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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 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 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 A varus-producing medial closing wedge high tibial osteotomy (MCWHTO) is an uncommon procedure. The aim of this retrospective study was to assess the survivorship and prevalence of post-operative subjective knee laxity and satisfaction in a large cohort of patients with a MCWHTO performed without a MCL-reefing procedure. Methods All patients ( n  = 176) who underwent a MCWHTO in our clinic between 2008 and 2016 were approached to participate. After review of patient charts, questionnaires were sent to willingly patients. Primary outcome was the survivorship of the MCWHTO; secondary outcome was patient-reported instability and satisfaction. Results One-hundred and thirteen patients participated in the study. The 5-year survival rate of the MCWHTO was almost 80%. A total of 77% of the patients was satisfied with the treatment. With regard to post-operative subjective knee laxity, 26% of the patients experienced instability of the knee post-operation. Instability was significantly correlated with the KOOS domains, the Lysholm score, the IKDC knee function score and the Physical and Mental Health Domains of the SF-36. Conclusion Medial closing wedge high tibial osteotomy provides good results regarding survivorship and patient satisfaction for patients with a valgus deformity which is located in the proximal tibia. Clinically relevant is that in the surgical technique without MCL-reefplasty instability is significantly correlated with worse patient-reported outcome measures. The addition of a MCL reefing procedure will improve outcome in selected patients. Level of evidence III.

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.

Purposes A fixed severe valgus knee is a surgical challenge. A safe post-operative Hip-Knee-Ankle angle (HKA) range of 180° ± 4 was recommended, but recent studies mentioned equal results from outliers of this range. Nevertheless, no distinction was made between varus and valgus knees, as well as over-corrected or under-corrected knees. Did post-operative nonaligned total knee replacements (TKR) from fixed severe valgus knees behave differently from the properly aligned population? Did over-corrected knees behave differently from under-corrected knees? Methods Through a multi-center retrospective cohort study, we provided 557 knees of at least 10° of minimal pre-operative valgus; in this population 75 presented a post-operative Hip-Knee-Ankle angle (HKA) outside of the 180° ± 4 range; 23 of them had at least 5° of varus; 52 of them had at least 5° of valgus. Median pre-operative HKA of the entire cohort was 194° (range 190–198). Median follow-up was 8 years (range 5–11); Knee Society Score (KSS) results, HKA, Femoral and Tibial Mechanical Angles (FMA, TMA) and complication rates were obtained. The outlier group (HKA ≤ 175 or ≥ 185) was compared to the control group (HKA 180 ± 4); over-corrected (HKA ≤ 175) and under-corrected (HKA ≥ 185) sub-groups were individually tested against the control group. Results The outlier group had a lower Final Knee Score than the aligned group ( p  = 0.023). In the over-corrected sub-group, median post-operative FMA was 88° (SD 4°) and median TMA was 87° (SD 4°). The complication rate was higher ( p  = 0.019). Knee ( p  = 0.018), Function ( p  = 0.034) and Final Knee Scores ( p  = 0.03) were statistically lower than in the control group. In the under-corrected sub-group, mean post-operative FMA was 93° (SD 2°) and mean TMA was 91° (SD 2°). The complication rate was lower ( p  = 0.019) and there was no difference with the control group concerning KSS. Conclusions In case of pre-operative fixed severe valgus knee, one should avoid over-correcting HKA angle and especially the TMA. Over-correction of a severe preoperative valgus in a post-operative varus was prejudicial for TKA survival. Keeping a severe valgus knee in low valgus to avoid using a more constrained implant and/or ligament releases will not decrease the 5–10 year implant survival and functional scores. Level of evidence Level IV—Case series.

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.

Background The Weber derotation osteotomy is an uncommon procedure that typically is reserved for patients with engaging Hill-Sachs defects who have had other surgical treatments for shoulder instability fail. It is unknown whether the desired humeral derotation actually is achieved with the Weber osteotomy. Questions/purposes The purposes of this study were to answer the following questions: (1) What are the complication (including redislocation) and reoperation rates of the Weber osteotomy? (2) What are the American Shoulder and Elbow Surgeons (ASES) and functional (ROM in internal rotation, self care) results? (3) What fraction of the patients had humeral derotation within 10° of the desired rotation? Methods A chart review of 19 Weber osteotomies and clinical assessment of 10 Weber osteotomies were performed by independent clinicians. The chart review, at a mean followup of 51 months (range, 13–148 months), focused on the complication rate and the frequency of redislocation. The clinical and CT assessments, at a mean followup of 54 months (range, 26–151 months), focused on ASES scores, ability of patients to perform self care with the affected arm, and CT scans to measure change in humeral retroversion. Results There were 25 complications and nine reoperations in 17 patients (19 shoulders), including pain (six patients, of whom one had complex regional pain syndrome), hematoma, infection, nonunion, delayed union, reoperations related to hardware and other noninstability-related causes (five patients), and internal rotation deficit. Redislocation occurred in one patient, who underwent repeat surgery, and subjective instability developed in two others. The mean ASES score was 78 points (of 100 points); six of the 10 patients (11 procedures) evaluated in person found it difficult or were unable to wash their backs with the affected arm. Humeral derotation varied from 7° to 77°; only three of the nine patients for whom CT scans were available had derotation within 10° of the desired rotation. Conclusions Complication rates with the Weber osteotomy were much higher than previously reported. Because seven of 17 patients were lost to followup, the redislocation rate may be higher than we observed here. Given the unpredictable variability in humeral derotation achieved with a Weber osteotomy, an improved surgical technique is critical to avoid osteoarthritis and loss of internal rotation associated with overrotation. Level of Evidence Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Objective Severe mismatch between pelvic incidence (PI) and lumbar lordosis (LL) leads to extra anterior displacement of the gravity line. The objective of this study is to investigate whether femoral head retroposition is a separate compensatory mechanism responsible for the extra anterior displacement. Subjects and methods Based on the values of PI and LL, 94 patients were divided into the PI-LL match group (PI-LL ≤ 0°), the mild PI-LL mismatch group (20°> PI-LL >0°), and the severe PI-LL mismatch group (PI-LL ≥ 20°). A series of parameters including PI, LL, PI-LL, thoracic kyphosis (TK), pelvic tilt (PT), sacral slope (SS), knee flexion angle (KFA), tibial obliquity angle (TOA), sagittal vertical axis (SVA), S1 overhang, femoral head shift (FHS), and pelvic shift (PS) were measured and compared among the three groups. Results The severe PI-LL mismatch group exhibited significantly greater PI, PI-LL, PT, KFA, SVA, PS, and FHS, and less LL and TK, compared with the control and mild PI-LL mismatch group. The mild PI-LL mismatch group had significantly greater PI-LL, PT, KFA, TOA, and S1 overhang, and less LL and SS than the control group. SS, TOA, and S1 overhang in the severe PI-LL mismatch group differed significantly from that in the control group, but did not differ significantly from that in the mild PI-LL mismatch group. Conclusion Femoral head retroposition is an entirely separate compensatory mechanism and, in this study, participated in the compensation for the anterior displacement of the gravity line induced by extra-sagittal spinal malalignment in patients with severe PI-LL mismatch.