Treatment of miserable malalignment syndrome: a systematic review

R Connell, D Rad, T Hossain

University Hospital Southampton NHS trust

James et al. (1979) coined the term “Miserable malalignment” to describe abnormal lower limb rotation (excessive femoral anteversion and tibial external rotation) contributing to anterior knee pain. Staheli et al. (1989) defined clinical parameters to diagnose abnormal lower limb rotation that may require surgery. These were hip internal rotation over 85º with external rotation under 10º and tibial external rotation over 30º. This systematic review assesses evidence for the use of two-level osteotomy to address anterior knee pain in individuals meeting this definition.

PRISMA was used to evaluate papers that met inclusion criteria: healthy patients meeting the above definition who underwent two level derotation surgery regardless of timing or technique.

4 studies (3 retrospective, 1 prospective) with a total of 56 operative limbs were identified. Marked heterogeneity existed within and between studies regarding osteotomy site, fixation method and outcome measures. Only Dickschas et al. (2012) performed a prospective study with validated outcome measures. This study was the only one to use a consistent surgical approach and it found no correlation between magnitude of correction (the outcome measure in 2 studies) and validated patient reported outcomes. The final study solely reported complications.

Evidence regarding surgical management of miserable malalignment syndrome is lacking. One study shows improvements in validated patient reported outcome measures but is confounded by the use of other operative procedures to address patella tracking in addition to lower limb rotation. Randomised, prospective research is needed to develop a more homogenous surgical strategy.