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Purpose: The aim of this study was to appraise various factors influencing the correction rate in temporary hemiepiphysiodesis (THE) around the knee joint. Specifically, the study analysed the relationship of correction rate with age, gender, aetiology, type and location of deformity., Methods: The retrospective study included children who underwent THE for a coronal plane deformity (genu valgus or varum) around the knee joint (distal femur or proximal tibia) over a ten year period (2010-2020). The primary outcome of interest was the correction rate of the deformity., Results: Thirty-three children (27 females and 6 males) with a mean age of 8.1 years involving 86 plates were included in the study. The mean correction achieved was 12.2° over a treatment period of 13.3 months. Subgroup analysis showed significant differences between the type (varus (0.8° per month), valgus (1.1° per month)) and the location of deformity femur (1.2° per month) and tibia (0.7° per month)]. On multivariate analysis, the location and the duration of treatment showed significant associations with the correction rate., Conclusion: The correction of coronal deformities following temporary hemiepiphysiodesis is influenced by several factors. Valgus, femoral and deformities in younger children correct at a faster rate. Location of deformity and duration of treatment emerged as potential factors affecting the correction rate., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: To present the technique of correction of multiplanar deformities around the knee in children and adolescents using the monolateral external fixator. Also, to evaluate the results of the technique regarding radiological correction, time to union, and possible complications., Methods: A total of 29 patients (47 limbs) were prospectively included in the study (14 males and 15 females). Their median age was 13 years (range, 7-17). All patients had at least a 2-plane deformity around the knee which was corrected using a monolateral external fixator. The primary outcome measure was deformity correction (correction of mechanical axis deviation (MAD) in both the coronal and sagittal planes with correction of rotational deformities). The secondary outcome measures included bony union, radiographic, and functional results (assessed by using the Association for the Study and Application of the Method of Ilizarov (ASAMI) score)., Results: The median pre-operative MAD improved from 6.3 to 0.4 cm post-operatively. According to the ASAMI scoring system, the radiographic scoring was excellent in all cases (100%), and the functional scoring was excellent in 22 cases (89.7%) and good in three cases (10.3%)., Conclusion: The simple monolateral fixator can be an effective tool for multiplanar correction of complex deformities around the knee without limb length discrepancy., (© 2024. The Author(s).)

Purpose: While the coronal plane alignment of the knee (CPAK) classification serves as a useful guide in personalising total knee arthroplasty (TKA), the extent of its correlation with segmental coronal extra-articular knee deformities remains uncertain. This study aims to investigate the potential correlation between CPAK matrix groups and segmental coronal extra-articular deformities in prearthritic knees, shedding light on the relationship between these two factors that seems to be both essential to perform personalised TKA., Materials and Methods: A radiological assessment of 1240 nonarthritic knees was performed by evaluating lower limb measurements following the protocol established by Paley et al. Subsequently, all knees were classified into their respective CPAK matrix groups. In our quest to discern any correlation between the CPAK matrix groups and the presence of segmental coronal extra-articular knee deformities, nine potential coronal extra-articular deformity phenotype (CEDP) groupswere identified based on medial proximal tibial angle (MPTA) and mechanical lateral distal femoral angle (mLDFA). Neutral values for MPTA and mLDFA were set at 90.0° ± 3.0° and then at 87.0° ± 2.0°. Each CPAK matrix group underwent detailed coronal morphology analysis and then, segmental coronal extra-articular deformities were assessed by comparing them with the CEDP groups., Results: The study revealed a mean hip-knee-ankle angle (HKA) of 178.6° ± 4.4°, mLDFA of 86.9° ± 2.5°, MPTA of 85.4° ± 2.4°, arithmetic HKA of -1.4° ± 3.2° and joint line obliquity of 172.5° ± 3.7°. The varus CPAK groups (I/IV/VII) included 435 patients, the neutral groups (II/V/VIII) comprised 630 patients and the valgus groups (III/VI/IX) had 175 patients. Notably, CPAK matrix groups were not distinctly associated with specific coronal extra-articular deformity phenotype (CEDP) groups. Particularly among the most common CPAK matrix groups (I/II/III/IV/V), there was a significant variation in segmental coronal extra-articular deformity patterns. Moreover, when neutral MPTA/mLDFA values were set at 87.0° ± 2.0°, the CPAK matrix groups exhibited even greater variability in coronal extra-articular deformities., Conclusion: The CPAK matrix groups do not exhibit a direct correlation with a specific extra-articular deformity pattern (CEDP), thus rendering them unsuitable for determining segmental coronal extra-articular knee deformities., Level of Evidence: Level III, retrospective diagnostic study., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: This study aimed to elucidate the characteristics of varus knee deformities in the Japanese population, prevalence of various around knee osteotomy procedures and influence of femoral and tibial bowing., Methods: Varus knee deformity was defined as a weight-bearing line ratio of <50%. A total of 1010 varus knees were selected from 1814 varus knees with weight-bearing full-length radiographs, obtained at two facilities, based on exclusion criteria. Various parameters were measured, and around knee osteotomy simulations based on the deformity centre were conducted using digital planning tools. Bowing of the femoral and tibial shafts was measured, with bowing defined as follows: ≤ -0.6° indicating lateral bowing and ≥ 0.6° indicating medial bowing. Statistical analysis was performed to investigate age-related correlations and their impact on surgical techniques., Results: The study revealed that the proximal tibia was the centre of deformity in Japanese varus knees (42.8%), and high tibial osteotomy was frequently indicated (81.6%). Age demonstrated a mild correlation with femoral shaft bowing (r = -0.29), leading to an increase in the mechanical lateral distal femoral angle and to a decrease in the hip-knee-ankle angle and weight-bearing line ratio (r = -0.29, 0.221, 0.219). The tibial shaft bowing was unaffected by age (r = -0.022)., Conclusion: A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates for high tibial osteotomy. No age-related alterations were discerned in tibial morphology, indicating that the occurrence of constitutional varus knees is attributable to tibial deformities in the Japanese patient cohort., Level of Evidence: Level IV., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Introduction: Studies have shown that 2-hole reconstruction plates can be used effectively as tension band plates for temporary hemiepiphysiodesis. However, limited data is available regarding the effectiveness of such plates in terms of complete correction rates. This study was aimed to find out the prevalence of complete correction following temporary hemiepiphysiodesis using 2-hole reconstruction plates among skeletally immature patients with angular deformities around knees., Methods: A descriptive cross-sectional study was carried out among skeletally immature patients with angular deformities around knees undergoing temporary hemiepiphysiodesis after getting approval from the Institutional Review Committee (Reference number: B&BIRC-23-05). The data were collected between 1 January 2012 to 31 December 2018. All skeletally immature patients with angular deformities around knees undergoing temporary hemiepiphysiodesis using 2-hole reconstruction plates were included. Patients who required additional procedures or implants for deformity correction and those who did not provide consent were excluded. Convenience sampling method was used. Point estimate at 95% Confidence Interval was calculated., Results: Among 102 patients, 66 (64.70%) patients achieved complete correction (59.97-69.43 at 95% Confidence Interval). Mean age of the patients was 8.21±3.11 years and 43 (65.15%) were males and 23 (34.84%) were females., Conclusions: The prevalence of complete correction following temporary hemiepiphysiodesis using 2-hole reconstruction plate among skeletally immature patients with angular deformities around knees was lower than that reported in other international studies.

Distal femoral varus osteotomy (DFVO) is a widely recognized surgical procedure used to address valgus malalignment in patients with knee joint disorders. However, it still remains unclear whether anterior cruciate ligament (ACL) reconstruction can be performed in a single procedure along with DFVO. Herein, we present a 73-year-old female patient who developed lateral osteoarthritis of the knee with valgus alignment due to chronic ACL deficiency following a twisting injury during skiing. She was physiologically very active, and strongly demanded to return to sports. We performed a combined procedure involving a medial closing wedge DFVO using an anatomical locking plate, along with double-bundle ACL reconstruction. The postoperative radiograph confirmed successful correction of knee alignment, specifically achieving varus alignment with precise conformance of the anatomical plate to the medial contour of the distal femur following the osteotomy. The patient resumed her previous sports activities without experiencing knee pain. The operated knee demonstrated restored anterior stability, as indicated by negative Lachman test results, and regained full range of motion. Both the Knee Injury and Osteoarthritis Outcome Score and the 2011 Knee Society score demonstrated continuous postoperative improvements over the three-year follow-up period, indicating positive functional outcomes and joint preservation. To the best of our knowledge, this is the first case of medial closing wedge DFVO with anatomic double-bundle ACL reconstruction in the symptomatic femoral valgus deformity with chronic ACL deficiency in the literature.

Background: The present study aims to investigate the frequency of recurrence and tethering effect after only metaphyseal screw removal (sleeper plate technique) compared with the conventional complete plate removal in the treatment of lower extremity deformities with guided growth surgery., Methods: Seventy-two patients (107 limbs) treated by an 8-plate hemiepiphysiodesis technique around the knee joint were evaluated. After the desired correction, only metaphyseal screw was removed (sleeper plate group) in 35 limbs (25 patients), whereas both screws and plate were removed (plate removal group) in 72 limbs (47 patients). An increase of 5 degrees or more in joint orientation angles in the direction of the initial deformity was considered as recurrence. The rate of rebound, tethering, and maintenance of correction in groups was analyzed at the latest follow-up (mean of 49 mo)., Results: The mean age of the patients was 97 months (range: 80 to 129 mo) at the time of index surgery. After a mean of 49 months (range: 16 to 86), 17 (48.5%) limbs maintained the desired stable correction in the sleeper plate group compared with 59 stable limbs (72.2%) in the plate removal group ( P <0.001). There was no statistically significant difference regarding recurrence between the sleeper plate group and the plate removal group (34.3% vs. 27.8%, respectively) ( P =0.216). Reinsertion of the metaphyseal screw was possible 8/12 limbs, and the remaining 4 limbs underwent further surgeries. There were 6 limbs (17.3%) of tethering in the sleeper plate group, and 4/6 limbs required further corrective surgeries. The remaining 2 limbs with slight tethering did not require further surgeries., Conclusions: Removing only metaphyseal screw increases the risk of tethering. In addition, reinsertion of the screw may not be possible in all cases due to bony growth, and further corrective surgeries may be necessary. Close follow-up is required if the sleeper plate technique is to be applied., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tension band plating is widely used in the surgical treatment of coronal plane deformities around the knee. The rebound phenomenon after implant removal is a common complication of this technique. Overcorrection of joint orientation angles is a method to minimize the effect of the rebound phenomenon. This study aims to investigate the natural course of overcorrected joint orientation angles after plate removal in patients with genu valgum deformity., Methods: Patients who underwent hemiepiphysiodesis with tension band plating due to genu valgum deformity between 2010 and 2019 were retrospectively analyzed. Mechanical lateral distal femoral angles (mLDFA) and mechanical medial proximal tibial angles were calculated before plate application, before implant removal, and at the last follow-up. At the implant removal, mLDFA>90 degrees and mechanical medial proximal tibial angles <85 degrees were accepted as overcorrected., Results: Seventy-two segments from 45 patients were included. For femoral valgus deformities (n=59), the mean mLDFAs at index surgery, implant removal, and the last follow-up were 79.8±3.9 degrees, 95.5±3.7 degrees, and 87.3±5.1 degrees, respectively. In the more and less than 10 degrees rebound groups, the median age of patients at index surgery were 66 and 101 months ( P =0.04), the mLDFA during implant removal were 97.8 degrees and 94.4 degrees ( P =0.005), and the mean amount of correction in mLDFA was 17 degrees and 13 degrees ( P =0.001), respectively. At the last follow-up, joint orientation angles were found to be still overcorrected in 16 (22%), within normal limits in 36 (50%), and undercorrected in 20 (28%) segments. Ten (13%) segments required additional surgery due to residual deformity., Conclusions: Overcorrection with tension band plating is an effective modality in the treatment of genu valgum deformity. Rebound after plate removal increases as the age at index surgery decreases and the amount of conscious overcorrection increases. Most segments return to normal joint orientation angle limits after overcorrection. We recommend a mean of 5 degrees routine overcorrection in patients with genu valgum deformity to overcome the rebound phenomenon and to make future interventions easier if ever needed., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Patients with X-linked hypophosphatemic rickets (XLH) often develop coronal plane knee deformities despite medical treatment. Hemiepiphysiodesis is an effective way to correct coronal plane knee deformities in skeletally immature patients, but a full understanding of the rate of angular correction after hemiepiphysiodesis in XLH patients, compared with idiopathic cases is lacking., Methods: We retrospectively reviewed charts of 24 XLH patients and 37 control patients without metabolic bone disease who underwent hemiepiphysiodesis. All patients were treated with standard-of-care medical therapy (SOC=active vitamin D and phosphate salt supplementation) in our clinical research center and had a minimum of 2-year follow-up after hemiepiphysiodesis. Demographic data as well as complications, repeat procedures, or recurrence/overcorrection were recorded. Standing lower extremity radiographs were evaluated before the surgical intervention and at subsequent hardware removal or skeletal maturity, whichever came first. Mean axis deviation, knee zone, mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle were measured on each radiograph. The rate of angular correction was calculated as the change in mLDFA and medial proximal tibial angle over the duration of treatment., Results: The magnitude of the initial deformity of the distal femur was greater in XLH patients as compared with control for varus (XLH mLDFA 97.7 +/- 4.9 vs. Control mLDFA 92.0 +/- 2.0 degrees) and valgus (XLH mLDFA 78.7 +/- 6.2 vs. Controls mLDFA 83.6 +/- 3.2 degrees). The rate of correction was dependent on age. When correcting for age, XLH patients corrected femoral deformity at a 15% to 36% slower rate than control patients for the mLDFA (>3 y growth remaining XLH 0.71 +/- 0.46 vs. control 0.84 +/- 0.27 degrees/month, <3 y growth remaining XLH 0.37 +/- 0.33 vs. control 0.58 +/- 0.41 degrees/month). No significant differences were seen in the rate of proximal tibia correction. XLH patients were less likely to end treatment in zone 1 (55.0% XLH vs. 77.8% control). XLH patients had longer treatment times than controls (19.5 +/- 10.7 vs. 12.6 +/- 7.0 mu, P value <0.001), a higher average number of secondary procedures than controls (1.33 +/- 1.44 vs. 0.62 +/- 0.92 number of procedures), a higher rate of overcorrection than controls (29.2% vs. 5.4%), and a higher rate of subsequent corrective osteotomy than controls (37.5% vs. 8.1%). There was no significant difference in the rate of complications between groups (8.3% vs. 5.4%)., Conclusions: Patients with XLH undergoing hemiepiphysiodesis have a 15% to 36% slower rate of femoral deformity correction that results in longer treatment times, a higher likelihood to undergo more secondary procedures, and a lower likelihood to reach neutral mechanical alignment., Significance: This study provides important information to guide the timing and treatment of patients with XLH and coronal plane knee deformities. In addition, results from this study can be educational for families and patients with respect to anticipated treatment times, success rates of the procedure, complication rate, and likelihood of needing repeat procedures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purposes: Temporary hemiepiphysiodesis (TH) using eight-plates is one of the most frequently performed surgeries for correcting angular deformities of the lower extremities in adolescents. Rarely have studies examined children with X-linked hypophosphataemic rickets (X-LHPR) treated with TH using eight-plates. This study was conducted to investigate the efficacy, the endpoint, and the complications of TH using eight-plates to correct angular deformities of the lower extremities in skeletally immature children., Methods: We reviewed a total of 26 children (86 physes, 52 knees) with X-LHPR (mean age of 6.2 years, range from 2 to 13 years) who underwent TH using eight-plate to correct angular deformities of the lower extremities. Radiographs and clinical records of these patients were evaluated for demographic data and related clinical factors., Results: The average correction of the mechanical lateral distal femoral angle (mLDFA) was 11.7 ± 8.7° (range from 1.0 to 29.7°), and the average correction of the mechanical medial proximal tibial angle (mMPTA) was 8.4 ± 5.0° (range from 0.3 to 16.7°). The mean deformity correction time was 22.7 months (range from 7 to 60 months), and the mean follow-up after eight-plate removal was 43.9 months (range from 24 to 101 months). Overall, 76.9% (20/26 patients) of the angular deformities of the knee were completely corrected and 15.4% (4/26) of the patients received osteotomy surgery. The femoral correction velocity (0.9° per month) was significantly higher than the proximal tibial (0.6° per month) (p = 0.02). The correction velocity of the mLDFA and mMPTA with the TH procedure was faster than that in the absence of intervention (0.9° vs. 0.2°, 0.7° vs. 0.4° per month, p < 0.05). The correction velocity of the mLDFA (1.2° vs. 0.5° per month, [Formula: see text]) and mMPTA (0.7° vs. 0.5° per month, p = 0.04) of patients whose age ≤ five years old was faster than that of patients whose age > five years old. A total of 69.2% (18/26) patients experienced one TH procedure using eight-plates only. Two patients had screw loosening (2/26, 7.7%). One patient (1/26, 3.8%) had a rebound phenomenon after the removal of eight-plate and had the TH procedure again. There was no breakage, infection, physis preclosure, or limited range of movement found in the follow-up., Conclusion: TH using eight-plates is a safe and effective procedure with a relatively low incidence of complication and rebound, and it could be used as part of a streamlined treatment for younger X-LHPR patients with resistant or progressive lower limb deformity despite optimal medical treatment. Early intervention can achieve better results., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose of Review: This study aimed to review the established concepts and advances related to growth modulation for treating knee angular deformities. Although they are considered well tolerated procedures, careful indications and accurate techniques are necessary to ensure good results., Recent Findings: In addition to general clinical and radiographic evaluations, new tools such as two-dimensional low-dose radiography and gait analysis have been used to clarify angular and torsional combinations and the impact of mild angulations on the knee joint. Temporary epiphysiodesis is commonly the choice, and it can be performed with different implants such as staples, tension band plates (TBP), percutaneous transphyseal screws (PETS), sutures, and screws., Summary: Considering its principles, TBP has been preferred for younger children. Cost can be a limitation, and research for alternative implants such as screws and nonabsorbable sutures indicate they might be an alternative in the future. In adolescents, PETS becomes an attractive alternative; however, its reversible character has been controversial, and further studies are needed to establish limits in younger patients., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This cross-sectional study aimed to explore the differences of the medial and lateral sides of the knee joint and precise radiographic abnormalities in contribution to the knee pain and clinical outcomes., Design: Participants 60 years or older who underwent radiographic evaluation were included. Knee radiography was assessed using grading systems of the Osteoarthritis Research Society International (OARSI) atlas. The Japanese Knee Osteoarthritis Measure (JKOM) was evaluated as clinical outcomes. Serum high-sensitivity C-reactive protein (hsCRP) was used to evaluate systemic inflammation. We divided the participants into normal, medial-, lateral-, and medial & lateral-OA types and compared their JKOM using an analysis of covariance. Furthermore, we analyzed the relationship between the knee pain and stiffness of JKOM and the grading of each radiographic feature using a multiple regression model., Results: Lateral- and medial & lateral-OA groups had a significantly worse symptoms in the total and the pain score, especially in movement subscales, in JKOM score. Lateral-OA groups had higher hsCRP than medial-OA group. Multivariate analysis showed that medial joint space narrowing (JSN), and lateral femoral and tibial osteophytes significantly affected knee pain (adjusted odds ratios: 1.73, 1.28, and 1.55, respectively). The radiographic changes are associated with pain more in JSN in the medial side and osteophytes in the lateral side., Conclusion: Lateral- and medial & lateral-OA groups showed worth symptom. In addition, medial JSN and lateral osteophytes have potent effects on the knee pain.

Background: Lateral patellar dislocation (LPD) frequently causes damage to the knee. Injury patterns and risk factors contributing to such injuries have not yet been examined in detail., Methods: We retrospectively analyzed 50 consecutive patients with primary LPD. Two reviewers evaluated the MRI images regarding risk factors for LPD (Dejours classification; Caton-Deschamps Index, CDI; distance from the tibial tuberosity to trochlear groove, TT-TG; trochlear depth, TD) as well as joint damages according to the Whole-Organ Magnetic Resonance Imaging Score (WORMS)., Results: 33 male and 17 female patients with a mean age of 23.2 (±9.6) years were included in this study. 52% were classified Dejours ≥ B, 34% had a CDI ≥ 1.3, 22% a TT-TG ≥ 20mm and 52% a TD < 3mm. 49 out of 50 patients (98%) showed abnormalities according to WORMS. The most frequently observed abnormalities were synovitis/effusion (49/50, 98%), bone marrow oedema (44/50, 88%) and cartilage damage (42/50, 84%). Most frequently affected subregions were medial (41/50, 82%) and lateral (31/50, 62%) patella as well as the anterior (43/50, 86%), central (42/50, 84%) and posterior (11/50, 22%) portion of the lateral femoral condyle. There was no significant correlation between any of the examined risk factors and joint damages according to WORMS. Male patients had higher scores regarding total cartilage damage (5.11 vs. 2.56, p = 0.029), total score for the lateral femorotibial joint (3.15 vs. 1.65, p = 0.026) and overall total WORMS score (12.15 vs. 8.29, p = 0.038)., Conclusion: Risk factors for LPD do not influence the risk of damages to the knee joint after primary LPD. Although LPD is generally known to affect more female than male patients, male patients suffered more severe injuries after primary LPD, particularly of the lateral femorotibial joint. Overall, our results underline the importance of MRI imaging after primary LPD., Competing Interests: The authors have declared that no competing interests exist.

Bartsocas-Papas syndrome (BPS) is a rare autosomal recessive disorder characterized by popliteal pterygia, syndactyly, ankyloblepharon, filiform bands between the jaws, cleft lip and palate, and genital malformations. Most of the BPS cases reported to date are fatal either in the prenatal or neonatal period. Causative genetic defects of BPS were mapped on the RIPK4 gene encoding receptor-interacting serine/threonine kinase 4, which is critical for epidermal differentiation and development. RIPK4 variants are associated with a wide range of clinical features ranging from milder ectodermal dysplasia to severe BPS. Here, we evaluated a consanguineous Turkish family, who had two pregnancies with severe multiple malformations compatible with BPS phenotype. In order to identify the underlying genetic defect, direct sequencing of the coding region and exon-intron boundaries of RIPK4 was carried out. A homozygous transversion (c.481G>C) that leads to the substitution of a conserved aspartic acid to histidine (p.Asp161His) in the kinase domain of the protein was detected. Pathogenicity predictions, molecular modeling, and cell-based functional assays showed that Asp161 residue is required for the kinase activity of the protein, which indicates that the identified variant is responsible for the severe BPS phenotype in the family., (© 2021 Wiley Periodicals LLC.)

Background: Orthopedic manifestations of congenital insensitivity to pain (CIP) can be devastating if left untreated. Knee deformities are common in patients with CIP and might lead to joint destruction and loss of walking ability. The purpose of the present study was to report the results and complications of guided growth procedures around the knee in patients with CIP., Methods: In a retrospective review, all patients with CIP who underwent guided growth procedures around the knee from 2009 to 2017 at a tertiary referral hospital were evaluated. Patients with secondary insensitivity to pain (e.g., syringomyelia), as well as patients with incomplete records, were excluded. Demographic data, clinical findings, correction rate, and complications were recorded., Results: Ten knees in six patients fulfilled the inclusion criteria. The median age was 10 (range, 5-12), with a mean follow-up of 31 months (range, 16-56). Distal femoral tension-band hemiepiphysiodesis was the most common procedure, followed by proximal tibial hemiepiphysiodesis. The mean correction rate was 0.28°/month for femoral deformity. Staples were removed prematurely in one patient due to extrusion. No cases of infection or skin dehiscence were observed. None of the patients needed a reconstructive knee procedure during the study period., Conclusions: The findings of this study suggest that guided growth procedures might have a role in the correction of knee deformities in patients with CIP. However, the correction rate is lower than that of typically developing children, patients should be closely followed to prevent complications, and stringent patient selection criteria should be followed to ensure success.

Background: Historically, total meniscectomy was recommended as the treatment for a symptomatic discoid meniscus. Improved meniscal repair techniques and inferior long-term outcomes associated with meniscectomy have resulted in a trend toward meniscal preservation, with saucerization and repair of meniscocapsular tears. Reoperation rates after treatment of torn discoid menisci vary, with some series reporting high rates of reinjury and reoperation. The purpose of this study is to describe the intermediate-term outcomes of pediatric patients treated with saucerization and meniscocapsular repair of discoid lateral menisci with peripheral rim instability., Methods: A single-institution retrospective review was performed of consecutive patients less than 18 years of age treated with saucerization and repair for a meniscocapsular tear of a discoid lateral meniscus from 2013 to 2017. All patients had a minimum 24-month follow-up. A chart review was performed to describe tear location and repair type. The primary outcomes were revision meniscus surgery and Pedi-International Knee Documentation Committee and Tegner activity scores obtained at the final follow-up., Results: In total, 32 knees in 30 patients, including 15 males and 15 females with a mean age of 12 years (range, 5 to 17 y), were included. Tear patterns included anterior meniscocapsular (14 knees), posterior meniscocapsular (16 knees), and both anterior and posterior meniscocapsular (2 knees). Arthroscopic saucerization and meniscocapsular repair were performed in all knees. Repair types were outside-in (10 knees), inside-out (8 knees), all-inside (8 knees), and hybrid (6 knees). The mean follow-up was 54 months (range, 30 to 86 mo). Three knees (9%) underwent revision meniscus surgery, including 2 all-inside repairs and 1 partial meniscectomy. At the final follow-up, mean International Knee Documentation Committee score was 96 (range, 82 to 100). A total of 89% of patients reported returning to the same or higher level of activity following surgery., Conclusions: Saucerization of discoid lateral menisci with repair of meniscocapsular tears is associated with low rates of revision surgery and good intermediate-term outcomes., Level of Evidence: Level IV.

The fabella is a sesamoid bone present in 30% of the population and, in the majority of cases, it is shown in the proximal head of the lateral gastrocnemius articulating with the lateral femoral condyle. Fabella syndrome is an uncommon disease and it must be considered when dealing with posterolateral pain that increases with extension of the knee. Because of its rarity and underdiagnosis, the literature reports few articles relating to its therapeutic management. The articles reviewed demonstrate that conservative treatment has high recurrence rates, surgical excision being the most effective treatment to eradicate symptoms. We found exceptional articles in the literature related to the surgical treatment of fabella syndrome in professional athletes. In this article we report the surgical experience of a 21-year-old elite swimmer who achievedcomplete pain relief and fast recovery after surgical excision of the fabella., (Copyright © 2020 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Knee ultrasonography has been used effectively as a screening tool for determining risk for knee injuries in athletes. Ultrasonography may be a valuable screening tool for relative risk of noncontact knee injuries that occur over a typical playing career in collegiate American football players. In this prospective longitudinal study, we evaluated American football players ( n  = 48) in an academic institution affiliated with the National Collegiate Athletic Association Division I athletic program. Players underwent comprehensive ultrasonography of both knees prior to beginning their collegiate careers. Anatomic structures were evaluated for presence and severity of abnormalities. Noncontact lower extremity injuries sustained over the collegiate career of the subjects were documented. Data were analyzed for correlations, differences in proportions, and odds ratio (OR). Seventy-nine percent of the athletes had at least one ultrasonographic abnormality, with quadriceps tendon (47.9%) and patellar tendon (39.6%) abnormalities predominating. Seventy-nine percent of players had at least one noncontact lower extremity injury (23.5% involving the knee) during their careers with an average of 2.8 injuries per career. The majority of injuries occurred in the second and third playing years. There was a significantly higher likelihood of patellar tendon injury based on the presence of patellar tendon ultrasonographic pathology ( p  = 0.024; OR = 11x). There was a significantly higher likelihood of quadriceps muscle-tendon injury based on the presence of quadriceps tendon ultrasonography pathology ( p  = 0.0012; OR = 140x). All athletes sustaining meniscal injuries had preexisting joint effusion but no preexisting ultrasonographic meniscal pathology. Knee ultrasonography along with patient history and complete physical examination may help reduce injury risk through education, prevention, and training programs., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: To quantify the prevalence of complete tibial insertion of the biceps femoris tendon in patients presenting for knee MRI scans., Methods: Knee MRI scans over a 4-year period (2014-2018) were accessed at a tertiary referral centre and community-based private practice. A total of 433 scans were reviewed. 30 scans were excluded from the study due to repeat imaging or incomplete coverage of the biceps femoris tendon insertion. Appearances of the distal biceps tendon bony insertion were scrutinized on the remaining 403 scans. Each biceps femoris tendon insertion was classified into one of the four categories-complete fibular insertion, predominant fibular insertion, predominant tibial insertion and complete tibial insertion., Results: Out of the final 403 scans included in the study, five cases of complete tibial insertion of the biceps femoris tendon were identified (just over 1% of the total population). 42 cases were identified as having predominant tibial insertion (10% of the total population). 113 cases had predominantly fibular insertion and 243 cases had complete fibular insertion., Conclusion: Complete anomalous insertion of the biceps femoris tendon on the anterolateral tibia is an uncommon entity. Such an attachment is found in approximately 1% of patients presenting for MRI evaluation of the knee.

Case: We report 2 cases of congenital absence of anterior cruciate ligament with symptomatic knee instability in young children. This report describes the surgical technique and outcomes of extra-articular tenodesis using autogenous iliotibial band (ITB) without drilling across the open physis. Excellent results were observed at a short-term follow-up., Conclusion: Severe symptoms of knee instability even in young children may warrant surgical approach. Extra-articular tenodesis using autogenous ITB in young children is a good option with positive improvements in knee stability and symptomatic relief.

Objective: To explore the short-term effectiveness of arthroscopic combined with dual-plane high tibial osteotomy in the treatment of anterior cruciate ligament injury combined with varus deformity of knee joint. Methods: A retrospective study was performed on 17 patients with anterior cruciate ligament injury combined with varus deformity of knee joint who underwent arthroscopic combined with dual-plane high tibial osteotomy at Department of Bone and Joint, the Affiliated Hospital of Southwest Medical University from January 2017 to June 2018.There were 11 males (11 knees) and 6 females (6 knees), aged 41.3 years (range: 32 to 49 years) .During the surgery, the weight bearing line of lower extremity was set to 62.5% position of the tibial plateau on coronal plane. The tibial slope was adjusted to the normal range on sagittal plane, and anterior cruciate ligament was reconstructed to improve the stability of knee joint.At final follow up, full length weight bearing X ray was used to evaluate the position of weight bearing line, femoral tibial angle and tibial slope pre- and post-operatively.The Lysholm scores, Hospital for Special Surgery score, Tegner knee activity scores and International Knee Documentation Committee (IKDC) scores were used to estimate knee joint function, while the Lachman test, KT-1000 side-to-side difference and pivot-shift test were used to estimate the knee joint stability. Results: The patients were followed up for 1.8 years(range:1.2 to 2.5 years). No complication such as infection, deep vein thrombosis, graft failure, nonunion or delayed union was observed.The weight bearing line was corrected from (28.48±2.24)% preoperatively to (57.43±1.02)% postoperatively ( t= 46.80, P= 0.00) .The femoral tibial angle was improved from (172.31±3.37) ° preoperatively to (178.91±1.34) ° postoperatively( t= 10.46, P= 0.00). The tibial slope was decreased from (14.29±1.26) ° preoperatively to (9.31±0.79) ° postoperatively ( t= 24.59, P= 0.00) . The KT-1000 side-to-side difference decreased from (7.95±1.19) mm preoperatively to (1.79±0.49)mm postoperatively( t= 18.34, P= 0.00). At the last follow-up, Lysholm score, Hospital for Special Surgery score, Tegner score, and the IKDC knee evaluation score of patients showed significant improvement from preoperative( P< 0.05). Conclusion: Arthroscopic combined with dual-plane high tibial osteotomy can get a good short term efficacy in the treatment of anterior cruciate ligament injury combined with varus deformity of knee joint which can significantly improve the alignment of lower extremity and knee joint stability.

Purpose of Review: We present the reader with insight on the most common disorders of the knee in newborns and infants. Knee issues in this population may confuse the first contact physicians due to certain peculiarities of the immature immune system, small size and underdevelopment of joint anatomy. Data presented here are recent and significant, and something to bear in mind when caring for children of this age., Recent Findings: With the advent of new diagnostic methods, a shift in the causative agent of pediatric knee infections has been noted. Minimally invasive methods such as arthrocentesis and arthroscopy are successfully employed in treatment of knee problems in newborns and infants. A trial of conservative therapy in congenital patellar instability can give good results, and obviate the need for surgery in some cases. Various syndromes that affect the knee have specific characteristics that need to be recognized early to avoid problems in the future., Summary: Although rare, knee problems in infants can and do occur. Their cause varies significantly and good outcomes require a multidisciplinary approach. Early diagnosis, referral and initiation of treatment protocols can significantly influence the fate of the joint and with it the patients' functional status for life.

The aim of this study was to examine the effectiveness of Ilizarov method in severe congenital flexion deformity of the knee. This was a retrospective study of eight consecutive bilateral cases (five girls and three boys, with mean age of 4 years, involving 16 knees) with minimum 2-year follow-up. Four patients had multiple congenital contractures and two patients each had popliteal pterygium syndrome and complete tibial hemimelia. All patients were treated with Ilizarov fixator and gradual correction (additional soft tissue releases in three knees). Six patients had bilateral foot and ankle deformity treated with the same fixator, and cases with tibial hemimelia had centralization of fibula and quadriceps reconstruction. Flexion deformity could be corrected in all cases. Mean duration of dynamic phase was 78.5 (55-108) days, that of static phase was 42.4 (7-100) days, and total duration of external fixation was 120.9 (87-186) days. At mean follow-up of 34.5 (23-60) months, flexion deformity improved from the preoperative value of 74.9° (50°-130°) to 13.7° (10°-16°), and passive arc of motion of knee improved from the preoperative value of 38.8° (20°-55°) to 83.6° (55°-110°). Both were statistically significant (P < 0.0001). All patients (previously nonambulatory) were ambulatory with brace and support. All patients faced pin-tract and skin complications that were successfully managed. Ilizarov method is effective in severe congenital flexion deformity of the knee in improving ambulatory status. Realignment of quadriceps mechanism and limb mechanical axis (including ankle and foot deformities) must be given due importance. Minor recurrences of deformity must be expected in all cases.

Background: Radiographic imaging is an important tool to assess osteoarthritis (OA). Lateral compartment osteoarthritis (valgus OA) usually starts with cartilage degeneration along the posterior aspect of the lateral femoral condyle. There is evidence that the posterior-anterior (PA)-flexed view is more sensitive when diagnosing early stages of valgus OA compared to the anterior-posterior (AP) view. The current paper analyzes the value of the PA-flexed view for patients scheduled for total knee arthroplasty (TKA)., Methods: Radiographs of 134 valgus knees were assessed prior to TKA. The minimal joint space width (minJSW) was measured on AP and PA-flexed views. The extent of mechanical deformity was measured on hip to ankle standing films., Results: 49 (36.6%) AP views showed Kellgren and Lawrence (K/L)-grade 4 osteoarthritis in the lateral compartment, 82 (63.4%) showed grade 3 or less. The PA-flexed view resulted in an increased K/L-grading to grade 4 for 53 knees (62.4%) that were considered grade 3 or less on standard AP-radiographs. There was a significant differences between lateral minJSW on AP and PA-flexed view for patients with up to 10 degrees of mechanical valgus deformity (p < 0.001), as well as 11 to 15 degrees of mechanical deformity (p = 0.021). Only knees with severe deformity of more than 15 degrees did not show a difference in minJSW between PA-flexed view and AP view (p = 0.345)., Conclusions: The PA-flexed view is superior to the standard AP view in quantifying the extent of valgus OA in patients with zero to fifteen degrees of valgus deformity. It is recommended for the initial assessment of patients with valgus osteoarthritis and better documents the extent of osteoarthritis prior to TKA.

Background: Cyamella,the sesamoid bones of the popliteus muscle, are rare in humans. Snapping knee is an uncommon problem which can be difficult to diagnose., Case Presentation: In this case, we report a 24-year-old male with snapping knee caused by symptomatic cyamella in the popliteus tendon. A large cyamella was identified upon surgery and was removed. Postoperatively, the patient had immediate relief of preoperative symptoms, and there were no signs of recurrence after 1 years of follow-up., Conclusions: Although not previously suggested, symptomatic cyamella in the popliteus tendon should be considered as part of the differential diagnosis of the snapping knee.

Introduction: To analyze the application of 3D printed osteotomy guide plate-assisted total knee arthroplasty (TKA) for valgus knee deformity., Methods: The clinical data of 20 patients with valgus knee deformity admitted to our hospital from April 2012 to April 2017 were collected and analyzed. According to the treatment method, these patients were divided into two groups: 3D printed osteotomy guide plate-assisted TKA (combined treatment group, n = 10) and TKA (treatment group, n = 10). The operation time, intraoperative bleeding volume, postoperative mean femorotibial angle (MFTA), and Knee Society Score (KSS) of the two groups were statistically analyzed., Results: Compared with the treatment group, the operation time was significantly shorter (P < 0.05), the intraoperative blood loss and postoperative MFTA were significantly decreased (P < 0.05), and the clinical and functional scores were significantly increased (P < 0.05) in the combined treatment group., Conclusion: 3D printed osteotomy guide plate-assisted TKA for valgus knee deformity is more effective than TKA alone.

The integrity of the mammalian epidermis depends on a balance of proliferation and differentiation in the resident population of stem cells 1 . The kinase RIPK4 and the transcription factor IRF6 are mutated in severe developmental syndromes in humans, and mice lacking these genes display epidermal hyperproliferation and soft-tissue fusions that result in neonatal lethality 2-5 . Our understanding of how these genes control epidermal differentiation is incomplete. Here we show that the role of RIPK4 in mouse development requires its kinase activity; that RIPK4 and IRF6 expressed in the epidermis regulate the same biological processes; and that the phosphorylation of IRF6 at Ser413 and Ser424 primes IRF6 for activation. Using RNA sequencing (RNA-seq), histone chromatin immunoprecipitation followed by sequencing (ChIP-seq) and assay for transposase-accessible chromatin using sequencing (ATAC-seq) of skin in wild-type and IRF6-deficient mouse embryos, we define the transcriptional programs that are regulated by IRF6 during epidermal differentiation. IRF6 was enriched at bivalent promoters, and IRF6 deficiency caused defective expression of genes that are involved in the metabolism of lipids and the formation of tight junctions. Accordingly, the lipid composition of the stratum corneum of Irf6 -/- skin was abnormal, culminating in a severe defect in the function of the epidermal barrier. Collectively, our results explain how RIPK4 and IRF6 function to ensure the integrity of the epidermis and provide mechanistic insights into why developmental syndromes that are characterized by orofacial, skin and genital abnormalities result when this axis goes awry.

Purpose: The aim of this study was to assess whether preoperative valgus or varus deformity affected survivorship after total knee arthroplasty (TKA) and to quantify the risk factors for implant failure in a registry-based population., Methods: The Emilia-Romagna Registry of Prosthetic Orthopedic Implants was examined regarding TKAs performed on patients with a preoperative diagnosis of valgus or varus deformity. Demographics, implant characteristic and survivorships were investigated and compared. A total of 2327 TKA procedures performed from 2000 to 2016 were included in the study. Six hundred and forty primary TKAs with a diagnosis of valgus deformity were evaluated with a median follow-up of 3.3 years; 1687 primary TKAs with a diagnosis of varus deformity were evaluated with a median follow-up of 2.5 years., Results: Bi-compartmental, cemented posterior stabilised fixed-bearing implants were preferred. For both diagnoses, the implant survivorship rate was greater than 98% in the first year. However, the survival curve of the TKAs implanted for valgus deformity showed a greater slope in the first 3 years as compared to the survival curve of those implanted for varus deformity. Valgus deformity had a 2.1-fold higher risk for revision as compared with varus deformity. Infection was a major cause of implant failure in TKAs for varus deformity, 9/24 (37.5%), while its incidence was lower for valgus deformity, 1/21 (4.8%)., Conclusions: Preoperative valgus alignment showed a twofold risk of failure as compared to varus alignment after TKA. This should be considered in daily practice, and surgeons are called on to pay more attention when performing TKAs on such patients. Prospective randomised controlled trials are, therefore, necessary to better understand the role of preoperative coronal knee deformity in implant failure., Level of Evidence: Prognostic study, level III.

Background: With observed success and increased popularity of growth modulation techniques, there has been a trend toward use in progressively younger patients. Younger age at growth modulation increases the likelihood of complete deformity correction and need for implant removal before skeletal maturity introducing the risk of rebound deformity. The purpose of this study was to quantify magnitude and identify risk factors for rebound deformity after growth modulation., Methods: We performed a retrospective review of all patients undergoing growth modulation with a tension band plate for coronal plane deformity about the knee with subsequent implant removal. Exclusion criteria included completion epiphysiodesis or osteotomy at implant removal, ongoing growth modulation, and <1 year radiographic follow-up without rebound deformity. Mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, hip-knee-ankle angle (HKA), and mechanical axis station were measured before growth modulation, before implant removal, and at final follow-up., Results: In total, 67 limbs in 45 patients met the inclusion criteria. Mean age at growth modulation was 9.8 years (range, 3.4 to 15.4 y) and mean age at implant removal was 11.4 years (range, 5.3 to 16.4 y). Mean change in HKA after implant removal was 6.9 degrees (range, 0 to 23 degrees). In total, 52% of patients had >5 degrees rebound and 30% had >10 degrees rebound in HKA after implant removal. Females below 10 years and males below 12 years at time of growth modulation had greater mean change in HKA after implant removal compared with older patients (8.4 vs. 4.7 degrees, P=0.012). Patients with initial deformity >20 degrees had an increased frequency of rebound >10 degrees compared with patients with less severe initial deformity (78% vs. 22%, P=0.002)., Conclusions: Rebound deformity after growth modulation is common. Growth modulation at a young age and large initial deformity increases risk of rebound. However, rebound does not occur in all at risk patients, therefore, we recommend against routine overcorrection., Level of Evidence: Level IV-retrospective study.

Rationale: Valgus knees are relatively rare in the clinic. Treatments for valgus deviations >90° represent a surgical challenge to achieve a balance between the soft tissue and bone and prevent nerve damage., Patient Concerns: A 63-year-old woman with valgus deviations >90° in both knees complained that she had been unable to walk for 50 years., Diagnoses: Congenital malformation valgus deformity., Interventions: Bilateral total knee arthroplasty (TKA) was performed using a rotating hinge knee instrument from Endo-Model for axial correction and stabilization of the joint., Outcomes: The patient fully recovered 3 months after surgery. At the follow-up 6 years after the operation, the function of the knee joint clearly improved. The knee society score (KSS) increased from 35 to 90., Lessons: Constrained implants are commonly used to stabilize the joint and correct the bone axis in patients with severe ligamental instability, gross deformity, bone loss, and extreme deviation of the straight leg axis. Intraoperative exploration of the common peroneal nerve and the postoperative flexed position of the knee joints could help prevent nerve injuries.

Malalignment of the lower limb is a significant factor in the progression of arthritis of the knee and ankle, and correction of deformity can slow the progress and reduce symptoms. It is less clear that malalignment can cause arthritis de novo, but in post traumatic deformity it has been shown that a fracture of the tibia can increase the risk of pain and stiffness of the knee and ankle irrespective of deformity. The management of deformity of the lower limb by external fixation requires a careful systematic method of deformity analysis combining clinical and radiographic assessment is essential to avoid the pitfalls of overlooking potential soft tissue problems, and hidden secondary deformities. External fixators are powerful tools for the correction of deformity, but a sound grounding in deformity analysis is essential., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Osteoarthritis (OA) is the most common disabling joint disease throughout the world and its therapeutic effect is still not satisfactory in clinic nowadays. Recent studies showed that the exosomes derived from several types of mesenchymal stem cells (MSCs) could maintain chondrocyte homeostasis and ameliorate the pathological severity of OA in animal models, indicating that MSCs-derived exosomes could be a novel promising strategy for treating OA. In this study, we investigated the role and underlying mechanisms of infrapatellar fat pad (IPFP) MSCs-derived exosomes (MSC IPFP -Exos) on OA in vitro and in vivo. Our data revealed that MSC IPFP could produce amounts of MSC IPFP -Exos, which exhibited the typical morphological features of exosomes. The MSC IPFP -Exos ameliorated the OA severity in vivo and inhibited cell apoptosis, enhanced matrix synthesis and reduced the expression of catabolic factor in vitro. Moreover, MSC IPFP -Exos could significantly enhance autophagy level in chondrocytes partially via mTOR inhibition. Exosomal RNA-seq showed that the level of miR-100-5p that could bind to the 3'-untranslated region (3'UTR) of mTOR was the highest among microRNAs. MSC IPFP -Exos decreased the luciferase activity of mTOR 3'UTR, while inhibition of miR-100-5p could reverse the MSC IPFP -Exos-decreased mTOR signaling pathway. Intra-articular injection of antagomir-miR-100-5p dramatically attenuated MSC IPFP -Exos-mediated protective effect on articular cartilage in vivo. In brief, MSC IPFP -derived exosomes protect articular cartilage from damage and ameliorate gait abnormality in OA mice by maintaining cartilage homeostasis, the mechanism of which may be related to miR100-5p-regulated inhibition of mTOR-autophagy pathway. As it is relatively feasible to obtain human IPFP from OA patients by arthroscopic operation in clinic, MSC IPFP -derived exosomes may be a potential therapy for OA in the future., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: We evaluated the compensatory change in ankle alignment due to knee malalignment and its relationship with varus knee deformities, as well as sex differences in compensation., Methods: From October 2016 to September 2017, 103 patients with end-stage knee osteoarthritis underwent primary total knee arthroplasty (TKA). Ninety-five knees (78 patients) were included. The hip-knee-ankle angle (HKA) and ankle alignment and tilt were evaluated with full-leg standing anteroposterior radiographs. The ankle alignment was estimated according to the tibiotalar angle, tibial anterior surface angle (TAS), and lateral distal tibial angle. The talar tilt angle (TT), anatomical talocrural angle, angle between the tibial plateau and distal tibial plafond, angles between the ground and distal tibial plafond, and angles between the ground and upper talus were measured to evaluate ankle tilt. The patients were separated into two sex-based groups; correlations between the HKA and ankle parameters were estimated., Results: The mean HKA in men and women was 8.16 ± 4.36° and 7.69 ± 5.93°, respectively. The relative tilt of the talus and distal tibia plafond to the ground was increased when varus knee deformities progressed. In women, there was a positive correlation between the knee alignment and TAS (r = - 0.295, p = 0.016). As the knee mechanical axis became more varus, the distal tibia plafond became more valgus. In women, a negative correlation was observed between the HKA and TT (r = - 0.359, p = 0.003). Compensatory changes in the ankle alignment and TT to knee alignment were not observed in men., Conclusion: Compensatory ankle changes should be considered before TKA.

Variants in IRF6 can lead to Van der Woude syndrome and popliteal pterygium syndrome. Furthermore, genes upstream and downstream of IRF6, including GRHL3 and TP63, are also associated with orofacial clefting. Additionally, a variant in an enhancer (MCS9.7) that regulates IRF6 is associated with risk for isolated orofacial clefting. This variant (rs642961) abrogates AP2A protein binding at MCS9.7. Here, we found that AP2A protein regulates MCS9.7 enhancer activity in vivo and IRF6 protein expression in epidermal development. In addition, loss of IRF6 leads to supra-basal expression of AP2A protein. Finally, using an IRF6 allelic series, we found that either increasing or decreasing IRF6 protein expression can destabilize AP2A protein expression in vivo. These data suggest that IRF6 regulates AP2A protein level in epidermal development. Therefore, we conclude that IRF6 and TFAP2A are part of a genetic regulatory network that is critical in epithelial development, with implications for both orofacial and cutaneous tissues. Our work provides in vivo, functional data to explain the relationship between AP2A protein binding and the MCS9.7 enhancer in orofacial clefting. This work is important because the MCS9.7 enhancer element contains a variant that abrogates AP2A protein binding and increases risk for orofacial clefting worldwide., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Reasons for dissatisfaction with total knee arthroplasty (TKA) include unequal flexion or extension gap, soft tissue imbalance, and patella maltracking, which often occur with mismatch between femoral and tibial coronal bony alignment in the knee joint or extremely varus or valgus alignment. However, lower limb coronal alignment classification is based only on hip-knee-ankle angle (HKAA), leading to oversight regarding a mismatch between femoral and tibial coronal alignment. We aimed to classify alignment of the lower limbs according to the mechanical alignment of the femur and tibia in a healthy population., Methods: All 214 normal triple films were reviewed retrospectively. HKAA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), angle between the femoral anatomical axis and the mechanical axis (AA-MA), and knee alignment angle (KAA) were measured. Subjects were categorized into one of five types based on the mechanical alignment of femur and tibia., Results: Mean HKAA, mLDFA, and mMPTA of all subjects were 1.2°, 87.3°, and 85.8°, respectively. All subjects were classified into one of five types with significant differences (p < 0.001). About 61% of subjects showed neutral alignment, of which nearly 40% were type 2 (valgus of the femur and varus of the tibia with oblique joint line: mLDFA 85.0° ± 1.4°, mMPTA 85.1° ± 1.2°, TJLA 2.7° ± 2.4°) and 60% exhibited neutral alignment with a neutral femur and tibia (type 1). In varus and valgus types, mismatch between the mechanical angle of the femur and tibia was common. Varus alignment, including types 3 (varus of the tibia: mLDFA 88.0° ± 1.4°, mMPTA 83.5° ± 1.6°) and 4 (varus of both the tibia and femur: mLDFA 91.4° ± 1.4°, mMTPA 85.2° ± 2.0°), was found in 30% of subjects. Valgus alignment (type 5 valgus of femur: mLDFA 84.6° ± 1.6°, mMPTA 88.8° ± 2.0°) accounted for 8.9% of all subjects., Conclusions: Mismatch between mechanical alignment of the femur and tibia was common in varus and valgus alignment types. Joint line obliquity was also observed in 40% of the neutral alignment population. This classification provides a quick, simple interpretation of femoral and tibial coronal alignment, and more detailed guidance for preoperative planning for TKA than the traditional varus-neutral-valgus classification.

Case: Isolated patella absentia is an extremely rare phenomenon, with only a few published cases and even fewer follow-up reports. Nearly 40 years after the initial presentation of 2 brothers with bilateral congenital absence of the patella and the publication of a case report, we report the clinical and radiographic findings of their subsequent tibiofemoral osteoarthritis, which was treated with bilateral total knee arthroplasty., Conclusion: Understanding the biomechanical complications associated with congenital absence of the patella as it relates to a stable knee is vital; in the case of degenerative changes, total knee arthroplasty appears to provide a long-term solution for these patients.

Purpose: The aim of this systematic review is to compare the clinical outcomes of patients treated with different trochleoplasty procedures, the rate of complications and recurrence of patellar dislocation., Methods: A systematic review of the literature was performed, in accord with the PRISMA guidelines. PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases were comprehensively searched using the keyword combinations, "Dejour trochleoplasty", "Bereiter Trochleoplasty", "Albee Trochleoplasty", "Recession Trochleoplasty", "Trochlear Dysplasia", "Instability", "Adult", "Clinical Outcome" and "Surgery"., Results: Three-hundred and ninety-two knees in 371 patients were included. Bereiter U-shaped deepening trochleoplasty was the most commonly used technique for the treatment of trochlear dysplasia in the included studies with the lowest rate of recurrence and post-operative ROM deficiency. On the other hand, Dejour V-shaped deepening trochleoplasty showed the highest mean post-operative value of Kujala score with 79.3 (SD 8.4) points. Statistical differences were found in terms of redislocation rate between Goutallier procedure and Bereiter trochleoplasty (p < 0.05) and in terms of post-operative osteoarthritis between Bereiter and Dejour procedures (p < 0.05)., Conclusion: Bereiter trochleoplasty seems to be the most efficiency procedure in terms of post-operative patellar redislocation, post-operative osteoarthritis and ROM, but the highest mean post-operative Kujala score is obtained by Dejour procedure. Therefore, none of the surgical techniques analysed highlighted a real superiority. Randomised clinical trials are needed to establish whether of available surgical technique is the best to treat patient with trochlear dysplasia. The clinical relevance of this paper is that the three most popular trochleoplasty techniques are associated with significantly improved stability and function, showing a relatively low rate of osteoarthritis and pain, and a moderate rate of complications., Level of Evidence: Systematic review, Level IV.

: Van der Woude syndrome is the most generic form of syndromic orofacial cleft, present in approximately 2% of all cleft patients. The lower lip pits with or without cleft lip and/or palate is typical of this syndrome. Popliteal pterygium syndrome (PPS), also known as popliteal web syndrome or fasciogenito-popliteal syndrome, was first described by Trelat in 1869, the incidence is approximately 1 in 300,000 live births. The term PPS was coined by Gorlin et al in 1968 based on the most unusual anomaly, the popliteal pterygium. Popliteal pterygium syndrome shares features with van der Woude syndrome but, in addition, is characterized by genital anomalies, syndactyly of fingers and toes, and toenail dysplasia. In some patients, oral or eyelid synechiae are present. Van der Woude syndrome and PPS are autosomal dominantly inherited disorders caused by heterozygous mutations in IRF6. OBJECTIVE:: To report the familial nature of the disease in the mother and son, and to summarize the clinical characteristics, treatment, and outcomes in both patients.

Background: While many surgical techniques can achieve neutral limb alignment and soft tissue balance in severe valgus deformity during total knee arthroplasty (TKA), few published reports concern medial femoral epicondyle up-sliding osteotomy., Methods: A prospective investigation was conducted of patients with severe valgus deformities who underwent medial femoral epicondyle up-sliding osteotomy. Clinical measurements, radiological evaluation, and complication data were recorded., Results: Using posterior-stabilized prostheses, 26 patients underwent 28 TKAs performed by the same surgeon using medial femoral epicondyle up-sliding osteotomy to balance the soft tissue. On average, the follow-up was 54 ± 18 months, and the patient age was 63 ± 11 years. All knees were type II according to Krackow's classification. Varus-valgus knee motion was prohibited with the protection of long-leg knee brace for 3 months. At the last follow-up, the Knee Society function score, Hospital for Special Surgery knee-rating scale, and range of motion were 94 ± 6, 91 ± 4, and 116° ± 8°, respectively. All knees were stable laterally, whereas 2 knees had mild medial laxity and the others were stable. The hip-knee-ankle angle, femorotibial angle, condylar-hip angle, plateau-ankle angle, and valgus angle were 179.9° ± 3.4°, 172.9° ± 3.6°, 89.8° ± 2.5°, 90.2° ± 1.1°, and 7.3° ± 3.5°, respectively., Conclusion: Medial femoral epicondyle up-sliding osteotomy during TKA in patients with severe valgus deformities facilitates the restoration of lower limb alignment, soft tissue balance, and knee stability., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Congenital dislocation of the patella is a rare and difficult pathology to treat. We present a case of bilateral congenital dislocation of the patella with synostosis of proximal tibiofibular and proximal radioulnar joints without genu valgum deformity of both knees in a 30-year-old man. To our knowledge, congenital dislocation of the patella associated with synostosis of proximal tibiofibular and proximal radioulnar joints has not been reported in the literature yet.

Femoral bifurcation and tibial hemimelia are rare anomalies described as a variant of Gollop-Wolfgang complex. This article presents a case of Gollop-Wolfgang complex without hand ectrodactyly. A 5-year old patient presented with bilateral tibial hemimelia and left femoral bifurcation. The patient's left limb lacked knee extensor mechanism, disarticulation was done. The right leg which had Jones type 2 tibia hemimelia was treated with tibiofibular synostosis. Currently patient is ambulant with prosthesis on the left limb and ankle foot orthosis on the right. In the absence of proximal tibial anlage, especially in patients with femoral bifurcation, the knee should be disarticulated. Tibiofibular synostosis is a good choice in the presence of a proximal tibial anlage with good quadriceps function.

Objective: To assess the efficiency of knee-ankle-foot orthoses for treating painful genu recurvatum, and to determine users' tolerance and satisfaction., Patients: Patients included in the study had a genu recurvatum during the stance phase, confirmed by a medical doctor on physical examination. A total of 27 patients with 31 knee-ankle-foot orthoses were included., Methods: The main outcome was scored on a verbal numerical rating scale (VNRS) before and at least 3 months after a knee-ankle-foot orthosis was fitted, and scored on a verbal numerical pain rating scale (VRS). Secondary outcomes were rated with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST)., Results: After fitting the knee-ankle-foot orthosis, the median VNRS pain score decreased from 85/100 to 25/100 (p ≤ 0.001) and the description of pain on the VRS decreased from "extreme" to "mild" (p ≤ 0.001). The QUEST total score was 4.0., Conclusion: Treating a painful genu recurvatum with a knee-ankle-foot orthosis reduced the pain efficiently whatever the patients' diagnosis, and high scores were obtained for patients' satisfaction.

We discuss the pediatric patella, with an emphasis on diagnostic imaging. Topics include normal patellar development, anatomical variants and their physiologic significance, genetic syndromes that alter the appearance of the patella, physiology of patellar tracking and stability, patellofemoral instability, and injury patterns and classification. Recognition of appropriate development on imaging prevents diagnostic error and unnecessary evaluation. Knowledge of the pertinent features of syndromes associated with morphological patellar abnormalities can aid in generating a succinct and relevant differential diagnosis. In patellofemoral instability, the patient's baseline anatomy, factors that predispose to instability, and the specific injuries that occur as a result are critical considerations for determining the course of treatment. Patellar sleeve fractures are unique to pediatric patients, and timely identification is critical to achieving an optimal treatment outcome., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This study aimed to assess the incidence of genu recurvatum without neuromuscular disorders in knees that underwent navigation-assisted total knee arthroplasty (TKA), to evaluate short-term radiologic and clinical results of navigation-assisted TKA in genu recurvatum, and to evaluate differences in results according to the degree of pre-operative hyperextension and type of implant and insert., Methods: This study retrospectively reviewed 510 knees that underwent navigation-assisted TKA from January 2005 to December 2011. The incidence of knees that showed hyperextension of ≥5° (genu recurvatum) on navigation, and the accompanying alignment were evaluated. It assessed radiologic, intraoperative, and clinical results in recurvatum and control groups by using propensity score matching., Results: A total of 465 knees underwent navigation-assisted TKA for degenerative osteoarthritis. Genu recurvatum was observed in 55 knees (11.8%). Of these, 41 knees (74.5%) had degree of hyperextension between five degrees and 10°, and 47 (85.4%) had varus alignment. The thickness of the resected distal femur in the recurvatum group (7.6±1.6mm) was less than that in the control group (8.4±1.4mm, P=0.001). The thickness of the insert in the recurvatum group (12.5±2.3mm) was greater than in the control group (10.8±1.5mm, P<0.001). The sagittal alignment at the final follow-up was 1.3±3.4° in the control group and -0.1±0.7° in the recurvatum group (P=0.003). Subgroup analyses in the recurvatum group showed no significant difference in sagittal alignment and patient-related outcomes by degree of pre-operative hyperextension and implant/insert type (P>0.05 for all parameters)., Conclusions: Genu recurvatum was not uncommon among patients undergoing primary TKA. This review obtained satisfactory short-term clinical and radiologic results, with a smaller distal femoral resection and thicker insert., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: According to the severity of knee valgus, different operative approaches were applied in total knee replacement. Hence, we assessed the safety and efficacy of different operative approaches in the level IV study., Methods: From May 2011 to March 2014, a retrospectively analysis was conducted among 31 patients with knee valgus (mild in 10 cases, moderate in 8 cases and severe in 13 cases based on Keblish grade). Medial approach trip knee replacement was performed in mild and moderate patients, which were assigned as medial approach group. Lateral approach was performed in severe patients, which was assigned as lateral approach group. Relevant results were compared between medial approach group and lateral approach group, including valgus corrected angle, postoperative knee joint activity and Kss score. Furthermore, operative time, postoperative blood loss, patellar trajectory and anterior knee pain were also compared between the two groups., Results: All operations were successful without obvious complications. In medial approach group, postoperative knee valgus angle was (7 ± 1)°. Three months after operation, degree of knee joint activity was (85.2 ± 5.2)°, and KSS score of knee joint was (80.1 ± 5.2). Significant differences were detected in these compared with preoperative data (all P < .05). Moreover, similar results were found in lateral approach group with postoperative knee valgus angle as (8.2 ± 2.3)°, degree of knee joint activity three months after operation as (85.2 ± 5.3)°, and KSS score of knee joint as (80.3 ± 3.2). However, no significant differences were found among these three groups in operative time, postoperative blood loss, patellar trajectory or anterior knee pain., Conclusions: Different operative approaches in total knee replacement according to the severity of knee valgus were proved as effective and safe procedures, which deserved further application., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

This retrospective cohort study examined 20 patients (48 physes), 11 boys and nine girls, who were treated with hinge-plate or eight-plate. The mean age of the patients at surgery was 11.9±2.6 years. The mean follow-up duration was 13±2.7 months. The radiographic measurement of both distal femoral and proximal tibial deformity showed significant correction, with no difference between the hinge-plate and the eight-plate. Both screw divergence angle and the hinge angle showed significant changes at the last follow-up. The deformity correction of the distal femoral physis was quicker than the proximal tibial physis. The rate of mechanical femoral-tibial angle correction was 0.97°/month if both femoral and tibial physes were treated., Level of Evidence: III.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

A 22-year-old male patient admitted to our clinic with mild pain in left knee. Pain had started 10 years ago and there was no history of trauma. Pain was increased with kneeling. No abnormality was detected on physical examination. Imaging results revealed proximal tibiofibular synostosis in left knee.