Purpose: For patients with moderate to severe hallux valgus with increased intermetatarsal angle, correction with a proximal first metatarsal osteotomy is indicated. The purpose of this study is to compare the opening-wedge osteotomy of the proximal first metatarsal the proximal chevron osteotomy in the treatment of moderate to severe hallux valgus with increased intermetatarsal angle. Method: This prospective, randomized, multi-centered study is being conducted at three centers in Canada. Approximately 75 adult patients with hallux valgus are being randomized to either the proximal metatarsal opening-wedge osteotomy with plate fixation or the proximal chevron osteotomy. Patient functional scores using the SF-36, American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal inter-phalangeal score and Visual Analogue Scale (VAS) for pain, activity & patient satisfaction, are assessed prior to surgery and 3, 6, 12 and 24 months. Surgeon preference is being evaluated based on a questionnaire and actual surgical times. Radiologic measurements (inter-metatarsal angle correction, hallux valgus angle correction, sagital talus-first metatarsal (Meary’s) angle, metatarsal length and union) will also be assessed. Results: Preliminary results demonstrate that patients who undergo the opening-wedge osteotomy have less pain at 3 months (ave. VAS pain reduction 2.9, SE±1.0) than those with the chevron (ave. VAS pain reduction 2.4, SE±1.2). VAS for activity demonstrates greater improvements with the chevron osteotomy at 3 months (0.8, SE±0.8) versus the opening-wedge (0.1, SE±1.0). AOFAS scores improve on average 18.3 (SE±8.6) with the opening wedge compared to 20.8 (SE±7.4) with the chevron at 3 months. Average hallux valgus angle correction for opening-wedge and chevron osteotomies are 11.0 degrees (SE±2.5) and 19.0 degrees (SE±3.1) respectfully. Average intermetatarsal angle correction for opening-wedge and chevron osteotomies are 6.5 (SE±1.3) and 4.3 (SE±1.7) respectfully. Both procedures are effective at maintaining metatarsal length. The opening-wedge osteotomy takes on average 60.9 minutes (SE±3.9) to complete compared to 69.1 minutes (SE±5.1) for the chevron ostetotomy. Surgeon response to the new opening-wedge osteotomy is favorable. Conclusion: Opening-wedge and proximal chevron osteotomies have comparable pain, function and radiographic outcomes. Opening wedge osteotomy is technically less demanding and requires less surgical time

The purpose of this study was to compare posterior tibial slope preoperatively and postoperatively in patients undergoing navigational opening-wedge High tibial osteotomy (HTO) and to compare posterior slope changes for 2 and 3-dimentional (D) navigation versions. Between May 2009 and September 2010, 35 patients with unicompartmental osteoarthritis and varus deformity were treated by navigation-assisted open-wedge HTO. Patients were randomly divided into two groups according to the version of the Orthopilot (Aesculap) navigation system used; 2D group (18 patients, 2-D version) and 3D group (17 patients, 3-D version). Radiologic evaluations were conducted using pre- and postoperative leg axes. Posterior slope of proximal tibiae were measured using the proximal tibial anatomic axis method. Postoperatively the mechanical axis was corrected adequately to a mean valgus of 2.81° in 2D group and of 3.15° in 3D group. Mean posterior slopes were well maintained, and measured 7.9° and 10.3° preoperatively and 8.99° and 9.14° postoperatively in 2D and 3D groups, respectively. No significant difference was found between the two navigation versions with respect to posterior tibial slope; mean tibial slope changes were 1.09° and −0.2° in 2D and 3D groups (p = 0.04). Navigation-assisted opening-wedge HTO greatly improves the accuracy of the desired postoperative mechanical femorotibial axis and posterior tibial slope, and the use of 3D navigation results in significantly less change in posterior tibial slope. The authors recommend the use of the 3D navigation because they provide real time intraoperative information about coronal, sagittal, and transverse axis, which are important for the maintenance of a normal posterior tibial slope

Background. Medial opening-wedge high tibial osteotomy is one of the common surgical procedures in treatment of knee deformities. Many methods have been proposed to fill the medial side osseous gap. The results of using allograft as void filler compared to iliac crest autograft has not been subject to a randomized clinical trial. The purpose of this study was to examine the results of medial opening-wedge high tibial osteotomy using iliac crest allograft as compared to iliac crest autograft. Materials & Methods. Forty-six patients with genovarum deformity were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. Medial opening-wedge high tibial osteotomy was done using iliac crest allograft (23 patients) or autograft (23 patients) and the osteotomy site was internally fixed using proximal tibial T-plate. All patients were followed-up to 12 months after surgery. Anatomical indices of proximal tibia, complications of treatment, and functional outcome (using WOMAC osteoarthritis index) were assessed for both groups. Results. The amount of correction (degrees), recurrence of the deformity and loss of correction and time to clinical or radiologic union were similar in both groups with no statistically significant difference. Duration of operation was significantly less in allograft group (66.6±3.6 versus 52.9±5.3 minutes, p<0.001). Incidence of surgical site infection did not significantly differ in two groups. No nonunion or delayed union was encountered in either group. Some patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. Patients in both groups had statistically significant improvement in WOMAC index postoperatively (with no statistically significant difference between groups). Conclusions. According to the results of this study, iliac crest allograft may be safely used in medial opening-wedge high tibial osteotomy with comparable efficacy to iliac crest autograft in patients who do not accept the morbidity of autograft harvest

The medial opening-wedge high tibial osteotomy (OW-HTO) is an accepted option to treat the isolated medial compartment osteoarthritis (OA) in varus knee. Despite satisfactory outcomes were described in literature, consistent complication rate has been reported and the provided accuracy of coronal alignment correction using conventional HTO techniques falls short. Patient specific instrumentations has been introduced with the aim to reduce complications and to improve the intra-operative accuracy according to the pre-operative plan, which is responsible for the clinical result of the surgery. In this talk, an overview of the clinical results of HTO patient specific instrumentation available in literature will be performed. Moreover, preliminary intra-operative and clinical results of a new customised 3-D printed cutting guide and fixation plate for OW-HTO will be presented

Opening-wedge High Tibial Osteotomy (HTO) has been shown to be an effective procedure to treat mild to moderate osteoarthritis of the medial compartment of the knee in active individuals. It has also become a mandatory surgical adjunct to articular cartilage restoration when there is preoperative mal-alignment. However, its efficacy is directly correlated with the accuracy of the correction, which must be within 3° of the preoperative target. Achieving this goal is a significant challenge with conventional techniques. Therefore, computer-assisted navigation protocols have been developed; however, they do not adequately address the technical difficulties associated with this procedure. We present an integrated solution dedicated to the opening-wedge HTO. Advantages to the technique we propose include: 1) a minimum number of implanted bone trackers, 2) depth control of the saw, 3) improved 3-D accuracy in the location of the lateral tibial hinge, and 4) micrometric adjustment of the degree of correction. The proof of concept has been completed on all six specimens. The following key points have been validated: a) Compatibility with a minimally-invasive (5–6 cm) surgical incision b) The compact navigation station can be placed close to the operative field and manipulated through a sterile draping device c) Only two trackers are necessary to acquire the required landmarks and to provide 3-D control of the correction. These can be inserted within the surgical wound without any secondary incisions d) The optimised guide accurately controlled the external tibial hinge in all six cases e) The implant cavity could be milled effectively f) The distractor used to complete the desired realignment maintained stability of the distraction until final fixation with the PEEK implant g) The PEEK implant could be fixed to the tibia with excellent stability in a low-profile fashion. The solution presented here has the potential to help surgeons perform a medial opening-wedge HTO more safely and accurately. This will likely result in an increase in the number of HTOs performed for both isolated medial compartment osteoarthritis as well as for lower extremity realignment in association with cartilage restorative procedures

We aimed to analyse complication rates following medial opening-wedge high tibial osteotomy (OWHTO) for knee OA. A regional retrospective cohort study of all patients who underwent HTO for isolated medial compartment knee OA from 2003–2013. 115 OWHTO were performed. Mean age = 47 (95%CI 46–48). Mean BMI = 29.1 (95%CI 28.1–30.1). Implants used: 72% (n=83) Tomofix, 21% (n=24) Puddu plate, 7% (n=8) Orthofix Grafts used: 30% (n=35) autologous, 35% (n=40) artificial and 35% (n=40) no graft. 25% (n=29) of patients suffered 36 complications. Complications included minor wound infection 9.6%, major wound infection 3.5%, metalwork irritation necessitating plate removal 7%, non-union requiring revision 4.3%, vascular injury 1.7%, compartment syndrome 0.9%, and other minor complications 4%. Apparent higher rates of non-union occurred with the Puddu plate (8.3%) relative to Tomofix (3.6%) but was not statistically significant. No other significant differences existed in complication rates relative to implant type, bone graft used, patient age or BMI. Serious complications following HTO appear rare. The Tomofix has an apparent lower rate of non-union compared to older implants but greater numbers are required to determine significance. There is no significant difference in union rate relative to whether autologous graft, artificial graft or no graft is used

«Purpose». High tibial osteotomy (HTO) is a useful treatment option for osteoarthritis of the knee. Closing-wedge HTO (CW-HTO) had been mostly performed previously, but the difficulties of surgical procedure when total knee arthroplasty (TKA) conversion is needed are sometimes pointed out because of the severe deformity in proximal tibia. Recently, opening-wedge HTO (OW-HTO) is becoming more popular, but the difference of the two surgical techniques about the influence on proximal tibia deformity and difficulties in TKA conversion are not fully understood. The purpose of this study was to compare the influence of two surgical techniques with CW-HTO and OW-HTO on the tibial bone deformity using computer simulation and to assess the difficulties when TKA conversion should be required in the future. «Methods». In forty knees with medial osteoarthritis, the 3D bone models were created from the series of 1 mm slices two-dimensional contours using the 3D reconstruction algorithm. The 3-D imaging software (Mimics, materialize NV, Leuven, Belgium) was applied and simulated surgical procedure of each CW-HTO and OW-HTO were performed on the same knee models. In CWHTO, insertion level was set 2cm below the medial joint line [Fig.1]. While in OW-HTO, that was set 3.5cm below the medial joint line and passed obliquely towards the tip of the fibular head [Fig.2]. The correction angle was determined so that the postoperative tibiofemoral angle would be 170 degrees. The distance between the center of resection surface and anatomical axis, and the angle of anatomical axis and mechanical axis were measured in each procedure. Secondly, a simulated TKA conversion was operated on the each tibial bone models after HTO [Fig.3]. The distance between the nearest points of tibial implant and lateral cortical bone was assessed as the index of the bone-implant interference. «Results». The distance between the center of resection surface and anatomical axis was significantly shifted to the lateral side in CW group (0.62 ±2.95 mm lateral shift) than in OW group (0.93 ± 3.68 mm medial shift) (P<0.01). The angle of anatomical axis and mechanical axis was significantly increased in the CW group (CW: 0.77 ± 0.79 degree, OW: 0.49 ± 0.83 degree, P<0.01). In the simulation of TKA conversion, if thickness of the lateral cortical bone was 3mm, it was showed that the tibial implant was more interfered with the lateral cortical bone in CW group (2.77 ± 1.38 mm) than in OW group (4.32 ± 1.61 mm) (P<0.01). «Conclusions». The results suggested that bone deformity in proximal tibia after HTO might affect the difficulty of TKA conversion, particularly in the case of CWHTO

Summary Statement. Preoperative bone-marrow-derived cell mobilization by G-CSF is a safe orthopaedic procedure and allows circulation in the blood of high numbers of CD34+ve cells, promoting osseointegration of a bone substitute. Introduction. Granulocyte-colony-stimulating-factor(G-CSF) has been used to improve repair processes in different clinical settings for its role in bone-marrow stem cell(CD34+ and CD34-) mobilization. Recent literature suggests that G-CSF may also play a role in skeletal-tissue repair processes. Aim of the study was to verify the feasibility and safety of preoperative bone-marrow cell (BMC) mobilization by G-CSF in orthopaedic patients and to evaluate G-CSF efficacy in accelerating bone regeneration following opening-wedge high tibial valgus osteotomy(HTVO) for genu varum. Patients/Methods. 24 patients were enrolled in a prospective phase II trial. The osteotomy gap was filled by a hydroxyapatite-tricalciumphosphate bone substitute(HATriC). Patients were randomised to receive (GROUP A) or not receive (GROUP B) preoperatively a daily dose of 10µg/kg of G-CSF for three consecutive days, with an additional dose 4 hours before surgery. BMC-mobilization was monitored by white blood cell (WBC)-count, flow-cytometry analysis of circulating CD34+cells and Colony-forming cell assays. Patients were evaluated by: Lysholm and SF-36 scores preoperatively and at 1, 2, 3, 6, and 12 months after surgery;. X-ray evaluation preoperatively and at 1, 2, 3, 6, and 12 months after surgery, in order to compare the percentage of osseointegration of the bone-graft junction using the semi-quantitative score of Dallari[1]. CT-scan of the host bone-substitute interface at 2 months, in order to estimate the quality of the newly formed bone at the bone-graft junction by a quantitative measure of bone density (by Hounsfield unit) at the proximal and distal bone-graft junctions. Results. All patients completed the treatment program without major side effects; G-CSF was well tolerated. BMC-mobilization occurred in all Group A patients, with median peak values of 110/µL (range 29–256) of circulating CD34+ve cells. Circulating clonogenic progenitors paralleled CD34+ve cell levels. A significant improvement in the SF-36-Role-Physical scale and in the Lysholm score was recorded at follow-up in Group A compared to Group B(p<0.05). At the X-ray-evaluation, there was a significant increase in osseointegration at the bone-graft junction in Group A at 1, 2, 3 and 6 months post-surgery compared to Group B(p<0.05). CT-scans of the grafted area at 2 months post-surgery showed no significant difference in the quality of the newly formed bone between the two Groups. Discussion/Conclusions. These results suggest that G-CSF can be safely administered preoperatively in subjects undergoing HTVO. In addition, the clinical, radiographic and CT monitoring indicate that preoperative G-CSF administration promotes bone graft substitute osseointegration. Enhanced osseointegration might be the result of the direct activity of G-CSF on the host bone or a cellular effect mediated by bone marrow-derived progenitors mobilised by G-CSF, or by a combination of all these factors. This study is a proof-of-principle that preoperative G-CSF might be an alternative treatment option to enhance bone regeneration in the field of bone marrow stem cell therapy and reconstructive orthopaedic surgery

Introduction: The aim of this study was to determine the outcome of Tomofix plate fixation, in joint retaining surgery, for Medial compartment Osteoarthritis of the knee in young patients. Methods: We report on 33 patients (36 knees) who underwent High tibial osteotomy for unicompartmental osteoarthritis of the knee. The mean age was 39.5 (30–49). There were 20 males and 13 female. All the patients had Medial opening-wedge type Osteotomy using the Tomofix device. The mean duration of follow-up was 48 months (44–60 months). The patients were assessed on the basis of pre and post-operative oxford knee score, knee range of motion, radiological evidence of healing of the osteotomy site and alignment of the knee. Results: There were no nonunions at the osteotomy site and the medial open-wedge filled-in without any need for bone graft or its substitutes. The mean preoperative oxford knee score was 48 (S.D 4.7 Range 38–54). This improved to a mean score of 22 (S.D 5.9 Range 17–31) after 1 year follow-up. The improvement was significant (pvalue= 0.07). The preoperative average knee flexion was 103.1 (S.D 25.2 Range 10–125) which improved after 1 year follow up to 112 (S.D 15.9 Range 0–140). The mean preoperative Femorotibial angle was 10 degrees varus (range 9–15). The mean postoperative Femorotibial angle was 8 deg valgus (range 6–12). Radiologically, there was no loss of correction during our follow-up. One patient had post-operative DVT. Conclusion: Our study shows that Tomofix plate fixation in High Tibial osteotomy gives immediate stability, good deformity correction and allows early rehabilitation. The osteotomy gap does not require bone grafting and the correction is maintained. The Short term functional results are encouraging. Longer-term follow-up is however needed to establish its effectiveness in deferring joint replacement surgery in young patients

There is theoretical concern that volar plating has a disadvantage in cantilever bending when axially loaded dorsal to the neutral axis. This has implications for postoperative rehabilitation protocols and overall outcomes related to maintenance of reduction. Most recent biomechanical studies have compared volar locking plates to traditional dorsal non-locked plates. The purpose of this study was to compare the biomechanical stability of volar and dorsal locking plate fixation in a model of dorsally unstable distal radius fractures. Fourteen synthetic composite radii (Pacific Research Laboratories, Vashon, WA) were used for this study. A dorsally unstable, extra-articular distal radius fracture was simulated by creating a dorsal wedge-shaped defect in the distal metaphysis. Half of the specimens were plated dorsally (n=7) while the other half were plated volarly (n=7) with 2.4mm distal radius locking T-plates (Synthes, Canada). Each specimen was loaded axially in five different positions: central (along the neutral axis of the radius) as well as dorsal, volar, radial and ulnar to the neutral axis using a MTS Sintech 1/G materials testing machine (MTS Systems, Eden Prairie, MN). The plated radii were loaded to 100 N in each position simulating physiological loading during normal range of motion. The main outcome measure was construct stiffness of the plate-bone system (slope of load-displacement curve) for all five loading positions. Construct stiffness with dorsal locking plates was seven times greater than volar locking plates when dorsally loaded (p < 0.001), 60% greater when centrally loaded (p = 0.055) and 35% greater when volarly loaded (p = 0.029). There was no significant difference in stiffness with any other loading configurations. The stability of dorsal locking plate fixation is superior to volar locking plate fixation in the setting of large dorsal defects in the distal radius. This is applicable to both fractures with dorsal comminution and dorsal opening-wedge distal radial osteotomies. Further clinical investigation is needed to compare functional outcomes and complication rates between modern dorsal and volar locking plate techniques

A radiographic review of sixty-nine lateral closing wedge high tibial osteotomies and forty-two medial opening wedge osteotomies was conducted. Patellar height and tibial slope were measured. The Blackburne-Peel (BP) and Insall-Salvati (IS) ratios were used to measure patellar height. Our results show that 18.8% and 47.6% of the lateral closing wedge group had patella-infera (PI) according the the BP and IS ratios respectively. No opening-wedge cases demonstrated patella infera with either ratio. Tibial slope was found to be significantly more neutral in the closing wedge group versus the opening wedge (−2.2° vs. −7.28° respectively). Patients undergoing HTO typically require a definitive arthroplasty procedure at an average of six years post-HTO. Total knee arthroplasty can be complicated by the presence of PI which compromises exposure and increases the risk of patellar tendon avulsion leading to suboptimal results. The current study compares the incidence of PI between lateral closing and medial opening wedge HTO’s. Conversion of opening wedge HTO to TKA should have less technical challenge and improved outcomes as compared to lateral closing wedge HTO conversions. This is attributable to the absence of PI. Of the closing wedge group, 18.8% and 47.6% were found to have PI according to the BP and IS ratios respectively. Of the opening wedge group there were no cases of PI found with either ratio. Tibial slope was found to be significantly more neutral in the closing wedge compared to the opening wedge group (−2.2° vs. −7.28° respectively). The study cohorts were abstracted from surgeon records. Sixty-nine closing wedge and forty-two opening wedge HTO’s were identified. Lateral 30° flexion x-rays were measured for patellar height and tibial slope. Both the Blackburne-Peel (BP) and Insall-Salvati (IS) patellar height measurements were used. From this data we can conclude that in our study population the incidence of PI in the opening wedge group was 0% thus negating the potential deleterious effects of PI at the time of knee arthroplasty

Aim

It has been suggested that the use of a pilot-hole may reduce the risk of fracture to the lateral cortex. Therefore the purpose of this study was to determine the effect of a pilot hole on the strains and occurrence of fractures at the lateral cortex during the opening of a high tibial osteotomy (HTO) and post-surgery loading.

Objectives

The purpose of this study was to clarify the appearance of the reparative tissue on the articular surface and to analyse the properties of the reparative tissue after hemicallotasis osteotomy (HCO) using MRI T1ρ and T2 mapping.