Closing Wedge Osteotomy Research Articles

Correction of Triphalangeal Thumb with Small Delta Phalanx by Closed Wedge Osteotomy of the Proximal Phalanx: A Case Report

Background: Triphalangeal thumb (TPT) is a rare congenital anomaly, especially in the Asian population. Traditional treatments depend on the type of deformity and the presence of concomitant anomalies and include either excision in addition to the ligament reconstruction or fusion and shortening osteotomy. Instability and stiffness are the major concerns following the traditional techniques. Case Report: In this study, we report a case of right TPT with a small delta phalanx in a nine-year-old boy who was treated by proximal phalanx radial closed wedge osteotomy without delta phalanx resection or intracapsular dissection. The angular deformity and the appearance of the thumb were corrected by this simple procedure without resulting in instability and stiffness in the interphalangeal joint. Conclusion: Proximal phalanx closed wedge osteotomy is a rapid, simple, and effective technique with a low risk of unexpected complications for correcting the appearance in the cases of TPT with a small delta phalanx.

Biomechanical Changes to the Hindfoot After Zadek Osteotomy.

Insertional Achilles tendinopathy (IAT) is a common source of heel pain in active adults and athletes. The Zadek osteotomy (ZO) is a calcaneal dorsal closing wedge osteotomy that has demonstrated clinical success as a treatment for IAT, purported to favorably improve tendon mechanics, decrease impingement, and decrease pressure within the retrocalcaneal bursa. The present study aims to evaluate the biomechanical effects of ZO on Achilles strain, position of the Haglund prominence relative to the Achilles insertion, and retrocalcaneal pressure. The ZO was performed on 10 fresh-frozen foot and ankle mid tibia-fibula cadaveric specimens. An osteotomy was performed using a 1-cm dorsal closing wedge procedure secured with a 7.0 mm cannulated screw. Point pressure sensor catheters and differential variable reluctance transducers were used to measure the retrocalcaneal pressure and Achilles strain, respectively, pre- and postosteotomy. Paired t-tests were utilized to detect statistical differences (P < .05). After the ZO, the Haglund prominence was translated 9.9 mm anteriorly with respect to the insertion of the Achilles (P < .05) and the Achilles tendon insertion was translated 3.4 mm proximally (P < .05). The ratio of calcaneal length to greater tuberosity length, the X/Y ratio, increased from 2.56 to 3.52 with the osteotomy (P < .05). At maximum dorsiflexion, retrocalcaneal pressure decreased from 117 to 66 mm Hg (44%, P = .018). The Achilles strain changed from 0.00362 to 0.00436 in the anterior fibers (P = .484) and changed from 0.00467 to 0.00283 in the posterior fibers (P = .088). Biomechanical testing in a cadaveric model demonstrates that the ZO decreased retrocalcaneal pressure, shifted the Achilles tendon insertion proximally, increased the X/Y ratio of the calcaneus, and did not significantly change the strain of the Achilles tendon. Despite the clinical success demonstrated in recent literature, there are no biomechanical studies describing the effect of the ZO on the biomechanics of the hindfoot, and the mechanism of symptom relief of the ZO for IAT is not well understood. The present study measures two potential ZO effects relative to Haglund prominence by measuring retrocalcaneal pressure and displacement of the Achilles tendon with respect to the Haglund prominence, and measures one ZO effect relative to calcification of the tendon by measuring the Achilles tendon strain.

Comparative study of dorsiflexion closing wedge osteotomy of the metatarsal head and osteochondral autologous transplantation for Freiberg disease treatment: A multicenter analysis

Freiberg disease (FD) is a condition characterized by osteochondrosis affecting the metatarsal heads, with the second metatarsal head being the most commonly affected. Dorsiflexion Closing Wedge Osteotomy of the Metatarsal Head (DCWMO) has been conventionally employed, whereas Osteochondral Autologous Transplantation (OAT) represents a more recent technique with restricted comparative research. This study aimed to compare the outcomes of DCWMO and OAT for treating Freiberg disease (FD). Groups were established among two institutions. Institution-1 has made the treatment with OAT (8 patients) and Institution-2 has made the treatment with DCWMO (8 patients). The primary outcomes collected, including complications, range of motion, length of the metatarsal, American-Orthopaedic-Foot-and-Ankle-Society–lesser MTP-interphalangeal (AOFAS-LMI) score, visual-analog-scale (VAS), Foot-and-Ankle-Disability (FADI) score, and Short-Form-12 (SF-12), were all compared. The Sport-FADI and activity-FADI scores at final follow-up were significantly greater in the OAT group than in the DCWMO group (94.04 vs 84.75 and 97 vs 92, P = 0.021 and P = 0.04, respectively), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (43.13 vs 6.88 degrees, P < 0.001). The AOFAS-LMI score at final follow-up was significantly greater in the DCWMO group than in the OAT group (86.75 vs 75.38, P = 0.013). In conclusion, this study highlights the effectiveness of both OAT and DCWMO in treating Freiberg's disease, as evidenced by significant postoperative improvements in various functional scores, including AOFAS-LMI, VAS and FADI. Notably, OAT demonstrated favorable outcomes in SFADI and AFADI and plantarflexion ROM, while DCWMO led to improved the AOFAS-LMI score.Level of Evidence: Level 3

Contemporary use of 3D printed jigs and guides for osteotomies around the knee: a systematic review

Background. With improved accessibility of imaging and additive manufacturing, custom targeting guides and jigs are now widely accepted across many areas of orthopaedics. During orthopedic surgery, patient-specific guides assist in the accurate drilling and cutting of bone in conjunction with meticulous pre-operative planning. Given their increased uptake, it is important to define the lessons learned from recent clinical experience, and to document the reported benefits when using this technology intra-operatively. The aim of this review is to evaluate the potential benefits of patient-specific guides for osteotomies about the knee, and to clarify what evidence currently exists to support their use. Methods. A systematic review of PubMed, Embase, and Web of Science was performed for studies investigating the use of intra-operative patient-specific guides for realignment osteotomies about the knee. Randomised controlled trials, non-randomised studies, observational studies, case series, and case reports, as well as in vitro studies, were included. Screening was conducted with the Covidence software, and risk of bias was assessed with the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Results. A total of 38 studies satisfied the inclusion criteria: 21 of these included patient-specific instrumentation (PSI) for high tibial osteotomy, 6 with distal femoral osteotomy, 4 — for combined tibial/femoral rotational corrective osteotomies, 4 — in double-level osteotomies, and 6 — for intra-articular osteotomies. The main outcomes reported were accuracy of surgical correction, typically with reference to pre-operative plans, and execution accuracy based on radiographic measurements. Other common outcomes were operative time, intra-operative fluoroscopy, and operative costs. Many studies were observational in nature, with no control groups available for suitable comparison. Conclusions. For corrective osteotomies about the knee, the literature suggests PSI has very strong potential to improve accuracy in achieving pre-operative targets. This was reported for both opening and closing wedge osteotomies of the femur, and for high tibial osteotomy. Some contradictory results have been reported for high tibial osteotomy, based on limited evidence from small studies that in many instances lacked controls for comparative analysis. Additional controlled trials are necessary to confirm the benefits of PSI for osteotomies about the knee, considering it has not yet been conclusively validated. The literature currently available indicates PSI can improve the accuracy of corrective osteotomies about the knee.

Modified Cranial Closing Wedge Osteotomy (AMA-Based CCWO) to Treat Cranial Cruciate Ligament Deficient Stifle in 204 Dogs Over 50 Kg: Magnitude of the Craniocaudal Angulation of the Proximal Tibia and Rate of Surgical Site Infection.

The aim of this retrospective study was to report the magnitude of the craniocaudal angulation of the proximal tibia (CCAPT) quantified by the angle between the anatomical axis (AA) and the mechanical axis (MA), called the AMA angle, and the tibial plateau angle (TPA) in dogs >50 kg that were treated by cranial closing wedge osteotomy based on the AMA angle (AMA-based CCWO). Furthermore, the percentage of dogs in which the AA and MA could be aligned postoperatively and the rate of surgical site infection (SSI) were reported. Medical records (between January 2016 and September 2023) were reviewed for 204 dogs that had AMA-based CCWO stabilized with a double locking plate (DLP) fixation with or without joint exploration plus a Robert Jones bandage (RJB) and were given postoperative antibiotics. The median (range) preoperative AMA angle and TPA were 3.1° (0-5.1°) and 30° (22-49.6°), respectively, and the postoperative AMA angle and TPA were 0° (-2.4 to 1.6°) and 9.2° (4-15°), respectively. The AA and MA were aligned in 82% of dogs. Grade 4 healing occurred in all osteotomies by 8 weeks postoperatively. Except for one dog, no SSIs were recorded. Concerning the magnitude of CCAPT in dogs >50 kg and the low SSI rate, AMA-based CCWO stabilized with a DLP fixation plus an RJB and postoperative antibiotics should be considered for treating cranial cruciate ligament-deficient stifles in this subset of dogs.

Decompression corrective osteotomy of the distal radius for treatment of the DRUJ-incongruency and impingement syndrome with focus on posttraumatic cases

IntroductionPosttraumatic or congenital ulna-minus variance with altered shape of the sigmoid notch and increased tension of the distal oblique band of the interosseous membrane (DIOM) can lead to painful impingement in the distal radioulnar joint (DRUJ) during rotation and loading of the forearm. As an operative treatment concept, a new method was described in 2016. Its goal is to restore the osseous congruency, which is required for normal painless function. The hypothesis is based on remodelling of the joint surface and the decompression of the DRUJ by releasing the DIOM. The purpose of this study is to analyze the results of performed operations with detailed focus on posttraumatic cases. Materials and Methods: The indication for the operation is the impingement and incongruency in the DRUJ with ulna-minus variance. The surgical procedure is based on shortening and closed-wedge osteotomy of the distal radius with an ulnar translation of the radial shaft. Fifty-nine operations were performed between 2011 – 2022 on 52 patients (13 men, 39 women). Twenty-four patients were operated on the right side, 21 on the left side and 7 bilaterally. In 45 cases the operation was indicated because of congenital, in 12 cases due to posttraumatic incongruency and in 2 cases because of iatrogenic impingement after previously performed excessive ulnar shortening osteotomy. Modified Mayo-Wrist-Score, patient questioning, VAS and ROM were used to evaluate the results. ResultsSignificant reduction of pain on VAS from 7.22 to 1.98 (p < .001) was achieved. The pre- and postoperative range of motion did not show any significant changes (mean total arc of motion 301,94° vs. 295,20°, p = .300). Specific complications we observed included a too distally performed osteotomy, DRUJ instability, de Quervain´s tenosynovitis, persistent pain and conversion into an ulna-plus variance. ConclusionUnder consideration of the indication criteria and correct execution of the osteotomy, in about 90 % of the cases this operation leads to good-to-excellent results with pain reduction and improvement of weight-bearing and power. The preoperative examination, verification of the DRUJ stability and the radiological diagnostics are crucial for a good outcome.

Distal Radius Osteotomies for Kienbock's Disease—A Minimally Invasive Approach

Abstract Background Negative ulnar variance is a recognized predisposing factor for Kienbock's disease (KD). Radial shortening osteotomy (RSO) reduces radial height, thereby alleviating stress on the lunate. Conversely, radial closed wedge osteotomy (RCWO) involves removing a distal radius wedge to not only decrease radial height but also reduce radial inclination, thereby enhancing lunate coverage. Description This article outlines a straightforward and minimally invasive approach to RSO utilizing a single cut and stabilization with a single screw. Additionally, it introduces a technique for RCWO comprising two cuts, wedge removal from the distal radius, and fixation using a single headless screw. Literature Review Traditionally, RSO and RCWO procedures include a volar approach consistent with distal radius fracture fixation techniques. However, the reliance on “free-hand” cuts may necessitate larger hardware for stabilization. Overcorrection poses risks of suboptimal outcomes and often mandates subsequent hardware removal procedures. Clinical Relevance Both RSO and RCWO techniques offer minimally invasive solutions, which preserve the periosteum, and maintain stability. These techniques only require a single screw and a removable splint. RSO is indicated for KD wrists with negative ulnar variance, while RCWO is preferable for cases with negative ulnar variance and increased radial inclination.

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique.

There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Using an anterior approach to the distal tibia, the "alpha angle," which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the "beta angle." This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings. Olleac R, Farfan F, Acosta L, et al. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. Strategies Trauma Limb Reconstr 2024;19(2):104-110.

Infratubercle Anterior Closing Wedge Osteotomy Corrects Sagittal Alignment without Affecting Coronal Alignment or Patellar Height.

Background: Excessive posterior tibial slope (PTS) has been associated with a higher risk of graft failure after anterior cruciate ligament reconstruction (ACLR). Although anterior closing wedge osteotomy (ACWO) can reduce the PTS, it may also change the coronal alignment and patellar height. Purpose: To elucidate the radiological outcomes after infratubercle ACWO, specifically to evaluate its influence on perioperative changes in patellar height. Methods: Patients who underwent infratubercle ACWO with combined ACLR with a minimum follow-up of 3 months were included. Surgery was indicated when the PTS was greater than 12°. Radiological evaluation included measurements of the hip-knee-ankle angle (HKA), PTS, femoral patellar height index (FPHI), and Caton-Deschamps index (CDI) preoperatively and 3 months postoperatively. Patellar height was classified as patella baja, normal, or alta based on CDI values. Knee recurvatum was measured preoperatively and at final follow-up. Results: A total of 21 patients with a mean age of 21.6 ± 3.0 years were included. Although HKA did not significantly change, significant corrections were achieved in the PTS from 14.5° ± 1.6° to 5.7° ± 1.0° (p < 0.001). No significant change in FPHI was found (preoperative: 1.33 ± 0.11 vs postoperative: 1.30 ± 0.09). Patellar height categories showed no significant differences pre- and postoperatively, while three patients (14.3%) changed their patellar height category (all moved up one category). Knee recurvatum increased significantly from 4.9° ± 2.9° preoperatively to 7.8° ± 3.1° at the final follow-up (p < 0.001). Conclusions: Precise sagittal correction was achieved after infratubercle ACWO without altering the coronal alignment and patella height. Level of Evidence: IV, Case series.

In proximal tibial anterior closing wedge (slope changing) osteotomy lower starting points imply larger bone resection

BackgroundAnterior closing wedge osteotomy (ACWO) for tibial slope correction is a validated procedure in revision anterior cruciate ligament reconstruction (ACLR). This study aims to determine how different starting points of the osteotomy affect the amount of bone resection in ACWO. HypothesisWe hypothesized that the lower osteotomy starting points in ACWO imply larger bone resection. Patients and methodsA total 52 patients who underwent ACWO using infra-tuberosity technique in our institution were included in this study. Each of patients was simulated using additional two separate methods (based on osteotomy level: supra- and trans-tuberosity) based on lateral calibrated pre-operative X-rays of the whole tibia according to the post-operative correction angle. The resection height of the closing wedge, which corresponded to the base of the osteotomy, was measured and compared among the three groups. ResultsThe mean actual pre-operative proximal posterior tibial angle (PPTA) was 75.8 ± 2.0°. Post-operatively, PPTA was 84.0 ± 0.6°, and correction angle was 8.2 ± 2.2°. The mean resection height in the supra-tuberosity group was 7.5 ± 0.2 mm, 8.0 ± 2.1 mm in the trans-tuberosity group, and 9.2 ± 2.1 mm in the infra-tuberosity group. There were significant differences between each approach (p ≦ 0.0001). Resection height was moderate positively correlated with the starting point of osteotomy (r = 0.33, 95%CI: 0.18–0.46, p < 0.0001). ConclusionThis study suggests that selecting a distal starting point for the osteotomy in ACWO is directly proportional to the observed increase in bone resection, providing valuable insights for pre-operative planning. These findings are clinically relevant and will aid in preoperatively deciding approach in ACWO. Level of evidenceIV; retrospective case-control study.

Knee valgus deformity: indications and outcomes for a high tibial medial closing-wedge osteotomy

IntroductionTraditionally, knee valgus deformities have been corrected through distal femur osteotomies. The advances in preoperative planning allow surgeons to understand the leading site of deformity better and, therefore, propose corrections at the appropriate anatomical location. ObjectivesThe purpose of this evaluation is to present a case of a knee valgus deformity where most of the deformity resulted from the joint and the proximal tibia. A medial closing wedge tibial osteotomy corrected the proximal tibia deformity, while a fresh osteochondral allograft aimed to improve the surface of the lateral compartment of the knee, optimizing the joint lateral convergence angle. In addition, indications, outcomes and a scoping review of the literature for closing wedge high tibial osteotomy for knee valgus deformity is reviewed. MethodsA clinical case report example of a patient with knee valgus deformity requiring closing wedge high tibial osteotomy is presented. Detailed discussion of preoperative templating, planning and surgical completion is reviewed. A systematic review of previous studies and outcomes after closing wedge high tibial osteotomy was undertaken and summarized. ResultsThe case presented demonstrates an example of a valgus knee deformity with alignment correction vis a proximal tibial ostetomy. A review of and summary of previous case reports and outcomes studies for similar pathology demonstrates a high degree of success for this surgical approach. ConclusionsClosing wedge high tibial osteotomy is a viable treatment option for knee valgus deformity with an abnormal mechanical medial proximal tibial angle (mMPTA). A thorough evaluation of joint orientation angles is necessary to appropriately address limb deformity at the specific locations(s) of significant anatomic abnormality.

The application of proximal tibial anterior closing wedge osteotomy in anterior cruciate ligament reconstruction

IntroductionPosterior tibial slope (PTS) plays a vital role in knee stability. PTS of more than 12° may be considered with increased strain on the native anterior cruciate ligament (ACL) fibers. To handle the instability caused by changes in PTS degree, Proximal Tibial Anterior Closing Wedge Osteotomy (PT-ACWO) is adopted by surgeons. MethodsBetween October 2015 and October 2019, our department conducted a retrospective analysis of patients who experienced anterior cruciate ligament reconstruction (ACLR) graft failures, with a particular focus on pathological PTS. The time from initial ACLR to revision ranged from 1 to 10 years, with a mean of 2.5 years. Radiological assessments of PTS were conducted, and outcomes were quantified using the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The surgical technique and the use of 3D Patient-Specific Instrumentation (PSI) were outlined. Preoperative imaging included the use of Kirschner wires to establish tibial plateau reference points, and 3D-PSI was employed to guide the location and depth of the tibial osteotomy, which was performed obliquely. In a notable instance, a novel tibial tunnel was mapped out, and ortho-bridge system (OBS) fixation was utilized to ensure adequate space for the new tunnel. ResultsIn a cohort of seven patients with a mean follow-up of 28.1 months, a significant reduction in PTS was noted postoperatively (median [interquartile range, IQR], from 15.27° [13.46°, 16.60°] to 6.25° [5.89°, 6.78°]; P = 0.002). IKDC score improved to 85.10 (80.25, 88.10), P < 0.001; the Lysholm score to 88.00 (73.00, 90.50), P < 0.001; and the Tegner score to 8.00 (7.20, 8.05), P = 0.025 at final follow-up. Skin incision healing delays occurred in two instances, yet achieved closure by six weeks. Radiographs at three months demonstrated faster bone healing in oblique osteotomies than transverse ones. Knee joint stability was maintained, with no additional complications or evidence of instability noted. Magnetic resonance imaging (MRI) confirmed graft integrity in all patients, without signs of enlargement or mispositioning at last observation. ConclusionAn augmented PTS angle exceeding 12 may constitute a potential etiology for the failure of ACLR grafts. In such patients, the implementation of ACLR combined with PT-ACWO could mitigate the risk of surgical failure during initial ACLR or subsequent revision procedures.

Treatment of Congenital Ulnar Impingement Syndrome by Corrective Osteotomy of the Distal Radius - Clinical Results

In 2016, a new method was described to treat the painful impingement syndrome of the DRUJ: decompression corrective osteotomy of the distal radius. Clinical symptoms are based on a positive compression test; pain occurs with weight-bearing on the forearm. This phenomenon is seen in conjunction with a deformed sigmoid notch together with ulna minus-variance, which leads to increased tension in the distal oblique bundle of the interosseous membrane. The etiology of the condition can be either congenital, post-traumatic, or iatrogenic. Through the proposed osteotomy, decompression in the DRUJ is achieved. This study summarises the results of these surgical procedures performed in our hand centre exclusively in cases of congenital origin. Remodelling of the DRUJ is achieved through the shortening of the distal radius together with closed wedge osteotomy. Relief of the interosseous membrane is accomplished by ulnar translation of the radial shaft. This study only included patients with congenital incongruency in the DRUJ. The results were evaluated using a visual analogue scale (VAS) and the Krimmer Wrist Score and by measuring the preoperative and postoperative range of motion as well as grip strength. Within 11 years, 45 procedures were performed with our method on 38 patients, of which 17 were treated on the right side, 14 on the left side, and 7 bilaterally. In cases of bilateral incongruency, only the symptomatic side was treated. The statistical evaluation showed a significant reduction of pain on the VAS from 7.2 to 2 (p<0.001). No significant changes were seen in the range of motion (p=0.812). The Krimmer Wrist Score showed good to excellent results in almost 90% of cases. If the indication criteria are met, contraindications are avoided and the osteotomy is correctly performed, this technique leads to an improvement of patients' functionality and quality of life. From a preventive viewpoint, the influence on the progression of the degenerative changes is yet to be demonstrated in further studies. At any rate, this is a safe procedure, which leaves the path open for other possible options.

Dorsal Metatarsal Closed Wedge Osteotomy in the Treatment of Freiberg's Disease: A Prospective Observational Study.

The aim of this study was to prospectively evaluate the clinical and radiological results of dorsal metatarsal closed wedge osteotomy and headless screw fixation in the surgical treatment of Freiberg's disease.Thirty-four patients who were treated with dorsal metatarsal closed wedge osteotomy (DMCWO) for Freiberg's disease between February 2018 and March 2022 were included in the study. Patients were staged according to the classification system described by Smillie. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society's (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the visual analog scale (VAS), the range of motion (ROM) of the metatarsophalangeal (MTP) joint, and a subjective patient satisfaction questionnaire. For radiological evaluation, the amount of preoperative shortening of the involved metatarsal, the amount of metatarsal shortening developed after osteotomy, and radiological recovery times were recorded.Thirty-two (94.1%) of the patients were female, and two (5.9%) were male. The average postoperative follow-up period for patients was 33.7 months (range: 24 months to 41 months). The mean AOFAS scores increased from 53.24 to 86.26 (p<0.01). The mean VAS scores decreased from 8.59 to 1.79, and it was observed that the patients' pain improved significantly (p<0.01). The mean ROM of the MTP joint increased from 48.76 degrees to 70.76 degrees (p<0.01). An average of 2.5mm (range 1mm to 4.1mm) of shortening of the metatarsal length developed postoperatively (p<0.01). Arthrosis developed in 1 case (2.9%), and transfer metatarsalgia developed in 2 cases (5.8%).DMCWO is an effective treatment for both the early and advanced stages of symptomatic Freiberg's disease, leading to high patient satisfaction.

Paper 32: Leg Length Changes Following Distal Femoral Osteotomy: Validation of a Predictive Tool and Comparison of Lateral Opening Wedge and Medial Closing Wedge Techniques

Objectives: A DFO can be performed via two techniques: a lateral opening wedge (LOW) osteotomy and a medial closing wedge (MCW) osteotomy. Small case series have looked at how leg length is affected by a lateral opening wedge DFO, however, there is a lack of research comparing these leg length changes to medial closing DFO. Additionally, no studies have presented a model for predicting the leg length changes that will occur following DFO of either technique. Given that limb length differences can lead to accelerated osteoarthritis, back pain, hip pain, and other issues, being able to predict which technique can help prevent this pathology without a secondary procedure would be an important finding. Finally, the medial closing wedge osteotomy can allow for immediate weight-bearing while the lateral opening wedge does not and typically has associated cost with bone grafting. Therefore, we designed this study to validate a tool designed to predict leg length changes after distal femoral osteotomy (DFO) and compare changes following medial closing wedge (MCW) and lateral opening wedge (LOW) techniques. Methods: A collaborative retrospective review was performed of patients from Rush and Mayo Clinic databases who received a DFO and had full-length standing radiographs both pre-and postoperatively. For each preoperative radiograph, the region on the medial (for LOW) or lateral (for MCW) distal femur cortex that would be the “hinge point” during DFO was identified. The distances from the center of the femoral head to the hinge point (“A”), from the hinge point to the center of the tibial plafond (“B”), and the resultant angle at the hinge point (“α”) were measured (Figure 1). Figure 2 demonstrates the equation used to plot a graph of the predicted leg length changes corresponding to the change in α angle produced by DFO. Final leg length was calculated on postoperative radiographs, and the difference between predicted and true leg length changes was compared using paired Wilcoxon signed rank exact tests. Results: 10 MCW and 10 LOW patients were included. For both LOW (n=10) and MCW (n=10) osteotomies, the predicted leg length change was equivalent to the true change measured on postoperative radiographs (LOW P=0.16; MCW P=0.85). LOW DFO’s had 5.10 ± 2.77 mm (range: 1.45-10.87 mm) of leg lengthening, compared to 2.61 ± 1.25 mm (range: 0.50-4.56 mm) of leg shortening (p&lt;0.001) for MCW (Figure 3). On average, there was 0.85 mm of lengthening (range 0.5-1.3 mm) for every 1° of mechanical axis correction with LOW DFO, compared to 0.45 mm of shortening (range: 0.1-1.4 mm) per 1° of MCW correction. Conclusions: This study presents a tool to accurately and reliably predict the leg length changes seen after both medial closing and lateral opening wedge DFO’s. Knowing what leg length changes to expect with each DFO technique is a useful tool that surgeons can utilize during surgical planning. Preoperative radiographic imaging can be used to predict leg length change following DFO with high reliability and accuracy. Surgeons can expect approximately 0.85mm of lengthening per 1° of DFO correction when performing LOW, compared to 0.45mm of shortening per 1° correction for MCW osteotomies.

Paper 34: Supratubercle Anterior Closing Wedge Osteotomy: No Change in Patellar Height, Compared to Decreased Height for Medial Opening Wedge Proximal Tibial Osteotomy, and Significant Decreases in Anterior Tibial Translation at Six Months Postoperatively

Objectives: The purpose of this study was to radiographically assess changes in 1) patellar height, 2) anterior tibial translation (ATT), and 3) posterior tibial slope following supratubercle ACW-PTO and to compare changes in patellar height to a cohort of medial opening proximal tibial osteotomies (MOW-PTO). Methods: Patients who underwent supratubercle ACW-PTO by a single surgeon from July 2019-February 2023 were included. Institutional Review Board approval was obtained for this study. Radiographic assessment at four time points (preoperative, postoperative day 1, 3 months and 6 months) of patellar height (via the Caton Dechamps and Insall Salvati ratios), posterior tibial slope, and anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle was completed. A comparison cohort of patients undergoing MOW-PTO was included for comparison of patellar height. Results: Patellar height averages ( n=16) after ACW-PTO using the Caton-Deschamps ratio (Figure 1) demonstrated a significant increase in patellar height on postoperative day 1 ( p=0.004), but were not significantly different at 3 and 6 months postoperatively (Table 2). Conversely, averages of patellar height after MOW-PTO ( n=28) demonstrated no difference on postoperative day 1, but then was significantly decreased by 6 months postoperatively ( p=0.005) (Table 1). There was a significant difference between the closing and opening-wedge cohorts when comparing the difference in patellar height using the CD ratio between preoperative and 6 months ( p=0.011). Anterior tibial translation in the ACW-PTO cohort was significantly decreased by an average of 9.0 mm from preoperative to postoperative values ( p&lt;&lt;0.001) (Figure 2). Posterior tibial slope in the ACW-PTO cohort was significantly decreased by an average of 11.8° from preoperative to postoperative values ( p&lt;&lt;0.001). Conclusions: Supratubercle ACW-PTO performed for ACL failure in the setting of increased tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, following ACW-PTO there was a significant decrease in anterior tibial translation and posterior tibial slope.

An Update on Emerging Techniques and Considerations in Revision Anterior Cruciate Ligament Reconstruction.

» The rate of primary anterior cruciate ligament reconstruction (ACLR) failure in at-risk populations remains unacceptably high and necessitates thorough evaluation of native alignment and concomitant injuries.» Posterior tibial slope of >12° is a substantial risk factor of ACLR failure and should be corrected through anterior closing wedge osteotomy.» Varus malalignment of >5° exacerbates stress on the ACL graft, increases ACLR failure risks, and should be considered for correction through high tibial osteotomy at the time of revision ACLR.» Injuries to the anterolateral ligamentous complex are prevalent in ACL ruptures, and high-risk patients have shown benefit from anterolateral ligament reconstruction or lateral extra-articular tenodesis in the revision setting.» Addressing posterolateral corner, collateral ligament, and meniscal injuries, during revision ACLR, is vital to mitigate increased graft forces and optimize knee stability and functional outcomes.

Poster 261: The Influence of Slope Reducing Osteotomy on Patella Height in Patients Undergoing Revision ACL Reconstruction: An Evaluation of a Tibial Tubercle-Sparing Anterior Closing-Wedge Osteotomy Technique

Objectives: The purpose of this study was to evaluate the effect of tibial tubercle-sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstructions (ACLR). Methods: Patients who underwent arthroscopic revision ACLR combined with retro-tibial tubercle anterior closing wedge high tibial osteotomy (ACW-HTO) from 01/01/2016 to 31/03/2021 were assessed for eligibility. Patellar height was measured on full weightbearing lateral x-rays according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal x-rays using the Femoral Patellar Height Index (FPHI). The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral x-rays. The delta (post-operative - preoperative) and the ratio (pre-operative / post-operative) of the three patellar height indices and PTS were calculated. Preoperative to postoperative patellar height were compared using independent t tests for each index. It was also investigated whether patients changed patellar height category (baja, norma, or alta). Results: Among 475 revision ACLR, 47 tibial tubercle-sparing ACW-HTOs were performed. No significant difference in patellar height was found between pre- and postoperative x-rays regardless of the index (ISI P = .1729, CDI P = .4034, FPHI P = .5130). Despite the lack of a statistically significant difference, 15 patients (31.9%) exhibited a post-operative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down a category) and 18 (38.3%) patients changed category according to the CDI (10 moved up a category, 8 moved down a category). Conclusions: Although a statistically significant difference between pre- and postoperative patella height was not observed, changes in patellar height category were common after tibial tubercle-sparing anterior closing-wedge high tibial osteotomy, in patients undergoing revision ACL reconstruction. The clinical impact of these changes is unknown and further study is needed to investigate whether they may result in patellofemoral symptoms.

A TWO-STAGE APPROACH IN MANAGING DIABETIC FOREFOOT ULCERS

AimForefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers.MethodsConsecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months.Results112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening.In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1st metatarsal and 5th metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up.ConclusionThe described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL.

Supratubercle Anterior Closing Wedge Osteotomy: No Changes in Patellar Height and Significant Decreases in Anterior Tibial Translation at 6 Months Postoperatively

Background: Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope on increased anterior tibial translation and increased ACL graft forces. One potential concern in supratubercle anterior closing wedge proximal tibial osteotomy (ACW-PTO) for decreasing the posterior tibial slope is the risk of altering the patellar height. Purpose: To radiographically assess changes in (1) patellar height, (2) anterior tibial translation, and (3) posterior tibial slope after supratubercle ACW-PTO. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent supratubercle ACW-PTO by a single surgeon between July 2019 and June 2023 were included. Standardized lateral knee weightbearing radiographs to assess patellar height (via the Caton-Deschamps index), anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle, and posterior tibial slope were obtained at 4 time points (preoperatively and 1 day, 3 months, and 6 months postoperatively). Paired t test was used to compare differences between preoperative, 1-day, and 3- and 6-month values for patellar height as measured using the Caton-Deschamps index and for posterior tibial slope. Paired t test was also used to compare differences in the preoperative and 6-month postoperative values for anterior tibial translation. Results: In 20 patients after ACW-PTO, the Caton-Deschamps index demonstrated a significant increase in patellar height on postoperative day 1 (P < .001) but no significant differences at 3 (P = .057) and 6 (P = .176) months postoperatively. Anterior tibial translation on standing lateral knee radiographs was significantly decreased by a mean of 8.9 mm from preoperatively to 6 months postoperatively (P < .001). Posterior tibial slope was significantly decreased by a mean of 11.2° from preoperatively to 6 months postoperatively (P < .001). Conclusion: Supratubercle ACW-PTO performed for ACL reconstruction failure in the setting of an increased posterior tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, after ACW-PTO, there was a significant decrease in anterior tibial translation and posterior tibial slope.