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

Purpose. Successful outcome after opening wedge high tibial osteotomy (HTO) has been correlated with obtaining and maintaining angular correction while achieving union. Magnitude of correction, type of fixation and use of bone graft have been implicated as variables which can affect maintenance of correction. The purpose of this study was to determine whether loss of coronal plane correction occurs over time following opening wedge HTO using our standard surgical techniques (unlocked plate with allograft). Our aim was also to correlate clinical outcome measures and radiographic findings. Our hypothesis was that no significant loss of correction would occur. Method. We conducted a retrospective case series with prospectively obtained clinical and radiographic follow-up. The study population was drawn from surgical data bases of 4 fellowship trained surgeons and included all patients who underwent opening wedge HTO between 2007 and 2009, allowing a minimum of 1 year follow-up. Chart data collected included the model and size of opening wedge fixation plate, type of bone graft, concomitant procedures performed as well as patient factors such as smoking status, medical co-morbidities and body mass index (BMI). Patients underwent follow-up including documentation of complications and physical examination for range of motion and stability. Outcome scores obtained included the validated, disease-specific KOOS score (5 domains measured out of 100) and the SF-36 as a validated assessment of health related quality of life (8 domains averaged and reported using norm based scoring with population mean = 50). Full length weight bearing X-rays were obtained and measured and then compared with pre-operative and early post-operative X-rays. Measurements were performed with PACS digital imaging software. Results. Forty-one patients with 44 osteotomies were identified as being eligible for the study. Ten patients were lost to follow-up and 7 patients (8 knees) did not agree to participate in prospective evaluation. The total study population with complete retrospective and prospective data included 24 patients with 26 knees. Complications occurred in 4 cases (15%) with 2 patients who developed superficial infections treated with antibiotics and wound care. Two patients developed deep infections requiring multiple additional procedures. One additional patient underwent plate removal. All osteotomies united. No loss of significant loss of coronal plane correction occurred. Mean alignment was 1.1 degrees of mechanical valgus. Mean KOOS (pain) was 78.9 and SF-36 was 50.7. Conclusion. Our results demonstrate that no significant loss of correction occurred in our series after opening wedge HTO using unlocked plates and either allograft or no bone graft. Successful clinical and radiographic outcomes were demonstrated with mean health related quality of life scores equal to population norms. Patients with BMI < 30 and those who did not develop infections had superior results

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

Limited literature exists providing comprehensive assessment of complications following opening wedge high tibial osteotomy (OWHTO). We performed a retrospective study of local patients who underwent OWHTO for isolated medial compartment knee osteoarthritis from 1997–2013. One hundred and fifteen patients met inclusion criteria. Mean follow-up = 8.4years. Mean age = 47 (range 32–62). Mean BMI = 29.1 (range 20.3–40.2). Implants used included Tomofix (72%), Puddu plate (21%) and Orthofix (7%) (no significant differences in age/ sex/ BMI). Wedge defects were filled with autologous graft (30%), Chronos (35%) or left empty (35%). Five year survival rate (conversion to arthroplasty) = 80%. Overall complication rate = 31%. 25% of patients suffered 36 complications including minor wound infections (9.6%), major wound infections (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%). No thromboembolic complications were observed. A higher BMI (mean 34.2) was apparent in those patients suffering complications than those not (mean 26.9). No significant differences existed in complication rates relative to implant type, type of bone graft used or patient age at surgery. Complications following OWHTO appear higher than previously reported in the literature; serious complications appear rare

Opening wedge high tibial osteotomy (OWHTO) is a treatment option for medial compartment osteoarthritis of the knee in the young active adult. Limited evidence exists in the literature regarding return to activities following OWHTO. We performed a retrospective study of local patients who underwent OWHTO from 2005 – 2012 assessing post-operative return to sporting function. Patients with additional knee pathology, surgery or alternative issues affecting activity were excluded. 110 patients met inclusion criteria, 75 were successfully contacted. Mean improvement in pain score = 4.8/10 (95%CI 4.2 to 5.4, p<0.01). Mean pre-operative KOS-SAS score = 0.5/2, mean post-operative KOS-SAS score = 1.1/2, mean change in KOS-SAS score following OWHTO = 0.6 (95% CI 0.5 to 0.7, p<0.01). Mean pre-morbid Tegner score = 5.9/10, pre-operative = 2.7/10, post-operative = 4.2/10. Mean change in Tegner score following OWHTO = 1.5 (95% CI 1 to 1.9, p<0.01). Following OWHTO 25% of patients achieved pre-morbid Tegner scores. Patient BMI, age, type of implant or graft used had no significant effect on outcome. OWHTO can temporarily improve pain, activity and sporting levels in young patients with isolated medial compartment knee OA. Return to pre-morbid activity levels and even high level sports function is possible although not the norm

High tibial osteotomy (HTO) is an established treatment for medial compartment osteoarthritis of the knee; the aim being to achieve a somewhat valgus coronal alignment, thereby unloading the affected medial compartment. This study investigated knee kinematics and kinetics before and after HTO and compared them with matched control data.

A three dimensional motion analysis system and two force platforms were used to collect kinematic and kinetic data from eight patients with medial compartment knee osteoarthritis during walking preoperatively and 12 months following HTO (opening wedge). Nine control participants of similar age and the same sex were tested using the same protocol. Sagittal and coronal knee angles and moments were measured on both the operated and non-operated knees and compared between the two time points and between HTO participants and controls. In addition, preoperative and postoperative radiographic coronal plane alignments were compared in the HTO participants.

The point at which the mechanical axis passed through the knee joint was corrected from a preoperative mean of 10% tibial width from the medial tibial margin to 56% postoperatively. Stride length and walking speed both improved to essentially normal levels (1.57 m and 1.5 m/s) ostoperatively. In the coronal plane the mean peak adduction angle during stance reduced from 14.3° to 5.2° (control: 6.8°). Mean maximum adduction moments were similarly reduced to levels less than in control participants, in keeping with the aim of the surgical procedure: peak adduction moment 1: pre 3.8, post 2.7, control 3.6 peak adduction moment 2: pre 2.5, post 1.7 and control 2.6.

In the sagittal plane, both mean maximum flexion and extension during stance increased postoperatively—extension to greater than in control participants and flexion to almost control levels. The maximum external knee flexor moment during stance also increased to near normal postoperatively.

High tibial osteotomy appears to achieve the intended biomechanical effects in the coronal plane (reduced loading of the medial compartment during stance). At the same time there were improvements in sagittal plane kinematics and kinetics which may reflect a reduction in pain. The net effect was to reduce quadriceps demand.

«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.

Introduction. Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results. Materials & Methods. We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate. Results. 3 patients (4 limbs) had genu valgum due to constitutional causes and one was a case of distal femoral varus from a fracture. Preoperative mLDFA ranged from 70–75° and in one case of varus deformity it was 103°. We achieved satisfactory correction of mLDFA in (85–90°) in 4 limbs and one measured 91°. Femoral length was not altered. JLCA was not affected post correction. Patients were allowed to weight bear for transfers for the first six weeks and full weight bearing was allowed at six weeks with crutches until healing of osteotomy. All osteotomies healed at 16–18 weeks (average 16.8 weeks). Patients regained full range of movement. We routinely recommend removal of metal work to facilitate future knee replacement if one is needed. Follow up ranged from 4 months to 2 yrs. Irritation from metal work was noted in 2 patients and resolved after removing the plates at 9 months post-surgery. Conclusions. NWDFO is a good option for large corrections. We describe a technique that facilitates accurate correction of deformity in these complex cases. Osteotomy heals predictably with uniplanar osteotomy and dual plate fixation. Metal work might cause irritation like other osteotomy and plating techniques in this location

Introduction:. High tibial osteotomy (HTO) is a common treatment for medial compartment arthritis of the knee in younger, more active patients. The HTO shifts load away from the degenerative medial compartment and into the lateral compartment. This change can be accomplished with either a lateral closing or a medial opening wedge HTO. An HTO also potentially affects leg length. Mathematical models predict that the osteotomy type (opening versus closing) and the magnitude of the correction determine the change in leg length, but no in vivo studies have been published. The purpose of this study is to quantify and compare leg length change following opening and closing wedge HTO. Study Design:. Retrospective cohort study – Level III evidence. Methods:. Thirty-two medial opening and 32 lateral closing HTO's were selected from patients treated at our institution between 2006 and 2009. Pre-operative and one-year post-operative full-length lower extremity radiographs were obtained along with operative reports. Pre- and post-operative coronal plane alignment and leg length were measured and surgical details were collected. Results:. The 64 osteotomies were performed in 62 patients (43 male, 19 female) at an average age of 57 years. The mean opening wedge was 9.3 mm (range: 5 to 17 mm) and the mean closing wedge was 8.0 mm (range: 6 to 10 mm). Knee alignment changed from a mean of 174 degrees pre-operatively to a mean of 183 degrees post-operatively in both groups. In the medial opening wedge group, total leg length was found to increase from 836.3 ± 63.5 mm pre-operatively to 841.8 ± 64.1 post-operatively, a change of 5.5 ± 4.4 mm (p < 0.0001). A significant correlation was found between the amount of correction and the increase in overall leg length (r. 2. = 0.21, p = 0.009). In the lateral closing wedge group, total leg length was found to decrease from 840.6 ± 51.5 mm pre-operatively to 837.9 ± 52.0 post-operatively, a decrease of 2.7 ± 4.0 mm (p = 0.0008). No correlation was found between the amount of correction and the change in overall leg length. The difference in mean leg length change between opening and closing wedge osteotomies was 8.2 ± 5.9 mm (p < 0.0001). Conclusions:. Medial opening wedge HTO can result in significant leg lengthening depending on the degree of opening. Leg length changes associated with lateral closing wedge HTO are generally smaller. Both techniques results in less leg length change than mathematical models predict. Pre-operative leg length discrepancy should be considered when choosing an osteotomy technique

The optimal correction of the weight bearing line during High Tibial Osteotomy has not been determined. We used finite element modelling to simulate the effect that increasing opening wedge HTO has on the distribution of stress and pressure through the knee joint during normal gait. Subject-specific models were developed by combining geometry from 7T MRI scans and applied joint loads from ground reaction forces measured during level walking. Baseline stresses and pressures on the articulating proximal tibial cartilage and menisci were calculated. Progressive osteotomies were then simulated to shift the weight-bearing line from the native alignment towards/into the lateral compartment (between 40 – 80% of medial-lateral tibial width). Changes in calculated stresses and pressures were recorded. Both stress and pressure decreased in the medial compartment and increased in the lateral compartment as increasingly valgus osteotomies were simulated. The models demonstrated a consistent “safe zone” for weight bearing line position at 50%-65% medial-lateral tibial width, outside of which compartment stresses and pressures substantial increased. This study suggests a safe correction zone within which a medial opening wedge HTO can be performed correcting the WBL to 55% medio-lateral width of the tibia

Introduction. We assessed the role of four different High Tibial osteotomies (HTOs) for medial compartment osteoarthritis of knee (MCOA): Medial Opening Wedge High Tibial Osteotomy (MOWHTO), Focal Dome Osteotomy with Ilizarov Fixator (FDO-I), intra-articular, Tibial Condylar Valgus Osteotomy with plating (TCVO-P) and intra-articular plus extra-articular osteotomy with Ilizarov(TCVO-I); in correcting three deformity categories: primary coronal plane varus measured by Mechanical Axis deviation (MAD), secondary intra-articular deformities measured by Condylar Plateau Angle (CPA) and Joint Line Convergence Angle (JLCA), and tertiary sagittal, rotational and axial plane deformities in choosing them. Materials and Methods. We retrospectively studied HTOs in 141 knees (126 patients). There were 58, 40, 26, and 17 knees respectively in MOWHTO, FDO-I, TCVO-P and TCVO-I. We measured preoperative (bo) And postoperative (po) deformity parameters. Results. Average age was 56.1, average follow-up was 44.6 months. Mean bo-MAD in MOWHTO, FDO-I, TCVO-P, and TCVO-I were 8.8, −14.7, −11.5, −30.8% respectively. po-MAD was close to Fujisawa point in all except TCVO-P (45.2%). CPA corrected from −4.9° to −1.4° (p=0.02)and JLCA from 5.6° to 3.2° (p=0.001); CPA was better corrected by Intra-articular osteotomies (p=0.01). Conclusions. MOWHTO corrects isolated mild primary varus deformities (bo-MAD≥ 0%). Primary varus (bo-MAD= −25% −0%) with associated tertiary sagittal, rotational, or axial deformities, without secondary intra-articular deformities needed FDO-I. Primary varus (bo-MAD= −25% −0%) with secondary intra-articular deformities, without tertiary deformities, corrected well with TCVO-P. TCVO-I corrects severe primary varus (bo-MAD< −25%) with large deformities in secondary and tertiary categories

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporizing measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7- to 10-year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intra-operatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporizing measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7 to 10 year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intraoperatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure

Patients presenting with arthrosis following high tibial osteotomy (HTO) pose a technical challenge to the surgeon. Slight overcorrection during osteotomy sometimes results in persisting medial unicompartmental arthrosis, but with a valgus knee. A medial UKA is desirable, but will result in further valgus deformity, while a TKA in someone with deformity but intact cruciates may be a disappointment as it is technically challenging. The problem is similar to that of patients with a femoral malunion and arthrosis. The surgeon has to choose where to make the correction. An ‘all inside’ approach is perhaps the simplest. However, this often means extensive release of ligaments to enable ‘balancing’ of the joint, with significant compromise of the soft tissues and reduced range of motion as a consequence. As patients having HTO in the first place are relatively high demand, we have explored a more conservative option, based upon our experience with patient matched guides. We have been performing combined deformity correction and conservative arthroplasty for 5 years, using PSI developed in the MSk Lab. We have now adapted this approach to the failed HTO. By reversing the osteotomy, closing the opening wedge, or opening the closing wedge, we can restore the obliquity of the joint, and preserve the cruciate ligaments. Technique: CT based plans are used, combined with static imaging and on occasion gait data. Planning software is then used to undertake the arthroplasty, and corrective osteotomy. In the planning software, both tibial and femoral sides of the UKA are performed with minimal bone resection. The tibial osteotomy is then reversed to restore joint line obliquity. The placing of osteotomy, and the angling and positioning in relation to the tibial component are crucial. This is more important in the opening of a closing wedge, where the bone but is close to the keel cut. The tibial component is then readjusted to the final ‘Cartier’ angle. Patient guides are then made. These include a tibial cutting guide which locates both the osteotomy and the arthroplasty. At operation, the bone cuts for the arthroplasty are made first, so that these cuts are not performed on stressed bone. The cuts are not in the classical alignment as they are based upon deformed bone so the use of patient specific guides is a real help. The corrective osteotomy is then performed. If a closing wedge is being opened, then a further fibular osteotomy is needed, while the closing of an opening wedge is an easier undertaking. Six cases of corrective osteotomy and partial knee replacement are presented. In all cases, the cruciates have been preserved, together with normal patello-femoral joints. Patient satisfaction is high, because the deformity has been addressed, restoring body image. Gait characteristics are those of UKA, as the ACL has been preserved and joint line obliquity restored

Background. High tibial osteotomy is a common procedure to treat symptomatic osteoarthritis of the medial compartment of the knee with varus alignment. This is achieved by overcorrecting the varus alignment to 2–6° of valgus. Various high tibial osteotomy techniques are currently used to this end. Common procedures are medial opening wedge and lateral closing wedge tibial osteotomies. The lateral closing wedge technique is a primary stable correction with a high rate of consolidation, but has the disadvantage of bone loss and change in tibial condylar offset. The medial opening wedge technique does not result in any bone loss but needs to be fixated with a plate and may cause tibial slope and medial collateral ligament tightening. Purpose. The purpose of this article is to examine correlation between femoral rotational angle and subjective satisfaction of high tibial osteotomy outcome of the range of motion of knee joint. Materials and methods. The subjects were 15 patients (6 males, 9 females) with primary osteoarthritis undergoing high tibial osteotomy from June of 2004 to August of 2008. They were CT tested on the knee joint before and after high tibial osteotomy. TEA and Akagi's line are analysed as percentages. The Kendall's and Spearman's nonparametric correlation coefficient were used for the statistical tests with 0.5 level of significance. Results. We observed a negative linear relationship (p = 0.0001) between the femoral component external rotation (measured by TEA) and active and passive ROM. Pearson Coefficient was −0.80, −0.57, respectively. We can find a negative linear relationship (p=0.001) between Akagi's line and passive ROM, and Pearson coefficient was −0.863. Preoperative flexion contracture, age, tibiofibula angle, pain, and other factors do not influence the ROM of the patient. Follow up duration do not influence the ROM of the patient. Conclusion. The result reveals that femoral rotational angle correlates with not the range of motion of knee joint but subjective satisfaction of the patients. In HTO, beside deformity correction in coronal plane, rotation of the femur contributes postoperative pain relief

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporising measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7 to 10 year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intraoperatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure

The biomechanical rationale for osteotomy and the pathogenesis of degenerative arthrosis accompanying malalignment has been delineated well. Malalignment of the limb results in added stress on damaged articular cartilage and causes further loss of articular cartilage that subsequently exacerbates the limb malalignment. A downward spiral of progressive deformity and additional loss of articular cartilage occurs over time. Osteotomy can be used to realign the limb, reduce stress on the articular cartilage at risk and share the load with the opposite compartment of the knee. In appropriately selected patients osteotomy is a reliable operation to improve pain and function. Over the past two decades osteotomy has been viewed largely as a temporising measure to buy time for patients before they ultimately have a total knee arthroplasty. In this role, osteotomy has largely been accepted as successful. Substantial improvements in pain and function have been documented and seem to hold up well over a 7 to 10 year period after the osteotomy. Medial opening wedge osteotomy has recently gained in popularity in the United States after a long period of use in Europe. Potential advantages of the medial opening wedge technique include the ability to easily adjust the degree of correction intra-operatively, the ability to correct deformities in the sagittal plane as well as the coronal plane, the need to make only one bone cut, and avoiding the tibiofibular joint. The downsides of the opening wedge technique include the need for bone graft to fill the created defect, a potentially higher rate of non-union or delayed union, and a longer period of restricted weight bearing after the procedure

Introduction. The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI). Patients and Methods. Thirty five patients undergoing valgus high tibial osteotomy between Oct 2004 and Feb 2010. Surgical outcome was assessed using Oxford Knee score, pre- and post-operative pain scores, change in employment and patient satisfaction. Results. Mean age at the time of surgery was 41 (22 to 62), mean BMI was 30.9 (21 to 43) and mean Oxford score was 37/48 (16 to 48). Patients rated their overall satisfaction as 7.9/10. Three patients were lost to follow-up, two patients died of unrelated disease. Fifteen (50%) patients had heavy manual jobs and of these 12 (80%) returned to their previous employment post-operatively within 6 months. Seven patients had a BMI > 35 (Mean 39) with a mean weight of 126 Kg (105Kg to 144Kg). These patients had a mean Oxford Score of 42/48 and overall satisfaction of 90%. Pain improved from 8.4/10 pre-op to 1.5/10 post-op (P < 0.0001). None had further procedures. Conclusion. Opening wedge high-tibial osteotomy offers a successful alternative treatment of medial osteoarthritis in young patients with high BMI who place high demands on their knees

Osteotomies for valgus deformity are much less frequent than those for varus deformity as evidenced by published series which are, on one hand, less numerous and on the other hand, based on far fewer cases. For genu varum deformity, it has been proved that navigation allows to reach easier the preoperative correction goal. Our hypothesis was that navigation for genu valgum could be as accurate as for genu varum deformity. The aim of this paper was to present the mid-term results of 29 computer-assisted osteotomies for genu valgum deformity performed between September 2001 and March 2013. The series was composed of 27 patients (29 knees), 20 females and 7 males, aged from 15 to 63 years (mean age: 42.4+/−14.3 years). The preoperative functional status was evaluated according to the Lyshölm-Tegner score. The mean score was of 64+/−20.5 points (18–100). The stages of osteoarthritis were evaluated according to modified Ahlbäck's criteria. We operated on 12 stage 1, 9 stage 2, 5 stage 3 and 1 stage 4. 2 female patients had no osteoarthritis but a particularly unesthetic deformity (of which one was related to an overcorrected tibial osteotomy). The pre and postoperative HKA angle was measured according to Ramadier's protocol. We measured also the medial tibial mechanical angle (MTMA) and the medial femoral mechanical angle (MFMA). The mean preoperative HKA angle was 189.3°+/−3.9° (181° to 198°); the mean MFMA was 97.2° +/− 2.6° (93° to 105°) and the mean MTMA was 90.1° +/− 2.8° (86° to 95°). The goal of the osteotomies was to obtain an HKA angle of 179° +/− 2° and a MTMA of 90°+/2° in order to avoid an oblique joint line. We performed 24 femoral osteotomies (14 medial opening wedge and 10 lateral closing wedge) and 5 double osteotomies (medial tibial closing wedge + lateral opening wedge osteotomy). The functional results were evaluated according to Lyshölm-Tegner, IKS and KOO Scores, which were obtained after revision or telephone call. We did not find any complication except a transient paralysis of the common fibular nerve. 23 patients (4 lost to follow-up) were reviewed at a mean follow-up of 50.9+/−38.8 months (6–144). The mean Lyshölm-Tegner score was 92.9+/−4 points (86–100), the mean KOO score 89.7+/−9.3 (68–100), the mean IKS ≪knee≫ score 88.7 +/−11.4 points (60 à 100) and the mean ≪function≫ score 90.6 +/−13.3 points (55–100). 22 of the 23 reviewed patients (25 knees) were very satisfied or satisfied of the result. Regarding the radiological results, the mean HKA angle was of 180.1°+/−1.9° (176° to 185°), the mean MFMA of 90.7°+/−2.5° (86°-95°) and the mean MTMA of 89.1°+/−1.9° (86°-92°). The preoperative goal was reached in 86.2% (25/29) of the cases for HKA angle and in 100% of the cases for MTMA when performing double level osteotomy (5 cases). At this follow-up, no patient was revised to TKA. Computer-assisted osteotomies for genu valgum deformity lead to excellent results a mid-term follow-up. Navigation is very useful to reach the preoperative goal

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