Case Report: Locking Plate for Cubitus Varus Correction in a 7-Year-Old Girl With Osteogenesis Imperfecta

Background: Cubitus varus deformity is a common complication of untreated elbow fractures in children. However, cubitus varus in osteogenesis imperfecta (OI) children is a rare but challenging situation. To the author's knowledge, this is the first study discussing the correction of cubitus varus deformity in patient with OI.Case Presentation: Here we report a case of a 7-year-old OI girl with cubitus varus deformity due to a supracondylar fracture of humerus 3 year ago. The patient's parent gave a history of supracondylar fracture of left humerus in 2015. Without medical intervention, the patient was admitted into our institution for corrective surgery with the diagnosis of osteogenesis imperfecta and cubitus varus deformity in the left arm.Result: Medications including calcium, vitamin D and bisphosphonates were administered before the corrective surgery of cubitus varus, and a single locking plate was used to fixate the osteotomy. After the surgery, the appearance and range of motion (ROM) of the left arm was almost normal. Combined with gradual rehabilitation, the ROM of the left arm was normal without pain during daily use within the 1-year follow up. The hardware was removed as the nailing of the forearm fractures was performed at the same time. In the latest follow-up in September 2021, the appearance and ROM of the left arm was normal.Conclusion: Cubitus varus is a common deformity in children with elbow injuries, but it presents a challenging situation in compound fractures in OI patients. Locking plate combined with meticulous pharmacological intervention provides a good option for corrective surgery of cubitus varus in patients with OI.

Accuracy of CT-Derived Patient-Specific Instrumentation for Total Ankle Arthroplasty: The Impact of the Severity of Preoperative Varus Ankle Deformity

Background Significant preoperative varus tibiotalar deformity was once believed to be a contraindication for total ankle arthroplasty (TAA). Our primary goal was to evaluate the influence of increasing preoperative varus tibiotalar deformity on the accuracy of final implant positioning using computed tomography (CT)-derived patient-specific guides for TAA. Methods Thirty-two patients with varus ankle arthritis underwent TAA using CT-derived patient-specific guides. Patients were subcategorized into varying degrees of deformity based on preoperative tibiotalar angles (0°-5° neutral, 6°-10° mild, 11°-15° moderate, and >15° severe). Postoperative weightbearing radiographs were used to measure coronal plane alignment of the tibial implant relative to the target axis determined by the preoperative CT template. Average follow-up at the time of data collection was 36.8 months. Results Average preoperative varus deformity was 6.06° (range: 0.66°-16.3°). Postoperatively, 96.9% (30/31) of patients demonstrated neutral implant alignment. Average postoperative tibial implant deviation was 1.54° (range: 0.17°-5.7°). Average coronal deviation relative to the target axis was 1.61° for the neutral group, 1.78° for the mild group, 0.94° for the moderate group, and 1.41° for the severe group (P = .256). Preoperative plans predicted 100% of tibial and talar implant sizes correctly within 1 size of actual implant size. Conclusion. Our study supports the claim that neutral postoperative TAA alignment can be obtained using CT-derived patient-specific instrumentation (PSI). Furthermore, final implant alignment accuracy with PSI does not appear to be impacted by worsening preoperative varus deformity. All but one patient (96.9%) achieved neutral postoperative alignment relative to the predicted target axis. Level of Evidence: Level IV, Clinical Case Series

Genome-wide association study identifies SNPs for growth performance and serum indicators in Valgus-varus deformity broilers (Gallus gallus) using ddGBS sequencing

Background Valgus-varus deformity (VVD) is a lateral or middle deviation of the tibiotarsus or tarsometatarsus, which is associated with compromised growth, worse bone quality and abnormal changes in serum indicators in broilers. To investigate the genetic basis of VVD, a genome wide association study (GWAS) was performed to identify candidate genes and pathways that are responsible for VVD leg disease, serum indicators and growth performance in broilers. Results In total, VVD phenotype, seven serum indicators and three growth traits were measured for 126 VVD broilers (case group) and 122 sound broilers (control group) based on a high throughput genome wide genotyping-by-sequencing (GBS) method. After quality control 233 samples (113 sound broilers and 120 VVD birds) and 256,599 single nucleotide polymorphisms (SNPs) markers were used for further analysis. As a result, a total of 5 SNPs were detected suggestively significantly associated with VVD and 70 candidate genes were identified that included or adjacent to these significant SNPs. In addition, 43 SNPs located on Chr24 (0.22 Mb - 1.79 Mb) were genome-wide significantly associated with serum alkaline phosphatase (ALP) and 38 candidate genes were identified. Functional enrichment analysis showed that these genes are involved in two Gene Ontology (GO) terms related to bone development (cartilage development and cartilage condensation) and two pathways related to skeletal development (Toll−like receptor signaling pathway and p53 signaling pathway). BARX2 (BARX homeobox 2) and Panx3 (Pannexin 3) related to skeleton diseases and bone quality were obtained according to functional analysis. According to the integration of GWAS with transcriptome analysis, HYLS1 (HYLS1 centriolar and ciliogenesis associated) was an important susceptibility gene. Conclusions The results provide some reference for understanding the relationship between metabolic mechanism of ALP and pathogenesis of VVD, which will provide a theoretical basis for disease-resistant breeding of chicken leg soundness.

Restoration of Native Leg Length After Opening-Wedge High Tibial Osteotomy: An Intraindividual Analysis

Background: Opening-wedge high tibial osteotomy (OWHTO) has been shown to significantly increase leg length, especially in patients with large varus deformity. Thus, the current literature recommends closing-wedge high tibial osteotomy to correct malalignment in these patients to prevent postoperative leg length discrepancy. However, potential preoperative leg length discrepancy has not been considered yet. Hypothesis: It was hypothesized that patients have a decreased preoperative length of the involved leg compared with the contralateral side and that OWHTO would subsequently restore native leg length. Study Design: Case series; Level of evidence, 4. Methods: Included were 67 patients who underwent OWHTO for unilateral medial compartment knee osteoarthritis and who received full leg length assessment pre- and postoperatively. Patients with varus or valgus deformity (>3°) of the contralateral side were excluded. A musculoskeletal radiologist assessed imaging for the mechanical axis, full leg length, and tibial length of the involved and contralateral lower extremity. Statistical analysis determined the pre- and postoperative leg length discrepancy and the influence of the mechanical axis. Results: Most patients (62.7%) had a decreased length of the involved leg, with a mean preoperative mechanical axis of 5.0° ± 2.9°. Length discrepancy averaged –2.2 ± 5.8 mm, indicating a shortened involved extremity ( P = .003). OWHTO significantly increased the mean lengths of the tibia and lower limb by 3.6 ± 2.9 and 4.4 ± 4.7 mm ( P < .001), leading to a postoperative tibial and full leg length discrepancy of 2.8 ± 4.3 mm and 2.2 ± 7.3 mm ( P < .001 and P = .017, respectively). Preoperative leg length discrepancy was significantly correlated with the preoperative mechanical axis of the involved limb ( r = 0.292; P = .016), and the amount of correction was significantly associated with leg lengthening after OWHTO ( r = 0.319; P = .009). Patients with a varus deformity of ≥6.5° (n = 14) had a preoperative length discrepancy of –4.5 ± 1.6 mm ( P < .001) that was reduced to 1.8 ± 3.5 mm ( P = .08). Conclusion: Patients undergoing OWHTO have a preoperative leg length discrepancy that is directly associated with the varus deformity of the involved extremity. As OWHTO significantly increases leg length, restoration of native leg length can be achieved particularly in patients with large varus deformity.

Use of External Approach for Severe Genu Valgo Knee Arthroplasty

The deformities of the lower limbs (genu valgus and genu varus) are alterations frequently developed properly by physiological processes which usually disappear at 2 years (genu varus) and at 7-8 years (genu valgus), being considered in adults normal a 4º-6º genu valgus, however the appearance of the latter is also related to various metabolic pathologies, tumors, traumatic sequelae, infections, skeletal dysplastic and idiopathic genu valgus. In the bibliography, there is a greater consensus on the approach to varus deformity, not so in valgus deformities, where there is no bibliography with a level of evidence that defines established protocols to treat severe valgus deformities>20, currently good treatment results have been demonstrated by means of knee arthroplasty to correct genu valgus deformities, which showed good results in the alignment of the lower extremities through the balance of ligaments in patients with severe genu valgus with pain reduction. , improvements in knee function and with a low rate of complications, the use of these alternatives such as the external approach in total knee replacement in patients with severe genu valgus and medial collateral ligament insufficiency allows correcting large deformities using a technique simple and in most cases without the use of a prosthesis that generates a degree of constraint, progressively improving their living conditions.

Double-Level Osteotomy in Severe Varus Malalignment to Optimize Knee Joint Restoration

Background: Lower extremity alignment-correcting procedures for unicompartmental osteoarthritis are experiencing a rapid rise. Medial open-wedge high tibial osteotomy (MOW-HTO) thereby represents the most common technique among osteotomies but is limited in cases of severe malalignment. Some cases make a double-level osteotomy necessary. Indications: If planning of malalignment correction using a MOW-HTO results in a mechanical medial proximal tibial angle (mMPTA) of more than 93° (causing an oblique joint line), double-level osteotomy is indicated to avoid nonphysiological knee kinematics. Technique Description: After clinical examination and detailed analysis of malalignment (full-weight-bearing long-leg radiograph: hip-knee-angle [HKA], mMPTA, mechanical lateral distal femoral angle [mLDFA], joint line convergence angle [JLCA]), as well as individualized planning of the correction, the surgical procedure starts with an arthroscopy to evaluate the cartilage conditions and eventually treat intraarticular pathologies. Then, the femoral supracondylar correction is performed (closed wedge, biplanar osteotomy [ to increase bony healing]) according to the presurgical planning by resecting the osteotomy wedge with the measured length. K-wires are placed to check the correction. An angle-stable plate is used for osteosynthesis. The wedge taken out will be used as bone stock for the MOW-HTO afterward. The biplanar open-wedge tibial osteotomy is then performed subsequently using a medial tibial approach and an angle-stable plate. Opening of the osteotomy is then performed and double checked with intraoperative fluoroscopy using an alignment rod. Postoperative partial weight bearing for 6 weeks is recommended. Results: In recent literature, only few publications report on results of double-level osteotomies. Babis et al reports that it is a valuable procedure for patients with large varus deformity. Nakayama et al noted a significant improvement in patient-registered clinical outcomes in early postoperative evaluation of 20 patients. Schröter et al reports on 37 knees and findings include good clinical results, despite progressive osteoarthritis. Discussion/Conclusion: In cases of severe malalignment, adequate axis correction may require a double-level osteotomy. Exact preoperative planning is essential. Results reported in recent publications are promising. By splitting 1 large correction into 2 smaller ones, complications like hinge fracture and delayed bone healing are lowered.