Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results

BACKGROUND

Although high tibial osteotomy has been proved effective for the treatment of painful osteoarthritis of the medial compartment of the knee, the role of proximal tibial varus osteotomy for the treatment of painful osteoarthritis of the lateral compartment still remains controversial.

METHODS

From 1974 to 1993, we performed proximal tibial varus osteotomy for the treatment of osteoarthritis of the lateral compartment of the knee in thirty-six consecutive patients. The procedure consisted of a proximal lateral opening-wedge varus osteotomy of the tibia with use of corticocancellous bone grafts from the iliac crest. The valgus deformity was posttraumatic in twenty-three patients, followed a lateral meniscectomy in five, was due to overcorrection of a varus deformity in four, and was idiopathic in four. The preoperative valgus deformity averaged 11.6 degrees (range, 4 degrees to 22 degrees ).

RESULTS

At a mean of eleven years (range, five to twenty-one years) after the operation, the clinical results for thirty-four of the thirty-six patients were analyzed. None of the patients had severe progression of the osteoarthritis after the osteotomy, and none had a meaningful loss in the range of motion of the knee joint. A superficial wound infection developed in one patient, and another patient had thrombophlebitis. Three patients (9%) had a transient palsy of the peroneal nerve. According to the system of Insall et al., the mean knee score was 84 points (range, 54 to 99 points). According to the knee score described by Lysholm and Gillquist, the subjective result was excellent in nine patients (26%), good in twenty-one (62%), fair in three (9%), and poor in one (3%).

CONCLUSIONS

We concluded that when the indications outlined in this study are followed and our opening-wedge technique is used, a proximal lateral opening-wedge varus osteotomy of the tibia is a good alternative for the treatment of isolated osteoarthritis of the lateral compartment of the knee. High accuracy in preoperative planning, based on a slight overcorrection, is important to prevent failure.

Treatment strategies in osteochondral defects of the talar dome: a systematic review

The aim of this study was to investigate the results of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from 1966 to July 1998 were systematically screened. Based on our inclusion criteria 32 studies describing the results of treatment strategies for OCD of the talus were included. No randomized clinical trials (RCT's) were identified. Fourteen studies described the results of excision alone, 11 the results of (EC), 14 the results of (ECD), 1 the results of cancellous bone grafting after EC, 1 the results of osteochondral transplantation and 3 the results of fixation. The average success rate of non-operative treatment (NT) was 45%. Comparison of different surgical procedures shows that the average highest success rate was reached by excision, curettage and drilling (ECD) (85%) followed by excision and curettage (EC) (78%) and excision alone (38%). Based on this systematic review we conclude that NT and excision alone are not to be recommended in treating talar OCD. Both EC and ECD have been shown to lead to a high percentage good/excellent results. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further prospective randomized controlled trials are required to compare the outcome of these two surgical strategies for OCD of the talus.

Arthroscopy for problems after ankle fracture

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.

[Chondrosarcoma of the bony thoracic wall]

An 85-year-old man was admitted because of a slowly growing mass in his left flank, which had been present for 16 years. A very large chondrosarcoma was diagnosed, weighing 8.5 kg. After radical resection of the tumour the patient recovered well. No recurrences developed during follow-up.

Long-term follow-up of inversion trauma of the ankle

In our institution lateral ankle ligament injuries are classified into three grades according to the extent of instability found on physical examination and/or stress X-rays. Grade I and II lesions are taped, while treatment of grade III lesions consists of operative reconstruction of the ruptured ligaments. In 1989 we published the results of 1012 patients after 9 months' follow-up. About 30% had residual complaints. The nature and frequency of the complaints were equally divided among the three groups. To examine the long-term follow-up results, we conducted a retrospective study with the same group of patients after 6.5 years. Although ankle ligament injuries are still considered rather innocent lesions, we conclude that even after 6.5 years patients can still have residual complaints (pain, fear of giving-way, actual instability, swelling), which interfere with daily living and/or sport activities. The result deteriorated with time. This was especially prominent in the grade II group, where the percentage of poor and fair results doubled. The overall percentage of residual complaints was 39%. We conclude that there is no such thing as "a simple sprain".