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Buchbeitrag: Isall & Scott, Surgery of the Knee, 5th edition. International Roundtable Discussion

Chapter 96 – Osteotomy About the Knee  :  International Roundtable Discussion

 

Michael Stuart,
David Backstein,
Martin Logan,
Thomas Muellner

 

Osteotomy about the knee has traditionally been used to treat the middle-aged patient with gonarthrosis, but the indications have broadened to include the younger patient or athlete with ligament deficiencies, chondral defects, absent menisci, or posttraumatic degenerative arthritis. We have assembled a panel of experts that includes Michael Stuart (moderator), David Backstein, Martin Logan, and Thomas Muellner, who will share their personal ideas and preferences based on extensive experience with this procedure.

Michael Stuart

 

For many orthopedic surgeons, unicompartmental or total knee arthroplasty has supplanted realignment osteotomy as their primary treatment for gonarthrosis.

   Is there a role for osteotomy in treating isolated medial or lateral compartment arthritis in your practice, and what specific factors affect your treatment decision making?
David Backstein

 

The frequency of osteotomy for unicompartmental arthritis of the knee has declined somewhat in my practice over the past 5 to 10 years; however, I strongly believe that there are still several excellent indications for osteotomy around the knee. In addition to unicompartmental arthritis, other indications include osteonecrosis, adult osteochondritis dissecans, and osteotomy in combination with osteochondral grafting to off-load the involved compartment.

Candidates must have adequate bone stock to allow effective fixation and early range of motion, a preoperative range of motion arc of at least 90 degrees, and less than 15 degrees flexion-contracture. Because of osteoporosis and its impact on fixation, it is my practice to avoid performing an osteotomy on males older than 65 years and females older than 60 years.

Martin Logan

 

Undoubtedly, osteotomy has a role in patients with isolated unicompartmental osteoarthritis. Our improved understanding of knee kinematics and joint implant design makes unicompartmental arthroplasty a more attractive option than ever before. That said, the joint registry data on unicompartmental arthroplasty around the world show a higher failure rate in patients younger than 55 years of age.

Factors that affect decision making include patient motivation, understanding, compliance, and occupation. For example, a manual laborer in his mid 40s is a better candidate for osteotomy rather than unicompartmental arthroplasty. A sedentary female with isolated medial osteoarthritis and normal preoperative alignment is unlikely to be satisfied functionally and cosmetically with an osteotomy; therefore, I would prefer a unicompartmental arthroplasty.

Michael Stuart

 

We all agree that osteotomy still has a role in selected patients with unicompartmental arthritis and malalignment.

   Thomas, in your opinion, who is the “ideal candidate” for an osteotomy?
Thomas Muellner

 

There is absolutely a role for realignment osteotomies in treating isolated medial or lateral compartment arthritis in patients with varus or valgus malalignment. In my practice, the ideal candidate for a realignment procedure is the middle-aged patient who has pain during heavy work or recreational sports activities. If instability is an accompanying symptom, combined realignment and ligament reconstruction should be considered.

David Backstein

 

Yes, the ideal candidate for a proximal tibial valgus osteotomy is a young, physically active patient with medial compartment osteoarthritis of the knee and varus tibiofemoral alignment, for example, the young patient with a highly physical job such as a firefighter or construction worker, who possesses the capacity for a fairly prolonged and at times arduous rehabilitation process. Although this is not commonly encountered, young and active individuals with isolated lateral compartment arthritis and valgus alignment are similarly excellent candidates for osteotomy and are treated with distal femoral varus osteotomy.

Martin Logan

 

In my mind, the ideal candidate is a male in his early 50s with normal BMI—a highly motivated nonsmoker who has isolated medial osteoarthritis with normal patellofemoral articulation, intact lateral meniscus, normal cruciate ligaments, and a preserved lateral tibiofemoral joint. The knee would be in 5 to 10 degrees of varus compared with the normal contralateral limb and would have a full range of motion without a fixed flexion deformity.

Michael Stuart

 

The consensus seems to be that an osteotomy is a good option for the young, active patient with a stable, arthritic knee and good bone stock.

   Who would you consider to be an “unacceptable candidate” for an osteotomy?
David Backstein

 

Contraindications for a proximal tibial valgus osteotomy include moderate to severe lateral compartment arthritis or significant and symptomatic patellofemoral arthritis. In particular, I avoid an osteotomy if the patient experiences anterior knee pain when climbing or descending stairs, after prolonged sitting, or when getting up from a chair. Osteotomy is also contraindicated in patients with an arc of motion less than 90 degrees, a flexion deformity greater than 15 degrees, and maximum flexion less than 90 to 100 degrees. Inflammatory arthritis, which by its very nature affects the entire joint in a congruous manner, is considered unacceptable for this operation. Two additional situations that are relative contraindications to osteotomy include (1) a high adductor moment (varus thrust), because it is associated with poorer results and recurrence of varus deformity after tibial osteotomy; and (2) obesity, which has been shown to be a risk factor for early failure of high tibial osteotomy.

Martin Logan

 

Absolute contraindications in my practice include inflammatory arthropathy, previous meniscectomy or arthritis in the compartment intended for weight bearing, gross obesity with BMI over 50, and a patient who is a smoker or a noncompliant patient.

Thomas Muellner

 

I would add the uncooperative patient, loss of bone with “teeter effect,” and an associated hip flexion contracture.

Michael Stuart

 

The orthopedic literature has taught us that the success of an osteotomy is dependent on adequate correction of limb malalignment (see Coventry M, Ilstrup D, Wallrichs S: Proximal tibial osteotomy: a critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196–201, 1993). Therefore, it is essential to accurately determine the desired amount of correction before surgery and then employ meticulous surgical technique.

   What is your typical routine for preoperative planning? Is there a role in your practice for gait analysis?
Martin Logan

 

I always get long-leg weight-bearing films and use the Miniaci technique, usually aiming to overcorrect by around 2 degrees and taking into consideration the natural alignment of the contralateral limb (see Miniaci A, Ballmer FT, Ballmer PM, Jakob RP: Proximal tibial osteotomy: a new fixation device. Clin Orthop Relat Res 246:250–259, 1989).

I don't routinely use gait analysis for osteotomy.

David Backstein

 

I also get full-length anterior-posterior weight-bearing radiographs of the lower limbs, including the hips, ankles, and knees, to establish the mechanical axis, the anatomic axis, and the point of intersection of the weight-bearing line at the joint line. I aim for a correction that results in passage of the weight-bearing line through the 62% coordinate of the tibia articular surface (medial border of tibia articular surface is 0%, and lateral border is 100%), resulting in preferential loading of the lateral tibiofemoral compartment. The angular correction is calculated by drawing a line from the center of the femoral head to the 62% coordinate of the tibia at the knee. A second line is then drawn from the center of the ankle to the 62% coordinate. The angle between the first and second lines represents the angle of correction required.

I don't use gait analysis: however, I do examine the patient's gait, and I consider a severe varus thrust as a relative contraindication to HTO.

Thomas Muellner

 

In patients who are potential candidates for a realignment procedure, it is essential to assess the alignment on long-standing radiographs (femorotibial angle, LDFA, MPTA, Mikulicz's line), lateral radiographs of the knee in 90 degrees of flexion, patella tangential, and MRI of the knee. I also use intraoperative control with the image intensifier, which allows accuracy of about ±2 degrees.

Unfortunately, I have only restricted access for gait analysis in my patients to study the adduction moments.

Michael Stuart

 

I don't have any experience with osteotomy computer navigation, but it may be helpful for intraoperative verification of multiplanar corrections in complex cases. I routinely use the weight-bearing line method because it is a simple and reproducible technique for determining the desired coronal plane correction angle (Fig. 96-1) (see Dugdale TW, Noyes FR, Styer D: Preoperative planning for high tibial osteotomy: the effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264, 1992). The surgeon chooses the desired coordinate, which equals the angle of correction according to the specific clinical situation (typically 62%; range, 50% to 75%). Remember that standing radiographs can overestimate the magnitude of correction as the result of osseous defects and/or attenuated ligaments. Compare the amount of lateral joint space opening (in millimeters) with the contralateral knee and subtract the difference from the calculated angle (1 degree per millimeter) to avoid overcorrection.

 

Click to view full size figure

 

Figure 96-1  The weight-bearing line method is a simple technique for determining the coronal plane correction angle.
(From Stuart MJ: Opening wedge-proximal tibial osteotomy. In Lotke PA, Lonner JH [eds]: Knee arthroplasty, ed 3, Baltimore, 2009, Wolters Kluwer Health/Lippincott William & Wilkins [Master Techniques in Orthopaedic Surgery], pp 361–371.)


 

The lateral closing wedge osteotomy of the proximal tibia was the procedure of choice in the past to correct a varus deformity. In recent years with the advent of new implant designs, the medial opening wedge technique has become popular.

   Please describe your preferred surgical technique for correcting varus malalignment. Do you have any technical pearls for surgeons who are learning this technique?
David Backstein

 

My preference for varus deformity correction of less than 15 degrees is a medial, opening wedge osteotomy. For situations in which the deformity is 15 to 20 degrees, I perform a closing wedge lateral osteotomy because of the lesser risk of nonunion by opposing and compressing host bone. A fixed varus deformity greater than 20 degrees may necessitate an osteotomy of both the proximal tibia and the distal femur to achieve correction.

Pearls

 

       Position the patient supine on a radiolucent table to allow intraoperative visualization of the hip, knee, and ankle with fluoroscopy.
       Make a 10-cm longitudinal, midline incision that can be easily used for TKA at a later date.
       Prevent an overly large lateral hinge, which can result in fracture propagation into the tibial articular surface when the osteotomy is opened.
       Regardless of technique, don't allow undercorrection, because this has been associated with poorer survival results. I aim for a 3-degree overcorrection.
       Place the plate and the “wide portion” of its block as posterior as possible to avoid increasing the posterior tibial slope.
Thomas Muellner

 

In patients with an extra-articular tibial varus deformity, I prefer an opening wedge osteotomy. In patients with a combined deformity of the distal femur and the proximal tibia, combined osteotomies have to be considered to avoid an oblique joint line.

Pearls

 

       Patients with ligament instability should also have correction of the tibial slope when ligament reconstruction is not planned at the index operation. In ACL-deficient patients, the slope is decreased. In PCL-deficient patients, the slope is increased.
       The osteotomy should be biplanar to increase the amount of bone contact and to prevent possible rotational deformity.
Michael Stuart

 

I also prefer the opening wedge osteotomy for most patients because it avoids violation of the proximal tibiofibular joint, does not change the fibular collateral ligament length, and allows for more precise intraoperative correction and an easier biplanar correction, and you can use the same incision for concomitant procedures (ACL reconstruction, osteochondral allografts, etc.) or for subsequent knee arthroplasty.

For a severe deformity, a combined distal femoral and proximal tibial osteotomy may be necessary to achieve adequate correction and avoid excessive joint line obliquity (Fig. 96-2).

 

Click to view full size figure

 

Figure 96-2  Anteroposterior radiograph following combined distal femoral and proximal tibial valgus-producing osteotomies to achieve the desired correction and maintain a level joint line.


 

Pearls

 

       Protect the patellar tendon and neurovascular structures by flexing the knee when using the saw and osteotome and placing malleable retractors along the anterior and posterior tibial cortices (Fig. 96-3).
       Prevent intra-articular fracture with the use of fluoroscopic guidance to determine the depth of osteotome penetration while maintaining 1 cm of intact lateral tibial bone, and gradually open the osteotomy. If the osteotomy does not open, use an osteotome to ensure that the anterior and posterior tibial cortices have been cut.
       Avoid increased posterior slope (unless desired for a posterior cruciate–deficient knee), place the plate as posterior as possible, and create an anterior tibial gap that is approximately    of the posterior tibial gap.
       Ensure a stable construct by osteoclasis of the lateral tibial cortex to maintain an intact periosteal hinge and to preserve the medial tibial cortex at the site of the plate tines; consider bicortical autograft or allograft wedges for added stability if large correction is required.
       Avoid hematoma or compartment syndrome by releasing the tourniquet prior to bone grafting to attain hemostasis; place a drain if necessary.
       Prevent loss of correction or nonunion by irrigating the bone when using an oscillating saw and by achieving stable internal fixation (Fig. 96-4).

 

Click to view full size figure

 

Figure 96-3  Malleable retractors placed along anterior and posterior tibia to protect the patellar tendon and neurovascular structures.
(From Stuart MJ: Opening wedge-proximal tibial osteotomy. In Lotke PA, Lonner JH [eds]: Knee arthroplasty, ed 3, Baltimore, 2009, Wolters Kluwer Health/Lippincott William & Wilkins [Master Techniques in Orthopaedic Surgery], pp 361–371.)


 

Click to view full size figure

 

Figure 96-4  Anteroposterior fluoroscopic view prior to bone graft insertion, demonstrating osteoclasis of the lateral tibial cortex with an intact periosteal hinge and preservation of the medial tibial cortex at the site of the plate tines.
(From Stuart MJ: Opening wedge-proximal tibial osteotomy. In Lotke PA, Lonner JH [eds]: Knee arthroplasty, ed 3, Baltimore, 2009, Wolters Kluwer Health/Lippincott William & Wilkins [Master Techniques in Orthopaedic Surgery], pp 361–371.)


 

Martin Logan

 

I prefer a lateral closing wedge osteotomy for the young patient with varus malalignment. Opening wedge osteotomy is associated with a higher complication rate, including nonunion, and the plate often requires removal because of pain. If autograft is used, the added morbidity of the bone graft donor site is significant. I wouldn't do an opening wedge tibial osteotomy in an obese patient or in a smoker (see Hernigou P, Medevielle D, Debeyre J, Goutallier D: Proximal tibial osteotomy for osteoarthritis with varus deformity: a ten- to thirteen-year follow-up study. J Bone Joint Surg Am 69:332–354, 1987; Brouwer RW, Bierma-Zeinstra SMA, van Koeveringe AJ, Verhaar JAN: Patellar height and the inclination of the tibial plateau after high tibial osteotomy: the open versus the closed-wedge technique. J Bone Joint Surg Br 87:1227–1232, 2005; Hart JAL, Sekel R: Osteotomy of the knee: is there a seat at the table? J Arthroplasty 17[Suppl 1]:45–49, 2002).

Pearls

 

Lateral Tibial Closing Wedge Technique

 

       Make an 8- to 10-cm longitudinal, anterolateral incision centered between the fibula head and the tibial tuberosity without exposing the peroneal nerve.
       Use an osteotome to remove only the anteromedial aspect of the fibular head (Fig. 96-5).
       Insert a drill bit at the level of the lateral flare of the tibia, parallel to the joint under fluoroscopic control, stopping 1 cm before the medial cortex.
       Use a jig system to place a second drill bit at the chosen angle (Fig. 96-6).
       Tilt the plane of the first proximal tibial cut around 10 to 15 degrees to the shaft of the tibia to ensure that the cut is parallel to the tibial slope, and that the posterior cortex is cut in the “curve” of the tibia safely away from the artery.
       Make a second parallel cut along the inferior drill bit and parallel to the first cut to correct a fixed flexion deformity or anterior cruciate ligament laxity and remove more bone anteriorly. To correct hyperextension or posterior cruciate ligament laxity, remove more bone posteriorly.
       Do not cut the medial cortex. The blade can be palpated subcutaneously on the anteromedial aspect and a measurement made of the length of the saw blade. This is the length of the saw cut along the posterior cortex, where the cutting edge of the blade cannot be palpated. Alternatively, fluoroscopy can be used to follow the saw cuts to ensure that the medial cortex is not breached. Also the length of the drill in the tibia can be used as a guide to the length of the saw cut.
       One or two stepped staples usually provide sufficient fixation (Figs. 96-7 and 96-8).

 

Click to view full size figure

 

Figure 96-5  Identification of the superior tibiofibular joint and then osteotomy of the anteromedial part of the fibular head. Note that the drill bit has been inserted parallel to the joint.


 

Click to view full size figure

 

Figure 96-6  A second drill bit is placed through the jigging system, ensuring an accurate resection angle.


 

Click to view full size figure

 

Figure 96-7  Two stepped staples have been inserted to stabilize the fixation of the closed wedge osteotomy.


 

Click to view full size figure

 

Figure 96-8  Postoperative check radiograph of a closing wedge high tibial osteotomy.


 

Michael Stuart

 

   Do you use computer navigation in the operating room when performing an osteotomy about the knee?
Martin Logan

 

I think that computer navigation is not necessary.

David Backstein

 

I have no experience with computer navigation in conjunction with osteotomy around the knee.

Thomas Muellner

 

Computer navigation will be as reliable and cost-effective as it is in total knee arthroplasty.

Michael Stuart

 

A variety of void fillers have been used when performing an opening wedge osteotomy, including iliac crest autograft, cancellous or structural allograft wedges, and synthetics. I routinely use densely packed cancellous allograft mixed with platelet-rich fibrin matrix. The healing rate is excellent, but I am unaware of any studies that show a faster or more reliable union rate using this blend. I prefer to use autograft for a large defect, and I don't consider a smoker a candidate for an opening wedge osteotomy.

   What is your preferred material to fill the defect? Does your preference change for a high-risk patient: obese, smoker, large correction, etc.? Is there a role for platelet-rich plasma?
David Backstein

 

I use local autologous bone mixed with allograft, whichprovides both structural and biologic characteristics. Morcellized cancellous allograft bone from a young donor is used only for large corrections that involve a wedge greater than 15 mm. I have no experience with bone graft substitutes in this context.

Martin Logan

 

When performing an opening wedge tibial osteotomy to increase the posterior tibial slope in the setting of posterolateral corner insufficiency, I always use iliac crest autograft. I have no experience using platelet-rich plasma for osteotomies.

Thomas Muellner

 

So far, I use only iliac crest autografts and only in patients with an opening tibial wedge greater than 12 mm. This may change because bone allografts cleaned and processed with supercritical CO2 are now available in my country.

I have not yet used platelet-rich plasma. The studies that I am aware of have small sample sizes, and the results are not so clear regarding whether the use of platelet-rich plasma made any difference. I think that further research is needed.

Michael Stuart

 

Although this is not frequently encountered, lateral compartment arthritis and valgus deformity can be treated with a distal femoral varus-producing osteotomy.

   Please describe your preferred surgical technique for correcting valgus malalignment.
David Backstein

 

In my practice, knees with lateral tibiofemoral compartment disease resulting in valgus deformity are treated with DFVO. I rarely use a tibial osteotomy for lateral compartment arthritis. These knees tend to have a superolateral tilt to the joint line, and medial closing or lateral opening wedge osteotomy of the tibia tends to worsen this obliquity. Furthermore, most valgus deformities are associated with a hypoplastic lateral femoral condyle; thus a femoral osteotomy addresses the problem more directly.

We recently published our long-term results of DFVO and reported very satisfactory outcomes (Int Orthop 2009 May 26 [Epub ahead of print]). Thirty-three consecutive DFVOs (31 patients) with a minimum follow-up of 10 years (mean, 15.1; range, 10 to 25) had a survivorship of 89.9% at 10 years and 78.9% at 15 years.

My preference is to use a medial, femoral, closing wedge technique for correction of valgus knees. Fixation is achieved with a 90-degree offset dynamic compression blade plate. If the plate cannot be brought into contact with the medial femoral diaphyseal cortex after the blade is inserted, a slot can be created to better accommodate the shoulder of the blade plate until satisfactory contact is achieved. The osteotomized bone wedge is morcellized and used as an autograft along the medial aspect of the osteotomy. This technique ensures that the medial part of the femoral cortex and the transepicondylar femoral line are 90 degrees to each other, resulting in an anatomic tibiofemoral angle of approximately 0 degrees.

Martin Logan

 

My preferred technique is to perform a lateral-based, varus-producing, opening wedge distal femoral osteotomy. In my experience, locking distal femoral osteotomy plates that use bicortical locking screws proximally are essential for this procedure. I routinely use iliac crest autograft for this operation.

Thomas Muellner

 

Usually, I perform a lateral femoral opening wedge osteotomy in patients with a femoral valgus malalignment.

Michael Stuart

 

Intra-articular problems that are amenable to arthroscopic treatment may coexist. I will evaluate the intra-articular structures only if the patient has symptoms or MRI findings consistent with an unstable meniscus tear, chondral flap, or loose body.

   Do you routinely perform arthroscopy at the time of osteotomy? If not, what are your indications for concomitant arthroscopy?
David Backstein

 

I do not perform arthroscopy for any of my osteotomy patients. My intra-articular assessment is based on the history and physical examination. If I am in doubt about the status of one or more compartments, I obtain a preoperative MRI.

Martin Logan

 

I always perform an arthroscopy before proceeding to the osteotomy.

Thomas Muellner

 

I routinely perform an arthroscopy at the time of osteotomy, not only to treat coexisting intra-articular problems, but also to evaluate the integrity of the contralateral compartment.

Michael Stuart

 

The specific surgical technique, type of implant, and amount of correction can affect the stability of the construct and the postoperative regimen.

   What is your typical postoperative protocol, including weight-bearing status, use of a brace, and physical therapy instructions?
David Backstein

 

I prescribe non–weight bearing for 6 to 8 weeks after surgery until early evidence of osteotomy healing is seen. Range-of-motion exercises are initiated at 7 to 10 days, along with isometric quadriceps exercises. At 6 weeks, partial weight bearing usually commences, as do light resistance exercises. If radiographic and clinical evidence of union is apparent, full weight bearing is usually allowed by 10 to 12 weeks postoperatively.

I do not use any braces.

Martin Logan

 

Postoperatively, the patient is touch-weight bearing on crutches for 2 weeks. Weight bearing is progressed with the aim of full weight bearing with crutches by 6 weeks. Range-of-motion exercises begin at 2 weeks with the brace off. The patient progresses to independent weight bearing over the next 2 to 4 weeks. Rehabilitation is continued for an additional 6 to 8 weeks, and home exercises for 3 months.

Thomas Muellner

 

My patients wear a brace for 6 weeks, bear partial weight after 2 weeks, and initially use a continuous passive motion machine, then a stationary bike and a muscle-strengthening program.

Michael Stuart

 

The risk of deep vein thrombosis and pulmonary embolus may be less after osteotomy as compared with total knee arthroplasty, but nonetheless remains a concern. I prescribe enteric-coated aspirin twice daily for 6 weeks after surgery, but I recommend low-molecular-weight heparin for 10 days followed by aspirin for those patients at higher risk (history of deep vein thrombosis, steroid use).

   Do you routinely use any methods for thromboembolic prophylaxis before, during, or after osteotomy?
David Backstein

 

Yes, I prescribe low-molecular-weight heparin for 10 days postoperatively.

Martin Logan

 

The patient wears compression stockings for 6 weeks. I give the patient a perioperative single injection of low-molecular-weight heparin, and postoperatively they are commenced on low-dose aspirin for the first 6 weeks.

Thomas Muellner

 

Following the osteotomy, patients are given low-molecular-weight heparin for at least 2 weeks. In case of any additional risk factors, the LMWH is continued for a total of 6 weeks.

Michael Stuart

 

In my practice, the indications for an osteotomy have actually expanded in recent years to include patients with a misaligned knee who require ACL/PCL reconstruction, meniscus transplantation, osteochondral transplantation, microfracture, or autologous chondrocyte implantation.

   What criteria do you use to determine the need for an osteotomy in these patients? Is there a role for an osteotomy in the acute setting when a patient with a varus knee requires an ACL reconstruction or a multiligament reconstruction (ACL combined with FCL and posterolateral repair or reconstruction)?
David Backstein

 

Our center has extensive experience with proximal tibial and distal femoral osteotomy in combination with a fresh osteochondral allograft. A distal femoral osteotomy in conjunction with lateral osteochondral tibial grafts and a proximal tibial osteotomy with medial osteochondral femoral grafts have improved survivorship. Our series of tibial grafts published in 2003 (J Bone Joint Surg Am 85:33–39, 2003) demonstrated that realignment osteotomy should be conducted concomitant with fresh osteochondral allograft procedures whenever the final alignment will be less than overcorrected. Table 96-1 reflects our experience.

 


Table 96-1   -- Osteotomy
Osteotomy TimingMean HSS ScoreTime to TKR Conversion
Prior osteotomy 95.0 ± 6.2 NA
Coincident w/graft 85.4 ± 11.9 115.8 months
Delayed osteotomy 76.8 ± 6.7 83.2 months

HSS, Hospital for Special Surgery; NA, not applicable; TKR, total knee replacement.



 

Martin Logan

 

If a patient has malalignment and requires articular cartilage grafting, it is sensible to combine this procedure with an osteotomy. I don't think an osteotomy should ever be used to overcorrect a normal knee just to protect an articular cartilage procedure or a meniscus transplantation.

If a varus knee requires ACL reconstruction, as long as the medial meniscus is intact or repairable, I would not do an osteotomy. My only indication for osteotomy in the context of ligament reconstruction is to address posterolateral instability and a varus thrust. In these patients, I perform a medially based, opening wedge, proximal tibial osteotomy, aiming to increase the posterior tibial slope. My personal preference is to use a locking plate with iliac crest autograft.

Thomas Muellner

 

In the acute setting of an ACL reconstruction, I would not perform an osteotomy at the same time if no other changes indicate that the medial compartment will deteriorate soon. In an active professional soccer player, an osteotomy is a contraindication unless he or she is willing to finish his or her career. In a patient with a varus thrust and lateral instability, an osteotomy has to be performed prior to ligament reconstruction.

Michael Stuart

 

Chronic anterior cruciate deficiency has been considered to be a relative contraindication for medial unicompartmental arthroplasty.

   Do you think there is a role for simultaneous anterior cruciate ligament reconstruction and opening wedge high tibial osteotomy?
David Backstein

 

Young, active patients with ACL deficiency in combination with medial arthritis and a varus deformity are treated with proximal tibial osteotomy alone. Before ACL reconstruction is considered in this scenario, an osteotomy is performed and the posterior tibial slope is increased slightly.

Patients with instability and varus deformity in the absence of medial arthritis are treated with ACL reconstruction alone as a first step. If they remain symptomatic, an osteotomy is conducted as a second procedure.

Martin Logan

 

No, I think if you are going to do an ACL reconstruction and a proximal tibial osteotomy, then the closing wedge technique is by far the best option. It is all too easy to increase the posterior tibial slope with an opening wedge; this will not help the longevity of the ACL graft (see Rodner CM, Adams DJ, Diaz-Doran V, et al: Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure. Am J Sports Med 34:1431–1441, 2006). ACL reconstruction does not restore normal tibiofemoral kinematics in the lateral compartment, and ACL reconstruction combined with a unicompartmental arthroplasty is less satisfactory than a total knee arthroplasty (see Logan MC, Williams A, Lavelle J, et al: Tibiofemoral kinematics following successful anterior cruciate ligament reconstruction using dynamic magnetic resonance imaging. Am J Sports Med 32:984–992, 2004).

Thomas Muellner

 

ACL deficiency for me is an absolute contraindication for unicompartimental arthroplasty. ACL reconstruction with simultaneous opening wedge osteotomy has a role in ACL-deficient patients with cartilage damage and/or medial meniscus tears.

Michael Stuart

 

I would like to thank each of you for your insightful comments regarding patient selection for an osteotomy about the knee. The technical pearls are pragmatic and will definitely come in handy in the operating room. It is clear from your discussion that osteotomy of the proximal tibia and of the distal femur continues to play an important role. These procedures are typically successful, provided that we choose patients carefully, plan precisely before surgery, and use fastidious surgical technique.

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