Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

Background: We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy. Methods: We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups. Results: There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P > .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs –2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01). Conclusion: In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis. Level of evidence: Level III, retrospective comparative study.

Development of Garments with Elastic Straps and Pressure Applicator (GESPA) and “GVcorrect” App to Follow the Changes in Lower-Extremity Alignment (Genu Valgum)—A Pilot Study

Background: There are non-invasive methods of correcting genu valgum (GV), but to date, there is no method to evaluate mechanotherapeutic intervention that does not restrict child’s natural movements while the process is on-going so that timely decisions could be made on effectiveness of intervention. The aim of study was to develop and assess the comfortability of garments with elastic straps and pressure applicator (GESPA) and the reliability and user-friendliness of “GVcorrect” app, which aims to catch the elastic straps’ pressure level (mN). Methods: 6 children (5–7 y) with intermalleolar distance ≥5 cm wore GESPA daily for 3 months. Anthropometrical and goniometrical measurements were done according to standard technique; tone and biomechanical parameters of skeletal muscles determined with MyotonPRO; feedback about GESPA and “GVcorrect” collected via questionnaire. Results: Based on feedback from children and parents, new, more comfortable and user-friendly GESPA were designed; several updates were made to “GVcorrect” app; new goals were set for the next phase of the study. Conclusions: GESPA and the “GVcorrect” app serve their purpose, but there are still a number of important limitations that need to be removed before the product can be marketed. The study continues with product development until a medical device certificate is obtained.

Genu valgum deformity – correction by a wedgeless implantless femoral “V” osteotomy

Coronal malalignment of the knee joint is very common in developing countries especially because of nutritional rickets. Significant valgus deformity needs to be treated surgically to improve appearance, gait and function of the patient. The purpose of this prospective study was to evaluate the results of supracondylar “V” osteotomy as a surgical technique for correction of the valgus knee deformity. This study was conducted in a tertiary level teaching hospital and 30 cases were included in the study. For all the patients deformity was assessed using ana- tomical tibiofemoral angle, mechanical axis deviation and intermalleolar distance preoperatively and post- operatively. The average age of our patients was 13.7 years and the average follow up was3.29 years (1.39-14.22 yrs). Clinically the average value of intermalleolar distance preoperatively was 16cm and 3.2 cm postperatively. Average pre-operative tibiofemoral angle was 23° and the average postoperative angle was 6 0 which was found to be statistically significant using the Paired t test (p<0.005). The average value of preoperative mechanical axis deviation was 3.1 cm which decreased to an average value of 1.1 cm postoperatively. The results with this technique have been encouraging. The advantages of this technique are low morbidity, good stability allowing early ambulation, ability to adjust alignment postoperatively by casting and no need for internal fixation. Few studies have been conducted on osteotomies that do not require internal fixation and are inherently stable. This technique has the advantage of practically no occurrence of any infection or a second surgery to remove hardware in children and adolescents. Since no specialized instrumentation, image intensifier and implants are required, it is cost effective and can be used in any primary care or district level surgical setup in a developing country like ours.

Ginocchio valgo punto per punto: quello che deve sapere il pediatra

Knee valgus is one of the most frequent paediatric orthopaedic problems based on the evaluation by the paediatricians. Most cases are physiological variants that resolve spontaneously with growth, however pathological cases require surgical treatment. Therefore, the paediatrician must know how to distinguish between the two entities from the beginning, sending the child to the specialist when necessary, thus respecting the correct timing for treatment. The most frequent condition is idiopathic knee valgus, which occurs when the physiological variant persists after the age of 8 without spontaneous resolution. Children who always need specialist evaluation are those who on physical examination show a tibiofemoral angle greater than 15° with an intermalleolar distance of about 10 cm that persists beyond 10 years of age. The gold standard treatment in these children is growth-guided hemiepiphysiodesis, namely a simple and minimally invasive procedure that reshapes the altered angle of the knees through the application of the 8-plate. The correction is based on the presence of residual growth of the physical cartilages, therefore it should not be performed too late, but not before 10 years of age.

Clinical measurement of intermalleolar distance in Western Indian population

Background: Angular deformities around the knee are one of the common basis of presentation at orthopaedic clinic and intermalleolar distance (IMD) is an essential anthropometric tool for evaluation of the angular status of the lower limb.Methods: 500 healthy (330 male and 170 female) subjects between 20 to 40 years of age were taken for IMD measurement in standing and supine position by digital vernier caliper.Results: The normal range of IMD in western Indian population in between 32-58 mm. IMD in standing position was 42.47 mm with (95% CI = 40.51 to 44.42 mm) and in supine position was 34.45 mm with (95% CI = 32.78 to 36.13 mm). Mean IMD in male in standing position was 40.01 mm while in female it was 43.74 mm observed. Statically significant difference was observed in posture change and according to age.Conclusions: Significantly higher value in female, in standing position and in higher age group were observed.

OP0076 CLINICAL DISEASE ACTIVITY, MRI SPINAL INFLAMMATION AND ENTHESITIS ARE KEY DETERMINANTS OF IMPAIRMENT OF SPINAL MOBILITY IN EARLY AXIAL SPONDYLOARTHRITIS – DATA FROM THE DESIR COHORT

Background:It has been shown that spinal mobility impairment in axial spondyloarthritis (axSpA) is independently determined both by irreversible spinal damage and by reversible spinal inflammation. However, these relationships have only been investigated in patients with longstanding disease (ankylosing spondylitis). Moreover, only the composite score Bath Ankylosing Spondylitis Metrology Index (BASMI) has been evaluated rather than individual mobility assessments.Objectives:Our aim was to investigate the determinants of spinal mobility in patients with early axSpA.Methods:We analysed longitudinal data from the DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR) cohort, collected during the first five years of follow-up. We selected patients with a definite diagnosis of axSpA according to the treating rheumatologist, at the end of follow-up (month 60). Associations were tested using generalised estimating equations (GEE), a multilevel approach that adjusts for within-patient correlation. The Bath Ankylosing Spondylitis Metrology Index (BASMI) or the individual components of BASMI (lateral spinal flexion, tragus-to-wall distance, cervical rotation, anterior lumbar flexion, maximal intermalleolar distance) were used as dependent variables, and clinical and demographic variables were used as independent variables in univariable models. Spinal MRI inflammation was assessed using the Berlin scoring system and radiographic structural damage was assessed using the modified Stoke ankylosing spondylitis spinal score (mSASSS)]. As physical function and quality of life are considered to be hierarchically superior to spinal mobility, they were not included in the analysis. Multivariable models were built, adjusting for potential confounding. Variables with a p-value <0.10 were re-tested in the multivariable models. Six models were built, one regarding the BASMI total score and five regarding the individual components of BASMI.Results:Data from 644 patients and 5152 visits were analysed. In the multivariable analyses (table), we found an independent association between higher BASMI values and age [adjusted B (aB)=1.02, confidence interval (CI)=1.01-1.03], Ankylosing Spondylitis Disease Activity Score-C Reactive Protein (ASDAS-CRP) (aB=1.23, CI=1.15-1.32), enthesitis score (aB=1.02, CI=1.01-1.04) and MRI inflammation score (aB=1.13, CI=1.05-1.23). All individual BASMI components were independently associated with ASDAS-CRP. Apart from maximal intermalleolar distance, all other mobility measures were associated with MRI spinal inflammation. Lateral spinal flexion, cervical rotation and maximal intermalleolar distance were associated with the enthesitis score. mSASSS was associated with lateral spinal flexion and a contributory factor to tragus-to-wall distance and cervical rotation.Conclusion:In early axSpA, spinal mobility impairment is independently determined by clinical disease activity, MRI spinal inflammation and the severity of enthesitis. Maximal intermalleolar distance (which is not a true measure of spinal mobility) was the only measure not associated with MRI spinal inflammation. The influence of spinal inflammation prevails in the early phase of axSpA while spinal damage becomes more relevant in later disease stages.References:None.Disclosure of Interests:Pedro Carvalho: None declared, Ana Marreiros: None declared, Joao Eurico Fonseca: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB

The Profile and Development of the Lower Limb in Setswana-Speaking Children between the Ages of 2 and 9 Years

Profile data on normal lower limb development and specifically tibiofemoral angle development in black, Setswana-speaking South African children are lacking. This study aimed to provide profiles on the development of the tibiofemoral angle, hip anteversion angle and tibial torsion angles in two- to nine-year-old children. Measurements of the tibiofemoral angle, intercondylar distances or intermalleolar distances, quadriceps-angle, hip anteversion- and tibial torsion angle were clinically obtained from 691 healthy two- to nine-year-old children. Two-year-old children presented with closest to genu varum at −3.4° (±3.4°). At three years, a peak of −5.7° (±2.3°) genu valgum was seen, which plateaued at −4.5° (±2.1°) at age nine years. Intermalleolar distance results support tibiofemoral angle observations. Small quadricep-angles were observed in the two-year-old group, (−3.81° ± 3.77°), which increased to a mean peak of −9.2° (±4.4°) in nine-year-olds. From the age of four years old, children presented with neutral tibial torsion angles, whilst two- and three-year-olds presented with internal tibial torsion angles. Anteversion angles were the greatest in three-year-olds at 77.6° ± 13.8° and decreased to a mean angle of 70.8° ± 6.9° in nine-year-olds. The tibiofemoral angle developed similarly to those tested in European, Asian and Nigerian children, but anteversion- and internal tibial torsion angles were greater in the Setswana population than angles reported in European children. Our findings indicate that lower limb development differs in different environments and traditions of back-carrying may influence the development, which requires further investigation.

Frequency of Impaired Spinal Mobility in Patients with Chronic Back Pain Compared to Patients with Early Axial Spondyloarthritis

Objective.To examine the frequency of impaired spinal mobility in patients with chronic back pain of short duration and to compare it with the frequency of impaired spinal mobility in patients with axial spondyloarthritis (axSpA), possible SpA, and no SpA.Methods.The SpondyloArthritis Caught Early (SPACE) cohort includes patients with chronic back pain (≥ 3 mos, ≤ 2 yrs, onset < 45 yrs). Spinal mobility was assessed with lateral spinal flexion, chest expansion, cervical rotation, occiput-to-wall distance, and lumbar flexion. Hip mobility was assessed with intermalleolar distance. Mobility measures were defined as impaired if below the 5th percentile reference curve from general population, adjusted for age and height when appropriate. Proportions of patients categorized with impaired mobility were examined with chi square.Results.In total, 393 patients with chronic back pain were included: 142 axSpA, 140 possible SpA, and 111 no SpA. Impairment in ≥ 1 mobility measure was present in 66% of all patients. The most frequently impaired mobility measure was lateral spinal flexion (40%), followed by chest expansion (22%), cervical rotation (18%), intermalleolar distance (17%), lumbar flexion (15%), and occiput-to-wall distance (11%). No statistically significant differences in proportion of patients with impaired spinal mobility were found between patients with axSpA and the other subgroups in any of the tests.Conclusion.Two out of 3 patients with chronic back pain of short duration had impaired spinal mobility compared to the general population. Impaired spinal mobility occurs as often in patients with early axSpA as in other forms of chronic back pain.