Valgus high tibial osteotomy for osteoarthritis of the medial compartment of the knee can be performed using medial opening- and lateral closing-wedge techniques. The latter have been thought to offer greater initial stability. We measured and compared the stability of opening- and closing-wedge osteotomies fixed by TomoFix plates using radiostereometry in a series of 42 patients in a prospective, randomised clinical trial. There were no differences between the opening- and closing-wedge groups in the time to regain knee function and full weight-bearing. Pain and knee function were significantly improved in both groups without any differences between them. All the osteotomies united within one year. Radiostereometry showed no clinically relevant movement of bone or differences between either group. Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening-wedge technique was more likely to produce the intended correction

We compared the results ten years after an inverted V-shaped high tibial osteotomy with those of a historical series of conventional closing-wedge osteotomies. The closing-wedge series consisted of 56 knees in 51 patients with a mean follow-up of 11 years (10 to 15). The inverted V-shaped osteotomy was evaluated in 48 knees in 43 patients at a mean follow-up of 14 years (10 to 19). All the patients were scored using the Japanese Orthopaedic Association rating scale for osteoarthritis of the knee and radiological assessment. The pre-operative grade of osteoarthritis was similar in both groups. Post-operatively, the knee function score was graded as satisfactory in 63% (35) of the closing-wedge group but in 89% (43) of the inverted V-shaped osteotomy group. Post-operative radiological examination showed that delayed union and loss of correction occurred more often after a closing-wedge osteotomy than after an inverted V-shaped procedure. Our study suggests that the inverted V-shaped osteotomy may offer more dependable long-term results than traditional closing-wedge osteotomy

Objective: The objective of this retrospective study is to evaluate our results with proximal closing-wedge osteotomy of first metatarsal for the treatment of hallux valgus with severe intermetatarsal (IM) angle and normal proximal articular set angle (PASA). Material and methods: We reviewed 110 patients (141 feet) who had been treated by proximal closing-wedge osteotomy of first metatarsal between March-97 and February-04. 87% were women and the mean age was 47.8 years. A single cannulated screw was used for osteotomy fixation in 82% of patients. Additional procedures as phalangeal osteotomy or Keller resection were done when necessary. Results: With a mean follow-up of 42.3 months, correction of the deformity was good or excellent in 80.5% of cases and fair in 15.4%. Pain due to bunion disappeared in 94.3% of feet. Mean preop IM (angle) was 17.3 and postop was 7.9. Metatarsal-phalangeal angle improved from 42.4 to 15.9. Fusion was achieved in 6.8 weeks (average). Complications were: hypercorrection in 13 feet (2 required reoperation); recurrence of deformity in 10 feet (1 reoperation); central metatarsalgia in 8 feet. Neither infection nor nonunions were observed. Patient satisfaction was excellent or good in 92.7% of patients. Conclusion: Proximal closing-wedge osteotomy of first metatarsal is a good technique for the treatment of hallux valgus with severe IM angle and normal PASA. It is an easy and reproducible technique with good results, low number of complications and a high rate of patient satisfaction

Purpose: The purpose of this study was to assess the subjective, clinical and radiological improvement in patients with moderate to severe hallux rigidus undergoing Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy. Methods: Between March 2003 and November 2004, 17 patients (18 feet) underwent Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy, 14 were available for clinical follow-up; pre and post-operative X-rays were available for all of them. The Clinical assessment was based on modified American Orthopaedic Foot and Ankle Society’s hallux-metatarsophalangeal scale. The subjective assessment was done by a questionnaire and radiological assessment was done by using digital radiographs. Results: Out of the 18 feet we studied, 1 was of Grade 1, 9 of Grade 2 and 8 of Grade 3. 12 out of 14 patients (85%) were satisfied with the outcome after an average follow-up period of 14 months. There was an increase in the Mean mAOFAS score of 49.6 (from a mean score of 26.2 to 75.8); the improvement in pain score was 27.4. With a mean osteotomy thickness of 1.78 mm, the proximal phalangeal length was decreased by a mean of 3.7mm. The medialization achieved in the men M1-P1 angle was 6.8 degrees. There was a highly significant gain of 25 degrees in Mean Dorsiflexion which cannot be explained by a mean increase of only 0.9 mm in the lateral dorsal joint space attributable to cheilectomy. Conclusion: Dorsomedial Proximal Phalangeal Closing-wedge Osteotomy combined with Cheilectomy gives good subjective and clinical results regarding satisfaction, pain relief and gain in dorsiflexion; at least in the short-term. This gain in movement might be explainable by an improved EHL lever-arm resulting from dorsome-dial nature of the phalangeal osteotomy

From 1990 to 1993 we treated 22 consecutive patients who had progressive spinal kyphosis due to ankylosing spondylitis by a closing-wedge posterior vertebral osteotomy with partial corporectomy of L4 and transpedicular fixation. The average correction was 32 degrees (24 to 52) with a mean loss of correction after operation of 2.7 degrees (0 to 13). The average operating time was 185 minutes (135 to 240) and blood loss was 2500 ml (1200 to 5000). The osteotomy corrected all patients sufficiently to allow them to see ahead and their posture was improved. There were no fatal complications, but in two cases there was failure of the instrumentation and one patient needed reoperation for nerve compression. Two deep wound infections required removal of the implant and six patients had superficial skin infections under the plaster. The use of a circoelectric bed and intermittent prone lying eliminated this problem

We systematically reviewed the published literature on the complications of closing wedge high tibial osteotomy for the treatment of unicompartmental osteoarthritis of the knee. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled group clinical (CCTs) trials, case series in publications associated with closing wedge osteotomy of the tibia in patients with osteoarthritis of the knee and finally a Cochrane review. Many of these trials included comparative studies (opening wedge versus closing wedge) and there was heterogeneity in the studies that prevented pooling of the results.

Aims. To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management. Methods. We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire. Results. The mean follow-up was 8.4 years (2 to 14.9). There were 85 patients (96.6%) with a thoracic deformity. Posterior spinal fusion with closing-wedge osteotomies and hybrid instrumentation was used in 86 patients; two patients underwent combined anterior and posterior spinal fusion. The mean kyphosis was corrected from 94.5° to 47.5° (p < 0.001). Coronal and sagittal balance returned to normal. The rate of complications was 12.5%: there were no neurological deficits, implant failure, or revision surgery. SRS-22 scores improved from a mean 3.6 (1.3 to 4.1) to 4.6 (4.2 to 5.0) at two years (p < 0.001) with a high rate of patient satisfaction. Non-smokers and patients with lower preoperative SRS-22 scores showed greater improvement in their quality of life. Sagittal pelvic balance did not change after correction of the kyphosis and correlated with lumbar lordosis but not with thoracic or thoracolumbar kyphosis. Conclusion. Posterior spinal fusion using hybrid instrumentation, closing-wedge osteotomies, and iliac bone grafting achieves satisfactory correction of a severe kyphosis resulting in improvements in physical and mental health and a high degree of patient-reported satisfaction. Cite this article: Bone Joint J 2021;103-B(1):148–156

Our aim was to compare the degree of patellar descent and alteration in angle of the inclination of the tibial plateau in lateral closing-wedge and medial opening-wedge high tibial osteotomy (HTO) in 51 consecutive patients with osteoarthritis of the medial compartment and varus malalignment. Patellar height was measured by the Insall-Salvati (IS) and the Blackburne-Peel (BP) ratios. The tibial inclination was determined by the Moore-Harvey (MH) method. Multivariate linear regression analysis was used to determine the influence of the type of HTO (closing vs opening wedge) on the post-operative patellar height or tibial inclination. The intra- and interobserver variability of these methods was determined before operation and at follow-up at one year. After an opening-wedge HTO the patellar height was significantly more decreased (mean post-operative difference: IS = 0.15; 95% confidence interval (CI) 0.06 to 0.23; BP = 0.11; 95% CI 0.05 to 0.18) compared with a closing-wedge HTO. The angle of tibial inclination differed significantly (mean post-operative difference MH = −6.40°; 95% CI −8.74 to −4.02) between the two HTO techniques, increasing after opening-wedge HTO and decreasing after closing-wedge HTO. There was no clinically-relevant difference in the intra- and interobserver variability of measurements of patellar height either before or after HTO

A prospective, randomised, controlled trial compared two different techniques of high tibial osteotomy with a lateral closing wedge or a medial opening wedge, stabilised by a Puddu plate. The clinical outcome and radiological results were examined at one year. The primary outcome measure was the achievement of an overcorrection of valgus of 4°. Secondary outcome measures were the severity of pain (visual analogue scale), knee function (Hospital for Special Surgery score), and walking distance. Between January 2001 and April 2004, 92 patients were randomised to one or other of the techniques. At follow-up at one year the post-operative hip-knee-ankle angle was 3.4° (± 3.6° . sd. ) valgus after a closing wedge and 1.3° (± 4.7° . sd. ) of valgus after an opening wedge. The adjusted mean difference of 2.1° was significant (p = 0.02). The deviation from 4° of valgus alignment was 2.7° (± 2.4° . sd. ) in the closing wedge and 4.0° (± 3.6° . sd. ) in the opening-wedge groups. The adjusted mean difference of 1.67° was also significant (p = 0.01). The severity of pain, knee score and walking ability improved in both groups, but the difference was not significant. Because of pain, the staples required removal in 11 (23%) patients in the closing-wedge group and a Puddu plate was removed in 27 (60%) patients in the opening-wedge group. This difference was significant (p < 0.001). We conclude that closing-wedge osteotomy achieves a more accurate correction with less morbidity, although both techniques had improved the function of the knee at one year after the procedure

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m. 2. ), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis. The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy. Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity

We prospectively reviewed 24 patients (35 feet) who had been treated by a Scarf osteotomy and Akin closing-wedge osteotomy for hallux valgus between June 2000 and June 2002. There were three men and 21 women with a mean age of 46 years at the time of surgery. The mean follow-up time was 20 months. Our results showed that 50% of the patients were very satisfied, 42% were satisfied, and 8% were not satisfied. The mean American Orthopaedic Foot and Ankle Society score improved significantly from 52 points pre-operatively to 89 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15° and 33° to 9° and 14°, respectively. These improvements were significant (p < 0.0001). The change in the distal metatarsal articular angle was not significant (p = 0.18). There was no significant change in the mean pedobarographic measurements of the first and second metatarsals after surgery (p = 0.2). The mean pedobarographic measurements of the first and second metatarsals at more than one year after surgery were within the normal range. Two patients had wound infections which settled after the administration of antibiotics. One patient had an intra-operative fracture of the first metatarsal and one required further surgery to remove a long distal screw which was irritating the medial sesamoids. We conclude that the Scarf osteotomy combined with the Akin closing-wedge osteotomy is safe and effective for the treatment of hallux valgus

Aims

Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group.

Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

«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

1 . The indications, technique and results of supra-malleolar wedge osteotomy of the tibia in the management of valgus or varus deformity of the ankle in children with myelomeningocele are described. 2. This operation should not be performed until as much correction as possible has been obtained by soft-tissue release and muscle balance has been restored by tendon transfer. 3. In sixteen feet satisfactory correction was obtained and maintained in fourteen, one of which had required revision for over-correction. 4. A closing-wedge osteotomy is recommended ; the two failures occurred after opening-wedge osteotomies. 5. In the fourteen feet with satisfactory correction the complications were negligible, deformity has not recurred and epiphysial growth has been well sustained

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned

Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1. At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open. At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age. Conclusions: An association of distal radial wedge-closing osteotomy and either distal ulnar hand resection or shortening distal ulnar osteotomy to correct Madelung’s deformity gave very good results in line with other reports. The limited number of our cases may be compensated by the very lengthy long-term follow-up of our series that showed how the results of these corrective operations do not deteriorate in time; moreover no radiographic osteoarthritis was present even almost 50 years after the operation

Aims

There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome.

Aims

Cubitus varus is the most common late complication of a supracondylar fracture of the humerus in children. Correction can be performed using one of a number of techniques of osteotomy but each has disadvantages. We describe a new technique for correcting post-traumatic cubitus varus using a lateral closing wedge isosceles triangular osteotomy.