High tibial valgus osteotomy. A clinical review

Thirty-one consecutive high tibial valgus osteotomies for varus gonarthrosis performed by one surgeon using one technique were evaluated to determine correction of deformity, functional result, subjective impression, and subsequent surgery for the same problem. Twenty-five patients had satisfactory follow-up evaluations. Preoperative tibiofemoral angulation averaged 7 degrees varus. Postoperative tibiofemoral angulation averaged 5 degrees valgus. Ninety-two percent had excellent or good results, according to Coventry's criteria and the H.S.S. knee score. Eighty-eight percent claimed postoperative improvement, 8% were unchanged, and one patient was worse. Eighty-eight percent had had no further surgery. Excellent/good results deteriorated from 92% at two years to 88% at five years, to 91% at seven years, and to 80% at nine years. This is a smaller rate of deterioration than noted in other series. Analgesic and antiinflammatory drug use was significantly reduced after operation. No significant differences were noted in patients older than or younger than 60 years of age at the time of surgical correction. Factors contributing to success included careful patient selection; correction of the limb to the mechanical axis; and precise surgical technique. Osteotomy proved a successful alternative to total knee replacement for treatment of varus gonarthrosis in a carefully selected group of patients.     

High tibial osteotomy

High tibial osteotomy (HTO) is a widely performed procedure to treat medial knee arthrosis. In general, published studies on HTO report good long-term results with a correct patient selection and a precise surgical technique. The ideal candidate for an HTO is a middle aged patient (60 to 65 years of age), with isolated medial osteoarthritis, with good range of motion and without ligamentous instability. Some issues that need resolution remain; these include the choice between opening and closing wedge tibial osteotomy, the graft selection in opening wedge osteotomies, the type of fixation, the comparison with unicompartmental knee arthroplasty and whether HTO significantly affects a subsequent total joint replacement. Precise indication, preoperative planning, and operative technique selection are essential to achieve good results.     

High tibial osteotomy

High tibial osteotomy is effective for managing a variety of knee conditions, including gonarthrosis with varus or valgus malalignment, osteochondritis dissecans, osteonecrosis, posterolateral instability, and chondral resurfacing. The fundamental goals of the procedure are to unload diseased articular surfaces and to correct angular deformity at the tibiofemoral articulation. Although the clinical success of total knee arthroplasty has resulted in fewer high tibial osteotomies being done during the past decade, the procedure remains useful in appropriately selected patients with unicompartmental knee disease. Renewed interest in high tibial osteotomy has occurred for a number of reasons. These include the prevalence of physiologically young active patients presenting with medial compartment osteoarthritis; the advent of new techniques for performing the procedure (ie, improved instrumentation and fixation plates for medial opening wedge osteotomy, dynamic external fixation for medial opening wedge osteotomy, and improved instrumentation for lateral closing wedge osteotomy); and the need to concomitantly correct malalignment when performing chondral resurfacing procedures (ie, autologous chondrocyte transplantation, mosaicplasty, and microfracture).     

High tibial osteotomy

The results of high tibial osteotomy performed in a 12-year period in 75 patients (88 knees) were followed for at least five years or until failure occurred. Of the 86 knees available for subjective follow-up evaluation, 64 were in men and 22 were in women. Roentgenographic data were available for 75 knees. The results were rated good (no or minimal pain, occasional analgesics required, slight limitation of activity), fair (regular analgesics required, noticeable decrease in activity), poor (moderate to severe pain, marked decrease in activity), or failed (arthroplasty required). On the basis of these definitions, 51% of the results were good, 9% were fair, 4% were poor, and 36% were failed. Results were satisfactory in 94% at two years, 87% at five years, and 69% at ten years. The absolute amount of angular correction did not correlate with the results. The change in axial alignment with time was unpredictable. Gender and age of patient were not factors in the outcome, although women seemed to require a longer period to become support-free. Better long-term results were obtained if the correction was to 10 degrees or more of anatomic valgus.     

胫骨高位截骨术

退变性腰椎管狭窄症(denenerative lumbar sp inal stenosisDLSS)是导致中老年腰腿痛或腰痛的常见病之一[1]。CT检查是确定狭窄程度的主要依据,为探讨退变性腰椎管狭窄症CT分型在治疗中的参考价值,本文对一组综合保守治疗的退行性腰椎管狭窄症病例进行回顾性分析。1资料与方法1·1一般资料2005年1月-2007年6月共综合保守治疗退变性腰椎管狭窄症89例,病例资料完整并获近期随访者52例,其中男31例,女21例;年龄最小43岁,最大79岁,平均63岁;随访时间3~30·7个月,平均12·9个月。病程最短3个月,最长20年4个月,平均4年6个月。1·2诊断标准及分…     

High tibial barrel-vault osteotomy. A clinical study and statistical analysis of 91 long-term results]

91 high tibial valgus barrel-vault osteotomies were subject of a follow-up study from 10 to 19 years (phi 11.9) after the osteotomy. 20 of the patients rate themselves as excellent, 29 as good, 22 as poor and 22 as failed. Adipositas was a factor that mainly worsened the results. Furthermore a postoperative flexion deformity and preoperative joint-space-narrowing were negative conditions, too. A slight overcorrection, more than the physiological valgus proved to be advantageous. The results were not influenced by age, sex and preoperative radiographic stage and range of motion. In summary the osteotomy has been shown to be a successful measure to prolong the period until final destruction of the knee joint will happen.     

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.     

Proximal tibial osteotomy for genu recurvatum. A review and case report

Genu recurvatum may be due to weakness of the muscles that stabilize the knee, with secondary bone changes. The more common etiology is primary bone deformity of the proximal tibia, which may result from multiple causes. An operation is described for the anatomical correction of the latter type. A corrective opening wedge osteotomy is maintained with full thickness bicortical iliac triangular wedges. This technique has been successfully used in one patient who has been followed for 12 years.     

Total knee arthroplasty after high tibial osteotomy. A systematic review

Background  

Previous osteotomy may compromise subsequent knee replacement, but no guidelines considering knee arthroplasty after prior osteotomy have been developed. We describe a systematic review of non-randomized studies to analyze the effect of high tibial osteotomy on total knee arthroplasty.     

Proximal tibial osteotomy. A survivorship analysis

Proximal tibial osteotomy is generally accepted as a treatment for the patient with unicompartmental arthritis. However, a few reports of the long-term results of this procedure are available in the literature, and none have used the technique known as survivorship analysis. This technique has an advantage over conventional analysis because it does not exclude patients for inadequate follow-up, loss to follow-up, or patient death. In this study, survivorship analysis was applied to 78 proximal tibial osteotomies, performed exclusively by the senior author for the correction of a preoperative varus deformity, and a survival curve was constructed. It was concluded that the reliable longevity of the proximal tibial osteotomy is approximately 6 years.     

Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study.

High tibial osteotomy for medial gonarthrosis was performed in 28 patients (28 knees). At the time of surgery, arthroscopy was also performed and a cartilage-bone biopsy was obtained. Postoperatively, 15 patients were randomized to a cylinder plaster cast, whereas 13 patients had a hinged cast brace for early knee mobilization. At follow-up examination, two years after surgery, 16 patients accepted an arthroscopic examination with a cartilage-bone biopsy. In overcorrected knees, cartilage regeneration was found in eight of 14 patients on the medial tibial condyle and in nine of 14 on the medial femoral condyle. The main repair feature was proliferation of fibrocartilage, which covered bone and areas of fibrillated cartilage and filled vertical clefts in hyaline cartilage. The hyaline cartilage showed an increased cellularity with numerous nests of proliferating chondrocytes. No correlation was found between clinical outcome and the degree of cartilage regeneration as observed by arthroscopy, biopsy, or roentgenography. Knees with a brace postoperatively had better knee flexion two years after surgery. No difference in cartilage regeneration was recorded between knees with a plaster cast or a cast brace postoperatively.     

Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study

We prospectively reviewed 24 patients (35 feet) who had been treated by a Scarf osteotomy and Akin closing-wedge osteotomy for hallux valgus between June 2000 and June 2002. There were three men and 21 women with a mean age of 46 years at the time of surgery. The mean follow-up time was 20 months. Our results showed that 50% of the patients were very satisfied, 42% were satisfied, and 8% were not satisfied. The mean American Orthopaedic Foot and Ankle Society score improved significantly from 52 points pre-operatively to 89 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15 degrees and 33 degrees to 9 degrees and 14 degrees, respectively. These improvements were significant (p < 0.0001). The change in the distal metatarsal articular angle was not significant (p = 0.18). There was no significant change in the mean pedobarographic measurements of the first and second metatarsals after surgery (p = 0.2). The mean pedobarographic measurements of the first and second metatarsals at more than one year after surgery were within the normal range. Two patients had wound infections which settled after the administration of antibiotics. One patient had an intra-operative fracture of the first metatarsal and one required further surgery to remove a long distal screw which was irritating the medial sesamoids. We conclude that the Scarf osteotomy combined with the Akin closing-wedge osteotomy is safe and effective for the treatment of hallux valgus.     

A relationship between gait and clinical changes following high tibial osteotomy

We studied the cases of twenty-one patients with high tibial osteotomy in order to determine the relationship between knee-joint loading during gait and clinical outcome. The patients were tested before surgery, one year after surgery, and again at an average of 3.2 years after surgery. An age-matched group of fifteen control subjects was also studied. The results of this study indicate that certain characteristics of preoperative walking are associated with postoperative clinical results. In particular, the moment tending to adduct the knee joint during walking preoperatively was predictive of postoperative clinical results. The patients were classified into a high adduction-moment group and a low adduction-moment group according to the magnitude of the knee-adduction moment. The adduction moment was reduced in both groups after high tibial osteotomy. However, the average postoperative adduction moments in the low adduction-moment group were still significantly lower than those in the high adduction-moment group. The two groups were indistinguishable on the basis of preoperative knee score, initial varus deformity, immediate postoperative correction, age, and weight. However, at an average 3.2-year follow-up, patients with low preoperative adduction moments had substantially better clinical results than did patients with high adduction moments. The low adduction-moment group had 100 per cent excellent or good clinical results, while only 50 per cent of the patients in the high adduction-moment group had an excellent or good result. Furthermore, there was a significant recurrence of varus deformity in the patients in the high adduction-moment group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Proximal tibial osteotomy. A new fixation device

A new internal fixation device was applied to 41 proximal tibial osteotomies to ensure against loss of postoperative correction. An oblique osteotomy was stabilized by two screws and a five-hole one-half tubular plate. Thirty-six patients with 41 proximal tibial osteotomies were reviewed for an average roentgenographic follow-up time of 22.6 months (range, six to 48 months) with no loss of correction. In addition, 16 patients with 19 osteotomies and a minimum clinical follow-up time of two years were reviewed using the Hospital for Special Surgery knee scoring system; these early results demonstrated a similar outcome to previously published series. The new fixation device is simple to use, permits early postoperative motion, and maintains the exact correction obtained at the time of surgery.     

"Hybrid" total knee arthroplasty with the Miller-Galante prosthesis. A prospective clinical and roentgenographic evaluation

Twenty-nine "hybrid" Miller-Galante total knee arthroplasties, in 22 patients, were evaluated prospectively and according to the clinical and roentgenographic guidelines of The Knee Society. Selection of this technique, incorporating an uncemented, porous-ingrowth femoral component and a cemented tibial component, was based on patient age, medical condition, activity level, and intraoperative assessment of bone quality and ligament competency. The average age of the patients at the time of surgery was 71 years. The average preoperative Knee Society Knee Score was 32; average pain score was 14; and the average function score, 47. After an average follow-up interval of 28 months postsurgery (minimum, 24 months), the average Knee Society Knee Score was 93; the average pain score, 47; and the average function score, 79. Range of motion averaged 110 degrees. Only one knee, with persistent pain of obscure origin, rated an unsuccessful result. No arthroplasties were revised for any reason. Twenty-three knees had fluoroscopically guided roentgenograms to assess the bone-prosthesis and bone-cement interfaces. No significant or progressive radiolucencies were noted under any of the components. No apparent adverse bone remodeling was associated with the uncemented femoral component. The fluoroscopically guided roentgenograms were significantly more sensitive in detecting interface radiolucencies than plain ones. Clinical and roentgenographic evidence of component loosening were absent in all patients. Results of this study suggest that the hybrid fixation technique can reliably provide satisfactory pain relief and restoration of function in properly selected patients. Potential advantages of an uncemented femoral component include decreased operative time, reduction of polyethylene wear from cement debris, and avoidance of a possible adverse biologic response to polymethylmethacrylate.