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Summary1
High Tibial Osteotomy (HTO) is an established treatment for unicompartmental osteoarthritis of the knee
with malalignment. The classic procedure for correcting varus deformity is the lateral closed wedge
osteotomy of the tibia with osteotomy of the fibula. The
disadvantages of this technique are well known. Open
wedge osteotomy from the medial sideeliminates the
risk of compartment syndrome and peroneal nerve
injuries. A new fixation device (TomoFix) with an
adapted surgical technique allows stable fixation of the
osteotomy without the need to fill the osteotomy gap
with bone grafts.
In a prospective study, 92 consecutive cases were
treated with this procedure. Bony healing with remodelling of the medial and posterior cortical bone was
observed. Full weight-bearing was possible ten weeks
after surgery. There were no implant failures. Complications included one delayed union, two revarisations
and one deep infection.
Keywords: High Tibial Osteotomy (HTO), openwedge osteotomy, TomoFix plate, medial osteoarthritis, varus knee
Injury 2003, Vol. 34, Suppl. 2
Introduction
High Tibial osteotomy (HTO) is a common procedure
for managing medial osteoarthritis (OA) of the knee
1
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tional bone substitutes filling the osteotomy gap [7]. The
new TomoFix plate has been designed to achieve optimal stability without the interference of bone healing
and without any bone graft. The principle of the locking compression plate system (LCP) [8] meets our
requirements. The locking-head screws provide a stable
fixation without compression between plate and bone.
In a subsequent prospective study, we evaluated this
new device and asked whether the correction could be
maintained without bone substitution until bone healing is radiologically completed. The outcome was evaluated by clinical assessment and conventional radiography.
Fig. 1: Preoperative planning of the osteotomy. Overcorrection of the new mechanical axis according the work of Fujisawa (from AO folder p. 4).
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Results
92 open-wedge HTOs, without bone substitute, were
carried out in our hospital on 90 consecutive patients
between May 2000 and May 2002. The operations were
performed by the authors. All patients had an arthroscopic evaluation of the joint status. In nine patients, an
anterior cruciate ligament (ACL) reconstruction was
performed at the same time as the HTO. Other concomitant procedures were: 72 patients with a partial
resection of the medial meniscus, six patients also had
a cartilage debridement and in one patient had a mosaicplasty. The mean correction was 9.2 degrees, with a standard deviation of 3.41 (range: 2 to 20 degrees). All
patients were followed until bony union of the
osteotomy had been radiologically documented.
During the follow-up period, from May 2000 to September 2002, 37 implants were removed, on average
twelve months (range: *2.5 to 17 months) after the operation. 25 of the 90 patients were women and 65 were
men. The mean age was 50 years, ranging from 18 to 75
years. The mean follow-up period was nine months
(range: 3-24 months).
Using the visual analogue scale (VAS), the patients
reported a significant subjective reduction of pain, from
a score of 4 (range: 3.5-5) before the operation to a score
of 2 (range: 1.5-3) after six and twelve weeks, and were
almost free of symptoms (scores of 1.5 to 0.5) under full
weight-bearing at the follow-up examinations (Table1).
Walking without crutches and full weight-bearing was
achieved after an average of ten weeks (range: 6-12
weeks).
At the first follow-up examinations, hyposensitivity
in the area of the cutaneus branch of the saphenous
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nerve (N. infrapatellaris) was observed in ten patients.
This complication was subsequently prevented by careful subcutaneous dissection. Other neurological complications were not seen.
In three patients, a knee arthroplasty was performed
because of progressive osteoarthritis and persistence of
the symptoms, and in a further two patients, a knee
arthroplasty was recommended. The range of passive
motion reached the baseline values, at the 12-week follow-up examination. Radiologically, consolidation is
evident with bone formation in the osteotomy gap and
variable formation of callus in the lateral and dorsal part
of the osteotomy (Fig. 7). Quantification of the bone formation was not possible on the basis of the conventional
radiographs because of projection artefacts and superposition of the implant.
The postoperatively achieved femorotibial axis
(Table2) and tibial slope was maintained during the
bony healing phase without statistically significant loss
of correction. In the early postoperative radiograph, the
femorotibial axis appears with a smaller valgus angle
(postoperative: 6.9) than in the subsequent follow-up
examinations (six weeks: 8.5). This difference arises
from the fact that the x-ray 1-2 days after the operation
was not taken in full extension and with full weightbearing. Rotational errors, which affect the femorotib-
Fig. 7: Ap radiography of a right knee 12 months postoperatively. Bony consolidation of the osteotomy gap with remodelling of the medial cortex is visible.
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Table 2: The femorotibial axis measured from ap radiographs through the follow up examinations are shown.
Mean values with standard deviation at the defined follow
up intervals are documented.
Discussion
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system was most stressed in the dorsal area of the
osteotomy, as the plate lies anteromedial and there is no
primary bone contact in the posterior aspect of the
osteotomy. This relative instability was shown by a frequently visible formation of callus at the posterior cortex. During the bone-healing phase, the tibial slope
showed no statistically significant change.
Delayed union
The single case that developed delayed union showed
an instability in the postoperative radiograph due to a
dehiscent fracture of the lateral cortex. The plate fixation was not performed correctly, because the fourth
locking-head screw was not placed in the proximal fragment, and the first screw distal to the osteotomy was not
fixed bicortically as recommended (Fig. 8). This led to
an insufficient stability which, through micro-motion in
the area of lateral osteotomy gap, led to delayed union.
To prevent pseudarthrosis, we started to pre-tension the
plate with a lag screw. This screw is placed after proximal fixation of the plate through the first sliding hole in
the plate, which results in primary contact and interfragmentary compression of the lateral cortex. Removing the previously inserted lag screw results in additional compression of the lateral osteotomy gap. By
inserting a bicortical, locked screw distal to the
osteotomy, the overall stability of the system allows
rapid bone healing.
According to the literature, exact adjustment of the
load-bearing axis is critical for a good long-term prognosis of a unicompartmental osteoarthritis with varus
alignment [12]. In the presented open-wedge osteotomy
technique, this can be achieved in all planes, including
rotation. In our series of cases, there is clear tendency to
undercorrect the deformity (mean femorotibial axis
after the operation: 8.2 degrees). This technical shortcoming in the surgical realisation of the preoperative
Loss of correction:
We observed a change in the tibial slope in the initial
phase, between the preoperative and postoperative values. During the operation, there was a tendency for the
slope to enlarge, as the strong mediodorsal ligaments
and the pes anserinus act against the opening of the
osteotomy. To prevent flexion malalignment, a soft-tissue release should be carried out, especially in the case
of contract medial capsule and ligaments. The tibial
slope was marked by a K-wire inserted subcutaneously
parallel to the direction of the joint surface. The fixation
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plan can be overcome by fluoroscopic control of the leg
axis during surgery or by computer assisted surgery
[20].
Conclusions
The fixation system described here meets the stability
criteria that are necessary for an open-wedge correction
osteotomy on the tibia without interposition. Even in
cases with delayed healing no implant failure occurred.
Early functional postoperative rehabilitation is possible
and the preconditions for bone consolidation are fulfilled. Long-term follow-up examinations are necessary
to assess the quality of the newly formed bone, especially after removal of the implant. Premature removal
of the implant, i.e. before twelve months after the operation, can lead to secondary loss of correction, especially
in association with undercorrection.
The surgical technique needs careful attention otherwise failures, especially in respect of delayed healing,
may be encountered. Disorders of normal bone healing
and inadequate axial correction may also lead to treatment failures. Based on our experience, we do not recommend this surgical procedure for patients over the
age of 65 years or cigarette smokers.
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Correspondence address:
Carlo De Simoni
Klinik St. Anna, Luzern
E-mail: cc.desimoni@bluewin.ch