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.
Minimally invasive plate osteosynthesis is a technically feasible surgical alternative to treat displaced diaphyseal fractures of the tibia. In recent years, this technique has evolved in response to the poor results following tibial fracture stabilization using the traditional open method of plate fixation. Devascularisation with periosteal stripping of bone fragments using open reduction and internal fixation to ensure adequate fracture visualisation led to a substantial percentage of complications including deep infection, delayed union or non union, and refractures after plate removal. Using the technique of minimally invasive plate osteosynthesis, fracture management is achieved with closed reduction followed by stabilisation using a subcutaneous epiperiosteal LC-DC-plate. Twenty-four patients with 25 tibial fractures were treated by minimally invasive plate osteosynthesis at the Kantonsspital, Fribourg, Switzerland, between 1997 and 1999. These cases were retrospectively reviewed. There were 11 male and 13 female patients with a mean age of 41 years (range 16 -64). Nineteen tibial diaphyseal fractures (7 type A, 11 type B, and 1 type C) and six tibial epiphyseal-metaphyseal fractures (4 type A, 1 type B, and 1 type C) were surgically treated. Three fractures were open (grade I). Twenty-four fractures were treated using a 4.5 mm titanium LC-DC-plate, and in one fracture a 4.5 mm stainless steel DC-plate was used for tibial fixation. Open reduction and internal fixation of the fibula was necessary in eleven fractures, nine of which were stabilized with a one-third tubular plate and two with a 3.5 mm LC-DC-plate. The postoperative regimen included partial weight bearing for eight weeks followed by progressive and protected weight bearing until fracture union was achieved. Fracture union was confirmed with radiographs obtained at six to eight weeks, twelve to sixteen weeks, and at final follow-up. The mean time to final follow-up was eighteen months. All fractures had solidly united within four months postoperatively. Radiographically, healing was characterised by callus formation located on the lateral and posterior aspects of the tibial diaphysis, and was similar to that which is usually seen after stabilisation of tibial fractures using an intramedullary rod. Both ankle and knee range of motion were similar to the uninjured side by final follow-up. There were eight cases of residual valgus malalignment of less than five degrees, and were associated with distal third tibial diaphyseal fractures with concomitant fibula fractures which were not rigidly stabilised. Postoperative complications included two deep wound infections and one postoperative compartment syndrome. Overall good results were obtained by using minimally invasive plate osteosynthesis of diaphyseal fractures of the tibia. Although this technique is more technically demanding than standard open reduction and internal fixation of tibial diaphyseal fractures, preservation of the soft tissue envelope and periosteal blood supply is beneficial for fracture healing. Surgical indications for minimally invasive plate osteosynthesis of the tibial diaphysis include a narrow tibial medullary canal as well as distal and proximal metaphyseal fractures not suitable for intramedullary rodding, and associated intra-articular tibial fractures. Minimally invasive plate osteosynthesis should be considered as a surgical alternative for the treatment of displaced diaphyseal fractures of the tibia.
Between 1989 and 1994 we used a vascularised ipsilateral fibular graft in 24 patients with segmental tibial defects. We report 12 patients with a minimum follow-up of two years. The graft was either transposed medially or inverted on its vascular pedicle. Full weight-bearing was achieved at between four and seven months. We had few complications and consider that the use of this method is a valuable option in reconstruction of the tibia.
We reviewed retrospectively 490 patellar ligament reconstructions for cruciate ligament injuries performed from 1980 to 1990. There were six cases of patellar splitting and three displaced patellar fractures in donor knees. The fissure fractures all occurred during the removal of the patellar bone block. The displaced fractures were sustained during early rehabilitation, and in two of the three patients, involved the normal contralateral knee. The major reasons for this complication were imprecise saw cuts, spreading osteotomies, and the use of a too large patellar bone block. When a trapezoidal bone block is used to self-lock in the femoral tunnel, this should preferably be taken from the tibia. Special care is needed in rehabilitation when the graft has been taken from the contralateral knee.
There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury.
We evaluated the accuracy of six clinical tests for posterior instability in 24 knees with acute surgically-proven posterior cruciate ligament injuries and intact anterior cruciate ligaments. We also performed stress radiography under anaesthesia. The gravity sign and the posterior drawer test in near extension and its passive reduction were diagnostic in 20 of the 24 knees, and the active reduction of posterior subluxation was diagnostic in 18. The reversed pivot shift sign helped to diagnose severe posterior and posterolateral subluxations, but the external rotation recurvatum test was negative in all 24 knees. Stress radiography in near extension revealed a highly significant increase in posterior tibial subluxation in the injured knees.
A logical, objective and reproducible grading system for the pivot shift test is proposed. The rationale is based on performing the examination in varying positions of rotation of the tibia, allowing the type and degree of the different laxities to be defined and quantified. The system has been assessed against a new "unblocked" test for anterior subluxation and against radiographic measurements, operative findings and results. This grading system can be valuable in pre-operative assessment and planning and its use in postoperative evaluation would enable results from different centres and different procedures to be compared more accurately.
The Blackburne and Peel method of assessing the position of the patella was applied to 185 knees with Osgood--Schlatter disease in 125 patients. The normal index of 0.80 was confirmed in 73 control knees. The average index in the knees with Osgood--Schlatter disease measured 1.01 (patella alta) boys and 0.91 in girls. The value increased to 1.06 in boys with radiological evidence of loose ossicles in the tibial tuberosity or the patellar tendon. This finding indicates that the strong pull of the well-developed quadriceps muscle is probably the most important aetiological factor in patella alta associated with Osgood--Schlatter disease.
A new method for the measurement of tibial torsion using computerised transverse tomography is presented. Its accuracy is equal to that of cadaveric skeletal measurement. This method may be used in patients with unilateral post-traumatic torsional deformities, especially when these are combined with genu varum or valgum. The study of torsional aberrations in connection with congenital abnormalities of the foot is of further interest.
From an anatomical study and clinical review of fractures of the lateral humeral condyle in children, the following conclusions are drawn. The mechanism of injury is a violent varus force with the elbow in extension, the condyle being avulsed. by the lateral ligament and the extensor muscles. If the fracture is incomplete, with an intact hinge of pre-osseous cartilage medially, the fragment will not be displaced. If the fracture is complete the fragment may be displaced, and open reduction with internal fixation is mandatory. The results of open reduction more than three weeks after the fracture are no better than those of no treatment at all, and may kill the lateral condylar fragment by damaging its blood supply. The major problem of a neglected fracture is tardy ulnar nerve palsy; to avoid this, immediate anterior transposition of the nerve is recommended, operation for the fracture itself being of no benefit.
