Total knee arthroplasty with long stem for treatment of nonunion after high tibial osteotomy

Nonunion is an uncommon complication of high tibial osteotomy (HTO), and thus literature regarding treatment of it is very limited. The usual treatment for nonunion after HTO is repeat fixation of the osteotomy site. When union is not achieved, hinge or constrained total knee arthroplasty (TKA) is used. We describe a patient for whom nonunion after HTO was successfully treated using long-stem TKA with bone graft to have the nonunion site unite simultaneously.     

Patellar height after barrel-vault high tibial osteotomy.

The purpose of the study was to assess the influence of barrel-vault high tibial osteotomy on patellar position and to evaluate the reliability and interobserver variability of three patellar height ratios. The radiographs of 24 knees that had undergone barrel-vault height tibial osteotomy with available preoperative as well as postoperative radiographs of the last follow-up were enrolled in the study. The patellar position was evaluated with the use of the Insall-Salvati, Blackbourne-Peel and Caton-Linclau methods. The indices were calculated with the tibial slope angle measured by the Moore-Harvey method. The average patellar index in the Blackburne-Peel and Caton-Linclau measurements had a statistically significant tendency to increase after barrel-vault tibial osteotomy. The results of the Insall-Salvati assessment method showed no statistically significant differences. Intrasession ICCs (intraclass correlation coefficient) varied between 0.8 and 0.99. The kappa value for the inter-observer agreement of all three ratios determined varied between 0.48 for the Blackburne-Peel index and 0.5 for the Insall-Salvati and Caton-Linclau indices. The average tibial slope before the surgery was 11.8 degrees (+/- 3.6) and decreased to 6.6 degrees (+/- 4.3). No significant associations between the index change and tibial slope change were detected. The data suggest that since some of patellar height indices measure different anatomical relationships, comparable types of indices should be used in order to estimate the patellar height or patellar relation to the joint line.     

Patellar infera after high tibial osteotomy

Forty-six knees in 41 patients that had undergone high tibial osteotomy (HTO) were evaluated to assess the potential correlation between alteration in the inclination of the proximal tibial articular surface and subsequent patellar height. Of the knees examined, 61% lost > or =5 degrees of posterior tibial inclination after HTO, whereas 54% of knees showed a relative lowering of patellar height of >10%, as measured by the Insall-Salvati ratio. The loss of the normal posterior tibial inclination was found to have a statistically significant association with the subsequent loss of the patellar height. Clinically, these results suggest that careful preservation of the posterior tibial inclination at the time of HTO could minimize the risk of subsequent patellar infera and alteration in patellofemoral mechanics.     

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.     

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     

胫骨高位截骨术后髌骨低位

目的探讨胫骨高位截骨术治疗膝关节内侧间室骨性关节炎后髌骨低位与胫骨近端关节面后倾角度改变之间的关系,并提出预防和控制髌骨低位的措施。方法41例(48膝)膝关节内侧间隙骨性关节炎患者,男30例(33膝),女11例(15膝);年龄45～56岁,平均52岁。所有病例均行胫骨外侧高位楔形截骨术。根据术前测量的截骨角度(内翻角+正常外翻角+过度矫形3°～5°),在槽刀和导向器等辅助下切除楔形骨块,用改良Giebel槽式钢板拉力螺钉内固定,术后不需外固定。测量48膝行胫骨高位截骨术患者术前及术后X线片的Insall-Salvati比值、胫骨近端关节面后倾角度、胫骨结节高度、患肢解剖轴线角度,并用χ2检验和直线回归分析进行统计学处理。检验时假定术后胫骨近端关节面后倾角度减小≥5°以及髌骨高度下降≥10%具有临床意义。结果术后胫骨近端关节面后倾角度比术前平均减小6.14°,Insall-Salvati比值术前、术后相对变化率为10.6%,胫骨结节高度比术前平均下降3.13mm。64.6%的病例胫骨近端关节面后倾角度减小≥5°。按Insall-Salvati比值结果,56.2%的病例髌骨高度相对下降率≥10%。胫骨近端关节面后倾角度的减小与髌骨高度的相对下降具有显著的统计学相关性。结论胫骨近端关节面后倾角度的减小与髌骨低位具有相关性,提示在施行胫骨高     

Distraction osteogenesis in a segmental tibial delayed union

The treatment of open segmental tibia fracture associated with bone loss is very demanding. Despite the fact that the principles of the distraction osteogenesis are being followed commonly in these fractures, there is not a single technique that fits all situations. In this article, we report a case where the initial fractures were stabilized with a monolateral bridging external fixator with no evidence of callus formation 6 weeks later. The proximal fracture was used as “an osteotomy” for bone transport after a latent period of 6 weeks of compression. The successful outcome in this patient, confirms that distraction of a delayed union even when it is mobile, can lead to bone formation and healing of the delayed union.     

Distraction osteogenesis with conventional external fixator for tibial bone loss

Between 1991 and 2002, we treated 21 patients with tibial bone loss using a conventional external fixator. Nine patients had an infected open fracture and 12 patients an infected nonunion. After corticotomy, the bone was distracted at the rate of 1 mm (1 mm/step) on alternate days or every 48 h. The mean follow-up period was 18.7 (6–108) months after fixator removal. The mean new bone gained was 7.4 (2–17) cm. The mean healing index was 44.7 (17–86) days/cm. Total wound infection was resolved in 19 limbs (90.5%), and 11/12 (91.6%) nonunions united. Union with acceptable alignment (<7° of angulation) and limb-length difference (<2.5 cm) was achieved in 18 limbs (85.7%). The bone result was excellent in 17 tibiae, good in three, and poor in one. Eighteen limbs had an excellent and three a good functional result. This modified technique of distraction osteogenesis using AO/ASIF conventional external fixator is safe, cost effective, and a versatile tool in the management of tibial bone loss associated with infected nonunion and open fractures.

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Résumé Entre 1991 et 2002 nous avons traité 21 malades avec perte osseuse tibiale en utilisant un fixateur externe conventionnel. Neuf malades avaient une fracture ouverte infectée et 12 malades une pseudarthrose infectée. Après corticotomie, los a été distrait au taux de 1 mm (1 mm/step) par jours alternatifs ou chaque 48 heures. La période de suivi moyen était de 18,7 (6–108) mois après ablation du fixateur. Le nouvel os formé était en moyenne de 7.4 (2–17) centimètres. Lindex curatif moyen était de 44,7 (17–86) jours/cm. Linfection a totalement guérie pour 19 membres (90,5%) et 11/12 (91,6%) pseudarthroses ont consolidé. La consolidation avec un alignement acceptable (<7degrés dangulation) et une faible différence de la longueur du membre (<2,5 centimètres) a été accomplie pour 18 membres (85,7%). Le résultat osseux était excellent pour 17 tibias; bon pour trois, et mauvais pour un. Dix-huit membres avaient un excellent résultat et trois un bon résultat. Cette technique modifié dostéogenèse par distraction qui utilise un fixateur externe conventionnel AO/ASIF est sre, rentable, et cest un outil pratique dans la gestion des pertes de substance du tibia associées aux pseudarthroses infectées et aux fractures ouvertes.

     

Total knee arthroplasty after high tibial osteotomy

Between 1980 and 1995, 95 consecutive total knee replacements were performed at an average of 10 years 4 months after high tibial osteotomy. The average age of the 82 patients was 66 years, with a preoperative diagnosis of osteoarthritis in 94 knees. One patient died 6 months after surgery. The followup of the remaining 81 patients (94 knees) averaged 8.6 years (range, 2-17 years). Knee Society knee score at final followup improved to an average of 87.6 points from a preoperative average of 38.1 points. No pain was present in 86.2% of knees, and 12.8% of knees had only mild or occasional pain. Tibial radiolucencies were identified in 12 (12.8%) knees at final followup, and in only four knees were radiolucent lines found about the lateral zones. Only one tibial component required revision 3 years after surgery. Although no preoperative factor was identified that predisposed to an inferior knee score, function score, or pain score, the severity of the preoperative flexion contracture and the number of previous surgeries did relate to diminished postoperative motion. However, an increased number of patellar radiolucencies were seen in the knees in which the lateral joint line was raised (referenced from the fibular head) a greater degree. The clinical results of total knee replacement after high tibial osteotomy appeared similar to those of primary total knee replacement. The previous high tibial osteotomy had no adverse effect on the eventual results of a cemented posterior cruciate retaining total knee replacement.     

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I–TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I–TSF were compared with 25 patients treated with a conventional circular frame. In the I–TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.     

Distraction osteogenesis through high energy fractures

We present a series of three patients with segmental, high energy open tibial fractures with bone loss (2-7 cm), where we have used distraction through a fracture site to replace lost bone. The open fracture was treated by debridement and shortening to eliminate the bone and soft tissue defect. Limb length was restored by distraction instituted through the closed segmental fracture. The length of regenerate formed at the fracture site ranged from 10 to 30 mm. In each case, bone formation at the distracted fracture site was satisfactory and times for regenerate consolidation were similar to those seen in standard corticotomies. These findings suggest that new bone will form in distraction reliably from high-energy fracture sites.     

Recovery of muscle strength after high tibial osteotomy

 To assess muscle strength after high tibial osteotomy (HTO) using percutaneous drilling, we prospectively evaluated the isometric and isokinetic muscle torque of the thigh before operation and after operation over time. We evaluated 27 joints of 26 patients with a mean age of 66 years. The muscle torque/weight ratio was seen to decrease, and the hamstrings/quadriceps (H/Q) ratio increased at 3 months after HTO; both ratios showed no significant difference at 6 months. Improved muscle strength appeared at isometric extensor of 50°, not 80°, and at slow isokinetic speeds of 30°/s, not 90°/s. There was no significant difference in terms of the age of patients regarding the recovery of muscle strength. We also compared patients with a varus angle of ≥5° and those with a varus angle <5° before the operation. In terms of extension, the group with varus angles <5° showed a greater postoperative increase in isometric torque at 80° flexion of the knee and isokinetic torque at 90°/s than did the group with varus angles of ≥5°. Received: July 5, 2002 / Accepted: November 11, 2002 Offprint requests to: T. Kawazoe     

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.     

Medial unicompartmental arthroplasty after failed high tibial osteotomy

Satisfactory selection criteria are essential for the successful outcome of unicompartmental knee arthroplasty (UCA). We report the frequency of revision of the Oxford medial unicompartmental arthroplasty in knees previously treated for anteromedial osteoarthritis by high tibial osteotomy (HTO). The combined results from three sources were used to allow statistical analysis of this uncommon subgroup. In the combined series of 631 knees (507 patients) which had medial unicompartmental replacement, 613 were primary procedures and 18 were for a failed HTO. The mean follow-up times of the two groups were similar (5.8 years and 5.4 years, respectively). At review, 19 (3.1%) of the primary procedures and five (27.8%) of those undertaken for a failed HTO had been revised to total knee replacement. Survival analysis revealed the ten-year cumulative survivals to be 96% and 66%, respectively. The log-rank comparison of these survivals revealed a highly significant difference (p < 0.0001). We recommend that the Oxford UCA should not be used in knees which have previously undergone an HTO.     

Common peroneal nerve dysfunction after high tibial osteotomy

We assessed 16 patients before and after high tibial osteotomy by electrophysiological recordings, creatine phosphokinase levels, radiographs and intracompartmental pressure monitoring. We found mild electrophysiological abnormalities pre-operatively in 12 of the 16 patients, but postoperatively these had deteriorated in 11 of the 14 patients studied. Creatine phosphokinase levels, compartment pressure and radiological deformity were not predictive of the development of postoperative common peroneal nerve palsy. Patients who also had a proximal fibular osteotomy had greater electrical abnormalities postoperatively and two of them developed common peroneal palsies. Proximal fibular osteotomy appears to be a causative factor in the development of common peroneal nerve palsy; more work is needed on the blood supply of the nerve.     

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.