Closing Wedge Research Articles

Comparison between achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional achilles tendinopathy: A meta-analysis

BackgroundThe debridement and Achilles tendon reinsertion (DATR) have been the most common surgical approach for the treatment of Insertional Achilles Tendinopathy (IAT), while dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity as an alternative surgical option. This study aimed to systematically review the published literature on both surgical techniques and compare their clinical outcomes and complication rates. MethodsA systematic review was performed according to the PRISMA guidelines using Medline, Embase, and Scopus databases. The inclusion criteria encompassed clinical studies reporting functional outcomes and complications, with a minimum of 10 patients and at least 12 months of follow-up. ResultsSeven studies (n = 169) were included for the analysis of DATR, and eight studies (n = 227) were included for the analysis of open DCWCO. Both groups showed a similar improvement in AOFAS score. The overall complication rates were 16.6% in the DATR group and 9.2% in the DCWCO group, but the difference was not statistically significant. However, there was a significantly higher incidence of wound complications in the DATR group (10.1%, 95% C.I.: 4.7–15.6) compared to the DCWCO group (2.5%, 95% C.I.: 0.6–4.4) as the confidence intervals did not overlap. ConclusionsClinical outcomes and overall complication rates of both techniques were comparable, although DCWCO had a lower incidence of wound complications. Further research should be focused on prospective studies comparing the two techniques to corroborate the current findings. Level of evidenceLevel IV; meta-analysis

Clinical Outcomes and Complications of the Zadek Calcaneal Osteotomy in Insertional Achilles Tendinopathy: A Systematic Review and Meta-analysis

Category: Hindfoot; Ankle Introduction/Purpose: Insertional Achilles Tendinopathy (IAT) is a degenerative process at the insertion of Achilles tendon onto the calcaneal tuberosity that often coexists with retrocalcaneal bursitis and Haglund’s deformity. The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with IAT that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT. Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95% confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). Results: Ten studies with 232 patients were included. The AOFAS (American Orthopaedic Foot and Ankle Society) Ankle- Hindfoot Score and the VISA-A score (Victorian Institute of Sports of Australia-Achilles score) were significantly improved after the Zadek osteotomy (p < 0.00001). Pain levels were also significantly reduced (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia. Conclusion: The Zadek osteotomy is a safe and effective procedure for patients with IAT. The osteotomy improves pain levels and functions and is associated only with minor complications and a low complication rate. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

Early Outcomes after Minimally Invasive Percutaneous Zadek Osteotomy for the Treatment of Insertional Achilles Tendinitis and Haglund’s Deformity

Category: Hindfoot; Other Introduction/Purpose: Zadek dorsal closing wedge calcaneal osteotomy (DCWCO) has been increasingly investigated as an effective technique for the treatment of Insertional Achilles Tendinopathy and Haglund’s deformity. More recently, this strategy has been modified using minimally invasive techniques. A percutaneous approach, in comparison to the standard open DCWCO, allows for reduced postoperative complication, improved clinical function, and decreased pain. This retrospective chart review aims to evaluate the postoperative outcomes of patients undergoing Zadek osteotomy via a minimally invasive percutaneous approach to assess early functional outcomes, complication rates, and revision rates. Methods: Two fellowship-trained foot and ankle orthopaedic surgeons at one academic institution performed minimally invasive percutaneous Zadek osteotomies on 21 patients. All cases were completed between March 2021 and February 2023. Patient charts were reviewed for outcome data including complication rate, union rate, revision rate, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Results: Average age of patients was 54 years. Average BMI was 39.4. Average follow up was 111.6 days. Complications included 1/21 (4.7%) superficial infection that resolved with oral antibiotics, 1/21 (4.7%) tibial neuritis that resolved 3 months after surgery, and 1/21 (4.7%) postoperative plantar fasciitis that resolved with home stretching by 6 months. There were no revisions to open procedures or hardware removal. All participants achieved union. 20/21 (95%) were very satisfied with their surgery. Average preoperative PROMIS scores regarding physical function, pain interference, and mobility were 38.3 (27-51), 65.1 (55-75), and 35.0 (25-46), respectively. Average postoperative PROMIS scores in these same domains were 38.5 (19-54), 58.8 (39-72), and 36.8 (22- 51). There was an average improvement in PROMIS scores in all domains (0.23, -6.35, and 1.76). Conclusion: Minimally invasive percutaneous Zadek osteotomy appears to be an efficacious and safe treatment option for insertional Achilles tendinitis and Haglund’s deformity with low complication profile, high union rate of the osteotomy and high patient satisfaction. Early functional outcome data shows trends in improvements in PROMIS scores. However, longer term data will be needed to assess long term functional outcomes and revision rates.

Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults.

Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described1-6. The presently described wedgeless V-shaped osteotomy7,8 is a good option among the various alternative procedures listed below. The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies1-6. All of these procedures have certain limitations and shortcomings. The wedgeless V-shaped osteotomy is another described procedure that is inherently stable7,8. It is a safe procedure and yields good clinical outcomes8,9. The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al.8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (range, 16° to 29°) preoperatively to 5.1° (range, 0° to 10°) postoperatively (p < 0.001). Similarly, the mean lateral distal femoral angle improved from 79.2° preoperatively to 89.1° postoperatively (p < 0.001) and the mean mechanical axis deviation improved from 19.6 mm preoperatively to 3.7 mm postoperatively (p < 0.001). A total of 44 of 46 cases had an excellent functional outcome, with the other 2 having good outcomes. None of the patients in the study had an unsatisfactory outcome. It is important to keep the whole lower limb accessible to the image intensifier intraoperatively.Identification of the leash of vessels underneath the vastus medialis is important to decide the level of the osteotomy.It is important to preserve the periosteal sleeve on the lateral aspect of the femur. CORA = center of rotation of angulationECG = electrocardiogramLDFA = lateral distal femoral angleMAD = mechanical axis deviationMPTA = medial proximal tibial angle.

Outcomes following Surgical Intervention for Freiberg's Infraction: A Systematic Review

Category: Lesser Toes; Other Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates following surgical intervention for Freiberg's Infraction. Methods: During December 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical intervention for the management of Freiberg's Infraction. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Eighteen studies were included. In total, 299 patients (302 feet) underwent surgical intervention for the management of Freiberg's Infraction at a weighted mean follow-up of 49.9±45.1 months. The distribution of patients by Smillie's (SI-V) classification was recorded in as follows: SI (0 patients), SII (20 patients), SIII (42 patients), SIV (69 patients), SV (54 patients). The most common surgical procedure was dorsal closing wedge metatarsal osteotomy. The weighted mean AOFAS score improved from a pre-operative score of 60.3±9.0 to a post-operative score of 84.3±24. The weighted mean total ROM improved from 46.4±11.7° pre-operatively to 66.2±15.1° post-operatively. The weighted mean time to osseous union was 7.4±3.6. The complication rate was 5.2%, the most common of which was pain. Four failures (1.6%) were observed. Conclusion: This systematic review found improvements in subjective and objective clinical outcomes together with a low complication rate following surgical intervention for Freiberg's infraction at mid-term follow-up. However, the level and quality of evidence of the included studies were low and there was marked heterogeneity and under-reporting of data between the included studies. Although surgical intervention appears to is the mainstay treatment option for Freiberg's infraction, further higher quality comparative studies are warranted to determine the optimal surgical technique for Freiberg's infraction.

Effect of Medial Closing Wedge Distal Femoral Varization Osteotomy on Coronal Ankle and Hindfoot Alignment

Category: Hindfoot; Ankle Introduction/Purpose: To date, only a few studies have reported postoperative changes in coronal ankle alignment after valgus knee correction through Medial Closing Wedge Distal Femoral Varization Osteotomy (MCWDFO). This study aimed to measure the changes of MCWDFO on coronal ankle and hindfoot alignment. Methods: We retrospectively reviewed the radiographic findings of 27 consecutive patients (34 cases) with knee valgus malalignment who underwent MCWDFO for either lateral knee joint osteoarthritis (OA) or recurrent patellar subluxation/dislocation (RPD) . Several radiographic parameters were measured and compared based on the reason for operation, followed by the status of preoperative hindfoot alignment (hindfoot alignment angle [HAA] &gt; 4°, varus; -4° HAA 4°, neutral; HAA &lt; -4°, valgus) in each group. Results: Overall, pre- and postoperative hindfoot alignments were within the neutral alignment range and were not significantly changed after the operation (P &gt; 0.05). Nineteen cases were for lateral knee OA and 15 were for RPD, respectively. In both groups, preoperative neutral hindfoot alignments accounted for the largest portion (52.6% in the lateral OA group; 80.0% in the RPD group). Postoperatively, regardless of the reason for operation, hindfoot alignments changed toward the neutral range in all subgroups (i.e., no changes in the preoperative neutral group; increased in the valgus group; decreased in the varus group). Conclusion: We recommend that surgeons leave the hindfoot untouched when they plan the MCWDFO to correct knee joint valgus malalignment concomitant with hindfoot valgus or varus deviation as the hindfoot malalignment appears to change towards neutral range postoperatively.

Supramalleolar Osteotomy Combined with Medial Malleolar Osteotomy for Varus Ankle Osteoarthritis with Varus Medial Malleolar Deformity

Category: Ankle Arthritis; Ankle Introduction/Purpose: In some cases of varus ankle osteoarthritis (VAO), the varus medial malleolar deformity causes widening of the mortise and reduced conformity. In such cases, the angles of the medial distal tibial platform and the angle of the talar medial shoulder are different, so it is necessary to match the angles of both to improve the compatibility of the mortise. We performed lateral closing wedge supramalleolar osteotomy (LCWSMO) with opening wedge medial malleolar osteotomy (OWMMO) to achieve lateral shift of the load-bearing axis and mortise-plasty at the same time. The purpose of this study was to evaluate the therapeutic outcomes of this technique for VAO with the varus medial malleolar deformity. Methods: The subjects were 12 joints in 12 cases, two males and ten females, the mean age at the surgery was 58.2 years (36-76 years), and the mean follow-up period was 9 years and 1 month (1-20 years and 4 months). After LCWSMO was performed, OWMMO was made to fit the mortise, and autogenous bone grafting was performed in the gap. Additional surgery included two lateral ligament reconstructions, one osteochondral graft, and one high tibial osteotomy. Clinical evaluation was performed using the score of Takakura et al. For arthroscopic evaluation, we used our five grades classification, which is based on the percentage of eburnation areas on the articular surface. The radiographic assessments were the Takakura-Tanaka staging system, the tibial articular surface angle, the tibial lateral surface angle, the talar tilting angle, and the ratio of the medial distal tibial platform angle to the medial talar shoulder angle. Results: The clinical score improved from a preoperative average of 65.0±9.3 points to 82.8±9.8 points at the final follow-up. All arthroscopic grade improved at one year after surgery except one each of grade 2 and grade 3 joints which remained unchanged. According to the postoperative radiographic staging, 6 joints had improved, 3 had not changed, and 3 had progressed. The tibial articular surface angle increased from an average of 84.4 ± 2.1° preoperatively to 97.4 ± 3.6° at the last observation, the tibial lateral surface angle from 80.5 ± 2.5° to 83.7 ± 5.9°, the talar tilting angle increased 11.3 ± 4.7° to 7.9 ± 4.3°, and the ratio of the medial distal tibial platform angle to the medial talar shoulder angle from 112.3±4.9% to 103.6±5.8%. Conclusion: For VAO with varus medial malleolar deformity and large mortise opening, good results can be obtained by lateral shift the load-bearing axis with LCWSMO and improving the fit of the mortise with OWMMO.

Comparing the Clinical Outcomes of Percutaneous Cheilectomy to Open Cheilectomy with Moberg Osteotomy for the Treatment of Hallux Rigidus

Category: Midfoot/Forefoot; Other Introduction/ Purpose: Cheilectomy of the first metatarsophalangeal joint (MTP) is employed as an early treatment option to alleviate pain and restore some motion in patients with hallux rigidus. A dorsal closing wedge osteotomy of the proximal phalanx (Moberg) is often added to the cheilectomy to theoretically increase functional range of motion of the MTP joint. While cheilectomy with Moberg (OCM) has traditionally been performed through an open dorsal incision exposing the entire joint, percutaneous cheilectomy (PC) has become increasingly popular due to smaller incisions, minimal pain, and quicker recovery; however, few studies have compared the PC to commonly practiced open techniques to determine if the PC could deliver similar outcomes. Therefore, we aimed to compare the patient reported outcomes of PC to open cheilectomy with Moberg osteotomy. Methods: This retrospective cohort study included 119 patients who underwent PC or OCM for a diagnosis of hallux rigidus. Patients were included if they were over 18 years old and had preoperative and minimum 1-year postoperative PROMIS scores. Patients were excluded if they had prior cheilectomy or any concomitant procedures on the ipsilateral forefoot. Patients were divided into two groups based on their procedures. Forty-eight patients were classified into the “percutaneous cheilectomy” group (mean age: 60 years) while 71 patients belonged to the “open cheilectomy with Moberg” group (mean age 54.2 years). Preoperative, minimum 1-year postoperative, and preoperative to postoperative change in PROMIS physical function, pain interference, pain intensity, global physical health, global mental health, and depression domains were analyzed between groups. Complications were also noted and compared. Results: Preoperatively, the OCM group demonstrated worse physical function, pain interference, pain intensity, and global physical health compared to the PC group. There were no significant differences in mental health-related domains. Postoperatively, there were no significant differences in any PROMIS domain between groups (Table 1). Length of follow-up was 20.3 months in the PC group and 13.8 months for the OCM group (p &lt;.001). While both groups experienced significant preoperative to postoperative improvement in physical function, pain interference, and pain intensity, in addition to global physical health for the OCM group, the degree of preoperative to postoperative improvement for the OCM group was significantly greater. There were no significant differences in complications between groups. Conclusion: While we found a greater degree of improvement in function and pain in the OCM group, postoperative scores were not different from the PC group. This implies that patients undergoing OCM had greater preoperative deficits in pain and function, and thus demonstrated greater improvements to end up with similar postoperative outcomes as the PC group. Therefore, since the percutaneous cheilectomy resulted in similar postoperative function and pain levels, it appears to deliver an adequate surgical treatment when compared to open cheilectomy with Moberg.

Predicting tibial plateau angles following four different types of cranial closing wedge ostectomy.

To investigate how tibial long axis (TLA) shift affects the postoperative tibial plateau angle (TPA) in four cranial closing wedge ostectomy (CCWO) techniques. In silico study. A total of 15 client-owned dogs. Computed tomography (CT) scans of 15 client-owned dogs were reviewed using an open-source 3D computer graphics editor. Each computer-generated 3D tibia model underwent a CCWO, with cranial cortex alignment, in 10° increments up to 70° using each of the four previously described techniques. The TLA shift, TPA and mechanical tibial length (mTL) were calculated, using trigonometry, for each model. Equations for predicting final TPA were generated with linear regression. A total of 433 3D computer generated tibial models were analyzed. With each technique, the TPA varied in a linear fashion within the studied range of wedge angles. The TLA shift and tibial shortening magnitude varied between the four different CCWO techniques, with maximum mTL reduction of ranging from 7.5% to 40.9%. All predicted TPAs using the generated equations were within the target range of 4-6°. A linear relationship between ostectomy wedge angle and TPA correction was observed in this study, which allowed for generation of accurate corrective equations. These results allow extrapolation of the wedge angle required to reach a postoperative TPA of 5°, by considering the TLA shift. The use of the generated corrective equations may thus increase CCWO planning precision.

A Supratuberosity Anterior Closing-Wedge Proximal Tibial Osteotomy Increases Patellar Height: A Simulated Time Zero Uniplanar Radiographic Study

PurposeThe purpose of this time-zero radiographic study was to simulate the effect of supra-tuberosity tibial anterior closing wedge osteotomy (ACWO) in knees with posterior tibial slope (PTS) ≥12° on patellar height when aiming for a target PTS of 5°. MethodsThe authors retrospectively reviewed true lateral radiographs of the knees of skeletally mature patients scheduled for primary anterior cruciate ligament reconstruction (ACLR), and included all knees with excessive PTS (≥12°). Coordinates of 11 landmarks were digitized to calculate patellar height (Caton-Deschamps index, CDI) and mid-shaft posterior tibial slope (mPTS). The change in patellar height following a simulated supra-tuberosity ACWO was calculated and compared for knees with patella norma versus alta. A linear univariable regression model predicted the effect of change in mPTS on CDI. ResultsIn the final cohort of 83 patients, a simulated supra-tuberosity ACWO increased CDI from 1.13 (range, 0.73 to 1.74) to 1.29 (range, 0.84 to 1.91; p<0.001). In 56 patients with patella norma, a simulated supra-tuberosity ACWO increased CDI from 1.02 (range, 0.73 to 1.19) to 1.18 (range, 0.84 to 1.41; p<0.001), whereas in patients with patella alta, a simulated supra-tuberosity ACWO increased CDI from 1.33 (range, 1.20 to 1.74) to 1.52 (range, 1.36 to 1.91; p<0.001). The linear regression model revealed that a 1° decrease in mPTS increased CDI by 0.02. ConclusionSimulation of a supra-tuberosity ACWO revealed that the procedure increases patellar height in all knees, but did not induce significant differences in patellar height characteristics between knees with patella norma versus alta. A linear regression model revealed that a 1° decrease in mPTS could theoretically increase CDI by 0.02.

High tibial lateral closing wedge and opening wedge valgus osteotomy produce different effects on posterior tibial slope and patellar height.

To compare the clinical outcomes of performing a closed tibial high osteotomy with an open osteotomy and the changes in posterior tibia slope and patellar height. Methods were collected from three hundred and forty patients (440 knees) with high tibial osteotomy performed from January 2019 to January 2020. Forty patients (50 knees) had a lateral closed wedge tibial osteotomy (LCWHTO), and 300 patients (390 knees) had a medial open wedge tibial osteotomy (MOWHTO). The follow-up periods were 20.5 months and 19.9 months, respectively. At the final follow-up visit, both groups evaluated the Lysholm score and joint range of motion (ROM). Changes in preoperative and postoperative mechanical axis deviation (MAD), proximal medial tibial angle (MPTA), posterior tibial slope (PTS), and M-K index were compared between the two groups of patients. Lysholm scores were 79.6 ± 15.6 preoperatively and 96.0 ± 5.0 postoperatively in the LCWHTO group (p < 0.01); 83.7 ± 16.0 preoperatively and 94.3 ± 9.1 postoperatively in the MOWHTO group (p < 0.01). ROM was 136.0° ± 8.4° preoperatively and 133.2° ± 10.1° postoperatively in the LCWHTO group (p > 0.05); 136.5° ± 8.4° preoperatively and 135.7° ± 9.3° postoperatively in the MOWHTO group (p > 0.05). the MAD was (26.5 ± 4.1) mm preoperatively and 0.3 ± 2.9 mm postoperatively in the LCWHTO group (p < 0.01); 21.8 ± 6.5 mm preoperatively and -0.3 ± 2.6 mm postoperatively in the MOWHTO group (p < 0.01). The MPTA in the LCWHTO group was 75.3° ± 3.2° preoperatively and 89.5° ± 2.4° postoperatively (p < 0.01). 77.1° ± 3.0° preoperatively and 90.6° ± 2.7° postoperatively in the MOWHTO group (p < 0.01). M-K index was 0.78 ± 0.08 preoperatively and 0.79 ± 0.07 postoperatively in the LCWHTO group (p > 0.05). 0.78 ± 0.05 before and 0.75 ± 0.05 after surgery in the MOWHTO. 10.8° ± 3.0° PTS before and 8.1° ± 3.4° after surgery in the LCWHTO group (p < 0.05); 10.2° ± 3.1° preoperatively and 10.9° ± 4.0° postoperatively (p > 0.05). LCWHTO decreases the PTS and has no effect on patellar height; MOWHTO does not affect the PTS but decreases patellar height. The patient should individualize the choice of the osteotomy.

A mismatch of planning and achieved tibial plateau angle in cranial closing wedge surgery: An in silico and clinical evaluation of 100 cases.

(1) To determine whether Oxley's modified cranial closing wedge osteotomy (CCWO) results in a tibial plateau angle (TPA) of 5° in silico, (2) compare in silico to clinical postoperative TPA and (3) determine the impact of ostectomy distalization in silico. Cross-sectional retrospective radiographic in silico study. A total of 100 stifle radiographs; 90 dogs (small ≤25 kg = 84; large >25 kg = 16). Tibial plateau angles were measured preoperatively (TPAPre ), after in silico planning (TPAPlan ), and postoperatively (TPAPost ). Virtual ostectomies were evaluated for plate fit. Postoperative ostectomy position was measured. Virtual ostectomies were performed 5/7.5/10/15 mm from the patellar tendon insertion in 10 dogs from each preoperative TPA category (≤20°/21-25°/ 26-30°/31-35°/>35°). Comparisons for TPAPre , TPAPost , and TPAPlan were made between small and large dogs, and the outcome to the target 5° between TPA categories and ostectomy positions. Mean ± SD TPAPre was 28.6 ± 6.2° and higher in small than large dogs. Mean TPAPlan was 7.6 ± 2.7°. Plate fit was appropriate in all. In silico, TPAs were greater than 5° except for cases with TPAPre > 35°. Median TPAPost was 5.5° (-4-21) and was higher in small (7°) than large (4.5°) dogs. Postoperative ostectomy position was more distal than Oxley's guidelines. When distalized >7.5 mm in silico, the magnitude of under-correction increased. Oxley's modified CCWO did not result in TPA of 5° in most cases. Ostectomy distalization exacerbated under-correction. Current guidelines should be modified to achieve 5° TPA postoperatively.

Effect of Anterior Tibial Closing Wedge Osteotomy on Coronal Tibial Alignment in Relation to Preoperative Medial Proximal Tibial Angle and Wedge Height.

The posterior tibial slope has been identified as an anatomic risk factor for anterior cruciate ligament insufficiency and reruptures after anterior cruciate ligament reconstruction. Anterior tibial closing wedge osteotomy for correction of sagittal plane deformities has the potential to cause an unintended change in coronal plane alignment. To evaluate the effects of anterior tibial closing wedge osteotomies for correction of posterior tibial slope on coronal plane alignment using an infratuberosity surgical approach and to identify predictive factors for a change in medial proximal tibial angle (MPTA). Case series; Level of evidence, 4. This study reports on retrospectively obtained data from radiographic measurements of 38 anterior tibial closing wedge osteotomies. All patients underwent revision anterior cruciate ligament reconstruction and had undergone ≥1 previous anterior cruciate ligament reconstruction. In all patients, an infratuberosity approach was used with angular stable plate fixation. Pre- and postoperative radiographs were examined retrospectively to detect changes in the sagittal and coronal plane alignment (posterior tibial slope and MPTA). A multivariate regression analysis was used to identify predictors for a change in MPTA. The study group consisted of 14 women and 24 men whose mean ± SD age at the index procedure was 31.6 ± 8.7 years (range, 17-51 years). Posterior tibial slope decreased significantly (by 7.2° ± 2.3°; P < .001) from 14.6° ± 2.0° preoperatively to 7.4° ± 2.1° postoperatively. MPTA decreased significantly by 1.3° ± 1.5° (P = .005) from pre- to postoperative measurement. Mean wedge height was 9.3 ± 1.1 mm. A lower preoperative MPTA (coefficient = 0.32; P = .017; 95% CI, 0.06-0.59) and larger wedge height (coefficient = 0.48; P = .029; 95% CI, 0.05-0.9) were significant predictive factors for a decrease in MPTA. Anterior tibial closing wedge osteotomy for posterior tibial slope reduction resulted in a slight but significant decrease of the MPTA in the coronal plane. These changes were dependent on the preoperative MPTA and the wedge height.

Paper 23: Taking the Load Off: Effect of Varus Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area in Varying Stages of Knee Flexion

Objectives: Study Objective: Evaluate mean contact area, mean contact pressure, and peak contact pressure in the medial and lateral compartment of the knee following varus producing high tibial osteotomy and distal femoral osteotomy in varying states of knee flexion (0*, 30*, 60*, 90*). Background: Genu valgum causes mechanical pressure to be transferred to the lateral compartment. In patients with valgus alignment and a diseased lateral compartment, both lateral opening wedge distal femoral osteotomy (DFO) and high tibial closing wedge osteotomy (HTO) can be used to unload a diseased lateral compartment of the knee. To the best of our knowledge, there are no biomechanical studies investigating how a DFO and HTO affect lateral compartment contact pressure and area in varying states of flexion. Prior anatomic studies have shown that, in valgus knees, the tibial wear is posterior. Additional, biomechanical studies have indicated that DFO exerts the greatest effect in full extension but it’s effect is decreased as flexion angle rises. Hypothesis: Medial closing wedge high tibial osteotomy will significantly decrease contact area, mean contact pressure and peak contact pressure in the lateral knee compartment through knee flexion to a greater extent compared to lateral opening wedge distal femoral osteotomy. Methods: Lateral opening wedge DFO and medial closing wedge HTO was performed, correcting a mean of 8°, in 10 cadaveric knees using plate fixation. Tibio- femoral contact pressure of the medial and lateral compartment was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors (K-scan Model 4000, 1500 psi; Tekscan Inc, South Boston, MA) and load applied through an Instron device (Instron, Norwood, MA). Peak contact pressure (PCP), average contact pressure (ACP), and contact area (CA) were measured for each condition. Mixed-effects regression analyses were used to compare the change in variables before and after osteotomy and between flexion angles. Results: The lateral ACP was significantly decreased in the HTO state when compared to native in 30° (p=0.015), 60° (p=0.0199), and 90° (p&lt;0.0001) of flexion. The lateral ACP was also significantly decreased in the HTO state when compared to the DFO state in 60° (p=0.0093) and 90° of flexion (p&lt;0.0001). Following DFO, the lateral ACP returned to that of the native state in 60° (p=1.000) and 90° (p=1.000) of flexion. The medial ACP was significantly increased when compared to both the native and HTO state in 60° (p&lt;0.001; p=0.015) and 90° (p&lt;0.0001; p=0.0435) of flexion. Conclusions: With varus corrections of &lt;10°, medial closing HTO is more effective at unloading the lateral compartment than lateral opening DFO. This effect is amplified as the knee flexion angle increases.

Republication of "Percutaneous Basal Closing Wedge Osteotomy of the First Metatarsal in the Treatment of Moderate to Severe Hallux Valgus and Its Short-Term Clinical Outcomes".

Although percutaneous surgery for the treatment of hallux valgus is popular in Europe, there is sparse English written literature documenting its efficacy. This study described the operative techniques using percutaneous basal closing wedge osteotomy of the first metatarsal in correction of moderate to severe hallux valgus (HV) and its short-term clinical outcomes. We postulated that satisfactory correction of hallux valgus (HV) angle, intermetatarsal (IM) angle, and patients' clinical outcomes could be achieved with this technique. We conducted a retrospective review of 25 feet in 23 patients who underwent a percutaneous basal closing wedge osteotomy of the first metatarsal (MT1) combined with a mini-open modified McBride procedure and mini-open resection of medial eminence. Follow-up averaged 21.5 months. Radiographic outcomes included pre- and postoperative HV angle, IM angle, absolute and relative shortening of MT1, and time to union. American Orthopaedic Foot & Ankle Society (AOFAS) scores were compared between pre- and postoperatively. The average HV angle improved from 39.4 (range, 29-58.3) degrees preoperatively to 14.7 (range, 0.1-23.2) degrees postoperatively (P < .05). IM angle improved from 14.9 (range, 6.7-22.4) degrees to 6.6 (range, 0.9-14.8) degrees (P < .05). The average absolute shortening was 3.8 (range, 0.27-12.91) mm and the relative shortening was 0.8 (range, 0.05-1.91) mm. There was no delayed union or malunion at the osteotomy site. The average AOFAS score improved from 39 (range, 12-50) to 81 (range, 70-93) (P < .05). Satisfactory hallux valgus deformity correction and patients' outcomes were achieved with this technique. Our results are similar to results reported in other studies using open techniques. There was no malunion or delayed union of the osteotomy. Level IV, case series study.

Patient-Specific Instrumentation for Medial Closing Wedge Distal Femoral Osteotomy With Patellar Osteochondral Allograft

The primary indications for performing a medial closing wedge distal femoral osteotomy are valgus knee malalignment, lateral knee compartment overload, lateral meniscus insufficiency, and/or lateral compartment osteoarthritis or cartilage damage. Without correction of this malalignment, there is an increased risk for chondral damage in the lateral and patellofemoral compartment of the knee. The optimal candidates for this procedure are young, active individuals with moderate to severe arthritis in the lateral compartment. Recently, preoperative planning for high tibial and distal femoral osteotomies (HTOs and DFOs) using 3-dimensional (3D) patient-specific instrumentation (PSI) has increased in popularity. Successful patient outcomes have been reported using this technique. This Technical Note illustrates our preferred technique that uses 3D PSI in addition to a patellar OCA transplant when treating a symptomatic cartilage lesion associated with genu valgum.

Morphologic impact of four surgical techniques to correct excessive tibial plateau angle in dogs: A theoretical radiographic analysis.

To determine morphologic differences between four tibial osteotomy techniques used to correct excessive tibial plateau angle (eTPA). Retrospective radiographic analysis. Sixteen dogs (27 tibias) with eTPA. Virtual corrections of eTPA were performed on sagittal plane radiographs of canine tibia using four tibial osteotomy techniques and categorized into respective groups. Group A represented the center of rotation of angulation (CORA)-based leveling osteotomy (CBLO) and coplanar cranial closing wedge ostectomy (CCWO), Group B the tibial plateau leveling osteotomy (TPLO) and CCWO, Group C the modified CCWO (mCCWO), and Group D the proximal tibial neutral wedge osteotomy (PTNWO). Pre- and post-correction TPA, tibial length and mechanical cranial distal tibial angle (mCrDTA) were measured and compared. Mean TPA prior to correction was 42.67 ± 6.1°. Post-correction mean TPAs were 10.47 ± 2.1°, 6.77 ± 1.6°, 4.76 ± 1.5°, and 7.09 ± 1.3° for Groups A, B, C, and D, respectively. TPA correction accuracy in Groups A and D varied least from target TPAs. Tibial shortening was documented in Group B in contrast to other groups. The greatest mechanical axis shift was identified in Group A. Each technique achieved TPA < 14° despite having different effects on tibial morphology including alteration of tibial length, mechanical axis shift and variation in correctional accuracy. Despite all methods being able to correct eTPA, the choice of technique will affect morphology in unique ways and should be considered prior to surgery to consider the implications in a given patient.

Normo-or slightly overcorrection show better results after medial closing wedge high tibial osteotomy.

The objectives of this study were to evaluate functional results, revision-free survival, and the influence of postoperative alignment on outcomes after MCWHTO. This retrospective study included 27 MCWHTO operated on from 2009 to 2021. Radiographic measurements were performed pre- and postoperatively. The HKA (Hip-Knee-Ankle angle), MPTA (Medial Proximal Tibial angle), LDFA (Lateral Distal Femoral Angle), JLO (Joint Line Obliquity), and JLCA (Joint Line Convergence Angle) were evaluated. The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee Score, and the Subjective Knee Value (SKV) as well as revision-free survival were evaluated. Postoperative alignment and its influence on clinical outcomes were also analysed. The mean follow-up was 61.9months ± 31.4 (13-124). The HKA, MPTA, and JLCA angles were decreased post-operatively (respectively, Δ = 5.9° ± 2.6, p < 0.001; Δ = 6.1° ± 3.2, p < 0.001 and Δ = 2.5° ± 1.9, p < 0.001). LDFA and JLO were unchanged, post-operatively (respectively, Δ = 0.1° ± 2.2, p = 0.93 and Δ = 1.2° ± 3.3, p = 0.23). Postoperative HKA correlated with knee IKS (R = -0.15, p = 0.04) and function IKS (R = -0.44, p = 0.03). Postoperative LDFA correlated with knee IKS(R = 0.8, p < 0.01). Patients with postoperative HKA ≤ 180° had better KOOS (Δ = 12.3, p = 0.04) and IKS function (Δ = 28.1, p < 0.01) than those with HKA > 180°. Functional results and revision-free survival after MCWHTO are satisfactory when the deformity is located in the proximal tibia. The joint line obliquity is not significantly altered with small tibial correction and, obtaining an overall neutral or slightly varus alignment under the conditions of this study allowed an improvement in the postoperative clinical scores. The literature is still inconclusive on the ideal alignment for valgus deformities and larger series are needed to draw definitive conclusions. IV, case series.

NEUTRAL WEDGE DISTAL FEMORAL OSTEOTOMY (NWDFO) FOR CORRECTION OF LARGE VALGUS AND VARUS DEFORMITIES: TECHNIQUE AND RESULTS

IntroductionAngular 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 &amp; MethodsWe 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 &gt; 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.Results3 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.ConclusionsNWDFO 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.

Radiographic Comparison of Virtual Surgical Corrective Options for Excessive Tibial Plateau Angle in the Dog.

The main aim of this study is to compare the impact of six proximal tibial osteotomies on the geometry and alignment of tibias with and without excessive tibial plateau angle (TPA). Mediolateral radiographs of 30 canine tibias were divided into three groups (n = 10/group): moderate TPA (≤34 degrees), severe TPA (34.1-44 degrees) and extreme TPA (>44 degrees). Six proximal tibial osteotomies were simulated on each tibia using orthopaedic planning software: cranial closing wedge ostectomy (CCWO), modified CCWO (mCCWO), isosceles CCWO (iCCWO), neutral isosceles CCWO (niCCWO), tibial plateau levelling osteotomy with CCWO (TPLO/CCWO) and coplanar centre of rotation of angulation-based levelling osteotomy (coCBLO). All tibias were reduced to a standard target TPA. Pre- and postoperative measurements were obtained for each virtual correction. Compared outcome measures included tibial long axis shift (TLAS), cranial tibial tuberosity shift (cTTS), distal tibial tuberosity shift (dTTS), tibial shortening and osteotomy overlap. Across all TPA groups, TPLO/CCWO had the lowest mean TLAS (1.4 mm) and dTTS (6.8 mm); coCBLO had the largest TLAS (6.5 mm) and cTTS (13.1 mm); CCWO had the largest dTTS (29.5 mm). CCWO had the largest degree of tibial shortening of 6.5 mm, while mCCWO, niCCWO and coCBLO resulted in minimal tibial lengthening (1.8-3.0 mm). These trends were generally conserved across different TPA groups. All findings had a p-value less than 0.05. mCCWO balances moderate alterations to tibial geometry while preserving osteotomy overlap. The TPLO/CCWO has the least effect on tibial morphology alteration, whereas the coCBLO results in the largest alteration.