Addressing a Complex Proximal Femoral Deformity With Custom Cutting Guides Using 3D-Computer Design Software: A Case Report and 2-year Follow-Up

We report a case of a 23-year-old female with a history of congenital proximal femoral deformity and malunion of a prior proximal femoral corrective osteotomy, who presented seeking treatment for debilitating end-stage arthritis of her hip. Consideration for total hip arthroplasty (THA) for this patient was complicated by her young age and the complexity of her proximal femoral deformity. A 3-dimensional bone model of the patient’s femur was created using digital reconstructive software based on preoperative CT-imaging and used to plan our corrective osteotomy and arthroplasty component specifications. Using the detailed characterization of the femoral morphology, custom cutting guides were designed to fit uniquely into the correct position and ensure a high degree of accuracy with our osteotomy cuts. This unique case highlights the use of 3D-modeling software and printing technology for detailed surgical planning and precise execution in patients with complex deformities or otherwise abnormal anatomy.

Locking compression plate fixation of femoral intertrochanteric fractures in patients with preexisting proximal femoral deformity: a retrospective study

Background To investigate the clinical efficacy of locking compression plate fixation for the treatment of femoral intertrochanteric fractures in patients with preexisting proximal femoral deformity. Methods A retrospective analysis was conducted on 37 patients with femoral intertrochanteric fractures combined with preexisting proximal femoral deformity between January 2013 and July 2019. The patients included 24 males and 13 females aged from 23 to 69 years old, with an average age of 47.5 years. The preexisting proximal femoral deformities resulted from poliomyelitis sequela, proximal femoral fibrous dysplasia, malunion and implant failure combined with coxa vara after intramedullary nailing fixation. There were 6 cases of 31-A2.1, 6 cases of 31-A2.2, 20 cases of 31-A3.1, and 5 cases of 31-A3.2, determined based on the AO classification of intertrochanteric fractures. All fractures were managed through open reduction and locking plate fixation. The hip disability and osteoarthritis outcome score (HOOS) was used to assess hip function before injury and at the last postoperative follow-up. The short form 36 (SF-36) Health Survey Questionnaire was used to assess quality of life. Results Thirty-seven patients were followed up for 12 to 27 months (average, 20.7 months). All patients achieved bone healing within 5.1 months on average (range, 3 to 6 months). Postoperative complications included deep vein thrombosis in three patients, bedsores in one and delayed union in one patient. No other complications, such as surgical site infection, fat embolism, nonunion and re-fracture, were presented. There was no significant difference in the HOOS scores and the SF-36 Health Questionnaire outcomes at pre-injury and at the last postoperative follow-up (p > 0.05). Conclusions It is difficult to perform intramedullary fixation of femoral intertrochanteric fractures in patients with preexisting proximal femoral deformity, while locking compression plate fixation is a simple and effective method of treatment.

Functional and radiological outcome of wedgeless ‘V’ osteotomy for genu valgum in adolescents: a prospective cohort study

Background: Genu valgum, commonly called "knock-knee, is a coronal plane angular deformity of knee, which is a common disorder affecting children and adolescents. Distal femoral wedgeless V osteotomy is one of the various methods of treating genu valgum.Methods: A prospective cohort study was conducted between July 2017 to March 2020 in Govt Medical College, Jammu on 28 patients of genu valgum with femoral deformity. A wegdeless V osteotomy was done at the supracondylar level and fixed with K wires. The results were compaired on the basis of radiological parameters such as TFA and MAD. IMD was also compared. The functional outcome was evaluated using Bostman knee score at 6 months of follow-up. 1 patient was lost in follow up and was not included in the study.Results: 27 patients were included in the study with a mean age of 17.5 years (range 15-21 years). The radiological parameters such as TFA showed improvement from a mean of 20.71 to 5.87 postoperatively. IMD decreased from a mean of 13.77 cm to 3.69 cm and MAD from 18.76 mm to 3.03 mm. The functional assessment was made using Bostman score with a mean of 27.1 at final follow up.Conclusions: Supracondylar wedgeless V-osteotomy is an excellent technique for correction of the genu valgum deformity in the adolescent. The learning curve, surgical exposure, and surgical time being minimal. Sparse complications have been reported with this technique as compared to the other type of osteotomies.

Defining the Borderline Hip: High Variability in Acetabular Coverage and Femoral Deformity

Objectives: Borderline acetabular dysplasia is radiographically defined as a lateral center edge angle (LCEA) of 20-25 degrees. It is well accepted that some borderline hips have instability while others have primarily impingement. The optimal management of borderline dysplasia is challenging and particularly complex due to the anatomic variability that exists among patients but has not been well characterized. The purpose of this current study was to investigate the variability in hip deformity present on low-dose CT in a cohort of patients with symptomatic borderline acetabular dysplasia. Methods: Seventy consecutive hips with borderline acetabular dysplasia undergoing surgical treatment were included in the current study. Radiographic evaluation included LCEA, acetabular inclination, anterior center edge angle (ACEA), and alpha angles on AP, Dunn, and frog views. All patients underwent low-dose pelvic CT for preoperative planning. Femoral deformity was assessed with femoral version, alpha angle (measured at 1:00 increments), and maximum alpha angle. Radial acetabular coverage was calculated according to standardized clockface positions [measured from 8:00 (posterior) to 4:00 (anterior)] and defined as normal, undercoverage, or overcoverage relative to 1 SD from the mean of normative values. Results: The mean LCEA was 22.1+1.4, while the mean acetabular inclination was 10.3+3.3. The mean ACEA in the group was 25.3+5.8 (range 10.1-43.9), with 16% having an ACEA < 20 and 50% having an ACEA < 25. The mean femoral version was 17.9° (range -4° to 59°). The mean maximal alpha angle was 57.2° (range 43° to 81°) with 61.4% greater than 55°. Lateral coverage (RAC at 12:00) was deficient in 74.1% of cases. Anterior coverage (RAC at 2:00) was highly variable with 17.1% undercoverage, 72.9% normal, and 10.0% overcoverage. Posterior coverage (RAC at 10:00) was also highly variable with 30.0% undercoverage, 62.9% normal, and 7.1% overcoverage. The three most common patterns of coverage were: isolated lateral undercoverage (31.4%), normal coverage (18.6%), and lateral and posterior undercoverage (17.1%). Conclusion: Patients with borderline acetabular dysplasia demonstrate highly variable three-dimensional deformities including anterior, lateral, and posterior acetabular coverage, femoral version, and alpha angle. Comprehensive deformity characterization in the population is important to guide diagnosis and treatment decisions. [Figure: see text][Figure: see text][Figure: see text]

FORENSIC ASSESSMENT OF ADVERSE OUTCOMES OF ISOLATED DIAPHYSEAL FEMORAL FRACTURES

FORENSIC ASSESSMENT OF ADVERSE OUTCOMES OF ISOLATED DIAPHYSEAL FEMORAL FRACTURES Sokol V. Fractures of the diaphysis of the femur are one of the most frequent mechanical injuries of the skeleton, however, the frequency and causes of the development of the complicated post-traumatic period are not well understood. The aim of this research was to study the causes of the development of adverse outcomes of isolated diaphyseal femoral fractures. Object and methods of research. Retrospective analysis of the protocols of clinical and radiological examination of 21 patients with adverse outcomes of a femoral diaphysis fracture, which, according to the results of the initial expert assessment, did not establish the severity of injuries due to the development of complications in the postoperative period. Results. The main cause of fractures in this category of patients is road traffic accidents (90.4% of cases); closed fractures of the femoral diaphysis (85.7%) in the middle third (76.1%) in men (76.2%) prevailed. The following reasons for the unsatisfactory results of surgical treatment of diaphyseal fractures of the femur were revealed: 1) patient-dependent: a combination of overweight and arthrosis of adjacent (hip and knee) joints - 57.1%; violation of the motor regime in the form of physical inactivity (19.0%) and excessive axial load on the operated leg (19.0%); 2) implant-dependent: a mismatch between the dimensions of the device for immersion osteosynthesis and the anatomical sizes of the corresponding segments of the femur in all cases; 3) surgical-dependent causes: unresolved intraoperative displacement of fragments of the femur (23.8%), violation of the technology of radiation diagnostics (14.3%), violation of the terms of postoperative x-ray monitoring (23.8%) and perioperative antibiotic prophylaxis (14.3%). The consequence of this was a violation of the stability of osteosynthesis in 95.2% with a secondary displacement of bone fragments of the femur (47.6%), delayed consolidation of a hip fracture (61.9%), the formation of pseudarthrosis of the femur (38.1%), and post-traumatic femoral deformity bones (71.4%), development of post-traumatic contracture of the knee joint (81.0%), suppuration of the postoperative wound (23.8%), development of post-traumatic osteomyelitis (14.3%), migration of screws from the osseous plate (47.6% ), migration of a distal blocked nail from the intramedullary st rust (4.8%), intramedullary rod migration (4.8%). Keywords: diaphyseal femoral fracture, surgical treatment, perioperative risk factors, postoperative complications, unsatisfactory outcomes. Резюме. СУДОВО-МЕДИЧНА ОЦІНКА НЕСПРИЯТЛИВИХ НАСЛІДКІВ ІЗОЛЬОВАНИХДІАФІЗАРНИХ ПЕРЕЛОМІВ СТЕГНОВОЇ КІСТКИ. Сокол В.К. Переломи діафіза стегнової кістки є однією з найбільш частих механічних травм скелета, проте частота і причини розвитку ускладненого посттравматичного періоду вивчені недостатньо. Метою даного дослідження стало вивчення причин розвитку несприятливих наслідків ізольованих діафізарних переломів стегнової кістки. Об'єкт і методи досліджень.Ретроспективний аналіз протоколів клініко-рентгенологічного обстеження 21 хворого з несприятливими наслідками перелому діафіза стегнової кістки, яким за підсумками первинної експертної оцінки не була встановлена ​​ступінь тяжкості тілесних ушкоджень у зв'язку з розвитком ускладнень в післяопераційному періоді. Результат досліджень. Основна причина переломів у даній категорії пацієнтів - дорожньо-транспортні пригоди (90,4% випадків); переважали закриті переломи діафіза стегнової кістки (85,7%) в середній третині (76,1%) у чоловіків (76,2%). Виявлено наступні причини незадовільних результатів хірургічного лікування діафізарних переломів стегнової кістки: 1) паціентзалежні: поєднання надмірної ваги і артрозу суміжних (кульшового і колінного) суглобів - 57,1%; порушення рухового режиму у вигляді гіподинамії (19,0%) і надлишкового осьового навантаження на оперовану ногу (19,0%); 2) імплантзалежні: невідповідність розмірів пристрою для погружного остеосинтезу і анатомічних розмірів відповідних сегментів стегнової кістки у всіх випадках; 3) хірургзалежні причини: неусунення інтраопераційно зміщення фрагментів стегнової кістки (23,8%), порушення технології променевої діагностики (14,3%), порушення термінів післяопераційного рентгенконтроля (23,8%) і періопераційної антибіотикопрофілактики (14,3%). Наслідком цього стало порушення стабільності остеосинтезу в 95,2% з вторинним зміщенням кісткових фрагментів стегнової кістки (47,6%), сповільнена консолідація перелому стегна (61,9%), формування псевдоартрозу стегнової кістки (38,1%), посттравматична деформація стегнової кістки (71,4%), розвиток посттравматичної контрактури колінного суглоба (81,0%), нагноєння післяопераційної рани (23,8%), розвиток посттравматичного остеомієліту (14,3%), міграція гвинтів з накісткової пластини (47,6% ), міграція дистального цвяха, що блокує, з інтрамедулярного стрижня (4,8%), міграція інтрамедулярного стрижня (4,8%). Ключові слова: діафізарний перелом стегна, хірургічне лікування, періопераційні фактори ризику, післяопераційні ускладнення, незадовільні наслідки діафізарних переломів стегна. Резюме. СУДЕБНО-МЕДИЦИНСКАЯ ОЦЕНКА НЕБЛАГОПРИЯТНЫХ ИСХОДОВ ИЗОЛИРОВАННЫХ ДИАФИЗАРНЫХ ПЕРЕЛОМОВ БЕДРЕННОЙ КОСТИ. Сокол В.К. Переломы диафиза бедренной кости являются одной из наиболее частых механических травм скелета, однако частота и причины развития осложненного посттравматического периода изучены недостаточно. Целью данного исследования стало изучение причин развития неблагоприятных исходов изолированных диафизарных переломов бедренной кости. Объект и методы исследований. Ретроспективный анализ протоколов клинико-рентгенологического обследования 21 больного с неблагоприятными исходами перелома диафиза бедренной кости,которым по итогам первичной экспертной оценки не была установлена ​​степень тяжести телесных повреждений в связи с развитием осложнений в послеоперационном периоде.Результат исследований. Основная причина переломов у данной категории пациентов - дорожно-транспортные происшествия (90,4% случаев); преобладали закрытые переломы диафиза бедренной кости (85,7%) в средней трети (76,1%) у мужчин (76,2%). Выявлены следующие причины неудовлетворительных результатов хирургического лечения диафизарных переломов бедренной кости: 1) пациентзависимые: сочетание избыточного веса и артроза смежных (тазобедренного и коленного) суставов - 57,1%; нарушение двигательного режима в виде гиподинамии (19,0%) и избыточной осевой нагрузки на оперированную ногу (19,0%); 2) имплантзависимые: несоответствие размеров устройства для погружного остеосинтеза и анатомических размеров соответстующих сегментов бедренной кости во всех случаях; 3)хирургзависимые причины: неустраненное интраоперационно смещение фрагментов бедренной кости (23,8%), нарушение технологии лучевой диагностики (14,3%), нарушение сроков послеоперационного рентгенконтроля (23,8%) и периоперационной антибиотикопрофилактики (14,3%). Следствием этого явилось нарушение стабильности остеосинтеза в 95,2% с вторичным смещением костных фрагментов бедренной кости (47,6%), замедленная консолидация перелома бедра (61,9%), формирование псевдоартроза бедренной кости (38,1%), посттравматическая деформация бедренной кости (71,4%), развитие посттравматической контрактуры коленного сустава (81,0%), нагноение послеоперационной раны (23,8%), развитие посттравматического остеомиелита (14,3%), миграция винтов из накостной пластины (47,6%), миграция дистального блокируемого гвоздя из интрамедуллярного стержня (4,8%), миграция интрамедуллярного стержня (4,8%). Ключевые слова: диафизарный перелом бедра, хирургическое лечение, периоперационные факторы риска, послеоперационные осложнения, неудовлетворительные исходы переломов диафиза бедра.

DEFINING THE BORDERLINE HIP: HIGH VARIABILITY IN ACETABULAR COVERAGE AND FEMORAL DEFORMITY

Introduction Borderline acetabular dysplasia is radiographically defined as a lateral center edge angle (LCEA) of 20-25 degrees. It is well accepted that some borderline hips have instability while others have primarily impingement. The optimal management of borderline dysplasia is challenging and particularly complex due to the anatomic variability that exists among patients but has not been well characterized. Purpose The purpose of this current study was to investigate the variability in hip deformity present on low-dose CT in a cohort of patients with symptomatic borderline acetabular dysplasia. Methods Seventy consecutive hips with borderline acetabular dysplasia undergoing surgical treatment were included in the current study. Radiographic evaluation included LCEA, acetabular inclination, anterior center edge angle (ACEA), and alpha angles on AP, Dunn, and frog views. All patients underwent low-dose pelvic CT for preoperative planning. Femoral deformity was assessed with femoral version, alpha angle (measured at 1:00 increments), and maximum alpha angle. Radial acetabular coverage was calculated according to standardized clock-face positions [measured from 8:00 (posterior) to 4:00 (anterior)] and defined as normal, under-coverage, or over-coverage relative to 1 SD from the mean of normative values. Results The mean LCEA was 22.1±1.4, while the mean acetabular inclination was 10.3±3.3. The mean ACEA in the group was 25.3±5.8 (range 10.1-43.9), with 16% having an ACEA ≤ 20 and 50% having an ACEA ≤ 25. The mean femoral version was 17.9° (range -4° to 59°). The mean maximal alpha angle was 57.2° (range 43° to 81°) with 61.4% greater than 55°. Lateral coverage (RAC at 12:00) was deficient in 74.1% of cases. Anterior coverage (RAC at 2:00) was highly variable with 17.1% under-coverage, 72.9% normal, and 10.0% over-coverage. Posterior coverage (RAC at 10:00) was also highly variable with 30.0% under-coverage, 62.9% normal, and 7.1% over-coverage. The three most common patterns of coverage were: isolated lateral under-coverage (31.4%), normal coverage (18.6%), and lateral and posterior under-coverage (17.1%). Discussion Patients with borderline acetabular dysplasia demonstrate highly variable three-dimensional deformities including anterior, lateral, and posterior acetabular coverage, femoral version, and alpha angle. Comprehensive deformity characterization in the population is important to guide diagnosis and treatment decisions.