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Combined Lateral Closing and Medial Opening-Wedge High Tibial Osteotomy

Nagi, O.N., MS(Ortho), MSc(Oxford)1; Kumar, Senthil, MS(Ortho), MRCS2; Aggarwal, Sameer, MS(Ortho)3

doi: 10.2106/JBJS.E.01089
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Background: Long-term studies have indicated that the clinical success of high tibial osteotomy deteriorates with time. The purpose of this study was to evaluate the long-term results of a combined lateral closing and medial opening-wedge technique for high tibial osteotomy with a minimum follow-up of fifteen years.

Methods: From January 1981 to June 1990, ninety-two patients (ninety-four knees) had a high tibial valgus osteotomy. The average preoperative varus deformity was 13.5°. The surgical technique consisted of a proximal lateral closing-wedge osteotomy and use of the lateral wedge as a graft on the medial side of the osteotomy. No internal fixation was used. A knee brace was used to maintain the 8° to 10° of valgus overcorrection. Seventy-two knees in seventy patients with at least fifteen years of follow-up were evaluated. Clinical evaluation was done with The Hospital for Special Surgery knee-rating scale. The femorotibial alignment, posterior tibial slope, and the Insall-Salvati ratio were measured on radiographs.

Results: The mean initial postoperative correction (and standard deviation) for all knees was to 8.3° ± 2.7° of valgus alignment. Survivorship analysis showed that the probability of survival (and 95% confidence interval), with conversion to total knee arthroplasty as the end point, was 100% at one year, 92% ± 5.8% at ten years, 80% ±7.7% at fifteen years, and 58% ± 4.3% at twenty years. The survivorship, with a Hospital for Special Surgery knee score of <70 points as the end point, was 80% ± 4.5% at ten years, 72% ± 5.6% at fifteen years, and 42% ± 4.2% at twenty years. Twenty-six knees underwent an arthroplasty at an average of 15.6 years after the index procedure. For the forty-six knees that had not undergone an arthroplasty, the knee score improved from an average of 67 points preoperatively to 82 points at the time of the most recent follow-up. There were two superficial wound infections and one delayed union.

Conclusions: We believe that our technique of a combined lateral closing and medial opening-wedge high tibial osteotomy can provide good long-term outcomes because of the off-loading of the diseased medial compartment with minimal complications.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

1 Department of Orthopaedics, Sir Ganga Ram Hospital, New Delhi - 110060, India. E-mail address: profnagi@yahoo.co.in

2 Mona Vale Hospital, Sydney, NSW 2103, Australia

3 Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 101, India

Copyright © 2007 by The Journal of Bone and Joint Surgery, Incorporated
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