Comprehensive treatment of late-onset tibia vara

BACKGROUND: Late-onset tibia vara (Blount disease) can be difficult to treat because of frequent morbid obesity and associated deformities, including distal femoral varus, proximal tibial procurvatum, and distal tibial valgus, that contribute to lower extremity malalignment. We present a comprehensive approach that addresses all components of the deformity and allows restoration of the anatomic and mechanical axes. METHODS: Fifteen consecutive patients (nineteen lower extremities) with late-onset tibia vara were managed with this comprehensive approach. The mean age of the patients at the time of surgery was 14.9 years, and the mean weight was 113 kg. Standing anteroposterior and lateral radiographs were made preoperatively and at the time of the final follow-up. Preoperatively, the mean mechanical axis deviation was 108 mm, the mean lateral distal femoral angle was 95 degrees , and the mean mechanical medial proximal tibial angle was 71 degrees . In all nineteen extremities, the proximal tibial varus deformity was corrected by means of a valgus osteotomy and application of an Ilizarov ring external fixator. Distal femoral varus was corrected by means of either hemiepiphyseal stapling or valgus osteotomy with blade-plate fixation in thirteen of the nineteen extremities. Distal tibial valgus was treated either with hemiepiphyseal stapling or with varus osteotomy and gradual correction with use of the Ilizarov external fixator in eleven of the nineteen extremities. RESULTS: After a mean duration of follow-up of 5.0 years, the mean mechanical axis deviation had improved to 1 mm (range, 20 to -30 mm), the lateral distal femoral angle had improved to 87 degrees (range, 83 degrees to 98 degrees), and the mechanical medial proximal tibial angle had improved to 88 degrees (range, 83 degrees to 98 degrees ). The mean time required for correction of the proximal tibial varus deformity was thirty-one days, and the external fixator was removed at a mean of 4.5 months postoperatively. All patients had development of one or more superficial pin-track infections (mean, 1.9 pin-site infections per patient). No wound infections, nonunions, or neurovascular complications occurred. Eighteen of the nineteen extremities were pain-free at the time of the final follow-up. CONCLUSIONS: This comprehensive approach allowed restoration of the mechanical and anatomic axes of the lower extremity in patients with late-onset tibia vara, resulting in a resolution of symptoms as a result of normalization of the weight-bearing forces across the knee and ankle. We believe that this approach will decrease the risk of early degenerative arthritis of the knee.     

Opening wedge tibial osteotomy for large varus deformity with CeraverTM resorbable beta tricalcium phosphate wedges

The results in 53 knees that had been treated by proximal tibial opening-wedge osteotomy for large varus deformity and osteoarthritis of the medial compartment were evaluated after a mean length of follow-up of ten years (range, 8–12 years). We used a porous beta-tricalcium phosphate (β-TCP) wedge because it is resorbable and osteoinductive. All osteotomies were completely consolidated and complete osseointegration of the remnant of the β-TCP wedge took place. However, after a mean maximum follow-up of ten years none of the cases showed complete resorption. After ten years, 40 (81%) of the 53 knees had an excellent or good result, and in 13 knees there was recurrent pain for which six had an arthroplasty. 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 knees that had a hip-knee-ankle angle of 183–186 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 three knees that had an angle of more than 186 degrees, all five had progressive degenerative changes in the lateral compartment. In the 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. Therefore, proximal tibial osteotomy is a very suitable operation even for patients who have gonarthrosis of the medial compartment and a large varus deformity. Although, a rigidly standardised 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, and this exact alignment is difficult to obtain for patients with large varus deformity.     

Treatment of severe early onset Blount’s disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame

Purpose  Severe Blount’s disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity. Methods  Four patients were treated for severe Blount’s disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest. Results  Mechanical axis was corrected from a mean 23° (13°–30°) to 0° in three patients and 6° valgus in 1. Tibias were lengthened by 1–4 cm. At follow-up, the mechanical axis was 0° in two patients and 7° varus in two. The overlengthening was diminishing as planned. Conclusions  The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount’s disease.     

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.     

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.     

Outcome of hemiepiphyseal stapling for late-onset tibia vara

BACKGROUND: The results of hemiepiphysiodesis for the treatment of late-onset tibia vara have been reported to be favorable, but the technique requires careful timing and an accurate estimation of skeletal age. Hemiepiphyseal stapling does not require a careful estimation of skeletal age, and it has been reported to yield good results with low morbidity. However, we are not aware of any study evaluating the intermediate-term radiographic results or complications of this procedure. METHODS: Twenty-six patients with thirty-three extremities with late-onset tibia vara were treated with proximal tibial hemiepiphyseal stapling. Fourteen extremities had substantial concomitant distal femoral varus and also had hemiepiphyseal stapling of the distal part of the femur. Eighteen patients (twenty-three involved extremities) had juvenileonset tibia vara and eight patients (ten involved extremities) had adolescent-onset tibia vara. The mean age at the time of stapling was 11.8 years. The mean duration of follow-up was 3.8 years. We reviewed standardized standing radiographs to determine the mechanical axis deviation, the medial proximal tibial angle, the lateral distal femoral angle, and the zone of the knee through which the mechanical axis passed. RESULTS: The mean mechanical axis deviation improved from 58 mm (range, 27 to 157 mm) preoperatively to 22 mm (range, -33 to 117 mm) at the time of the last follow-up, and the mean medial proximal tibial angle improved from 77 degrees (range, 50 degrees to 85 degrees ) to 85 degrees (range, 48 degrees to 95 degrees ). In the fourteen lower extremities in which distal femoral hemiepiphyseal stapling was performed, the mean lateral distal femoral angle improved from 96 degrees (range, 92 degrees to 100 degrees ) to 86 degrees (range, 79 degrees to 97 degrees ). At the time of the final follow-up, seven extremities were considered to be in moderate varus; four, in mild varus; twenty, in normal alignment; and two, in valgus. No differences in radiographic outcome were noted between the juvenile and adolescent forms of tibia vara. Only one of the four extremities with severe preoperative varus was corrected to normal alignment; the remaining three were left with moderate varus. CONCLUSIONS: Hemiepiphyseal stapling of the lateral aspect of the proximal tibial physis and, as needed, the lateral aspect of the distal femoral physis is safe and effective in children with late-onset tibia vara if the physes are sufficiently open and the varus deformity is mild to moderate. Hemiepiphyseal stapling is particularly effective in patients who are ten years of age or younger. LEVEL OF EVIDENCE: Therapeutic Level IV.     

Medical and lateral gonarthrosis treated with high tibial osteotomy. A prospective study

A prospective series comprising 52 knees in 48 patients suffering from medial or lateral unicompartmental gonarthrosis and treated by means of high tibial osteotomy shows, by comparing mechanical axis (MA) 0 degrees corrected knees, how important is the overcorrection of the MA into valgus in medial osteoarthritis. The clinical results were significantly correlated to overcorrection, the results 2 years postoperatively being better than those obtained at a follow-up 1 year after the operation. Of the results, 82% were good within a limit of +/- 3 degrees after 2 years, while only 77% were correspondingly good 1 year postoperatively. In lateral gonarthrosis overcorrection was not as good, but there was a mean overcorrection of +2 degrees, and with respect to this overcorrection, the results were quite acceptable. The results were directly correlated to the opening up of the joint space affected (80%) and diminution or disappearance of subluxation, 1/3 being 0 degrees preoperatively, 1/2 postoperatively in medial gonarthrosis. In lateral gonarthrosis, subluxation was increased, with 2/3 being 0 degrees preoperatively, 1/3 being 0 degrees postoperatively. The extension deficit in varus knees significantly diminished after valgus osteotomy; the change in valgus knees was also evident but not significant. The mean value of extension deficit was below 5 degrees in all cases at the 2 years' follow-up examination. However, 95% of all patients showed good or fair results after a follow-up period of 2 years.     

Simultaneous femoral osteotomy and total knee arthroplasty for treatment of osteoarthritis associated with severe extra-articular deformity

BACKGROUND: In the presence of large extra-articular deformity, complex imbalance of the collateral ligaments may result if standard techniques of soft-tissue releases and intra-articular bone resection are used during total knee arthroplasty. The purpose of this paper is to review our experience with simultaneous corrective osteotomy and total knee arthroplasty for the treatment of severe extra-articular femoral deformity associated with ipsilateral osteoarthritis of the knee. METHODS: The results of simultaneous corrective osteotomy and total knee arthroplasty in eleven knees with osteoarthritis and associated extra-articular angular deformity of the femur were reviewed retrospectively. The femoral deformity resulted from fracture malunion in ten knees and from hypophosphatemic rickets in one. There were five primarily uniplanar deformities (four varus deformities and one antecurvatum deformity), five biplanar (varus and antecurvatum) deformities, and one triplanar (varus, antecurvatum, and internal rotation) deformity. Four knees were approached through a standard medial parapatellar arthrotomy and seven, through an anterolateral subvastus approach with an osteotomy of the tibial tubercle. The site of the femoral osteotomy was fixed with a blade-plate in seven patients, a press-fit long-stemmed femoral component in two, and a retrograde femoral nail in two. An extramedullary alignment system was utilized in eight patients, and intramedullary alignment was used in three. RESULTS: The duration of follow-up averaged forty-six months (range, twenty-six to eighty-eight months). According to the classification system of the Knee Society, the mean function score increased from 22 points preoperatively to 81 points at the time of follow-up and the mean knee score increased from 10 points preoperatively to 87 points at the time of follow-up. The mean flexion contracture decreased from 19 degrees preoperatively to 2 degrees at the time of follow-up. The arc of motion averaged 56 degrees (range, 30 to 75 degrees) preoperatively and 89 degrees (range, 65 to 115 degrees) at the time of follow-up. The mechanical alignment in the coronal plane was restored to within 2 degrees of normal in each patient. Ten femoral osteotomy sites healed, and one, in a patient treated with a press-fit long-stemmed femoral component, had not healed by the time of follow-up. All seven sites of the tibial tubercle osteotomies healed. There were no complete radiolucent lines at the prosthetic interfaces, and no total knee arthroplasty was revised. One patient had a nonfatal postoperative pulmonary embolism. As determined by clinical examination and the patients' assessment of function, no ligament imbalance was noted at the time of the most recent follow-up. CONCLUSIONS: Simultaneous femoral osteotomy and total knee arthroplasty is a technically difficult but effective treatment for patients with severe femoral deformity associated with ipsilateral osteoarthritis of the knee. We recommend that the femoral osteotomy site be secured with a plate or a locked intramedullary nail, depending on the location of the deformity and the subsequent osteotomy.     

Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees

One hundred seventy-three knees in 117 patients with varus deformity exceeding 20 degrees were prospectively evaluated. Using selective posteromedial release, reduction osteotomy of posteromedial tibial flare, and extra-articular tibial osteotomy, with the preservation of medial collateral ligament integrity, mean tibiofemoral angle of 22.7 degrees varus preoperatively (range, 15 degrees-62 degrees) was corrected to 5.3 degrees valgus (range, 2 degrees-9 degrees) postoperatively. Eighty-six percent of the knees were in 4 degrees to 10 degrees valgus postoperatively. Mean Knee Society score improved from 22.8 (range, 0-64) to 91.1 (range, 52-99), and function score from 22.8 (range, 0-64) to 72.1 (range, 5-100) at 2.6 years (range, 2-9 years). Mean femoral component valgus was 95.5 degrees (range, 92 degrees-98 degrees), and mean tibial component valgus was 89.8 degrees (range, 86 degrees-94 degrees). Of 30 grafts for posteromedial tibial defects, 28 were successfully incorporated. No patient reported significant instability. Three knees (1.7%) showed tibial component loosening with recurrence of deformity. Correction of severe varus deformity by the technique reported can successfully restore alignment, pain-free motion, and stability.     

Fresh osteochondral allografts for post-traumatic defects in the knee. A survivorship analysis.

Fresh osteochondral allografts were used to repair post-traumatic osteoarticular defects in 92 knees. At the time of grafting, varus or valgus deformities were corrected by upper tibial or supracondylar femoral osteotomies. A survivorship analysis was performed in which failure was defined as the need for a revision operation or the persistence of the pre-operative symptoms. There was a 75% success rate at five years, 64% at ten years and 63% at 14 years. The failure rate was higher for bipolar grafts than for unipolar and the results in patients over the age of 60 years were poor. The outcome did not depend on the sex of the patient and the results of allografts in the medial and lateral compartments of the knee were similar. Careful patient selection, correction of joint malalignment by osteotomy, and rigid fixation of the graft are all mandatory requirements for success. We recommend this method for the treatment of post-traumatic osteochondral defects in the knees of relatively young and active patients.     

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.     

Total knee arthroplasty after varus osteotomy of the distal part of the femur

BACKGROUND: There is little information in the literature regarding the outcome of total knee arthroplasty following distal femoral varus osteotomy. The purpose of the present study was to evaluate the intermediate-term results of total knee arthroplasty following distal femoral varus osteotomy. METHODS: The study group consisted of nine consecutive patients (eleven knees) who had had a total knee arthroplasty following varus osteotomy of the distal part of the femur. The average age of the patients was forty-four years (range, fifteen to seventy years) at the time of the arthroplasty. The results were evaluated with use of the Knee Society score preoperatively and after a mean duration of follow-up of 5.1 years. Radiographs made preoperatively and at the time of follow-up were evaluated for alignment in the coronal plane. RESULTS: The mean Knee Society knee score was 35 points before the arthroplasty and 84 points after the arthroplasty. The mean Knee Society function score was 49 points before the arthroplasty and 68 points after the arthroplasty. The mean interval between the femoral osteotomy and the total knee replacement was fourteen years (range, two to thirty-two years). A constrained prosthesis was required in five of the eleven knees. Two knees had an excellent result, five had a good result, and four had a fair result. The mean arc of motion improved from 81.8 degrees to 105.9 degrees. The mean radiographic alignment was 3.6 degrees of valgus (range, 7 degrees of varus to 18 degrees of valgus) before the arthroplasty and 3.3 degrees of valgus (range, 1 degrees of valgus to 6 degrees of valgus) at the time of the latest follow-up. There were no infections or wound complications. CONCLUSION: Total knee arthroplasty following distal femoral varus osteotomy decreases pain and improves knee function, but the procedure is technically demanding and is associated with inferior results when compared with those of primary arthroplasty performed in a patient without a prior femoral osteotomy. In the present series, the use of an intramedullary femoral alignment guide increased the tendency to place the femoral component in relative varus angulation (that is, in <5 degrees of valgus). We recommend checking the alignment of the femoral component with an extramedullary guide in knees that have had a previous distal femoral varus osteotomy.     

胫骨内侧高位楔形截骨治疗膝关节骨性关节炎

目的　探讨胫骨内侧高位楔形截骨治疗伴有膝内翻畸形的膝关节骨性关节炎的疗效。方法　对 1996年 7月～ 1999年 9月 ,采用胫骨内侧高位楔形截骨结合髂骨植骨钢板内固定术治疗 19例 (2 6膝 )膝关节骨性关节炎伴膝内翻畸形 ,病程 1～ 2 4年 ,平均 6 .3年 ,按 Ahlback分类 度 10膝 , 度 9膝 , 度 6膝 , 度 1膝。患者术前、术后 8周和术后 2年进行患肢全长 X线片检查 ,测量胫股角、胫骨角、股骨角、胫股关节面切线夹角及胫股内侧关节间距大小。按膝关节功能评定标准 ,评定术后膝关节功能恢复情况。　结果　 19例 (2 6膝 )术后获随访 2 4～ 4 5个月 ;术后 2年随访膝关节功能自 (4 8.6± 16 .6 )分增至 (81.7± 14 .8)分 ,胫股内侧关节间距自 (2 .2± 1.6 ) mm增至 (4 .9± 1.5 ) mm,胫股关节面切线夹角自 7.4°± 3.1°减少至 1.7°± 3.1°。植骨愈合满意 ,无膝内翻复发。术中出现关节内骨折 1例 ;皮肤感染 2例。结论　胫骨内侧高位楔形截骨结合植骨钢板内固定 ,可作为治疗伴有膝内翻畸形的膝关节骨性关节炎的有效方法之一。     

Infantile tibia vara: Treatment of Langenskiold stage IV

An eight year old girl presented with a progressively increasing deformity of the left proximal tibia since last 2 years. She had no history of trauma, fever and swelling of left knee. There were no obvious signs of rickets/muscular dystrophy. She had 25 degrees of tibia vara clinically with lateral thrust and a prominent fibular head. The radiograph of left knee revealed tibia vara with medial beaking and a significant depression of the medial tibial epiphysis and metaphysis. A computed tomography (CT) scan revealed significant depression of the medial tibial epiphysis but no bony bar in the physis or fusion of the medical tibial epiphysis. There was a posterior slope in addition to the medial one. She was treated with elevation of the medial tibial hemiplateau with subtuberosity valgus derotation dome osteotomy. She also underwent a lateral proximal tibial hemiphysiodesis (temporary stapling). A prophylactic subcutaneons anterolateral compartment fasciotomy was also performed. All osteotomies united in 2 months. All deformities were corrected and she regained a knee range of 0 to 130 degrees. At final followup (4 years), there was no recurrence of varus deformity, knee was stable, with 1cm of leg length discrepancy. In Langenskiold stage IV tibia vara, elevation of medial tibial plateau, a subtuberosity valgus derotation osteotomy and a concomitant lateral hemiephiphysiodesis has given good results.     

Bifocal tibial corrective osteotomy with lengthening in achondroplasia: an analysis of results and complications

The results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplastic patients were analyzed. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at fixator removal, and at last follow-up. Of these parameters, statistically significant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 +/- 7.05 degrees, 103.2 +/- 11.8 degrees, 25.1 +/- 14.6 mm (medial), and 22.7 +/- 10 degrees (internal) preoperatively to 87.3 +/- 6.3 degrees, 90.9 +/- 5.4 degrees, 5.3 +/- 10 cm (medial), and 15.8 +/- 4.2 degrees (external), respectively, at the time of fixator removal; and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84 +/- 1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy. This procedure is safe and efficacious if performed with strict adherence to prescribed technique.     

Decrease of osteosclerosis in subchondral bone of medial compartmental osteoarthritic knee seven to nineteen years after high tibial valgus osteotomy

Osteosclerosis of the subchondral bone was measured by densitometer on plain radiographs in 55 medial compartmental osteoarthritic knees of 40 patients who were treated with high tibial valgus osteotomy for correction of varus deformity. The ratio of the osteosclerosis value of the medial side of the knee to that of the lateral side (Medial/Lateral ratio) was calculated and used as a parameter. The Medial/Lateral ratio of osteosclerosis decreased rapidly within three years after osteotomy at the reference points of the femur and the tibia. Even 7 to 19 years after osteotomy, a decrease of the ratio was noted in 16 knees with a standing femorotibial angle (FTA) less than 168 degrees (12 degrees of anatomical valgus angulation). This was interpreted to mean that osteosclerosis of the medial condyle decreased compared with that of the lateral condyle after overcorrection of varus deformity. In the cases of more than 7 years after high tibial osteotomy, a positive straight regression line was drawn by calculation between Medial/Lateral ratio and postoperative limb alignment expressed by standing femorotibial angle, with coefficient of correlation (gamma) of 0.295 (p < 0.01).     

Varus inclination of the distal femur and high tibial osteotomy

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3 degrees or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy.     

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.     

Medial and lateral gonarthrosis treated with high tibial osteotomy

Summary A prospective series comprising 52 knees in 48 patients suffering from medial or lateral unicompartmental gonarthrosis and treated by means of high tibial osteotomy shows, by comparing mechanical axis (MA) 0° corrected knees, how important is the overcorrection of the MA into valgus in medial osteoarthritis. The clinical results were significantly correlated to overcorrection, the results 2 years post-operatively being better than those obtained at a follow-up 1 year after the operation. Of the results, 82% were good within a limit of ± 3° after 2 years, while only 77% were correspondingly good 1 year postoperatively. In lateral gonarthrosis overcorrection was not as good, but there was a mean overcorrection of + 2°, and with respect to this overcorrection, the results were quite acceptable. The results were directly correlated to the opening up of the joint space affected (80%) and diminution or disappearance of subluxation, 1/3 being 0° preoperatively, 1/2 postoperatively in medial gonarthrosis. In lateral gonarthrosis, subluxation was increased, with 2/3 being 0° preoperatively, 1/3 being 0° postoperatively. The extension deficit in varus knees significantly diminished after valgus osteotomy; the change in valgus knees was also evident but not significant. The mean value of extension deficit was below 5° in all cases at the 2 years¹ follow-up examination. However, 95% of all patients showed good or fair results after a follow-up period of 2 years.