Low tibial osteotomy for varus-type osteoarthritis of the ankle

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications. We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months). Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a.     

Oblique tibial osteotomy in the correction of tibial deformity in children

A new method of oblique tibial metaphyseal osteotomy that uses a single osteotomy cut has been used to allow correction of multiplanar rotational deformities in children. Graphs are used to predict the necessary angle of osteotomy. The osteotomy is performed through a 1-cm incision in the proximal tibial metaphysis, using multiple drill holes and an osteotome. Correction is maintained by casting with or without internal fixation. Fourteen such osteotomies have been followed an average of 27 months without major complications. This osteotomy allows maximal maintenance of length, stability, and metaphyseal contact through a small, cosmetically acceptable incision. Minimal soft-tissue dissection is necessary.     

Focal dome osteotomy for the correction of tibial deformity in children

Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.     

The Teramoto distal tibial oblique osteotomy (DTOO): surgical technique and applicability for ankle osteoarthritis with varus deformity

We have devised a medial peri-articular osteotomy, the distal tibial oblique osteotomy (DTOO), and have used this technique since 1994 for ankle osteoarthritis of advanced and late stages associated with varus inclination. This report describes the surgical technique and its applicability. DTOO can be used for cases of varus ankle osteoarthritis with a range of the ankle joint movement of at least 10° or more. The osteotomy is obliquely directed cut across the distal tibia from proximal-medial to distal lateral and is of an opening-wedge type with the centre of rotation coincident with the centre of the tibiofibular joint. A laminar spreader instrument is inserted in the osteotomy to open the wedge until the lateral surface of the talar body is seen on X-ray to be in contact and congruent with medial articular surface of the lateral malleolus. Common obstacles which may prevent this contact and congruency are bony spurs present on the anterior side of fibula or on the lateral side of the tibia; these require removal. The opening-wedge osteotomy is held in position by an Ilizarov external fixator or internally fixed with a plate. Bone graft is taken from the iliac crest and inserted into the open wedge. If, after completion of the osteotomy, the dorsiflexion angle of the ankle joint does not exceed 0°, a Z-lengthening is performed of the Achilles tendon. In the DTOO for ankle osteoarthritis, the contact area of the ankle joint increases and decreases the load pressure per unit area. Furthermore, as the width of the ankle mortice is restored through the realignment of the body of the talus, instability at the ankle joint decreases. There is additional improvement with restoration of the inclination of the distal tibial articular surface as this directs the hindfoot valgus and corrects the alignment of the foot, with consequent improvement of ankle pain.     

Supramalleolar osteotomy for ankle deformity and arthritis

Supramalleolar osteotomy is an effective surgical strategy to treat malunion, arthrosis, and congenital deformities about the ankle. Strict adherence to the principles of deformity correction provides reliable limb realignment and redistribution of joint forces without the introduction of secondary deformities. Clinical outcomes support the role of osteotomy as an effective joint preservation procedure with few complications.     

Late recurrence of varus deformity after proximal tibial osteotomy

One hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus-producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years (mean, 6.3 years). Sixty-four knees (57%) were pain free or had only mild discomfort when walking. The standing femorotibial angle decreased from a postoperative average of 9.3 degrees valgus to 7.8 degrees valgus at the final follow-up examination. The tendency for varus recurrence greater than 5 degrees and for medial- or lateral-compartment arthritic progression was evaluated using the Kaplan-Meier survival method. Varus recurred in 18%, lateral-compartment arthritic progression in 60%, and medial-compartment arthritic progression in 83% by nine years after surgery. The probability of arthritic progression is much higher than the probability of significant varus recurrence in long-term roentgenographic follow-up studies of patients with valgus-producing proximal tibial osteotomies.     

Arthroscopic ankle arthrodesis after tibial pilon open reduction internal fixation

Ankle arthrodesis is an essential tool in the foot and ankle surgeon's armamentarium. Despite the evolving technology and ongoing research in ankle arthroplasty, arthrodesis continues to be a proven and safe option for the majority of patients with ankle arthritis refractory to conservative management. Here, the authors present their technique of an arthroscopic ankle arthrodesis specifically in the setting of a previous open-reduction internal fixation (ORIF) for a tibia plafond type fracture. They have found this to be a reliable technique to achieve a solid ankle arthrodesis while minimizing soft-tissue trauma and dissection in an already compromised soft-tissue envelope.     

Low tibial osteotomy for moderate ankle arthritis

Low tibial osteotomy is one of the significant advances of ankle reconstruction techniques that has been made recently in an effort to halt arthritis in its early stages and leave fusion as the last, not the only, alternative treatment of ankle arthritis. From 1989 to 1995, we performed 18 low tibial osteotomies which included 6 cases of post-traumatic arthritis and 12 cases of degenerative arthritis. The ages of the 7 male and 11 female patients ranged from 18 to 78 years with an average of 41.9 years. The follow-up period lasted a mean of 47.7 months, ranging from 25 to 82 months. The average functional score changed from 49.6 pre-operatively to 88.5 at the last follow up, and showed yearly improvement. Complications included one case of late infection and two cases of implant failure, none of which led to nonunion. The indication for low tibial osteotomy is the intermediate stage of moderate ankle arthritis with a medial joint lesion and intact lateral facet. Using pressure redistribution on the joint surface, this procedure is an alternative treatment for ankle arthritis which may save an arthritic ankle from the fate of fusion or at least postpone fusion surgery. Received: 14 September 1999     

Simultaneous arthrodiastasis and deformity correction for a patient with ankle osteoarthritis and lower limb deformity: A case report

We here report a case of a 50-year-old male with ankle osteoarthritis and lower limb deformity, for which simultaneous deformity correction and arthrodiastasis were performed. The patient initially experienced an open fracture on the left tibia at 19 years, but it was malunited. The Japanese Society for Surgery score of the foot for the left ankle was 53 points. X-ray and CT imaging showed rotational and angular tibial deformities with shortening by 1.6 cm and end-stage osteoarthritis of the left ankle. An external fixator was applied to correct the lower limb deformity, and ankle arthrodiastasis was performed. A good result was achieved in alignment correction and joint function. The patient had an improved clinical score of 98 points at a 2-year followup. We found that external fixation was useful because external fixator is the only appropriate instrument by which arthrodiastasis and deformity correction for ankle osteoarthritis can be simultaneously performed.     

Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study

The results in ninety-three knees that had been treated by proximal tibial opening-wedge osteotomy for varus deformity and osteoarthritis of the medial compartment were evaluated after a mean length of follow-up of 11.5 years (range, ten to thirteen years). After ten years, only forty-two (45 per cent) of the ninety-three knees had an excellent or good result, and in fifty-one knees there was recurrent pain for which seventeen had another operation. At five years, on the other hand, 90 per cent of the knees had a good result. Deterioration occurred at an average of seven years after the osteotomy and was always associated with recurrence of pain. Although the results deteriorated with time, time was not the only determinant of the result. Alignment, measured as the hip-knee-ankle angle on radiographs of the whole limb that were made with the patient bearing weight, was also a determinant of long-term results. The best results were obtained in the twenty knees that had a hip-knee-ankle angle of 183 to 186 degrees. In these knees, there was no pain and no progression of the arthrosis in either the medial or the lateral tibiofemoral compartment. Of the five knees that had an angle of more than 186 degrees, all five had progressive degenerative changes in the lateral compartment. In the sixty-eight undercorrected knees (an angle of less than 183 degrees), the results were less satisfactory, and there was a tendency toward recurrence of the varus deformity and progression of the arthritis of the medial compartment. However, when the correction was insufficient the deterioration was slow (average, seven years), and it was not associated with lateral laxity and deterioration of the lateral compartment, which are the changes that characterize the natural course of gonarthrosis as described by Hernborg and Nilsson. Therefore, proximal tibial osteotomy is a very suitable operation for patients who have gonarthrosis of the medial compartment, but a rigidly standardized and precise operative technique is required as well as accurate radiographic measurements of the mechanical axis of the limb, because exact postoperative alignment is the prerequisite for the longest possible period of relief of symptoms after osteotomy.     

High tibial osteotomy for osteoarthritis of the knee with varus deformity utilizing the hemicallotasis method

Introduction: A hemicallotasis method has been developed utilizing an external fixator as high tibial osteotomy (HTO), and satisfactory results of this method with the external fixator have been reported. This external fixator has a universal joint that moves in all directions. We have recently designed a hemicallotasis device for this operation. Methods: HTO for the knee with varus deformity utilizing the hemicallotasis method was performed on 44 knees. The patients had a mean age at operation of 65 years (range 49–82 years), a mean follow-up period of 68 months (range 36–119 months), and a mean preoperative knee score of 66 points (range 27–90 points). Results: The operated knees had a mean knee score at the final follow-up of 86 points (range 51–98 points), but the mean range of knee motion was not changed as follows. Before surgery, the mean flexion was 129° (range 90–150°) and the mean extension was −5° (range −30 to 0°), whereas at the final follow-up, the corresponding values were 127° (range 85–150°) and −4° (range −25 to 0°), respectively. Radiographically, the femorotibial joint was classified as grade 2 in 9 knees, grade 3 in 21 knees, and grade 4 in 14 knees according to the classification of osteoarthritis (Kellgren and Laurence). The patellofemoral joint was also classified as grade 1 in 39 knees, grade 2 in 2 knees, and grade 3 in 3 knees. The mean femorotibial angle was 184° (4° varus) before surgery, 169° (11° valgus) after pin extraction, and was maintained at the final follow-up. The complications of this method were relatively few and consisted of pin-tract infection (8 knees), deep vein thrombosis (3 knees), and delayed union (2 knees). No peroneal nerve palsy or compartment syndrome was encountered. No knee was converted to total arthroplasty. However, administration of analgesics was necessary in ten knees at the final follow-up. Conclusion: The hemicallotasis method easily determined the angle of correction even in the knees with ligamentous laxity. Nevertheless, one of the major demerits of this method was a longer period of application of the external fixator. The level of evidence was level IV (case series).     

Modified distal tibial oblique osteotomy for osteoarthritis of the ankle: Operative procedure and preliminary results

Background

Low tibial osteotomy is an effective joint-preserving surgery for ankle arthritis. However, poor postoperative wound healing, infection, and delayed or non-union of bones remain significant concerns. We describe a modified distal tibial oblique osteotomy procedure and report preliminary results for varus ankle arthritis.

Long-term results of arthrodesis for osteoarthritis of the ankle

A bone graft in the shape of a triangular prism was taken from the anterior surface of the tibia and used in the arthrodesis in 43 joints of 42 patients with primary and secondary osteoarthritis of the ankle. The modified anterior sliding inlay graft method was used. The average period of external immobilization was 5.8 weeks (range, 27-84 days), and followup ranged from 2 years 4 months to 14 years 11 months (average, 7 years 2 months). Nonunion was detected in three (7%) patients: one patient returned to work without additional treatment, and the other two patients underwent followup surgery within 7 months, and bony union was achieved. The final rate of nonunion was 2.3%. After the operation, excellent alleviation of pain was obtained. However, dorsiflexion of the foot decreased from the preoperative average value of 10.5 degrees to the postoperative value of 4.2 degrees, and plantar flexion also decreased from the preoperative value of 24.7 degrees to the postoperative value of 14 degrees. In addition, the range of motion of the subtalar and Chopart joints gradually improved with little effect on daily living activities. The most appropriate position of arthrodesis of the ankle appears to be in the neutral position between dorsal and plantar flexion. In addition, the varus and valgus angle of the hindfoot should be in a neutral or slightly valgus position. Degenerative arthritis developed and advanced in the subtalar joint in 32.5% of the patients, and these degenerative changes were exacerbated in many patients if such changes were present before surgery. Tibial stress fracture occurred in two (4.7%) patients as a complication that was specific to the current surgical method. Thus, the surgical procedure was modified to prevent the onset of tibial stress fracture.     

Outcome after foot and ankle deformity correction using circular external fixation

BACKGROUND: External fixation is the method of choice for correction of chronic severe foot and ankle deformities. We report our experience and outcomes of circular external fixation. METHODS: Fifty-five patients (60 feet) were treated with circular external fixation. The mean age at surgery was 36 (range 16 to 65) years. The mean followup was 4.4 (range 1 to 10) years. The mean time spent in external fixation was 2.1 (range 1 to 12) months. RESULTS: There were six excellent, 35 good, eight fair, and six poor results, five of which had below knee amputations. All the patients who had an amputation were treated for infected nonunion of the ankle. CONCLUSION: Circular external fixation was found to be an effective method for treating a variety of complex foot and ankle problems. The complications were more common in patients with infected nonunions.     

Three-dimensional knee motion before and after high tibial osteotomy for medial knee osteoarthritis

Background High tibial osteotomy (HTO) is an established surgical option for treating medial knee osteoarthritis. HTO moves the mechanical load on the knee joint from the medial compartment to the lateral compartment by changing the leg alignment, but the effects of the operation remain unclear. The purpose of this study was to evaluate the change in three-dimensional knee motion before and after HTO, focusing on lateral thrust and screw home movement, and to investigate the relationship between the change in knee motion and the clinical results. Methods A series of 19 patients with medial knee osteoarthritis who had undergone HTO were evaluated. We performed a clinical assessment, radiological evaluation, and motion analysis at 2.4 years postoperatively. The clinical assessment was performed using the Japanese Orthopaedic Association knee score. Results The score was significantly improved in all patients after operation. Motion analysis revealed that lateral thrust, which was observed in 18 of the 20 knees before operation, was reduced to 7 knees after operation. Regarding active terminal extension of the knee, three patterns of rotational movement were observed before operation: screw home movement (external rotation), reverse screw home movement (internal rotation), and no rotation. By contrast, after operation, only reverse screw home movement and no rotation were observed; the screw home movement disappeared in all patients. In the knees with reverse screw home movement after operation, the preoperative score was significantly lower than those in the knees with no rotation after operation. Conclusions Kinetically, HTO was useful for suppressing lateral thrust in medial knee osteoarthritis, although the rotational movement of the knee joint was unchanged.     

Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis

The cases of twenty-one consecutive patients who had a minimally constrained total knee arthroplasty (six of whom had a cemented and fifteen, an uncemented prosthesis) after a failed proximal tibial osteotomy for osteoarthritis were compared with those of a non-consecutive group of twenty-one patients who had had a primary total knee arthroplasty for osteoarthritis. The groups were matched according to age and sex of the patient, type of prosthesis and fixation, and length of follow-up. At an average length of follow-up of 2.9 years, a good or excellent result was obtained in 81 per cent of the patients who had had a previous osteotomy. At an average length of follow-up of 2.8 years, a good or excellent result was obtained in 100 per cent of the patients who had had a primary arthroplasty. Two patients in the osteotomy group and none in the primary arthroplasty group required additional surgery. At the time of arthroplasty, technical difficulties in exposing the proximal part of the tibia were noted in three patients in the group that had undergone an osteotomy. The results of total knee arthroplasty after failed proximal tibial osteotomy approached but did not equal the results after primary total knee arthroplasty.     

Quadriceps muscle function after high tibial osteotomy for osteoarthritis of the knee

In patients with osteoarthritis of the knees, quadriceps muscle dysfunction is an early and common clinical feature and an important determinant of disability. In the current study, changes in quadriceps muscle strength and voluntary quadriceps muscle activation after high tibial osteotomies for primary osteoarthritis of the knee in 19 patients were investigated. Quadriceps muscle function was assessed during different degrees of isometric maximum voluntary contraction using a specially built chair. One year after surgery all patients had reexamination of their surgically treated and contralateral knees. Voluntary activation and maximum voluntary contraction values of the followup assessment were significantly lower in the surgically treated knees compared with the preoperative assessment. In the contralateral knees, there were no differences between preoperative and followup measurements. High tibial osteotomy is an extraarticular operative therapeutic approach to treatment of osteoarthritis of the knee that does not lead to improvement of quadriceps muscle function. Because there is evidence that quadriceps sensorimotor dysfunction is important not only for the disability in osteoarthritis of the knee, but also for progression of the disease, knee function may be worsened by high tibial osteotomy in some patients.