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Background The coincidence rate of femoroacetabular impingement (FAI) or acetabular retroversion (AR) with anterior ankle impingement (AAI) is not known. In this preliminary study, we investigated the coexistence of FAI and AR in a cohort of patients presented with AAI. Methods In a cross-sectional study, 56 patients who presented with AAI and underwent arthroscopic surgery for AAI treatment were included. The concurrent FAI was assessed clinically and radiographically. The concurrent acetabular retroversion was investigated by the evaluation of the crossover sign and ischial spine sign. Results Concurrent FAI was observed in 43% (24 of 56 patients), which was bilateral in 67% (16 of 24 patients) and unilateral in 33% (8 of 24 patients). Out of 24 patients with concurrent hip impingement, only six (25%) patients had symptomatic hips. In total, concurrent FAI was observed in 40 hips, which was cam-type in 55% (22 of 40 hips), pincer-type in 30% (12 of 40 hips), and mixed-type in 15% (6 of 40 hips). Concurrent AR was detected in 52% (29 of 56 patients), which was unilateral in 28% (8 of 29 patients) and bilateral in 72% (21 of 29 patients). In 25% of patients (14 of 56 patients), AR coexisted with FAI. Conclusion A considerable number of patients presenting with AAI were found to have concurrent FAI and/or AR. While the clinical significance of this association remains uncertain, these findings may warrant further investigation into whether evaluating for hip deformities in AAI patients could be of diagnostic or preventive value. Level of evidence IV.

Purpose The objective of this study was to compare the outcome of constrained and unconstrained primary total knee arthroplasty (TKA) in the management of the valgus deformity. Methods This is a retrospective review of patients with type II valgus knee who underwent primary TKA from 1999 to 2011. There were fifty patients in Group 1 who underwent varus–valgus constrained TKA. They were matched with another fifty patients in Group 2 who underwent unconstrained TKA. Results The mean joint line shift was significantly higher in Group 1 (+8 mm, SD 6 mm) than in Group 2 (+2 mm, SD 3 mm) ( p  = 0.03). At 2 years, there was no difference in anterior–posterior stability and mediolateral stability according to the Knee Society Score, and patients in Group 2 reported significantly better mean function score of 66.2 (SD 9.3) (mean 48, SD 7.1 in Group 1) ( p  = 0.002). Two patients (6 %) in Group 1 underwent revision surgery—one for a broken central peg and the other for aseptic loosening. Three patients (2 %) in Group 2 underwent revision surgery—two for global instability and one for poly wear. The estimated survivorship time was 8.3 years for constrained TKA and 12.0 for unconstrained TKA. Conclusion Constrained TKA was associated with more significant joint line changes for the management of valgus arthritic knee, when compared with unconstrained TKA. Level of evidence Retrospective study, Level III.

Purpose The aim of the present study was to assess the changes in rotational alignment introduced by total knee arthroplasty (TKA) and the reproducibility of pre- and postoperative CT measurements of rotational limb alignment. Methods For this purpose we analyzed data from 196 consecutive cruciate-retaining, fixed bearing Columbus TKA procedures. Both pre- and postoperative scans torsion difference CT scans were available for measurements in 89 cases. Using these CT scans the neck-malleolar angle (NMA), the femoral posterior condylar angle (fPCA), the tibial posterior condylar axis (tPCA) and the tibial torsion angle (TTA) were independently assessed by three raters. CT scans were re-evaluated 8 weeks later by the most experienced rater for assessment of intraobserver agreement. Results Measurements of all angles were prone to high standard deviations reflecting interindividual variability. Mean fPCA changed from 1.3° to 2.7° internal rotation preoperatively to 0.1°–1.9° internal rotation postoperatively. Based on a relative external rotation of the tibial base plate as compared to the preoperative situation, we found a relative internal rotation of the postoperative NMA and tibial torsion of 3°–5.4° and 6°–7.5°, respectively. Intra- and interobserver agreement was strong for all angles assessed (ICCs 0.7–1.0) except for fPCA (ICC 0.2–0.6). However, mean absolute measurement differences for fPCA were clinically acceptable (1.2°–2.6°). Conclusions Reproducibility of CT rotational limb alignment measurements was found to be clinically acceptable. Rotational alignment of the femoral and even more so of the tibial component will ultimately affect the rotational alignment of the entire limb—at least when fixed bearings are used. Level of evidence Diagnostic study, Level III.

Purpose There is a lot of inter-individual variation in the rotational anatomy of the distal femur. This study was set up to define the rotational anatomy of the distal femur in the osteo-arthritic knee and to investigate its relationship with the overall coronal alignment and gender. Methods CT-scans of 231 patients with end-stage knee osteo-arthritis prior to TKA surgery were obtained. This represents the biggest series published on rational geometry of the distal femur in literature so far. Results The posterior condylar line (PCL) was on average 1.6° (SD 1.9) internally rotated relative to the surgical transepicondylar axis (sTEA). The perpendicular to trochlear anteroposterior axis (⊥TRAx) was on average 4.8° (SD 3.3°) externally rotated relative to the sTEA. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups ( p  < 0.001): 1.0° (SD 1.8°) in varus knees, 2.1° (SD 1.8°) in neutral knees and 2.6° (SD 1.8°) in valgus knees. The same was true for the ⊥TRAx in these 3 groups ( p  < 0.02).There was a clear linear relationship between the overall coronal alignment and the rotational geometry of the distal femur. For every 1° in coronal alignment increment from varus to valgus, there is a 0.1° increment in posterior condylar angle (PCL vs sTEA). Conclusion The PCL was on average 1.6° internally rotated relative to the sTEA in the osteo-arthritic knee. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups. Level of evidence III.

Purpose In a prospective, consecutive study, a navigation-based technique for calculating the sliding distance of the lateral epicondyle prior to osteotomy in TKA surgery of fixed valgus deformity has been developed, and early results have been evaluated. Materials and methods Twenty-seven knees with a fixed valgus deformity undergoing TKA received this new treatment. Clinical scores and radiograph evaluation were performed preoperatively and 1-year postoperatively. Static and dynamic kinematic data were obtained from navigation at the beginning and at the end of surgery. Results The calculated amount of sliding distance varied between 5 and 16 mm. No complications regarding this technique occurred. All clinical scores showed a significant improvement, and radiological evaluation showed a correction of all parameters in 100 % of patients. Conclusion With this navigation-based technique, it is possible to calculate the amount of sliding distance prior to osteotomy and obtain excellent early results. All axes have been corrected completely, and flexion and extension gaps were balanced. No specific complications of this technique have occurred so far. Level of evidence II.

Purpose Type II valgus knees are defined by medial collateral ligament laxity. This paper studies the results of posterior stabilized (PS) and cruciate retaining (CR) knee implants in type II valgus knees. Methods From 1999 to 2009, there were 100 type II valgus knees in 95 patients eligible for study (63 PS, 37 CR). Patients had prospectively collected clinical data up to 2 years after surgery. Results At 24 months after surgery, the CR group had reduced range of motion (PS: median 126.0°, CR: median 114°; n.s.) and a marginally but statistically significant increased valgus alignment (PS: median 5°, CR: median 6°; p  = 0.011). Despite this, both groups produced equal and marked improvements in SF-36, function score and knee score of the Knee Society score, and Oxford knee score. Conclusions Overall, both PS and CR implants performed equally well in type II valgus knees at 24 months post-operatively. Further longer-term studies would be warranted to assess for late instability. Level of evidence Retrospective, Level III.

Background Acetabular retroversion can cause impaction-type femoroacetabular impingement leading to hip pain and osteoarthritis. It can be treated by anteverting periacetabular osteotomy (PAO) or acetabular rim trimming with refixation of the labrum. There is increasing evidence that acetabular retroversion is a rotational abnormality of the entire hemipelvis and not a focal overgrowth of the anterior acetabular wall, which favors an anteverting PAO. However, it is unknown if this larger procedure would be beneficial in terms of survivorship and Merle d’Aubigné scores in a midterm followup compared with rim trimming. Questions/purposes We asked if anteverting PAO results in increased survivorship of the hip compared with rim trimming through a surgical hip dislocation in patients with symptomatic acetabular retroversion. Methods We performed a retrospective, comparative study evaluating the midterm survivorship of two matched patient groups with symptomatic acetabular retroversion undergoing either anteverting PAO or acetabular rim trimming through a surgical hip dislocation. Acetabular retroversion was defined by a concomitantly present positive crossover, posterior wall, and ischial spine sign. A total of 279 hips underwent a surgical intervention for acetabular retroversion at our center between 1997 and 2012 (166 periacetabular osteotomies, 113 rim trimmings through surgical hip dislocation). A total of 99 patients (60%) were excluded from the PAO group and 56 patients (50%) from the rim trimming group because they had any of several prespecified conditions (eg, dysplasia or pediatric conditions 61 [37%] for the PAO group and two [2%] for the rim trimming group), matching (10 [6%]/10 [9%] hips), deficient records (10 [6%]/13 [12%] hips), or the patient declined or was lost to followup (18 [11%]/31 [27%] hips). This left 67 hips (57 patients) that underwent anteverting PAO and 57 hips (52 patients) that had acetabular rim trimming. The two groups did not differ in terms of age, sex, body mass index, preoperative ROM, preoperative Merle d’Aubigné-Postel score, radiographic morphology of the acetabulum (except total and anterior acetabular coverage), alpha angle, Tönnis grade of osteoarthritis, and labral and chondral lesions on the preoperative MRI. During the period in question, we generally performed PAO from 1997 to 2003. With the availability of surgical hip dislocation and labral refixation, we generally performed rim trimming from 2004 to 2010. With growing knowledge of the underlying pathomorphology, anteverting PAOs became more common again around 2007 to 2008. A minimum followup of 2 years was required for this study. Failures were included at any time. The median followup for the anteverting PAO group was 9.5 years (range, 2–17.4 years) and 6.8 years (range, 2.2–10.5 years) for the rim trimming group (p < 0.001). Kaplan-Meier survivorship analysis was performed using the following endpoints at 5 and 10 years: THA, radiographic progression of osteoarthritis by one Tönnis grade, and/or Merle d’Aubigné-Postel score < 15 points. Results Although the 5-year survivorship of the two groups was not different with the numbers available (86% [95% confidence interval {CI}, 76%–94%] for anteverting PAO versus 86% [95% CI, 76%–96%] for acetabular rim trimming), we found increased survivorship at 10 years in hips undergoing anteverting PAO for acetabular retroversion (79% [95% CI, 68%–90%]) compared with acetabular rim trimming (23% [95% CI, 6%–40%]) at 10 years (p < 0.001). The drop in the survivorship curve for the acetabular rim trimming through surgical hip dislocation group started at Year 6. The main reason for failure was a decreased Merle d’Aubigné score. Conclusions Anteverting PAO may be the more appropriate treatment for hips with substantial acetabular retroversion. This may be the result of reduction of an already smaller lunate surface of hips with acetabular retroversion through rim trimming. However, rim trimming may still benefit hips with acetabular retroversion in which only one or two of the three signs are positive. Future randomized studies should compare these treatments. Level of Evidence Level III, therapeutic study.

Background Salter innominate osteotomy has been identified as an effective additional surgery for the dysplastic hip. However, because in this procedure, the distal segment of the pelvis is displaced laterally and anteriorly, it may predispose the patient to acetabular retroversion. The degree to which this may be the case, however, remains incompletely characterized. Questions/purposes We asked, in a group of pediatric patients with acetabular dysplasia who underwent Salter osteotomy, whether the operated hip developed (1) acetabular retroversion compared with contralateral unaffected hips; (2) radiographic evidence of osteoarthritis; or (3) worse functional scores. (4) In addition, we asked whether femoral head deformity resulting from aseptic necrosis was a risk factor for acetabular retroversion. Methods Between 1971 and 2001, we performed 213 Salter innominate osteotomies for unilateral pediatric dysplasia, of which 99 hips (47%) in 99 patients were available for review at a mean of 16 years after surgery (range, 12–25 years). Average patient age at surgery was 4 years (range, 2–9 years) and the average age at the most recent followup was 21 years (range, 18–29 years). Acetabular retroversion was diagnosed based on the presence of a positive crossover sign and prominence of the ischial spine sign at the final visit. The center-edge angle, acetabular angle of Sharp, and acetabular index were measured at preoperative and final visits. Contralateral unaffected hips were used as controls, and statistical comparison was made in each patient. Clinical findings, including Harris hip score (HHS) and the anterior impingement sign, were recorded at the final visit. Results Patients were no more likely to have a positive crossover sign in the surgically treated hips (20 of 99 hips [20%]) than in the contralateral control hips (17 of 99 hips [17%]; p = 0584). In addition, the percentage of positive prominence of the ischial spine sign was not different between treated hips (22 of 99 hips [22%]) and contralateral hips (18 of 99 hips [18%]; p = 0.256). Hips that had a positive crossover or prominence of the ischial spine sign in the operated hips were likely also to have a positive crossover sign or prominence of the ischial spine sign in the unaffected hips (16 of 20 hips [80%] crossover sign, 17 of 22 hips [77%] prominence of the ischial spine sign). At the final visit, five hips (5%) showed osteoarthritic change; one of the five hips (20%) showed positive crossover and prominence of the ischial spine signs, and the remaining four hips showed negative crossover and prominence of the ischial spine signs. There was no significant difference in HHS between the crossover-positive and crossover-negative patient groups nor in the prominence of the ischial spine-positive and prominence of the ischial spine-negative patient groups (crossover sign, p = 0.68; prominence of the ischial spine sign, p = 0.54). Hips with femoral head deformity (25 of 99 hips [25%]) were more likely to have acetabular retroversion compared with hips without femoral-head deformity (crossover sign, p = 0.029, prominence of the ischial spine sign, p = 0.013). Conclusions Our results suggest that Salter innominate osteotomy does not consistently cause acetabular retroversion in adulthood. We propose that retroversion of the acetabulum is a result of intrinsic development of the pelvis in each patient. A longer-term followup study is needed to determine whether retroverted acetabulum after Slater innominate osteotomy is a true risk factor for early osteoarthritis. Femoral head deformity is a risk factor for subsequent acetabular retroversion. Level of Evidence Level III, therapeutic study.

Purpose A modified technique referred to as a medial femoral epicondyle upsliding osteotomy was proposed to address severe valgus deformity with unconstrained posterior stabilized (PS) arthroplasty. The study compared the effectiveness of the technique and PS arthroplasty with constrained arthroplasty during primary total knee arthroplasty (TKA). Methods Fifty-three patients presenting with valgus knees with a mean valgus angle (VA) greater than 30° were prospectively randomized and divided into two groups, and both groups received primary TKA. Upsliding osteotomy with PS arthroplasty was performed on the knees of 27 patients (group A), while the remaining 26 patients (group B) received a constrained arthroplasty. The Knee Society function score (KSF), Hospital for Special Surgery knee score (HSS), range of motion (ROM), mediolateral stability and hospitalization expenses were recorded. The hip–knee–ankle angle (HKA), femorotibial angle (FTA) and VA were analysed. Complications were also recorded. Results The patients received follow-up care for more than 50 months. The postoperative KSF, HSS and ROM showed marked improvement in both groups ( p  < 0.05). Radiological assessments showed that HKA, FTA and VA for group A were restored to (179.9 ± 3.0)°, (173.0 ± 2.4)° and (7.0 ± 2.4)°, respectively. For group B, the HKA, FTA and VA were restored to (181.5 ± 2.3)°, (172.5 ± 2.3)° and (7.5 ± 2.3)°, respectively. Only two patients from group A demonstrated mild medial laxity in their knees, and the remaining patients from both groups were stable medially and laterally. However, the total hospitalization expenses and material expenses of group A were less than those of group B because of the more expensive constrained prosthesis and stems. No late-onset loosening or recurrent valgus deformity was displayed. Conclusions Both medial femoral epicondyle upsliding osteotomy with PS arthroplasty and constrained arthroplasty showed good outcomes for the restoration of neutral limb alignment and soft tissue balance, which are demonstrated to be safe and effective techniques for correcting severely valgus knees. Therefore, the clinically important finding of this study is that medial femoral epicondyle upsliding osteotomy with PS arthroplasty can be an alternative method for correcting severe valgus knees. Level of evidence II.

Purpose The relationship between posterior shoulder instability and increased glenoid retroversion has been documented. Posterior open wedge glenoid osteotomy is a possible treatment option for patients with increased glenoid retroversion, but outcomes in the literature are limited. Therefore, the purpose of this study was to report the clinical and radiological outcomes following posterior glenoid osteotomy. Methods Patients that underwent posterior glenoid osteotomy for posterior shoulder instability with a GR angle of more than or equal to 10°, and were at least 12 months out from surgery, were included in the study. General data, medical history, and radiographic data such as the pre- and postoperative glenoid retroversion angle were extracted from the patients’ hospital documentation notes. To evaluate the postoperative outcome, the Rowe standard rating scale for shoulder instability and the Oxford shoulder instability score were collected retrospectively. Results A total of 12 shoulders (11 patients) could be included. The mean pre-operative glenoid retroversion was 23.3° (range 12°–35°) and this reduced significantly ( p  = 0.003) to a mean of 13° (range 1°–28°) postoperatively. At a mean follow-up of 19.8 months (range 14–36), the median Rowe score was 90 points (range 45–100 points) and the median Oxford instability score was 44 points (range 21–48 points). There were no postoperative re-dislocations or revision surgeries; however, one patient reported signs of recurrent shoulder instability and four asymptomatic glenoid neck fractures occurred. Conclusion Open wedge posterior glenoid osteotomy provides reliable clinical results with a low rate of clinical failure in a stringently selected patient cohort at short-term follow-up. However, due to the risk of potentially severe complications, we advocate this procedure for experienced shoulder surgeons only, who are familiar with its anatomical and technical considerations. Level of evidence IV (case series).