膝内翻伴胫骨旋转的治疗

目的 观察胫骨高位截骨，胫骨结节旋转抬高治疗膝内翻伴胫骨旋转畸形的效果。方法 通过膝关节生物力学研究。简化了胫骨高位截骨的测量方法，在胫骨高位截骨的同时进行胫骨结节旋转抬高，恢复胫股关节，髌股关节的生理功能。结果 随访1-8年，通过X线，CT检查及膝关节功能评定，其优良率为88%。结论 胫骨高位截骨，胫骨结节旋转抬高治疗膝关节内侧间隔退行性关节炎，胫骨旋转所致髌股关节炎，符合生物力学要求，长期随访效果满意。     

High tibial closing wedge osteotomy for medial compartment osteoarthrosis of knee

Background:

Most patients of symptomatic osteoarthrosis of knee are associated with varus malalignment that is causative or contributory to painful arthrosis. It is rational to correct the malalignment to transfer the functional load to the unaffected or less affected compartment of the knee to relieve symptoms. We report the outcome of a simple technique of high tibial osteotomy in the medial compartment osteoarthrosis of the knee.

Materials and Methods:

Between 1996 and 2004 we performed closing wedge osteotomy in 78 knees in 65 patients. The patients selected for osteotomy were symptomatic essentially due to medial compartment osteoarthrosis associated with moderate genu varum. Of the 19 patients who had bilateral symptomatic disease 11 opted for high tibial osteotomy of their second knee 1-3 years after the first operation. Preoperative grading of osteoarthrosis and postoperative function was assessed using Japanese Orthopaedic Association (JOA) rating scale.

Results:

At a minimum follow-up of 2 years (range 2-9 years) 6-10° of valgus correction at the site of osteotomy was maintained, there was significant relief of pain while walking, negotiating stairs, squatting and sitting cross-legged. Walking distance in all patients improved by two to four times their preoperative distance of 200-400 m. No patient lost any preoperative knee function. The mean JOA scoring improved from preoperative 54 (40-65) to 77 (55-85) at final follow-up.

Conclusion:

Closing wedge high tibial osteotomy performed by our technique can be undertaken in any setup with moderate facilities. Operation related complications are minimal and avoidable. Kirschner wire fixation is least likely to interfere with replacement surgery if it becomes necessary.     

Proximal tibial osteotomy for genu varum: Radiological evaluation of deformity correction with a plate vs external fixator

BACKGROUND High tibial osteotomy(HTO) is a well-known procedure for the correction of knee varus. The purpose of this study was to compare the radiological results and accuracy of deformity correction performed using two different techniques: acute opening wedge correction using a plate and gradual correction with a monolateral external fixator.AIM To compare of the radiological results of two different techniques: acute opening wedge correction(a plate and screw) and gradual correction(external fixator).METHODS A total of 43 patients with plates and 36 patients with external fixators were included. All patients had moderate uniplanar varus deformities. We measured radiographic parameters, including the mechanical axis deviation(MAD), medial proximal tibial angle(MPTA), Caton-Deschamps Index(CDI), posterior proximal tibial angle, and joint line obliquity angle(JLOA). The accuracy of MAD correction was calculated based on a correction goal of neutral or overcorrection for medial compartment arthritis.RESULTS Demographics including age, body mass index, sex, and preoperative deformities were similar between the groups. The MAD significantly improved from 23.6 mm medial to the midline(SD = 8.2 mm) to 6.9 mm lateral to the midline(SD = 5.4 mm)(P 0.001). The accuracy of MAD correction did not differ between the groups and was 96.1%(SD = 8.1%) in the plate group and 98.2%(SD = 5.2%) in the external fixator group(P = 0.18). The MPTA significantly improved from 83.9°(SD = 2.9°) to 90.9°(SD = 3.3°)(P 0.001), and the change was similar between the groups. Differences were noted in patella height, with a CDI change of-19.2%(SD = 13.7%) and 3.1%(SD = 8.0%) for the plate and external fixator groups, respectively(P 0.001). The change in JLOA was 1.6 degrees(SD = 1.1 degrees) and 0.9 degrees(SD = 0.9 degrees) for the plate and external fixator groups, respectively(P = 0.04).CONCLUSION Reliable correction of moderate varus alignment was achieved with both the acute opening wedge technique with a plate and the gradual monolateral external fixator technique. The patellar height decreased with the open wedge plate technique. Joint line obliquity decreased to a greater degree with the open wedge plate technique, perhaps as a result of medial collateral ligament release. The appropriate technique should be selected based on surgeon and patient preferences; however, external fixation may be a better choice when the preservation of patellar height is deemed important.     

Total knee arthroplasty after failed high tibial osteotomy

The objective of this review was to propose surgical techniques for different technical problems in total knee arthroplasty after high tibial osteotomy and to discuss the literature on the subject. Whereas early results of high tibial osteotomy in the treatment of unicompartmental osteoarthritis of the knee were promising, long-term follow-up indicates recurrence of symptoms and finally the need for total knee replacement in most cases. One of the major problems caused by high tibial osteotomy is an extraarticular deformity difficult to correct with ligament balancing. Based on the parameters “valgus angle”, “ROM” and “patella position”, the knees were evaluated and classified, then surgical techniques for the different grades of this classification were described. Most studies show that arthroplasty in a knee after osteotomy is more prone to complications such as persisting pain, malalignement and infections. After reviewing the literature, the overall results of total knee arthroplasties after failed high tibial osteotomy were found to be inferior to that after primary total knee arthroplasty. We concluded that total knee arthroplasty after failed high tibial osteotomy is technically more demanding than primary arthroplasty and that the use of the appropriate technique, determined by meticulous preoperative planning, is crucial for the outcome of the procedure.     

The postoperative patella height: a comparison of additive and subtractive high tibial osteotomy in correcting the genu varum

Introduction  Intraligamentary correctional operations like a high tibial osteotomy were performed in genua valga to prevent later medial gonarthrosis especially in younger patients. An unwanted effect of this method seems to be the inferiorization of the patella. This is feared because of the complications in case of subsequent alloarthroplasty. Besides the classical Coventry method as a subtractive osteotomy the hemicallotasis has been established as a sustainable additive procedure. This means a gradual open wedge correction using an external fixateur. Objective  The aim of this study was to determine the position of the patella pre- and postoperatively and in follow-ups with subtractive versus additive intraligamentary high tibial osteotomies on the basis of five radiological parameters. It was expected that an additive osteotomy leads to an inferiorized patella position whereas a subtractive osteotomy leads postoperative to a higher position of the tibia. Method  Between 1990 and 2001, 54 patients (61 legs) had undergone an operation due to a genu varum either by the subtractive osteotomy (n = 30) according to Coventry’s method or the additive gradually hemicallotasis (n = 31) with an external fixator. Results  In coherence with the Coventry’s osteotomy a significant inferiorization of the postoperative patella position with all five radiological parameters was observed, the hemicallotasis showed no operation-related significant alteration of the patella height. Instancing the Insall–Salvati Index there were four (12.9%) preoperative and three (9.7%) postoperative patella baja positions detected. Along with the subtractive osteotomy there were 5 preoperative patellae baja (16.7%) and 11 postoperative patellae baja (36.7%) positions. Furthermore a significant interrelation was noticed between the extent of the correctional angle and the postoperative alteration of the patella. Conclusion  The results are surprising, contrary was expected. First this can be explained by its gradual, additive correctional property in contrast to the spontaneous correction by the conventional method according to Coventry, second by the postoperative treatment, which allows an early mobilization and active remedial gymnastics, provided an impact resistant osteosynthesis by a fixateur externe is given. In the case of the additive hemicallotasis an intraligamentary osteotomy is recommended. Technically expensive step cuts in order to osteotomize below the tuberositas tibiae are not necessary. Due to the low quota of complications and the small operative expense the continuous distraction is preferential to ad hoc correction. A postoperative patella baja position has not to be afraid in hemicallotasis.     

Long-term outcome after high tibial osteotomy

Introduction The frequency of tibial osteotomy in the treatment of osteoarthritis of the knee has decreased due to the demanding surgical procedure and the rising number of total knee replacements (TKR). Only few data exist concerning survival rates after high tibial osteotomy (HTO) with a follow-up exceeding 10 years. We want to present long-term results with a follow-up of more than 18 years after operation. Materials and Methods Survival rates and the influence of age, gender and the mechanical axis were investigated in 134 lateral closing-wedge osteotomies in 111 patients. Results The survival rate was 94% after 5 years, 79.9% after10 years, 65.5% after 15 years, and 54.1% after 18 years. Age had a significant influence on the survival and gender and the mechanical axis had no significant influence. Conclusion We conclude, that with a 54.1% survival after 18 years HTO is a useful facility to protract the implantation of a total knee prosthesis. An erratum to this article can be found at     

Total knee arthroplasty after failed high tibial osteotomy long-term follow-up of matched groups

Forty patients with 51 knee arthroplasties after high tibial osteotomy were compared with a matched group of patients with primary knee arthroplasties. Patients were matched according to length of follow-up, age, sex, prosthetic design, and surgeon. At an average of 12.6 years, the patients were reviewed and assessed clinically using the Hospital for Special Surgery scoring system. Radiologic assessment was also performed. Although the overall Hospital for Special Surgery scores showed no significant difference between the 2 groups, there were more patients in the osteotomy group with a poor result (P = .027), significantly reduced flexion (P = .006), and higher reoperation rate. There were more failures after high tibial osteotomy. Failures tend to occur in the medium to long term, emphasizing the importance of long-term follow-up.     

两种截骨术治疗膝骨关节炎合并膝内翻的比较

目的观察对比两种胫骨高位截骨术治疗膝骨关节炎合并膝内翻畸形的临床疗效。方法分别采用胫骨高位截骨连同腓骨中段截骨和胫骨高位截骨连同腓骨小头截骨纠正膝内翻畸形，术后5年以内及5年以后者按同一标准对其疗效进行评价。结果随访结果按窦宝信标准进行评估。胫骨高位截骨连同腓骨中段截骨5年以内及5年以后随访的优良率分别为84．6％、69．2％；胫骨高位截骨连同腓骨小头截骨5年以内及5年以后随访的优良率分别为81．7％、68．1％。两种手术方法的临床优良率基本相似。胫骨高位截骨连同腓骨小头截骨手术时间、手术切口长度、出血量显著低于胫骨高位截骨连同腓骨中段截骨。结论胫骨高位截骨治疗膝关节骨关节炎合并内翻畸形临床疗效确切，远期疗效有下降趋势。胫骨高位截骨连同腓骨小头截骨具有手术创伤小、出血少、手术时间短、腓深神经损伤发生率低等优点。     

胫骨高位嵌插截骨锁定钢板固定治疗老年膝内翻型骨性关节炎

2003年7月-2008年12月,我科采用胫骨高位嵌插截骨锁定钢板固定治疗48例膝内翻型骨性关节炎患者,疗效满意。 1材料与方法1.1病例资料本组48例54膝,男19例21膝,女29例33膝,年龄60-75（66.8±3.4）岁。病程3-15（8.5±2.5）年。     

Effect of medial opening wedge high tibial osteotomy on intraarticular knee and ankle contact pressures

High tibial osteotomy (HTO) is a commonly used surgical technique for treating moderate osteoarthritis (OA) of the medial compartment of the knee by shifting the center of force towards the lateral compartment. Previous studies have documented the effects of HTO on the biomechanics of the knee. However, the effects of the procedure on the contact pressures within the ankle joint have not been as well described. Seven cadavers underwent an HTO procedure with sequential 5° valgus realignment of the leg up to 15° of correction. An axial force of up to 550 N was applied and the intraarticular pressure was recorded. Minor valgus realignment of the proximal tibia does not significantly alter the biomechanics of the ankle. However, moderate‐to‐large changes in proximal tibial alignment result in significantly decreased tibiotalar contact surface area and in changes in intraarticular ankle pressures. These findings are clinically relevant, as they provide a biomechanical rationale for the diagnosis and treatment of ankle symptoms in the setting of lower limb malalignment or after alignment correction procedures. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:598–604, 2015.     

Unexplained proximal tibiofibular joint pain after high tibial osteotomy

Problems of the proximal tibiofibular joint (pTFj) after high tibial osteotomy (HTO) are rare. With this case report, we strive to highlight the importance of investigating the pTFj in patients with unexplained knee pain after HTO. A 44 year old male patient presented with diffuse pain on his left knee 3 years after medial opening wedge HTO due to medial compartment overloading in a varus knee. Patient described persistent anterior tibial and lateral knee pain. 2 years after HTO, patient underwent implant removal but the knee pain persisted. As the reason for the persistent pain was not identified, further radiological evaluation was done. Single photon emission computerized tomography/computerized tomography (SPECT/CT) revealed that there was no increased uptake within the tibiofemoral joint, indicating a biologically well performed correction of the varus deformity. However, markedly increased tracer uptake was found at the pTFj. On the inherent axial CT scans, it was seen that the proximal screws were too long and placed within the pTFj. Along with this a severe osteoarthritis of the pTFj was identified. The cause of the patient''s pain was then confirmed by a CT guided infiltration of local anesthetic. An arthrodesis of the pTFj was performed and at 12 months followup after the arthrodesis the patient was pain free. This case highlights how important it is to evaluate the pTFj in patients with unexplained pain after HTO. SPECT/CT was helpful in identifying the patient''s problem in this challenging case.     

A critical appraisal of medial open wedge high tibial osteotomy for knee osteoarthritis

A medial open wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure to correct varus deformity related to Knee Osteoarthritis. It consistently provides relief in knee pain and improves knee function. This technique is recommended for active, middle and old aged individuals with an isolated medial compartment knee OA. The MOWHTO scores several advantages over lateral closed wedge osteotomy and hence is now a preferred choice of HTO.     

Changes in load distribution in the knee after opening-wedge or closing-wedge high tibial osteotomy

The treatment of unicompartmental osteoarthritis of the knee by high tibial osteotomy has been carried out by closing-wedge osteotomy. The advantages for opening-wedge osteotomy are ease of procedure and improved correction with comparable short-term to midterm results. It is not known how the opening-wedge high tibial osteotomy procedure alters the load distribution between the medial and lateral compartments of the knee. The current biomechanical study investigated opening-wedge vs closing-wedge osteotomies in 5 pairs of cadaver knees. The results showed that at 5 degrees osteotomy, the closing-wedge provided superior results of load transfer from medial to lateral compartment than that seen with opening-wedge, but at 10 degrees osteotomy, there was no significant difference in load transfer in the knee compartments between the 2 surgery modes.     

Nonunion after a tibial shaft fracture complicating tibial tubercle osteotomy

Tibial shaft fracture after tibial tubercle osteotomy in total knee replacement is a rare complication. We report on a 67-year-old man who had a knee revision arthroplasty in which a long tubercle osteotomy was performed to facilitate exposure. Three weeks after surgery, he presented with a transverse shaft fracture, which became a nonunion requiring surgical management. This shaft nonunion and its solution after tibial tubercle osteotomy is discussed as well as relevant literature.     

Outcomes of total knee arthroplasty following high tibial osteotomy

Background:

Total knee arthroplasty (TKA) following high tibial osteotomy (HTO) is a technically demanding procedure with varying results. The purpose of our study was to analyze the clinicoradiological results of TKA following HTO and to identify the factors that may influence the final outcome.

Materials and Methods:

55 patients (58 knees) who had undergone a previous HTO were treated with a TKA from 1991 to 2009. There were 34 female and 21 male patients. The average age was 61.9 years (range 52-82 years) and the average weight was 79.5 kg (range 54-106 kg), with an average body mass index of 29.6 (range 21.8-34.6) at the time of TKA. The knee society scores (KSSs) and knee society functional scores were evaluated for every patient pre and postoperatively and the results evaluated.

Results:

The mean period of followup was 11.2 years (range 3-18 years) and the patients were followed up every year. The average KSS score at final followup improved from 38.5 (range 0-80 points) preoperatively to 88.5 postoperatively (range 35-95 points) (P < 0.05). The mean femorotibial angle corrected from 6.8 degrees (range 5-12°) varus preoperatively to a valgus of 4.4 (2-8°) degrees postoperatively. The average joint line height improved to an average of 9.6 mm (range 4.4-22 mm) (P < 0.01) at the last followup. The average Insall Salvatti Ratio also improved (average 1.11 preoperative - 1.21 average postoperative) (P < 0.05). The average range of motion improved to 108° (range 85°-125°) from 76° preoperative (range 55°-100°) (P < 0.01).

Conclusion:

Although TKA postHTO is a demanding surgery however, with newer component designs, results are comparable to primary TKA. Technical difficulties in exposure can sometimes lead to component malpositioning, which can affect the final outcome. Inadequate soft tissue balancing and limb malalignment should always be kept in mind. Regular followup to look for evidences of loosening is advised in such patients].     

Mid-term results of total knee arthroplasty after high tibial osteotomy

Background The outcome of total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is still controversial. In order to determine if osteotomy has any effect on this outcome we performed a medium-term review of a cohort of patients with knee osteoarthritis. Materials and methods Thirty-two patients (38 knees), who were treated with a HTO before the TKA during the last 8 years, were compared with a matched group who underwent primary TKA. The knees were evaluated preoperatively and postoperatively according to the scoring systems of the Knee Society and Hospital for Special Surgery (HSS). The anteroposterior tibiofemoral alignment, the Insall–Salvati patellar position ratio, range-of-motion and the location of the lateral joint line, were also recorded. The patients were reviewed with a mean follow-up of 4.5 years after TKA. Results The preoperative and postoperative knee scores had no statistically significant differences between the two groups. So was the case with the intraoperative releases, blood loss, thromboembolic or neurologic complications and infection rates in either group. Access to perform the arthroplasty was reportedly more difficult and took an average of 25 min longer. A significant difference (p < 0.05) was detected in terms of impingement of the tibial stem on the lateral tibial cortex, patellar subluxation and patella baja between the two groups but this did not have any influence on the outcome of the prosthesis. Knee alignment and stability so as range of motion (ROM) measurements were also found with no statistical significance. Conclusion Although we did manage to detect statistically significant differences mainly in radiographic results between the two groups, this situation did not appear to influence the clinical outcome of the patients, however. The fact that most of the patients had good or excellent results at an average follow-up of 4.5 years suggests that HTO does not have a significant negative effect on later TKA.     

Acute correction of proximal tibial coronal plane deformity in small children using a small monolateral external fixator with or without cross-pinning

PurposeSurgical correction of proximal tibia deformity in small children can be challenging. We present the surgical technique and outcome of proximal tibia osteotomy fixed with small monolateral external fixator in this patient group.MethodsA total of 17 cases in eight patients younger than nine years of age were study subjects. A proximal tibia osteotomy was fixed with a small monolateral external fixator with or without cross-pinning. Outcome was evaluated by changes of radiographic parameters such as medial proximal tibia angle (MPTA), metaphyseal diaphyseal angle (MDA) and clinical findings of complications, time interval until weight bearing and fixator removal time.ResultsMPTA improved from a preoperative mean of 73° (sd 4°; 66° to 78°) to an immediate postoperative mean of 90° (sd 3°; 85° to 96°) in varus tibiae, and from 104° (sd 1°; 103° to 105°) to 89° (sd 1°; 88° to 89°) in valgus tibiae. In all, 15 of the 17 cases (88.3 %) achieved postoperative MPTA within the normal range (85° to 90°). MDA improved from a preoperative mean of 19° (sd 5°; 11° to 24°) to an immediate postoperative mean of 0° (sd 4°; -6° to 7°) in varus tibiae, and from -25° (sd 2°; -22° to -24°) to 2° (SD 1°; 1° to 3°) in valgus tibiae. Full weight bearing was possible at mean 1.7 months (0.5 to 3.0). Mean follow-up period was 6.5 years (sd 5.4; 1.0 to 16.0). No complications developed during the follow-up.ConclusionProximal tibia osteotomy fixed with small monolateral external fixator provides accurate, safe and efficient correction in the management of coronal plane angular deformity in small children.Level of EvidenceLevel IV     

胫骨高位倒L形截骨并外固定架固定治疗膝内翻畸形性骨性关节炎

目的 分析应用胫骨高位倒L形截骨术治疗膝关节内翻畸形性骨性关节炎的疗效及应用AO外固定架固定的优点.方法 对30例(48肢)内翻畸形性骨性关节炎患者行胫骨高位倒L形截骨术,应用AO外固定架固定.采用膝骨性关节炎治疗效果判定标准(JOA)、股胫角改变及患者的主诉来判断手术疗效.结果 30例随访2～18个月,所有患者疼痛均明显减轻或消失,有3例出现小腿肿胀,经治疗后痊愈,股胫角明显改善.结论 胫骨高位行倒L形截骨,使骨折端接触面积进一步加大,增加了骨折断端的稳定性.AO外固定架与克氏针结合固定截骨端,属于一种弹性固定,对骨折端有持续性加压作用,更有利于骨折的愈合.     

“U”形截骨孟氏架外固定矫治膝内外翻畸形33例

本文通过对３３例膝内、外翻畸行“Ｕ”形截骨孟氏架外固定治疗及疗效观察，认灯一法矫形确切、固定牢靠、调整灵活、组织损小、截骨愈合早、功能恢复快、是膝内，外翻畸形手术治疗的好方法。     

Impact of medial open-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee

BACKGROUNDMost populations worldwide, who are used to squatting and sitting cross-legged for their activities of daily living, largely comprise the lower socioeconomic strata, thus making them candidates for exclusion for total knee arthroplasty. Proximal/high tibial osteotomy (HTO) is a preferred strategy for clinically symptomatic osteoarthritis (OA) with genu varum due to painful medial compartment OA which is not amenable to conservative measures.AIMTo evaluate the outcomes of medial open-wedge HTO along with autologous bone grafting and buttress plate for the treatment of genu varum due to OA of the knee in a rural population of central India.METHODSA total of 65 knees in 56 patients with a mean age of 58.22 ± 5.63 years with genu varum due to intractable painful knee OA were treated with medial open-wedge HTO along with autologous bone grafting and buttress plate osteosynthesis from June 2015 to May 2018. The mean preoperative radiological angle of genu varum was 13.4°. Clinical outcomes were assessed by the range of movement, knee scores, pain scores, and functional scores. Radiographic studies were performed preoperatively and at regular intervals during the follow-up period.RESULTSAll patients reported pain relief immediately after the osteotomy and during the long-term analysis covering between one to three years. The genu varum angle was overcorrected to approximately four degrees in all patients. There was a loss of reduction by approximately three degrees in all patients at around six weeks postoperatively. Preoperative knee movements were restored in all patients. No major perioperative complications were noted during surgery and postoperative follow-up and the clinical scores were significantly improved during the final analysis which revealed good pain relief.CONCLUSIONMedial open-wedge HTO is a reliable, safe, practical, physiological, and feasible treatment for populations who are used to increased activity in their occupation and lifestyle and is associated with excellent short-term and long-term results for OA in genu varum knees.