Orthopaedic Journal of Sports Medicine | 2019
Dome-Shaped Osteotomy for Revision of Failed Closing-Wedge High Tibial Osteotomy
Abstract
Clinical indications for high tibial osteotomy (HTO) include patients with unicompartmental arthritis, patients with malalignment of the leg and ligament instability of the knee, and patients with complex deformities. Deformity of the knee results in an asymmetric load on 1 compartment and leads to degeneration of the joint. The osteotomy realigns the anatomic axis of the knee and transfers the mechanical axis to the center of or lateral to the joint to reduce the medial stress, thus preventing progression of the medial arthritis. Satisfactory results are best achieved when the mechanical axis passes through the Fujisawa point (the lateral one-third of the lateral femorotibial compartment). Widening of a previously narrow joint space may lead to regression of the subchondral cysts and sclerosis if stress is sufficiently reduced, and the degenerative articular cartilage in the medial compartment may regenerate after surgery. Various models of HTO have been proposed since Jackson and Waugh introduced the concept in 1961. Coventry first popularized the HTO by using a lateral closed-wedge procedure proximal to the tibial tuberosity. Lateral closed and medial opening osteotomies are still the most common procedures. Less commonly used techniques for the management of axial deformities of the knee include dome osteotomies, chevron osteotomies, and callus distractions with external fixation. These procedures have a high success rate when appropriate correction has been obtained in a properly select patient. Excellent or good 10-year results were obtained in 70% of 51 knees in which a lateral closingwedge osteotomy had been performed. Undercorrection or failure to maintain valgus alignment has been shown to be associated with failure of HTO. As cited in Tsuda et al, Sprenger and Doerzbacher reported 10-year outcomes of HTO showing that 90% of 41 knees that had retained a valgus alignment between 8 and 16 at 1 year had survived and functioned well, whereas 45% of 28 knees with <8 or >16 of valgus at 1 year had to be converted to a total knee arthroplasty. These results suggest that long-term joint survival can be predicted by the knee alignment in the early postoperative period. In addition, if further osteoarthritic changes have not occurred, recurrent varus alignment during the early postoperative phase might be correctable with revision realignment surgery, thus enhancing the long-term results. At the same time, some authors have found that an accurate correction of the knee deformity does not appear to be essential for pain relief, nor does the best correction gives the best results. This case report describes the 5-year follow-up results of a patient who received a dome-shaped HTO with the TomoFix (Anatomical) Lateral High Tibia Plate (DePuy-Synthes) to correct a recurrent varus deformity as a result of a failed lateral closing-wedge HTO. *Address correspondence to Diogo F. Gama, MD, Department of Orthopaedic Surgery, Inf Dom Pedro Hospital, Av Dr Arthur Ravara 3810, 193, Aveiro, Portugal (email: [email protected]). † Department of Orthopaedic Surgery, Inf Dom Pedro Hospital, Aveiro, Portugal. ‡ Department of Orthopaedic Surgery, Academic Medical Centre, São João University Hospital, Porto, Portugal. § Department of Orthopaedic Surgery, Academic Medical Centre, Santa Maria University Hospital, Lisbon, Portugal. || Department of Orthopaedic Surgery, Knee and Ankle Surgery, Arthroscopy and Sports Trauma Unit, Cuf Descobertas Hospital, Lisbon, Portugal. The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.