Combined High Tibial Osteotomy Research Articles

Combined High Tibial Osteotomy Decreases Biomechanical Changes Radiologically Detectable in the Sagittal Plane Compared With Closing-Wedge Osteotomy

The purpose of this randomized, prospective study was to compare radiologic changes in the sagittal plane after closing-wedge and combined high tibial osteotomies (HTOs) performed in patients with medial knee arthrosis associated with a varus deformity and requiring a 10 degrees correction. The patellar height, determined by the Insall-Salvati index (ISI), and tibial slope (TS) angle, measured by the Dejour-Bonnin method, were compared after 45 closing-wedge osteotomy (CWO) and 46 combined osteotomy (CO) procedures. CO is a relatively new technique effectively being the combination of closing-wedge and opening-wedge HTOs. It involves performing a proximal osteotomy parallel to the tibial plateau, followed by a distal osteotomy extending from the lateral part of the tibia to the line of the proximal osteotomy at the center of the tibial condyle. After closure of the lateral part of the osteotomy and consequent opening of the medial part, the removed lateral bone wedge is transferred to the gap on the medial side. We found that at the end of the study, 12 months after the operation, CO resulted in significantly smaller changes in TS angle (4.7% v 38.2%) and ISI (2.2% v 5.7%) values than CWO. The main conclusion of this study is that based on our radiologic findings, CO results in significantly smaller changes in TS angle and ISI values than CWO; therefore, CO is better at preserving the normal or near normal condition of the knee than CWO. Altogether, when a 10 degrees correction is required during HTO, we recommend choosing CO instead of CWO. Level II, prospective comparative study.

Biomechanical comparison between high tibial osteotomy (HTO) and combined HTO and fibular osteotomy

The ojectives of this study were to determine the changes in the lateral ligamentous stability of knee joint that occur after performing high tibial osteotomy with and without fibular osteotomy. Utilizing cadaveric specimens, lateral ligamentous stability was assessed by calculating the length of the lateral collateral ligament, and the lateral opening at different flexion angles when varus stress was applied to the tibia. The Polhemus 3- SPACE system was used to collect motion data describing the six-degrees-of-freedom three-dimensional tibiofemoral motions. It was found that the separation distance between the two attachment points of the lateral collateral ligament decreased by an average of 5 mm at all flexion angles after performing a 5-degree valgus high tibial osteotomy. Performing an additional 5-degrees of osteotomy caused this distance to further decrease. It was further found that performing a fibular osteotomy following a 5-degree valgus high tibial osteotomy produced no changes in the length of the lateral collateral ligament. It was also found that the lateral opening increased an average of 5 mm at all flexion angles after performing a 5-degree valgus high tibial osteotomy. Performing a 10-degree osteotomy caused a further increase in the lateral opening. It was further found that performing a fibular osteotomy following a 5-degree valgus high tibial osteotomy caused the lateral opening to return to its original value. That is to say, the fibular osteotomy negated the lateral opening caused by the tibial osteotomy and produced a pattern of lateral opening similar to the one found in the intact knee.

Osteochondral Allografts in the Treatment of Osteonecrosis of the Knee

In summary, patients with spontaneous osteonecrosis of the knee requiring surgery were elderly and generally had late stage IV disease. They seemed to do better with osteotomy and debridement than with osteochondral allograft replacement because they could not tolerate restricted weight bearing. Patients with steroid-induced osteonecrosis did well initially after allograft replacement (6 to 18 months), especially in experiencing pain relief. However, because of the continuous use of high doses of steroids, revascularization of the allografts was poor, resulting in graft subsidence. Patients have better long-term results following osteotomy and debridement. Patients with traumatic osteonecrosis and osteochondritis dissecans had the best results following osteochondral allograft replacements. In conclusion, based on our series and others, our current surgical approach in the management of osteonecrosis of the knee is as follows: 1. In patients with spontaneous osteonecrosis with asymptomatic small lesions, nonsurgical treatment is recommended. For an asymptomatic or symptomatic large lesion with associated angular deformity, the active patient should have a tibial osteotomy for stages I and II and tibial osteotomy and debridement for stages III and IV. Less active patients with symptomatic stage III or IV disease should have unicompartmental or total knee prosthetic arthroplasty. 2. For steroid-induced osteonecrosis, osteochondral allografts are not recommended. If the patient's systemic disease has a limited prognosis, or if the patient has multijoint involvement, total knee or unicompartmental arthroplasty is warranted. If the patient has a good prognosis and is active, debridement with or without realignment should be performed. 3. For traumatic osteonecrosis in the younger patient or for osteochondritis dissecans, fresh osteochondral allograft replacement is recommended. High tibial osteotomy in combination with allograft replacement should also be done if there is associated malalignment. The realignment should be done prior to or simultaneously with the allograft (providing the osteotomy is done on the side of the joint opposite the allograft).

Combined Coventry-Maquet Procedure for Two-compartment Degenerative Arthritis

The combined Coventry-Maquet procedure has been proposed as a means of treating dual-compartment degenerative arthritis of the knee. The procedure was investigated in a prospective study of 14 patients treated by combined high tibial osteotomy and tibial tubercle elevation. Preoperative scores averaged 50 points and scores at follow-up evaluation averaged 57 points with a modified 100-point total knee grading system. There were no excellent results, one good result, and 13 poor results. Five patients whose results were poor have since had total knee arthroplasty. The combined Coventry-Maquet procedure required too much dissection, had too high a complication rate, and yielded a minimal improvement in knee function and pain. Two-compartment degenerative arthritis should be treated by an alternative method, such as total knee arthroplasty, when surgical intervention is indicated.