Open wedge tibial osteotomy with acrylic bone cement as bone substitute

doi:10.1016/S0968-0160(00)00061-2

The Knee

Volume 8, Issue 2, May 2001, Pages 103-110

https://doi.org/10.1016/S0968-0160(00)00061-2 Get rights and content

Abstract

We studied the results of 245 valgus producing high tibial osteotomies performed with the use of an opening wedge technique and rigid internal fixation followed by early passive and active motion of the knee. Previous studies have used iliac bone grafts or hemicollastasis held by an external fixator for opening the osteotomy. In our series the opening was obtained by a block of cement interposed in the postero-medial part of the osteotomy. This series confirms that the opening wedge osteotomy allows good accuracy for the correction. Ninety-three percent of the knees had a correction adjusted between 180 and 187° for the hip–knee–ankle angle. Survivorship analysis showed an expected rate of survival, with conversion to a total knee on the end point, of 94% at 5 years, 85% at 10 years and 68% at 15 years. Conversion to a total knee arthroplasty was accomplished without difficulty in the patients who had this procedure done. We recommend opening wedge tibial osteotomy with acrylic cement bone cement as bone substitute, rigid internal fixation, and early motion for patients who undergo high tibial osteotomy.

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)

P. Blaimont
Osteotomie curviplane dans le traitement de la gonarthrose
Acta Orthop Belge
(1982)
M.B. Coventry et al.
Proximal osteotomy. A critical long-term study of eighty-seven cases
J Bone Jt Surg
(1993)
P.H. Hernigou
Technique d'ostéotomie tibiale par ouverture interne
Rev Chir Orthop
(1992)
P.H. Hernigou
Ostéomies tibiales: facteurs de succès à long terme
Rev Chir Orthop
(1992)
P.H. Hernigou
Results of tibial osteotomy for medial gonarthrosis with 20 year follow-up: one osteotomy vs. repeat osteotomy
Orthop Trans
(1997)
P.H. Hernigou et al.
Total knee arthroplasty after opening wedge osteotomy
J Bone Jt Surg
(1999)
P.H. Hernigou
Total knee arthroplasty after opening wedge osteotomy: a comparison study in patients undergoing prosthesis with and without a previous osteotomy
Orthop Trans
(1999)
P.H. Hernigou 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)
P.H. Hernigou 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)

There are more references available in the full text version of this article.

Cited by (125)

Clinical and radiological outcomes of medial opening-wedge monoplanar and biplanar high tibial osteotomy using a triangular allograft impaction technique: A retrospective single centre study
2023, Knee
The aim of the study was to research the clinical and radiological outcomes between monoplanar and biplanar medial opening-wedge high tibial osteotomy. We hypothesized that there would be no differences between both techniques when using a triangular allograft impaction technique.
A single-centre, observational, retrospective study was conducted on 103 opening-wedge high tibial osteotomy patients from January 2017 to September 2019. Data collection, NRS and KOOS-PS, was performed preoperatively, 3 months and 12 months postoperatively. Radiological assessment (Kellgren-Lawrence, mechanical femoral-tibial angle, posterior tibial slope angle, lateral patellar tilt, patellar height) was performed on standing radiographs.
In total 32 patients were included in the biplanar group and 71 patients in the monoplanar group. NRS and KOOS-PS scores improved significantly (p < 0.001) in time for both groups from baseline to 3 m PO and further to 1 year postoperatively. Our results showed no differences in radiological outcomes such as patellar height, LPT and posterior tibial slope angle. The monoplanar group did have more Takeuchi I and III fractures and a higher mFTA angle without clinical repercussion.
Using a triangular allograft impaction technique for monoplanar and biplanar medial opening-wedge high tibial osteotomy gives no differences in clinical (NRS and KOOS) and radiological outcomes. Although a difference in Takeuchi fractures was found for monoplanar patients, no additional fixation was necessary, nor did clinical complications occur. We can conclude that triangular allograft impaction technique creates a stable construct and standardizes the healing procedure postoperatively for both monoplanar and biplanar medial opening-wedge high tibial osteotomy.
Assessment of joint line obliquity and its related frontal deformity using long-standing radiographs
2023, Journal of Orthopaedics
To investigate how radiographic techniques and osteoarthritis grade influence measurements of knee joint line obliquity (KJLO) and KJLO-related frontal deformity, and to propose preferable KJLO measurement methods.
Forty patients with symptomatic medial knee osteoarthritis indicated for high tibial osteotomy were assessed. Measurements were compared between single-leg and double-leg standing radiographs for KJLO measurement methods including joint line orientation angle by femoral condyles (JLOAF), joint line orientation angle by middle knee joint space (JLOAM), joint line orientation angle by tibial plateau (JLOAT), Mikulicz joint line angle (MJLA) and medial proximal tibial angle (MPTA), as well as KJLO-related frontal deformity parameters including joint line convergence angle (JLCA), knee ankle joint angle (KAJA) and hip-knee-ankle angle (HKA). Influences of bipedal distance in double-leg standing and osteoarthritis grade on the above measurements were analysed. Measurement reliability was evaluated by intraclass correlation coefficient.
From single-leg to double-leg standing radiographs MPTA and KAJA did not change significantly, whereas the other measurements showed significant changes: JLOAF, JLOAM and JLOAT decreased 0.88°, 1.24° and 1.77°, MJLA and JLCA decreased 0.63° and 0.85°, and HKA increased 1.11° (p < 0.05). Bipedal distance in double-leg standing radiographs moderately correlated with JLOAF, JLOAM and JLOAT (r_p = −0.555, −0.574 and −0.549). Osteoarthritis grade moderately correlated with JLCA in single-leg and double-leg standing radiographs (r_s = 0.518 and 0.471). All measurements had at least good reliability.
In long-standing radiographs, measurements of JLOAF, JLOAM, JLOAT, MJLA, JLCA and HKA are all influenced by single-leg/double-leg standing; JLOAF, JLOAM and JLOAT are also affected by bipedal distance in double-leg standing; and JLCA is affected by osteoarthritis grade. Knee joint obliquity as assessed by MPTA measurement is independent of single-leg/double-leg standing, bipedal distance or osteoarthritis grade, and has excellent measurement reliability. We therefore propose MPTA as the preferable KJLO measurement method for clinical practice and future research.
III, cross-sectional study.
A biomechanical study: Comparison of three different implant options in high Tibial osteotomy
2022, Clinical Biomechanics
Many implant options could be preferable for fixation after osteotomy in varus knee medial compartment arthrosis. Due to usage characteristics, it is important to compare the biomechanical properties of them. For this purpose, we aimed to examine three different implant types biomechanically in our study.
Ovine tibiae undergoing medial open-wedge high tibial osteotomy were fixed in vitro with three different implants using an angular wedge plate, a metal block plate and an external fixator system. The fixed ovine tibiae were subjected to axial tensile, axial loading and three-point bending tests in a test machine. All biomechanical tests were repeated five times, the maximum and minimum values were ignored, and the average values of the remaining three test results were taken into account. The test results were interpreted after converted into force-elongation curves in Trapezium-X software.
Biomechanical test results revealed some differences between implant types. While the metal block plate had the highest axial tensile strength value, it was the fixation group showing the lowest strength in axial load tests. The used fixator system was the highest strength in axial load tests and the lowest strength in axial tensile tests.
Considering the clinically significant forces related to the biomechanical stability of the three different implants used for high tibial osteotomy, the fixator system would appear to be slightly superior, although it should be noted that torsional forces, as well as parameters that could change in living tissue, might affect the results.
Satisfactory long-term survival, functional and radiological outcomes of open-wedge high tibial osteotomy for managing knee osteoarthritis: Minimum 10-year follow-up study
2021, Journal of Orthopaedic Translation
This prospective cohort study was designed to evaluate the survivorship and functional outcomes associated with long-term results of medial open-wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in the Chinese population. Although MOWHTO is a well-established procedure in the management of medial osteoarthritis of the knee, the long-term outcome in the Chinese population has not been reported in current literature. We hypothesised that MOWHTO would result in long-term preservation of knee function in Chinese, similar to that reported in the Caucasian population.
A cohort of 22 young adult patients (age < 55 years old) undergoing MOWHTO for the treatment of symptomatic medial compartment knee osteoarthritis between 2002 and 2008 was retrospectively surveyed with a minimum follow-up of 10 years. Kaplan–Meier survival analysis was performed, and the failure modes were investigated. The outcomes on survival (not requiring arthroplasty), clinical outcome (Knee Society Knee Score and Knee Society Function Score) and range of motion (numeric rating scale) at preoperative, 1-year postoperative follow-up and at last follow-up (>10 years) were evaluated. In addition, the mechanical tibiofemoral angle was also measured. The Wilcoxon signed-rank test was used for statistical evaluation of nonparametric data in these related samples.
A total of 31 knees in these 22 cases were included. The follow-up rate was 100% at 13.4 ± 1.9 years (11–17). Mean age at time of surgery was 45.8 ± 9.5 years (18–53). At 10-year follow-up, four knees converted to require total knee arthroplasty (survival: 87.1%). Preoperative varus alignment with mechanical tibiofemoral angle of −9.26 ± 2.83 was corrected to 2.58 ± 2.46 after surgery and remained 2.01 ± 3.52 at the latest follow-up. Knee Society Knee Score increased significantly from 53.7 ± 11.1 preoperatively to 93.8 ± 6.8 at 1-year follow-up and 91.8 ± 9.7 at latest follow-up. Similarly, the functional score also increased significantly from 67.4 ± 21.0 preoperatively to 86.3 ± 14.5 at 1-year follow-up and 82.1 ± 16.6 at latest follow-up (p < 0.01). Whereas, the range of motion significantly decreased from 122.7 ± 6.6 preoperatively to 116.1 ± 15.5 at the latest follow-up.
Even in cases of severe medial osteoarthritis and varus malalignment, MOWHTO would be a good treatment option for management in active Chinese population less than 55 years. Although the long-term survival and functional outcome after MOWHTO was proven to be satisfactory in our cohort during the 10-year follow-up, a larger cohort to illustrate the long-term functional outcome is still warranted.
The finding in this study indicated MOWHTO is a feasible treatment option for young adult patients with osteoarthritis to achieve long-term satisfactory results.
Mid-term CT assessment of bone healing after nanohydroxyapatite augmentation in open-wedge high tibial osteotomy
2020, Knee
Citation 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].
The aim of the present study was to confirm the effectiveness of adding nanohydroxyapatite (NHA) to a heterologous bone graft in open-wedge high tibial osteotomy (OWHTO) by measuring the bone density via multislice computed tomography (CT) of the tibial osteotomy gap in a mid-term follow-up (five years).
Twenty-six patients undergoing OWHTO were randomly assigned to two groups: a pure graft group (Group A), in which the osteotomy gap was filled with only heterologous bone graft, and an NHA group (Group B), in which the osteotomy gap was filled with heterologous bone graft and NHA. CT was performed within one week of the operation, after two months, after 12 months and after five years. CT volume acquired in Hounsfield units (HU) was measured on three planes.
The normal bone density was 110.2 ± 11.7 HU. The value of mean density at five years in Group A was 296.8 ± 81.8 HU, while in Group B, it was 202.2 ± 45.1 HU, showing a density more similar to normal bone and greater bone uniformity inside the osteotomy. The difference between the two groups was statistically significant (p < 0.05). Furthermore, both groups showed excellent mid-term clinical outcomes without significant differences.
This study revealed that absorbability and bone formation at the osteotomy site in the NHA group was significantly higher as compared with the pure graft group at five years postoperatively.
Failures of Realignment Osteotomy
2020, Operative Techniques in Sports Medicine
Citation 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
Realignment osteotomies about the knee, consisting of proximal tibial and distal femoral osteotomies, are excellent methods for addressing mechanical axis deviation in the setting of unicompartmental knee osteoarthritis, ligament insufficiency, meniscus deficiency, and/or focal cartilage defects. These procedures, however, are not without complications. Complications encountered with theses osteotomies include cortical hinge fracture, tibial slope alterations, changes in patellar height, vascular injuries, and various early and late postoperative complications, including delayed unions and nonunions. This current concept article reviews the etiology, diagnosis, and management strategies for various complications related to high tibial and distal femoral osteotomies. In addition, technical strategies are provided for how to recognize and revise failed osteotomies in the setting of delayed unions and nonunions.

View all citing articles on Scopus

View full text

Open wedge tibial osteotomy with acrylic bone cement as bone substitute

Abstract

Introduction

Section snippets

Material

Technique for obtaining the cement wedge

Operative technique

Complications

Discussion

Osteotomie curviplane dans le traitement de la gonarthrose

Acta Orthop Belge

Proximal osteotomy. A critical long-term study of eighty-seven cases

J Bone Jt Surg

Technique d'ostéotomie tibiale par ouverture interne

Rev Chir Orthop

Ostéomies tibiales: facteurs de succès à long terme

Rev Chir Orthop

Results of tibial osteotomy for medial gonarthrosis with 20 year follow-up: one osteotomy vs. repeat osteotomy

Orthop Trans

Total knee arthroplasty after opening wedge osteotomy

J Bone Jt Surg

Total knee arthroplasty after opening wedge osteotomy: a comparison study in patients undergoing prosthesis with and without a previous osteotomy

Orthop Trans

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

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