- Email: [email protected]
Closed Wedge Osteotomy
Closed Wedge Osteotomy Matthias Jacobi, MD, and Roland P. Jakob, MD Closed wedge high tibial osteotomy is the traditional method to treat medial osteoarthritis of the knee. Nowadays it is peformed less frequently because of the increasing importance of open wedge osteotomy. Nevertheless, there are indications in which the classic technique should be preferred. In this article indication, planning, and the authors’ preferred technique are presented and discussed. Correct indication, planning, and a precise surgical technique results in a long lasting follow-up for at least 10 years. Oper Tech Orthop 17:51-57 © 2007 Elsevier Inc. All rights reserved. KEYWORDS medial knee osteoarthritis, closed wedge osteotomy, technique, indication, planning
H
igh tibial osteotomy (HTO) is a traditional technique for the treatment of unicompartimental osteoarthritis. Historically, it started to our knowledge with Langenbeck in the 19th century.1 In the modern literature, it became popular with Jackson,2 Coventry,3 and Maquet.4 The classical Coventry closed wedge procedure with the osteotomy performed proximal to the tuberosity was performed, with some modifications, until recently. In the last decade, open wedge osteotomies became more popular because of better fixation devices so that today an increasing number of HTO are performed in the open wedge fashion.5-7 This technique has several advantages: it is faster, more precise, and poses less risk for the peroneal nerve. Both open and closed wedge osteotomies have demonstrated similar good short- and longterm results. Closed wedge ostoeotomy has some advantages over the open wedge technique and is, in our opinion, strongly indicated in certain circumstances. Patella baja is a relative contraindication for open wedge because, with this procedure, the patella lowers significantly and can cause problems, especially in cases with preexisting femoropatellar symptoms. An increased posterior slope is another indication for a closed wedge osteotomy because it can be better controlled using this technique. Another good indication for this variant is the necessity of performing a lateral arthrotomy or in cases with a preexisting scar on the lateral side.
Department of Orthopaedic Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland. Address reprint requests to Matthias Jacobi, MD, Department of Orthopaedic Surgery, Hôpital Cantonal Fribourg, Bertigny, 1708 Fribourg, Switzerland. E-mail: [email protected]
1048-6666/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2006.09.011
Indications Patient selection is the key to achieving good results. An isolated and symptomatic varus osteoarthritis of the knee is the typical situation in which to perform an HTO. Other reasons are osteochondrosis dissecans, osteonecrosis, and traumatic cartilage lesions of the medial condyle when associated with varus deformity. History-wise, patients present with knee pain during weight-bearing activity and sometimes at rest. In the clinical examination, the pain should be localized to the medial compartment but the lateral and femeropatellar compartment should be pain free. A sufficient mobility is another prerequisite that we define as a minimal flexion of 120° and a maximal loss of extension of 10°. Stability of the knee should be maintained, although in some cases a combined procedure (ie, ACL reconstruction with HTO8,9) can be performed. Radiographic examinations include one leg standing anteroposterior and lateral views (Figs. 1 and 2) as well as a posteroanterior 45° standing view.10 With these pictures, osteoarthritis is confirmed, which often is better visualized in the 45° view because the cartilage loss in the posterior aspect of the condyle is often more important. “Intercondylar-osteophytes” also are seen better on this view and can if not removed during surgery, avoid the shift of load bearing from the medial to the lateral compartment. Varus and valgus stress views can even better show the residual cartilage in the medial as well as in the lateral compartment. In addition, they show the instability of the collateral ligaments in a reproducible way, which can have an impact on the preoperative planning (see “Planning” section). A long leg standing film is a prerequisite for indication and planning. Additional examinations can be indicated in specific questions. Magnetic resonance imaging may be necessary if a meniscal tear or osteo51
M. Jacobi and R.P. Jakob
52
rates at 8 or higher, he or she is not a good candidate. Physically inactive patients usually rate their pain as greater than active individuals.
Planning Accurate planning is fundamental to perform any osteotomy around the knee and to achieve a correct postoperative axis. We perform based on a study of Fujisawa and coworkers14,15 our planning on a full-length radiogram of the lower extremity which consists of 3 main steps: 1. The first planning step is only necessary in case of instability of the lateral collateral ligament. If this is present and visualized on the stress radiogram we draw a virtual “push view” image based on the varus and valgus stress view as shown in Figure 3. This step helps us to avoid overcorrection. 2. The desired new axis has now to be determined. We
Figure 1 Preoperative anteroposterior one leg standing view shows medial osteoarthritis.
necrosis is suspected. A scintigraphy can in unclear cases show, on a metabolic basis, the integrity of the external compartment and high uptake due to osteoarthritis of the internal compartment. Patients who are 60 to 65 years of age are a relative contraindication, although this is not an absolute contraindication because the biologic age and activity of the patient is even more important. Caution should be taken if a patient presents with chondrocalzinosis,11 obesity, osteoporosis, or is a smoker, these can be a relative contraindications. Also, if inflammatory arthritis or a generalized is osteoarthritis present, osteotomy is contraindicated.12,13 If a patient presents with varus deformity and joint space narrowing but no osteophyts, has full range of motion, and is still very active, we propose osteotomy instead of an artificial joint, especially if on the Visual Analog Scale1-10 he or she rates not greater than 5. We inform the patient that we can decrease him or her by 3 points (ie, from 5 to 2). If a patient
Figure 2 Preoperative lateral standing view.
Closed wedge osteotomy
53
Figure 3 Preoperative planning step 1: In case of laxity of the lateral collateral ligament, a virtual “push view” image is drawn, based on the varus and valgus stress radiographs, to avoid overcorrection. Therefore, the complete limb is drawn on a transparent paper (1) then the joint spaces from the stress views are added (2). The drawing is then put back onto the long leg film according the new joint spaces.
usually tend to plan it between 10% and 35% in the lateral compartment, where 0% is the center of the articulation and 100% is the lateral border.15,16 In cases of severe osteoarthritis we plan a more lateral correction than in slight osteoarthritis (Fig. 4).17 3. The main planning step is to calculate the correction angle. Therefore the hinge of the osteotomy is connected with the old and the planned mechanical axis at the ankle. The angle between these lines corresponds to the desired correction (Fig. 5).
Authors’ Preferred Technique Preparation Standard disinfection and draping is performed with the iliac crest draped free. A sterile tourniquet is placed on the thigh and is inflated.
Arthroscopy
Figure 4 Preoperatve planning step 2: Depending on the cartilage wear on the medial compartment, the planned axis is determined between 10% and 35% in the lateral compartment. In the case of a more severe osteoarthritis, the axis is planned more lateral than in a slighter case.17
A routine arthroscopy is performed in every case to confirm the integrity of the lateral compartment and, frequently, we perform abrasion arthroplasty combined with microfractures for the medial compartment and intercondylar osteophytes are also removed. Associated meniscal tears also are treated. If an anterior cruciate ligament reconstruction is part of the treatment, it is performed at the end of the procedure or as a separate surgery at a later date.
M. Jacobi and R.P. Jakob
54
Figure 5 Preoperative planning step 3: Correction angle is planned on a full leg view. The present and the planned mechanical axis are drawn, whereas the planned line passes the lateral compartment at 10% to 35% (1). The present and the planned center of the ankle joint are connected with the hinge of the osteotomy, which gives the angle of correction (2).
Figure 6 Preparation of the osteotomy with the AO-osteotomy device.
Figure 7 The osteotomy is performed between the K-wires. A chisel protects the tuberosity and a retractor the posterior structures during osteotomy.
Closed wedge osteotomy
Figure 8 The plate is fixed proximally.
55
Figure 10 The osteotomy is carefully and slowly closed with the AO plate tensioning devise.
Osteotomy A straight longitudinal incision on the anterolateral aspect of the proximal tibia with respecting the need for a future total knee arthroplasty is done. Extensor mussels are carefully detached from the tibia and fibula. The neck of the fibula is now prepared, and a stepwise osteotomy of the fibula is performed: first, an osteotomy of the anterior cortex only in the proximal aspect is
Figure 9 The plate is fixed proximally, where it sticks off distally and the osteotomy is still open.
Figure 11 Osteotomy is closed and the plate has approached the tibia. The plate tensioning devise is still in place.
M. Jacobi and R.P. Jakob
56
Figure 12 The plate is also fixed distally.
Figure 14 Postoperative anteroposterior view.
Figure 13 Postoperative lateral view.
done, then the fibula is osteotomized completely 1 cm more distally. With this, pressure to the nerve is avoided. If in doubt, the fibular nerve is identified. A partial osteotomy of the tuberosity is performed in the frontal plane to protect it during osteotomy. The level of the joint line is determined with 2 small K-wires. A plate with angular stability (ie, Synthes Tomofix) is chosen, and the plate is placed and fixed proximally with Kwires, whereas the distal end of the plate is kept in about 10 mm distance from the tibia. The plate is removed again and the level of the main osteotomy is now determined, which we tend to do slightly oblique, and the sagittal correction should also be respected at this point. It is performed with the AO-osteotomy devise which has a precision of 0-5° (Fig. 6). This device also allows one to maintain 5 to 10 mm of the medial cortex, which is important for the stability especially if less stable implants are used. Osteotomy is now performed with an anterior protection of the tuberosity between the K-wires (Fig. 7). After this, the wedge is removed and the plate is fixed again proximally (Figs. 8 and 9). Distally, the AO-plate tensioning device is prepared. With this device, the gap is slowly and carefully closed (Figs. 10
Closed wedge osteotomy and 11). During this step, attention for the correct displacement of the fibula osteotomy should be given. Finally, the plate is also fixed distally (Fig. 12). Extensor mussels are reattached, Redon drainages are put in place to avoid a compartment syndrome, and the wound is closed layer-wise.
Postoperative Management We administer antibiotics for 24 hours. Drains are removed on the second postoperative day. Partial weight-bearing activity (10-15 kg) is started the second postoperative day with protection in a removable splint with full extension. Passive movement of the knee is started the fifth day postoperatively. Radiographic controls are performed postoperatively at 6 and 12 weeks (Figs. 13 and 14). If at 6 weeks radiographic control shows evidence of consolidation, progressive weight-bearing activity is allowed.
Complications Many complications are described in association with this procedure. Most important are damage to the peroneal nerve or the popliteal artery, intra-articular fracture, compartment syndrome, infection, deep vein thrombosis or pulmonary embolism, and delayed or nonunion of the osteotomy. Nevertheless, as the result of proper selection of patients, good preoperative planning, accurate operative technique, and correct postoperative management, the complication rate can be limited to a minimum.18
Discussion Closed wedge osteotomy is the traditional method to perform valgus osteotomy for medial osteoarthritis of the knee. The majority of studies have shown good outcomes during the first years of follow-up with deterioration over the time. Normally during the first 5 to 15 years results are very satisfactory.13,19-25 Insall et al26 showed in their study that at 2 years follow-up, 97% of patients show a good result, whereas after 5 years it decreases to 85% and after 9 years still 63% of patients are satisfied. Unsatisfactory results are normally the result of inadequate patient selection or planning of the osteotomy. Another possible problem is the loss of correction caused by insufficient stability of the implant. Closed wedge osteotomy has lost importance during the last years, whereas open wedge osteotomy is performed more frequently. This newer technique is easier, faster, and more precise and presents fewer risks to the peroneal nerve.5-7 Because of new implants with better stability available, a bone graft from the iliac crest is no longer mandatory. Nevertheless, we see some persisting indications for the closed wedge technique in the case of a patella baja, if the posterior slope has to be decreased or if a lateral arthrotomy has to be done.
References 1. Langenbeck B: Die subkutane Osteotomie. Dtschi-Klinik 6:327, 1854 2. Jackson JP: Osteotomy for osteoarthristis of the knee. In Proceedings of
57
3.
4. 5.
6.
7. 8.
9.
10.
11.
12. 13. 14.
15. 16. 17.
18. 19. 20. 21.
22.
23.
24.
25. 26.
the Sheffield Regional Orthopaedic Club. J Bone and Joint Surg 40-B:826, 1958 Coventry MB: Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report. J Bone and Joint Surg 47A:984, 1965 Maquet P: Valgus osteotomy for osteoarthritis of the knee. Clin Orthop Relat Res 143-148, 1976 Lobenhoffer P, Agneskirchner JD: Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132-138, 2003 Staubli AE, De Simoni C, Babst R, et al: TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia– early results in 92 cases. Injury 34:B55-B62, 2003 (suppl 2) Jacobi M, Jakob RP: Open wedge osteotomy in the treatment of medial osteoarthritis of the knee. Tech Knee Surg 4:70-78, 2005 Lattermann C, Jakob RP: High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees. Knee Surg Sports Traumatol Arthrosc 4:32-8, 1996 Agneskirchner JD, Bernau A, Burkart AC, et al: [Knee instability and varus malangulation—Simultaneous cruciate ligament reconstruction and osteotomy (Indication, planning and operative technique, results)]. Z Orthop Ihre Grenzgeb 140:185-193, 2002 Rosenberg TD, Paulos LE, Parker RD, et al: The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am 70:1479-1483, 1988 Job-Deslandre C, Languepin A, Benvenuto M, et al: [Tibial valgization osteotomy in gonarthrosis with or without chondrocalcinosis. Results after 5 years]. Rev Rhum Mal Osteoartic 58:491-496, 1991 Coventry MB: Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee. J Bone Joint Surg Am 69:32-38, 1987 Coventry MB: Osteotomy about the knee for degenerative and rheumatoid arthritis. J Bone Joint Surg Am 55:23-48, 1973 Fujisawa Y, Masuhara K, Shiomi S: The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am 10:585-608, 1979 Gautier E, Jakob RP: [The value of corrective osteotomies–indications, technique, results]. Ther Umsch 53:790-796, 1996 Miniaci A, Ballmer FT, Ballmer PM, et al: Proximal tibial osteotomy. A new fixation device. Clin Orthop 250-259, 1989 Marti CB, Gautier E, Wachtl SW, et al: Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 20:366-372, 2004 Coventry MB: Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am 67:1136-1140, 1985 Aglietti P, Buzzi R, Vena LM, et al.: High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study. J Knee Surg 16:21-26, 2003 Aglietti P, Rinonapoli E, Stringa G, et al: Tibial osteotomy for the varus osteoarthritic knee. Clin Orthop 239-251, 1983 Coventry MB, Ilstrup DM, Wallrichs SL: Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196-201, 1993 Hernigou P: [A 20-year follow-up study of internal gonarthrosis after tibial valgus osteotomy. Single versus repeated osteotomy]. Rev Chir Orthop Reparatrice Appar Mot 82:241-250, 1996 Hernigou P, Medevielle D, Debeyre J, et al: Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69:332-354, 1987 Odenbring S, Egund N, Lindstrand A, et al: Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study. Clin Orthop 210-216, 1992 Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop 185-193, 1998 Insall JN, Joseph DM, Msika C: High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am 66:10401048, 1984
H
igh tibial osteotomy (HTO) is a traditional technique for the treatment of unicompartimental osteoarthritis. Historically, it started to our knowledge with Langenbeck in the 19th century.1 In the modern literature, it became popular with Jackson,2 Coventry,3 and Maquet.4 The classical Coventry closed wedge procedure with the osteotomy performed proximal to the tuberosity was performed, with some modifications, until recently. In the last decade, open wedge osteotomies became more popular because of better fixation devices so that today an increasing number of HTO are performed in the open wedge fashion.5-7 This technique has several advantages: it is faster, more precise, and poses less risk for the peroneal nerve. Both open and closed wedge osteotomies have demonstrated similar good short- and longterm results. Closed wedge ostoeotomy has some advantages over the open wedge technique and is, in our opinion, strongly indicated in certain circumstances. Patella baja is a relative contraindication for open wedge because, with this procedure, the patella lowers significantly and can cause problems, especially in cases with preexisting femoropatellar symptoms. An increased posterior slope is another indication for a closed wedge osteotomy because it can be better controlled using this technique. Another good indication for this variant is the necessity of performing a lateral arthrotomy or in cases with a preexisting scar on the lateral side.
Department of Orthopaedic Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland. Address reprint requests to Matthias Jacobi, MD, Department of Orthopaedic Surgery, Hôpital Cantonal Fribourg, Bertigny, 1708 Fribourg, Switzerland. E-mail: [email protected]
1048-6666/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2006.09.011
Indications Patient selection is the key to achieving good results. An isolated and symptomatic varus osteoarthritis of the knee is the typical situation in which to perform an HTO. Other reasons are osteochondrosis dissecans, osteonecrosis, and traumatic cartilage lesions of the medial condyle when associated with varus deformity. History-wise, patients present with knee pain during weight-bearing activity and sometimes at rest. In the clinical examination, the pain should be localized to the medial compartment but the lateral and femeropatellar compartment should be pain free. A sufficient mobility is another prerequisite that we define as a minimal flexion of 120° and a maximal loss of extension of 10°. Stability of the knee should be maintained, although in some cases a combined procedure (ie, ACL reconstruction with HTO8,9) can be performed. Radiographic examinations include one leg standing anteroposterior and lateral views (Figs. 1 and 2) as well as a posteroanterior 45° standing view.10 With these pictures, osteoarthritis is confirmed, which often is better visualized in the 45° view because the cartilage loss in the posterior aspect of the condyle is often more important. “Intercondylar-osteophytes” also are seen better on this view and can if not removed during surgery, avoid the shift of load bearing from the medial to the lateral compartment. Varus and valgus stress views can even better show the residual cartilage in the medial as well as in the lateral compartment. In addition, they show the instability of the collateral ligaments in a reproducible way, which can have an impact on the preoperative planning (see “Planning” section). A long leg standing film is a prerequisite for indication and planning. Additional examinations can be indicated in specific questions. Magnetic resonance imaging may be necessary if a meniscal tear or osteo51
M. Jacobi and R.P. Jakob
52
rates at 8 or higher, he or she is not a good candidate. Physically inactive patients usually rate their pain as greater than active individuals.
Planning Accurate planning is fundamental to perform any osteotomy around the knee and to achieve a correct postoperative axis. We perform based on a study of Fujisawa and coworkers14,15 our planning on a full-length radiogram of the lower extremity which consists of 3 main steps: 1. The first planning step is only necessary in case of instability of the lateral collateral ligament. If this is present and visualized on the stress radiogram we draw a virtual “push view” image based on the varus and valgus stress view as shown in Figure 3. This step helps us to avoid overcorrection. 2. The desired new axis has now to be determined. We
Figure 1 Preoperative anteroposterior one leg standing view shows medial osteoarthritis.
necrosis is suspected. A scintigraphy can in unclear cases show, on a metabolic basis, the integrity of the external compartment and high uptake due to osteoarthritis of the internal compartment. Patients who are 60 to 65 years of age are a relative contraindication, although this is not an absolute contraindication because the biologic age and activity of the patient is even more important. Caution should be taken if a patient presents with chondrocalzinosis,11 obesity, osteoporosis, or is a smoker, these can be a relative contraindications. Also, if inflammatory arthritis or a generalized is osteoarthritis present, osteotomy is contraindicated.12,13 If a patient presents with varus deformity and joint space narrowing but no osteophyts, has full range of motion, and is still very active, we propose osteotomy instead of an artificial joint, especially if on the Visual Analog Scale1-10 he or she rates not greater than 5. We inform the patient that we can decrease him or her by 3 points (ie, from 5 to 2). If a patient
Figure 2 Preoperative lateral standing view.
Closed wedge osteotomy
53
Figure 3 Preoperative planning step 1: In case of laxity of the lateral collateral ligament, a virtual “push view” image is drawn, based on the varus and valgus stress radiographs, to avoid overcorrection. Therefore, the complete limb is drawn on a transparent paper (1) then the joint spaces from the stress views are added (2). The drawing is then put back onto the long leg film according the new joint spaces.
usually tend to plan it between 10% and 35% in the lateral compartment, where 0% is the center of the articulation and 100% is the lateral border.15,16 In cases of severe osteoarthritis we plan a more lateral correction than in slight osteoarthritis (Fig. 4).17 3. The main planning step is to calculate the correction angle. Therefore the hinge of the osteotomy is connected with the old and the planned mechanical axis at the ankle. The angle between these lines corresponds to the desired correction (Fig. 5).
Authors’ Preferred Technique Preparation Standard disinfection and draping is performed with the iliac crest draped free. A sterile tourniquet is placed on the thigh and is inflated.
Arthroscopy
Figure 4 Preoperatve planning step 2: Depending on the cartilage wear on the medial compartment, the planned axis is determined between 10% and 35% in the lateral compartment. In the case of a more severe osteoarthritis, the axis is planned more lateral than in a slighter case.17
A routine arthroscopy is performed in every case to confirm the integrity of the lateral compartment and, frequently, we perform abrasion arthroplasty combined with microfractures for the medial compartment and intercondylar osteophytes are also removed. Associated meniscal tears also are treated. If an anterior cruciate ligament reconstruction is part of the treatment, it is performed at the end of the procedure or as a separate surgery at a later date.
M. Jacobi and R.P. Jakob
54
Figure 5 Preoperative planning step 3: Correction angle is planned on a full leg view. The present and the planned mechanical axis are drawn, whereas the planned line passes the lateral compartment at 10% to 35% (1). The present and the planned center of the ankle joint are connected with the hinge of the osteotomy, which gives the angle of correction (2).
Figure 6 Preparation of the osteotomy with the AO-osteotomy device.
Figure 7 The osteotomy is performed between the K-wires. A chisel protects the tuberosity and a retractor the posterior structures during osteotomy.
Closed wedge osteotomy
Figure 8 The plate is fixed proximally.
55
Figure 10 The osteotomy is carefully and slowly closed with the AO plate tensioning devise.
Osteotomy A straight longitudinal incision on the anterolateral aspect of the proximal tibia with respecting the need for a future total knee arthroplasty is done. Extensor mussels are carefully detached from the tibia and fibula. The neck of the fibula is now prepared, and a stepwise osteotomy of the fibula is performed: first, an osteotomy of the anterior cortex only in the proximal aspect is
Figure 9 The plate is fixed proximally, where it sticks off distally and the osteotomy is still open.
Figure 11 Osteotomy is closed and the plate has approached the tibia. The plate tensioning devise is still in place.
M. Jacobi and R.P. Jakob
56
Figure 12 The plate is also fixed distally.
Figure 14 Postoperative anteroposterior view.
Figure 13 Postoperative lateral view.
done, then the fibula is osteotomized completely 1 cm more distally. With this, pressure to the nerve is avoided. If in doubt, the fibular nerve is identified. A partial osteotomy of the tuberosity is performed in the frontal plane to protect it during osteotomy. The level of the joint line is determined with 2 small K-wires. A plate with angular stability (ie, Synthes Tomofix) is chosen, and the plate is placed and fixed proximally with Kwires, whereas the distal end of the plate is kept in about 10 mm distance from the tibia. The plate is removed again and the level of the main osteotomy is now determined, which we tend to do slightly oblique, and the sagittal correction should also be respected at this point. It is performed with the AO-osteotomy devise which has a precision of 0-5° (Fig. 6). This device also allows one to maintain 5 to 10 mm of the medial cortex, which is important for the stability especially if less stable implants are used. Osteotomy is now performed with an anterior protection of the tuberosity between the K-wires (Fig. 7). After this, the wedge is removed and the plate is fixed again proximally (Figs. 8 and 9). Distally, the AO-plate tensioning device is prepared. With this device, the gap is slowly and carefully closed (Figs. 10
Closed wedge osteotomy and 11). During this step, attention for the correct displacement of the fibula osteotomy should be given. Finally, the plate is also fixed distally (Fig. 12). Extensor mussels are reattached, Redon drainages are put in place to avoid a compartment syndrome, and the wound is closed layer-wise.
Postoperative Management We administer antibiotics for 24 hours. Drains are removed on the second postoperative day. Partial weight-bearing activity (10-15 kg) is started the second postoperative day with protection in a removable splint with full extension. Passive movement of the knee is started the fifth day postoperatively. Radiographic controls are performed postoperatively at 6 and 12 weeks (Figs. 13 and 14). If at 6 weeks radiographic control shows evidence of consolidation, progressive weight-bearing activity is allowed.
Complications Many complications are described in association with this procedure. Most important are damage to the peroneal nerve or the popliteal artery, intra-articular fracture, compartment syndrome, infection, deep vein thrombosis or pulmonary embolism, and delayed or nonunion of the osteotomy. Nevertheless, as the result of proper selection of patients, good preoperative planning, accurate operative technique, and correct postoperative management, the complication rate can be limited to a minimum.18
Discussion Closed wedge osteotomy is the traditional method to perform valgus osteotomy for medial osteoarthritis of the knee. The majority of studies have shown good outcomes during the first years of follow-up with deterioration over the time. Normally during the first 5 to 15 years results are very satisfactory.13,19-25 Insall et al26 showed in their study that at 2 years follow-up, 97% of patients show a good result, whereas after 5 years it decreases to 85% and after 9 years still 63% of patients are satisfied. Unsatisfactory results are normally the result of inadequate patient selection or planning of the osteotomy. Another possible problem is the loss of correction caused by insufficient stability of the implant. Closed wedge osteotomy has lost importance during the last years, whereas open wedge osteotomy is performed more frequently. This newer technique is easier, faster, and more precise and presents fewer risks to the peroneal nerve.5-7 Because of new implants with better stability available, a bone graft from the iliac crest is no longer mandatory. Nevertheless, we see some persisting indications for the closed wedge technique in the case of a patella baja, if the posterior slope has to be decreased or if a lateral arthrotomy has to be done.
References 1. Langenbeck B: Die subkutane Osteotomie. Dtschi-Klinik 6:327, 1854 2. Jackson JP: Osteotomy for osteoarthristis of the knee. In Proceedings of
57
3.
4. 5.
6.
7. 8.
9.
10.
11.
12. 13. 14.
15. 16. 17.
18. 19. 20. 21.
22.
23.
24.
25. 26.
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