TIBIAL OSTEOTOMY
From Sports Medicine: Current Concepts in the Treatment & Rehabilitation of Sports Injuries, sponsored by the
University of Vermont College of Medicine
| HIGH TIBIAL OSTEOTOMIES/REALIGNMENT PROCEDURES —Thomas J. Gill, MD, Associate Professor of
Orthopaedic Surgery, Harvard Medical School, Boston, MA
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| Valgus osteotomies of the varus knee: basic considerations—overall bony anatomy; alignment from hip to ankle;
mechanical axis vs anatomic axis; surgical technique essential to success (main cause of failure, over- or under-correction)
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| Ideal patient: relatively young; active (unable to perform job or sport on knee replacement); unicompartmental arthritis
(patellofemoral arthritis no longer absolute contraindication); pain predominantly medial; range of motion
125°; normal laxity; adverse prognostic factors significant flexion contractures; lateral compartment involvement
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| Indications for osteotomy: basic—pain; instability; protection needed for concomitant procedure; newer—
instability problems, eg, complex lateral laxity, posterior cruciate ligament (PCL) disruption, and lateral cruciate
ligament (LCL) disruption; most common—in conjunction with articular cartilage resurfacing and meniscal procedure,
eg, meniscal allograft (normal mechanical axis essential)
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| Patient assessment: determine—whether pain localized to deficient cartilage (medial alone) or also lateral or in
patellofemoral joint; if procedure appropriate to level of expectation or activity; whether better treated by other
means; anatomic axis—normal femoral shaft-tibial shaft angle 5° to 7° valgus; mechanical axis—hip-knee-ankle
0°; basis for performing procedure; joint loading—normal medial 60%, lateral 40%; high adduction moment increases
load on medial joint and joint reaction forces; watch patient walk (large lateral thrust indicates varus deformity)
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| Correction: failures result from under- or over-correction; placement of joint line—lateral aspect of lateral tibial
spine (≈66% of distance from medial to lateral side of tibial plateau); correction may be greater or lesser, depending
on actual deformity
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| Preoperative planning options: cut-out—place tracing paper over tibial shaft; cut osteotomy at level of metaphysis
and open up; drop mechanical axis from center of hip to center of ankle and measure correction needed;
more mathematical approach—draw line from center of hip to point on lateral aspect of lateral spine; draw tibial
line from center of ankle to same point; resulting “x” angle of correction (for 0° mechanical axis)
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| Closing wedge: advantages of systems—accurate cuts based on predetermined angle; reliable healing; speaker prefers
Intermedics system (cutting jigs; rigid fixation); fibula osteotomy—potential problem; residual pain from nonunion
or peroneal nerve injury; neurologic complications (present in 2%-20% of cases); effect on subsequent total
knee arthroplasty (TKA)—results similar to revision TKA; problems with exposure and scarring around patellar
tendon
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| Medial opening wedge: plate fixation systems available; involves oblique osteotomy and distraction of joint; anteromedial
incision; elevate pes and possibly medial collateral ligament (MCL); avoid placing plate too high (affects
posterior tibial slope); continue osteotomy 75% of distance across (≤1 cm of lateral cortex); Bovie cord used
in ensuring mechanical axis neutral; bone graft—speaker prefers autologous iliac crest mixed with allograft cancellous
chips; ligamentous issues—anterior cruciate ligament (ACL) or PCL deficiency requires adjusting slope
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| Opening wedge: advantages—ease of surgical technique; can modify correction intraoperatively; able to try different
plates; no fibular osteotomy or peroneal nerve injuries; no shortening of leg; revision to TKA may be easier;
disadvantages—prolonged time to healing; risk of cracking lateral cortex; distraction osteogenesis technique—
reserved for corrections ≥17.5 to 20 mm on medial side; external fixator—for corrections >20 mm; involves corticotomy
and applying external fixator; dial-in correction enables continuous distractions and x-ray until alignment
optimal; pin tract infections; ≥66% of patients eventually require short course of antibiotic therapy
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| Successful outcome: depends primarily on ideal body weight and degree of surgical accuracy; achieving ≥8° of
valgus associated with longest survival
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| MENISCAL ALLOGRAFT, LIGAMENT RECONSTRUCTION, AND OSTEOTOMY: SALVAGE OF THE SEVERELY
COMPROMISED KNEE —John C. Richmond, MD, Professor of Orthopaedic Surgery, Tufts University
School of Medicine, and Chairman, Orthopaedic Surgery, New England Baptist Hospital, Boston, MA
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| Alignment essential: for successful meniscal transplantation
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| Results of allograft meniscal transplantation: speaker’s long-term results reported in 2001; 2- to 8-yr follow-up
of 22 patients; many also had osteotomy; healing rate 100%; marked improvement in function and decrease in pain
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 | Meniscus retorn: in 38% (8 of 22); after total complete meniscectomy in 2 active young patients; why allograft
retears—histology (less cellular than normal); molecular biology (cells significantly less active)
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| Conclusions: 100% healing (80 patients); inadequate biologic maintenance leads to eventual failure; appropriate procedure
for right indication; indications—painful compartment post-meniscectomy; stable joint (reconstruct if necessary);
acceptable alignment (neutral; correct varus knee toward lateral side; valgus knee toward medial side)
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| Preoperative assessment: history—major meniscectomy or multiple partial resections? pain in involved compartment;
examination—laxity; watch gait
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| Radiography: posteroanterior (PA) weight-bearing view; plain films to assess joint space narrowing (>2 mm indicates
articular surface problems and need for arthroscopy); flattened condyle with marginal osteophyte (no space
for meniscus); PA hip-to-ankle view for alignment; magnetic resonance imaging (MRI)—to evaluate ACL or
ACL graft
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| Arthroscopy: determine size of meniscal remnant, quality of articular surface; assess contralateral compartment
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| Allograft selection: match ages of donor and recipient (within 5 yr); size based on tibia (using plain films with
marker); cryo-preserved or fresh frozen (current choice, based on cost)
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| Allograft implantation (medial side): technical notes—provides ≈66% of normal meniscus (if size of existing
meniscus equivalent, consider alternative treatment); resect residual rim; guide pin through posterior attachment
(oblique, to match bone tunnel); 8-mm coring reamer for 7-mm posterior plug; cylindrical plug or trapezoidal block
for anterior plug; notch preparation (reduce medial spine); suture used to pull in meniscus
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| Preoperative varus correction: high tibial osteotomy; opening wedge preferred for women and smaller corrections
(≤10 mm); closing wedge for posterior lateral corner, ACL laxity, and larger corrections
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| Opening wedge: Puddu plate used for fixation; delayed union; loss of correction; increased tibial slope; technical
points—keep plate posterior; use trapezoidal block
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| Closing wedge: allows immediate full-weight bearing; fibula neck osteotomy (advance fibula head for LCL and
PCL laxity)
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| Valgus alignment: problems addressed—symptomatic lateral compartment disease; absent lateral meniscus; surgical
options—distal femoral opening wedge (combine with meniscal transplantation; both exclude weight-
bearing for period; not indicated in overweight patients); distal femoral medial closing wedge (for overweight
patients)
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| Postoperative rehabilitation: protection against weight bearing and bracing until osteotomy heals (9-10 wk for
opening wedge); all salvage procedures (require limitation of athletic activity)
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| Summary: allograft menisci tenuous at best (alignment must be protected); involves articular cartilage; requires altered
lifestyle with realistic long-term athletic goals; provides excellent pain relief
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| SURGICAL TREATMENT OF ARTHROFIBROSIS OF THE KNEE —Thomas N. Lindenfeld, MD, Associate Director,
Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH
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| Arthrofibrosis: term used to describe spectrum of knee pathology with lack of motion; definition being
discussed—dense proliferative scar formation; intra- and extra-articular adhesions; often progressive; scar can
obliterate suprapatellar pouch, notch, gutters, and fat pad
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| Loss of knee motion: 0° to 135° said to be normal knee motion; best to compare to opposite knee; in addition to flexion/extension,
consider patellar mobility; document superior-inferior glide and medial-lateral glide; causes—ACL surgery
(4% to 35% of cases); displaced meniscus; flexion/extension mechanism interruption (eg, patellar tendon rupture,
neurologic injury); cyclops lesion (fibrous nodule in notch; occurs after ACL surgery, usually in 6 mo, but sometimes
10 yr later [eg, minor hyperextension injury leading to bleeding around lesion]); non-isometric ACL graft placement
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| Patient evaluation: clinical manifestations—stiffness, often progressive (eg, 10°-110° at wk 3 and 20°-80° at wk
5); warm boggy knee (swollen but no effusion); poor patellar mobility; pathologic findings—decreased capsular
volume; dense scar formation; articular cartilage degeneration; chondrification and ossification;
pathophysiology—unknown; probably activation of inflammatory cascade
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| Treatment: goals—restore normal motion; no further damage to joint (avoid forceful manipulation of joint); preventive
measures—control pain and effusion; limit immobilization; control inflammation (early steroid burst and
taper, eg, methylprednisolone [Medrol Dosepak])
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| Surgical technique: document—flexion/extension vs gravity; patellar mobility (superior-inferior; medial-lateral);
entrance to joint—likely option at or above suprapatellar pouch (create superior portal; sweep cannula around to
create working space); if unable to insert cannula, use scissors for “blind lateral release”; may also need medial
release; do not force placement of arthroscopic cannula
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| Extension: most difficult to obtain; address before flexion; tissue very tough; infra-patellar fat pad often obliterated
by scar; cyclops lesion in notch possible; patellar tendon scarred into tibia from top of tibial plateau to tibial tuberosity;
menisci scarred in posteriorly displaced position; if tissue too tough or space too limited, make medial
parapatellar incision; dissect from behind patellar tendon and anteriorly to menisci (inferior pole to tibial tuberosity)
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| Free menisci: probe and assess mobility; using ablator, remove scarring from gutters and free coronary ligament (anterior
horn to mid-meniscus); extension becomes possible
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| Posterior release: rarely needed; medial (posterior oblique ligament from femur); lateral (posterior capsule)
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| Flexion: loss due to scarring in suprapatellar pouch; move from patella to femur; clear scar from medial and lateral gutter;
recreate full volume of pouch; check ACL placement
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| Postoperative care: pain control (epidural drug for 3 days in hospital); therapy 2 to 3 times daily (hang weights on
extended knee); restoring motion (active motion preferred, but passive motion restores biphasic motion to cartilage;
continuous passive motion [CPM] machine; alternatively, place “bad leg” on the good leg 5-6 times daily and
go through full range of motion); control effusion; control inflammation (may require steroids)
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| PANEL DISCUSSION —Drs. Gill, Richmond, and Lindenfeld
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| Anticoagulation prophylaxis: Dr. Gill—thromboembolic disease (TED) hose; concerned about potential risks;
1 aspirin daily for 2 wk; early motion lowers risk of deep vein thrombosis (DVT); Dr. Lindenfeld—aspirin; enoxaparin
(Lovenox) in cases with previous DVT, women on oral contraceptives, or other risk factor
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| Possible medical therapy for arthrofibrosis: Dr. Gill—unaware of any; cannot envision ability to selectively
shut off unwanted scarring in healing process; Dr. Richmond —speaker’s study found abnormal expression of
growth factor in arthrofibrosis (as well as in Dupuytren’s contracture and adhesive capsulitis of shoulder); treatment
theoretically possible but nonexistent
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| Timing of surgery for arthrofibrosis: Dr. Lindenfeld—prompt surgery required in severe loss of motion (eg,
22°-35° total arc); if arc of motion reasonable (15°-110°), tries to delay until joint less warm and painful; if little
progress after 3 mo, surgery needed to prevent articular cartilage degeneration; may require additional surgery for
stiffness; Dr. Lindenfeld—psychological barrier impedes early surgery in some patients; Dr. Gill—benefits of
early surgery offer psychological lift
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| Physical therapy and arthrofibrosis: Dr. Lindenfeld—therapists in office alert surgeon to lack of progress; Dr.
Gill—damage to articular cartilage during therapy probably caused by disease, not therapist
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| Treatment for patella baja: Dr. Richmond—first determine that patella baja actual source of pain; options include
sliding up tibial tubercle (≈1.5 to ≤2 cm), or proximal quadriceps shortening (benefits limited); Dr.
Lindenfeld—first, prevent patella baja; tibial shortening of 10% to 20% can be reversed by turning quadriceps
back down; if quadriceps shut-down suspected, obtain lateral x-rays; treatment options (debriding fat pad and removing
scar tissue; tibial tubercle slide); any quadricepsplasty worsens problem
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Educational Objectives
| The goal of this program is to educate the listener about tibial osteotomy. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Identify candidates for high tibial osteotomy.
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| 2. Select the optimal approach to osteotomy, using either the closing wedge, medial opening wedge, or opening
wedge technique.
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| 3. Perform meniscal allograft transplantation for the severely compromised knee, as well as ligament reconstruction
and osteotomy to achieve proper alignment.
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| 4. Employ effective rehabilitative measures following osteotomy and related procedures.
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| 5. Provide surgical treatment for arthrofibrosis of the knee.
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Discussed on This Program
Enoxaparin sodium [Lovenox]
Methylprednisolone acetate [Medrol Dosepak 4 mg, others]
Suggested Reading
Alford JW et al: Rapid progression of chondral disease in the lateral compartment of the knee following meniscectomy.
Arthroscopy 21:1505, 2005; Aoki Y et al: Inverted V-shaped high tibial osteotomy compared with closing-
wedge high tibial osteotomy for osteoarthritis of the knee. Ten-year follow-up result. J Bone Joint Surg Br 88:1336,
2006; Brouwer RW et al: Osteotomy for medial compartment arthritis of the knee using a closing wedge or an
opening wedge controlled by a Puddu plate: A One-Year Randomised, Controlled Study. J Bone Joint Surg Br
88:1454, 2006; Cebesoy O et al: High tibial osteotomy and external fixator. Knee Surg Sports Traumatol Arthrosc
14:1033, 2006; Cosgarea AJ et al: The surgical treatment of arthrofibrosis of the knee. Am J Sports Med 22:184,
1994; Flecher X et al: A 12-28-year followup study of closing wedge high tibial osteotomy. Clin Orthop Relat Res
452:91, 2006; Graf KW Jr et al: Long-term results after combined medial meniscal allograft transplantation and
anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy 20:129, 2004; Kim HJ et
al: Approach to meniscal tears in anterior cruciate ligament reconstruction. Orthop Clin North Am 34:139, 2003;
Klein W et al: Arthroscopic management of postoperative arthrofibrosis of the knee joint: indication, technique, and
results. Arthroscopy 10:591, 1994; Ohsawa S et al: High tibial osteotomy for osteoarthritis of the knee with varus
deformity utilizing the hemicallotasis method. Arch Orthop Trauma Surg 126:588, 2006; Papachristou G et al:
Deterioration of long-term results following high tibial osteotomy in patients under 60 years of age. Int Orthop 30:403,
2006; Papp M et al: Short- and mid-term results after combined high tibial osteotomy. Orthopedics 29:1014, 2006;
Richmond JC et al: Arthroscopic management of arthrofibrosis of the knee, including infrapatellar contraction syndrome.
Arthroscopy 7:144, 1991; Richmond JC: Three surgical methods of anterior cruciate ligament reconstruction
were equally effective. J Bone Joint Surg Am 84-A:323, 2002; Sekiya JK et al: Clinical outcomes after
combined meniscal allograft transplantation and anterior cruciate ligament reconstruction. Am J Sports Med 31:896,
2003; Sekiya JK et al: Meniscal allograft transplantation. J Am Acad Orthop Surg 14:164, 2006; Shelbourne KD
et al: Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction. Am J
Sports Med 24:857, 1996; Wirth CJ et al: Long-term results after combined medial meniscal allograft transplantation
and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy 20:782, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following
has been disclosed: Dr. Gill—Linvatec (consultant; educational support); Dr. Richmond—DuPuy-Mitek (board of
directors; consultant); Axya Medical (surgical advisory board); Tissue Regeneration (surgical advisory board);
LifeNet (surgical advisory board); Stryker Orthobiologics (advisory board)
Drs. Gill, Richmond, and Lindenfeld were recorded at Sports Medicine: Current Concepts in the Treatment & Rehabilitation
of Sports Injuries, sponsored by the University of Vermont College of Medicine in Burlington, VT, October
5-6, 2006. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production
of this program.
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