JBJS | High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up*

The Journal of Bone & Joint Surgery, Volume 82, Issue 1

Articles | January 01, 2000

High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up*

ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE CITY, UTAH

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Investigation performed at the Department of Orthopedics, University of Utah School of Medicine, Salt Lake City

The Journal of Bone & Joint Surgery. 2000; 82:70-9

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Abstract

Background: We studied the results of sixty-four valgus-producing high tibial osteotomies performed with the use of a calibrated osteotomy cutting guide and rigid internal fixation, and followed by early motion, in fifty-six patients who had medial unicompartmental osteoarthritis and varus malalignment. Long-term studies have demonstrated that a high tibial osteotomy performed with staple fixation and followed by immobilization in a cast has an expected survival rate of approximately 85 percent at five years and 60 percent at ten years (in studies of ninety-five knees and 213 knees, respectively). To the best of our knowledge, there are no long-term reports on high tibial osteotomies performed with a calibrated osteotomy cutting guide and rigid internal fixation and followed by early motion.

Methods: The indications for high tibial osteotomy were medial unicompartmental osteoarthritis and varus malalignment. A lateral closing-wedge osteotomy was performed. The patients were reexamined to obtain a knee score, to make lateral radiographs of both knees, and to make a full-length anteroposterior radiograph (showing the entire lower extremity, including the hip and ankle) of the involved knee with the patient standing.

Results: Twenty-one knees were treated with a subsequent total knee arthroplasty at an average of sixty-five months after the high tibial osteotomy. The remaining forty-three knees had a good or excellent clinical result, with an average knee score of 94 points at an average of 8.5 years after the osteotomy. Survivorship analysis showed an expected rate of survival, with conversion to a total knee arthroplasty as the end point, of 85 percent at five years and 53 percent at ten years. No patient had patella baja postoperatively. There were six complications: four superficial wound infections, one superficial-vein thrombosis, and one delayed union (union occurred at five months).

Conclusions: High tibial osteotomy has been criticized because of a high rate of complications, a loss of effectiveness with time, and the difficulty of conversion to a total knee arthroplasty secondary to patella baja. In our series, in which an osteotomy was performed with a calibrated osteotomy cutting guide and rigid internal fixation and was followed by early motion, the rate of complications was low and approximately two-thirds of the knees had a good or excellent clinical result at an average of 8.5 years. Conversion to a total knee arthroplasty was accomplished without difficulty in the patients who had this procedure. We highly recommend high tibial osteotomy with a calibrated osteotomy cutting guide, rigid internal fixation, and early motion for patients who wish to continue an active lifestyle.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

High tibial osteotomy has long been recognized as beneficial for the treatment of osteoarthritis involving the medial or lateral compartment of the knee. Pauwels showed that a previously narrowed joint space will widen postoperatively and both subchondral cysts and sclerosis will regress if stress in the affected compartment is reduced sufficiently³⁸. Such a stress reduction occurs in the medial compartment of the knee when the mechanical axis is transferred from the medial compartment to the center of the joint or just lateral to the center of the joint^7,32,41-43. This alignment is achieved with the knee between 8 and 10 degrees of valgus². Akamatsu et al. conducted bone-density studies on 144 knees with osteoarthritis involving the medial compartment, twenty-three of which were treated with a high tibial osteotomy². The ratio of the bone density in the medial compartment to that in the lateral compartment had been high in all patients preoperatively, and this ratio increased with progression of the disease. At one year postoperatively, the ratio had decreased significantly (p < 0.0001) in all twenty-three patients who had been managed with a high tibial osteotomy. Furthermore, articular cartilage has been shown to regenerate, both grossly and histologically, on an operatively unloaded joint surface⁹. Most importantly, patients have had relief of pain. Adequate correction of osseous malalignment is crucial for sufficient reduction in stress in a diseased compartment^7,32,41-43.

Many methods and types of fixation have been used to achieve a more uniform distribution of weight across the knee joint. To our knowledge, Jackson and Waugh were the first to utilize this concept using a tibial osteotomy distal to the tibial tuberosity²¹. Coventry popularized the procedure in the United States; he used a closing-wedge osteotomy proximal to the tibial tubercle⁷, a technique originally described by Gariépy¹².

The most common problems with this procedure are difficulty in achieving an accurate correction of osseous malalignment, a relatively high rate of complications (thirty-eight complications after forty-seven osteotomies in one study³³), and the recurrence of the varus or valgus deformity. In 1991, one of us (A. A. H.) and colleagues reported their preliminary results with high tibial osteotomies that had been performed at our hospital with use of an osteotomy jig and rigid fixation and that had been followed by early motion¹⁶. Preliminary results were encouraging, with a low rate of complications, improved rehabilitation due to early motion, and reproducibility of the technique with the accurate placement of the osteotomy cuts. In the present study, we report the results, after a minimum of five years, of high tibial osteotomy in sixty-four consecutive knees.

*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Loma Linda University Medical Center, 11234 Anderson Street, A521, Loma Linda, California 92354.

‡Orthopaedic Specialty Clinic, 9631 North Nevada, Suite 302, Spokane, Washington 99218.

§Department of Orthopedics, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.

†Department of Orthopaedic Surgery, Loma Linda University Medical Center, 11234 Anderson Street, A521, Loma Linda, California 92354.

‡Orthopaedic Specialty Clinic, 9631 North Nevada, Suite 302, Spokane, Washington 99218.

§Department of Orthopedics, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.

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FIG1:: Fig. 1 Illustration demonstrating measurement of the Insall-Salvati ratio¹⁷ (LL/LP) and the Blackburne-Peel ratio⁵ (a/b). LL = length of the patellar ligament, LP = length of the patella, a = perpendicular distance from the tibial plateau to the inferior articular surface of the patella, and b = length of the articular surface of the patella.

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FIG2-A:: Figs. 2-A through 2-E: Drawings illustrating the operative technique. Fig. 2-A: With the transverse osteotomy guide in place, the tibial width is measured.

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FIG2-B:: Fig. 2-B: The saw blade is inserted to leave a ten-millimeter medial bone bridge.

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FIG2-C:: Fig. 2-C: The oblique osteotomy guide is then applied to allow accurate osseous wedge resection.

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FIG2-D:: Fig. 2-D: Slow compression of the osteotomy site allows plastic deformation medially.

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FIG2-E:: Fig. 2-E: The compressed osteotomy site (arrows) with placement of the distal screws.

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FIG3:: Fig. 3 Photograph showing the osteotomy plate and screws.

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FIG4-A:: Fig. 4-A Intraoperative radiographs showing the wedge resection (Fig. 4-A) and the mechanical axis (Fig. 4-B).

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FIG4-B:: Fig. 4-B Intraoperative radiographs showing the wedge resection (Fig. 4-A) and the mechanical axis (Fig. 4-B).

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FIG5:: Fig. 5 Kaplan-Meier survival curve²⁴ with Hall-Wellner 95 percent confidence intervals¹³, with the performance of an arthroplasty as the end point.

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FIG6-A:: Figs. 6-A and 6-B: A patient who had a high tibial osteotomy. Fig. 6-A: Preoperative radiographs.

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FIG6-B:: Fig. 6-B: Radiographs made eight years after the procedure, showing preservation of the medial joint space.

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TABLE I: RADIOGRAPHIC FINDINGS FOR ALL KNEES*

*The values are given as the average and the standard deviation.†A negative value indicates varus angulation.‡The apex was medial.§A negative value indicates varus angulation, and a positive values indicates valgus angulation.

	Preop.	At 6 Wks. Postop.	At Most Recent Follow-up
Femorotibial anatomical alignment† (degrees)	-1.4 ± 3.37	9.2 ± 3.69	7.4 ± 4.94
Joint-line convergence angle‡ (degrees)	3.9 ± 2.06	3.6 ± 1.78	4.1 ± 2.18
Tibial alignment§ (degrees)	-4.2 ± 3.46	5.2 ± 3.42	4.5 ± 3.96
Posterior slope (degrees)	8.7 ± 4.31	6.5 ± 3.92	6.0 ± 3.25
Insall-Salvati ratio¹⁷	1.1 ± 0.19	1.1 ± 0.16	1.0 ± 0.16
Blackburne-Peel ratio⁵	0.8 ± 0.13	0.8 ± 0.16	0.8 ± 0.12

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TABLE I: RADIOGRAPHIC FINDINGS FOR ALL KNEES*

	Preop.	At 6 Wks. Postop.	At Most Recent Follow-up
Femorotibial anatomical alignment† (degrees)	-1.4 ± 3.37	9.2 ± 3.69	7.4 ± 4.94
Joint-line convergence angle‡ (degrees)	3.9 ± 2.06	3.6 ± 1.78	4.1 ± 2.18
Tibial alignment§ (degrees)	-4.2 ± 3.46	5.2 ± 3.42	4.5 ± 3.96
Posterior slope (degrees)	8.7 ± 4.31	6.5 ± 3.92	6.0 ± 3.25
Insall-Salvati ratio¹⁷	1.1 ± 0.19	1.1 ± 0.16	1.0 ± 0.16
Blackburne-Peel ratio⁵	0.8 ± 0.13	0.8 ± 0.16	0.8 ± 0.12

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TABLE II: RADIOGRAPHIC FINDINGS FOR KNEES WITH AND WITHOUT REVISION OF THE OSTEOTOMY TO A TOTAL KNEE ARTHROPLASTY*

*The values are given as the average and the standard deviation.

	Knees with Revision	Knees without Revision
Femorotibial anatomicalalignment at 6 wks.postop. (degrees)	8.9 ± 3.99	9.3 ± 3.59
Loss of correction atfollow-up (degrees)	2.2 ± 4.75	1.5 ± 3.31
Joint-line convergenceangle at follow-up (degrees)	4.6 ± 2.01	3.9 ± 2.25
Tibial alignment (valgus)at follow-up (degrees)	3.4 ± 5.20	4.9 ± 3.30

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TABLE II: RADIOGRAPHIC FINDINGS FOR KNEES WITH AND WITHOUT REVISION OF THE OSTEOTOMY TO A TOTAL KNEE ARTHROPLASTY*

*The values are given as the average and the standard deviation.

	Knees with Revision	Knees without Revision
Femorotibial anatomicalalignment at 6 wks.postop. (degrees)	8.9 ± 3.99	9.3 ± 3.59
Loss of correction atfollow-up (degrees)	2.2 ± 4.75	1.5 ± 3.31
Joint-line convergenceangle at follow-up (degrees)	4.6 ± 2.01	3.9 ± 2.25
Tibial alignment (valgus)at follow-up (degrees)	3.4 ± 5.20	4.9 ± 3.30

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Sixty-nine consecutive lateral closing-wedge proximal tibial osteotomies were performed in sixty-one patients (eight of whom had a bilateral procedure) between April 1985 and March 1993 by one surgeon. Most of the sixty-one patients (sixty-three of the sixty-nine knees), including all of those who had a bilateral osteotomy, had degenerative joint disease involving the medial compartment due to previous trauma or genu varum deformity. In addition, two patients had osteonecrosis of the medial femoral condyle, two had osteochondritis dissecans, one had Blount disease, and one had malunion of a tibial fracture.

The indications for the high tibial osteotomy were pain in the medial side of the knee that limited activities and decreased the quality of life, varus malalignment, and a desire to remain active. The amount of medial joint space remaining was considered irrelevant if these three conditions were met. Some patients had a considerable amount of medial cartilage remaining and some had no medial joint space remaining as seen on weight-bearing anteroposterior radiographs.

Twelve of the sixty-one patients were women, and forty-nine were men. The average age was forty-nine years, with a range of twenty-three to sixty-nine years, and the average weight was 208 pounds (94.3 kilograms), with a range of 141 to 330 pounds (64.0 to 149.7 kilograms).

Five of the sixty-one patients (five of the sixty-nine knees) were not available for long-term follow-up. Two additional patients died, but as they had been followed for more than two years they were included in the study. The average duration of follow-up for the patients who did not have a subsequent revision was 8.5 years, with a range of five to thirteen years.

Sixteen patients had had previous operative procedures, including arthroscopy, arthrotomy, meniscectomy, and reconstruction of the anterior cruciate ligament. Three patients had had several (three to seven) previous procedures, and one patient had had an osteotomy and a torn anterior cruciate ligament.

All of the patients' charts were reviewed retrospectively to determine demographic characteristics, previous operative procedures, the preoperative diagnosis, and the preoperative knee score according to the scale of The Hospital for Special Surgery¹⁹. When a patient had had a subsequent total knee arthroplasty, the chart was also reviewed to determine the knee score just before the arthroplasty and the most recent knee score after the arthroplasty. Patients who had not had a total knee arthroplasty were reevaluated at the time of the study to determine a knee score, to make lateral radiographs of both knees, and to make a full-length anteroposterior radiograph (showing the entire lower extremity, including the hip and ankle) of the involved knee with the patient standing. A statistical analysis with the Kaplan-Meier method²⁴ with Hall-Wellner¹³ confidence intervals was performed to determine the survival curve.

Radiographic Evaluation

The results of fifty-two preoperative, fifty-three postoperative (six-week), and fifty-three long-term follow-up radiographic examinations, which consisted of bilateral lateral radiographs and of an anteroposterior radiograph made on a long cassette with the patient standing, were available for review. Of the fifty-three long-term examinations, fifteen were performed just before the patient had a total knee arthroplasty.

All radiographs were reviewed by one of us (A. B.). ResearchMetrics (Ortho-Graphics, Salt Lake City, Utah) was used to determine the femorotibial anatomical alignment, the angle between the femoral condyles and the tibial plateau (the joint-line convergence angle), and the angle between the anatomical axis of the tibia and a line perpendicular to the tibial plateau on the anteroposterior radiograph (tibial alignment). The angle between a line perpendicular to the tibial plateau and the anatomical axis of the tibia on the lateral radiograph (posterior slope) was also determined, as were both the Insall-Salvati¹⁷ and Blackburne-Peel⁵ ratios on the bilateral lateral radiographs.

The Insall-Salvati and Blackburne-Peel ratios are two different methods for evaluating patella baja and patella alta. The Insall-Salvati ratio is the ratio of the length of the patellar ligament to the length of the patella (Fig. 1). The average Insall-Salvati ratio in the general population is 1.0. A ratio of greater than 1.2 is considered patella alta, and a ratio of less than 0.8 is considered patella baja¹⁷. The Blackburne-Peel ratio is the ratio of the perpendicular distance from the tibial plateau to the inferior articular surface of the patella to the length of the patellar articular surface (Fig. 1). The average Blackburne-Peel ratio in the general population is 0.8. A ratio of greater than 1.0 is considered patella alta, and a ratio of less than 0.6 is considered patella baja⁵. Both ratios are measured on lateral radiographs with the knee flexed to 30 degrees. This ensures that there is no slack in the patellar ligament.

Operative Technique

A standard lateral approach with an L-shaped incision was made with division of the proximal aspect of the tibiofibular capsule. Keith needles were used to identify the joint line, and a transverse osteotomy jig was fixed with two 3.2-millimeter drill points (Fig. 2-A). The transverse limb portion of the osteotomy was performed with the medial cortex kept intact (Fig. 2-B). The desired correction (the difference in degrees between the anteroposterior alignment on preoperative radiographs made on a long cassette with the patient standing and the desired postoperative result of 8 degrees of valgus) was achieved with use of a slotted osteotomy jig with 2-degree increments to perform the oblique portion of the osteotomy (Fig. 2-C). An L-buttress plate (Sulzer Orthopedics, Austin, Texas) was applied to the proximal part of the tibia with two fully threaded cancellous-bone screws (Fig. 3), and an external compressor device (Figs. 2-D and 2-E) was used to draw the osteotomy site closed before screws were placed in the distal portion of the plate. C-arm fluoroscopy was used to monitor correction (Figs. 4-A and 4-B).

A bulky Jones dressing was applied, and continuous passive motion from 0 to 30 degrees was started immediately postoperatively. The Jones dressing was removed after forty-eight hours. The range of continuous passive motion was increased by 10 degrees when the dressing was removed and every day thereafter until discharge, usually on the fourth postoperative day. Fifty percent weight-bearing was also allowed immediately postoperatively. Full weight-bearing was allowed at six weeks. All patients received one gram of Ancef (cefazolin) intravenously twenty minutes before the procedure and then every eight hours for twenty-four hours after it. Coumadin (warfarin) or aspirin was used by all patients for prophylaxis against deep-vein thrombosis. Ten milligrams of Coumadin was given the night before the procedure, and the dose was titrated to keep the international normalized ratio between 1.5 and 2.0 for the week immediately after the procedure. The patient was given 2.5 milligrams of Coumadin every day for the second week after the procedure and every other day for the third week after the procedure. Aspirin (ten grains twice daily for two weeks) was used instead of Coumadin after some of the earlier procedures.

Results

Introduction | Materials and Methods | Results | Discussion | References

Twenty-one (33 percent) of the sixty-four knees that were available for long-term follow-up had had a subsequent arthroplasty at an average of sixty-five months (range, twenty-four to 119 months) after the index procedure. Survivorship analysis showed the probability of survival (with 95 percent confidence interval), with total knee arthroplasty as the end point, to be 100 percent at one year, 85 ± 6.8 percent at five years, and 53 ± 24.7 percent at ten years (Fig. 5).

The average duration of follow-up of the forty-three knees (67 percent) that did not have a subsequent arthroplasty was 8.5 years (range, five to thirteen years). According to the system of The Hospital for Special Surgery¹⁹, the average preoperative knee score for all patients was 71 points (range, 64 to 81 points). At the time of the most recent follow-up, the average knee score was 94 points (range, 78 to 100 points) for the knees that had not had an arthroplasty (Figs. 6-A and 6-B). One knee had an extension lag of 5 degrees. All others had full extension and an average arc of flexion of 124 degrees (range, 110 to 140 degrees). The knees that had an arthroplasty had had an average knee score of 72 points (range, 67 to 81 points) immediately before the arthroplasty, and they had an average knee score of 97 points (range, 95 to 100 points) at the time of the latest follow-up, at an average of forty-one months after the arthroplasty.

Fifty-seven of the sixty-nine knees were corrected to between 5 and 13 degrees of valgus. Five were corrected to less than 5 degrees of valgus; three of them were treated with a subsequent arthroplasty (at twenty-four, sixty-five, and sixty-six months), and one was not available for follow-up. Seven knees were corrected to more than 13 degrees of valgus, and two of them had a subsequent arthroplasty (at sixty-one and ninety-six months).

The average initial postoperative correction (and standard deviation) for all knees was to 9.2 ± 3.69 degrees of valgus (Table I), which was very similar to the average postoperative alignment for the knees that had a subsequent arthroplasty (8.9 ± 3.99 degrees of valgus) (Table II). Thirteen knees had lost more than 2 degrees of correction at the time of the latest follow-up. The average initial postoperative correction for these knees was to 9.4 ± 4.12 degrees (range, 4 to 17 degrees) of valgus. Of the knees that lost more than 2 degrees of correction, four subsequently had a total knee arthroplasty. Two knees had severe regression to the previous varus deformity (5 and 9 degrees of varus), and one of them had a subsequent arthroplasty. Overall, the average loss of correction was 1.7 ± 3.78 degrees (Table II).

The joint-line convergence angle and the tibial alignment just before the arthroplasties were also similar to those values at the time of the most recent follow-up in the knees that were not revised (Table II). The posterior slope did not change appreciably after the osteotomies (Table I).

The average Insall-Salvati¹⁷ and Blackburne-Peel⁵ ratios after the osteotomies were very similar to those in the general population (Table I). No knee had an Insall-Salvati ratio of less than 0.8 or a Blackburne-Peel ratio of less than 0.6. The Insall-Salvati and Blackburne-Peel ratios were also measured for the contralateral knees; the average values were 1.0 ± 0.15 and 0.8 ± 0.13, respectively, which were identical to those in the general population.

There were six complications in the sixty-nine knees, a rate of complications of 9 percent. There were four superficial wound infections, three of which were treated with oral administration of antibiotics (500 milligrams of Keflex [cephalexin] four times a day for one week). The fourth wound infection necessitated readmission to the hospital for intravenous administration of antibiotics (one gram of Ancef [cefazolin] three times a day for five days followed by one week of oral administration of Keflex after discharge). There was also one superficial-vein thrombosis, which was treated conservatively with hot packs and elevation, and one delayed union (union occurred at five months). There were no peroneal nerve palsies, nonunions, intra-articular fractures, compartment syndromes, infections necessitating subsequent operative procedures, or deep-vein thromboses.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Osseous deformities or loss of cartilage resulting in loss of the joint space in the medial compartment may cause varus malalignment^7,37. Lateral joint laxity has also been associated with genu varum deformities, especially dynamic varus deformities³⁷. This laxity may be due to overstretch of the lateral aspect of the capsule and the lateral ligaments secondary to osseous malalignment, or it may be due to actual ligamentous laxity from osseous overgrowth and proximal migration of the fibular head^7,37. Some authors have strongly recommended that this laxity be corrected at the time of the high tibial osteotomy^7,37,43, whereas others have shown that the lateral soft-tissue structures contract spontaneously if adequate correction is achieved³².

Many investigators have agreed, however, that the method used to disrupt the strutting effect of the fibula is crucial to maintaining or correcting ligamentous balance^{6,7,10,15,23,35,37,43}. Excision of the fibular head and excision of a segment of the fibular diaphysis are both commonly described. However, the rate of peroneal nerve palsy after both osteotomies is high (as high as seven of forty-two osteotomies²⁷) unless the excision is done in the distal third of the fibula^14,27,33,40. We divide the proximal tibiofibular joint capsule, allowing the fibula to migrate proximally, and none of our patients managed with this method have had a peroneal nerve palsy.

Some authors have suggested that the use of internal fixation decreases the possibility of recurrence of varus deformity^11,16. Insall et al. reported regression to varus deformity after twenty-nine of ninety-five osteotomies that had been performed without internal fixation²⁰. Additionally, several authors found that the varus deformity did not recur in knees that had been overcorrected^7,43. In our study, we did not find a good association between postoperative correction and loss of correction. The average postoperative correction had been to 9.8 degrees of valgus in the knees that lost more than 2 degrees of correction.

Recurrence of the deformity has been directly implicated in the recurrence of pain and therefore in a less satisfactory clinical result^7,11,43. Although this was the case for four of our patients, for most of them it was not. Of the thirteen knees that lost more than 2 degrees of correction, four subsequently had a total knee arthroplasty; this rate was similar to the rate of arthroplasty in the overall series. The average loss of correction after the osteotomies that were eventually converted to a total knee arthroplasty (2.2 ± 4.75 degrees) was higher than the average loss of correction after the remaining osteotomies (1.5 ± 3.31 degrees); however, with the numbers available for study, the difference could not be shown to be significant.

The tibial alignment and the joint-line convergence angle were measured at the time of the most recent follow-up or just before revision to an arthroplasty in order to determine whether there were other variables that could be implicated either in recurrence of the deformity or in the need for an arthroplasty. Both the tibial alignment and the joint-line convergence angle were very similar in the two groups of patients (those who subsequently had an arthroplasty and those who did not) (Table II). It is interesting to note, however, that although the tibial alignment changed dramatically after the osteotomy (from an average of 4.2 ± 3.46 degrees of varus preoperatively to an average of 4.5 ± 3.96 degrees of valgus at the most recent follow-up evaluation), the joint-line convergence angle did not (average, 3.9 ± 2.06 degrees preoperatively compared with 4.1 ± 2.18 degrees at the most recent follow-up evaluation) (Table I). This angle is dependent on both the dynamic medial and lateral collateral ligament balance and the thickness of the medial and lateral cartilage as well as on the osseous alignment.

Many authors have reported better long-term clinical results when the varus deformity had been overcorrected^{7,20,32,41,43}. In an investigation of eighty-seven knees, Coventry et al. performed extensive analysis of both postoperative correction and weight⁹. Survivorship analysis revealed a 90 percent rate of survival (that is, the osteotomy had not failed) at five years and a 65 percent rate at ten years for patients in whom the knee had been corrected to at least 8 degrees of valgus and who weighed less than 1.32 times the ideal body weight. (The number of patients in each subgroup was not reported.) However, when the knee had been corrected to less than 8 degrees of valgus and the patient weighed more than 1.32 times the ideal body weight, the rate of survival decreased to 38 percent at five years and to 19 percent at ten years. Yasuda et al. showed that overcorrection is associated not only with better long-term clinical results but also with a marked decrease in the loss of valgus correction between one and ten years⁴³. They recommended overcorrection to 12 to 16 degrees of valgus. We found that overcorrection does not reduce the need for revision to an arthroplasty. Of the seven knees that were corrected to more than 13 degrees of valgus in our study, two subsequently had a total knee arthroplasty, a rate that is similar to the rate of arthroplasty in our overall series.

Coventry⁷ recommended correction to 10 to 13 degrees of valgus and Insall et al.²⁰ recommended correction to 5 to 10 degrees of valgus because excessive overcorrection leads to undesirable cosmetic results. Vainionpää et al. achieved the best results with correction to 5 to 13 degrees of valgus⁴¹. Kettelkamp et al. noted a good or excellent result at five years for twenty-one of twenty-seven knees that had been corrected to at least 5 degrees of valgus but for only nine of eighteen knees that had been corrected to less than 5 degrees²⁶. In Maquet's study, 101 of 110 knees that had been overcorrected with use of a barrel-vault osteotomy had a good or excellent result at one to twelve years³². We attempted to achieve 8 degrees of anatomical femorotibial valgus in most of our patients.

Accurate achievement of acceptable postoperative alignment is limited by the operative technique^{10,18,22,30,32,37}. Coventry's method⁷, which was initially proposed by Bauer et al.³, of one millimeter of lateral cortex for 1 degree of correction has been shown to be accurate only for a tibia that is fifty-seven millimeters in width at the osteotomy site^{4,11,25,37,42}. Lippert and Kirkpatrick²⁹, Myrnerts³⁴, and Ogata et al.³⁶ all described the use of a jig to assist in the accuracy of the osteotomy cuts, but these devices are cumbersome and somewhat inaccurate. Others have used Steinmann pins and drill-guides, but the inability to make a fourteen by thirty-six-inch (35.6 by 91.4-centimeter) radiograph in the operating room makes the intraoperative assessment of accuracy very difficult²⁸. The osteotomy jig utilized in the present study allows accuracy and reproducibility of the osteotomy cuts. Also, the resulting osseous surfaces are parallel after realignment, minimizing the possibility of delayed union or nonunion. The average postoperative alignment at six weeks was to 9.2 ± 3.69 degrees of valgus in our study, and there were no nonunions.

Five knees were corrected to less than 5 degrees of anatomical valgus. This undercorrection was most likely due to errors in preoperative planning^4,16,42.

Some studies have shown an association between age and outcome, with younger patients having better long-term clinical results than older patients^20,33,42. Our study, along with others⁹, does not support this finding. Older patients had the same probability of pain relief and revision to arthroplasty as younger patients had.

Insall et al. reported a good or excellent result for ninety-two of ninety-five knees at two years, eighty of ninety-five knees at five years, and sixty of ninety-five knees at ten years²⁰. Coventry noted a good or excellent result for 130 of 213 knees at ten years⁸, and Vainionpää et al. reported such a result for eighty-six of 103 knees at 6.9 years⁴¹. In the study by Hernigou et al., eighty-four of ninety-three knees had a good or excellent result at five years and forty-two of ninety-three knees had such a result at more than ten years¹⁵. More recently, Catagni et al. reported marked pain relief in fifty-four of fifty-five patients who had been followed for twenty-four to sixty months after use of an Ilizarov apparatus for fixation⁶. Our results were similar. At an average of 8.5 years, forty-three (67 percent) of sixty-four knees had an average knee score¹⁹ of 94 points. The remaining twenty-one knees (33 percent) had had a total knee arthroplasty, and at the time of the latest follow-up (at an average of forty-one months after the arthroplasty) they had an average knee score of 97 points.

One of the criticisms of high tibial osteotomy has been that there is a high rate of patella baja (eleven of sixty-six osteotomies were followed by patella baja in one report³⁹), resulting in a difficult conversion to a total knee arthroplasty^37,39. When the wedge of bone is removed proximal to the tibial tubercle, the distance between the tubercle and the joint line is decreased, creating redundancy of the patellar ligament, which may or may not contract and therefore result in a pseudo-patella baja secondary to scarring in the retropatellar fat pad and retinacular structures surrounding the patella^37,39. Patella baja did not develop in any patient in our study, most likely because continuous passive motion was used immediately after the procedure.

The rate of complications of high tibial osteotomy has been 5 to 17 percent (eleven complications after 213 osteotomies⁸ to eighteen complications after 103 osteotomies⁴¹) in most studies, but it has been as high as 40 to 81 percent (fifty-six complications after 139 osteotomies¹ to thirty-eight complications after forty-seven osteotomies³³) in others^{1,6-8,15,20,27,31,33,40,41}. The most serious complications are peroneal nerve injury, compartment syndrome, delayed union or nonunion, infection, thrombophlebitis, pulmonary embolism, and intra-articular fracture^4,7,20,25. In our study, there were six complications after sixty-nine osteotomies. Four patients had a superficial wound infection, one patient had a delayed union (which united at five months), and one patient had a superficial-vein thrombosis, which resolved without sequelae.

High tibial osteotomy results in a positive outcome and allows a pain-free, active lifestyle for several years. We highly recommend this procedure, especially for patients in whom a total knee arthroplasty is not desirable because of their young age or their high activity level.

References

Introduction | Materials and Methods | Results | Discussion | References

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Harris, E. K., and Albert, A.: Survivorship Analysis for Clinical Studies, pp. 13-49. New York, Dekker, 1991.

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FIG2-A:: Figs. 2-A through 2-E: Drawings illustrating the operative technique. Fig. 2-A: With the transverse osteotomy guide in place, the tibial width is measured.

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FIG2-B:: Fig. 2-B: The saw blade is inserted to leave a ten-millimeter medial bone bridge.

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FIG2-C:: Fig. 2-C: The oblique osteotomy guide is then applied to allow accurate osseous wedge resection.

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FIG2-D:: Fig. 2-D: Slow compression of the osteotomy site allows plastic deformation medially.

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FIG2-E:: Fig. 2-E: The compressed osteotomy site (arrows) with placement of the distal screws.

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FIG3:: Fig. 3 Photograph showing the osteotomy plate and screws.

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FIG4-A:: Fig. 4-A Intraoperative radiographs showing the wedge resection (Fig. 4-A) and the mechanical axis (Fig. 4-B).

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FIG4-B:: Fig. 4-B Intraoperative radiographs showing the wedge resection (Fig. 4-A) and the mechanical axis (Fig. 4-B).

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FIG5:: Fig. 5 Kaplan-Meier survival curve²⁴ with Hall-Wellner 95 percent confidence intervals¹³, with the performance of an arthroplasty as the end point.

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FIG6-A:: Figs. 6-A and 6-B: A patient who had a high tibial osteotomy. Fig. 6-A: Preoperative radiographs.

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FIG6-B:: Fig. 6-B: Radiographs made eight years after the procedure, showing preservation of the medial joint space.

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TABLE I: RADIOGRAPHIC FINDINGS FOR ALL KNEES*

	Preop.	At 6 Wks. Postop.	At Most Recent Follow-up
Femorotibial anatomical alignment† (degrees)	-1.4 ± 3.37	9.2 ± 3.69	7.4 ± 4.94
Joint-line convergence angle‡ (degrees)	3.9 ± 2.06	3.6 ± 1.78	4.1 ± 2.18
Tibial alignment§ (degrees)	-4.2 ± 3.46	5.2 ± 3.42	4.5 ± 3.96
Posterior slope (degrees)	8.7 ± 4.31	6.5 ± 3.92	6.0 ± 3.25
Insall-Salvati ratio¹⁷	1.1 ± 0.19	1.1 ± 0.16	1.0 ± 0.16
Blackburne-Peel ratio⁵	0.8 ± 0.13	0.8 ± 0.16	0.8 ± 0.12

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TABLE I: RADIOGRAPHIC FINDINGS FOR ALL KNEES*

	Preop.	At 6 Wks. Postop.	At Most Recent Follow-up
Femorotibial anatomical alignment† (degrees)	-1.4 ± 3.37	9.2 ± 3.69	7.4 ± 4.94
Joint-line convergence angle‡ (degrees)	3.9 ± 2.06	3.6 ± 1.78	4.1 ± 2.18
Tibial alignment§ (degrees)	-4.2 ± 3.46	5.2 ± 3.42	4.5 ± 3.96
Posterior slope (degrees)	8.7 ± 4.31	6.5 ± 3.92	6.0 ± 3.25
Insall-Salvati ratio¹⁷	1.1 ± 0.19	1.1 ± 0.16	1.0 ± 0.16
Blackburne-Peel ratio⁵	0.8 ± 0.13	0.8 ± 0.16	0.8 ± 0.12

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TABLE II: RADIOGRAPHIC FINDINGS FOR KNEES WITH AND WITHOUT REVISION OF THE OSTEOTOMY TO A TOTAL KNEE ARTHROPLASTY*

*The values are given as the average and the standard deviation.

	Knees with Revision	Knees without Revision
Femorotibial anatomicalalignment at 6 wks.postop. (degrees)	8.9 ± 3.99	9.3 ± 3.59
Loss of correction atfollow-up (degrees)	2.2 ± 4.75	1.5 ± 3.31
Joint-line convergenceangle at follow-up (degrees)	4.6 ± 2.01	3.9 ± 2.25
Tibial alignment (valgus)at follow-up (degrees)	3.4 ± 5.20	4.9 ± 3.30

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TABLE II: RADIOGRAPHIC FINDINGS FOR KNEES WITH AND WITHOUT REVISION OF THE OSTEOTOMY TO A TOTAL KNEE ARTHROPLASTY*

*The values are given as the average and the standard deviation.

	Knees with Revision	Knees without Revision
Femorotibial anatomicalalignment at 6 wks.postop. (degrees)	8.9 ± 3.99	9.3 ± 3.59
Loss of correction atfollow-up (degrees)	2.2 ± 4.75	1.5 ± 3.31
Joint-line convergenceangle at follow-up (degrees)	4.6 ± 2.01	3.9 ± 2.25
Tibial alignment (valgus)at follow-up (degrees)	3.4 ± 5.20	4.9 ± 3.30