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1.  High Tibial Valgus Osteotomy: Closing, Opening or Combined? Patellar Height as a Determining Factor 
According to the literature, closing and opening wedge high tibial valgus osteotomies can raise or lower the patella, and diffèrent methods of patella height measurement show similarly conflicting results. Clarification of this was thought to be important because there is much literature describing morbidity secondary to patella alta or patella infera (baja). Effects on tibial slope and patellar tendon length are not well delineated and the influence of sex and age is unknown.
A group of patients who underwent high tibial valgus osteotomy was investigated to determine how surgical technique influenced postoperative (1) patellar height and (2) tibial slope and patellar tendon length, and (3) whether age or gender independently influenced postoperative patellar height. To eliminate the often conflicting results seen when several ratio methods are used, patellar height was measured by one method, before and after surgery, shown previously to be reliable.
Patellar height was measured on radiographs using the plateau-patella angle in a retrospective case series consisting of three cohorts: 18 patients with closing wedge osteotomies, 26 with opening wedge osteotomies, and 32 with combined osteotomies. The indication for surgery in all three cohorts was medial osteoarthritis with secondary varus. Before surgery there were no significant differences in patellar height, femorotibial angle, age, or gender among the three groups, and no patients were lost to followup during the 8-week study period after surgery. Seven of the 76 patients (9.2%), all in the opening wedge cohort, had concomitant ACL reconstruction at the time of the tibial osteotomy. No other surgery, except arthroscopy, was performed at the time of osteotomy. Patellar tendon length was assessed by the Insall-Salvati index and tibial slope by the angle between the posterior tibial cortex and the medial tibial joint line. Postoperative measurements were made between 6 and 8 weeks. The influence of sex and age was calculated using patellar height measurements made before any surgery.
All closing wedge osteotomies produced patellar ascent by an average of 13% (p < 0.001), all opening wedges produced descent by an average of 21% (p < 0.001), and the combined osteotomy mean showed minimal change (p = 0.0034). The absolute consistency of the changes and their direction allow suggested guidelines for selection of osteotomy type. There were only slight changes in tibial slope. A significant change in patellar tendon length was seen in seven knees of the opening wedge cohort that had concomitant ACL reconstruction. All had a mean reduction of the Insall-Salvati index of 0.05 (approximately 5%), p = 0.0002. New findings showed higher patellae in female and older patients, unrelated to the surgery.
If it is accepted that patella baja and patella alta should be avoided, then closing wedge osteotomies should be performed only when the patella is low riding, and opening wedge osteotomies should be done only for patients with preexisting patella alta. The combined osteotomy minimizes changes in patellar height. Patellar tendon contractures and tibial slope changes can be avoided. The plateau-patella angle should be measured preoperatively to help decide the type of osteotomy.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4182389  PMID: 25070919
2.  Topographic Analysis of the Glenoid and Proximal Medial Tibial Articular Surfaces – A Search for the Ideal Match for Glenoid Resurfacing 
Current knowledge of the appropriate site of osteochondral allograft harvest to match glenoid morphology for the purposes of glenoid resurfacing is lacking. This has led to difficulty with adequately restoring the geometry of the glenoid using current available techniques. The purpose of this study was to quantify the articular surface topography of the glenoid and medial tibial plateau via 3-dimensional (3D) modeling to determine if the medial tibial articular surface provides an anatomic topographic match to the articular surface of the glenoid.
We hypothesized that the medial tibial plateau will provide a suitable osteochondral harvest site due to its concavity and anatomic similarity to the glenoid.
Study Design
Descriptive Laboratory Study
Materials and Methods
Computed tomography (CT) was performed on four cadaveric proximal tibias and four scapulae, allowing for 16 glenoid-tibial comparative combinations. 3D CT models were created and exported into point cloud models. A local coordinate map of the glenoid and medial tibial plateau articular surfaces was created. Two zones of the medial tibial articular surface (anterior and posterior) were quantified. The glenoid articular surface was defined as a best-fit circle of the glenoid articular surface maintaining a two millimeter bony rim. This surface was virtually placed on a point on the tibial articular surface in 3D space. The tibial surface was segmented and its 3D surface orientation was determined with respect to its surface. 3D orientation of the glenoid surface was reoriented so that the direction of the glenoid surface matched that of the tibial surface. The least distances between the point-clouds on the glenoid and tibial surfaces were calculated. The glenoid surface was rotated 360 degrees in one-degree increments and the mean least distance was determined at each rotating angle.
When the centroid of the glenoid surface was placed on the medial tibial articular surface, it covered approximately two-thirds of the anterior or posterior tibial surfaces. Overall, the mean least distance difference in articular congruity of all 16 glenoid-medial tibial surface combinations was 0.74 mm (standard deviation; ± 0.13 mm). The mean least distance difference of the anterior and posterior two-thirds of the medial tibial articular surface was 0.72 mm (± 0.13 mm) and 0.76 mm (± 0.16 mm), respectively. There was no significant difference between and the anterior and posterior two-thirds of the tibia with regard to topographic match of the glenoid (p=0.187).
We describe a novel methodology to quantify the topography of the tibial and glenoid articular surfaces. The findings suggest that the medial tibial articular surface provides an appropriate anatomic match to the glenoid articular surface. Both the anterior and posterior two-thirds of the medial tibial articular surface can serve as potential sites for osteochondral graft harvest. This methodology can be applied to future studies evaluating the ideal sites of graft harvest to treat zonal glenoid bone wear and/or loss.
Clinical Relevance
This study provides evidence of a near anatomic topographic match between the medial tibial plateau and glenoid articular surfaces, which has direct clinical application for future biologic osteochondral glenoid resurfacing. This concept has not been described in the literature to date.
PMCID: PMC4074354  PMID: 23857887
Glenoid; topography; glenoid resurfacing; articular surfaces
3.  The use of fibrin matrix-mixed gel-type autologous chondrocyte implantation in the treatment for osteochondral lesions of the talus 
This study assessed the clinical results and second-look arthroscopy after fibrin matrix-mixed gel-type autologous chondrocyte implantation to treat osteochondral lesions of the talus.
Chondrocytes were harvested from the cuboid surface of the calcaneus in 38 patients and cultured, and gel-type autologous chondrocyte implantation was performed with or without medial malleolar osteotomy. Preoperative American orthopedic foot and ankle society ankle-hind foot scores, visual analogue score, Hannover scoring system and subjective satisfaction were investigated, and the comparison of arthroscopic results (36/38, 94.7 %) and MRI investigation of chondral recovery was performed. Direct tenderness and relationship to the active daily life of the donor site was evaluated.
The preoperative mean ankle–hind foot scores (71 ± 14) and Hannover scoring system (65 ± 10) had increased to 91 ± 12 and 93 ± 14, respectively, at 24-month follow-up (p < 0.0001), and the preoperative visual analogue score of 58 mm had decreased to 21 mm (p < 0.0001). Regarding subjective satisfaction, 34 cases (89.5 %) reported excellent, good or fair. Chondral regeneration was analysed by second-look arthroscopy and MRI. Complications included one non-union and two delayed-unions of the osteotomy sites, and 9 ankles (9/31, 29.0 %) sustained damaged medial malleolar cartilage due to osteotomy. Marked symptoms at the biopsy site did not adversely affect the patient’s active daily life.
Fibrin matrix-mixed gel-type autologous chondrocyte implantation using the cuboid surface of the calcaneus as a donor can be used for treating osteochondral lesions of the talus.
Level of evidence
Therapeutic study, prospective case series, Level IV.
PMCID: PMC3657090  PMID: 22752415
Talus; Osteochondral lesion; Autologous chondrocyte implantation; Arthroscopy; Donor
4.  The morphology of medial malleolus and its clinical relevance 
Objective: To provide morphological data of medial malleolus to decrease the possibility of posterior tibial tendon injury and inadvertent ankle penetration.
Methods: Computed tomography scans of the ankle in 215 patients were reviewed. Then parameters in the 3-D reconstruction images were measured by three independent, qualified observers on two separate occasions.
Results: The average angle between tibia plafond and the articular facet of the medial malleolus was 55.88±4.11°. The distance from the most anterior point of the anterior colliculus to the center of the intercollicular groove was 11.68±1.13 mm. And the average angle between the bimalleolar axis and the articular facet of the medial malleolus was 76.61±2.04°. Significant differences were observed in the distance from the most anterior point of the anterior colliculus to the center of the intercollicular groove between males and females. (P<0.05) All of the parameters exhibited moderate to excellent intra-class correlation coefficient (ICC).
Conclusions: According to this study, the insertion angle is much smaller than previously believed, and adequate space only exists for two 4.0-mm screws in some large cases. The second screw will probably be near the posterior tibial tendon, especially in some small cases.
PMCID: PMC3999008  PMID: 24772141
Medial malleolus; Tibia; Tomography; X-ray computed; Imaging; three-dimensional
5.  Effects of tibial torsion on distal alignment of extramedullary instrumentation in total knee arthroplasty 
Acta Orthopaedica  2013;84(3):275-279.
Background and purpose
Whether tibial torsion affects the positioning of extramedullary instrumentation and is a possible factor in malalignment of the tibial component in total knee arthroplasty (TKA) is unknown. We assessed the influence of tibial torsion on distal alignment of extramedullary systems for TKA, using the center of the intermalleolar distance as anatomical reference at the ankle joint.
Patients and methods
We analyzed CT scans of knee and ankle joints of 50 patients with knee osteoarthritis (mean age 73 years, 52 legs). The tibial mechanical axis was identified and translated anteriorly at the level of the medial one-third (proximal AP axis 1), at the medial border of the tibial tuberosity (proximal AP axis 2), and at the level of the talar dome (distal AP axis). The center of the intermalleolar distance and the width of the medial and lateral malleolus were calculated. The proximal AP axes 1 and 2 were translated at the level of the ankle joint and any difference between their alignment and the distal AP axis was calculated as angular and linear values.
The center of the ankle joint was located, on average 2 mm medial to that of the intermalleolar distance. The distal AP axis was externally rotated by 18° and 27° compared to the proximal AP axes 1 and 2, respectively. Overall, the center of the ankle joint was shifted laterally by 9–11 mm with respect to the proximal AP tibial axes.
To avoid a varus tibial cut in TKA, extramedullary alignment systems should be aligned more medially at the ankle joint than previously thought, due to the effect of tibial torsion and—to a lesser extent—to the different malleolar width.
PMCID: PMC3715826  PMID: 23594222
6.  Ankle Alignment on Lateral Radiographs: Part 1: Sensitivity of Measures to Perturbations of Ankle Positioning 
In ankles with end-stage osteoarthritis or with total ankle replacement (TAR), radiographic landmarks based on joint surface morphology are usually obscured and thus inadequate for radiographic measurement. Furthermore, because of difficulty in reproducibly positioning the ankle for a standing radiograph, any radiographic measure to accurately describe ankle alignment needs to tolerate perturbations of ankle positioning in clinical radiographs. To identify a radiographic measure of antero-posterior (AP) tibial-talar alignment that meets those requirements, three candidate measures were compared by means of sensitivity to perturbations of ankle positioning.
Ten cadaver ankles had lateral radiographs taken while varying ankle position, at nine prespecified positions in the transverse plane and at seven positions in the sagittal plane. The AP tibial-talar alignment was quantified by three candidate measures. Sensitivity to changes of ankle position in each plane was then compared across the measures.
With the tibial axis-talar ratio (T-T ratio: the ratio into which the mid-longitudinal axis of the tibial shaft divides the longitudinal talar length), sensitivity to ankle positional changes in either plane was lowest, with errors associated with 10 degrees of ankle malpositioning being around 2.2%. The posterior line-talar ratio (P-T ratio: a similar ratio, but using the posterior longitudinal line of the tibial shaft) showed higher sensitivity in the transverse plane than the T-T ratio, though the associated errors in either plane were nearly comparable. The tibial axis-lateral process distance (T-L distance: the perpendicular distance from the tibial axis to the tip of the lateral talar process) showed highest sensitivity in both planes.
The T-T ratio tolerated perturbations of ankle positioning best among the tested measures. This measure is potentially applicable to clinical radiographic measurement when determining the AP tibial-talar alignment in ankles with articular degeneration or TAR. The P-T ratio also appears to have reasonable tolerance.
PMCID: PMC2274959  PMID: 16487458
ankle; alignment; radiographic measurement; cadaver experiment
7.  Ankle Alignment on Lateral Radiographs: Part 2: Reliability and Validity of Measures 
In ankles with end-stage osteoarthritis or after total ankle replacement (TAR), radiographic landmarks based on joint surface morphology are usually obscured and thus inadequate for measurement. Two candidate measures for quantifying AP tibial-talar alignment without relying on those landmarks were identified in a corollary cadaver-based study. This study aimed to verify reliability and validity of those candidate measures.
On clinical radiographs of thirty-three non-arthritic and thirty-five arthritic ankles, the AP tibial-talar alignment was quantified by the two candidate measures; the tibial axis-talar ratio (T-T ratio: the ratio into which the mid-longitudinal axis of the tibial shaft divides the longitudinal talar length) and the posterior tibial line-talar ratio (P-T ratio: a similar ratio, but using the posterior longitudinal line along the tibial shaft). Two observers performed every measurement twice, in order to evaluate intra- and inter-observer reliability of the candidate measures. For non-arthritic ankles, the AP tibial-talar alignment was further determined by a control measure that directly quantifies orientation of the talar dome relative to the tibial shaft. Correlation of each candidate measure with the control measure was then evaluated for validity.
Measurement of the T-T ratio with arthritic ankles was highly reproducible with the coefficients of determination (R2) greater than 0.95, for either inter- or intra-observer. Correlation between this measure and the control measure was supported (R2 = 0.60, p < 0.0001). Reliability of the P-T ratio was also strong (R2 > 0.91), though both reliability and validity of this measure was relatively inferior to the T-T ratio.
The T-T ratio reliably and validly described the AP tibial-talar alignment on clinical radiographs, regardless of the condition of ankle joint surface. This measure appears to be a reliable radiographic measure for determining the magnitude of AP talar subluxation in ankles with articular degeneration or after TAR, and can facilitate clinical investigations.
PMCID: PMC2267757  PMID: 16487459
ankle; alignment; radiographic measurement
8.  Correlation of Radiographic Patellofemoral Indices with Tibial Tubercle Transfer Distance in Fulkerson Osteotomy Pl 
A laterally tracking patella is commonly seen in patients with chronic recurrent lateral patellar dislocations. Clinical appearance of the J-sign occurs when the patella is congruent with the trochlear groove in flexion and moves over the lateral border of the femoral condyle as the lower leg reaches complete extension. A Fulkerson osteotomy procedure corrects this maltracking of the patella by medially transferring the tibial tubercle. There are many radiographic patellofemoral indices that can be used describe this incongruence about the patelloformal joint. The current literature supports the use of the tibial tubercle-trochlear groove (TT- TG) index in determining the appropriate amount medialization of the extensor mechanism. However there is little agreement in how far to transfer the tibial tubercle to best achieve maximum patello- femoral congruency. It is the senior author's belief that lateral patellar edge (LPE) measure on voluntary quadriceps active hyperextension MRI scan has the strongest correlation with final operative tibial tubercle transfer distance needed to achieve maximum patellofemoral congruency.
The purpose of this study was to show that the voluntary quadriceps active hyperextension MRI measurement of lateral patellar edge (LPE) has the strongest correlation with tibial tubercle transfer distance required to achieve maxium patellofemoral congruency intraoperatively in the terminal 30 degrees of active knee extension compared to all other patellofemoral indices measured on axial MRI scans with the knee in voluntary active knee extension to 30 degrees of flexion, passive full extension, and voluntary quadriceps active hyperextension.
Study Design
Retrospective case series via review of the electronic medical record.
Forty-three Fulkerson osteotomy patient charts were reviewed retrospectively. Three different pre-operative axial MRI views were then examined and measured for Tibial Tubercle- Troch-lear Groove (tt-tg), lateral patellar edge (LPE), bisect offset (BSO), and lateral patellar displacement (LPD). Each patient had three MRIs: one with the knee resting in extension, one in voluntary quadriceps active hyperextension, and one in voluntary quadriceps active 30 degree flexion. Statistics were then calculated using Statistical Package for the Social Sciences (SPSS) (IBM corp).
Tibial tubercle transfer distances required to achieve congruency intraoperatively correlated moderately (0.500-0.300) and were statistically significant (alpha. 050) for passive extension MRI measurement of TT-TG (Pearson- 0.403, alpha 0.010) and LPD (Pearson. 362, alpha 0.022); voluntary quadriceps active hyperextension TT-TG (Pearson 0.487, alpha, 0.001); voluntary quadriceps active flexion TT-TG (Pearson. 548, alpha< 0.001), LPE (Pearson. 332, alpha 0.029), and LPD (Pearson 0.446 alpha. 003).
The hypothesis that voluntary quadriceps active hyperextension MRI LPE measurement best correlated with tibial tubercle transfer distance was incorrect. The data collected showed correlation and statistical significance for voluntary quadriceps active flexion LPE with required tibal tubercle transfer distance (Pearson 0.34, alpha 0.026). The MRI measurement that best correlated with tibial tubercle transfer distance was voluntary quadriceps active flexion measure of TT-TG (Pearson. 556, alpha< 0.001).
PMCID: PMC4127745  PMID: 25328455
Patellar instability; lateral patellar subluxation; Fulkerson osteotomy; lateral patellar edge (LPE); lateral patella displacement (LPD); tibial tubercle- trochlear groove (TT-TG); bisect offset (BSO); anatomy; radiographic landmarks
9.  Relationship Between Meniscal Tears and Tibial Slope on the Tibial Plateau 
The Eurasian Journal of Medicine  2011;43(3):146-151.
The geometry of the tibial plateau has a direct influence on the translation and the screw home biomechanics of the tibiofemoral joint. Little information on the relationship between the tibial slope and meniscal lesions is available. The objective of this retrospective study was to examine the effect of the tibial slope on the medial and lateral meniscus lesions in patients with intact ACLs.
Materials and Methods:
The MRIs and lat roentgenograms of 212 patients with meniscus lesions were examined to determine the possible effect of the tibial slope on meniscal tears. First, the anatomic axis of the proximal tibia was established. Then, the angle between the line drawn to show the tibial slopes (medial and lateral) and the line drawn perpendicular to the proximal tibial anatomic axis was established on MRI. The patients with previously detected meniscus lesions were classified into three categories: patients with only medial meniscal tear (Group 1, 90 patients); patients with only lateral meniscal tear (Group 2, 15 patients); and patients with both medial and lateral meniscal tear (Group 3, 19 patients). Group 4 had no meniscal tear (88 patients). The MRIs of the patients who had applied to the Orthopedic Outpatient Clinic with patellofemoral pain and no meniscal tear were included as the control group.
The average tibial slope of the medial tibial plateau was 3.18° in group 1, 3.64° in group 2, 3° in group 3, and 3.27° in group 4. The average tibial slope of the lateral tibial plateau was 2.88° in group 1, 3.6° in group 2, 2.68 in group 3, and 2.91 in group 4. The tibial slope on the medial tibial plateau was significantly larger than the lateral tibial plateaus in group 1 and group 4 (p<0.05). In group 2, there was no statistically significant difference between the tibial slopes of the two sides (p>0.05). In addition, the tibial slope on the lateral side of group 2 was significantly larger than that of groups 1, 3, and 4 (p<0.05).
An increase in the tibial slopes, especially on the lateral tibial plateau, seems to increase the risk of meniscal tear.
PMCID: PMC4261393  PMID: 25610183
Knee injury; Meniscal tear; Tibial slope
10.  Simple method for confirming tibial osteotomy during total knee arthroplasty 
Achieving precise implant alignment is crucial for producing good outcomes after total knee arthroplasty (TKA). We introduce a simple method for confirming the accuracy of tibial osteotomy during TKA.
Two metallic markers were placed on the skin 20 cm apart, one on the tibial tuberosity and other on the tibial crest, points that are easily identified and palpated intraoperatively. Anteroposterior radiographs of the legs were obtained. We defined the line along the markers as the tuberosity line. The osteotomy line is perpendicular to the anatomical axis of the tibia. We then calculated the angle between these two lines and designated it the osteotomy angle. We set the osteotomy angle of the protractor, and cut the bone parallel to the osteotomy line of the protractor. Postoperatively, we analyzed the varus angle of the tibial osteotomy in 35 TKAs using the protractor. The average of the varus angle of the tibial osteotomy was 89.4° ± 1.6° (95% confidence interval of −1.0976, 0.0119). There was no significant difference from the target angle of 90° (p = 0.055). The varus angles of 90° and 90° ± 2° for the tibial osteotomy were 42.9% and 82.9%, respectively.
We determined the accuracy of the tibial osteotomy in the coronal plane using the protractor to be satisfactory.
PMCID: PMC3529693  PMID: 23153271
Total knee arthroplasty; Tibial osteotomy; Extramedullary; Alignment; Protractor
11.  The use of the reconstruction plate in multiplanar tibial osteotomies in children 
External fixation and cross-pin fixation appear to be the two most commonly used forms of fixation after a tibial osteotomy in children described in the literature. The purpose of this study is to describe our experience using a properly bent and contoured reconstruction plate for mismatched surfaces after a multiplanar tibial osteotomy.
A retrospective review was conducted of 37 multiplanar tibial osteotomy surgeries in 23 children performed by a single surgeon using a reconstruction plate for internal fixation. A low fibular osteotomy and tibial osteotomy that required contouring and shaping of the plate were performed in all cases. A proximal tibial osteotomy was performed in 30 cases and a distal osteotomy in seven cases. All cases were reinforced with a long-leg cast. All charts were reviewed for intra- and postoperative complications. The surgery using the reconstruction plate internal fixation was considered to be a success if there was healing of the osteotomy and no hardware failure.
A properly bent and contoured reconstruction plate conformed well to the mismatched surfaces after tibial osteotomy. Hardware was removed in all but two cases, on average 7 months after surgery. There were no hardware failures. No child developed a deep wound infection or neurovascular complication, including compartment syndrome. Only two complications in 37 surgeries (5%) were encountered and were typical of any type of internal fixation. One child required an exploratory procedure because of screw extrusion and one child developed a post-plate removal fracture.
The reconstruction plate is very malleable and can be contoured to fit in nearly every direction to accommodate mismatched appositional surfaces. It has been successfully employed in 37 consecutive cases of multiplanar tibial osteotomy in children with relatively few complications, none directly related to the plate.
PMCID: PMC3058200  PMID: 22468156
Tibial osteotomy; Reconstruction plate; Multiplanar
12.  Preventing surgical complications: A survey on surgeons' perception of intra-articular malleolar screw misplacement in a cadaveric study 
Intra-articular hardware penetration can occur during osteosynthesis of ankle fractures, jeopardizing patients' outcomes. The intraoperative recognition of misplaced screws may be difficult due to the challenge of adequate interpretation of specific radiographic views. The present study was designed to investigate the diagnostic accuracy of standardized radiographic ankle views to determine the accuracy of diagnosis for intra-articular hardware placement of medial malleolar screws in a cadaveric model.
Nine preserved human cadaveric lower extremity specimens were used. Under direct visualization, two 4.0 mm cancellous screws were inserted into the medial malleolus. Each specimen was analyzed radiographically using antero-posterior (AP) and mortise views. The X-rays were randomly uploaded on a CD-ROM and included in a survey submitted to ten selected orthopaedic surgeons. The "Standards for Reporting of Diagnostic Accuracy" (STARD) questionnaire was used to determine the surgeons' perception of accuracy of screw placement in the medial malleolus. The selection of items was based on evidence whenever possible, therefore the "inconclusive" category was added. Inter and intraobserver variations were analyzed by kappa statistics to measure the amount of agreement.
There was a poor level of agreement (kappa 0.4) both in the AP and in the mortise view among all the examiners. Associating the two x-rays, the agreement remained poor (kappa 0.4). In the cases in which there was a diagnosis of articular penetration, there was a poor agreement related to which of the screws was intra-articular. The number of "inconclusive" responses was low and constant, without a statistically significant difference between the subspecialists
The routine intraoperative radiographic imaging of the ankle is difficult to interpret and unreliable for detection of intra-articular hardware penetration. We therefore recommend to reposition medial malleolar screws intraoperatively if there is any doubt regarding inadequate screw placement.
PMCID: PMC3199229  PMID: 21970367
Ankle; Fracture; Cadaver; STARD
13.  High tibial osteotomy: closed wedge versus combined wedge osteotomy 
High tibial osteotomy is a common procedure to treat symptomatic osteoarthritis of the medial compartment of the knee with varus alignment. This is achieved by overcorrecting the varus alignment to 2-6° of valgus. Various high tibial osteotomy techniques are currently used to this end. Common procedures are medial opening wedge and lateral closing wedge tibial osteotomies. The lateral closing wedge technique is a primary stable correction with a high rate of consolidation, but has the disadvantage of bone loss and change in tibial condylar offset. The medial opening wedge technique does not result in any bone loss but needs to be fixated with a plate and may cause tibial slope and medial collateral ligament tightening. A relatively new technique, the combined valgus high tibial osteotomy, claims to include the advantages of both techniques without bone loss. Aim of this prospective randomized trial is to compare the lateral closing wedge with the combined wedge osteotomy in patients with symptomatic varus osteoarthritis of the knee.
A group of 110 patients with osteoarthritis of the medial compartment of the knee with 6-12° varus malalignment over 18 years of age are recruited to participate a randomized controlled trial. Patients are randomized to undergo a high tibial osteotomy, with either a lateral closing wedge technique or a combined wedge osteotomy technique. Primary outcome measure is achievement of an overcorrection of 4° valgus after one year of surgery, assessed by measuring the hip-knee-ankle angle. Secondary objectives are radiological scores and anatomical changes after high tibial osteotomy; pain, functional scores and quality of life will also be compared.
Combined high tibial osteotomy modification avoids metaphyseal tibial bone loss, decreasing transposition of the tibial condyle and shortening of the patellar tendon after osteotomy, even in case of great correction. The clinical results of the combined wedge osteotomy technique are very promising. Hypothesis is that the combined wedge osteotomy technique will achieve more accurate overcorrection of varus malalignment with fewer anatomical changes of the proximal tibia after one year.
Trial registration
Dutch Trial Registry (Netherlands trial register): NTR3898.
PMCID: PMC3996902  PMID: 24721597
Knee; Tibial; Osteotomy; Osteoarthritis; Combined; Medial; Unicompartmental; Proximal
14.  Radiography and sonography of clubfoot: A comparative study 
Indian Journal of Orthopaedics  2012;46(2):229-235.
Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.
Materials and Methods:
Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.
MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.
All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.
PMCID: PMC3308667  PMID: 22448064
Clubfoot; congenital talipes equinovarus; pediatric; radiography; sonography
15.  Ankle Deformity Secondary to Acquired Fibular Segmental Defect in Children 
Clinics in Orthopedic Surgery  2010;2(3):179-185.
The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children.
Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs.
In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2° (range, 5° to 35°) and 10° (range, 5° to 12°), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times.
A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiöld supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.
PMCID: PMC2915398  PMID: 20808590
Fibula; Pseudarthrosis; Valgus deformity; Ankle; Children
16.  Association between knee alignment and knee pain in patients surgically treated for medial knee osteoarthritis by high tibial osteotomy. A one year follow-up study 
The association between knee alignment and knee pain in knee osteoarthritis (OA) is unclear. High tibial osteotomy, a treatment option in knee OA, alters load from the affected to the unaffected compartment of the knee by correcting malalignment. This surgical procedure thus offers the possibility to study the cross-sectional and longitudinal association of alignment to pain. The aims were to study 1) the preoperative association of knee alignment to preoperative knee pain and 2) the association of change in knee alignment with surgery to change in knee pain over time in patients operated on for knee OA by high tibial osteotomy.
182 patients (68% men) mean age 53 years (34 - 69) with varus alignment having tibial osteotomy by the hemicallotasis technique for medial knee OA were consecutively included. Knee alignment was assessed by the Hip-Knee-Ankle (HKA) angle from radiographs including the hip and ankle joints. Knee pain was measured by the subscale pain (0 - 100, worst to best scale) of the Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at one year follow-up. To estimate the association between knee alignment and knee pain multivariate regression analyses were used.
Mean preoperative varus alignment was 170 degrees (153 - 178) and mean preoperative KOOS pain was 42 points (3 - 86). There was no association between preoperative varus alignment and preoperative KOOS pain, crude analysis 0.02 points (95% CI -0.6 - 0.7) change in pain with every degree of HKA angle, adjusted analysis 0.3 points (95% CI -1.3 - 0.6).
The mean postoperative knee alignment was 184 degrees (171 - 185). The mean change in knee alignment was 13 degrees (0 - 30). The mean change in KOOS pain was 32 (-16 - 83). There was neither any association between change in knee alignment and change in KOOS pain over time, crude analysis 0.3 point (95% CI -0.6 - 1.2), adjusted analysis 0.4 points (95% CI 0.6 - 1.4).
We found no association between knee alignment and knee pain in patients with knee OA indicating that alignment and pain are separate entities, and that the degree of preoperative malalignment is not a predictor of knee pain after high tibial osteotomy.
PMCID: PMC2796991  PMID: 19995425
17.  Failure of knee osteotomy in a case of neuropathic arthropathy of the knee 
Neuropathic arthropathy (Charcot’s joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged.
PMCID: PMC3102815  PMID: 21607644
Neuropathic arthropathy; Knee; Schatzker fracture; Osteotomy
18.  Failure of knee osteotomy in a case of neuropathic arthropathy of the knee 
Neuropathic arthropathy (Charcot’s joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged.
PMCID: PMC3102815  PMID: 21607644
Neuropathic arthropathy; Knee; Schatzker fracture; Osteotomy
19.  Coronal Limb Alignment and Indications for High Tibial Osteotomy in Patients Undergoing Revision ACL Reconstruction 
Failed ACL reconstruction frequently is accompanied by irreparable medial meniscal tear and/or visible osteoarthritis (OA) in the medial tibiofemoral joint. Thus, assessment for the presence of varus malalignment is important in caring for patients in whom revision ACL reconstruction is considered.
We determined whether patients undergoing revision ACL reconstruction (1) have more frequent varus malalignment coupled with more severe degrees of medial meniscal injury and/or medial tibiofemoral OA, and (2) would meet potential indications for high tibial osteotomy more frequently than patients undergoing primary ACL reconstruction.
We compared 58 patients undergoing revision ACL reconstruction and 116 patients undergoing primary ACL reconstruction. The mechanical tibiofemoral angle and the weight loading line (%) of the knee were measured. Additionally, radiographic degrees of OA in the tibiofemoral joints, and meniscal conditions were assessed. Then, proportions of potential candidates for high tibial osteotomy between the two groups were compared based on the following indications: (1) weight loading line less than 5%, (2) weight loading line less than 25% and medial tibiofemoral OA Kellgren-Lawrence Grade 3 or greater, or (3) weight loading line less than 25% and Kellgren-Lawrence Grade 2 medial tibiofemoral OA plus subtotal or total medial meniscectomy status.
The revision ACL reconstruction group had more frequent varus malalignment in terms of proportion of knees with more varus mechanical tibiofemoral angle than varus 5° (19% versus 8%, p = 0.029) and knees with weight loading line less than 25% (22% versus 9%, p = 0.011). This group also had more frequent high-grade injury of the medial meniscus (34% versus 16%, p = 0.007) and tended to have more frequent higher-grade radiographic OA at the medial tibiofemoral joint (19% versus 9%, p = 0.076). The percentage of patients meeting potential indications for high tibial osteotomy was greater in this group (14% versus 2%, p = 0.003).
We found that many patients undergoing revision ACL surgery may be reasonable candidates for concurrent high tibial osteotomy to address concomitant alignment and OA issues in the medial compartment. However, whether that additional intervention is offset by added risk and morbidity should be the focus of a future study, as it cannot be answered by a study of this design.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3792260  PMID: 23877556
20.  CAM-Type Impingement in the Ankle 
Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion.
A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured.
34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus.
Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA.
Level of Evidence
Level III
PMCID: PMC3565388  PMID: 23576914
21.  Evolution of open-wedge high-tibial osteotomy: experience with a special angular stable device for internal fixation without interposition material 
International Orthopaedics  2009;34(2):167-172.
Surgical correction of bowed legs should be performed as early as possible. Overload osteoarthritis, even without significant varus deformity of the knee, is a further indication for open-wedge high-tibial osteotomy. Progression of damage to the joint surfaces due to overloading can be significantly retarded by realigning the extremity with the aim to, at least, reduce overload on the medial compartment to a value close to physiological. Significant improvement to open-wedge high-tibial osteotomy (OWHTO) has been made on two fronts: (a) by the use of a more appropriate surgical technique and (b) by promoting osteogenesis through an angular-stable fixation device with just the correct amount of elasticity. A retrospective study of 53 consecutive cases in which no interposition material was used to fill the wedge, with gap openings between 5 mm and 20 mm, showed that ossification of the gap always progressed from the lateral hinge towards the medial side. Standard radiographs showed 75% of the gap filled in with new bone within 6−18 months. In conclusion, we believe that open-wedge high-tibial osteotomy using the TomoFix® plate has proved to be successful in treating unicompartmental gonarthrosis, even without bone grafts or bone-substitute material.
PMCID: PMC2899355  PMID: 19921189
22.  Optimizing femorotibial alignment in high tibial osteotomy  
Canadian Journal of Surgery  1999;42(5):366-370.
To study factors that affect femorotibial (F-T) alignment after valgus closing wedge tibial osteotomy.
Study design
A review of standardized standing radiographs. Femorotibial alignment was measured 1 year postoperatively for over- and under-correction. Changes in F–T alignment and in tibial plateau angle were measured.
An urban hospital and orthopedic clinic.
Eighty-two patients with osteoarthritis and varus femorotibial alignment underwent valgus closing wedge tibial osteotomy. Patients having a diagnosis of inflammatory arthritis or a prior osteotomy about the knee were excluded.
A 1° wedge removed from the tibia resulted in an average correction of F–T alignment of 1.2°. A knee that had increased valgus orientation of the distal femur had a greater degree of correction, averaging 1.46° in F–T alignment per degree of tibial wedge. This resulted in excessive postoperative valgus alignment for some patients who had increased valgus tilt of the distal femur. Optimal F–T alignment of 6° to 14° of valgus occurred when the postoperative tibial inclination was 4° to 8° of valgus.
There was a trend for knees with increased valgus orientation of the distal femur to have greater correction in F–T alignment after tibial osteotomy, likely because of a greater opening up of the medial joint space during stance. Surgeons need to account for this in their preoperative planning.
PMCID: PMC3788903  PMID: 10526522
23.  Biomechanical Analysis of Operative Methods in the Treatment of Extra-Articular Fracture of the Proximal Tibia 
Clinics in Orthopedic Surgery  2014;6(3):312-317.
To determine relative fixation strengths of a single lateral locking plate, a double construct of a locking plate, and a tibial nail used in treatment of proximal tibial extra-articular fractures.
Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included: lateral plating (LP) using a locking compression plate-proximal lateral tibia (LCP-PLT), double plating (DP) using a LCP-PLT and a locking compression plate-medial proximal tibia, and intramedullary nailing (IN) using an expert tibial nail. To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was created 8 cm below the knee joint. For each tibia, a minimal preload of 100 N was applied before loading to failure. A vertical load was applied at 25 mm/min until tibial failure.
Under axial loading, fixation strength of DP (14,387.3 N; standard deviation [SD], 1,852.1) was 17.5% greater than that of LP (12,249.3 N; SD, 1,371.6), and 60% less than that of IN (22,879.6 N; SD, 1,578.8; p < 0.001, Kruskal-Wallis test). For ultimate displacement under axial loading, similar results were observed for LP (5.74 mm; SD, 1.01) and DP (4.45 mm; SD, 0.96), with a larger displacement for IN (5.84 mm; SD, 0.99). The median stiffness values were 2,308.7 N/mm (range, 2,147.5 to 2,521.4 N/mm; SD, 165.42) for the LP group, 4,128.2 N/mm (range, 3,028.1 to 4,831.0 N/mm; SD, 832.88) for the DP group, and 5,517.5 N/mm (range, 3,933.1 to 7,078.2 N/mm; SD, 1,296.19) for the IN group.
During biomechanical testing of a simulated comminuted proximal tibial fracture model, the DP proved to be stronger than the LP in terms of ultimate strength. IN proved to be the strongest; however, for minimally invasive osteosynthesis, which may be technically difficult to perform using a nail, the performance of the DP construct may lend credence to the additional use of a medial locking plate.
PMCID: PMC4143519  PMID: 25177457
Proximal tibial fracture; Locking plate; Nail; Biomechanical study
24.  The Effect of High Tibial Osteotomy on the Posterior Tibial Slope 
Mædica  2014;9(2):173-178.
High tibial osteotomy remains a useful procedure for delaying total knee arthroplasty for young patients with unicompartimental medial osteoarthritis of the knee. The tibial posterior slope is essential for both ligament function and knee kinematics. Even though many articles were published in the literature, the long term influence of open wedge high tibial osteotomy on the posterior slope of the tibial plateau remains unknown.
We assessed the relationship among the degree of correction, the surgical technique, the postoperative modification of tibial slope, knee flexion and Knee score at the two years.
Material and methods:
We used for evaluation a calibrated x-rays with correction factor. All the measures were done with Cedara I-View 6.3.2 application. All 47 patients were operated in our hospital between 2008-2011, with the same technique, open wedge high tibial osteotomy with an acrylic cement wedge. All patients postponed weight bearing for 6 weeks.
We found that there is no statistical significance (p=0.2) between the preoperative varus and the after surgery tibial slope, but the resulting posterior inclination after surgery influences the tibial posterior slope at 2 years (p<=0.005).The degree of correction has a strong influence over the increase or decrease of tibial posterior slope(p<0.005). An increase in tibial slope increases the knee flexion by 1.45° for every degree of inclination (p<0.05). Functional results are not influenced by small modifications in tibial inclination (p>0.05).
From this findings we may conclude that the most important factors that changes the posterior inclination of the tibia surface are the height of the cement wedge and the surgical technique, by placing the acrylic cement wedge more anteriorly. We have found that the vast majority of our high tibial osteotomies are in fact "flexion" osteotomies. At the 2 years control we have found a slight increase in tibial slope angle (average 1.77°) and knee flexion (average 2.56°) with no functional response. This is a case series study with level of evidence IV.
PMCID: PMC4296761
gonarthrosis; high tibial osteotomy; tibial slope
25.  Genu Recurvatum Deformity in a Child due to Salter Harris Type V Fracture of the Proximal Tibial Physis Treated with High Tibial Dome Osteotomy 
Case Reports in Orthopedics  2012;2012:219231.
Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.
PMCID: PMC3504237  PMID: 23259115

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