L’altezza della rotula dopo osteotomia tibiale prossimale: confronto fra tecnica di addizione mediale e sottrazione laterale

The clinical and radiographic results of patients with unicompartmental osteoarthritis or axial malalignment of the knee surgically treated with two different techniques of osteotomy of the proximal tibia were analysed. The patients, matched for age, sex and deformities, were divided into two groups: 47 cases treated with closed-wedge high tibial osteotomy and 40 cases with open-wedge high tibial osteotomy. For each case the height of the patella was measured by the Caton Method before surgery and at the last follow-up (at least 1 year after surgery). The purpose of this study was to analyse and search for any possible correlation between the variation of the patella and the degree of correction of the mechanical axis. It was concluded that patellar height after final osteotomy of the proximal tibia is modified and depends on the surgical technique used. Our study has shown a more frequent loss of patellar height with open-wedge high tibial osteotomy rather than closed-wedge high tibial osteotomy, the latter followed by a rather high rate of patellar elevation.     

Precise Patellar Tendon Insertion Protection and Osteotomy Surface Advantage of Transtibial Tuberosity–High Tibial Osteotomy

ObjectiveMedial opening wedge high tibial osteotomy (HTO) is successful in the treatment of knee osteoarthritis with medial compartment stenosis and tibial varus deformity, but patella infera is the main complication. This study aims to design a new medial tibial open osteotomy scheme, transtibial tuberosity‐high tibial osteotomy (TT‐HTO), which can fully protect the patellar tendon insertion. In addition, the area of the osteotomy surface and wedge volume were evaluated in TT‐HTO, biplanar distal tibial tuberosity osteotomy (biplanar‐DTO), and uniplanar‐DTO to evaluate the potential advantages of this technology in bone healing.MethodsThe tibial tubercle was divided into four equal sections from proximal to distal, which were defined as zones A, B, C, and D. From September to December 2020, the imaging examinations of 200 patients (95 males and 105 females) with a mean age of 40.6 years (range 19–60 years) were evaluated to observe the zonation of the tibial tubercle where the insertion of the patellar tendon is located. Then, 59 patients (23 males and 36 females) with a mean age 59.6 years (range 43–77 years), for a total of 69 knees (32 right and 37 left), who underwent routine knee surgery were observed and verified. According to the position of the patellar tendon insertion, TT‐HTO was designed. Fifteen tibial sawbones were divided equally into three groups: TT‐HTO; biplanar‐DTO; and uniplanar‐DTO. The total area of the osteotomy surface was compared using the graph paper method. The wedge volume at wedge heights of 10 mm was compared among osteotomy types using the plasticine Archimedes principle. One‐way repeated‐measures analysis of variance was used to compare the total area of the osteotomy surface and the wedge volume.ResultsThe osteotomy line of TT‐HTO passes through the boundary point of zones B and C of the tibial tubercle to fully protect the insertion point of the patellar tendon. The total area of the osteotomy surface in TT‐HTO and biplanar‐DTO was significantly larger than that in uniplanar‐DTO (P < 0.05). The wedge volume in uniplanar‐DTO was significantly smaller than that in TT‐HTO and biplanar‐DTO (P < 0.05). No significant differences in the osteotomy surface and the wedge volume were identified between TT‐HTO and biplanar‐DTO.ConclusionTT‐HTO can protect the patellar tendon insertion and avoid postoperative patella infera. The osteotomy surface is large and located in an area of cancellous bone, which ensures its good healing characteristics.     

Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality

The aim of this study was to present the different surgical procedures of tibial tubercle osteotomies for patellar instability or patellar mispositioning such as patella alta or patella infera. This study analysed the Caton–Deschamps index used for assessment of vertical patella height in order to make a precise plan for tibial tuberosity osteotomies. This study included 61 knees (50 patients) treated for patellar instability with patella alta and 24 patients treated for patella infera of mechanical origin. The results of medial transfer of the tibial tuberosity, with or without distal transfer in cases of patellar instability with patella alta, gives excellent results for stability in 76.8% of the cases. The results of the proximal transfer of the tibial tuberosity in cases of patella infera were excellent or good in 80% of the cases in our series of 24 patients. A precise preoperative plan is needed with determination of the vertical patellar height using the Caton–Deschamps index and the situation of the tibial tuberosity and the Tibial Tubercle to Trochlear Groove distance (TT-TG) of the knee on CT scan in order to obtain satisfactory results.     

Model predictions of increased knee joint loading in regions of thinner articular cartilage after patellar tendon adhesion

Patellar tendon adhesion is a complication from anterior cruciate ligament (ACL) reconstruction that may affect patellofemoral and tibiofemoral biomechanics. A computational model was used to investigate the changes in knee joint mechanics due to patellar tendon adhesion under normal physiological loading during gait. The calculations showed that patellar tendon adhesion up to the level of the anterior tibial plateau led to patellar infera, increased patellar flexion, and increased anterior tibial translation. These kinematic changes were associated with increased patellar contact force, a distal shift in peak patellar contact pressure, a posterior shift in peak tibial contact pressure, and increased peak tangential contact sliding distance over one gait cycle (i.e., contact slip). Postadhesion, patellar and tibial contact locations corresponded to regions of thinner cartilage. The predicted distal shift in patellar contact was in contrast to other patellar infera studies. Average patellar and tibial cartilage pressure did not change significantly following patellar tendon adhesion; however, peak medial tibial pressure increased. These results suggest that changes in peak tibial cartilage pressure, contact slip, and the migration of contact to regions of thinner cartilage are associated with patellar tendon adhesion and may be responsible for initiating patellofemoral pain and knee joint structural damage observed following ACL reconstruction. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1168–1177, 2011     

The management of patella infera in current practice

Patella infera described by Caton et al.The measurement is made in 1982 is an accompanying symptom in certain knee affections secondary to the abnormal situation of the patella. The measurement is made on the X-ray with sagittal view after measuring the patellar height, using the original technique described by the author, when the ratio between the articular surface of the patella and the distance form the patellar tip to the tibial tubercle. Indications of surgery may be when this ration is inferior or equals 0.6. The origin of the patella infera can be mechanical or inflammatory. The operative technique addresses the etiology. In current practice, the patellar height and the patellar tendon length may be evaluated using a sagittal section MRI. In the authors’ experience, when the Caton ratio is lower or equals 0.6 and when the length of the patellar tendon is over 25 mm, the indication of surgery includes proximal transfer of the tibial tubercle. If the length of the patellar tendon is less than 25 mm, it is often necessary to perform a patellar tendon lengthening (PTL). This type of surgery is contraindicated in the authors’ experience in depressive or pusillanimous subjects. The two surgical techniques are described. Both techniques use an anterior and medial approach. The proximal transfer of the tibial tubercle (PTT) includes medial and lateral retinaculum release. The tibial tubercle is detached and transferred upwards according to the pre-operative planning generally 1 or 2 cm and is fixed with 2 screws. PTL includes a medial and lateral retinaculum release often with the fat pad. The patellar tendon is dissociated in the middle over its whole length, and the medial pad is detached of the tibial tubercle and the lateral of the patella. After lengthening, the edges of the tendon are sutured, and this suturing reinforced. Alternative procedures may be used when PTT or PTL are not possible, using transplantation with an allograft of the extensor system or a plasty with hamstring muscles.     

High tibial osteotomy using polycaprolactone-tricalcium phosphate polymer wedge in a micro pig model

Medial open-wedge high tibial osteotomy has been gaining popularity in recent years, but adequate supporting material is required in the osteotomy gap for early weight-bearing and rapid union. The purpose of this study was to investigate whether the implantation of a polycaprolactone-tricalcium phosphate composite scaffold wedge would enhance healing of the osteotomy in a micro pig model. We carried out open-wedge high tibial osteotomies in 12 micro pigs aged from 12 to 16 months. A scaffold wedge was inserted into six of the osteotomies while the other six were left open. Bone healing was evaluated after three and six months using plain radiographs, CT scans, measurement of the bone mineral density and histological examination. Complete bone union was obtained at six months in both groups. There was no collapse at the osteotomy site, loss of correction or failure of fixation in either group. Staining with haematoxylin and eosin demonstrated that there was infiltration of new bone tissue into the macropores and along the periphery of the implanted scaffold in the scaffold group. The CT scans and measurement of the bone mineral density showed that at six months specimens in the scaffold group had a higher bone mineral density than in the control group, although the implantation of the polycaprolactone-tricalcium phosphate composite scaffold wedge did not enhance healing of the osteotomy.     

Operative management of patellofemoral pain

In short, the surgical treatment of patients with patellofemoral pain will depend on understanding each specific disorder and the pattern of articular degeneration. Tilt alone generally responds well to lateral release. Subluxation, particularly when more severe, may require medial imbrication and/or a distal (Trillat) procedure in addition to lateral release to achieve extensor mechanism balance. When there is significant patellar arthrosis, an oblique osteotomy deep to the tibial tubercle will permit unloading of the patellar articular surface in addition to realignment. A small amount of metaphyseal bone placed in this oblique osteotomy will permit straight anterior displacement of the tibial tubercle of 15-20 mm with minimal bone graft when necessary. These basic surgical procedures will permit adequate treatment of most patients with resistant patellofemoral pain (with or without arthrosis) when non-operative measures have failed and the appropriate procedure is selected for a specific mechanical disorder.     

A comparison of plate versus staple-and-cast fixation in maintaining femoral tibial alignment after valgus tibial osteotomy.

PURPOSE: To compare 2 methods of fixation for maintenance of alignment during healing of valgus tibial osteotomies. METHODS: We performed a retrospective chart and radiographic review of valgus tibial osteotomy cases of staple fixation supplemented by a postoperative cast and of blade plate fixation for maintenance of femoral-tibial alignment during healing of the osteotomy. RESULTS: Both groups (staple-and-cast, n = 16; plate, n = 28) were similar in terms of age, preoperative alignment, extent of osteoarthritis and degree of intra-operative correction. Between-group differences in the maintenance of femoral-tibial alignment during healing were not significant. In both groups there was a strong correlation between degree of bone contact at the osteotomy site and maintenance of alignment (p < 0.005). In cases done with the plate, 90% of osteotomies with good or excellent bone contact maintained alignment during healing; with poor or fair bone contact, 75% had loss of alignment > 5 degrees during healing. There was a trend toward a greater incidence of delayed or non-union with plate fixation compared with staple fixation that did not reach statistical significance. All of these cases of delayed/non-union had loss of femoral-tibial alignment > 5 degrees during healing. CONCLUSION: As a result of this study, we have modified our surgical technique. We now use intra-operative fluoroscopy for optimization of bone contact, and we have reverted to the less invasive staple method for fixation of tibial osteotomies.     

Extended tibial tubercle osteotomy in total knee arthroplasty

Thirty tibial tubercle osteotomies were performed to obtain exposure and facilitate patellar tracking in 29 patients who underwent total knee arthroplasty. The thickness and width of the bone fragment were gradually tapered from proximal to distal. Fixation was obtained with three or four titanium screws. Average follow-up period was 18 months. Twenty-nine of the osteotomies healed primarily. In one patient, postoperative displacement of the tibial tubercle developed requiring additional screw and suture fixation. Extended tibial tubercle osteotomy is a useful technique during difficult total knee arthroplasty. Poor tibial bone stock is a relative contraindication. The authors recommend that a long tapered bone fragment that is 1.5 to 2 cm thick at the level of the tibial tubercle be elevated and fixation achieved with screws.     

Editorial Commentary: Tibial Slope Should Be Naturally Maintained by Proper Posterior Cortical Osteotomy and Gap Distraction in Open-Wedge High Tibial Osteotomy

The tibial slope usually increases after open-wedge high tibial osteotomy (OWHTO) because of several factors. The anteromedial cortex of the proximal tibia is angulated 45° relative to the posterior cortex, whereas the lateral cortex is nearly perpendicular. Therefore, an OWHTO with equal anterior and posterior gaps will increase the tibial slope. In addition, an anteromedial approach to the proximal tibia because of concern about neurovascular injury results in the failure to perform a proper osteotomy of the posterolateral cortex. Slope-optimization methods include a sagittally oriented hinge, posterior bone grafting, posterior plating, and forcefully extending the knee to compress the anterior gap sagittally oriented hinge, posterior positioning of the wedged plate, and knee extension during fixation. However, if the tibial slope is easily controlled using knee extension, this may indicate fracture of the lateral hinge, whereas a preserved lateral hinge is a prerequisite for a successful OWHTO. Most of all, a proper posterior cortical osteotomy is the key step to preventing increased tibial slope in OWHTO. Again, if an incomplete osteotomy is performed posterolaterally, the opening gap is increased anteriorly, leading to an unnecessary increase in posterior tibial slope; for biplanar osteotomy, retrotubercular osteotomy should be performed close to the patellar tendon and not be advanced to the posterolateral side of the hinge.     

Die öffnende valgisierende Osteotomie der proximalen Tibia mit Fixation durch einen medialen Plattenfixateur

High tibial osteotomy (HTO) is an established technique for the treatment of the symptomatic varus malaligned knee. Correction is usually achieved by closed wedge osteotomy from a lateral exposure. This procedure has a certain risk potential regarding peroneal nerve injuries, instability of the osteotomy and secondary loss of correction. We present four technical modifications of HTO which improve safety and reproducibility of this operation. 1) Open wedge osteotomy from a medial exposure avoids lateral muscle detachment, dissection of the peroneal nerve, proximal fibula osteotomy and leg shortening. Only one osteotomy needs to be performed and the correction can be adapted intraoperatively. 2) A biplanar osteotomy provides improved rotational stability of the osteotomy and creates an anterior buttress against sagittal tilting. 3) An incomplete osteotomy with plastic deformation of the intact lateral bone bridge avoids fractures of the lateral cortex and instabilities and promotes bone healing. 4) Rigid fixation with a medial plate-fixator (Tomofix) allows for early mobilisation and avoids loss-of-correction. 262 patients were consecutively operated using the described modified technique until now. No loss-of-correction occurred in this group, two patients with delayed healing received secondary cancellous bone grafts.     

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.     

Combined medial open-wedge high tibial osteotomy and modified Maquet procedure for medial compartmental osteoarthritis and patellofemoral arthritis of the knee

Purpose

Patellofemoral arthritis comes frequently with medial compartmental osteoarthritis. The combination of closed wedge high tibial osteotomy with tibial tuberosity anteriorization osteotomy has been introduced in several reports, but this technique is a technically demanding procedure and the outcomes of this technique show variable results. This article describes a novel osteotomy technique that combines medial open-wedge high tibial osteotomy (HTO) and tibial tuberosity anteriorization osteotomy (TTAO) for medial compartmental osteoarthritis and patellofemoral arthritis of the knee.

Methods

Twelve knees in 10 patients who were diagnosed with combined medial compartmental osteoarthritis with patellofemoral compartmental arthritis were treated with the combination of medial open-wedge HTO and TTAO and were followed up for more than 1 year. We evaluated the patients with the Lysholm functional questionnaires, the hospital for special surgery score (HSS), and the international knee documentation committee (IKDC) criteria (mean follow-up, 14.8 months).

Results

Union was achieved in all cases within 12 weeks. The mean Lysholm score increased from 42 preoperatively to 82.5 postoperatively (p < 0.001), the HSS increased from 57.5 preoperatively to 83 postoperatively (p < 0.001), and the IKDC score increased from 51 preoperatively to 82 postoperatively (p < 0.001). There were no other complications, such as iatrogenic fractures, nonunion, wound problem, collapse or loss of correction, and so on.

Conclusions

The combination of medial open-wedge HTO and modified Maquet procedure (TTAO) is considered to be an effective treatment modality for medial and patellofemoral compartmental osteoarthritis. This technique could, therefore, constantly provide a minimally invasive, precise correction of the deformity and a firm fixation that is enough to allow early rehabilitation.     

Editorial Commentary: Reducing the Tibial Tuberosity-Trochlear Groove Distance in Patella Stabilization Procedure. Too Much of a (Good) Thing?

A recent study suggests that aggressive correction of the tibial tuberosity-trochlear groove (TT-TG) distance by tibial tubercle osteotomy and medialization during patellar stabilization surgery can result in diminished outcomes. The mechanism may be overmedialization resulting in excessive medial patellofemoral and tibial-femoral pressure. Measurement of TT-TG may be inaccurate, and medialization of the tibial tubercle may not be required in cases of lateral patellar instability with TT-TG >20 mm (which is a current algorithm). My indication for tibial tubercle osteotomy, generally anteromedialization, is lateral patellofemoral chondrosis, and my goal is to create an intraoperative tubercle-sulcus angle of 0, which can be readily visualized with the knee at 90°. This is true regardless of the preoperative TT-TG measurement, and this intraoperative measurement mitigates against an excessive tubercle-sulcus angle of 0, which can be readily visualized with the knee at 90° and is true regardless of the preoperative TT-TG medialization.     

Opening wedge high tibial osteotomy using tibial wedge allograft: a case series study

High tibial osteotomy has been established as an effective surgical intervention in patients with unicompartment osteoarthritis of the knee associated with varus deformity and abnormal load through the medial compartment. The aims of this study were to report the result of open-wedge osteotomy performed with allograft bone and also to evaluate the postoperative clinical results in a series of patients. There are still little medical literatures regarding the use of an allograft bone transplant in open-wedge osteotomy. 37 consecutive cases that had undergone opening wedge osteotomy using allograft bone were studied. They were followed each 2 months after surgery until 6 month. There were 7 men and 30 women, aged ranging from 16 to 66. All patients were followed 6 months after surgery until clinical and radiographic healing of the osteotomy site. All patients could stand and walk on operated limb 6 months after operation, but 11 of them had still pain after this duration. There were no cases of non-union or osteotomy site collapse associated with the use of allograft. Moreover, no significant complication has been detected in these patients with choosing appropriate patients and performing good surgical technique, and the proximal tibial wedge allograft is a satisfactory choice that provides effective clinical and radiographic bone union.     

Editorial Commentary: Posterolateral Malposition of the Cortical Hinge During Medial Open-Wedge High Tibial Osteotomy Increases Posterior Tibial Slope: Incomplete Posterior Osteotomy May Shift the Hinge From Lateral to Posterolateral

Medial open-wedge high tibial osteotomy is an established treatment option for relatively young patients with medial-compartment osteoarthritis and varus deformity. This procedure is mainly focused on correcting coronal malalignment; however, it inevitably affects the posterior tibial slope (PTS) in the sagittal plane. The alteration of the PTS significantly affects knee stability and kinematics. When medial open-wedge high tibial osteotomy is performed, incomplete osteotomy of the posterior cortex could lead to a cortical hinge shift from the lateral side to the posterolateral side, which indicates the alteration of the axial hinge axis. In this case, there is a risk of an increasing PTS. In addition, incomplete posterior cortex osteotomy can lead to a lateral hinge fracture.     

Open-wedge osteotomy of the proximal tibia hemicallotasis.

Conventional high tibial osteotomy for losteoarthritis of the medial compartment of the knee with closed-wedge or dome osteotomy (DMO) may produce shortening of the patellar tendon and loss of inclination of the proximal tibial plateau or of the offset of the tibial condyle relative to its bony axis. This can make subsequent total knee arthroplasty technically demanding. We undertook a prospective study comparing these changes after DMO with those after using open-wedge osteotomy hemicallotasis (HCO). A total of 50 knees with arthritis of the medial compartment in 46 consecutive patients was randomly allocated to either DMO or HCO. There were no significant differences between the groups with regard to age, gender, femorotibial angle before operation or the angle of correction. Radiological studies showed that HCO caused little change in the length of the patellar tendon or the inclination angle of the tibial plateau, while after DMO both gradually decreased. The degree of tibial condylar offset increased in both groups, but less so in the HCO group.     

Tibial plateau fracture following oblique osteotomy of the tibial tubercle: a case report

Oblique osteotomy of the tibial tubercle is a preferred technique in patellofemoral disorders, resulting in a satisfactory clinical outcome. However, postoperative fractures of the proximal metaphysis of the tibia may often develop. An incomplete fracture of the lateral tibial plateau occurred in a 23-year-old female patient following an oblique osteotomy of the tibial tubercle. There was no history of trauma. The patient had undergone two operations in the same knee due to patellar instability. She also had bilateral high congenital hip dislocation. The correct diagnosis could only be made by computed tomography. Complete union was obtained following six weeks of plaster cast fixation. Due to inherent biomechanical limitations, complications may arise following oblique osteotomy of the tibial tubercle even adequate care is given to the surgical technique.     

Die aufklappende Tibiakopfosteotomie mittels kontinuierlicher Kallusdistraktion

High tibial osteotomy is an accepted method for treatment of medial osteoarthritis. An alternative technique is an open-wedge osteotomy and consecutive callotasis (CO) using an external fixator. The purpose of this study was to evaluate the clinical and radiological results and the efficiency of this technique for precise correction. This prospective study included 41 patients (44 knees) evaluated by the HSS score, radiological stage of osteoarthritis, bone healing, and complications after a follow-up period of 49 (36-61) months. The HSS score increased from median 67 preoperatively to 82 points at the time of follow-up (p<0.001). Of 44 knees, excellent/good results were found in 70.5% and fair/poor in 29.5%. The median preoperative femorotibial anatomical angle was 3.6 degrees varus and 9.4 degrees valgus at the latest follow-up examination. The total time in external fixation was median 80 (61-125) days. We observed one early collapse of the new bone wedge, one complete corticotomy, and pin tract infections in ten cases. Furthermore, two hematomas required revision surgery. Hemicallotasis with external fixators allows constant manipulation of alignment during the healing process to optimize alignment. The disadvantage of the external fixation is the risk of pin track infection. Therefore, CO may constitute an important contribution to our algorithm in the treatment of varus gonarthrosis.     

Unusual course of the extensor pollicis longus tendon associated with tenosynovitis,presenting as de Quervain disease--a case report

Background and purpose Tibial tubercle osteotomy (TTO) is an established surgical technique for exposing the stiff knee in revision total knee arthroplasty (RTKA). The osteotomy is usually performed through the anterior metaphyseal cancellous bone of the tibia but it can be extended into the intramedullary canal if tibial stem and cement removal are necessary. Furthermore, repeat osteotomy may be required in another RTKA. We assessed whether intramedullary extension of TTO or repeat osteotomy affected the healing rate in RTKA.

Methods We retrospectively evaluated 74 consecutive patients (39 women) with an average age of 60 (29–89) years who underwent 87 TTOs during RTKA. 1 patient had bilateral TTO. 10 patients had repeat TTO and 1 patient received 3 TTOs in the same knee. The osteotomy was extramedullary in 57 knees and intramedullary in 30 knees. Osteotomy repair was performed with bicortical screws and/or wires.

Results Bone healing occurred in all the cases. The median time to union was 15 (6–47) weeks. The median healing time for the extramedullary osteotomy group was 12 weeks and for the intramedullary osteotomy group it was 21 weeks (p = 0.002). Repeat osteotomy was not associated with delayed union. Neither intramedullary nor repeat osteotomy was found to increase the complication rate of the procedure.

Interpretation Reliable bone healing can be expected with intramedullary extension or repeat TTO in RTKA. However, intramedullary extension of the osteotomy prolongs the union time of the tibial tubercle.