Proximal Tibial Valgus Osteotomy Research Articles

High Tibial Osteotomy Using the ‘Tomofix™’ Plating System: Short Term Outcomes in Young Adults

Proximal tibial valgus osteotomy is one of the treatment options for painful medial compartment osteoarthritis and varus deformity of the knee. The aim of our study was to determine and quantify how much osteotomy altered symptoms from medial compartment gonoarthrosis. In addition we aimed to establish whether the Tomofix plating system would permit early weight bearing and achieve union without the use of bone grafts. We prospectively analysed our experience with medial opening wedge high tibial osteotomy using the Tomofix plate.
 Thirty-five knees were included in the study. The mean age was 47 years (36-59 years). Mean duration of follow-up was 23 months (7-48 Months). All patients underwent medial opening wedge high tibial osteotomy using the Tomofix plating system. Data was recorded using the Oxford Knee score, the Knee Injury Osteoarthritis Outcome score and through review of pre and postoperative x-rays. Good outcomes were seen with statistically significant improvement of both scores.
 There were two delayed unions, the remainder united without requirement for graft. There was improvement, in Oxford and Knee injury osteoarthritis scores. Correction of mal-alignment was seen in all cases. Early weight bearing was found to be permissible without risk of adverse event.
 The Tomofix plate provided immediate stability and satisfactory healing of the osteotomy site without the need for bone graft. Good functional results were seen.

Proximal Tibial Valgus Osteotomy: Lateral Closing Wedge.

Valgus-producing high tibial osteotomy (HTO) is a well-accepted treatment modality in active patients with varus malalignment and symptomatic medial unicompartmental osteoarthritis (OA) of the knee. One of the key factors for long-term success of the osteotomy is the achievement of an even distribution of the mechanical load on the knee joint by obtaining an ideal alignment of the lower-extremity mechanical axis. Proper surgical techniques are very important, and lateral closing wedge proximal tibial valgus osteotomy (CWO) is highly effective in achieving the desired overcorrection of 3° to 7° of valgus. The major steps of CWO are (1) preoperative planning, in which the frontal plane varus knee deformity is assessed on a standard whole-leg radiograph; (2) a transverse anterolateral incision from the tubercle toward the posterior aspect of the proximal part of the fibular head; (3) exposure and snaring of the common peroneal nerve; (4) resection of the anterior aspect of the proximal part of the fibular head; (5) use of a calibrated slotted wedge resection guide to perform the osteotomy proximal to the tuberosity under fluoroscopic guidance; (6) removal of an osseous wedge and closure of the osteotomy site, with the medial opposite cortex acting as a hinge; and (7) fixation of the osteotomy site with two step staples. Complications (e.g., nonunion, deep infection, and peroneal neuropathy) are rare. At follow-up, CWO has been shown to improve knee function and reduce pain. Male patients with early-onset knee OA have an almost ten times lower probability of failure of a CWO than women with more degenerative disease. The survival rate, with knee replacement as the end point, is approximately 75% at ten years following CWO. CWO postpones primary total knee arthroplasty (TKA) for a median of seven years, and there is low-quality evidence that osteotomy does not compromise subsequent knee replacement.

EXTENSOR MECHANISM COMPLICATIONS FOLLOWING TOTAL KNEE ARTHROPLASTY

The patellofemoral joint is an important source of pain and complications following total knee arthroplasty. In a recent series of revisions of total knee arthroplasties, almost 12% of the reoperations were done because of a problem related to the extensor mechanism1. The prevalence of complications related to the extensor mechanism has generally decreased over the past twenty years but remains around 4%2-7. Anterior knee pain, patellar instability, fracture, rupture of the extensor mechanism, and a variety of miscellaneous problems affecting the patella can adversely affect the results of a total knee arthroplasty. Patient selection is an important variable influencing complications related to the extensor mechanism (Table I)8-18. A lateral retinacular release is frequently required at the time of a total knee arthroplasty for a patient with patellofemoral arthritis. The rate of lateral retinacular release has ranged from 29% to 68%8-10. Hypoplasia of the trochlear groove combined with shortening of the extensor mechanism is common in patients with a chronically dislocated patella, and it increases the potential for postoperative patellar instability15. A patient with a large preoperative valgus deformity may have hypoplasia of the lateral femoral condyle, which makes rotational positioning of the femoral implant difficult. A patient with a previous proximal tibial valgus osteotomy may have patella infera, which makes exposure difficult and can contribute to avulsion of the patellar tendon. Patella infera can result in impingement between the patella and the tibial component, leading to pain or patellar instability. When a patient has posttraumatic arthritis and malunion, there can be complex problems with regard to implant positioning and balancing of the soft tissues, including the extensor mechanism16-18. Finally, a patient with severe osteoporosis is at risk for patellar …

Unicompartmental arthritis of the knee.

• Unicompartmental arthritis of the knee is a degenerative condition characterized by abnormal articular cartilage in the medial or lateral part of the tibiofemoral joint, which may be associated with meniscal disruption, ligamentous instability, and limb malalignment. • Nonoperative treatments for unicompartmental degenerative arthritis of the knee include oral and injectable medications, weight loss, exercise, physical therapy, canes, crutches, braces, and orthoses. • Arthroscopy for unicompartmental arthritis of the knee can provide a clinical benefit in terms of reduced pain and improved function for patients with mechanical symptoms, mild degenerative disease, and minimal or no malalignment. Meniscal tears, loose bodies, osteophytic spurs, or chondral flaps can cause mechanical symptoms, which can be treated successfully with arthroscopy. • Proximal tibial valgus osteotomy and distal femoral varus osteotomy for treatment of unicompartmental arthritis of the knee can realign a deformed limb, reduce pain, and improve function for active, high-demand patients with a projected life expectancy of twenty years or more. • As a patient's life expectancy and expectations for activity decrease as a result of age and disease, unicompartmental and total knee arthroplasty provide predictably successful surgical options for the treatment of unicompartmental arthritis of the knee. Arthritis of the knee is a common clinical problem: 2% of the United States population older than seventeen years of age and 10% of Americans over sixty-five years of age have clinically relevant arthritis of the knee 1. Arthritis of the knee causes pain and restricts activity, and patients with arthritis are twice as likely to seek medical care as are their peers without arthritis 2. Unicompartmental arthritis of the knee is defined as a condition characterized by degenerative articular cartilage in the medial or lateral aspect of the tibiofemoral joint, which may be associated with meniscal disruption, ligamentous instability, and malalignment 1 …

Management of musculoskeletal complications of hemophilia.

Prophylactic treatment from ages 2 to 18 years could prevent the development of hemophilic arthropathy if the concentration of the patient's deficient factor is kept from falling below 1% of normal. Early treatment is of paramount importance because the immature skeleton is very sensitive to the complications of hemophilia. Major hemarthrosis and chronic hemophilic synovitis should be treated aggressively to prevent hemophilic arthropathy. When advanced hemophilic arthropathy is present with severe disability, the aim should be to restore function while minimizing the risk to the patient. Joint debridement is an effective method to achieve this goal, especially around the elbow or ankle, and can be considered an alternative to knee replacement in the younger age groups. Proximal tibial valgus osteotomy is a reliable treatment method for painful genu varum of the mobile hemophilic knee. Supramalleolar tibial varus osteotomy is an attractive alternative to the more commonly used surgical option of arthrodesis. Finally, joint replacement can usually be relied on to restore both mobility and function in a diseased joint. The potential benefits of joint replacement must always be weighed against the long-term sequelae, however, especially loosening and consequent revision surgery.

Realignment osteotomy of the knee—Part 1: Distal femoral varus osteotomy for osteoarthritis of the Valgus knee

Realignment osteotomy of the knee is indicated for the young active patient with unicompartmental osteoarthritisand an associated deformity. Varus deformity in association with medial compartment osteoarthritis is most commonly corrected through the proximal tibia. Valgus deformity with lateral compartment osteoarthritis is most commonly corrected through the distal femur because of the often-associated superior-lateral slope of the joint line. However, if the deformity is minimal and there is no superolateral slope to the joint line, then the correction can be made through the proximal tibia. This article has 2 parts. Part 1 covers the valgus knee and a detailed description of our technique for distal femoral varus osteotomy. Part 2 covers the varus knee and our technique for proximal tibial valgus osteotomy, which is described in detail.

Realignment osteotomy of the knee—Part 2: Proximal valgus tibial osteotomy for osteoarthritis of the varus knee

Realignment osteotomy of the knee is indicated for the young active patient with unicompartmental osteoarthritisand an associated deformity. Varus deformity in association with medial compartment osteoarthritis is most commonly corrected through the proximal tibia. Valgus deformity with lateral compartment osteoarthritis is most commonly corrected through the distal femur because of the often-associated superior-lateral slope of the joint line. However, if the deformity is minimal and there is no superolateral slope to the joint line, then the correction can be made through the proximal tibia. This article has 2 parts. Part 1 covers the valgus knee and a detailed description of our technique for distal femoral varus osteotomy. Part 2 covers the varus knee and our technique for proximal tibial valgus osteotomy, which is described in detail.

Articular cartilage regeneration of the knee joint after proximal tibial valgus osteotomy: a prospective study of different intra- and extra-articular operative techniques.

In this prospective study high tibial osteotomy for medial gonarthrosis was performed in 95 patients (105 knee joints). The patients underwent simultaneously diagnostic and operative arthroscopic surgery of the knee joint. A follow-up arthroscopic examination could be performed in 75 patients (85 knee joints) at the time of implant removal. In group 1 (20 knee joints), the osteotomy was performed after diagnostic arthroscopy without arthroscopic operation of the knee joint. The fixation of the osteotomy was accomplished by staples, postoperative plaster fixation and physiotherapy. In group 2 (20 knee joints), osteotomy was performed without additional operative arthroscopy after diagnostic arthroscopy, internal fixation by AOT-plate, no external fixation postoperatively and physiotherapy. In group 3 (22 knee joints), osteotomy was performed with additional operative arthroscopy (Pridie drilling), internal fixation by AOT-plate no external fixation postoperatively no external fixation, physiotherapy and continuous passive motion. In group 4 (23 knee joints), osteotomy was performed with additional operative arthroscopy (abrasio-arthroplasty), internal fixation by AOT-plate, no external fixation postoperatively, physiotherapy and continuous passive motion. All patients underwent arthroscopic examination of the knee with cartilage biopsies taken from three different regions of the femoral condyle during the same operative session as the osteotomy. At follow-up arthroscopy cartilage biopsies were taken from the same regions. There was no great difference in clinical outcome after 1 year between all groups. Arthroscopy as well as routine and electron microscopy showed better cartilage regeneration in groups 3 and 4. Groups 1 and 2 showed only regeneration isles, sometimes not well fixed to the underlying bone, while in groups 3 and 4 cartilage regeneration was thicker and more stable, sometimes covering all of the pre-existing erosions. Therefore, we recommend osteotomy of the tibia for osteoarthritis together with operative arthroscopy in the same operative session.

Total knee arthroplasty after failed proximal tibial valgus osteotomy

The results of total knee arthroplasty were evaluated in 113 patients with gonarthrosis (14 patients with and 99 without prior operation with proximal tibial valgus osteotomy). There was no difference in the final result after follow-up periods of 4–9 years with respect to average Hospital for Special Surgery score, degree of knee flexion, and later knee revisions between the 14 osteotomized and 99 nonosteotomized patients. The average femorotibial angle did not differ between the groups; neither did the average wear of the tibial polyethylene. No difference was found in operative time, but a significantly greater blood loss and other postoperative complications were noted among the previously osteotomized group of patients, indicating a more complicated procedure for the knee arthroplasty operation compared with the nonosteotomized group of patients.

Proximal tibial osteotomy in patients who are fifty years old or less. A long-term follow-up study.

Proximal tibial valgus osteotomy was performed for unicompartmental osteoarthritis in forty-five patients (fifty-one knees). The average age of the patients was forty-one years (range, twenty-three to fifty years), and the average length of follow-up was ten years. At follow-up, 70 per cent (thirty-six knees) were rated as good or excellent and 30 per cent (fifteen knees) were rated as fair or poor. There was no clear correlation between the quality of the result and the radiographic evidence of the severity of the arthritis preoperatively, the age of the patient at osteotomy, or the length of follow-up. There was a correlation between an improved result and an increased angle of correction after osteotomy, but the values were not statistically significant. The most important factor influencing the quality of results was the over-all level of disease in the knee as reflected in the preoperative knee score. Deficiency of the anterior cruciate ligament at the time of the osteotomy did not prevent a good result. We believe that proximal tibial osteotomy for unicompartmental arthritis of the knee is a good and effective procedure for patients who are less than fifty years old and who have an active life-style, and that lasting results can be achieved if the procedure is done early in the course of the disease.

Combined Maquet and Proximal Tibial Valgus Osteotomy

A combined Maquet and proximal tibial valgus osteotomy has been used to treat patients presenting with anterior and medial compartmental degenerative arthritis. Patients with clinically symptomatic lateral compartmental disease, gross instability, or a nonfunctional range of motion were excluded. Thirty-four knees in 31 patients whose average age was 59.6 years were studied. Follow-up periods range from six to 36 months (mean, 16 months). Results have been tabulated with respect to the patient's preoperative radiographs and clinical knee ratings. The surgical technique has been the same throughout the series and is notable for the absence of metallic fixation and for the division of the tibiofibular joint proximally without an associated fibular osteotomy. Neither nonunion nor peroneal nerve dysfunction was encountered postoperation. To date, 68% of the results have been graded as good to excellent, 20% as fair, and 12% have failed. No correlation was found between preoperative radiographic rating and postoperative result.