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. 2023 Oct 11;18(1):768.
doi: 10.1186/s13018-023-04252-z.

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

Ahmed A Elsheikh  1   2 , George W V Cross  3 , Jonathan Wright  3 , William David Goodier  3 , Peter Calder  3
Affiliations

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

Ahmed A Elsheikh et al. J Orthop Surg Res. .

Abstract

Introduction: Miserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.

Methods: Fifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle-trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.

Results: There was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°-54°), and external tibial torsion 50° (37-70). The mean age at surgery was 21 years (12-37) with a mean follow-up of 20 months (9-83). All osteotomies healed, and the frames were removed at a mean of 111 days (80-168). The mean VAS score improved from 8(5-9) to 1(0-4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30-75) to 92 (54-100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°-50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with - 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.

Conclusion: Gradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

Keywords: Anterior knee pain; External fixator; Femoral anteversion; Miserable malalignment syndrome; Tibia de-rotation; Tibia torsion.

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Conflict of interest statement

All other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Figures

Fig. 1
Fig. 1
Kujala knee scores (preoperative compared with postoperative)
Fig. 2
Fig. 2
Visual analogue score (preoperative compared to postoperative)
Fig. 3
Fig. 3
Clinical appearance following right tibial correction with a neutral foot progression angle. The left leg held with patella facing forwards to demonstrate the external foot progression prior to future correction
See this image and copyright information in PMC

References

    1. Stanitski CL. Anterior knee pain syndromes in the adolescent. J Bone Jt Surg (Am) 1993;75:1407–1415. doi: 10.2106/00004623-199309000-00016. - DOI
    1. Drexler M, Dwyer T, Dolkart O, et al. Tibial rotational osteotomy and distal tuberosity transfer for patella subluxation secondary to excessive external tibial torsion: surgical technique and clinical outcome. Knee Surg Sports Traumatol Arthrosc. 2014;22:2682–2689. doi: 10.1007/s00167-013-2561-5. - DOI - PubMed
    1. Meister K, James SL. Proximal tibial de-rotation osteotomy for anterior knee pain in the miserably malaligned extremity. Am J Orthop (Belle Mead, NI) 1995;24:149–155. - PubMed
    1. Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop. 1996;16:484–488. doi: 10.1097/01241398-199607000-00012. - DOI - PubMed
    1. Bruce WD, Stevens PM. Surgical correction of miserable malalignment syndrome. J Pediatr Orthop. 2004;24:392–396. doi: 10.1097/01241398-200407000-00009. - DOI - PubMed

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