The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 11

Scientific Articles | November 01, 2009

Opening-Wedge High Tibial Osteotomy with a Locked Low-Profile Plate

Werner Kolb, MD¹; Hanno Guhlmann, MD²; Christoph Windisch, MD²; Klaus Kolb, MD³; Heiko Koller, MD³; Paul Grützner, MD³

¹ Department of Trauma Surgery, Bethesda Hospital, Hohenheimer Strasse 21, 70184 Stuttgart, Germany. E-mail address: drwerner.kolb@t-online.de
² Department of Trauma Surgery, Friedrich-Schiller-University, Bachstrasse 18, 07740 Jena, Germany. E-mail address for H. Guhlmann: sasu96@t-online.de. E-mail address for C. Windisch: c.b.windisch@t-online.de
³ Department of Trauma Surgery, Katharinenhospital, Kriegsbergstrasse 60, 1 Stuttgart, Germany. E-mail address for K. Kolb: k.kolb@katharinenhospital.de. E-mail address for H. Koller: heiko.koller@t-online.de. E-mail address for P. Grützner: p.gruetzner@katharinenhospital.de

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Trauma Surgery, Friedrich-Schiller-University, Jena, and Katharinenhospital, Stuttgart, Germany

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Nov 01;91(11):2581-2588. doi: 10.2106/JBJS.H.01047

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Abstract

Background: High tibial osteotomy has been recognized as a beneficial treatment for osteoarthritis of the medial compartment of the knee. The purpose of this prospective study was to assess the short-term results of opening-wedge high tibial osteotomies with locked plate fixation.

Methods: From September 2002 to November 2005, fifty-one consecutive medial opening-wedge high tibial osteotomies were performed. The mean age of the patients at the time of the index operation was forty-nine years. The preoperative and postoperative factors analyzed included the grade of arthritis of the tibiofemoral compartment (the Ahlbäck radiographic grade), the anatomic tibiofemoral angle, patellar height, the Hospital for Special Surgery rating system score, and the Lysholm and Gillquist knee score.

Results: Postoperatively, one superficial wound infection occurred. Fifty of the fifty-one osteotomies healed after an average period of 12.9 weeks (range, eight to sixteen weeks) without bone grafts. A nonunion developed in a sixty-two-year-old patient who was a cigarette smoker. The average postoperative tibiofemoral angle was 9° of valgus. Forty-nine patients were followed for a mean of fifty-two months. The average score on the Hospital for Special Surgery rating system was 86 points at the time of the most recent follow-up. The rating was excellent in twenty-eight patients (57%), good in twelve (24%), fair in four (8%), and poor in five (10%). The average score on the Lysholm and Gillquist knee-scoring scale was 83 points. According to these scores, the outcome was excellent in nine patients (18%), good in thirty-one (63%), fair in three (6%), and poor in six (12%). Four knees failed after an average of thirty-six months.

Conclusions: Our results suggest that an opening-wedge high tibial osteotomy with locked plate fixation allows a correct valgus angle to be achieved with good short-term results.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Osteotomy has been recognized as a beneficial treatment for osteoarthritis of the medial compartment of the knee^1—3. Currently, a medial opening-wedge high tibial osteotomy is often performed and protected from collapse with an external fixator for several weeks. The disadvantage of this technique is the risk of pin-track infection, with rates as high as 18%, which often requires pin removal before union has been achieved, thus jeopardizing subsequent arthroplasty⁴. There are few reports of medial opening-wedge osteotomy with internal fixation^5—8. The complications described for this technique include implant failure, nonunion of the osteotomy, patella baja, loss of correction, and a potential increase in tibial slope if the osteotomy is not adequately opened posteriorly^6,7. Furthermore, when an autogenous iliac crest graft is used, there is relevant donor-site morbidity^8,9. Pollock et al.¹⁰ described substantial donor-site pain following iliac crest bone harvesting and its effect on walking.

Internal fixators with locked screws allow the healing of the osteotomy without compression between the plate and bone, and, in most patients, bone grafts can be avoided⁷. TomoFix (Synthes, West Chester, Pennsylvania) is an anatomically precontoured internal fixator for the proximal-medial aspect of the tibia that is inserted into a subcutaneous tunnel with minimal bone exposure. Our hypothesis was that this device is suitable for fixation of a medial opening-wedge high tibial osteotomy and can achieve good short-term results.

The aims of this prospective study were to evaluate the correction of osseous malalignment and to analyze the short-term results of medial opening-wedge high tibial osteotomy with locked plate fixation.

Materials and Methods

Patient consent and institutional review board approval were obtained for this study, which was not registered in a clinical trials registry. We studied fifty-one consecutive medial opening-wedge high tibial osteotomies treated by orthopaedic surgeons experienced with the TomoFix internal fixator from September 2002 to November 2005. Inclusion criteria were active patients with varus malalignment of the limb without evidence of radiographic subluxation or lateral thrust during gait, an arc of motion of at least 100°, symptomatic overloading in the medial compartment, an intact lateral compartment, and medial soft-tissue coverage. Patients with open growth plates; a previous lateral meniscectomy; rheumatoid arthritis; grade-III or IV articular cartilage lesions, according to the system of Outerbridge¹¹, in the lateral compartment; a flexion contracture of >10°; systemic or local infection; bone-healing disorders; heavy smoking (more than fifteen cigarettes per day); inadequate soft tissue overlying the medial tibial plateau; a body mass index of >30 kg/m²; and an age of more than seventy years were excluded. Patients with a high tibial osteotomy of the contralateral knee were excluded, if the first knee had been included in this trial. Thirty-six men and fifteen women underwent the procedure. The mean patient age was forty-nine years (range, eighteen to sixty-six years) at the time of the index operation (Table I). Forty-six knees had osteoarthritis, and five knees had posttraumatic arthritis. Thirty right knees and twenty-one left knees were treated. Nine patients had had a prior partial medial meniscectomy. Eight patients had old injuries (a fracture of the tibial plateau in four, old ruptures of the anterior cruciate ligament in three, and posterolateral instability in one).

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TABLE I Clinical Findings

					Hospital for Special Surgery Score*					Lysholm Score*
Sex	No. of Patients	Age*(yr)	Side (L/R)	Duration of Follow-up*(mo)	Preop.	1-Yr Postop.	Most Recent Follow-up	Preop.	1-Yr Postop.	Most Recent Follow-up
Male	36	47.8 (18-66)	17/19	50.5 (30-65)	65.8 (50-98)	92.2 (73-100)	85.4 (54-100)	60.1 (43-86)	90.0 (79-100)	83.0 (68-100)
Female	15	52.2 (41-61)	4/11	55.1 (33-66)	65.9 (52-90)	94.6 (75-100)	86.0 (68-95)	60.4 (47-78)	90.8 (71-100)	83.3 (47-100)
All	51	49.2 (18-66)	21/30	52 (30-66)	65.8 (50-98)	92.9 (73-100)	85.6 (54-100)	60.2 (43-86)	90.6 (71-100)	83.1 (47-100)

The values are given as the mean, with the range in parentheses.

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TABLE I Clinical Findings

					Hospital for Special Surgery Score*					Lysholm Score*
Sex	No. of Patients	Age*(yr)	Side (L/R)	Duration of Follow-up*(mo)	Preop.	1-Yr Postop.	Most Recent Follow-up	Preop.	1-Yr Postop.	Most Recent Follow-up
Male	36	47.8 (18-66)	17/19	50.5 (30-65)	65.8 (50-98)	92.2 (73-100)	85.4 (54-100)	60.1 (43-86)	90.0 (79-100)	83.0 (68-100)
Female	15	52.2 (41-61)	4/11	55.1 (33-66)	65.9 (52-90)	94.6 (75-100)	86.0 (68-95)	60.4 (47-78)	90.8 (71-100)	83.3 (47-100)
All	51	49.2 (18-66)	21/30	52 (30-66)	65.8 (50-98)	92.9 (73-100)	85.6 (54-100)	60.2 (43-86)	90.6 (71-100)	83.1 (47-100)

The values are given as the mean, with the range in parentheses.

Preoperative clinical evaluation included knee stability, passive range of motion, meniscal tests, patellar tracking, and patellar pain. Radiographic assessment included a full-length anteroposterior standing radiograph with the patella facing directly anteriorly, a lateral radiograph with the knee in 30° of flexion, a weight-bearing tunnel radiograph with the knee flexed, and skyline radiographs of the patella with the knee in 30° of flexion. Valgus and varus stress anteroposterior radiographs with the knee flexed were made for patients with ligament instability. The degree of arthritis of the tibiofemoral and the patellofemoral compartments was classified according to the method of Ahlbäck¹² (Table II). Angles were measured with a goniometer and recorded to the nearest 0.5°.

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TABLE II Preoperative Grade of Arthritis in Knees According to the Classification System of Ahlbäck¹²

Ahlbäck Grade	Medial Compartment	Lateral Compartment	Patellofemoral Compartment
0	0	49	43
I	6	2	8
II	16	0	0
III	29	0	0
IV	0	0	0

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TABLE II Preoperative Grade of Arthritis in Knees According to the Classification System of Ahlbäck¹²

Ahlbäck Grade	Medial Compartment	Lateral Compartment	Patellofemoral Compartment
0	0	49	43
I	6	2	8
II	16	0	0
III	29	0	0
IV	0	0	0

Patients were seen at six-week intervals until the osteotomy had healed and then at one year and again at the time of the latest follow-up. The osteotomy was considered healed when bone formation in the osteotomy gap and callus in the lateral and anterior parts of the osteotomy were visible on the radiographs. The follow-up evaluation was performed by two surgeons who had not managed the patient.

During clinical and radiographic follow-up evaluations, we recorded arthritis of the tibiofemoral and patellofemoral compartments, axial alignment, loss of correction, delayed union, nonunion, infection, neural complications, subjective rating of the final result, and the findings of a clinical examination by the authors. Delayed union was defined as prolonged healing of the osteotomy over four months, while nonunion was defined as no evidence of healing six months after the osteotomy. Two plain radiographs of the knee as well as full-length radiographs and a skyline radiograph of the patella were made at six weeks, at one year, and at the latest follow-up examination. The anatomic tibiofemoral angle, the mechanical tibiofemoral angle, the medial-proximal tibial angle¹³, the posterior proximal tibial angle (or posterior slope)¹³, the joint line convergence angle¹³, and the Insall-Salvati¹⁴ and Blackburne-Peel¹⁵ ratios were measured preoperatively, at six weeks, at one year, and at the latest follow-up evaluation (Figs. 1-A through 1-E). Loss of correction was defined as a postoperative increase or decrease of >5° of the tibiofemoral angle. Failure was defined as conversion to total knee arthroplasty. The time to failure was recorded.

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Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E: Figs. 1-A through 1-E Illustrations demonstrating high tibial osteotomy radiographic measurements. Fig. 1-A Frontal plane joint orientation. The anatomic tibiofemoral angle, the medial-proximal tibial angle (MPTA), and the joint line convergence angle (JLCA)¹³. Fig. 1-B Frontal plane joint orientation. The mechanical tibiofemoral angle, the medial-proximal tibial angle (MPTA), and the joint line convergence angle (JLCA)¹³. Fig. 1-C Sagittal plane joint orientation. The posterior proximal tibial angle (PPTA or posterior slope)¹³. Fig. 1-D The Insall-Salvati ratio (T/P) to determine the height of the patella. T = the length of the tendon, and P = the greatest diagonal length of the patella¹⁴. Fig. 1-E The Blackburne-Peel ratio (A/B) to determine the height of the patella. A = the perpendicular distance between the lowest part of the articular surface, and B = the length of the articular surface of the patella¹⁵.

The results were rated objectively according to the Hospital for Special Surgery rating system¹⁶ and subjectively according to the knee-scoring scale described by Lysholm and Gillquist¹⁷.

Surgical Technique

Preoperative planning included a determination of the desired correction with use of full-length standing radiographs according to the method of Miniaci et al.¹⁸. The mechanical axis was shifted to a point 62% lateral on the transverse diameter of the tibial plateau according to the criteria of Fujisawa et al.¹⁹.

The surgical technique used was developed by Staubli et al. and Lobenhoffer et al.^5,6. The procedure was performed with the patient under general or spinal anesthesia and placed in a supine position on a radiolucent standard operating table with a lateral support. An arthroscopy was performed first to assess the lateral compartment and treat additional intra-articular lesions. We made an oblique incision 6 to 8 cm long, 4 cm distal to the joint line and 1 cm proximal to the pes anserinus, extending from the medial aspect of the tibial tuberosity to the posterior border of the tibial plateau. We made a v-shaped osteotomy at a slow pace under continuous irrigation with cold fluid to avoid bone necrosis, leaving a 10-mm lateral bone bridge intact. Alignment was checked with the cable method²⁰. We did not change the tibial slope except in one patient with preexisting posterolateral instability. In that patient, we increased the slope 5° and combined this procedure with rerouting of the iliotibial tract to address posterolateral instability^21,22. The TomoFix was inserted into a subcutaneous tunnel over the soft tissues on the anteromedial aspect of the tibia. No bone graft was used (Figs. 2 and 3). A detailed technical description of the procedure is provided in the Appendix.

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Fig. 2: Schematic figure of the v-shaped osteotomy. (Reprinted with permission of Synthes, Inc.)

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Fig. 3: Schematic figure showing the final configuration of the plate and screws. (Reprinted with permission of Synthes, Inc.)

Postoperatively, patients were allowed toe-touch weight-bearing for six weeks. No cast or brace was applied. After removal of the drains on the second postoperative day, active physical therapy with strengthening exercises and continuous passive motion was initiated. The patients left the hospital when they were able to walk with two crutches after an average of eight days (range, three to twenty-one days). After six weeks, they began full weight-bearing.

Statistical Analysis

The findings at both the preoperative and the most recent evaluation with regard to the Hospital for Special Surgery score¹⁶, the Lysholm and Gillquist score¹⁷, and the tibiofemoral angle were compared with use of the paired-samples Student t test. The Wilcoxon matched-pairs test compared the medial-proximal tibial angle, the posterior proximal tibial angle (or posterior slope), the joint line convergence angle, and the Blackburne-Peel¹⁵ ratio preoperatively and postoperatively. The preoperative and most recent Insall-Salvati¹⁴ ratio was compared with the Bowker test for symmetry. The Spearman correlations between the tibiofemoral angle and the Hospital for Special Surgery score¹⁶ and the Lysholm and Gillquist score¹⁷ at the time of follow-up were assessed in order to estimate dependency between outcome measures. The level of significance was set at 0.05.

Source of Funding

There was no external funding source for this study.

Results

Postoperatively, one patient (2%) had a superficial wound infection, which healed with local wound care. No deep infection or vascular or neural complication occurred. All osteotomies healed without bone graft by an average of 12.9 weeks (range, eight to sixteen weeks) with the exception of nonunion in a sixty-two-year-old patient who smoked. After thirteen months, the patient had a revision osteosynthesis with a TomoFix device and an autogenous iliac crest graft that healed without further complications. The average anatomic tibiofemoral angle in the fifty-one patients was 9.2° (range, 6° to 12°) of valgus, and the average mechanical tibiofemoral angle was 2.1° (range, -1° to 6°) at six weeks postoperatively (Table III). The mean size of the opening wedge was 10.9 mm (range, 8 to 14 mm). During the follow-up period, we observed no loss of correction and no implant failure. We removed twelve implants after twenty-two months (range, eight to forty-five months). Two patients with thin subcutaneous tissue had pain around the internal fixator; the others had no symptoms but requested that the fixator be removed. Conversion to total knee arthroplasty was performed in four patients with primary osteoarthritis after eighteen, thirty-six, forty-three, and forty-seven months because of progressive osteoarthritis and persistent symptoms (Table IV). The osteotomy created no technical difficulty in performing the subsequent arthroplasty.

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TABLE III Radiographic Findings for All Knees

	Preop.*	6-Wk Postop.*	1-Yr Postop.*	Most Recent Evaluation*	Comparison of Preop. and Most Recent Evaluation (p value)
Anatomic tibiofemoral angle¹³(deg)	-2.7 (-8-6)	9.2 (6-12)	9.1 (6-12)	8.4 (6-11)	<0.001
Mechanical tibiofemoral angle¹³(deg)	-9.5 (-15-0)	2.1 (-1-6)	2 (-1-6)	1.3 (-1-5)	<0.001
Medial-proximal tibial angle¹³(deg)	82.2 (79-87)	93.0 (90-96)	92.7 (90-96)	92.5 (90-96)	<0.001
Posterior proximal tibial angle¹³(deg)	80.1 (77-84)	79.5 (74-83)	79.1 (74-83)	79.2 (74-84)	<0.001
Joint line convergence angle¹³(deg)	2.8 (1-6)	2.7 (1-4)	2.6 (1-4)	2.4 (2-4)	0.557
Insall-Salvati ratio¹⁴	0.99 (0.9-1.1)	1.0 (0.8-1.1)	1.0 (0.8-1.1)	1.01 (0.9-1.2)	0.094
Blackburne-Peel ratio¹⁵	0.82 (0.75-0.9)	0.75 (0.6-0.9)	0.75 (0.6-0.85)	0.75 (0.6-0.75)	<0.001

The values are given as the mean, with the range in parentheses. Varus angulation was designated by a minus sign.

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TABLE III Radiographic Findings for All Knees

	Preop.*	6-Wk Postop.*	1-Yr Postop.*	Most Recent Evaluation*	Comparison of Preop. and Most Recent Evaluation (p value)
Anatomic tibiofemoral angle¹³(deg)	-2.7 (-8-6)	9.2 (6-12)	9.1 (6-12)	8.4 (6-11)	<0.001
Mechanical tibiofemoral angle¹³(deg)	-9.5 (-15-0)	2.1 (-1-6)	2 (-1-6)	1.3 (-1-5)	<0.001
Medial-proximal tibial angle¹³(deg)	82.2 (79-87)	93.0 (90-96)	92.7 (90-96)	92.5 (90-96)	<0.001
Posterior proximal tibial angle¹³(deg)	80.1 (77-84)	79.5 (74-83)	79.1 (74-83)	79.2 (74-84)	<0.001
Joint line convergence angle¹³(deg)	2.8 (1-6)	2.7 (1-4)	2.6 (1-4)	2.4 (2-4)	0.557
Insall-Salvati ratio¹⁴	0.99 (0.9-1.1)	1.0 (0.8-1.1)	1.0 (0.8-1.1)	1.01 (0.9-1.2)	0.094
Blackburne-Peel ratio¹⁵	0.82 (0.75-0.9)	0.75 (0.6-0.9)	0.75 (0.6-0.85)	0.75 (0.6-0.75)	<0.001

The values are given as the mean, with the range in parentheses. Varus angulation was designated by a minus sign.

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TABLE IV Changes in Arthritis Grade in Knees According to the Classification System of Ahlbäck at Most Recent Follow-up Evaluation*

Ahlbäck Grade	Medial Compartment	Lateral Compartment	Patellofemoral Compartment
Definitely worse	2	5	4
Possibly worse	0	6	5
Same	43	38	40
Possibly better	3	0	0
Definitely better	1	0	0

Two patients were lost to follow-up.

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TABLE IV Changes in Arthritis Grade in Knees According to the Classification System of Ahlbäck at Most Recent Follow-up Evaluation*

Ahlbäck Grade	Medial Compartment	Lateral Compartment	Patellofemoral Compartment
Definitely worse	2	5	4
Possibly worse	0	6	5
Same	43	38	40
Possibly better	3	0	0
Definitely better	1	0	0

Two patients were lost to follow-up.

Forty-nine patients were followed for a mean of fifty-two months (range, twenty-eight to sixty-six months). Two patients were lost to follow-up. At the latest follow-up examination, the average anatomic tibiofemoral angle was 8.4° (range, 6° to 11°) and the average mechanical tibiofemoral angle was 1.3° (range, -1° to 5°). No correlation was found between the follow-up anatomic tibiofemoral angle and the follow-up Hospital for Special Surgery score¹⁶ (Spearman rho = -0.06, p = 0.658). A weak but significant correlation existed between the follow-up anatomic tibiofemoral angle and the follow-up Lysholm and Gillquist score¹⁷ (Spearman rho = -0.296, p = 0.049) (Fig. 4). The mean preoperative medial-proximal tibial angle and posterior proximal tibial angle had changed significantly postoperatively (p < 0.001). The mean preoperative and postoperative Insall-Salvati ratios¹⁴ were 0.99 (range, 0.9 to 1.1) and 1.01 (range, 0.9 to 1.2), respectively (p = 0.094). The mean preoperative and postoperative Blackburne-Peel ratios¹⁵ were 0.82 (range, 0.75 to 0.9) and 0.75 (range, 0.6 to 0.75), respectively (p < 0.001).

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Fig. 4: Spearman correlation between tibiofemoral angle and Lysholm and Gillquist score at the time of the latest follow-up (Spearman rho = -0.296, p = 0.049).

The average Hospital for Special Surgery score¹⁶ was 86 points (range, 54 to 100 points) at the time of the most recent follow-up, leading to a rating of excellent in twenty-eight patients (57%), good in twelve (24%), fair in four (8%), and poor in five (10%). Walking and standing was unlimited for eighteen patients (37%); walking was limited to five to ten blocks with intermittent (less than one-half hour) standing ability for twenty patients (41%); walking was limited to one to five blocks with standing ability for up to one-half hour for six patients (12%); and walking was limited to less than one block for five patients (10%). Forty patients (82%) were able to climb stairs without support, and nine patients (18%) climbed stairs with use of a cane. Transfer activity was possible for thirty-six patients (73%), and transfer activity with support was possible for thirteen patients (27%). The average score on the knee scoring scale described by Lysholm and Gillquist¹⁷ was 83 points (range, 47 to 100 points) at the most recent follow-up evaluation; according to these scores, the outcome was excellent in nine patients (18%), good in thirty-one (63%), fair in three (6%), and poor in six (12%).

Discussion

Proximal tibial osteotomy is a common and generally successful surgical treatment for patients with moderately severe, primarily unicompartmental, degenerative arthritis of the knee associated with angular deformity⁹. The five-year survival rate has ranged from 73% to 94%^{1,2,7,9,23—26}; the ten-year survival rate, from 28% to 88%^{1,2,7,9,24—27}; and the fifteen-year survival rate, from 39% to 68%^25,26. Several factors may affect the postoperative result of a high tibial osteotomy, including age, sex, weight, degree of osteoarthritis, ligamentous stability, preoperative range of motion, and preoperative or postoperative angles^7,25.

Loss of correction correlates with the duration of fixation, the degree of correction, and the time to osseous union⁹. Sixty-seven of 113 knees lost some correction when monitored for at least five years in a study of late recurrence of varus deformity after proximal tibial osteotomy by Stuart et al.²⁸. Varus alignment recurred in sixteen knees (14%), medial compartment arthritis progressed in seventy-three (65%), and lateral compartment arthritis progressed in fifty-three knees (47%) by nine years after surgery²⁸.

In a study with long-term follow-up that ranged from ten to thirteen years, all varus deformities needing revision had exhibited a varus deformity one year after the initial osteotomy⁷. In our short-term follow-up study with use of the internal fixator, varus alignment did not recur, except in one patient with a nonunion. In a report by Staubli et al.⁶, the only failures in their patients in whom the TomoFix internal fixator was used were those over the age of sixty-four years or those who were cigarette smokers. Correction losses after implant removal were described only if the fixator was removed less than six months after the operation and in patients with insufficient initial correction (<5° of femorotibial valgus)⁶.

The closing wedge is the most stable high tibial osteotomy technique compared with the opening-wedge osteotomy and the barrel-vault (dome) osteotomy, as the periosteum and cortex adjacent to the apex of the removed wedge act as a tether when the osteotomy is closed²⁹. The most common problems with this procedure are difficulty achieving an accurate correction of osseous malalignment, the need for fibular osteotomy or separation of the proximal tibiofibular joint, contracture of the patellar tendon leading to patella baja, leg shortening, and a high rate of complications. In a study of forty patients who underwent a closing-wedge proximal tibial osteotomy, Matthews et al.⁹ reported that four patients (10%) had neurovascular injury, six (15%) had delayed union or nonunion, three (8%) had thrombophlebitis, nine (23%) had minor skin necrosis, eight (20%) had an intra-articular fracture, seven (18%) had postoperative instability, and seven (18%) had recurrence of the valgus or varus deformity⁹.

The potential advantages of a medial opening-wedge osteotomy fixed with a plate and screws include a simple reproducible bone cut, no need for disruption of the proximal tibiofibular joint or a fibular osteotomy, a minimized risk of peroneal nerve injury, avoidance of patella baja, and maintenance of the bone stock. There is also no need for muscle detachment, and the deformity can be corrected close to normal (tibial bone varus angle³⁰) with fine-tuning of the desired correction in both the coronal (varus-valgus position) and the sagittal (posterior slope) planes during the procedure, which may facilitate subsequent arthroplasty^4—6. In a randomized study comparing the hip-knee-ankle angle after opening-wedge osteotomy by hemicallotasis and the closed-wedge technique⁴, significantly more corrections were achieved with the opening-wedge technique within the range of 182° to 186°.

The main disadvantages of opening-wedge osteotomies are limitation of the amount of opening possible, limitation in the achievable correction angle, higher compression in the medial compartment, less stable fixation, prolonged non-weight-bearing and protection time, a risk of creating a flexion deformity or malrotation at the osteotomy site, a risk of saphenous nerve injury because of the medial incision, and a risk of creating patellofemoral osteoarthritis³¹.

A fracture of the lateral cortex substantially reduces the stability of the fixation in the opening-wedge osteotomy. Stoffel et al.³² compared the modified Arthrex osteotomy plate (Puddu plate; Arthrex, Naples, Florida) and the TomoFix plate in a biomechanical study and found significantly higher stability with the TomoFix in both torsion and compression when the lateral cortex is injured. The locked angled screws of the TomoFix stabilize the lateral cortex, and an additional lateral osteosynthesis is not necessary. The v-shaped osteotomy further improves rotational and sagittal stability⁵.

Opening-wedge osteotomies have a higher risk of nonunion compared with closed-wedge osteotomies^8,27. In the study by Brouwer et al., when the opening wedge was >7.5 mm, the open gap of the Puddu plate osteosynthesis was filled with bone harvested from the ipsilateral iliac crest⁸. Three patients (7%) required another operation because of recurrent varus alignment after one year of fixation with the Puddu plate⁸. In a prospective study comparing the use of the Puddu plate and an internal fixator in opening-wedge osteotomies, the Puddu plate failed in 17% of the patients, while no implant failure was seen in the internal fixator group³³. We believe that internal fixators allow a larger distance between the two screws adjacent to the osteotomy, resulting in lower elastic deformation of the plate and the interfragmentary tissue. The osteotomies in the series described by Staubli et al.⁶ healed without bone grafts, with the exception of one nonunion and one delayed union; both patients were over sixty years of age. Lobenhoffer et al.⁵ used cancellous bone grafts for opening-wedge osteotomies exceeding 12.5 mm, while Staubli et al.⁶ did so when the opening-wedge osteotomy exceeded 15 mm.

In conclusion, our results suggest that medial opening-wedge high tibial osteotomy with locked plate fixation allows a correct valgus angle to be achieved with good short-term results.

Appendix

A description of the opening-wedge high tibial osteotomy with a locked plate fixator and figures showing the surgical technique are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on "Supplementary Material") and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD). Image Not Available

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Topics

arthritis ; bone plates ; osteoarthritis ; osteotomy ; tibia, proximal, osteotomy of

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Werner Kolb, Hanno Guhlmann, Christoph Windisch, Klaus Kolb, Heiko Koller, Paul Grützner; Opening-Wedge High Tibial Osteotomy with a Locked Low-Profile Plate. The Journal of Bone & Joint Surgery. 2009 Nov;91(11):2581-2588.

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