Open wedge tibial osteotomy with acrylic bone cement as bone substitute
Introduction
In patients with varus deformity from osteoarthritis of the knee, which is suitable for a valgus upper tibial osteotomy (UTO), an opening medial wedge is our preferred method of treatment [8], [9], [10]. A medial opening wedge avoids neurological complications, and overcomes the difficulties that can be encountered when performing a total knee replacement following a lateral closing wedge osteotomy [4], [7], [13]. It is not associated with the complications of infection that can follow osteotomies stabilised by an external fixator [1], [15], [16].
In the original technique described for an opening wedge osteotomy an iliac crest cortico-cancellous graft was required to fill the gap (Fig. 1) [10], [11]. This had disadvantages related to the donor site such as, post-operative pain, haematoma, sepsis, and discomfort when wearing clothes. Since 1985 we have replaced this with a block of acrylic cement interposed in the postero-medial part of the osteotomy. The cement block is fashioned into a wedge shape, and maintains the height of the opening wedge, based on a lateral bony hinge. In combination with an antero-medial plate it provides a stable construct (Fig. 2). This study reports the results of a personal case series.
Section snippets
Material
Between January 1985 and December 1994, 245 opening wedge osteotomies stabilised with bone cement were performed on 197 patients. There were 78 males with a mean age of 59 (35–73 years old), and 126 females with a mean age of 61 (48–72 years old). The mean follow-up was 10 years (6–15 years) of which 87 were over 10 years. Thirty patients (42 knees) were lost to follow-up. Follow-up was obtained by a clinical examination, postal or telephone review.
The alignment of the knee was determined by
Technique for obtaining the cement wedge
This is made at the beginning of the operation using a simple jig (Fig. 4) which allows a wedge to be made that has constant antero-posterior, and medial–lateral dimensions but has a variable height. The wedge is fashioned after calculating the correct height required as shown above.
Operative technique
A longitudinal incision is made from the medial border of the patellar ligament distally along the medial aspect of the tibia for 10 cm [3]. The insertion of the sartorius, gracilis and semitendinosus tendons are divided and separated from the bone (Fig. 5), The pes anserinus is incised longitudinally 0.5 cm medial to its attachment to the tibia. If the valgus correction is only moderate the incision can be incomplete. The distal portion of the superficial medial collateral ligament (MCL) is
Complications
There were four post-operative infections. Two were immediately post-operative and were resolved by a further operation which replaced the original cement block with one impregnated with antibiotics. Two other infections required removal of the metal work after a 2- and 3-year follow-up.
There were no deep peroneal nerve palsies, and no compartment syndromes. One patient had a partial vascular injury. Seven patients developed deep vein thromboses.
There were two delayed unions where
Discussion
In this series 93% of the post-operative HKA's were between 180 and 187° similar to Maygar's findings for opening medial wedge osteotomy [15], [16]. It is a technique that can give fairly precise results. It has the advantage of avoiding pintrack infection that can occur with hemicallotasis using external fixators. It also avoids the neurological complications of lateral opening wedges.
The use of a cement block eliminates the morbidity associated with iliac crest graft harvest, and yet does not
References (18)
Osteotomie curviplane dans le traitement de la gonarthrose
Acta Orthop Belge
(1982)- et al.
Proximal osteotomy. A critical long-term study of eighty-seven cases
J Bone Jt Surg
(1993) Technique d'ostéotomie tibiale par ouverture interne
Rev Chir Orthop
(1992)Ostéomies tibiales: facteurs de succès à long terme
Rev Chir Orthop
(1992)Results of tibial osteotomy for medial gonarthrosis with 20 year follow-up: one osteotomy vs. repeat osteotomy
Orthop Trans
(1997)- et al.
Total knee arthroplasty after opening wedge osteotomy
J Bone Jt Surg
(1999) Total knee arthroplasty after opening wedge osteotomy: a comparison study in patients undergoing prosthesis with and without a previous osteotomy
Orthop Trans
(1999)- et al.
Devenir de l'articulation femoropatellaire du genu varum arthrosique apres osteotomic tibiale de valgisation par addition interne. Recul de 10 a 13 ans
Rev Chir Orthop
(1987) - et al.
Usure osseuse sous chondrale des plateaux tibiaux dans les gonarthroses femorotibiales. Aspect radiologique sur l'incidence de profil. Correlations anatomiques et consequences
Rev Rhum Mal Osteoartic
(1990)
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2020, KneeCitation Excerpt :Except for small dimension gap, filling strategies are usually preferred for OWHTO in order to favor bone healing and obtain good stability of the correction [17]. Because of the comorbidity of the donor site and the longest surgical time, autologous grafts have lost popularity over the last 10 years [18], whereas the use of synthetic bone substitutes (SBSs), such as bioglass, acrylic bone cement [19], hydroxyapatite (HA) [8] and tricalcium phosphate (TCP) [20], are increasingly used. Nevertheless, the use of SBSs shows many disadvantages as well, and the most important of them are soft tissue irritation, infection, lack of primary stability, poor remodeling and osseointegration, higher costs and rate of delayed union [17,21].
Failures of Realignment Osteotomy
2020, Operative Techniques in Sports MedicineCitation Excerpt :While there is a paucity of literature evaluating delayed unions and nonunions of distal femoral osteotomies71 when compared to that of high tibial osteotomies, the same principles discussed for high tibial osteotomies are applicable to DFO delayed unions and nonunions. Delayed unions and nonunions of high tibial osteotomies have been well-described in the literature, although are not very frequent.2,4,72-76 Nonunion is generally less common in LCWHTO due to the better healing potential of metaphyseal cancellous bone in the proximal tibia that is in direct apposition and mechanically stable.77