Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomised, controlled study

A prospective, randomised, controlled trial compared two different techniques of high tibial osteotomy with a lateral closing wedge or a medial opening wedge, stabilised by a Puddu plate. The clinical outcome and radiological results were examined at one year. The primary outcome measure was the achievement of an overcorrection of valgus of 4 degrees . Secondary outcome measures were the severity of pain (visual analogue scale), knee function (Hospital for Special Surgery score), and walking distance. Between January 2001 and April 2004, 92 patients were randomised to one or other of the techniques. At follow-up at one year the post-operative hip-knee-ankle angle was 3.4 degrees (+/- 3.6 degrees SD) valgus after a closing wedge and 1.3 degrees (+/- 4.7 degrees SD) of valgus after an opening wedge. The adjusted mean difference of 2.1 degrees was significant (p = 0.02). The deviation from 4 degrees of valgus alignment was 2.7 degrees (+/- 2.4 degrees SD) in the closing wedge and 4.0 degrees (+/- 3.6 degrees sd) in the opening-wedge groups. The adjusted mean difference of 1.67 degrees was also significant (p = 0.01). The severity of pain, knee score and walking ability improved in both groups, but the difference was not significant. Because of pain, the staples required removal in 11 (23%) patients in the closing-wedge group and a Puddu plate was removed in 27 (60%) patients in the opening-wedge group. This difference was significant (p < 0.001). We conclude that closing-wedge osteotomy achieves a more accurate correction with less morbidity, although both techniques had improved the function of the knee at one year after the procedure.     

The effect of plate position and size on tibial slope in high tibial osteotomy: a cadaveric study

Opening wedge high tibial osteotomies are performed for degenerative changes and varus. Opening wedge osteotomies can change proximal tibial slope in the sagittal plane, possibly imparting stability in the ACL-deficient knee. The aim of this study was to assess the effect of plate position and size on change in tibial slope. Eight cadaveric knees underwent opening wedge high tibial osteotomy with Puddu plates of each different size. Plates were placed anterior, central, and posterior for each size used. Lateral radiographs were obtained. Tibial slope was measured and compared with baseline slope. Tibial slope was affected by plate position (P < 0.05) and size (P < 0.001). Smaller, posterior plates had less effect on tibial slope. However, anterior and central plates increased tibial slope over all plate sizes (P < 0.05). This study found that tibial slope increases with opening wedge high tibial osteotomy. Larger corrections and anterior placement of the plate are associated with larger increases in slope.     

Complications in high tibial (medial opening wedge) osteotomy

Introduction The high tibial (medial opening wedge) osteotomy (HTO) is a standard procedure in the treatment of varus gonarthrosis. This is potentially associated with various complications. The aim of this study was an analysis of complications and potential technical mistakes.Materials and methods A total of 85 patients (49 male and 36 female) suffering from varus gonarthrosis underwent a medial opening wedge HTO. The osteotomy was fixed in 55 patients by a spacer plate (Puddu plate; group A). In group B (n=30), the osteotomies were fixed by C-plate.Results The rate of complications was 43.6% in group A and 16.7% in group B (p<0.05). Infraction of the lateral tibial head is a possible intraoperative complication. This was seen in 11.7%. An additional osteosynthesis was required in group A. In contrast, the C-plate can solve this problem without additional measures. General complications of the HTO were seen: infection (4.7%), hematoma (4.7%), and thrombosis (2.3%). In every case of a severe deep infection, the osteotomy space was filled with synthetic bone graft. These grafts were used only in group A. Failure of the implants is a potential cause of loss of correction. This complication was seen nine times in group A but never in group B.Conclusion A diligent surgical technique and a convenient implant are obligatory in (medial opening wedge) HTO.     

Impact of medial opening or lateral closing tibial osteotomy on bone resection and posterior cruciate ligament integrity during knee arthroplasty

To compare lateral closing to medial opening wedge high tibial osteotomy regarding change in proximal tibial anatomy and PCL tibial attachment integrity after standard tibial arthroplasty resection. Controlled cadaveric study. Ten cadaveric lower limbs received either a 12° lateral closing or 12.5-mm medial opening wedge high tibial osteotomy. Radiographs were performed before and after each osteotomy, and each PCL tibial attachment was dissected. Postosteotomy, tibial arthroplasty resection was performed and the remaining PCL attachment area calculated. Lateral closing wedge specimens demonstrated a greater change in proximal tibial anatomy. After tibial arthroplasty resection, there was a significant difference in remaining PCL tibial attachment percentage area. Proximal tibial anatomy is altered differently for each type of osteotomy despite similar correction angles. Arthroplasty conversion may be more challenging after lateral closing wedge procedures.     

Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening‐wedge technique

Background and purpose?The aim with high tibial valgus osteotomy (HTO) is to correct the mechanical axis in medial compartmental osteoarthritis of the knee. Loss of operative correction may threaten the long‐term outcome. In both a lateral closing‐wedge procedure and a medial opening‐wedge procedure, the opposite cortex of the tibia is usually not osteotomized, leaving 1 cm of bone intact as fulcrum. A fracture of this cortex may, however, lead to loss of correction; this was examined in the present study.

Patients and methods?We used a prospective cohort of 92 consecutive patients previously reported by Brouwer et al. (). The goal in that randomized controlled trial, was to achieve a correction of 4 degrees in excess of physiological valgus. In retrospect, we evaluated the 1‐year radiographic effect of opposite cortical fracture. Opposite cortical fracture was identified on the postero‐anterior radiographs in supine position on the first day after surgery.

Results?44 patients with a closing‐wedge HTO (staples and cast fixation) and 43 patients with an opening‐wedge HTO (non‐angular‐stable plate fixation) were used for analysis. 36 patients (four‐fifths) in the closing‐wedge group and 15 patients (one‐third) in the opening‐wedge group had an opposite cortical fracture (p < 0.001). At 1 year, the closing‐wedge group with opposite cortical fracture had a valgus position with a mean HKA angle of 3.2 (SD 3.5) degrees of valgus. However, the opening‐wedge group with disruption of the opposite cortex achieved varus malalignment with a mean HKA angle of 0.9 (SD 6.6) degrees of varus.

Interpretation?Fracture of the opposite cortex is more common for the lateral closing wedge technique. Medial cortex disruption has no major consequences, however, and does not generally lead to malalignment. Lateral cortex fracture in the medial opening‐wedge technique, with the use of a non‐angular stable plate, leads more often to varus malalignment.     

Utilizing reamer irrigator aspirator (RIA) autograft for opening wedge high tibial osteotomy: A new surgical technique and report of three cases

INTRODUCTION

The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes’ double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft.

PRESENTATION OF CASE

We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up.

DISCUSSION

Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft.

CONCLUSION

All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee.     

Optimizing femorotibial alignment in high tibial osteotomy.

OBJECTIVE: To study factors that affect femorotibial (F-T) alignment after valgus closing wedge tibial osteotomy. STUDY DESIGN: A review of standardized standing radiographs. Femorotibial alignment was measured 1 year postoperatively for over- and under-correction. Changes in F-T alignment and in tibial plateau angle were measured. SETTING: An urban hospital and orthopedic clinic. PATIENTS: Eighty-two patients with osteoarthritis and varus femorotibial alignment underwent valgus closing wedge tibial osteotomy. Patients having a diagnosis of inflammatory arthritis or a prior osteotomy about the knee were excluded. RESULTS: A 1 degree wedge removed from the tibia resulted in an average correction F-T alignment of 1.2 degrees. A knee that had increased valgus orientation of the distal femur had a greater degree of correction, averaging 1.46 degrees in F-T alignment per degree of tibial wedge. This resulted in excessive postoperative valgus alignment for some patients who had increased valgus tilt of the distal femur. Optimal F-T alignment of 6 degrees to 14 degrees valgus occurred when the postoperative tibial inclination was 4 degrees to 8 degrees of valgus. CONCLUSIONS: There was a trend for knees with increased valgus orientation of the distal femur to have greater correction in F-T alignment after tibial osteotomy, likely because of a greater opening up of the medial joint space during stance. Surgeons need to account for this in their preoperative planning.     

Avoidance of medial cortical fracture in high tibial osteotomy: improved technique

A new technique in oblique incomplete high tibial osteotomy that permits an increase of valgus correction while preventing fracture of the medial cortex was investigated. Closing wedge or opening wedge osteotomy was done on 23 tibias from cadavers before loading in an Instron testing machine. In seven specimens (Group 1), lateral oblique wedge osteotomy was done. In seven other specimens (Group 2), one medial oblique cut was made. In both groups, the osteotomy terminated 10 mm from the cortex and approximately 2 cm below the plateau. In nine specimens (Group 3), the osteotomy terminated in a 5-mm diameter hole, drilled in an anteroposterior direction, with its center positioned 10 mm from the medial cortex and 2 cm below the articular surface. The maximum angle of opening or closing before fracture of the cortex took place was recorded. In Groups 1 and 2, similar maximum correction angles were observed, 6.7 degrees versus 6.5 degrees, respectively. In Group 3, the stress relieving hole allowed the correction angle to be increased to 10 degrees. An oblique high tibial valgus closing wedge osteotomy with an apical drill hole allows a significant increase of the correction angle compared with the same osteotomy without a drill hole. Medial open wedge osteotomy offers no advantage over lateral closed wedge osteotomy in the maximum obtainable correction angle without failure of the cortex.     

Mid-term outcome of opening-wedge high tibial osteotomy for varus arthritic knees

Gonarthrosis in the relatively young and active population causes major daily discomfort and disability. If the arthritic process is mainly limited to the medial compartment, the axis of a varus knee can be realigned laterally with high tibial osteotomy to unload the medial compartment and allow some cartilage regeneration and pain relief. This study describes the outcomes of patients who underwent opening-wedge high tibial osteotomies using Puddu plate (Arthrex, Naples, Florida) fixation. Eighteen patients (22 knees) with genu varum and medial compartment osteoarthritis were followed-up for an average of 6.3±2.3 years after high tibial osteotomy with Puddu plate fixation and iliac crest allograft. Clinical outcome was assessed by the Oxford Knee Score and subjective satisfaction rating. Pre- and postoperative radiographs were evaluated for tibiofemoral angle, Insall-Salvati index, and Kellgren-Lawrence Grading Scale for osteoarthritis. Mean patient age at surgery was 44±13.7 years, and mean body mass index was 29.1±4.7 kg/m(2). At last follow-up, mean Oxford Knee Score improved from 22.4±13.5 to 37.2±13.7 (P=.002). Average subjective satisfaction rate at last follow-up was 8±3. The measured tibiofemoral angle was corrected to an average genu valgum of 3.3°±4.8° (P=.001). No patient showed severe postoperative osteoarthritis (ie, Kellgren-Lawrence grade 4) at last follow-up. All radiographs showed full incorporation of the bone grafts. At the end of the study, 2 patients underwent total knee replacement. Opening-wedge high tibial valgus osteotomy with Puddu plate fixation can be a reliable procedure for the treatment of medial-compartment osteoarthritis of the knee associated with varus deformity.     

Patellar height after high tibial osteotomy

We analysed two series of patients affected by unicompartmental arthrosis or axial malalignment of the knee treated with two different techniques of high tibial osteotomy. Forty-seven knees were treated with a closing wedge osteotomy (CWO) and 40 with an opening wedge osteotomy (OWO). The two groups were comparable with respect to age, gender and deformity. For each patient the patellar height was measured by Caton's method before surgery, and at the latest assessment (at least 1 year after operation). The correction rate for the two series was analysed to assess any possible correlation between the variation of the patellar height and the degree of correction of the knee axis. We concluded that a high tibial osteotomy modifies the patellar height and that this depends on the technique employed. Patellar 'lowering' occurred more often with OWO than with CWO and the latter also produced a high degree of patellar elevation.     

Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity

A retrospective radiographic review of 57 feet was conducted to compare maintenance of correction of the modified Lapidus arthrodesis with the first metatarsal closing base wedge osteotomy for moderate to severe hallux valgus deformity. Radiographic parameters were measured on the preoperative, early postoperative, and greater than 11-month postoperative weightbearing radiographs. These measurements included the intermetatarsal angle, the hallux abductus angle, and the tibial sesamoid position. The patients who underwent the closing base wedge osteotomy had an average initial intermetatarsal correction of 10.4 degrees; for the modified Lapidus arthrodesis, it was 7.6 degrees. The patients who underwent the closing base wedge osteotomy had an average loss of intermetatarsal correction of 2.55 degrees from early to late postoperative radiographs; for the modified Lapidus arthrodesis, it was 1.08 degrees. Our results demonstrated that the modified Lapidus arthrodesis maintains correction to a greater degree than the first metatarsal closing base wedge osteotomy with statistical significance (P = .0039). Both the modified Lapidus arthrodesis and the first metatarsal closing base wedge osteotomy are effective procedures with respect to degree of radiographic correction for moderate to severe hallux valgus deformities.     

Stability of medial opening wedge high tibial osteotomy: a failure analysis

Medial opening wedge high tibial osteotmy (HTO) is often used to treat varus gonarthrosis in young, active, highly demanding patients, although it has many pitfalls, which were evaluated in a consecutive cohort of patients. A retrospective analysis of a consecutive series of 45 patients with 49 medial opening HTO for varus gonarthrosis using a spacer plate (Puddu I, Arthrex, USA) were included. A Chi square test was used to study the effect between the wedge size and complications. Complications occurred in 22 knees (45%). There was no significant difference between groups for individual complications; however, when combined, there were significantly more complications in the >10 mm wedge group (Chi square p = 0.05). The overall complication rate in this series was 45%. The majority were related to intrinsic instability at the osteotomy site (24%) and surgical technique (20%). The evaluated spacer provided inadequate stability.     

Observations on patellar height following opening wedge proximal tibial osteotomy

Patellar height and patellar ligament length were assessed pre- and postoperatively in 28 patients who underwent a medial opening wedge proximal tibial osteotomy for varus gonarthrosis. This procedure produced no significant change in patellar ligament length. Pre- and postoperative Insall-Salvati ratios were 0.96+/-0.12 and 0.97+/-0.15, respectively (P=.30). The Insall-Salvati ratio decreased in 29% of patients, and no patient experienced a decline >0.07. The distance between the patella and tibiofemoral joint line ("patellar height") decreased in 100% of patients. The mean Blackburne-Peel ratio declined from 0.75+/-0.13 to 0.53+/-0.15 (P<.001). Sixty-four percent of the postoperative Blackburne-Peel values satisfied the radiographic criterion for patella infera (Blackburne-Peel ratio <0.54). Whereas the loss of patellar height, historically associated with lateral closing wedge proximal tibial osteotomy, is a function of patellar ligament contracture, the decreased distance between the patella and the tibiofemoral joint line following medial opening wedge proximal tibial osteotomy is a function of joint line elevation. The high incidence of patella infera following medial opening wedge proximal tibial osteotomy may have deleterious effects on patellofemoral biomechanics or may complicate subsequent total knee arthroplasty.     

Reorientation of the distal radial articular surface in Madelung's deformity by a reversed cuneiform osteotomy

A technique of cuneiform osteotomy of the distal end of the radius is presented. It was used in three female patients with Madelung's deformity (two bilateral cases and one unilateral case). A wedge of bone was harvested in situ from the metaphysis, then returned and replaced in situ. This technique, performed through the Henry's approach, combines closing wedge osteotomy on the longer radial cortices with opening wedge osteotomy on the shorter radial cortices. The biplane osteotomy, which provides the bony wedge, involves the entire width of the metaphysis and is performed with an oscillating saw. Once the wedge is reversed and replaced, stabilization is obtained with an anterior plate. In all five cases the forward subluxation of the carpus was reduced as well as the distal radioulnar dislocation through the backward projection of the epiphysis. The reversed cuneiform osteotomy brings new possibilities of reorienting the radial articular surface and its technical mastery allows for accurate correction of severe deformities.     

Distal femoral osteotomy for valgus arthritic knees

BackgroundPatients with genu valgum and isolated osteoarthritis of the lateral compartment are candidates for distal femoral varus osteotomy. Opening wedge osteotomy is a precise method to realign the knee axis with good short to midterm results. The aim of this study was to evaluate the outcome of patients who have had opening wedge distal femoral varus osteotomy utilizing the Puddu plate (Arthrex, Naples, FL, USA) fixation.MethodsThe study included 6 patients (7 knees) followed for an average of 6.5 ± 1.5 years after distal femoral varus osteotomy with Puddu fixation and iliac crest allograft. Clinical outcome was assessed by the Oxford Knee Score and subjective satisfaction rating. Pre- and postoperative radiographs were evaluated for tibiofemoral angle, Insall-Salvati index and Kellgren-Lawrence Grading Scale for osteoarthritis.ResultsThe mean age at surgery was 46.7 ± 10.7 years. The mean body mass index at surgery was 29.6 ± 5.6 kg/m². Overall at the last follow-up the mean Oxford Knee Score improved from 13.1 ± 8.6 to 26 ± 12.5. The average subjective satisfaction rate at the last follow-up was 6.6 ± 2.8. The measured tibiofemoral angle was corrected by an average of 11.9°. There was no worsening of arthritic changes in comparison to the preoperational radiographs. All radiographs showed full incorporation of the bone grafts, and there were no hardware failures. At the end of this study none of the patients required additional surgery, and none had knee replacement.ConclusionsOpening wedge distal femoral varus osteotomy with Puddu plate fixation can be a reliable procedure for the treatment of lateral compartment osteoarthritis of the knee associated with valgus deformity.     

Medial opening-wedge high tibial valgus osteotomy, using a stable TomoFix plate, in genu varum arthritis: surgical technique

The authors present the technique of high tibial correction osteotomy by the medial opening procedure, with the use of an angle-stable TomoFix plate. The prerequisite for a long-term good outcome of corrective osteotomy in genu varum is to achieve limb alignment permitting transfer of weight-bearing from the affected medial compartment to the healthy lateral compartment of the knee. The development of implants that maintain a stable angle has facilitated corrective osteotomy with an opening wedge on the medial side of the proximal tibia. These implants provide stable fixation even when a high correction of the mechanical axis is needed. The authors present the case of a patient with varus malalignment following a fracture of the tibia. In order to achieve correction of the limb's mechanical axis, it was necessary to open the proximal tibia osteotomy with a wedge that was 2.5 cm on the outer side.     

C7 decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis

Our objective is to report on the clinical and radiological outcome following a decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis. The only treatment available for severe fixed flexion deformity of the cervical spine in these patients is an extension osteotomy. Traditionally an anterior opening, posterior closing wedge osteotomy is performed with or without internal fixation. We describe a decancellisation closing wedge osteotomy of C7 accompanied by secure segmental internal fixation. Eight patients operated between 1990 and 2003 with mean age of 54 years and minimum follow up of 2 years were retrospectively evaluated. Restoration of normal forward gaze was achieved in all patients. No patient suffered spinal cord injury or permanent nerve root palsy. There was no loss of correction or pseudarthrosis at final follow up. C7 decancellisation closing wedge osteotomy supplemented with secure segmental internal fixation in experienced hands provides a safe and effective treatment for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis.     

Surgical correction of bowlegs in achondroplasia

A retrospective review of 39 surgical procedures to correct bowlegs in achondroplasia was performed. Three operative procedures had been used sequentially over 27 years. Sixteen tibiae were treated by proximal closing wedge tibial osteotomy, proximal fibular epiphysiodesis and casts. Twelve tibiae were treated by opening wedge osteotomies using external fixation with no fibular shortening. Eleven tibiae were treated by the Ilizarov technique with 3-cm tibial lengthening, deformity correction, and distal translation of the proximal fibula. The Ilizarov technique is the most satisfactory method for correction of proximal bowlegs in early childhood. Distal tibial osteotomy and fibular shortening is recommended for correction of distal bow legs in older children.     

Finite element analysis of Puddu and Tomofix plate fixation for open wedge high tibial osteotomy

The use of open wedge high tibial osteotomy (HTO) to correct varus deformity of the knee is well established. However, the stability of the various implants used in this procedure has not been previously demonstrated. In this study, the two most common types of plates were analysed (1) the Puddu plates that use the dynamic compression plate (DCP) concept, and (2) the Tomofix plate that uses the locking compression plate (LCP) concept. Three dimensional model of the tibia was reconstructed from computed tomography images obtained from the Medical Implant Technology Group datasets. Osteotomy and fixation models were simulated through computational processing. Simulated loading was applied at 60:40 ratios on the medial:lateral aspect during single limb stance. The model was fixed distally in all degrees of freedom. Simulated data generated from the micromotions, displacement and, implant stress were captured. At the prescribed loads, a higher displacement of 3.25 mm was observed for the Puddu plate model (p<0.001). Coincidentally the amount of stresses subjected to this plate, 24.7 MPa, was also significantly lower (p<0.001). There was significant negative correlation (p<0.001) between implant stresses to that of the amount of fracture displacement which signifies a less stable fixation using Puddu plates. In conclusion, this study demonstrates that the Tomofix plate produces superior stability for bony fixation in HTO procedures.