Patients With Lower Limb Deformity Report Worse Quality of Life Than Control Subjects Regardless of Degree of Deformity

Lower extremity osteotomies for limb preservation: Indications, outcomes, and risk factors

Objectives

To delineate the key factors associated with treatment success or failure for patients undergoing lower extremity osteotomies to address a spectrum of lower extremity joint and limb deformities at an Integrated Limb Preservation Center (ILPC).

Methods

Design: Retrospective cohort study. Setting: Level I Academic Trauma Center. Patient selection criteria: Patients of the ILPC with at least 1-year of follow-up data regarding previous surgery to correct trauma-or developmental-related deformities between January 1, 2005, and October 1, 2022. Outcome measures and comparisons: Patients were categorized first based on etiology (developmental vs. traumatic) and then based on the nature of deformity (joint, limb, nonunion). Treatment data, demographics including age, sex, body mass index (BMI), tobacco use history, insurance status, marital status, mental health history, and history of comorbidities, concurrent procedures, and post-operative infection, revision, reoperation, and bone healing status were extracted from the medical record and compared. Treatment failure was defined as conversion of the limb preservation surgery (ies) to amputation of any type.

Results

139 patients were included for analysis; 47 patients in the developmental-related cohort, and 92 patients in the trauma-related cohort. The treatment success rate in terms of preserving the affected limb for patients undergoing lower extremity osteotomies was 94.7 % for the developmental-related cohort and 92.4 % for the traumatic-related cohort. 57.4 % of patients in the developmental-related cohort and 59.8 % of patients in the trauma-related underwent unplanned secondary procedures Concurrent osteomyelitis debridement (p = 0.01) and postoperative infection (p = 0.049) were the only factors measured significantly associated with conversion to amputation.

Conclusions

Patients undergoing osteotomies at an ILPC to address developmental-related or trauma-related joint and/or limb deformities experienced high short-term success (>90 %) with respect to preserving the affected limb. However, 56 % of patients required subsequent unplanned surgeries and improvements in PROMs were only statistically significant in patients with trauma-related deformities.

Level of evidence

III.

Correction of Ankle Malalignment in Severe Fibular Hemimelia

BACKGROUND

Management of ankle joint deformity and instability are challenging issues in congenital fibular hemimelia (FH). This study aims to assess how much the SUPERankle procedure improves ankle alignment and provides durable ankle stability in patients with severe FH.

METHODS

Seventeen children aged 53.4±44.1 months with severe form of FH, equinovalgus foot deformation, ankle instability, and tibial curvature (Paley type IIIC), affecting 19 limbs, underwent the SUPERankle procedure. Foot and ankle position was evaluated clinically and radiologically before surgery, immediately after, and at follow-up of 63.0±19.7 months. Mechanical lateral distal tibial angle (mLDTA), tibiocalcaneal angle (mTCA), and tibiocalcaneal distance (mTCD) were measured on the AP radiograms, while the anterior distal tibial angle (mADTA) and lateral tibiocalcaneal angle (mLTCA) were measured on the lateral radiograms. Recurrences, additional procedures, and complications were documented based on medical records. Quality of life was evaluated with Limb Deformity-SRS questionnaire.

RESULTS

On clinical examination, the normal tibia and ankle alignment, along with a plantigrade foot were achieved in all limbs after the first surgery. In 11 limbs (58%) this result was maintained at follow-up. Due to recurrence, additional procedures were necessary to provide durable ankle alignment in 7 limbs (37%), while in 1 limb (5%) the ankle joint remained in equinus at the last follow-up. Significant improvement of radiologic alignment was found in all parameters (preoperative vs. postoperative vs. FU) as follows-mLDTA: 71.4±11.2 versus 88.7±5.6 versus 88.1±2.7 degrees, P =0.0001; mTCA: 41.4±14.9 versus 8.7±8.4 versus 11.6±8.9 degrees, P =0.0001; mTCD: 22.3±7.9 versus 4.0±3.6 versus 7.7±6.5 mm, P =0.0001; mADTA: 99.5±19.4 versus 82.3±4.2 versus 81.5±5.9 degrees, P =0.0002; mLTCA: 116.7±23.9 versus 95.8±11.7 versus 93.5±15.1 degrees, P =0.0002. The mean follow-up LD-SRS score was 4.03.

CONCLUSION

In children with severe fibular hemimelia, the SUPERankle procedure provided clinically and radiologically fully corrected ankle joint and plantigrade foot, suitable for further lengthening procedure. The 40% rate of deformity recurrence was managed with additional surgical intervention to achieve a good clinical, radiologic, and functional outcome in 95% of children at 5-year follow-up.

LEVEL OF EVIDENCE

Level IV.

The Debilitating Physical and Emotional Effects of Limb Deformity: A Tertiary Center Observational Study Utilizing the Limb Deformity-Modified Scoliosis Research Society Score (LD-SRS)

Background: Limb deformity describes a condition where a limb has an abnormal shape or length, resulting from an acquired or a congenital case. This condition can impair the normal function of patients' lives, leading to adverse psychological impacts. The limb deformity-modified Scoliosis Research Society (LD-SRS) score is a frequently used tool to assess quality of life. This observational study aimed to investigate the quality of life of patients with debilitating limb deformities in Saudi Arabia using the LD-SRS score. Methods: This is an observational analytical cross-sectional study conducted at the orthopedic clinic at King Saud University Medical City between March and May 2024. Patients diagnosed with any type of limb deformity (of different ages) were included in this study. Patients completed the LD-SRS score in the clinic and were divided into two groups based on whether they had undergone surgery for limb deformity. Results: This study included 152 participants, with the majority of participants in the 13-18-year age group and predominantly male (59.87%). Most participants were assessed before treatment, with significant differences observed in total scores based on the examination time (p < 0.001). Post-surgery scores showed marked improvement, with the overall total mean score for the surgery group being significantly higher than that of the non-surgery group (p < 0.001). Domain-specific scores revealed higher satisfaction in self-image/appearance for the surgery group, while the non-surgery group had lower scores in function/activity and mental health domains. No significant differences were found across age, gender, side of the body affected, or affected site. Conclusions: Preoperative patients had lower QoL scores as a whole group compared to those who had undergone surgery. The longer the duration postoperatively, the better the QoL score; those measured at three months had better QoL than preoperative patients, and those assessed at one and two years scored even higher. Self-image/appearance was a key factor, with the surgery group scoring higher in this domain than the non-surgery group. Future research should explore broader patient perspectives, including those related to mental and social well-being.

Correction of Tetratorsional Malalignment of the Lower Extremities Improves Patient-Reported Outcomes

Background

Axial malalignment of the bilateral femurs and tibias, previously known as "miserable" malalignment, now renamed tetratorsional malalignment (TTM), presents with hip and/or knee pain refractory to nonoperative treatment.

Purpose

We sought to investigate whether bilateral rotational osteotomy of the femur and tibia leads to improvement in a deformity-specific patient-reported outcome measure (PROM).

Methods

A retrospective review of patients who underwent staged rotational correction of the bilateral femur and tibias was performed. Computed tomography (CT) was used to measure the preoperative rotational profile and plan the surgical correction. Stabilization was predominantly with intramedullary nails. The primary outcome measure was the Limb Deformity-modified Scoliosis Research Society (LDSRS) score. Secondary outcomes included change in mechanical limb alignment and complications of the procedure.

Results

Sixteen patients (13 female and 3 male) with average age of 23.1 years (range: 15-36 years) underwent 4-segment rotational correction. The averages for femoral and tibial deformity correction were 23.5° (6.2° SD) and 20.9° (5.2° SD), respectively. The total LDSRS score improved from 3.67 (0.3 SD) to 4.39 (0.3 SD) (P = .001). The LDSRS sub-scores for function, pain, and self-image also significantly improved. In patients not undergoing concurrent coronal deformity correction, the limb mechanical axis was not significantly changed. No additional procedures were performed to obtain bone union. Three patients required peroneal nerve decompression following the index procedure, and all neurologic symptoms resolved.

Conclusion

This retrospective review suggests that correction of TTM of the lower extremities may lead to improvements in function, pain, and self-image. There were minimal complications and no iatrogenic deformity among 16 patients reviewed. The new diagnosis, TTM, is descriptive of this debilitating condition without communicating a negative patient image.

Transphyseal Curettage of Epiphyseal Brodie's Abscess: A Case Report

Epiphyseal Brodie's abscesses represent a rare, slow-progressing form of osteomyelitis that contrasts with the more aggressive types of infection typically seen in bone. These abscesses develop from a low-grade infection and progress gradually, posing unique challenges for treatment due to their proximity to the growth plate and joint structures. While the literature on managing epiphyseal Brodie's abscesses is limited, common treatments include antibiotics and surgical drainage. However, removing these lesions can be complicated by the risk of growth plate damage. This case report describes a patient with an epiphyseal Brodie's abscess that persisted despite standard curettage. We employed an acute-angle trans-physical curettage technique, which allowed for complete lesion excision while preserving the integrity of the growth plate and minimizing the risk of growth disturbance. By accessing the abscess through the diaphysis, metaphysis, and physis, this method proved to be an effective treatment option for Brodie's abscesses located near the physis.

Evaluation of Physical and Mental Health in Adults Who Underwent Limb-Lengthening Procedures with Circular External Fixators During Childhood or Adolescence

BACKGROUND

Lower limb length discrepancy (LLD) in children and adolescents, often due to congenital or acquired conditions, is treated to achieve limb equality and alignment, optimizing function and minimizing cosmetic concerns for an active adulthood. This study evaluated the Health-Related Quality of Life (HRQoL) and physical functioning of adults who underwent unilateral limb lengthening with circular external fixators (EFs) in childhood.

METHODS

Fifty patients treated at a median age of 14.9 years completed the Short Form 36 (SF-36) and Stanmore Limb Reconstruction Score (SLRS) questionnaires in adulthood, with a median follow-up of 8.9 years.

RESULTS

Among the 50 patients, 38 underwent a single limb lengthening (21 tibia, 12 femur, 5 both), while 12 required multiple cycles. The median residual LLD was 0.4 cm, with 12 patients (24%) having over 2 cm. Complications occurred in 67% of procedures, mainly due to prolonged healing. Physical and mental health scores were significantly lower than normative data. The mean Physical Component Summary was 52.2 ± 7.2 (p = 0.20). The mean Mental Component Summary was 43.9 ± 8.6 (p = 0.001), notably lower in congenital LLD cases. Many SLRS items (Pain, Social, Physical Function, Work, and Emotions) strongly correlated with SF-36 items.

CONCLUSIONS

Adults treated with distraction osteogenesis for congenital LLD show normal physical but lower mental health scores compared to peers. Lengthening procedure characteristics did not significantly impact mental health. Routine psychological and social assessments are recommended to prevent long-term distress by providing appropriate support.

The Management of Complex Knee Deformity Using Ortho-SUV: A Case Study

Lower limb deformities are debilitating and affect the function of the lower limb and the social life of the patient. The deformities around the knee joint might be a combination of multiple deformities in various planes including coronal, sagittal, or rotational and may be present in both the femur and the tibia. We present a case of a 19-year-old female with complex deformity around the left knee joint involving both the femur and the tibia with shortening. The deformity was thoroughly planned and managed with both the Ortho-SUV and the Ilizarov technique. Complications such as neurological injury and nonunion were faced, but the neurology was improved spontaneously, and the autologous bone graft was done. The end result was excellent with no residual neurodeficit and no limb length discrepancy. Deformities such as these have to be addressed with meticulous planning and strategic surgical management. Complications such as nonunion, infection, neurological injury, and noncompliance might be faced in the course of the treatment. Though the Ilizarov apparatus is the most commonly used to address deformities and limb lengthening, the newer six-axis devices such as the Ortho-SUV can greatly aid in deformity correction.

Simultaneous correction of leg length discrepancy and angular deformity of the distal femur with retrograde Precice nails: a retrospective analysis of 45 patients

BACKGROUND AND PURPOSE

Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment?

METHODS

Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment.

RESULTS

The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication.

CONCLUSION

Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.

Bilateral Distal Femoral Osteotomy for Valgus Knee Deformity May Result in Improved Patient-Reported Outcome Scores

Background

The lateral opening wedge distal femoral osteotomy (DFO) is an effective treatment for genu valgum to improve mechanical alignment, decrease lateral compartment loads, and decrease the risk of knee osteoarthritis. Multiple studies have utilized outcome scores assessing functional changes related to pain and joint stability, with a focus solely on knee pain and functional outcomes.

Questions/purposes

The primary aim of this study was to evaluate patient-reported outcome measures (PROMs) that assessed knee function, pain, patient's perception of body image, and limb deformity-related quality of life, both preoperatively and at least 1-year postoperatively.

Methods

In a retrospective review of nontraumatic genu valgum patients who underwent bilateral DFO, preoperative and postoperative radiographs were evaluated. Routinely collected preoperative and 1-year postoperative PROMs scores were analyzed, using the Knee Injury and Osteoarthritis Outcome Score Jr. (KOOS-JR) and the Limb Deformity-Modified Scoliosis Research Society (LD-SRS) score, in 72 limbs (36 patients): 7 men (19.44%) and 29 women (80.56%) with an average age of 35.34 ± 13.57 years. The mean follow-up time was 36.85 ± 24.43 months.

Results

Overall mechanical axis deviation, lateral distal femoral angle, and mechanical axis alignment angle were significantly improved after DFO in all patients. Both PROMs also improved significantly from preoperative to postoperative scores: LD-SRS (3.10 ± 0.56 vs 4.19 ± 0.44, respectively) and KOOS-JR (63.02 ± 19.25 vs 78.06 ± 16.29, respectively).

Conclusion

This retrospective review suggests that bilateral lateral opening-wedge DFOs in patients with symptomatic valgus knee deformity may be associated with improved overall knee health, limb deformity-related quality of life, and patients' body image. Further study is needed.

Outcomes of percutaneous femoral derotational osteotomy in pediatric patients

Background

Percutaneous femoral derotational osteotomies are performed in both adult and pediatric patients. There is little published on the outcomes after femoral derotational osteotomy in pediatric patients.

Methods

A retrospective cohort study of pediatric patients treated with percutaneous femoral derotational osteotomy by one of two surgeons between 2016 and 2022 was performed. Data collected included patient demographics; surgical indications; femoral version; tibial torsion; magnitude of rotational correction; complications; time to hardware removal; pre-operative and post-operative patient-reported outcome scores, including Limb Deformity-Scoliosis Research Society and Patient-Reported Outcomes Measurement Information System; and time to consolidation. Descriptive statistics were used to summarize the data and t tests used to compare means.

Results

Thirty-one femoral derotational osteotomies in 19 patients were included with an average age of 14.7 (9-17) years. The average rotational correction was 21.5° ± 6.4° (10°-40°). The average length of follow-up was 17.9 ± 6.7 months. There were no instances of nonunion, joint stiffness, or nerve injury. No patients returned to the operating room for additional surgeries other than routine hardware removal. There were no cases of avascular necrosis of the femoral head. Of the 19 patients, 8 completed both a pre-operative and post-operative survey set. There were significant improvements in the Limb Deformity-Scoliosis Research Society Self-Image/Appearance sub-category and the Patient-Reported Outcomes Measurement Information System Physical Function sub-category.

Conclusion

Femoral derotational osteotomy using a percutaneous drill hole technique with antegrade trochanteric entry femoral nail is safe in the pediatric population and improves self-image in patients with symptomatic femoral version abnormalities.

LIMB-Q Kids—German Translation and Cultural Adaptation

(1) Purpose: Lower limb deformities can have a severe impact on health-related quality of life (HRQL). LIMB-Q Kids is a new patient-reported outcome measure (PROM) aiming to elucidate the experience of 8–18-year-old patients before, during and after treatment, and to measure the different aspects of HRQL. The aim of this study was to translate and culturally adapt LIMB-Q Kids to German. (2) Methods: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were followed. Three forward translations, a backward translation, an expert panel meeting with eight participants, and twenty cognitive debriefing interviews led to the final German version of LIMB-Q Kids. (3) Results: In the forward translations, 4/159 items were difficult to translate, and 2/159 items in the backward translation differed from the original English version. Cognitive debriefing interviews with 20 patients identified 7/159 items that were difficult to comprehend/answer, and 2 of these items were changed. (4) Conclusions: Lower limb deformities can have a great impact on children, and it is important to measure and consider the impact on HRQL. In order to be able to use PROMs in different countries, conceptually equivalent translations and cultural adaptations should be performed in order to ensure comprehensibility. The final German version of LIMB-Q Kids is ready for use in an international field test.

German Translation and Cross-Cultural Adaptation of the Limb Deformity-Scoliosis Research Society (LD-SRS) Questionnaire

Background: Patient-reported outcome measures are gaining increasing importance in clinical research and quality control. Clinical impairment through limb deformities can appear in various forms. This study aimed at translating and culturally adaptating the Limb Deformity-Scoliosis Research Society (LD-SRS) patient-reported outcome measure (PROM) into German by following the scientific rigor of the cross-cultural adaptation process as well as ensuring the reliability of the translated version. The LD-SRS is applicable in children and adults. Methods: The translation was performed in accordance with the creators of the LD-SRS following the Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for translation and cultural adaptation. Two forward translations were performed, and after a consensus meeting, a professional translator translated the PROM back to English. The creators reviewed the back translation of the preliminary German version. Thirty patients with upper and lower limb deformities participated in cognitive debriefing interviews. The version was proofread and, finally, the test-retest reliability was estimated. Results: The mean age was 19 years (range 6–61). Twenty-six patients (87%) completed the retest after 6 days (range 3–26). The internal consistency was estimated with a Cronbach’s alpha of 0.96 (range 0.94–0.97), and the intraclass correlation was 0.92 (range 0.89–0.94), indicating an excellent reliability. The scores were normally distributed. Thereafter, the German version was proofread and finalized. Conclusions: The German translation and cross-cultural adaptation of the LD-SRS score resulted in a high reliability and internal consistency. The German LD-SRS score is readily usable and may be applied in future studies of German-speaking limb deformity patients.