We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal

We retrospectively reviewed thirty-six patients who had undergone dorsal opening wedge osteotomies using cancellous bone graft and plate fixation for symptomatic healed angulated distal radius fractures. Average improvement of the distal radius dorsal articular tilt was 28° and the ulna variance 2.7mm. The final average range of motion was flexion 46°, extension 62°, pronation 79°and supination 75°. The range of supination and pronation was not significantly different from the unaffected limb (p> 0.115). For healed angulated distal radius fractures, dorsal opening wedge osteotomy combined with cancellous bone grafting and plate fixation, is a reliable technique allowing significant deformity correction. We retrospectively reviewed thirty-six patients with symptomatic healed angulated distal radius fractures who had undergone dorsal opening wedge osteotomies using cancellous bone graft and plate fixation by a single surgeon. Twenty-five patients were reviewed both clinically and radiologically with an average follow-up of forty-seven months. The radiographs of a further eleven patients were reviewed. Average age at surgery was fifty years with an interval from injury of twenty-nine months. All osteotomies united. 20% required plate removal. Preoperatively the average distal radius articular tilt was 25° dorsal, and ulna variance +4.3mm. Following correction, average articular tilt was 3° volar, and ulna variance +2mm. These changes were highly significant (p< 0.0005). There was no significant loss of correction of the deformity between the immediate postoperative radiographs and those following union (p> 0.33). The average range of motion was flexion 46°, extension 62°, pronation 79°and supination 75°. The range of pronation and supination was not significantly different from the unaffected limb (p> 0.115). The average Patient Rated Wrist Evaluation Score was thirty, indicating residual pain and disability greater than that for an age matched cohort of patients with uncomplicated distal radius fractures (PRWE=15), previously reported by our laboratory. Patients reported that they were satisfied with the cosmetic appearance and had regained 73% of wrist use – these values had a significant negative correlation with the final ulna variance (p< 0.05). For healed angulated distal radius fractures, dorsal opening wedge osteotomy combined with cancellous bone grafting and plate fixation, is a reliable technique allowing significant deformity correction

For hallux valgus correction, distal first metatarsal osteotomy is generally used for minor to moderate deformities, diaphyseal osteotomy for moderate deformities and basal osteotomy or fusion for severe deformities. With the advent of locking plates, there has been renewed interest in opening wedge basal osteotomy. As little has been written about its geometry, we undertook this study in order to understand its power and limitations. Proximal opening wedge osteotomies were performed on saw bone models in four orientations, with three different wedge sizes: 1. Perpendicular to the ground (PG); 2. Perpendicular to the shaft (PS); 3. Perpendicular to shaft with 30° declination (DEC); 4. 30° oblique (OB). Pre- and post-osteotomy measurements were made of axial and plantar translation and intermetatarsal angle. Plantar translation and intermetatarsal angle correction increased with increasing wedge size. The DEC osteotomy produced the greatest increase in length of metatarsal shaft, while the PS osteotomy gave the least. The most plantar translation was achieved with the DEC osteotomy. Overall, the PS osteotomy gave the largest correction of the intermetatarsal angle. Although there are several published clinical case series of the proximal opening wedge osteotomy, this is the first study to fully evaluate its geometry

Introduction: An osteotomy in the proximal first metatarsal corrects the metatarsal head position with much less movement of the fragment than an equivalent distal osteotomy. Most described techniques are technically demanding and reported complications including non-union, mal-union and transfer pain. We present our results of an opening wedge osteotomy with a medial wedge plate. We also present the pitfalls and tips to avoid complications. Materials and Methods: Thirty-four procedures in 30 patients were performed using the Arthrex wedge plate. Demographic and clinical data, AOFAS scores and radiological measurements of standardised radiographs were collected for all the patients. Results: All patients were females. The average age was 52 years. Twenty-seven were primary procedures and 7 patients had had previous, failed 1st ray surgery. No bone graft was used. Thirty-two feet showed clinical and radiological signs of union. Four complications occurred and one was treated with metatarsophalangeal joint fusion. One had an infection. Two patients had broken screws. The average hallux valgus angle and inter-metatarsal angle corrections were 200 and 90 respectively. Average increase in AOFAS scores: preoperative 47 to postoperative 81. Discussion: The spacer in the plate acts as a pillar and obviates the need for a bony strut. Keeping an intact lateral cortex and preventing any shaft displacement was important in avoiding transfer pain. 4.5mm or smaller plates appear to have fewer problems and better scores, al though this was statistically unproven. Screw breakage in the absence of infection had no bearing on overall outcome. Some patients with poor fixation may benefit from non-weight bearing for the first 6 weeks. Conclusion: The wedge plate osteotomy is a powerful tool to correct moderate to severe hallux valgus. It does not need additional bone graft and has a favorable clinical and radiological outcome. The prelude to optimum result was meticulous technique avoiding the discussed pit falls

Aims: The aims of this prospective study was to elucidate, how the high tibial opening wedge osteotomy (OW-HTO) corrected the varus angle of the lower extremity to the desired valgus angle in arthrotic knee joint, and what are the typical complications concerning this operation method. Methods: Twenty-one patients were operated on by using the operation technique (Puddu 1998) from September 1999 to August 2000. Results: The mean preoperative femoro-tibial varus-angle of the þrst 21 patients was 1.4. degrees, immediate postoperative valgus-angle was 7.1 degrees and at the latest follow-up, the valgus angle was 5.6 degrees, respectively. In 16 of these 21 patients the healing was uneventful. Five patients sustained complications. Three patients had fracture of the opposite tibial lateral cortex peroperatively. Two of these fractures healed without complication. One of these patients needed total knee arthroplasty later on because of pseudoarthrosis and loss of OW-HTO correction angle at the osteotomy site. Two patients sustained peroperative þssural fracture up to the lateral tibial joint articulation surface. These fractures healed uneventfully. Conclusion: A group of young, active heavy patients sustaining varus gonarthro-sis are candidates for HTO. After promising results of these 21 OW-HTO operations, we have operated 34 more patients. Complication rate has dropped because of better operative experience. However, OW-HTO is a sensitive operation with itñs possible complications. In experienced hands it is reliable and good operation. Also we have to remember, that this operation allow patients to keep their own knee joint with itñs normal kinesiology

High tibial valgus osteotomy is now well established in management of medial knee osteoarthritis. While conventional closing osteotomies are usually within 2 cm of the knee joint, opening wedges typically pivot more distally from the joint line; theoretically the same angular correction will cause greater linear shift of the tibial plateau away from the tibial long axis. We hypothesise that this may lead to an increased incidence of problems with future knee replacement where tibial stem augments are needed, and to evaluate this we used a computerbased templating system with web-based component templates for sizing and implant position planning. We studied 10 knees that had undergone opening wedge osteotomy. Pre-operative and postoperative mechanical and anatomical axes, and corrections achieved, were measured radiologically. Computer-based knee arthroplasty templating was then performed with the TraumaCad digital templating software (Orthocrat, Israel), using Depuy PFC tibial component templates with 75 mm stem augments. Cases were analysed for impingement of tibial stem augments when added to a well-placed tibial tray, and conversely for the need for tibial tray downsizing to avoid tray overhang if stem augments were placed centrally. Results: Mean pre-operative mechanical axis was 10.6o varus (1.6o to 22.3o). Mean osteotomy to joint line distance was 25.7mm (21.0mm to 33.1mm). In four knees, the addition of a 75 mm tibial stem augment to a well-placed tibial component caused stem impingement on cortex. In these four cases, central placement of the stem augment in the canal led to medialisation of the tibial component, necessitating downsizing of tibial tray by one to two sizes to avoid medial overhang and resulting in sub-optimal coverage of the cut tibia. These four cases all had valgus corrections of over 11o (11.5o to 19.6o). Conversely the six cases that did not have impingement or sizing problems all had corrections under 9o (3.0o to 8.2o). Our early results suggest that higher degrees of valgus correction with opening wedge osteotomy may lead to problems with future knee replacements requiring tibial stem augments. We are in the process of recruiting more cases to determine threshold levels for different makes and models of implants, using the same templating software system

Improved surgical techniques and new fixation methods have revived interest in high tibial osteotomy surgery in recent years. Our aim was to review our first 59 cases. All patients underwent radiological and clinical review including pre and post operative scores.

Mean age at surgery was 43 (22-59) and mean follow up is 22 months.

The mean pre-operative limb alignment was 5.4° varus (range 1°-16°) with correction to 2° valgus (range -1° - 7°).

HTO is known to increase tibial slope and in this series the change in tibial slope from -5.2° (95%CI: -6.36 to -4.07)) to -7.8° (-8.83 to –6.89) was statistically significant. p= 0.0014 (Mann Whitney).

Patellar height is often reduced following opening wedge HTO and this is confirmed in our series. The Blackburne-Peel ratio changed from 0.74 to 0.58 and the Caton-Descamps from 0.83 to 0.7. Both were statistically significant at p<0.0001 and p=0.0001 respectively.

All scores improved post operatively, the knee injury and osteoarthritis outcome (KOOS) from 48 (8-91) to 73 (27-96), the Oxford knee score (OKS) from 25 (3-47) to 37 (9-48), and the EQ5D from 189809 (11221-32333) to 14138 (11111-22233) with the EQ5D VAS improving from 58 to 75. There was no correlation between change in limb alignment, tibial slope or patellar height and any of the scores used.

There were three superficial wound infections, and one non union which was treated with grafting and re fixation. Six patients have had their plate removed.

Improvement in clinical scores in these patients confirms that medial opening wedge HTO is a reliable joint preserving procedure in the short term and our surgical technique is reproducible and consistent with other published series.

Aims. To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee. Methods. In all, 49 patients (52 knees) with a mean age of 47 years (31 to 64) underwent high tibial osteotomies (HTO), and 24 patients with a mean age of 48 years (31 to 62) low femoral osteotomies (LFO) with opening wedge technique due to medial, respectively lateral knee OA with malalignment. All osteotomies were stabilized with a Puddu plate and bone grafting performed in the same time period (2000 to 2008). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) pre-operatively and at six months, and at one, two, five, and ten years postoperatively. The knee OA was graded according to the Ahlbäck and Kellgren-Lawrence radiological scoring systems. Results. The mean angular corrections were 8.0° (4° to 12°) for the HTO and 9.6° (4° to 20°) for the LFO. Both the pre-operative KOOS and the osteoarthritic gradings were similar for the two patient groups. The five subscores of KOOS increased significantly during the postoperative period (p < 0.001 to 0.029) levelling out after one year in both groups. The KOOS subscore symptoms was significantly higher for patients with HTO than those with LFO at all follow-up times, for sport and recreation in the period one to five years, and for pain and quality of life at two to five years (p < 0.001 to 0.009). Eight HTOs (15%) and five LFOs (21%) were converted to total knee arthroplasty after mean 6.7 years (2.0 to 9.8) and 5.4 years (4.0 to 8.0) respectively. The ten-year osteotomy survival rates were 88% for the HTO and 79% for the LFO (p = 0.745). Conclusion. Patients with unicompartmental knee OA improved after a corrective opening wedge osteotomy, but four of the five subscores of KOOS were significantly higher for those with medial than those with lateral OA in most of the ten-year follow-up period. Cite this article: Bone Joint Open 2020;1-7:346–354

Tibial opening wedge osteotomy is still a worthwhile surgical procedure in the treatment of tibial varus deformity to prevent knee arthritis. However, it requires a long period without weight-bearing because of the need of bone harvesting substitution at the osteotomy site. The authors present their experience with endoscopic injection of Norian SRS calcium phosphate cement to speed patient recovery and to avoid any potential in soft tissue complications. From January 2001 the authors performed 13 tibial opening wedge osteotomy in 12 patients. All the patients previously underwent to a knee arthroscopy. The average age was 51 years (range 35–56). In all cases the injection of Norian SRS calcium phosphate cement was controlled arthroscopically and the fixation was maintained with a Puddu’s plate. The patients were assessed using the GIUM Score, pre-operatively and at the latest follow-up. The authors did not register any problems due to the Norian SRS calcium phosphate cement. Total weight-bearing was allowed after an average of 26 days. Radiographically the bone substitute appeared well integrated at the latest follow-up. Pre-operatively the mean GIUM score was 56.1 (range 36–68). At the latest follow-up the mean GIUM score was 94.2 (range 84–98). All the patients were satisfied and had returned to their previous occupation. The authors suggest Norian SRS calcium phosphate cement to speed patientrecovery after tibial opening wedge osteotomy

Purpose: Previous research has reported that increasing the posterior tibial slope through an opening wedge osteotomy results in an anterior shift in the position of the tibia relative to the femur. However, the effect of this on anterior cruciate ligament (ACL) strain remains insufficiently understood. The purpose of this study was to examine the relationship between tibial slope and tibial translation, as well as between tibial slope and ACL strain. It was hypothesized that increasing the posterior tibial slope would result in an increase in anterior tibial translation thereby increasing strain in the ACL. Methods: Five cadaveric knees were subjected to a randomized experimental design study. One knee was excluded due to failure of a strain gauge during experimentation, resulting in data for four knees. The femoral and tibial portions of the knee were potted with PMMA and fixed using fixation pins. An anterior-based osteotomy was performed with no osteotomy plate present. A strain gauge was then placed in the anteromedial bundle of the ACL. Each knee was mounted at a flexion angle of 15° and loaded with various combinations of A-P loads (18N, 108N, 209N) and axial loads (216N, 418N), according to the study design. Osteotomies of 5mm and 10mm were then performed and measurements of strain and tibial translation were taken after each according to the study design. Tibial slopes were determined through lateral fluoroscopic imaging. Results: As posterior tibial slope increased, anterior tibial translation increased as anticipated. However, contrary to expectations, as posterior slope increased, ACL strain decreased. One explanation for this result could be that by performing the osteotomy, the insertions sites of the ACL were being moved closer together resulting in increased ACL laxity. At higher slope angles, translation levels off, suggesting constraint of some tissue besides the ACL. Conclusions: Although increasing the tibial slope through opening wedge osteotomy leads to an anterior tibial translation, there is no increase in strain on the ACL. Further studies are needed to examine the effect of opening wedge osteotomy on other soft tissue restraints of the knee

Aim: The purpose of this study is to establish if there is any or no beneþt in performing an opening wedge tibial osteotomy (TO) in patients normally requiering a total knee replacement (TKR). Methods: A group of 70 patients having been initially diagnosed with a form of osteoarthritis of the knee that would normally coun-terindicate an osteotomy (age over 65, stages, Ahlback III or IV, presence of patello-femoral arthritis) but in which other factors (associated pathology, age under 40, hard physical labour) did not allow as to perform a total replacement of the joint and who þnally underwent a T.O. (using an acrylic cement spacer) was followed-up for a mean period of 6.5 year both clinically (using 2 functional scores) and radiologically. In all patients weight-bearing AP radiographs taken preoperatively showed a degree of varus malalignement. Results: Only 5 patients from the initial group required a TKR during the follow-up period. In most cases results were good regarding painless motion and activity and satisfactory regarding the amplitude of movement, even in cases with no radiological improvements. Conclusion: We consider that opening wedge osteotomy may still represent a valuable solution in treating severe cases of osteoarthritis of the knee in which T.K.R. is not possible due to various reasons, also bearing in mind that is far more easy to perform a TKR after an opening wedge osteotomy than after a closing wedge technique

Introduction. Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. Materials and Methods. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23). Results. There were two cases lost to follow-up with a median follow-up period 17 months (range 1–32 months). Union was achieved in all cases, with 1/23 requiring revision for early fixation failure for technical reasons. The median time to radiographic union 3.2 months (95% Confidence Interval (CI) 2.5–3.8 95% CI). CT scans demonstrated early periosteal callus, beneath the osteoperiosteal flap, bridging the opening wedge cortex. Clinical union occurred at 4.1 months (95% CI 3.9–4.2 months). Complications included superficial surgical site infection (1/23), deep vein thrombosis (1/23), and symptomatic metalwork requiring removal (7/23). Conclusions. The osteoperiosteal flap technique was a safe and effective technique for opening wedge osteotomies around the knee with a reliable rate of union

Introduction: The operational technique for opening wedge osteotomies has been simplified by the use of the Puddu-plate. This study presents results after use of Puddu-plates on distal femoral and proximal tibial osteotomies. Methods: Fifteen distal femoral and 25 proximal tibial osteotomies have been performed with opening wedge technique due to knee osteoarthritis with malalignment in the period 2000–2004. The knee osteoarthritis was mainly due to a previous meniscal extirpation. Ten patients had an additional rupture of the anterior cruciate ligament. The mean age of the patients was 49 years (31–66 years), and 17 females and 23 males were operated. The patients with femoral osteotomies had a mean preoperative tibiofemoral valgus angle of 12° (8°–20°) whereas those with tibial osteotomies had a mean tibiofemora varus angel of 1° (7° varus – 3° valgus). The osteotomy was fixed with a Puddu-plate securing the planned angular correction, and the osteotomy cleft was filled by autogenous pelvic bone. The mean follow-up time was 18 months (3–42 months). Results: The width of the osteotomy cleft was determined by the tooth of the implant. The mean width of the tooth was 8.6 mm (5–12.5 mm), and the mean angular correction measured on pre- and postoperative radiographs was 8.4° (5–15°). The osteotomy cleft healed after a mean of 13 weeks (7–26 weeks). One patient suffered venous thrombosis of the leg and one a postoperative wound infection. The knee injury and osteoarthritis outcome score (KOOS) increased significantly during the observation period. For pain the mean preoperative score was 53 and the score at follow-up was 82. The corresponding scores for symptoms were 56 and 75, for activity of daily life (ADL) 65 and 86, for sport and recreation 26 and 52 and for quality of life 33 and 64 (P< 0.001). Conclusion: The results after opening wedge osteotomy using the Puddu-plate seem satisfactory. The operational technique is simpler compared to previous methods, and the degree of angular correction is accurate depending on the width of the tooth of the implant which in mm corresponds relatively well with the degrees of angular correction

Closing wedge tibial osteotomy has been the gold standard in proximal osteotomy procedures to correct uni-compartmental osteoarthritis. Opening wedge tibial osteotomies are achieving similar long-term results while avoiding some of the pitfalls of the closing wedge procedure. Opening wedge osteotomies maintain patellar length, tibial inclination, and proximal tibia bone stock. This allows for a technically easier conversion to a total knee arthroplasty in the future. The purpose of this study was to assess the functional outcomes as well as the anatomical changes caused by opening wedge high tibial osteotomy. Opening and closing wedge osteotomies have been shown to have near equivolent long-term results. Using functional outcome studies (SF-36 and WOMAC ) and radiographic review we have shown good outcomes while maintaining the original anatomy of the knee. Opening wedge tibial osteotomy will allow for a less complicated conversion to a total knee arthroplasty than the closing wedge tibial osteotomy. The patients attained a significant valgus correction that was maintained postoperatively (pre-op 6.12 varus to 5.5 valgus). Clinical status of the patient was improved significantly in the functional outcomes testing using the WOMAC knee score( pre-op value 29.75 to 19.5; p = 0.0318 ) and the SF-36 ( pre-op value 64.4 to 81.7; p = 0.0035 ). Patellar height (Pre-op Insall-Salvati ratio 1.15 to 1.09; p = 0.2339 ) and tibial inclination( pre-op 7.3 degrees to 6.85 degrees; p = 0.6743 ) were maintained. This study retrospectively examined twenty-two patients with medial joint uni-compartmental osteoarthritis. Radiographic review of the pre-operative and post-operative films assessed the valgus correction, patellar height, and tibial inclination. The patients were seen in follow-up to assess the clinical exam and functional outcomes were measured using the SF-36 and WOMAC knee scores. Opening wedge HTO is able to achieve acceptable correction of deformity while maintaining the normal anatomy of the knee

Closing wedge tibial osteotomy has been the gold standard in proximal osteotomy procedures to correct uni-compartmental osteoarthritis. Opening wedge tibial osteotomies are achieving similar long-term results while avoiding some of the pitfalls of the closing wedge procedure. Opening wedge osteotomies maintain patellar length, tibial inclination, and proximal tibia bone stock. This allows for a technically easier conversion to a total knee arthroplasty in the future. The purpose of this study was to assess the functional outcomes as well as the anatomical changes caused by opening wedge high tibial osteotomy. Opening and closing wedge osteotomies have been shown to have near equivolent long-term results. Using functional outcome studies (SF-36 and WOMAC ) and radiographic review we have shown good outcomes while maintaining the original anatomy of the knee. Opening wedge tibial osteotomy will allow for a less complicated conversion to a total knee arthroplasty than the closing wedge tibial osteotomy. The patients attained a significant valgus correction that was maintained postoperatively (pre-op 6.12 varus to 5.5 valgus ). Clinical status of the patient was improved significantly in the functional outcomes testing using the WOMAC knee score( pre-op value 29.75 to 19.5; p = 0.0318 ) and the SF-36 ( pre-op value 64.4 to 81.7; p = 0.0035 ). Patellar height (Pre-op Insall-Salvati ratio 1.15 to 1.09; p = 0.2339 ) and tibial inclination( pre-op 7.3 degrees to 6.85 degrees; p = 0.6743 ) were maintained. This study retrospectively examined twenty-two patients with medial joint uni-compartmental osteoarthritis. Radiographic review of the pre-operative and post-operative films assessed the valgus correction, patellar height, and tibial inclination. The patients were seen in follow-up to assess the clinical exam and functional outcomes were measured using the SF-36 and WOMAC knee scores. Opening wedge HTO is able to achieve acceptable correction of deformity while maintaining the normal anatomy of the knee

An osteochondral defect greater than 3cm in diameter and 1cm in depth is best managed by an osteochondral allograft. If there is an associated knee deformity, then an osteotomy is performed. In our series of osteochondral allografts for large post-traumatic knee defects realignment osteotomy is performed about 60% of the time in order to off-load the transplant. To correct varus we realign the proximal tibia with an opening wedge osteotomy. To correct valgus, we realign the distal femur with a closing wedge osteotomy. Our results with osteochondral allografts for the large osteochondral defects of the knee both femur and tibia, have been excellent in 85% of patients at an average follow-up of 10 years. The Kaplan-Meier survivorship at 15 years is 72%. At an average follow-up of 22 years in 58 patients with distal femoral osteochondral allograft, 13 have been revised (22%). The 15-year survivorship was 84%. Retrieval studies of 24 fresh osteochondral grafts obtained at graft revision or conversion total knee replacement at an average of 12 years (5 – 25) revealed the following. In the areas where the graft was still intact, the cartilage was of normal thickness and architecture. Matrix staining was normal except in the superficial and upper mid zones. Chondrocytes were mostly viable but there was chondrocyte clusters and loss of chondrocyte polarity. Host bone had extended to the calcified cartilage but variable remnants of dead bone surrounded by live bone persisted. With a stable osseous base the hyaline cartilage portion of the graft can survive for up to 25 years

An osteochondral defect greater than 3cm in diameter and 1cm in depth is best managed by an osteochondral allograft. If there is an associated knee deformity, then an osteotomy was performed. In our series of osteochondral allografts for large post-traumatic knee defects, realignment osteotomy is performed about 60% of the time in order to off load the transplant. To correct varus we realign the proximal tibia with an opening wedge osteotomy. To correct valgus, we realign the distal femur with a closing wedge osteotomy. Our results with osteochondral allografts for the large osteochondral defects of the knee both femur and tibia, have been excellent in 85% of patients at an average follow-up of 10 years. The Kaplan-Meier survivorship at 15 years is 72%. At an average follow-up of 22 years in 58 patients with distal femoral osteochondral allograft, 13 have been revised (22%). The 15-year survivorship was 84%. Retrieval studies of 24 fresh osteochondral grafts obtained at graft revision or conversion to total knee replacement at an average of 12 years (5 – 25) revealed the following. In the areas where the graft was still intact, the cartilage was of normal thickness and architecture. Matrix staining was normal except in the superficial and upper mid-zones. Chondrocytes were mostly viable but there was chondrocyte clusters and loss of chondrocyte polarity. Host bone had extended to the calcified cartilage but variable remnants of dead bone surrounded by live bone persisted. With a stable osseous base the hyaline cartilage portion of the graft can survive for up to 25 years

Introduction. Osteotomy for medial gonarthrosis is most often done as a proximal tibial valgus osteotomy, either as a closing wedge osteotomy (HTO) or as an opening wedge osteotomy including hemicallostasis (HCO). In case of lateral gonarthrosis the osteotomy is done as a proximal tibial varus osteotomy, closing or opening wedge or as a distal femoral varus osteotomy depending on the anatomy of the knee. The early period after osteotomy is influenced by complications to osteotomy. Complications depend on the operative method and localisation of surgery. Short- and long-term results are presented as knee scores or survivorship of high tibial osteotomy. Most often used scores are the HSS-score, NHP-score and the knee scores according to Lysholm and Tegner. Scores from the patient’s perspective are NHP, SF-36. KOOS (Knee Injury and Osteoarthritis Outcome Score) was introduced recently, and only short-term results are available. Results. Osteotomy for medial gonarthrosis. Immediate postoperative results. The closing wedge osteotomy is the golden standard and reported complications are peroneal palsy in 0 – 8%, infection in 1 – 3%, fracture of the tibial plateau and delayed union in 3 – 5% and thromboembolism in 2 – 4%. When the opening wedge method including HCO is used peroneal palsy is extremely seldom, delayed union is reported in 2%, major pin-tract infection in 2 – 20 % and thromboembolism in 2 – 4%. Short-term results. The short-term results are generally good and one to two years after osteotomy excellent and good results are reported in 85 – 97 %. All five partial scales in KOOS with the exception of sports/ recreation function were significantly improved 3 – 4 months postoperatively. Long term results 5 – 20 years after surgery. Evaluations of osteotomies using survivorship of the osteotomy, with conversion to a total knee as the endpoint, show an expected rate of survival of 73–94% at 5 years, 51–85 % at ten years, 39–68 % at 15 years and 30% at 20 years. Analysis of risk factors show that age older than 50 years, presence of lateral tibial thrust and insufficient valgus correction were significantly associated with probability of early failure. Evaluations using knee scores with a mean follow-up time of 5 – 10 years show excellent and good result in 64 – 80%. At follow-up 11– 15 years after surgery the fraction good and excellent knees is 55 – 60% and 16– 20 years after osteotomy a minority of the knees are good or excellent, at most 46%. Stage of arthrosis: Good long-term results are reported for knees with early medial arthrosis with at most obliteration of the medial joint space or just minimal bone attrition. Results after HCO on knees with more advanced gonarthrosis are reported with a short follow-up and the change of osseous correction after osteotomy was less compared to HTO. Only minimal progress of arthrosis after osteotomy is reported in most papers. The results of some studies indicate that the greater the surgical correction, the slower the progress of the medial joint arthrosis. Alignment of the knee:. Most reports find better clinical results and less risk for failure when the osteotomy is corrected to a slight over-correction of the knee alignment. There is however no consensus on the smallest correction needed to change the load on the medial arthrotic compartment. Osteotomy for lateral gonarthrosis. The condition is uncommon and a minority of the papers on osteotomy for gonarthrosis concern osteotomy for lateral gonarthrosis. The aim of osteotomy for lateral gonarthrosis is to achieve a varus alignment of the knee with a joint line obliquity, which after surgery is less than 10 degrees. That affects the method, which is either a proximal tibial osteotomy or a distal femoral osteotomy. Most often the aetiology of the deformity is posttraumatic. Immediate postoperative results. When using the opening wedge osteotomy on tibia transient nerve palsy is reported in 9–50%. Infection is reported in 2% and thromboembolism in 2 – 4%. Pin tract infection when using HCO is reported in 2 – 20%. In a multicenter follow-up distal femoral varus osteotomy 11 complications were recorded in 32 patients (five non unions, three deep infections and three cases with a stiff knee). Short-term results. Short-term results one to two years after surgery are reported excellent and good in 85 – 95%. Results 5 – 15 years. Five to ten years after surgery good and excellent results are reported in 75 − 77%, and in 11 – 15 years after surgery in 50 – 80%. Results are much better in recent reports because of better patient selection and operative technique. The tibial varus osteotomy can be used in knees with less than 12 degrees of valgus. Furthermore the tilting of the tibiofemoral joint line should postoperatively be less than 10 degrees. Otherwise a distal femoral osteotomy should be used. Persistent excessive obliquity of the tibiofemoral joint line predisposes instability with risk of compromising the result. To summarize: Osteotomy is effective in a patient with a medial or a lateral gonarthrosis at most Stage II according to the classification of Ahlbäck, under the age of between 50 and 60 years and of high demands by reason of lifestyle and occupation. Aim at an overcorrection so when the osteotomy is healed you should have a slight overcorrection in valgus in medial gonarthrosis and in varus when you have a lateral gonarthrosis. Furthermore the joint line obliquity should postoperatively be less than 10 degrees. With this selection of patients and with a good surgical technique your patient can expect a probability of having a good knee in about 70 % after ten years. After ten years it is more difficult to make a prognosis for your patients knee

Osteotomies around the knee are still utilized a lot in Europe and in Asia while in US unicompartmental and total arthroplasty for the same indications have more and more taken over, partially due to fear of complications. We think that with careful planning and technique the indications can be maintained. Furthermore with modern methods of cartilage repair it is of utmost importance to unload overloaded compartments. Also many young patients having suffered ligamentous tears of the knee and having been reconstructed are in need of OT’s later on. Many of the poor results are due to absent or poor planning and to poor OT technique and fixation. Not every knee needs to be operated to an overcorrected position. While opening wedge OT has become trendy because of fewer neurological complications we think there are definite indications for closing wedge technique. In this lecture we would like to summarize the principles and the steps which are very personal and that are based on 20 years of practice. Indications for osteotomies around the knee. Varus Knee. Opening wedge osteotomy: Advantages: Rapid surgery, small incision, fast healing, precise correction. Indicated when:. Degree of OA moderate and angular correction of not > 8°. Useful in associated MCL Instability. Useful when open surgery on medial femoral condyle needed (Mosaicplasty). In case of associated ACL instability when tibial slope is not > 10°. Patella alta. Has a tendency to increase the tibial slope. We use tricortical grafts from the iliac crest where the base of the wedges in mm corresponds to the degrees of correction. A cervical spine AO plate with for screws is used for fixation. Creates less deformity of the proximal tibia which is an advantage for a later total knee. Increases the intraarticular pressure even when the MCL is cut or detached distally, without us knowing the effect on the degree of OA, no long term studies being known to us. Closing wedge osteotomy: Advantages: Allows higher degrees of correction. Degree of OA advanced, need for higher corrections. Useful when open surgery on lateral femoral condyle needed. In ACL instability when tibial slope must be corrected, because of need to break the medial cortical hinge a heavier implant is needed may be enforced by a sagital Ex.Fix. Patella baja. Corrections over 5 degrees need an OT of the proximal or distal fibula. We perform the resecting OT in the fibular neck, the proximal cut is incomplete removing only the anterior and lateral cortex, the distal cut is complete. This allows to shift the distal fragment proximally and in front of the proximal cortical shelf allowing nerve protection. For fixation of the tibial OT we use the 90° angled cannulated AO osteotomy plate, that is inserted over a 2,0 K wire using a specific “transporteur” in relation to the amount of correction. The OT is done using the precise AO osteotomy jig, cutting along 2,5 mm K wires inserted through the jig. The two cuts meet 5–10 mm short of the opposite cortex. The closing wedge OT creates more deformity, carries a certain risk of peroneal nerve injury and of compartment syndrome. Surgery must therefore been done very skilfully and demands expertise. All the studies about long term effect of HTO have been done one using closing wedge technique. Double Osteotomy. Indications:. For deformities of over 12° to avoid obliquity of the joint line otherwise created by tibial or femoral OT alone. When sagital deformity needs to be corrected together with frontal plane deformity, eg a flexum of 20° and a varus of 10°. Valgus knee. Closing wedge Osteotomy of the distal femur: Advantages are the potent fixation using the same plate as on the tibia leading to rapid healing. Approach is rather extensive. Indicated:. When deformity of valgus and sagital plane ( flexion contracture) need to be addressed. When valgus is marked ( in small deformities the OT can also be performed in the tibia). Opening wedge Osteotomy of the distal femur. Indicated:. When the deformity is small. When cartilage gestures need to be performed on the lateral femoral condyle. Planning of Osteotomies:. We use one leg standing films in ap, pa 45° flexion, and lateral projection, varusvalgus stress films with 15 kp (Telos) and Orthoradiogramm (hip-ankle). A potential contralateral opening on the standing film is compensated on the drawing by a push orthoradiogram which virtually brings both compartments into contact. For the varus knee the ideal crossing point of the mechanical xis sits at 30% in the lateral compartment, the centre between the tibial eminences being 0% the medial or lateral border of the tibia being 100%. This is the displacement corresponds to the classical 3° over-correction that is useful when the medial compartment is down to bone. This would be an overcorrection for the less damaged medial joint lines where however an OT may already be indicated. We therefore have prospectively studied and validated a more balanced approach. If the medial compartment in a varus knee has lost up to one third of his cartilage the axis is calculated to pass at 10% in the lateral compartment. If is down by two thirds it is meant to pass at 20% laterally. If it is totally worn it passes at 30%. The drawing for the high tibial OT on the orthoradiogram is simple:. Connect the centre of the femoral head with the point at 10, rsp. 20, rsp. 30% in the lateral compartment and prolong this new axis of the leg distally to a point lateral of the ankle joint. Now select the hinge joint for the opening or closing wedge OT 2–3 cm distal to the joint line and connect this point with the old and the new centre of the ankle. Measure the angle between the t line which corresponds to the amount of correction and the angle to open or resect. The planning for the varus OT of the distal femur in valgus deformity is somewhat more complicated but should aim at a correction which leaves a femorotibial valgus of 1–2°. Using these rules one is able to reach adequate correction

The parameters to be considered in the selection of a cartilage repair strategy are: the diameter of the chondral defect; the depth of the bone defect; the location of the defect (weight bearing); alignment. A chondral defect less than 3 cm in diameter can be managed by surface treatment such as microfracture, autologous chondrocyte transplantation, mosaicplasty, or periosteal grafting. An osteochondral defect less than 3 cm in diameter and less than 1 cm in depth can be managed by autologous chondrocyte transplantation, mosaicplasty or periosteal grafting. An osteochondral defect greater than 3 cm in diameter and 1 cm in depth is best managed by an osteochondral allograft. If there is an associated knee deformity, then an osteotomy should also be performed with all of the aforementioned procedures. In our series of osteochondral allografts for large post-traumatic knee defects realignment osteotomy is performed about 60% of the time in order to off load the transplant. To correct varus we realign the proximal tibia with an opening wedge osteotomy. To correct valgus, we realign the distal femur with a closing wedge osteotomy. Our results with osteochondral allografts for the large osteochondral defects of the knee have been excellent in 85% of patients at an average follow-up of 10 years. The Kaplan-Meier survivorship at 15 years is 72%. At an average follow-up of 22 years in 58 patients with distal femoral osteochondral allograft, 13 have been revised (22%). The 15-year survivorship was 84%. The results for the hip are early. To date we have performed this procedure on 16 patients. Surgical dislocation of the hip is carried out via a trochanteric osteotomy and the defect defined and trephined out. A press-fit fresh osteochondral allograft is inserted using the trephine technique. We have published our early results on a series of 8 patients with 5 good to excellent results, 1 fair result and 2 failures