Hemi-high tibial osteotomy: technical note and case report

Osteotomy around the knee: state of the art and new challenges

Knee osteoarthritis is a common and disabling disorder made worse by lower extremity malalignment [3]. Medial knee arthrosis is the most common indication for high tibial osteotomy (HTO). Surgical techniques include closing wedge osteotomy, opening wedge osteotomy, dome osteotomy, progressive callus distraction, and chevron osteotomy [4, 7]. Opening and closing wedge osteotomies are the most common. While lateral closing wedge HTO was once considered standard of care, both techniques have advantages and disadvantages, and neither has proven clinical superiority [3]. Technique selection, therefore, is largely driven by surgeon preference. Jackson [4] first described the closing wedge technique in the 1960s and demonstrated improvements in patient function and pain. This technique, however, is associated with fibular osteotomy or proximal tibiofibular joint release, possible peroneal nerve injury, longer rehabilitation, and a more challenging conversion to total knee arthroplasty [1, 6, 9]. Disadvantages of medial opening wedge osteotomy, on the other hand, include the possible need for bone graft, higher rates of nonunion, and the risk of collapse [9]. Reviewed here, Duivenvoorden’s article describes the mid-term follow-up on 92 patients randomized to high tibial opening wedge or closing wedge osteotomy for varus deformity and medial compartment OA. They investigated clinical and radiographic outcomes, in addition to survival rate, at a mean of 7 years postoperatively. The specific aims of this review are to (1) interpret this study’s findings and (2) to evaluate the validity of the authors’ conclusions and recommendations.

Dupuytren's disease.

Background: If an increased posterior tibial slope (PTS) and concomitant unicompartmental osteoarthritis are present, a simultaneous sagittal (slope) and coronal correcting high tibial osteotomy has been recommended. However, no study has investigated the accuracy of such combined high tibial slope correction osteotomies. Purpose: (1) To report the accuracy of navigated high tibial slope correction osteotomies using patient-specific instruments (PSI) and (2) to analyze the influence of an open wedge osteotomy (OWO) versus a closed wedge osteotomy (CWO) and the hinge axis angle (HAA) on the accuracy of the PTS correction. Study Design: Cohort study; Level of evidence, 3. Methods: All PSI PTS-reducing osteotomies performed at 1 institution between 2019 and 2022 were reviewed. Three-dimensional (3D) accuracy was defined as the mean absolute 3D angular difference between the planned and achieved surgical correction (in degrees) in 3D models of computed tomography data. The influence of OWO versus CWO and the HAA on the reported accuracy was analyzed and a cutoff defined using receiver operating characteristic curve analysis. Results: Eighteen patients who underwent a slope-reducing CWO (n = 9) or OWO (n = 9) were included. The 3D accuracy for PTS was 2.3°± 1.1° (mean ± SD), with CWO being more accurate than OWO (1.4°± 0.9° vs 3.1°± 0.6°; P < .01). Accuracy strongly correlated with the HAA (r = 0.788; P < .01). An HAA >38.9° predicted a PTS error >2° (odds ratio, 1.12 [95% CI, 1.04-1.20; P = .004]; area under the curve, 0.95 [95% CI, 0.89-1.00; P < .001]) corresponding to a coronal/sagittal correction of 0.8:1. Conclusion: Slope-reducing osteotomy can accurately be achieved using PSI. CWO demonstrated an increased accuracy when compared with OWO, which strongly depended on the HAA. With an aim of combined PTS and coronal correction, CWO should be considered the primary choice for accurate slope reduction with a coronal/sagittal correction cutoff of 0.8:1 (HAA, 38.9°).

Background: Currently, there is a tendency to increasing the proportion of knee joint organ-preserving surgeries. High tibial osteotomy (HTO) has proven itself a good method for the treatment of the knee joint varus deformity in extra-articular deformity cases. The question of the perfect angle of correction, which will not significantly impair the biomechanics of the knee and adjacent joints, remains controversial, as well as the issue of preventing excessive hypercorrection as an osteotomy complication.&#x0D; Clinical case description: A clinical case of a 59-year-old patient who underwent primary and revision HTOs is analyzed in this article. The patient had a varus deformity of the left lower limb with isolated medial knee osteoarthritis. The patients body mass index (BMI) was 28 kg/m2. The patient complained only of pain and a limited range of motion in the knee joint. According to the arthroscopy and magnetic resonance imaging (MRI) data, there was a cartilage damage classified as Outerbridge 4 stage of the medial compartment. There were no signs of a lateral compartment cartilage damage and patellofemoral joint arthritis. The varus deformity of the knee joint was 10. The patient underwent a medial high tibial open wedge osteotomy. During the preoperative planning, topograms of the lower limb with weight bearing were used. The clinical status before the operation, according to the used scales, was as follows: Knee injury and Osteoarthritis Outcome Score (KOOS) 46 points, Visual Analogue Scale (VAS) 7 cm, American Orthopaedic Foot and Ankle Society (AOFAS) 92 points. 6 months after the initial surgery, the clinical status was as follows: knee joint VAS 1 cm, ankle joint VAS 5 cm, KOOS 88 points, AOFAS 63 points. During the clinical examination and according to the instrumental studies, excessive valgus hypercorrection of 11.2 was noted. Also, the tibial plafond inclination (TPI) and the talar inclination (TI) were significantly increased. 1.5 years after the primary osteotomy, a revision closed wedge osteotomy was performed. The valgus deformity of the knee joint became 3, the axis of the ankle joint changed to the normal values. The clinical and functional results 6 months after the revision osteotomy were the following: KOOS 92 points, AOFAS 99 points, pain in the knee and ankle joint 1 cm by the VAS scale.&#x0D; Conclusions: The case showed that the careful preoperative planning and the use of additional methods for monitoring the intraoperative correction were important. Excessive valgus hypercorrection promotes good regeneration of the medial compartment cartilage; however, it overloads a lateral compartment and adversely affects the ankle joint and foot.

OBJETIVO: Avaliar radiograficamente individuos submetidos a osteotomia de abertura gradual da tibia proximal com o objetivo de analisar a inclinacao tibial proximal no plano frontal e no plano sagital e a altura patelar. METODO: Foram incluidos no estudo 22 individuos operados no Instituto Nacional de Traumatologia e Ortopedia (INTO) para correcao do desvio angular em varo da tibia pela tecnica de osteotomia de abertura gradual (OAG) com fixador externo monolateral da Orthofix. Foram analisados pacientes submetidos a OAG com termino de tratamento entre janeiro de 2000 e dezembro de 2006. A tecnica utilizada para a mensuracao dos valores foi obtida atraves de radiografias em AP com carga e perfil com flexao a 30o dos joelhos operados. RESULTADOS: Nao houve diferencas entre os valores dos indices de altura patelar e inclinacao tibial pre-operatorios e pos-operatorios de significância estatistica nos pacientes avaliados. CONCLUSAO: A osteotomia tibial de abertura gradual representa uma tecnica que evita os problemas apresentados pela osteotomia tibial proximal alta, pois ela e realizada sem promover alteracoes do mecanismo extensor, desequilibrio ligamentar ou distorcoes na tibia proximal.

Introduction:The aim of this study is to evaluate advantages of close vs. open HTO of a group of patients who underwent a one-stage combined operation for chronic ACL rupture and early medial compartment arthritis.Material and Methods:We retrospective evaluated two series of patients operated on for anterior cruciate ligament (ACL) reconstruction combined with high tibial valgus osteotomy (HTO) for chronic anterior knee instability associated with medial tibio femoral osteoarthritis. Close HTO using rigid plate fixation and ACL reconstruction with bone patellar tendon bone graft was performed in Group A (7 patients). An open HTO using Puddu plate and ACL reconstruction with hamstring tendon graft was performed in Group B (9 patients). The mean age in Group A was 41 years old with an average varus of 8 degrees. Mean age in Group B was 42 years old and with 4 degrees of varus. Lysholm Score, HSS and Radiographs were performed.Results:Group A obtained a mean Lysholm score of 94, mean HSS of 91. Group B showed a mean Lysholm score of 83, mean HSS of 87. The mean follow-up was 5 years in both groups. In all cases osteotomies consolidated.Discussion:Technically we found that open HTO with hamstrings had several advantages such as lower risk of peroneal nerve injury, use of one incision, no problems as regards graft length, possibility of fixing the graft in the proximal tibia, maintenance of tibial slope and preservation of bone stock. The Open HTO need of osseous graft, may produce patella baja and the risk of nonunion is higher. This technique is indicated for relaxed medial collateral ligament. As regards the Close HTO there may be possibilities of a peroneal nerve injury, it may decrease the tibial slope, patellar ascent, loss of bone, the need to disrupt either the fibula or proximal tibio-fibular joint and may generate instability in the posterolateral corner and the screws could compromise the tunnels path. The advantages are provision of bone to bone contact with excellent union rates and the potential for full early weight-bearing.Conclusion:In spite of these issues, both procedures relieved pain and restored knee stability and the choice will depend on each particular case.

Since a significant number of implant failures have been reported in association with the procedure of open wedge valgus high tibial osteotomy, the initial biomechanical stability of different fixation devices was investigated in this study. Fifteen third generation Sawbones composite tibiae were used as a model. Four different plates were tested: a short spacer plate (OWO) (n = 4), a short spacer plate with multi-directional locking bolts (MSO) (n = 5), a prototype version of a long spacer plate with multi-directional locking bolts (MSOnew) (n = 2), and a long medial tibia plate fixator with locking bolts (MPF) (n = 4). All opening wedge osteotomies were performed by the same surgeon (PL) in a standardized fashion. Axial compression of the tibiae was performed using a materials testing machine under standardized alignment of the loading axis. Single load to failure tests as well as load-controlled cyclical failure tests were performed. The required force and cycles to failure were recorded. Osteotomy gap motion was measured using linear displacement transducers. Residual stability after failure of the opposite lateral cortex was analysed. Failure occurred at the lateral cortex bone-bride in all tested implants. The rigid long plate fixator (MPF) resisted the greatest amount of force (2,881 N) in the single load to failure tests. In the cyclical load-to-failure tests, the constructs with MPF resisted more than twice the amount of loading cycles when compared to the short spacer plates. The osteotomy gap motion was smallest in the MPF, with a reduction of the displacements of up to 65, 66 and 88%, when compared to OWO, MSO and MSOnew, respectively. The highest residual stability after failure of the lateral cortex was observed in MPF as well. The results suggest that the implant design strongly influences the primary stability of medial opening wedge tibial osteotomy. A rigid long plate fixator with angle-stable locking bolts yields the best results.

Introduction: Knee osteoarthritis is typically the result of wear and tear and progressive loss of articular cartilage. Common clinical symptoms include knee pain, stiffness and swelling that worsens over time. Osteoarthritis commonly affects the medial compartment of knee giving rise to varus deformity. High tibial osteotomy (HTO) is a valuable treatment modality in correcting malalignment and thereby relieving the symptoms associated with medial unicompartmental osteoarthritis. Methodology: Twenty-eight young patients with complaints of knee pain were screened and those diagnosed as early knee osteoarthritis (grade I-III on Kellgren-Lawrence grading scale) were operated by high tibial osteotomy. Follow-up evaluation was done at 3, 6 and 9 months by Knee Society Scoring Scale and Visual Analogue Scale (VAS) for pain. Results: The mean knee score was 53.3 pre-operatively and post-operatively the score improved gradually to the mean of 83.2 at 9 months. The visual analog scale for pain in all patients showed a significant improvement at the final follow-up. Conclusion: High tibial medial opening wedge osteotomy is a good option in the treatment of unicompartmental osteoarthritis knee. It relieves pain and improves functional outcome. Accurate preoperative planning and good surgical technique gives better results.

Knee osteotomies realign the knee in an attempt to better distribute forces across the knee. The anatomic and physiologic function of the extensor mechanism, which includes the quadriceps tendon, patella, and patella ligament, may be altered during this procedure. An understanding of these changes is important especially when additional surgery becomes necessary, such as a conversion to a total knee arthroplasty. The current authors discuss patella mechanics and changes in the patella associated with osteotomies about the knee and the influence on normal patella biomechanics. Although patella changes are uncommon after a distal femoral osteotomy, poor total knee arthroplasty outcomes after a high tibial osteotomy attributable to patella alterations exist. Surgical technique during the primary high tibial osteotomy and the conversion to the total knee arthroplasty can reliably improve the final outcome. Rigid internal fixation with early knee mobilization after high tibial osteotomy reduces the incidence of patella baja and improves total knee arthroplasty outcome after a high tibial osteotomy, whereas while patella changes after a distal femoral osteotomy are minimal and largely ignored.

The effect of smoking on union rates following corrective osteotomies around the knee: A systematic review and meta-analysis

BACKGROUND:: The aim of this paper is to assess the effect that the isolated coronal plane obliquity/angle of cut made for an opening wedge osteotomy has on the opening wedge gap, and determine whether this effect is likely to have clinical relevance with respect to bony union. The proximal tibial osteotomy has been used as an example. METHODS:: Mathematical/schematic assessment. RESULTS:: The single plane obliquity of the osteotomy cut cannot be used in isolation to predict opening gap distance, unless an osteotomy is performed on a perfectly cylindrical bone whereby the smallest gap is produce by the most horizontal cut. CONCLUSIONS:: Reducing the opening gap distance can be achieved by utilizing the shortest osteotomy through the bone at the desired point of correction. CLINICAL RELEVANCE:: The degree of change in opening wedge gap between various angles of high tibial opening wedge osteotomy is small-and focus should probably be placed on other mechanical and surgical considerations.

Introduction: Osteoarthritis of knee is more common among all types of arthritic conditions. High tibial osteotomy is an accepted surgical technique for treatment of medial compartment arthrosis of knee in younger patients. Selection of the appropriate patients, extensive pre-operative planning and accurate surgical technique are essential for successful outcome. The methods of high tibial osteotomy include open wedge osteotomy and closed wedge osteotomy, the later procedure being more popular. Aims and Objectives: To assess the functional outcome among patients undergoing high tibial osteotomy. Methodology: A hospital based prospective interventional study was done on 30 patients of osteoarthritis with varus deformity. For all the 30 patients after a proper preoperative assessment the surgical intervention in the form of high tibial osteotomy was done and the outcome was evaluated using knee society scoring system. Results: Among the study population 73.3% of the patients had grade III type of osteoarthritis and only 26.6% had grade IV type of osteoarthritis based on Kellgren and Lawrence type of classification. The mean knee score and the mean functional score of the patients before surgery were 54.6 and 53.9 respectively and post operatively at the end of 12 months the knee score and functional score was 83.1 and 82 respectively. A statistically significant improvement was seen in both the knee society score and the functional score. Conclusion: The main improvements seen in this study was the increase in the knee score and functional score after high tibial osteotomy for the patients of osteoarthritis with varus deformity. Appropriate patient selection, proper osteotomy types and precise surgical techniques are essential for the success of high tibial osteotomy.

Total knee arthroplasty following medial opening wedge tibial osteotomy: Technical issues early clinical radiological results

Objectives:Open wedge proximal tibial osteotomy has gained popularity over recent years. This technique has several advantages over lateral closed wedge osteotomy, like lack of any need for fibular osteotomy and freedom from peroneal nerve complications, easier and more precise correction, no limb shortening and easier access for an eventual total knee arthroplasty. However it was been shown that open wedge osteotomy may reduce patellar height and increase sagittal tibial slope which can cause patellofemoral problems. The aim of the study was to evaluate the alterations in the angle of posterior slope of the tibia and the degree of patellar height following medial opening wedge proximal tibial osteotomy in our patients.Methods:26 females and 7 males, with a mean age of 48, who underwent medial opening wedge proximal tibial osteotomy were included in the study. In all cases, the preoperative measured varus angle was overcorrected to between 5-8° valgus. The posterior slope of the tibia was determined by the proximal tibial anatomical axis and patellar height was measured retrospectively by the Caton index on the pre- and postoperative radiograms at the end of the second month.Results:Preoperatively, on the standing orthoroentgenograms, the mean mechanical axis deviation was 12,36° (8-20) and the mean posterior tibial slope in the sagittal view was 16,24° (10-23). The mean postoperative tibial slope was 17,85° (6-25). Using paired samples test, this increase was statistically significant (p=0.049). Preoperative mean Caton index was 1,35 (1,01-1,92) and the postoperative average was 1,73 (1,11-2,76). There was also a statistical significant increase between the pre-and postoperative values (p<0.001) with paired samples test. There was a positive correlation between preoperative mechanical axis deviation and postoperative slope angle (p=0,014) but there was no correlation between preoperative mechanical axis deviation and postoperative patellar height.Conclusion:In conclusion, tibial slope and patellar height are strongly affected by open wedge high tibial osteotomy and this might have an adverse effect on an eventual knee arthroplasty.