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High Tibial Osteotomy: An Update for Radiologists. AJR Am J Roentgenol 2021; 218:701-712. [PMID: 34817194 DOI: 10.2214/ajr.21.26659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
High tibial osteotomy (HTO) is a surgical procedure to treat symptomatic unicompartmental osteoarthritis (OA) associated with knee malalignment. There has been a recent resurgence of interest in HTO in patients who prefer joint-preserving surgery, as HTO shifts the knee's mechanical axis from the arthritic compartment to a neutral position, thereby reducing knee pain, slowing progression of OA, and delaying the need for a total knee arthroplasty. The ideal candidates for HTO are young, active, nonobese patients with isolated varus deformity of the knee due to medial compartment OA. Radiography is critical in the preoperative evaluation for HTO and can help expand surgical indications to include a wider variety of patients. Radiography is also routinely obtained in postoperative assessment and is typically the first test to suspect complications. This review describes the radiologic aspects of HTO, including preoperative imaging assessment, as well as normal and abnormal postoperative imaging appearances. Surgical techniques and osteotomy fixation devices are described, with a focus on the medial opening wedge approach. Given the growing interest in HTO, radiologists should become familiar with the basics of the procedure and the role of imaging in preoperative and postoperative evaluation.
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Le Guéhennec L, Van Hede D, Plougonven E, Nolens G, Verlée B, De Pauw MC, Lambert F. In vitro and in vivo biocompatibility of calcium-phosphate scaffolds three-dimensional printed by stereolithography for bone regeneration. J Biomed Mater Res A 2019; 108:412-425. [PMID: 31654476 DOI: 10.1002/jbm.a.36823] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022]
Abstract
Stereolithography (SLA) is an interesting manufacturing technology to overcome limitations of commercially available particulated biomaterials dedicated to intra-oral bone regeneration applications. The purpose of this study was to evaluate the in vitro and in vivo biocompatibility and osteoinductive properties of two calcium-phosphate (CaP)-based scaffolds manufactured by SLA three-dimensional (3D) printing. Pellets and macro-porous scaffolds were manufactured in pure hydroxyapatite (HA) and in biphasic CaP (HA:60-TCP:40). Physico-chemical characterization was performed using micro X-ray fluorescence, scanning electron microscopy (SEM), optical interferometry, and microtomography (μCT) analyses. Osteoblast-like MG-63 cells were used to evaluate the biocompatibility of the pellets in vitro with MTS assay and the cell morphology and growth characterized by SEM and DAPI-actin staining showed similar early behavior. For in vivo biocompatibility, newly formed bone and biodegradability of the experimental scaffolds were evaluated in a subperiosteal cranial rat model using μCT and descriptive histology. The histological analysis has not indicated evidences of inflammation but highlighted close contacts between newly formed bone and the experimental biomaterials revealing an excellent scaffold osseointegration. This study emphasizes the relevance of SLA 3D printing of CaP-based biomaterials for intra-oral bone regeneration even if manufacturing accuracy has to be improved and further experiments using biomimetic scaffolds should be conducted.
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Affiliation(s)
- Laurent Le Guéhennec
- Department of Prosthetic Dentistry, Faculty of Dentistry, Nantes, France.,Department of Preclinical Biomedical Sciences, Mammalian Cell Culture Laboratory, GIGA-R, Faculty of Medicine, Liège, Belgium
| | - Dorien Van Hede
- Department of Periodontology and Oral Surgery, Faculty of Medicine, Liège, Belgium
| | - Erwan Plougonven
- Department of Chemical Engineering, Faculty of Applied Sciences, Liège, Belgium
| | - Grégory Nolens
- Department of Biomedical Sciences, Faculty of Medicine, Namur, Belgium
| | - Bruno Verlée
- Sirris, Additive Manufacturing Department, Seraing, Belgium
| | - Marie-Claire De Pauw
- Department of Preclinical Biomedical Sciences, Mammalian Cell Culture Laboratory, GIGA-R, Faculty of Medicine, Liège, Belgium
| | - France Lambert
- Department of Periodontology and Oral Surgery, Faculty of Medicine, Liège, Belgium
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Itoh M, Itou J, Kuwashima U, Fujieda H, Okazaki K. Deep peroneal nerve injury during plate fixation for medial open-wedge high tibial osteotomy: A case report and cadaveric study. Clin Case Rep 2019; 7:2225-2230. [PMID: 31788284 PMCID: PMC6878058 DOI: 10.1002/ccr3.2451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 11/27/2022] Open
Abstract
This report presents a case of deep peroneal nerve palsy caused by an injury during drilling for distal locking screws of a T-shaped locking plate used for osteosynthesis of medial open-wedge high tibial osteotomy. A cadaveric simulation study reproduced the risk of injury during the surgery.
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Affiliation(s)
- Masafumi Itoh
- Department of Orthopedic surgeryTokyo Women's Medical UniversityTokyoJapan
| | - Junya Itou
- Department of Orthopedic surgeryTokyo Women's Medical UniversityTokyoJapan
| | - Umito Kuwashima
- Department of Orthopedic surgeryTokyo Women's Medical UniversityTokyoJapan
| | - Hiroki Fujieda
- Department of AnatomyTokyo Women's Medical UniversityTokyoJapan
| | - Ken Okazaki
- Department of Orthopedic surgeryTokyo Women's Medical UniversityTokyoJapan
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Erquicia J, Gelber PE, Perelli S, Ibañez F, Ibañez M, Pelfort X, Monllau JC. Biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy, radiological and clinical analysis with minimum follow-up of 2 years. J Exp Orthop 2019; 6:10. [PMID: 30820763 PMCID: PMC6395462 DOI: 10.1186/s40634-019-0176-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/12/2019] [Indexed: 11/10/2022] Open
Abstract
Background High tibial osteotomy is an established and helpful treatment for unicompatimental osteoarthritis associated with varus deformity. However, asupratubercle high tibial osteotomy leads to a decrease in patellar height making the technique not suitable in case of concomitant patella baja. Moreover, this kind of osteotomy can change in situ forces at patellofemoral joint and the lateral patellar tilt. With the aim to widen the indication of high tibial osteotomy was proposed a biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy (B-OWHTO). This technique provide that the tibial tuberosity remains joined to the tibial metaphysis so as not to theoretically alter the patellar height. However, some Authors claim that BOWHTO could lead to an increase in tibial slope. The purpose of the present study was to assess the tibial slope, patella-femoral changes and axial correction as well as functional outcomes following a B-OWHTO. Methods Patients operated on with a B-OWHTO and a minimum 24 months of follow-up were included. The mechanical alignment of the lower limb, patellar height, lateral patellar tilt and posterior tibial slope were calculated preoperatively, immediately after surgery and at the 24-month follow-up. The clinical results were evaluated using the Lysholm, Kujala and Hospital for Special Surgery knee scores. The possible postoperative development of patellofemoral pain or radiologic patellofemoral alteration was also evaluated. Results Twenty-three patients were included with a mean follow-up of 33 months (range 27-41). The mechanical alignment of the lower limb shifted from a mean 9.3º ± 2.5 varus preoperatively to a mean 0.2º ± 2.2 valgus postoperatively. No changes in patellar height, lateral patellar tilt or in the posterior tibial slope were observed. The mean Lysholm and HSS scores improved from 68.3 ± 9.1 and 64.2 ± 5.2 preoperatively to 93.2 ± 2.1 and 94.1 ± 3.6 at final follow-up (p < 0.01). The mean Kujala score improved from 67.3 ± 9.8 to 86.4 ± 7.6 at final follow up (p < 0.01). No patients developed both radiological or clinical symptoms at patellofemoral joint. Conclusions Open wedge high tibial osteotomy with a dihedral L-cut distal and posterior to the tibial tubercle accurately corrected axial malalignment without any change at patella-femoral joint or any modification to the posterior tibial slope while providing improved knee function at short-term follow-up. The radiographic as well as the clinical results support the use of this technique to treat medial compartment knee osteoarthritis and varus malalignment in young and middle-aged patients with a normal-to-low patellar height. Level of evidence Case series with no comparison group, Level IV.
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Affiliation(s)
- Juan Erquicia
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain
| | - Pablo Eduardo Gelber
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain.,Department of Orthopaedic Surgery, Hospital de la Sta Creu i Sant Pau, UAB, Carrer de Sant Quintí, 89, Barcelona, 08026, Spain
| | - Simone Perelli
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain.
| | - Federico Ibañez
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain
| | - Maximiliano Ibañez
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain
| | - Xavier Pelfort
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain.,Department of Orthopaedic Surgery, Consorci Sanitari de l'Anoia, Hospital de Igualada, Av. Catalunya, 11, Barcelona, Spain
| | - Juan Carlos Monllau
- ICATME, Hospital Universitari Dexeus, UAB, Carrer de Sabino Arana, 5, Barcelona, 08028, Spain.,Department of Orthopaedic Surgery, Hospital del Mar. Universitat Autònoma de Barcelona (UAB), Passeig Marítim, 25, Barcelona, 08003, Spain
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Spitzer E, Ruzbarsky JJ, Doyle JB, Yin KL, Marx RG. A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy. HSS J 2018; 14:251-257. [PMID: 30258329 PMCID: PMC6148587 DOI: 10.1007/s11420-017-9591-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medial opening-wedge high tibial osteotomy (HTO) is one of the most common and effective HTO techniques, in which the proximal tibia is cut medially, leaving an intact lateral hinge of bone that can be opened to a variable amount for the desired correction, but the technical complications of lateral cortex fracture and intra-articular fracture are well described. The lateral bone hinge for medial opening-wedge HTO is crucial. If the hinge is too small, the tibia can fracture and become unstable, requiring further fixation. If the hinge is too large, the osteotomy can propagate into the joint as an intra-articular fracture when opening the osteotomy. PURPOSE We propose a new technique that utilizes digital preoperative templating to improve the accuracy of the cut. Preoperative digital templating may allow the surgeon to reproducibly obtain a lateral bone hinge of 10 mm, while also reducing radiation exposure relative to the traditional fluoroscopically assisted technique. METHODS Ten cadaver extremities from five cadavers were matched into pairs and randomized into two groups: those with and without preoperative templating. The templating protocol measures the distance between two points on the medial and lateral cortices, and 20 mm is subtracted to determine the depth of the saw cut (10 mm for the hinge and another 10 mm because the proximal tibia is oval in shape). The control method was done by making the cut using fluoroscopy with tactile feedback. Postoperative computed tomography scans were obtained of all legs to measure the width of the lateral bone hinge. Intraoperative fluoroscopy used during both techniques and the numbers of fluoroscopy shots were recorded. RESULTS We found neither the treatment group with preoperative planning nor the control group with the conventional technique had bone hinge widths that were different from the ideal 10 mm. The average hinge widths for the treatment and control groups were 11.2 and 11.5 mm, respectively. However, the treatment group was exposed to significantly less intraoperative fluoroscopy during the osteotomy cut. The average total number of fluoroscopy shots was 2.2 in the treatment group versus 6.3 for the control group. CONCLUSIONS This new preoperative planning technique achieves similar accuracy of the lateral bone hinge when compared to current methods but exposes the patient, surgeon, and staff to significantly less intraoperative radiation.
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Affiliation(s)
- Elad Spitzer
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - John B. Doyle
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Kaitlyn L. Yin
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Robert G. Marx
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Monllau JC, Erquicia JI, Ibañez F, Ibañez M, Gelber PE, Masferrer-Pino A, Pelfort X. Open-Wedge Valgus High Tibial Osteotomy Technique With Inverted L-Shaped Configuration. Arthrosc Tech 2017; 6:e2161-e2167. [PMID: 29349013 PMCID: PMC5765526 DOI: 10.1016/j.eats.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/07/2017] [Indexed: 02/03/2023] Open
Abstract
High tibial osteotomy (HTO) is a useful alternative in the treatment of symptomatic varus malalignment. However, among its drawbacks is the tendency to decrease patellar height and increase the posterior tibial slope. The increased tibial slope increases anterior cruciate ligament tension and may compromise its function. On the other hand, patella baja often causes anterior knee pain and, over time, may favor degeneration of the patellofemoral joint. The aim of this study is to describe a technical modification of the standard open-wedge HTO. It consists of a double inverted L-shaped cut, which includes the anterior tibial tuberosity in the proximal fragment, to avoid any alteration of patellar height and control the eventual increase of the posterior tibial slope.
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Affiliation(s)
- Juan C Monllau
- Department of Orthopaedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan I Erquicia
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Federico Ibañez
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maximiliano Ibañez
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pablo E Gelber
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery, Hospital de la Sta Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angel Masferrer-Pino
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Pelfort
- ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery, Consorci Sanitari de l'Anoia, Igualada, Spain
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Salim R, Fogagnolo F, Perina MM, Rubio UM, Kfuri Junior M. Conventional plate and screws in medial opening-wedge high tibial osteotomy: are they sufficiently stable? A retrospective study. Rev Bras Ortop 2017; 52:549-554. [PMID: 29062819 PMCID: PMC5643892 DOI: 10.1016/j.rboe.2016.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/09/2016] [Indexed: 11/28/2022] Open
Abstract
Objective Opening-wedge osteotomy of the proximal tibia is a widely performed procedure for treating medial gonarthrosis in active patients and in the presence of varus malalignment of the lower limb. The fixation method is controversial, and the use of conventional implants has been abandoned in favor of implants with more modern locking screws. The aim of the present clinical study was to assess the maintenance of the correction achieved in cases wherein fixation was performed using conventional implants. Methods This retrospective study included 51 patients who underwent opening-wedge high tibial osteotomy wherein fixation was performed using conventional implants (4.5-mm DCP plate and non-locking screws). Radiological findings regarding patellar height, tibial slope, and varus correction postoperatively and after consolidation were analyzed to assess the maintenance of the correction achieved by osteotomy. Results The mean loss of correction angle, calculated by the difference between the correction angle in the immediate postoperative period and that after consolidation, was 0.92° ± 0.9°. In addition, changes in patellar height determined by the Blackburne–Peel method and in the sagittal slope of the tibial plateau were not significant or clinically relevant. Conclusions The use of conventional plates and screws is viable in the fixation of opening-wedge high tibial osteotomy because they provide enough stability to maintain the achieved correction until consolidation, without significant changes.
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Affiliation(s)
- Rodrigo Salim
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Fabricio Fogagnolo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Mauricio Martins Perina
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Ugo Messas Rubio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Mauricio Kfuri Junior
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Ribeirão Preto, SP, Brazil
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O sistema convencional de placa e parafusos na osteotomia tibial alta em cunha de abertura medial é suficientemente estável? Um estudo retrospectivo. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Hernigou P, Dubory A, Pariat J, Potage D, Roubineau F, Jammal S, Flouzat Lachaniette CH. Beta-tricalcium phosphate for orthopedic reconstructions as an alternative to autogenous bone graft. Morphologie 2017; 101:173-179. [PMID: 28501353 DOI: 10.1016/j.morpho.2017.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/25/2017] [Accepted: 03/21/2017] [Indexed: 11/16/2022]
Abstract
Autogenous bone graft (autograft) remains the gold standard in the treatment of many orthopedic problems. However, graft harvest can lead to perioperative morbidity and increased cost. We tested the hypothesis that an osteoconductive matrix, beta-tricalcium phosphate (β-TCP), would be a safe and effective alternative to autograft alone. Beta-tricalcium phosphate (β-TCP) is considered as one of the most promising biomaterials for bone reconstruction. This study analyzes the outcomes of patients who received β-TCP as bone substitutes in orthopedic surgery. METHODS A total of 50 patients were enrolled in a controlled, non-inferiority clinical trial to compare the safety and efficacy of β-TCP (25 patients) with those of autograft (25 patients) in indications requiring usually autograft. These 50 patients were categorized according to the etiology and morphology of the 54 bone defects resulting from elective surgical procedures, such as 34 open-wedge high tibial osteotomies, and 20 osteonecrosis treatments with core decompression. Radiographic (healing process with or without integration of β-TCP), clinical (no other surgical procedure), functional outcomes and safety (with or without complications) were assessed through fifty-two weeks postoperatively. RESULTS With regard to the primary endpoint (radiographic evolution), the fusion rate of the 34 open-wedge osteotomies was 100% (17 among 17) for patients in the group with β-TCP compared with 94% (16 among 17) for patients in the autograft group. For the 20 cavitary defects (osteonecrosis), the radiographic union rates, as determined by the presence of osseous bridging, were 100% for patients in the group with β-TCP and 100% for those in the autograft group. Clinically at one year, all quality-of-life and functional outcome data supported non-inferiority of β-TCP compared with autograft, and patients in the β-TCP group were found to have less pain and an improved safety profile. CONCLUSIONS Treatment with β-TCP resulted in comparable fusion rates, less pain and fewer side effects as compared with treatment with autograft. This study established clinical parameters where the β-TCP alone can successfully support the osteogenic process.
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Affiliation(s)
- P Hernigou
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
| | - A Dubory
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - J Pariat
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - D Potage
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - F Roubineau
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - S Jammal
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - C H Flouzat Lachaniette
- Department of Orthopaedic Surgery, University Paris East (UPEC), hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
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Flouzat-Lachaniette CH, Roubineau F, Heyberger C, Bouthors C. Distraction to treat knee osteoarthritis. Joint Bone Spine 2016; 84:141-144. [PMID: 27178780 DOI: 10.1016/j.jbspin.2016.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2016] [Indexed: 01/27/2023]
Abstract
The objective of this article is to review data on joint distraction used to treat knee osteoarthritis. Joint distraction is a surgical procedure in which the two bony ends of the joint are gradually pulled apart then kept separated for 2 months in an external fixation frame. Weight bearing is continued to ensure variations in hydrostatic pressure within the joint. In published studies, joint distraction provided substantial clinical and structural improvements in patients with knee osteoarthritis, delaying joint replacement surgery for at least 2 years. Animal studies showed that joint distraction was associated with decrease in the secondary inflammatory response, cartilage breakdown, and subchondral bone remodeling. In vitro, the intermittent application of hydrostatic pressure stimulated the production of extracellular matrix, particularly in joints with osteoarthritis. Nevertheless, several considerations invite caution when considering the more widespread use of joint distraction. Published studies have short follow-ups and small sample sizes. In addition, the high frequency of pin tract infection is of concern, since most patients eventually require knee replacement surgery. These two considerations indicate a need for longer-term prospective studies of patient cohorts.
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Affiliation(s)
- Charles-Henri Flouzat-Lachaniette
- Service de chirurgie orthopédique et traumatologique, hôpital Henri-Mondor, AP-HP-UPEC, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
| | - François Roubineau
- Service de chirurgie orthopédique et traumatologique, hôpital Henri-Mondor, AP-HP-UPEC, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Clémence Heyberger
- Service de chirurgie orthopédique et traumatologique, hôpital Henri-Mondor, AP-HP-UPEC, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Charlie Bouthors
- Service de chirurgie orthopédique et traumatologique, hôpital Henri-Mondor, AP-HP-UPEC, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
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Woodacre T, Ricketts M, Evans JT, Pavlou G, Schranz P, Hockings M, Toms A. Complications associated with opening wedge high tibial osteotomy--A review of the literature and of 15 years of experience. Knee 2016; 23:276-82. [PMID: 26596554 DOI: 10.1016/j.knee.2015.09.018] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/27/2015] [Accepted: 09/30/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Complication rates following opening wedge high tibial osteotomy (OWHTO) is an issue that has not been comprehensively addressed in current literature. METHODS We performed a retrospective study of local patients who underwent OWHTO for isolated medial compartment knee osteoarthritis from 1997 to 2013. We analysed survivorship and complication rates and compared this to a literature review of previously reported data. RESULTS One hundred and fifteen patients met the inclusion criteria. Mean follow-up=8.4 years. Mean age=47 (range 32 to 62). Mean Body Mass Index (BMI)=29.1 (range 20.3 to 40.2). Devices used consisted of Tomofix (72%), Puddu plate (21%) and Orthofix (seven percent) (no significant differences in age/sex/BMI). Wedge defects were filled with autologous graft (30%), Chronos (35%) or left empty (35%). Five years survival rate (without requiring conversion to arthroplasty)=80%. Overall complication rate=31%. Twenty five percent of patients suffered 36 complications including minor wound infections (9.6%), major wound infections (3.5%), metalwork irritation necessitating plate removal (seven percent), non-union requiring revision (4.3%), vascular injury (1.7%), compartment syndrome (0.9%), and other minor complications (four percent). No thromboembolic complications were observed. CONCLUSION No significant differences existed in complication rates following OWHTO relative to BMI, implant type, type of bone graft used or patient age at surgery. When the complications from OWHTO were analysed closely they appear higher than previously reported in the literature; however serious complications appear rare. LEVEL OF EVIDENCE 3: Retrospective cohort study.
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Affiliation(s)
- T Woodacre
- Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX25DW, UK; Torbay Hospital, Newton Road, Torquay, Devon TQ27AA, UK.
| | - M Ricketts
- Torbay Hospital, Newton Road, Torquay, Devon TQ27AA, UK.
| | - J T Evans
- Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX25DW, UK.
| | - G Pavlou
- Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX25DW, UK.
| | - P Schranz
- Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX25DW, UK.
| | - M Hockings
- Torbay Hospital, Newton Road, Torquay, Devon TQ27AA, UK.
| | - A Toms
- Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX25DW, UK.
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van Egmond N, van Grinsven S, van Loon CJM, Gaasbeek RD, van Kampen A. Better clinical results after closed- compared to open-wedge high tibial osteotomy in patients with medial knee osteoarthritis and varus leg alignment. Knee Surg Sports Traumatol Arthrosc 2016; 24:34-41. [PMID: 25217316 DOI: 10.1007/s00167-014-3303-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 09/02/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Studies comparing mid- or long-term outcomes of open- and closed-wedge high tibial osteotomy are limited. Here, the midterm survival rate and clinical and radiographic outcomes were compared for these two techniques. The study hypothesis, based on short-term follow-up, was that after midterm follow-up, the two techniques would not differ. METHODS A prospective follow-up study was conducted for a previously reported randomized controlled trial of an original 50 patients (25 open-wedge osteotomy and 25 closed-wedge osteotomy) with medial knee osteoarthritis and a varus leg alignment. We analyzed patients without knee arthroplasty (mean age 48.7 years, SD 8.0) for clinical and radiographic follow-up. RESULTS Five patients in each group had undergone conversion to a total knee arthroplasty or unicompartmental knee arthroplasty, leaving 19 patients for analysis in each group. At 7.9 years of follow-up (range 7-9 years), survival did not differ significantly between groups (open-wedge group 81.3% [95% confidence interval (CI) 75.2-100], closed-wedge group 82.0% [95% CI 66.7-100]). At final follow-up, total Dutch Western Ontario and McMaster Universities Arthritis (WOMAC), Knee Society Score, and visual analog scale (VAS) pain did not differ between groups. However, the results were significantly better in the closed-wedge group for VAS satisfaction and WOMAC pain and stiffness compared to the open-wedge group. Radiographic evaluation did not differ between groups for any outcome at final follow-up. CONCLUSION After a mean follow-up of 7.9 years, patients undergoing a closed-wedge osteotomy had favorable clinical results compared to those who underwent an open-wedge osteotomy. LEVEL OF EVIDENCE II.
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Affiliation(s)
- N van Egmond
- Department of Orthopaedics, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - S van Grinsven
- Department of Orthopaedics, Rijnstate Hospital Arnhem, Wagnerlaan 55, 6800 TA, Arnhem, The Netherlands
| | - C J M van Loon
- Department of Orthopaedics, Rijnstate Hospital Arnhem, Wagnerlaan 55, 6800 TA, Arnhem, The Netherlands
| | - R D Gaasbeek
- Department of Orthopaedics and Traumatology, Meander Medical Center, P.O. Box 1502, 3800 BM, Amersfoort, The Netherlands
| | - A van Kampen
- Department of Orthopaedics, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Kwon SK, Moon HK, Choi CJ, Park SH, Lee JJ, Kim YC, Park YS, Koh YG. Accelerated degeneration of the discoid lateral meniscus after medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2015. [PMID: 23188498 DOI: 10.1007/s00167-012-2289-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE This study was undertaken to report clinical outcomes after high tibial osteotomy (HTO) in patients with a discoid lateral meniscus and to determine (1) whether discoid lateral meniscus degeneration by magnetic resonance imaging (MRI) progresses after HTO and (2) whether this progression adversely affects clinical results. METHODS The records of 292 patients (292 knees) who underwent medial opening HTO were retrospectively reviewed, and discoid types and grades of lateral meniscus degeneration as determined by MRI were recorded preoperatively. Of the 292 patients, 17 (5.8%) had a discoid lateral meniscus, and postoperative MR images were obtained at least 2 years after HTO for 15 of these 17 patients. RESULTS American Knee Society (AKS) pain, knee and function scores significantly improved in the 15 patients after surgery (p < 0.001). Eight (53%) had an incomplete and 7 (47%) had a complete discoid lateral meniscus. By preoperative MRI, the distribution of meniscal degeneration was as follows: grade 1, 4 patients; grade 2, 7 patients; and grade 3, 4 patients. At the final follow-up, the distribution of degeneration was as follows: grade 1, 2 patients; grade 2, 5 patients; and grade 3, 8 patients. Two patients with grade 3 degeneration who did not undergo partial meniscectomy showed tear progression. Thus, 8 of the 15 patients (53%) experienced progressive discoid meniscal degeneration after HTO. Median AKS pain score was significantly lower in the progression group than in the non-progression group (40 vs 45, respectively). CONCLUSION The results of this study suggest that increased load on the lateral compartment after HTO can accelerate discoid lateral meniscus degeneration by MRI and caution that when a discoid lateral meniscus is found by preoperative MRI, progressive degeneration may occur after HTO and clinical outcome may be adversely affected. LEVEL OF EVIDENCE Therapeutic study, Level IV.
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Affiliation(s)
- Sae Kwang Kwon
- Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 49-3 Yeokgok-dong, Wonmi-gu, Bucheon, 420-100, Korea
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14
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Hernigou P, Flouzat Lachaniette C, Delambre J, Guissou I, Dahmani O, Ibrahim Ouali M, Poignard A. Full weight bearing and dynamisation with Limmed® locked plate fixation accelerates bone regeneration in the volume of opening wedge high tibial osteotomy. INTERNATIONAL ORTHOPAEDICS 2014; 39:1295-300. [DOI: 10.1007/s00264-014-2633-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 12/02/2014] [Indexed: 11/28/2022]
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Hernigou P, Queinnec S, Picard L, Guissou I, Naanaa T, Duffiet P, Julian D, Archer V. Safety of a novel high tibial osteotomy locked plate fixation for immediate full weight-bearing: a case-control study. INTERNATIONAL ORTHOPAEDICS 2013; 37:2377-84. [PMID: 23974839 DOI: 10.1007/s00264-013-2066-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The safety and efficacy of the novel Limmed® system (locked plate fixation) for immediate full weight-bearing after medial opening wedge high tibial osteotomy (HTO) were evaluated in patients with symptomatic varus gonarthrosis. METHODS A case series of 85 consecutive osteotomies performed with Limmed® locked plate fixation for medial opening wedge HTO was compared to a historical matched case-control series of 85 HTOs (85 patients) performed using the same implant without locked screws. Subjects were observed at seven and 15 days and three, six and 12 months after surgery. Endpoints for evaluation included the reporting of adverse events, weight-bearing status without pain, radiographic evidence of bony union and changes in correction angle during healing. RESULTS Statistically significant differences were seen between groups in terms of safety (thrombophlebitis), time to weight-bearing, radiographic union and radiographic stability between the two groups. Patients of the Limmed® group reported less thrombophlebitis (one versus nine), outcome with shorter time for full weight-bearing (average 45 days difference, p = 0.01) and a shorter time for union (average four weeks difference). At the one-year follow-up the post-operative hip-knee-ankle angle was 4.2° of valgus in the Limmed® group and 2° of valgus in the control group. The adjusted mean difference of 2.2° was significant (p = 0.02) and related to loss of correction during healing in the control group with difference in implant stability. The severity of pain, knee score and walking ability improved in both groups with a significant difference before the third month (quicker for Limmed® group), while at the most recent follow-up only the difference for mobility in flexion was significant. CONCLUSIONS The Limmed® medial opening wedge HTO system represents a novel method of achieving a reliable correction while producing a stable fixation allowing satisfactory stability and bone healing with immediate full weight-bearing.
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Gomoll AH, Filardo G, Almqvist FK, Bugbee WD, Jelic M, Monllau JC, Puddu G, Rodkey WG, Verdonk P, Verdonk R, Zaffagnini S, Marcacci M. Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures. Knee Surg Sports Traumatol Arthrosc 2012; 20:468-86. [PMID: 22068267 DOI: 10.1007/s00167-011-1714-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 10/06/2011] [Indexed: 11/24/2022]
Abstract
UNLABELLED Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies. LEVEL OF EVIDENCE Systematic review, Level II.
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Affiliation(s)
- A H Gomoll
- Cartilage Repair Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Sternheim A, Garbedian S, Backstein D. Distal femoral varus osteotomy: unloading the lateral compartment: long-term follow-up of 45 medial closing wedge osteotomies. Orthopedics 2011; 34:e488-90. [PMID: 21902140 DOI: 10.3928/01477447-20110714-37] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.
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Affiliation(s)
- Amir Sternheim
- Department of Orthopedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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