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Figure A
50%
207/416
Figure B
6%
26/416
Figure C
19%
78/416
Figure D
22%
91/416
Figure E
3%
12/416
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Given this patients excessive valgus alignment, he would benefit most from a lateral opening wedge distal femoral osteotomy (Figure A). Valgus alignment is much less common than varus alignment and the center of rotation and angulation (CORA) is typically found at the distal femur, rather than varus alignment where it is usually seen in the proximal tibia. In younger patients without trauma or arthritic changes, skeletal dysplasias and metabolic abnormalities should be ruled out. In cases where adult patients have failed nonoperative management and there is valgus alignment >12°, surgical management may be undertaken. In younger patients, this is usually in the form of an osteotomy and if the CORA is at the distal femur then a lateral opening wedge distal femoral osteotomy is typically the best solution for reliable correction. A medial distal femoral closing wedge osteotomy can also be effective in achieving similar results. Total knee arthroplasty (TKA) should ideally be avoided in a patient this young and active.Wang and Hsu published on the use of distal femoral varus osteotomies for lateral compartment arthritis. They noted that 83% of patients had satisfactory results and 3 patients required conversion to total knee arthroplasty. They also noted that there were concomitant improvements in patellar tracking, even in the case of patients who had some degree of patellofemoral arthritis. Backstein et al. evaluated long-term follow-up of distal femoral varus osteotomies about the knee. At an average of 123 months follow-up in 40 patients, they reported that 24 patients had good or excellent results, 3 had fair results, 3 had poor results, and 8 patients had undergone conversion to TKA. Their 10 year survival rate was 82%, with the 15 year survival rate dropping to 45%. Figure A demonstrates a lateral opening wedge osteotomy of the distal femur. Figure B demonstrates a lateral closing wedge osteotomy of the distal femur and medial opening wedge osteotomy of the proximal tibia. Figure C demonstrates a lateral closing wedge osteotomy of the proximal tibia. Figure D demonstrates a medial opening wedge osteotomy of the proximal tibia. Figure E demonstrates a TKA.Incorrect Answers:Answer 2: The combination of a lateral closing wedge distal femoral osteotomy and a medial opening wedge high tibial osteotomy would be used to correct varus, not valgus alignment. Answers 3 & 4: Both medial opening wedge and lateral closing wedge techniques can be used in the proximal tibia to correct varus alignment and would not be useful in this patient.Answer 5: This patient is too young and active to consider TKA at this time.
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