Medial Open-wedge Osteotomy Research Articles

Open Wedge High Tibial Osteotomy and Combined Arthroscopic Surgery in Severe Medial Osteoarthritis and Varus Malalignment: Minimum 5-Year Results.

PurposeTo evaluate the radiologic and functional outcomes of medial open wedge high tibial osteotomy (HTO) combined with arthroscopic procedure in patients with medial osteoarthritis.Materials and MethodsFrom June 1996 to March 2010, 26 patients (32 knees) who underwent medial open wedge osteotomy and arthroscopic operation for medial osteoarthritis were retrospectively reviewed. Measurements included hip-knee-ankle (HKA) angle, femorotibial angle, medial proximal tibial angle, posterior tibial slope angle, and Kellgren-Lawrence grade. Clinical evaluation was performed using Lysholm knee scoring scale and knee and function score of the American Knee Society.ResultsDifferences between the mean preoperative and postoperative measurements were significant in all angles including the HKA angle (−5.7° and +5.5°), femorotibial angle (−1.9° and +9.8°), and medial proximal tibial angle (82.9° and 90.5°) (p<0.05). Mean Lysholm knee scoring scale was 63.6 preoperatively and 88.7 at the last follow-up, mean Knee Society knee score was 61.2 and 86.6, and mean function score was 59.3 and 87.2, respectively. All differences were significant (p<0.05).ConclusionsMedial open wedge HTO in combination with arthroscopic procedure is an effective treatment method for medial osteoarthritis to treat varus deformity and an intra-articular lesion.

Surgical treatment results for flexible flatfoot in adolescents

ObjectiveIdiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults. MethodsA total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances. ResultsAll procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet.Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again. ConclusionSoft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults. Level of clinical evidenceLevel IV, Therapeutic study.

The biplanar open wedge high tibial osteotomy preserving the tibial tubercle.

High tibial osteotomy (HTO) is a treatment option for relatively young patients with isolated medial compartment arthritis of the knee. Medial open wedge osteotomies allow easier control of correction, but can lead to patella infera as a result of distalization of the tibial tubercle. This retrospective study reports results of a biplanar tibial tubercle preserving HTO, designed to preserve patellar height. The study is a retrospective analysis of 12 consecutive patients (11 men, 1 woman) average age 39.6 years who underwent the procedure between 2009 and 2012. A biplanar open wedge tibial osteotomy was performed and stabilised with a medial locking plate. Patients were allowed full weight bearing at 6 weeks. Preoperative and postoperative function was recorded on the Oxford knee score, Lysholm score and Tegner activity scale. Minimum follow up was 26 months. All patients had healing of the osteotomy with no delayed union. Eleven patients reported improvement in symptoms with an average preoperative Oxford score of 26 and postoperative score of 39 out of 48. The Lysholm score improved from 58 to 72 out of 100. There was one point improvement in Tegner activity scale. There was no statistical difference in patellar height before and one year after surgery. The correction in varus averaged 8.3°. The biplanar High tibial Osteotomy allows preservation of patellar height, while achieving desired varus correction.

A Simple Method for Fixation of Proximal Opening-Wedge Osteotomy of the First Metatarsal for Correction of Hallux Valgus.

A simple, inexpensive technique for fixation of proximal opening-wedge osteotomy of the first metatarsal for correction of moderate or severe hallux valgus (HV) is described. After the opening-wedge osteotomy and bone grafting of the first metatarsal have been performed, 2 Kirschner wires are introduced for internal fixation and removed 8 weeks postoperatively. Twenty-three patients with symptomatic HV who had a proximal medial opening-wedge osteotomy of the first metatarsal in combination with a distal soft tissue procedure and bunionectomy were evaluated retrospectively. All osteotomies healed without complications and satisfaction was achieved in 22 patients. Hallux varus developed in 1 patient. Preoperatively, mean HV angle (HVA) was 41° (range, 35°-61°) and mean 1-2 intermetatarsal angle (IMA) was 19° (range, 16°-24°). Postoperatively, mean HVA was 14° (range, 10°-17°) and mean 1-2 IMA was 7° (range, 5°-9°). The mean decrease in the HVA was 27° (P<.001) and the mean decrease in the 1-2 IMA was 12° (P<.001). [Orthopedics. 2016; 39(6):e1213-e1217.].

Opening-Wedge Proximal Tibial Osteotomy

Varus knee malalignment caused by medial compartment arthritis results in progressive asymmetric wear of the tibiofemoral joint. This wear can cause progressively painful gonarthrosis. Surgical methods to address varus knee malalignment include lateral closing-wedge proximal tibial osteotomy, medial opening-wedge osteotomy, and arthroplasty. Medial opening-wedge proximal tibial osteotomy is an effective procedure for restoring proper coronal alignment and reducing knee pain. In this technical note, we present a reproducible technique for proximal tibial osteotomy.

Prospective study of the anterior cruciate ligament reconstruction associated with high tibial opening wedge osteotomy in knee arthritis associated with instability.

Chronic ACL insufficiency with associated varus malalignment due to knee osteoarthritis (OA) is challenging to treat surgically. A combined ACL reconstruction (ACLR) with medial open wedge high tibial osteotomy (HTO) without using any metallic implant for HTO is an effective technique. All the patients attending the outpatient department ACL injury and with associated medial compartment OA (Kellegren's grade 2 and grade 3) were considered for inclusion in the study. Forty patients who met inclusion criteria were included in the study. Simultaneous ACLR (single bundle of quadrupled hamstring graft fixed with Endobutton on femoral side and biointerference screw on the tibial side) along with medial opening wedge osteotomy (with tricalcium phosphate wedge) was done. The patients were assessed with IKDC, KOOS scores and any change in anterior tibial translation was also checked. The combined procedure showed mean varus angle correction of 9° (10.5-1.5°), and the mechanical axis of the knee was restored from an average of 172-181.5°. There was a significant improvement in knee score (KOOS and IKDC) after the surgery (p<0.05). The average time for the radiological union of the osteotomy was 3.56 months. The anterior tibial translation was improved. No intraoperative complications and slippage of the synthetic graft were noted in any case. Combined ACLR with HTO (using TCP wedge, without any hardware) is a reliable method that prevents rapid progression of OA. It reliably corrects varus deformity and obviates the use of any hardware.

Can fixator-assisted plating of focal dome osteotomy accurately correct varus deformity in medial compartment osteoarthritis?

Large varus deformities in medial compartment osteoarthritis are difficult to correct with lateral closing-wedge or medial opening-wedge osteotomies. They are easier to correct gradually with opening-wedge or dome osteotomies with external fixation. A focal dome osteotomy can support a large angular correction and yet retains good bony contact. It creates a large proximal fragment that allows for better fixation. However, external fixation devices are cumbersome and not well tolerated by older women and those who cannot follow-up over long distances. Fixator-assisted plating of the focal dome osteotomy combines the advantages of the fixator for accuracy of correction and the convenience of the locking plate. We retrospectively analyzed 34 focal dome high-tibial osteotomies in 31 patients performed over 6 years. Preoperative mechanical axis deviation was −19% (−150%-28%) which improved to 55% (3%-108%). The average preoperative medial proximal tibial angle was 79.8° (88°-63°) which improved to 93° (84°-107°). The average preoperative hip-knee-ankle angle was 195.2° (185°-225°) which improved to 177.5° (166°-204°). Femorotibial angle was 184.6° (182°-220°) which improved to 172° (158°-184°). The tibial slope reduced from 76.9° to 81.1°. Average follow-up was 70 months (45-113). Large varus deformities could be corrected safely with reasonable accuracy in this study.

Opening-wedge high tibial osteotomy: a seven - to twelve-year study

medial opening-wedge osteotomy is a widely performed procedure used to treat moderate isolated medial knee osteoarthritis. Historically, the literature has contained reports showing satisfactory mid-term results when accurate patient selection and precise surgical techniques were applied. This study was conducted to investigate the clinical and radiographic seven- to twelve-year results of opening-wedge high tibial osteotomy in a consecutive series of patients affected by varus knee malalignment with isolated medial compartment degenerative joint disease. we reviewed a case series of 147 medial opening-wedge high tibial osteotomies at an average follow-up of 9.5 years. Endpoints for evaluation included the reporting of adverse effects, radiographic evidence of bone union, radiographic changes in the correction angle during union, and clinical and functional final outcomes. good or excellent results were obtained in 94% of the cases: the patients reported no major complications related to the opening-wedge high tibial osteotomy surgical technique, bone graft resorption, implant choice or postoperative rehabilitation protocol. At final follow-up, the average hip-knee angle was 4° of valgus without major loss of correction during the healing process. A statistically significant change in the patellar height was detected postoperatively, with a trend towards patella infera. medial opening-wedge high tibial osteotomy is still a reliable method for correcting varus deformity while producing stable fixation, thus allowing satisfactory stability, adequate bone healing and satisfactory mid- to long-term results. Level IV, therapeutic cases series.

Medial opening wedge high tibial osteotomy: A technique to avoid patella infera

Background High tibial osteotomy (HTO) is an established treatment for medial compartment osteoarthritis of the knee with varus malalignment. Medial opening wedge osteotomy eliminates most of the disadvantages of the lateral closing wedge osteotomy. Nevertheless, the changes in tibial slope and patellar height after opening wedge HTO with frequent occurrence of patella baja make subsequent knee arthroplasty more difficult. Purpose The purpose of this study was to evaluate the results of a simple technique for medial opening wedge HTO with internal fixation and early mobilization in patients with combined medial compartment osteoarthritis and varus alignment of the knee. Patients and methods Opening-wedge HTO and internal fixation with a standard AO large-fragment T plate with posterior tricortical iliac bone autograft was assessed. Forty-five patients with 61 knees with combined medial femorotibial osteoarthritis and varus deformity of the knee were treated with opening wedge HTO. There were 21 women with 29 knees, with a mean age 45.5 years (30–58 years), and 24 men with 32 knees, with a mean age 41.63 years (30–55 years). Mean follow-up was 35.9 months (13–62 months). Radiographic measurements [femorotibial angle, tibial slope, Insall–Salvati, and Blackburne–Peel (BP) ratios] were taken preoperatively and postoperatively and on follow-up. Preoperative and postoperative (last follow up) values of these parameters were compared. Results Fifty of the 61 (82%) knees had an excellent or good result, whereas in 11 knees there was recurrent pain. There were no implant failures, loss or correction, delayed union, or nonunion. Femorotibial angle was changed from a mean of −7.2° of varus into a mean of 8.3° of valgus (P=0.000). Tibial slope was significantly decreased from a mean of 11.4° to a mean of 9.2° (P=0.002). Insall–Salvati ratio was significantly increased from a mean of 1.1 to a mean of 1.2 (P=0.000). There was a significant decrease in the BP ratio from a mean of 0.9 to a mean of 0.7 (P=0.005). Twenty-five percent of postoperative BP values satisfied the criteria for patella infera (BP Conclusion Opening wedge HTO using a simple technique with rigid fixation and early mobilization decreased the posterior inclination of the tibial slope, straightened the patellar tendon, and elevated the tibiofemoral joint line. The decrease in the inclination of the posterior slope of the tibia and the stretching of the patellar ligament compensate for the elevation of the joint line. This together with the early mobilization protocol resulted in the low incidence of patella infera.

Long-term follow up of single-stage anterior cruciate ligament reconstruction and high tibial osteotomy and its relation with posterior tibial slope.

Open-wedge high tibial osteotomy is considered to be an effective treatment for medial compartmental osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. Young patients with anterior cruciate ligament (ACL) deficiency along with medial compartment osteoarthritis need a combined procedure of ACL reconstruction along with high tibial osteotomy to regain physiological knee kinematics and to avoid chondral damage. We retrospectively analysed data from 30 patients who underwent arthroscopic ACL reconstruction along with medial opening-wedge osteotomy from Jan 2004 to June 2012 with a minimum follow up of 2years. The pre-operative and post-operative posterior tibial slopes were measured. Functional outcome was analysed using clinico-radiological criteria, IKDC scoring and Lysholm score. Post-operative patients improved both clinically and functionally. The patients who had posterior tibial slope >5° decrease, compared to patients who had less <5° decrease, had better functional scores (IKDC and Lysholm score), which was statistically significant (p<0.05). Our study has shown that decreasing the tibial slope >5° compared to pre-operative value has functionally favourable effect on the reconstructed ACL graft and outcome. It is known that increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that decreasing tibial slope may be protective in an ACL deficient knee. Hence by placing the tricortical graft posterior to midline in the opening wedge reduces the posterior tibial slope and thereby reduces the stress on the graft leading to better functional outcome.

Closing Verses Opening Wedge High Tibial Osteotomy: an Evidence-Based Review.

Knee osteoarthritis is a common and disabling disorder made worse by lower extremity malalignment [3]. Medial knee arthrosis is the most common indication for high tibial osteotomy (HTO). Surgical techniques include closing wedge osteotomy, opening wedge osteotomy, dome osteotomy, progressive callus distraction, and chevron osteotomy [4, 7]. Opening and closing wedge osteotomies are the most common. While lateral closing wedge HTO was once considered standard of care, both techniques have advantages and disadvantages, and neither has proven clinical superiority [3]. Technique selection, therefore, is largely driven by surgeon preference. Jackson [4] first described the closing wedge technique in the 1960s and demonstrated improvements in patient function and pain. This technique, however, is associated with fibular osteotomy or proximal tibiofibular joint release, possible peroneal nerve injury, longer rehabilitation, and a more challenging conversion to total knee arthroplasty [1, 6, 9]. Disadvantages of medial opening wedge osteotomy, on the other hand, include the possible need for bone graft, higher rates of nonunion, and the risk of collapse [9]. Reviewed here, Duivenvoorden’s article describes the mid-term follow-up on 92 patients randomized to high tibial opening wedge or closing wedge osteotomy for varus deformity and medial compartment OA. They investigated clinical and radiographic outcomes, in addition to survival rate, at a mean of 7 years postoperatively. The specific aims of this review are to (1) interpret this study’s findings and (2) to evaluate the validity of the authors’ conclusions and recommendations.

High Rate of Recurrence Following Proximal Medial Opening Wedge Osteotomy for Correction of Moderate Hallux Valgus.

The proximal medial opening wedge (PMOW) osteotomy has become more popular to treat moderate to severe hallux valgus with the recent development of specifically designed, low-profile modular plates. Despite the promising results previously reported in the literature, we have noted a high incidence of recurrence in patients treated with a PMOW. The purpose of this study was to report the clinical and radiographic outcomes of an initial cohort of patients treated with a PMOW osteotomy for moderate hallux valgus. We retrospectively analyzed prospectively gathered data on a cohort of 17 consecutive patients who were treated by the senior author using a PMOW osteotomy for moderate hallux valgus deformity. Average time to follow-up was 2.4 years (range, 1.0-3.5 years). The intermetatarsal angle (IMA), the hallux valgus angle (HVA), and the distal metatarsal articular angle (DMAA) were assessed on standard weightbearing radiographs of the foot preoperatively and at all follow-up visits. The Foot and Ankle Outcome Score (FAOS) was collected on all patients preoperatively and at final follow-up. Despite demonstrating good correction of their deformity initially, 11 of the 17 patients (64.7%) had evidence of recurrence of their hallux valgus deformity at final follow-up. Patients who recurred had a greater preoperative HVA (P = .023) and DMAA (P = .049) than patients who maintained their correction. Improvement in the quality-of-life subscale of the FAOS was noted at final follow-up for all patients (P = .05). There was no significant improvement in any of the other FAOS subscales. There was a high rate of recurrence of the hallux valgus deformity in this cohort of patients. Recurrence was associated with greater preoperative deformity and an increased preoperative DMAA. The PMOW without a concomitant distal metatarsal osteotomy may be best reserved for patients with mild hallux valgus deformity without an increased DMAA. Level IV, retrospective case series.

Combined Antero-Posterior Inverted-U Metaphyseal and Open-Wedge Medial-Epiphyseal Osteotomy for Advanced Blount Disease

Background: Blount disease is frequently associated with deformities that may not be adequately corrected by a single metaphyseal osteotomy. This study evaluated the outcome of a combined metaphyseal and epiphyseal osteotomy in severe cases. Methods: We prospectively evaluated the outcome of combining the antero-posterior inverted-U metaphyseal osteotomy with a medial open-wedge hemi-epiphyseal osteotomy in eighteen patients (27 tibiae) with Stage IV to VI Blount disease. Results: The average age of patients was 9 years (ranging from 5 to 17). The tibio-femoral angle improved from 43° varus (Range: 34° - 78°) to 2° varus (Range: 5° valgus to 8° varus). The metaphyseal-diaphyseal angle improved from 36° to 8° varus. Internal tibial torsion improved from 39° to 2°. All the patients were able to achieve 110° of knee flexion in a year. Conclusion: In conclusion, the combined metaphyseal and epiphyseal osteotomy satisfactorily corrected tibio-femoral and metaphyseal-diaphyseal varus and internal tibial torsion without recurrence in patients with severe Blount disease. Level of Evidence: IV.

Proximal Tibia Medial Biplanar Retrotubercle Open Wedge Osteotomy for Varus Knees with Medial Gonarthrosis

Objectives:The purpose of this study is to evaluate the early results of proximal tibia medial biplanar retrotubercle open wedge osteotomy for varus gonarthrosis and compare the results with the literatüre.Methods:The results of proximal tibia medial biplanar retrotubercle open wedge osteotomy for 23 knees of 22 patients with medial gonarthrosis were evaluated clinically and radiologically.Results:Twenty of the patients were female and two were male. Mean age of the patients was 56.24; mean boy mass index was 31.95 and preoperative HSS (Hospital for Special Surgery) score was 68.7. Mean tibiofemoral axis was 186.39° and mean Insall-Salvatti index value was 1.04 preoperatively. Mean follow up period was 30.19 months. Mean HSS score was 86.48, femorotibial anatomic axis angle was 175° and Insall-Salvati index value 1.06 during the last follow-up. The improvement of the HSS score and the femorotibial anatomic axis angle was statistically significant. However, the change in Insall Salvati index values was statistically insignificant. Nonfatal pulmonary embolus in 1 patient, and deep vein thrombosis that occured one year after the procedure in 1 patient, rhabdomyolysis in 1 patient and loss of correction (relapse) in 1 patient were encountered as complications.Conclusion:Our results show that proximal tibia medial biplanar retrotubercle open wedge osteotomy improves the frontal and sagittal plane deformities without changing the patellar tendon length. Hence, possible patellofemoral problems are prevented and the clinical results are improved.

Opening Wedge High Tibial Osteotomy Using Tricalcium Phosphate Wedge

Objectives:High tibial osteotomy is a standard procedure indicated for early medial sided osteoarthritis in varus knees. In this study, we present the early results of high tibial open wedge osteotomy cases using beta-tricalcium phosphate as a graft substitute and Otis-c plate.Methods:Between years 2010 and 2013, 47 cases of (34F, 13 M) medial compartmental gonarthrosis with genu varum deformity treated with high tibial osteotomy, were evaluated with at least one year follow-up, preoperatively both clinically and radiologically. Clinical evaluation involved functional assessment and pain evaluation using Lysholm and visual analog scale (VAS) scores, including knee range-of-motion. Radiological evaluation included medial joint space measurements on weight bearing knee radiographs with measurements of varus angle and posterior tibial slope. Surgical procedure included standard arthroscopy followed by medial sided opening wedge osteotomy with correction of the varus deformity using β- tricalcium phosphate graft substitute and fixation of the osteotomy site using Otis-C plate and locking screws. All patients were evaluated at the end of minimum one-year follow-up period.Results:Mean age of the patients was 56,7 (50- 65) years and mean follow-up period was 24,5 (12- 44) months. Mean duration of surgery was 47,4±10.2 minutes. No case of nonunion, delayed union, neurovascular injury or iatrogenic fracture was encountered. Two cases developed deep vein thrombosis and one case developed superficial wound infection managed successfully by local debridement with retention of implants and antibiotics. Mean duration of union was 13,4±2.7 weeks. Mean preoperative and follow-up range-of-motion were measured as 131±8.9 and 129±9.1 respectively with no statistical difference. Preoperative and follow-up VAS scores showed significant difference as 7.6±1.76 and 2.3±1.08 respectively (p=0.001). Also Lysholm scores improved significantly at the end of the follow-up period (43.23±4.01 vs. 76.3±3.7 p<0,001). Radiological evaluation revealed mean correction angle of 10.84±2.70 degrees at follow-up. Mean posterior tibial slope was measured relatively unchanged (8.6±1.70° degrees preoperatively versus 8.2±2.30° follow-up). Medial joint space width measurements showed a significant increase (pre-op 3.7±1.6 mm. versus 4.6±1.32 mm. at the follow-up (p<0.001)).Conclusion:Medial opening wedge osteotomy for treatment of early medial compartment gonarthrosis in varus knees is still a valuable option. Our short term preliminary results using beta-tricalcium phosphate wedge graft substitute and Otis-c plate-screw osteosynthesis revealed satisfactory short term clinical and radiological results with acceptable complication rates.

Development and validation of formulae to predict leg length following medial opening-wedge osteotomy of the proximal tibia with hemicallotasis

BackgroundA medial open-wedge osteotomy of the proximal tibia with hemicallotasis (HCO) affects the relative coronal alignment of the femur and tibia with respect to the floor; this also potentially reflects a change in leg length. PurposeThe aims of this study are to develop and verify formulae for predicting the postoperative whole leg length (WLL) in HCO. MethodsWe analyzed a training set of 25 HCOs in 25 patients. Formulae for predicting the postoperative leg length were developed using various factors including the length and coronal alignment of the femur and tibia, the length of the proximal or distal fragment from the tibial osteotomy site, the femoro–tibial angle, and the correction angle. The formulae were then verified using the interclass correlation coefficient in an independent consecutive set of 25 HCOs. ResultsSignificant postoperative increases in tibial bone length and WLL were noted with no postoperative change in femoral bone length. Furthermore, the coronal alignments of femoral and tibial bone axes were significantly abducted. For the formulae for predicting postoperative WLL developed in the training set, the interclass correlation coefficients between the predicted values and the real radiographic measurements in the validation set were more than 0.90, showing great consistency. ConclusionThe mathematical models established in this study seemed to predict almost completely the change in leg length after HCO. Our results suggest that these formulae may offer accurate, extremely useful information about the postoperative possibility of leg lengthening for patients planning an HCO. Level of evidenceTherapeutic case series; level 4.

Clinical outcome of medial opening wedge osteotomy with T-locking plate : two years follow-up.

This study was undertaken to determine clinical outcome after medial opening wedge osteotomy with Tlocking plate, with two- year follow up. Twenty-two patients (22 knees) who underwent medial opening wedge osteotomy with T-locking plate (stainless steel 316L, 6 holes) for treatment of varus malalignment of the leg between March 2005 and April 2008 were included in the study. The amount of correction ranged from 7° to 19° (mean, 9.77°). Clinical and radiographic findings were evaluated with VAS and the Lysholm score at sixth, twelfth and twenty- fourth months. Follow-up ranged from 18 to 37 months (mean, 2.1 years). Significant reduction was observed of VAS, from 4 (range: 3.5-5) to almost free of symptoms (1.0 to 0.5) at the twentyfourth month follow-up (P<0.01). Good results were achieved in the Lysholm score (P<0.01). Medial opening wedge osteotomy with T-locking plate is safe and efficient procedure for corrective varus deformity of knee. High tibial osteotomy, T-locking plate , medial opening wedge osteotomy, varus deformity.

Lateral Closing Wedge Osteotomy of Tibia for Degenerative Arthritis

Proximal tibial osteotomy is an effective, well-established treatment for unicompartmental arthritic knee with varus or valgus deformity. Four basic types are commonly described: lateral closing wedge osteotomy, medial open wedge osteotomy, dome osteotomy, and medial opening hemicallotasis. The objective of this procedure is to realign the weight-bearing axis through the knee by redistributing the forces of weight to the less involved compartment of the knee. With thorough preoperative planning and careful selection of patients, optimal outcome can be expected with preservation of the patient’s joint. In this article, we reviewed selection of patients, surgical planning, surgical technique, complications, pre- and post-operative change in mechanics, and long term surgical outcome of closing wedge osteotomy. Optimal outcome is expected in patients with young age (younger than 60), stable knee, medially confined osteoarthritis, and good range of motion. According to the literature, average 10-year survival rate is expected to be 60% to 90%. Closing wedge osteotomy allows for rapid bone healing, early weight bearing, rehabilitation, and low rates of correction loss. Surgeons should keep in mind that optimal indication, preoperative planning, and use of safe operative technique are essential to achievement of best results.

Foot and Ankle Reconstruction for Adult Acquired Flatfoot after Ligamentous Ankle Injury

Introduction: Ankle syndesmosis injuries typically occur when the foot is forced upward and outward. Syndesmosis of the ankle is the joint that connects the tibia and fibula and allows these two bones to work together to provide stability to the lower leg. Case: 24 year old active duty female service member presented to Womack Army Medical Center for left ankle pain approximately 12 weeks after incurring an injury while playing basketball. She reported increased pain with activity and no improvement when using a brace. Imaging studies performed on the weight bearing left leg, ankle, and foot revealed a healed proximal fibular fracture, syndesmosis widening with lateral shift and medial space widening, and decreased longitudinal arch height. A magnetic resonance imaging revealed a deltoid ligament tear and widening of the syndesmosis, but showed no tibialis posterior tendinopathy. The patient was taken to the operating room for open reduction internal fixation of the syndesmosis with a medial displacement calcaneal osteotomy, deltoid ligament repair, gastrocnemius recession, and medial cuneiform opening wedge osteotomy. Discussion: The coexistence of syndesmosis and deltoid ligament injuries modifies ankle joint motion and significantly destabilizes the ankle joint. Radiographs of the affected limb to rule out any fracture are important; however, stress radiographs may be needed to accurately determine stability of the ankle joint as clinical examination cannot assess or diagnose deltoid ligament injury.

Intraosseous and Extraosseous Blood Supply to the Medial Cuneiform

Osteotomies of the medial cuneiform are commonly used to correct forefoot deformity. Bone healing occurs despite periosteal stripping of the dorsal and medial surfaces of this widely articulated bone followed by osteotomy in the midsection of the bone. The objective of this study was to characterize the blood supply of the medial cuneiform. Thirty matched pairs of adult cadaver legs, 60 legs total, were amputated below the knee, and arterial casts were created with India ink and latex. Soft tissues were debrided, allowing visualization of the extraosseous blood vessels. In 53 specimens the vascular supply to the medial cuneiform was photographed and recorded. Forty-nine specimens were then cleared using a modified Spälteholz technique. The intraosseous vascularity of the medial cuneiform was successfully characterized and reviewed in 48 of these specimens. The extraosseous blood supply was similar to previous reports with a middle pedicle branch originating from the dorsalis pedis artery. The medial plantar and superficial medial plantar artery supplied the plantar aspect of the bone. Intraosseous analysis showed a dense capillary network throughout the cuneiform, with typically one central medial major and several minor nutrient arteries noted. Areas of hypovascularity were infrequent and when noted occurred at inconsistent locations. These findings support the clinical suspicion that the medial cuneiform is well vascularized from multiple sources. The plantar blood supply is likely sufficient to allow bone healing after dorsal periosteal exposure and possible injury to the middle pedicle branch of the distal medial tarsal artery. A medial cuneiform opening wedge osteotomy can be used to correct forefoot deformity. This study investigates the blood supply to that bone to better characterize the healing potential of the medial cuneiform.