Medial Closing Wedge Research Articles

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5Years.

Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship. (1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy? Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2years (mean, 5years; SD, 2; range, 2-12years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution's osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded. Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of±3° from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group. Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of±3° from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic. Level IV, therapeutic study.

Injury risk to extraosseous knee vasculature during osteotomies: a cadaveric study with CT and dissection analysis.

Realignment osteotomies about the knee may be performed as distal femoral or proximal tibial osteotomies; both may be performed either on the medial or lateral sides of the knee, in closing- or opening-wedge fashion. Although rare, injury to neurovascular structures may occur, and the proximity of the vascular structures to the osteotomy saw cuts has been incompletely characterized. We performed a cadaver study to assess the risk of vascular injury in patients undergoing realignment osteotomies by (1) quantifying the distances between osteotomy saw cuts and blood vessels using three-dimensional CT reconstruction after distal femoral and proximal tibial osteotomies; and (2) qualitatively describing the small- and medium-sized vasculature around the knee, to provide the link between the CT analysis and wedge incision measures, and better show the potential extraosseous supply to the regions investigated. Twelve human cadaveric knees were injected with a latex and barium sulfate suspension into the superficial femoral artery. Each specimen underwent CT to evaluate vascular perfusion and was randomized to either a lateral opening-wedge distal femoral osteotomy and medial opening-wedge proximal tibial osteotomy group, or a medial closing-wedge distal femoral osteotomy and lateral closing-wedge proximal tibial osteotomy group. Postoperatively, knees underwent CT in extension to measure the shortest distance between the osteotomies and the popliteal artery, anterior and posterior tibial arteries, and genicular arteries. Vessels between 5 mm and 10 mm from the osteotomy cut were considered in a zone of moderate risk for damage, while vessels less than 5 mm from the cut were considered in a zone of high risk for damage. Vessels more than 10 mm from the cut were not considered to be at risk. Subsequently, knees underwent dissection and chemical débridement to qualitatively describe the smaller vessels. This part of the study added visual information and gave a comprehensive overview of the vessels at risk. All variations of the osteotomies put at least one artery at risk. The popliteal artery was found in a risk zone for injury in two specimens during closing-wedge distal femoral osteotomy (median distance, 11.6 mm; range, 5.2-14.6 mm). The superior lateral genicular artery was in a risk zone in all the specimens during opening-wedge distal femoral osteotomy (median distance, 3.0 mm; range, 0.7-6.5 mm), and in five specimens during closing-wedge distal femoral osteotomy (median distance, 4.5 mm; range, 1.3-11.2 mm). A concomitant risk for superior medial genicular artery injury was observed in five specimens during opening-wedge distal femoral osteotomy (median distance, 8.7 mm; range, 0.8-13.9 mm) and in four specimens during closing-wedge distal femoral osteotomy (median distance, 4.1; range, 0.5-41.7 mm). The popliteal artery was in a risk zone in four specimens during opening-wedge proximal tibial osteotomy (median distance, 9.6 mm; range, 6.6-12.9 mm), and in three specimens during closing wedge proximal tibial osteotomy (median distance, 9.6 mm; range, 4.4-11 mm). The inferior medial genicular artery could be classified at risk in five specimens during opening-wedge proximal tibial osteotomy (median distance, 2.1 mm; range, 0.3-32 mm) and in five specimens during closing-wedge proximal tibial osteotomy (median distance, 5.8 mm; range, 1.4-13 mm). Furthermore, the inferior lateral genicular artery was found in a risk zone in two specimens of closing-wedge proximal tibial osteotomies (median distance, 17.4 mm; range, 8-23.3 mm). There were no differences between opening-wedge and closing-wedge distal femoral osteotomies and proximal tibial osteotomies in the vessels at risk during the procedure. After chemical débridement, knees showed abundant vascularization of the distal femur and lateral tibia, whereas the medial tibia contained few arteries. With the numbers available, we found that none of the osteotomy techniques performed was safer than any other in terms of the proximity of the major arterial structures and some vessels appear to be at relatively high risk during these procedures. This study clarifies that the genicular arteries on the opposite side of the surgical field, which cannot be seen and protected during the procedure, can be at risk of injury, particularly when the cortical hinge is compromised. Additional studies are necessary to address the potential risk of the dissection needed for plate placement and injuries related to drilling and screw placement during osteotomies around the knee.

The influence of the choice of closing wedge angle on leg length discrepancy after proximal femoral varus osteotomy.

Proximal femoral varus osteotomy improves the biomechanics of the hip and can stimulate normal acetabular development in a dysplastic hip. Medial closing wedge osteotomy remains the most popular technique, but is associated with shortening of the ipsilateral femur. We produced a trigonometric formula which may be used pre-operatively to predict the resultant leg length discrepancy (LLD). We retrospectively examined the influence of the choice of angle in a closing wedge femoral osteotomy on LLD in 120 patients (135 osteotomies, 53% male, mean age six years, (3 to 21), 96% caucasian) over a 15-year period (1998 to 2013). A total of 16 of these patients were excluded due to under or over varus correction. The patients were divided into three age groups: paediatric (< 10 years), adolescent (10 to 16 years) and adult (> 16 years). When using the same saw blades as in this series, the results indicated that for each 10° of angle of resection the resultant LLD equates approximately to multiples of 4 mm, 8 mm and 12 mm in the three age groups, respectively. Statistical testing of the 59 patients who had a complete set of pre- and post-operative standing long leg radiographs, revealed a Pearson's correlation coefficient for predicted versus radiologically observed shortening when using a wedge of either 10° or 20° of 0.93 (p < 0.001). The 95% limits of agreement from the Bland-Altman analysis for this subgroup were -3.5 mm to +3.3 mm. It has been accepted that a 10 mm discrepancy is clinically acceptable. This study identified a geometric model that provided satisfactory accuracy when using specific saw blades of known thicknesses for this formula to be used in clinical practice.

Changes of density distribution of the subchondral bone plate after supramalleolar osteotomy for valgus ankle osteoarthritis.

CT-osteoabsorptiometry (CT-OAM) has been used to visualize subchondral bone plate density distribution regarding to its mineralization. The purpose of this study was to display and analyze the density distribution of the subchondral bone plate before and after supramalleolar realignment osteotomies. We retrospectively analysed pre- and postoperative CT images of nine consecutive patients with post-traumatic unilateral valgus ankle OA. The distribution charts of CT-OAM scans were quantitatively analyzed for subchondral bone plate density distribution. VAS for pain and the Tegner activity scale were used to assess clinical outcome. At a mean follow-up of 20 ± 5.6 months (range 13-27), we observed a significant pre- to postoperative decrease of the mean high-density area ratio in tibia (lateral and posterior area) (p ≤ 0.05) and the talus (lateral area) (p ≤ 0.05). Pairwise comparison between the pre- and postoperative mineralization at the articular surface showed a significant decrease of the high-density area ratio for the tibia and the talus. The VAS decreased from 6.2 ± 0.9 pre- to 2.8 ± 0.9 postoperatively (p = 0.027), and the Tegner score inclined from 4.5 ± 1.1 preoperatively to 5.3 ± 0.7 after surgery (p = 0.082). The tibial and talar subchondral bone plate density, regarding to its mineralization, decreased after supramalleolar medial closing wedge osteotomy in patients with valgus ankle OA. The results of this study suggest that realignment surgery may decrease peak bone density areas corresponding to the alignment correction and contribute to a homogenization of the subchondral bone plate mineralization.

Biomechanical testing of distal femur osteotomy plate fixation techniques: the role of simulated physiological loading.

BackgroundImplants for fracture and/or osteotomy fixation are often tested according to basic mechanical test models such as open gap tests or 4-point-bending tests. These may be suitable to test and compare different implants for safety and clinical approval, but are not always representative of the post-operative situation, which is decisive when it comes to bone healing. In the current study the Knee Expert Group of the Association for the Study of Internal Fixation has compared the available open gap test results of the latest version of the TomoFix Medial Distal Femoral Plate and the antecedent plate design, with the test results of a more physiological and life-like test model. In the open gap test model the antecedent plate design was found to have superior stiffness and fatigue strength.MethodsIn the current study simulated postoperative conditions for medial closing wedge supracondylar osteotomies were used. The constructs were subjected to cyclical axial and torsional loading and were subsequently tested to failure.ResultsThe more life-like tests in this study showed that the latest version was either more or equally stable and stiff than the antecedent version of the plate, in all of the tests. It is argued that the difference in results between the two loading models is due to differences in test design.ConclusionsThese test results stress the importance of not only using standard open gap and 4-point-bending tests, but also to use as life-like as possible test conditions for any form of biomechanical testing of new implants.

Supramalleolar osteotomy: Techniques, indications and outcomes in a series of 83 cases

IntroductionSupramalleolar osteotomy is an alternative surgical procedure for the management of asymmetric early arthritis of the ankle. The main goal of this retrospective study was to evaluate the clinical and radiological benefits of supramalleolar osteotomy. The secondary goal was to identify prognostic factors to help decide upon this therapeutic indication. Materials and methodsEighty-three patients, mean age 45years old (17–79), presenting with post-traumatic asymmetric early arthritis of the ankle were followed up for a mean 3.5years (1–14years). Sixty-two patients presented with a varus deformity (mean: 13°), and 21 with a valgus deformity (mean: 17.5°). The presence of a preoperative clinical ‘sidewalk sign’ was looked for and it was considered positive if pain improved when the patient walked on a surface slope that was tilted in the opposite direction of their deformity. A functional preoperative evaluation and at the final follow-up were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale. The frontal deformity was measured by the Meary angle on a weight-bearing X-ray. Varus deformities were treated by a lateral closing wedge supramalleolar osteotomy or a medial opening wedge supramalleolar osteotomy. Valgus deformities were treated by a lateral opening wedge or a medial closing wedge supramalleolar osteotomy. ResultsAt last follow-up, the mechanical axis in the varus group was 1.3° and 7.5° in the valgus group. The AOFAS score significantly improved (P<0.001) by 15 points in patients with a varus deformity and 13 points in patients with a valgus deformity. A positive sidewalk sign (disappearance of pain) was correlated with a good outcome and had a positive predictive value of 0.88 (CI: 0.77–0.95) (P<0.001). DiscussionThe supramalleolar osteotomy is a conservative therapeutic surgical option for the management of arthritis of the ankle associated with varus or valgus deformities. The results are satisfactory for indications of arthritis with varus and valgus deformities and a positive ‘sidewalk’ sign (pain relief on a slope surface tilted in the opposite direction of the deformity). Level of evidenceLevel IV: retrospective case series.

Midterm results following medial closed wedge distal femoral osteotomy stabilized with a locking internal fixation device

Aim of this study was to evaluate the subjective and radiological outcome and to evaluate the complications of a medial closing wedge osteotomy at the femur for lateral osteoarthritis with genu valgum. Twenty-three patients with grade III to IV cartilage damage and valgus knee alignment were treated with medial closing wedge osteotomy at the distal femur. The osteotomy was stabilized with an internal plate fixator. Age varied between 25 and 55 years (mean 47 years). One patient was lost to final follow-up. After 3.5 years, all Knee Osteoarthritis Outcome Score (KOOS) subitems increased significantly. There was no significant difference in the subgroup analysis of KOOS subitems for patients with and without microfracture or age (>50 vs. <50 years). There were no perioperative complications. One patient had an overcorrection. All, but one osteotomy, showed stable bone healing. There was a loss of correction due to delayed bone healing in one case. Possible explanations for this complication were injury of the lateral cortex or smoking. This case required revision with bone graft and an additional lateral plate. In no case, a conversion to an endoprosthesis was necessary. The femoral medial closing wedge osteotomy is a surgical method for improving symptoms of lateral osteoarthritis in the valgus knee. IV.

Distal Femoral Varization Osteotomy

Distal femoral varization osteotomy is performed for treatment of lateral compartment osteoarthritis of the knee associated with valgus deformity for relief of pain and improvement of functional status. Careful selection of patients is the key to the success of this procedure. Distal femoral varus osteotomy is indicated for patients with isolated lateral compartment knee arthritis with a valgus deformity; candidates must have a range of motion arc of at least 90 degrees and less than 20 degrees of flexion-contracture. The indications of distal femoral varization osteotomy must be considered before surgery. Contraindications include patients with diffuse and nonspecific knee pain, primary complaint of patellofemoral pain, history of medial meniscectomy, and bicompartmental degeneratvie osteoarthritis. The success of an osteotomy is dependent on adequate correction of limb malalignment; therefore, accurate determination of the desired angle of correction is essential during preoperative planning. In recent years with the advent of new anatomical locking plate designs, medial closed wedge osteotomy has become popular. Compared to lateral opening wedge osteotomy, with medial closing wedge osteotomy, earlier union is expected and it provides stable fixation even with poor bone quality. Nevertheless, arthroplasty offers rapid pain relief and short-term rehabilitation period; however, risk of wear, difficulty and poor outcome of revision surgery, possible complication of infection or prosthetic failure in young and active patients, demanding high functional loading, is a cause for concern. Because this joint preserving procedure is not associated with prosthesis-related complication, it can be a good alternative option for young and active patients.

Osteotomie am distalen Femur zur Korrektur von Genu valgum und Torsionsfehlern

Femoral medial closing wedge osteotomy for the correction of valgus malalignment to unload the cartilage in the lateral compartment and/or correction of symptomatic torsional malalignment. Lateral unicompartmental osteoarthritis of the knee with genu valgum in young patients. Symptomatic torsional malalignement of > 30° and < 0°. Grade 3 and 4 cartilage damage in the medial compartment. Heavy smoking. Medial meniscectomy. Extreme obesity. Inadequate soft tissue conditions. The operation begins with arthroscopy of the knee joint. In case of grade 4 lateral cartilage damage, a microfracture is performed. The distal femur is exposed via an anteromedial longitudinal incision starting 10 cm above the patella and ending in the upper third of the patella. The medial femoral cortex is exposed using Hohmann retractors and an oblique closing wedge osteotomy is performed with an oscillating saw. In case of valgus correction, the lateral cortex is left intact. In case of correction of torsional malalignment, the osteotomy plane is horizontal and the lateral cortex is cut. The wedge height is determined preoperatively based on full leg x-rays. The leg axis is controlled intraoperatively with a long metal rod and the use of an image intensifier. The osteotomy is manually closed and stabilized with a locking plate. The patient is mobilized under load with 20 kg body weight for the first 6 postoperative weeks. Full range of motion is permitted. We treated 23 patients with lateral cartilage damage (grades 3 and 4) and genu valgum with medial closing osteotomy of the distal femur (6 men and 17 women). After 3.5-years follow-up, the KOOS increased from 48.4 points to 84.9 points. In one case, there was an early loss of correction, with subsequent revision with bone grafting and lateral osteosynthesis. No peri-or postoperative complications such as infection, thrombosis, and embolism occurred. In 5 cases a torsional osteotomy was performed. The torsional osteotomy was performed 4 times due to chronic patellofemoral instability, and once due to a medial tibiofemoral instability. Healing complications were not observed in this population. Recurrent instability was not observed.

A Modified Suture Technique for Fixation of the Akin Osteotomy

The Akin osteotomy is a frequently performed medial closing wedge osteotomy of the proximal phalanx of the hallux. It is usually used as a complimentary procedure in the correction of hallux valgus. Various implants and techniques have been described for fixation. Suture fixation has the advantage of a lower implant signature and a reduction in cost. However, the thin cortex of the phalanx can be prone to failure during suture application. We describe a new technique for suture fixation, which we have found to be reliable and to reduce the risk of phalangeal cortical failure.

The safety and feasibility of a less invasive distal femur closing wedge osteotomy technique: a cadaveric dissection study of the medial aspect of the distal femur

To investigate the feasibility and safety of a less invasive surgical approach to the distal medial aspect of the femur in supracondylar medial closing wedge osteotomy for the treatment of lateral compartment osteoarthritis of the knee. The aim of a less invasive approach is to minimize soft tissue disruption, reduce damage to neurovascular structures and thereby prevent muscle atrophy and optimize bone healing potential. A human cadaver dissection study on the vascular and neural structures of the medial side of the distal femur was conducted. Surgical dissection (n=4), cryomicrotomy and subsequent 3D reconstruction of the anatomy (n=1), and surgical dissection after performance of a supracondylar osteotomy through a less invasive approach (n=1) were performed in 6 legs in total. The surgical dissection and 3D reconstruction showed that a branch of the femoral artery, the distal genicular artery, supplies the distal area of the vastus medialis (VM) muscle. This artery has several branching patterns; crucial in the presented less invasive approach is its musculo-articular branch, which has an oblique course through the VM to the superomedial pole of the patella. The femoral nerve and saphenous nerve innervate the VM. These structures are at risk in the traditional subvastus approach, whereas no major damage was observed in the leg in which a less invasive approach was performed. In this cadaveric dissection study, a less invasive approach to the medial side of the distal femur proved to be feasible and safe. Damage to the VM and its neurovascular structures is minimized as compared to the traditional subvastus approach.

Distal Femoral Varus Osteotomy: Unloading the Lateral Compartment: Long-term Follow-up of 45 Medial Closing Wedge Osteotomies

Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.

Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from -11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from -0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.

Distal femoral varus osteotomy: problems associated with the lateral open-wedge technique

Varisation osteotomies on the distal femur are an established treatment method for valgus osteoarthritis of the knee in younger patients. Osteotomy can be done in a lateral open-wedge or medial closed-wedge manner. We retrospectively studied 14 patients treated by the lateral open-wedge technique, fixed with the Tomofix plate, with a mean duration of follow-up of 45 ± 3.4 months. We observed often delayed osteotomy healing after 3, 6 and 12 months, no secondary dislocations, and frequent troublesome irritation due to the plate being on the iliotibial band. However, outcome was satisfactory once the osteotomy healed and the plate was removed. Based on the often slow healing of the osteotomy and frequent irritation due to the plate, this procedure has been abandoned by the authors, and the medial closing-wedge osteotomy adopted as the alternative treatment.

Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations

Little is known regarding the biomechanical stability and stiffness of implants and techniques used in supracondylar femur osteotomies (SCO). Therefore, fixation stability and stiffness of implants to bone was investigated under simulated physiological loading conditions using a composite femur model and a 3D motion-analysis system. Five osteotomy configurations were investigated: (1) oblique medial closing-wedge fixated with an angle-stable implant; (2) oblique and (3) perpendicular medial closing-wedge, both fixated with an angled blade plate; and lateral opening-wedge fixated with (4) a spacer plate and (5) an angle-stable lateral implant. The motion measured at the osteotomy was used to calculate the stiffness and stability of the constructs. The least amount of motion and highest stiffness was measured in the medial oblique closing-wedge osteotomy fixated with the angled blade plate. The lateral opening-wedge techniques were less stable and had a lower stiffness compared with the medial; the oblique saw cuts were more stable and had a higher stiffness than the perpendicular. This experimental study presents baseline data on the differences in the primary stability of bone-implant constructs used in SCO. The data in this study can be used as reference for future testing of SCO techniques. Furthermore, it is recommended that based on the differences found, the early postoperative rehabilitation protocol is tailored to the stability and stiffness of the fixation method used.

Which osteotomy for a valgus knee?

A valgus knee is a disabling condition that can affect patients of all ages. Antivalgus osteotomy of the knee is the treatment of choice to correct the valgus, to eliminate pain in the young or middle age patient, and to avoid or delay a total knee replacement. A distal femoral lateral opening wedge procedure appears to be one of the choices for medium or large corrections and is particularly easy and precise if compared to the medial femoral closing wedge osteotomy. However, if the deformity is minimal, a tibial medial closing wedge osteotomy can be done with a faster healing and a short recovery time.

Realignment Surgery for Valgus Ankle Osteoarthritis

Improvement of joint congruence, reduction of pain, slowdown of osteoarthritis progression, and prevention or delay of total ankle arthroplasty or ankle fusion. Active patients with lateral valgus ankle joint degeneration. Patients in poor general condition. Inability to adhere to postoperative non-weight-bearing rehabilitation. Distinct cartilage degeneration of more than half of tibiotalar joint surface. Systemic joint disease. Insufficiency of the deltoid ligament with tibiotalar subluxation malalignment. Depending on stage of deformity: Stage I--collapse of the lateral tibia plafond and/or lateral malleolar gutter with subsequent valgus ankle arthritis: medial closing-wedge osteotomy of the distal tibia. Derotation- lengthening osteotomy in case of fibula malunion. Stage II--excessive calcaneus valgus: add medial sliding calcaneus osteotomy. Stage III--forefoot-induced hindfoot valgus (flatfoot deformity with forefoot abduction): add repair/augmentation of the posterior tibial tendon, superficial delta and spring ligaments; gastrocnemius/triceps release; flexion osteotomy of the first cuneiform or metatarsal bone or fusion of the first tarsometatarsal joint. Continuous active and passive range of motion starting at the 2nd postoperative day. Removable short leg cast during nights. Partial weight bearing for 6-8 weeks until osseous healing has occurred, followed by gradual return to full weight bearing and activity. 14 patients with stage I, three with stage II, and five with stage III valgus ankle osteoarthritis were treated. In two cases realignment surgery failed and progressive painful arthritis was treated by arthroplasty. The other 20 patients improved at an average follow-up of 4.5 years (range 3-6.5 years). Eight patients (41%) were free of pain. Tibiotalar arthritis and alignment (Takakura Score) improved significantly and correlated with significant improvement of pain (visual analog scale) and function (American Orthopaedic Foot and Ankle Society Score).

Osteotomies: The Surgical Treatment of the Valgus Knee

Lateral compartment arthrosis from congenital valgus or the result of previous lateral meniscectomy can be a disabling condition. Realignment osteotomy, which may avoid or delay the need for a total knee replacement, is appropriate for young or middle-aged patients suffering from a painful valgus knee. Medium or large corrections can be managed with distal femoral lateral opening wedge osteotomy while minimal deformities are best treated with medial closing wedge tibial osteotomy.

Correction of Moderate to Severe Hallux Valgus Deformity by a Modified Chevron Shaft Osteotomy

Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained. This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques. There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus. Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.

Effect of increasing distal medial closing wedge metatarsal osteotomies on the distal metatarsal articular angle.

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.