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‘Reverse wedge’ high tibial osteotomy
The Knee 1995; 1: 229-231
‘Reverse wedge’ high tibia1 osteotomy S Williams, Knee
J Ireland
Unit, Holly House Hospital, Essex, UK
Summary Five patients underwent a reverse wedge high tibia1 osteotomy for severe varus deformity of the knee. Four patients needed bone grafting for delayed union. All five patients had some loss of initial correction, with three partially reverting This method of high tibia1 osteotomy is not recommended. Keywords:
High tibia1 osteotomy,
reverse wedge, varus deformity,
Introduction Young patients with medial compartmental osteoarthritis and varus deformity of the knee are often treated by valgus high tibia1 osteotomy. Many surgeons prefer a closing wedge technique. When using this method, difficulty may arise in the correction of severe deformity. To obtain adequate correction with minimum alteration of the upper tibia1 profile, a reverse wedge osteotomy was used. Theoretically, the angle of valgus correction is twice that of the wedge cut. The operation was combined with an open medial joint debridement. The operative technique and the results of five procedures are reported.
atients and method Five men aged 31-47 years with symptomatic medial compartment arthritis due to significant varus deformity underwent this procedure. The diagnoses leading to the arthritis and the degrees of correction required are listed in Table 1. The degree of correction was determined preoperatively by clinical and radiographical measurements. The angle of the wedge to be cut was calculated as half the total angle of correction. This angle was marked on metal foil and a template prepared. Through a midline exposure, the usually-large medial femoral condylar osteophyte was removed and the underlying femoral edge smoothed with a rasp. Through Accepted: October 1994 Correspondence and reprint requests to: Mr J Ireland FRCS, Consultant Orthopaedic Surgeon, Knee Unit, Holly House Hospital, High Road, Buckhurst Hill, Essex IG9 5HX, UK @ 1995 Elsevier Science Ltd Q968-0160/95/0422943
to the original
varus
deformity.
(The Knee 1995; 1: 229-231) non-union
the lower part of the same incision, the upper tibia was exposed on both sides of the patellar tendon. A guide wire was passed parallel to the joint line, its position being checked on a radiograph. The size of the wedge was marked using the template and cut using a fine bladed oscillating saw. The excised wedge was then reversed and replaced to obtain the desired correction (Figure 1). A fibular osteotomy was not required and the tibia1 osteotomy was stabilized using staples in three of the five cases. Early weight bearing in a protective plaster cast was encouraged and full weight bearing was generally established by three to four weeks after operation. At this stage the plaster was removed and manipulation under general anaesthetic carried out, followed by a 48 h period of continuous passive movement. Thereafter, full weight bearing was continued in a removable light weight moulded splint.
Results Initial success (and a very satisfactory continuing result) in the first patient (operation May 1988) (Figure 2), encouraged the senior author to carry out four further procedures between March and May 1990. All five patients have been followed up for between one and five years. None of the patients, except Case 1, regained the preoperative range of movement. Bony union was delayed in four patients, three of whom required bone grafting. In one patient, prolonged plaster splintage was required until union became established at two years (Figure 3). Three of these patients had partial recurrence of the original varus deformity. In the other two, the initial valgus overcorrection was lost, with final neutral alignment (5” to 7” of anatomical valgus) (Table 2):
230
The Knee 1995; 1: No 4
Discussion
i
Figure 1. Technique.
Macintosh”, reported satisfactory results when open joint debridement complemented a high tibia1 osteotomy. None of our five patients achieved an increase in the range of movement, in fact there was difficulty in regaining their preoperative range of movement. High tibia1 osteotomies, when performed proximal to the tibia1 tubercle, have been reported as having a low incidence of delayed or non-union2B3. The senior author’s experience with conventional closing wedge tibia1 osteotomy would support this statement. The high incidence of these complications in this series was clearly a major disappointment and the technique has been abandoned. Avascularity of the reversed wedge, with subsequent softening and loss of graft height, probably contributed to the early loss of correction. Unbalanced compressive forces, i.e. excessive medial compressive forces with
Table 1.
Case I 2 3 4 5
Age (years)
Sex
Side
!nitial diagnosis
31 47 39 42 38
M M M M M
Left Left Left Left Right
CWPosterolateral instability OA/Bilateral meniscectomy OA/Medial meniscectomy OA/Obesity OAIACL deficiency
Correction required (degrees) 12 10 12 15 14
Table 2. Range of movement (degrees) Case 1 2 3 4 5
Date of operation
Follow up
3.5.88 2.3.90 13.3.90 26.4.90 8.5.90
5 3 1 3 3
lyead
Figure 2. Case 1: (a) Preoperative,
Preop
Postop
Bone union
Further operation
Final alignment
5-l 35 O-140 O-120 IO-I 10 O-140
o-135 O-90 O-105 IO-65 O-100
Satisfactory Delayed Delayed Delayed Delayed
Nil Bone grafting Nil Bone grafting Bone grafting
Neutral Neutral Varus Varus Varus
(b) postoperative,
(c) follow up - 5 years.
Williams
Figure 3. Case 5: (a) Preoperative,
(b) postoperative,
Conclusion of high tibia1 osteotomy for correction deformity is not recommended.
Reverse
wedge
high
tibia/
osteotomy
231
(c) follow up - 1 year.
force in the lateral part of loss of the normal compressive the osteotomy, probably resulted in delayed bony union. Relatively early mobilization, in an attempt to achieve a good range of postoperative movement, was probably another adverse factor for bony union.
This method severe varus
and Ireland:
of
References I Macintosh DL, Welsh RP. Joint debridement: a complement to high tibia1 osteotomy in the treatment of degenerative arthritis of the knee. J Bone Joint Surg [A] 1977; 59A: 1094-7 2 Vainionpaa S, Laike E, Kirves P et al. Tibia1 osteotomy for osteoarthritis of the knee: a five to ten year follow up study. J Bone Joint Surg [A/ 1981; 63: 93846 3 Jackson JP, Waugh W. Osteoarthritis of the knee. In: Surgery of the Knee Joint. London, UK: Chapman & Hall, 1984: 291X314
‘Reverse wedge’ high tibia1 osteotomy S Williams, Knee
J Ireland
Unit, Holly House Hospital, Essex, UK
Summary Five patients underwent a reverse wedge high tibia1 osteotomy for severe varus deformity of the knee. Four patients needed bone grafting for delayed union. All five patients had some loss of initial correction, with three partially reverting This method of high tibia1 osteotomy is not recommended. Keywords:
High tibia1 osteotomy,
reverse wedge, varus deformity,
Introduction Young patients with medial compartmental osteoarthritis and varus deformity of the knee are often treated by valgus high tibia1 osteotomy. Many surgeons prefer a closing wedge technique. When using this method, difficulty may arise in the correction of severe deformity. To obtain adequate correction with minimum alteration of the upper tibia1 profile, a reverse wedge osteotomy was used. Theoretically, the angle of valgus correction is twice that of the wedge cut. The operation was combined with an open medial joint debridement. The operative technique and the results of five procedures are reported.
atients and method Five men aged 31-47 years with symptomatic medial compartment arthritis due to significant varus deformity underwent this procedure. The diagnoses leading to the arthritis and the degrees of correction required are listed in Table 1. The degree of correction was determined preoperatively by clinical and radiographical measurements. The angle of the wedge to be cut was calculated as half the total angle of correction. This angle was marked on metal foil and a template prepared. Through a midline exposure, the usually-large medial femoral condylar osteophyte was removed and the underlying femoral edge smoothed with a rasp. Through Accepted: October 1994 Correspondence and reprint requests to: Mr J Ireland FRCS, Consultant Orthopaedic Surgeon, Knee Unit, Holly House Hospital, High Road, Buckhurst Hill, Essex IG9 5HX, UK @ 1995 Elsevier Science Ltd Q968-0160/95/0422943
to the original
varus
deformity.
(The Knee 1995; 1: 229-231) non-union
the lower part of the same incision, the upper tibia was exposed on both sides of the patellar tendon. A guide wire was passed parallel to the joint line, its position being checked on a radiograph. The size of the wedge was marked using the template and cut using a fine bladed oscillating saw. The excised wedge was then reversed and replaced to obtain the desired correction (Figure 1). A fibular osteotomy was not required and the tibia1 osteotomy was stabilized using staples in three of the five cases. Early weight bearing in a protective plaster cast was encouraged and full weight bearing was generally established by three to four weeks after operation. At this stage the plaster was removed and manipulation under general anaesthetic carried out, followed by a 48 h period of continuous passive movement. Thereafter, full weight bearing was continued in a removable light weight moulded splint.
Results Initial success (and a very satisfactory continuing result) in the first patient (operation May 1988) (Figure 2), encouraged the senior author to carry out four further procedures between March and May 1990. All five patients have been followed up for between one and five years. None of the patients, except Case 1, regained the preoperative range of movement. Bony union was delayed in four patients, three of whom required bone grafting. In one patient, prolonged plaster splintage was required until union became established at two years (Figure 3). Three of these patients had partial recurrence of the original varus deformity. In the other two, the initial valgus overcorrection was lost, with final neutral alignment (5” to 7” of anatomical valgus) (Table 2):
230
The Knee 1995; 1: No 4
Discussion
i
Figure 1. Technique.
Macintosh”, reported satisfactory results when open joint debridement complemented a high tibia1 osteotomy. None of our five patients achieved an increase in the range of movement, in fact there was difficulty in regaining their preoperative range of movement. High tibia1 osteotomies, when performed proximal to the tibia1 tubercle, have been reported as having a low incidence of delayed or non-union2B3. The senior author’s experience with conventional closing wedge tibia1 osteotomy would support this statement. The high incidence of these complications in this series was clearly a major disappointment and the technique has been abandoned. Avascularity of the reversed wedge, with subsequent softening and loss of graft height, probably contributed to the early loss of correction. Unbalanced compressive forces, i.e. excessive medial compressive forces with
Table 1.
Case I 2 3 4 5
Age (years)
Sex
Side
!nitial diagnosis
31 47 39 42 38
M M M M M
Left Left Left Left Right
CWPosterolateral instability OA/Bilateral meniscectomy OA/Medial meniscectomy OA/Obesity OAIACL deficiency
Correction required (degrees) 12 10 12 15 14
Table 2. Range of movement (degrees) Case 1 2 3 4 5
Date of operation
Follow up
3.5.88 2.3.90 13.3.90 26.4.90 8.5.90
5 3 1 3 3
lyead
Figure 2. Case 1: (a) Preoperative,
Preop
Postop
Bone union
Further operation
Final alignment
5-l 35 O-140 O-120 IO-I 10 O-140
o-135 O-90 O-105 IO-65 O-100
Satisfactory Delayed Delayed Delayed Delayed
Nil Bone grafting Nil Bone grafting Bone grafting
Neutral Neutral Varus Varus Varus
(b) postoperative,
(c) follow up - 5 years.
Williams
Figure 3. Case 5: (a) Preoperative,
(b) postoperative,
Conclusion of high tibia1 osteotomy for correction deformity is not recommended.
Reverse
wedge
high
tibia/
osteotomy
231
(c) follow up - 1 year.
force in the lateral part of loss of the normal compressive the osteotomy, probably resulted in delayed bony union. Relatively early mobilization, in an attempt to achieve a good range of postoperative movement, was probably another adverse factor for bony union.
This method severe varus
and Ireland:
of
References I Macintosh DL, Welsh RP. Joint debridement: a complement to high tibia1 osteotomy in the treatment of degenerative arthritis of the knee. J Bone Joint Surg [A] 1977; 59A: 1094-7 2 Vainionpaa S, Laike E, Kirves P et al. Tibia1 osteotomy for osteoarthritis of the knee: a five to ten year follow up study. J Bone Joint Surg [A/ 1981; 63: 93846 3 Jackson JP, Waugh W. Osteoarthritis of the knee. In: Surgery of the Knee Joint. London, UK: Chapman & Hall, 1984: 291X314