° and 14.0 mm) than those in OWHTO group (9.3° and 10.1 mm, p < 0.05). Conclusion Compared to OWHTO, TCVO had priority in treating advanced knee OA with intra-articular deformity. However, TCVO had a limited capacity to correct the varus angle. Besides, TCVO might be suitable for medial-compartment OA with a pre-operative FTA ≥ 185°.

Bilateral Primary Total Knee Arthroplasty and Reconstruction of the Medial Tibial Plateau by an Asymmetric Cone in a Patient with Charcot Arthropathy

Charcot arthropathy of the knee is an extremely rare orthopedic disease that is very challenging for the treating physician and is associated with many complications, especially if it is occurring on both knees. Meanwhile, in the advanced stage, despite many potential complications, TKA is recognized as the gold standard. However, destruction of the medial tibial plateau is typical for the disease, which makes a stable anchorage of the prosthesis much more difficult. Therefore, we present a case in which sufficient primary stability could be achieved with an asymmetrical second-generation tibial cone with an anatomical design and implantation instruments adapted to the bony anatomy in the presence of severe tibial destruction on both sides. In the two-year follow-up, the patient showed good mobility and stability on both sides. In advanced Charcot arthropathy of the knee, the use of asymmetric tibial cones appears to be an appropriate solution for secure fixation and stability of the implant.