Opening Wedge Osteotomy: Tibial

Giancarlo Puddu, Massimo Cipolla, Guglielmo Cerullo, Vittorio Franco, and Enrico Giannì

Tibial opening wedge medial osteotomy represents the treatment of choice to correct a painful varus knee in young and middle-aged patients.

This technique appears to be more precise than lateral closing wedge type of osteotomy and avoids the risks and complications of fibular osteotomy.

Indications

1. Severe varus knee in a young patient (Blount’s disease, often bilateral)
   
2. Arthritic painful varus knee in a middle-aged patient, very often following medial meniscectomy
   
3. Painful varus knee in anterior cruciate ligament (ACL)-deficient knees (“knee abusers”)
   
4. Varus knee following fractures

Contraindications

1. Elder patients (over 60 years)
   
2. Osteonecrosis of medial femoral condyle
   
3. Involvement of the lateral femorotibial compartment [as seen on magnetic resonance imaging (MRI), arthroscopy]
   
4. atella baja

Physical Examination

1. Varus knee in standing position
   
2. Varus thrust during the gait
   
3. Pain at the medial joint line
   
4. Pain after activities requiring standing for long periods
   
5. Swelling after mild activities

Diagnostic Tests

1. Standing 45-degree posteroanterior flexion weight-bearing radiograph of both knees (Rosenberg); standing anteroposterior radiograph of both limbs including hip and ankle joints
   
2. Abduction-stress radiograph at 30 degrees of flexion to evaluate the lateral compartment
   
3. MRI for evaluation of the lateral compartment
   
4. Arthroscopy (better if associated with the osteotomy)

Special Considerations

1. Once anesthesia is induced, abduction-stress fluoro-scopic view and arthroscopy can be used to investigate the status of the lateral compartment and confirm or not the right indication for osteotomy.
   
2. Bone grafting is required, preferably from the tibia itself or from the iliac crest.

Preoperative Planning and Timing of Surgery

1. Measurement of preoperative anatomic and mechanical axis of the varus knee
   
2. Calculation of the exact amount of the required correction, first in degrees and then in millimeters of wedge, to obtain a mechanical axis passing through the boundary between the central and the lateral third of the tibial plateau (63% of the width of the tibial plateau in coronal view)
   
3. Planning of a cruciate ligament reconstruction, if needed, at the same time

Special Instruments

1. Power drill and saw
   
2. Tibial plates with a central spacer ranging from 5 to 17.5 mm in height and four holes for screws (Fig. 53–1)
   
3. Graded wedge opener (Fig. 53–2A) and osteotomy cutting guide (based on surgeon’s preference)
   
4. Special Homan retractors (Figs. 53–3A and 53–4A).

Figure 53–1 Tibial plates with four holes ranging from 5 to 17.5 mm in width of the central spacer.

Figure 53–2 (A) Positioning of the wedge opener in coronal and axial plane. (B) The wedge opener inside the osteotomy cut of the tibia. The handle has been removed. The medial collateral ligament has been divided and the hamstring tendons retracted posteriorly. (C) The wedge opener.

Anesthesia

General anesthesia is preferable when bone grafting from the iliac crest is required. Epidural anesthesia is an alternative.

Patient and Equipment Positions

1. Patient is in the supine position on a radiotranspar-ent operating table.
   
2. Skin preparation of the free limb and of the iliac region
   
3. Arthroscopic set; particular care in waterproof dressing
   
4. Amplifier should be within easy access of the patient’s knee and hip.

Surgical Procedure

1. Arthroscopy: evaluation of medial, lateral, and patellofemoral compartments; treatment of meniscal and chondral pathology
   
2. A longitudinal 8-cm skin incision is made on the anteromedial aspect of the tibia along the anterior edge of the medial collateral ligament (MCL).
   
3. Hamstring tendons are dissected and retracted. The superficial layer of the MCL is divided 1 cm proximal to its distal insertion. A Homan retractor is positioned posteriorly to protect vessels and nerves from the osteotome.
   
4. Under fluoroscopic control a Steinmann pin is inserted in an oblique direction starting 4 cm from the medial joint line and directed laterally and proximally toward the tip of the fibular head, 1 cm distal to the lateral joint line (Fig. 53–3). Fibular osteotomy is not necessary.
   
5. The medial cortex of the tibia is cut first by an oscil lating saw and then by an osteotome. Lateral cortex 8. should be left intact, 5 mm in thickness (“hinge”) (Fig. 53–4).
   
6. The knee is forced into abduction stress, and the wedge opener is inserted into the osteotomy line until the required correction is obtained (Fig. 53–5). The mechanical axis is checked by fluoroscopy.
   
7. The appropriate plate is positioned through the wedge opener. Under fluoroscopic control the plate is fixed by two proximal 6.5-mm cancellous screws and two distal 4.5-mm cortical ones (Fig. 53–6).
   
8. The defect now can be filled with bone grafts taken from the tibia itself or, better, from the iliac crest, especially in those osteotomies larger than 7.5 mm.
   
9. Hamstring tendons are sutured, the MCL can be generally left open, and a deep drain is used routinely.
   
10. Radiographic control is useful at the end of surgery (Fig. 53–7).
    
11. Bone wax and deep drain are used to control bleeding from the iliac crest.

Related posts:

The Subvastus Approach Meniscal Injuries/Repair: Staples Arthroscopic Lateral Retinacular Release Meniscal Injuries/Repair: BioStinger Total Knee Replacement: Pearls of Posterior Cruciate Ligament Substitution Closing Wedge Proximal Tibial Osteotomy

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