J Korean Orthop Assoc.  2014 Apr;49(2):95-106. 10.4055/jkoa.2014.49.2.95.

Lateral Closing Wedge Osteotomy of Tibia for Degenerative Arthritis

• Ro DH
• Lee S
• Seong SC
• Lee MC

• KMID: 2185214
• DOI: http://doi.org/10.4055/jkoa.2014.49.2.95

Abstract

Proximal tibial osteotomy is an effective, well-established treatment for unicompartmental arthritic knee with varus or valgus deformity. Four basic types are commonly described: lateral closing wedge osteotomy, medial open wedge osteotomy, dome osteotomy, and medial opening hemicallotasis. The objective of this procedure is to realign the weight-bearing axis through the knee by redistributing the forces of weight to the less involved compartment of the knee. With thorough preoperative planning and careful selection of patients, optimal outcome can be expected with preservation of the patient's joint. In this article, we reviewed selection of patients, surgical planning, surgical technique, complications, pre- and post-operative change in mechanics, and long term surgical outcome of closing wedge osteotomy. Optimal outcome is expected in patients with young age (younger than 60), stable knee, medially confined osteoarthritis, and good range of motion. According to the literature, average 10-year survival rate is expected to be 60% to 90%. Closing wedge osteotomy allows for rapid bone healing, early weight bearing, rehabilitation, and low rates of correction loss. Surgeons should keep in mind that optimal indication, preoperative planning, and use of safe operative technique are essential to achievement of best results.

Keyword

osteotomy; high tibial osteotomy; lateral closing; osteoarthritis

MeSH Terms

Axis, Cervical Vertebra
Congenital Abnormalities
Humans
Joints
Knee
Mechanics
Osteoarthritis*
Osteotomy*
Range of Motion, Articular
Rehabilitation
Survival Rate
Tibia*
Weight-Bearing

Figure

• 

  Figure 1 Relationship between mechanical axis and anatomical axis in normal lower extremity. The mechanical axis is a line connecting the centers of the femur head and the tibiotalar joint, which passes through the center of the knee joint. It is in 3 degrees of valgus from the vertical axis of the body. Anatomical axis (femoral shaft axis) is in 6 degrees of valgus from the mechanical axis of the lower limb and 9 degrees of valgus from the true vertical axis of the body.

• 

  Figure 2 Progression of osteoarthritis in the varus knee (left to right). Varus deformity increases adduction moment of the knee during gait, which further increases medial tibiofemoral joint loading. Increased loading aggravates osteoarthritis and deformity. If lateral laxity accompanies, varus deformity can show rapid progress.

• 

  Figure 3 Preoperative simulation with a full-length standing radiograph. We simulate postoperative limb alignment according to the intersecting location of the mechanical axis. (A) This photograph shows preoperative alignment on the left extremity. (B) This photograph shows the mechanical axis that passes through the lateral tibial spine. (C) This photograph shows the Fujisawa point. We also measured anatomical axis and medial proximal tibial angle (MPTA) in each case. As the causes of varus deformity can differ, all of these variables should be considered together for development of an optimal results.

• 

  Figure 4 Calculation of wedge height usinga trigonometric method. Actual wedge height (y) is calculated with the desired angle of correction (θ) and actual tibial width (x). Actual tibial width should be measured at 2.0-2.5 cm distal to the joint line and should be normalized according to the amount of magnification.

• 

  Figure 5 Calculation of wedge height using a picture archiving and communication system (PACS). Desired angle of correction is measured using teleradiography. In this figure, desired angle of correction is 10 degrees when the mechanical axis passes through the Fujisawa point. This angle is marked at 2 cm distal to the joint line and the wedge height can then be measured directly.

• 

  Figure 6 Intraoperative picture (see text for detailed description). (A) Transverse skin incision from tibial tuberosity to the fibular head. (B) Exposed fascia. (C) Subperiosteal stripping using an elevator. (D) Insertion of the guide pin under the c-arm. (E) Proximal wedge removal. (F) Distal wedge removal. (G) Application of gentle valgus force to make plastic deformation of the contralateral cortex. (H) Internal fixation.

• 

  Figure 7 Fixation device for closing wedge osteotomy. (A) Stepped staple (Coventry staple). (B) Blade plate. (C) L-plate (condylar buttress plate). (D) Screw fixation. (E) Rigid stepped plate.

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