Osteotomy may be best suited for younger patients

Issue: May 2015

KOLOA, Hawaii — In younger patients with unicompartmental articular cartilage pathologies, closing wedge osteotomy provides faster healing, as well as more rapid ability to bear weight and return to work, according to a presenter at Orthopedics Today Hawaii 2015.

“Proximal tibial osteotomy, opening vs. closing wedge, is one of the least-performed orthopedic surgical procedures in the United States for unicompartmental articular cartilage pathology and is one of the least-taught procedures by the Academy or [Arthroscopy Association of North America], yet probably one of the most important to learn,” Jack M. Bert, MD, said during his presentation.

Alignment is crucial after articular surface surgery because the tissue is at risk, he said. In addition, proper alignment decreases medial compartment contact pressure.

According to Bert, despite some older research indicating that lateral closing wedge causes peroneal nerve palsy and shortening of the fibula, recent studies using rigid fixation devices have shown no nerve or vascular complications. Bert said there is some literature confirming that closing wedge yields better correction and patients can weight bear more rapidly after closing wedge osteotomy. Furthermore, patients experience a quicker return to work as well as faster healing.

However, he noted that opening wedge osteotomy is easy to do even though nonunions may occur and patients have more time non-weight and partial-weight bearing. Bert also noted opening wedge osteotomy increases the medial compartment pressure causing most surgeons to resect the medical collateral ligament insertion.

“I tend to take it off at its insertion and let it create a grade 2, almost a grade 3, tear pattern,” Bert said. “I tend to cut most of mine, to be quite frank, because I want to be sure to reduce the tension in the medial compartment.”

In most cases, osteotomy does not burn any bridges. “Revision to total knee arthroplasty does not appear to be an issue if rigid fixation techniques are used initially and, in most cases, have the same results as primary total knee arthroplasty,” Bert said.

Recent studies have indicated there is minimal difference in knee outcome scores, complications or revision success rates between high tibial osteotomy and unicompartmental knee arthroplasty, according to Bert. There was also no statistically significant difference in results when autologous chondrocyte implantation or marrow stimulation procedures were added when performing proximal tibial osteotomy.

Bert noted unloading bone without adding any other procedure has shown to produce a cartilaginous surface, most likely due to subsurface cartilage aggregates proliferation. Therefore, he advised not to add a marrow stimulation or an arthroscopic procedure to a proximal tibial osteotomy, as clinical results do not seem to improve.

He added, “Unloading bone alone may be the single most important factor in the formation of articular surface cartilage without doing damage to the subchondral surface which tends to occur with microfracture,” he said. – by Kristine Houck, MA, ELS, and Casey Tingle

Reference:

Bert JM. Always do osteotomy in the younger patient. Presented at: Orthopedics Today Hawaii; Jan. 18-22, 2015; Koloa, Hawaii.

For more information:

Jack M. Bert, MD, can be reached at Minnesota Bone & Joint Specialists Ltd., 17 W. Exchange ST., Ste. 110, St. Paul, MN 55102; email: bertx001@umn.edu

Disclosure: Bert is a consultant for Smith & Nephew, Exactech, Wright Medical Technology, Sanofi, Pacira, and Exscribe; is on the editorial board for Orthopedics Today; the board of directors for the Retired NFL Player’s Association and the AAOS Orthopedic Learning Center; and is the executive advisor for the AANA board of directors.