Abstract
In conventional closed-wedge high tibial osteotomy (CWHTO) with preservation of the medial hinge, flexion contracture cannot be improved because of the two-dimensional correction. Conversely, in hybrid CWHTO, for which the name is derived from a hybrid of the lateral closing and medial opening, the medial cortex is intentionally disrupted. The medial hinge disruption enables three-dimensional correction, which helps eliminate flexion contracture by decreasing posterior tibial slope (PTS). The fine adjustment of the anterior closing distance and thigh-compression technique further facilitates PTS control. In this study, we describe the use of the Reduction-Insertion-Compression Handle (RICH), which maximizes the benefits of hybrid CWHTO. This device permits accurate osteotomy reduction, easy screw insertion, and assists with providing sufficient compressive force at the osteotomy site, as well as the elimination of the flexion contracture. This Technical Note presents the details of using the RICH and the associated advantages and disadvantages in hybrid CWHTO for medial compartmental knee arthritis.
Introduction
Medial open wedge high tibial osteotomy (OWHTO) for medial compartmental knee osteoarthritis has become common since the introduction of specifically designed locking plates.1 Despite its simplicity, new complications, such as lateral hinge fracture,2, 3, 4 delayed gap filling,5 and increased posterior tibial slope (PTS)6 have arisen owing to the medial opening gap. To prevent these complications, we choose lateral closed-wedge high tibial osteotomy (CWHTO) in cases with a large opening gap. However, medial hinge fracture in conventional CWHTO (C-CWHTO)7 causes correction loss (Fig 1, A–D) with delayed union.8 Accordingly, opposite cortical fracture9 should be avoided in both OWHTO and C-CWHTO. Conversely, in hybrid CWHTO (H-CWHTO),10 for which the name is derived from a hybrid of the lateral closing and medial opening, the medial cortex is intentionally disrupted. The structural particularity that accepts hinge disruption (Table 1, Fig 1, E–H) enables three-dimensional deformity correction, such as extension osteotomy, by reducing the PTS (Fig 2). To maximize this advantage, the authors have developed a newly designed targeting device (Reduction-Insertion-Compression Handle [RICH]; Depuy Synthes Japan, Tokyo, Japan), which originates from the insertion guide for the less invasive stabilization system (LISS; Synthes, Solothurn, Switzerland) (Fig 3, A and B). The RICH device can assist with the following: 1) accurate osteotomy reduction with appropriate plate position; 2) easy insertion of the screws without cross-threading; and 3) application of sufficient compressive force to the osteotomy site (Table 2, Fig 3, C and D). Here, we introduce our innovative H-CWHTO procedure to improve flexion contracture using the RICH device.
Fig 1.
Comparison between conventional and hybrid closed-wedge high tibial osteotomy (CWHTO). (A) Conventional CWHTO with a proximal osteotomy line parallel to the joint line. The hinge point is located close to the medial cortex (red circle). (B) The proximal fragment diameter unavoidably becomes far larger than the distal fragment diameter. (C) Because of the discrepancy between the proximal and distal fragment diameters, the osteotomy construction may create an unstable “shaft-in-condyle” structure in cases with a laterally displaced medial hinge fracture (red arrow). (D) The shaft-in-condyle structure easily causes impaction on the medial side (blue arrow), which results in undercorrection and/or correction loss. (E) CWHTO with an oblique proximal osteotomy (black line). In CWHTO with a hinge point close to the medial cortex (red circle), the distal oblique osteotomy line arrives distally on the lateral cortex (red line), which results in a large closing distance after a large wedge removal. In hybrid CWHTO, in which the hinge point divides the proximal oblique osteotomy line in a 2 to 1 ratio (green circle), the distal osteotomy line is more proximal (green line), which can decrease the closing distance and the sizes of the wedge removal. (F) Thanks to the concave shape of the proximal lateral tibial cortex, the length of the proximal and distal oblique osteotomies are approximately equal (two sets of orange double lines). (G) Medial opening with simultaneous lateral closing is the origin of the name “hybrid” CWHTO. After wedge closure, the equality of the length of the osteotomy lines minimizes the step-off at the lateral cortex (green arrow). The medial opening procedure tightens the superficial medial collateral ligament (red double-headed arrow), which creates medial stability. (H) The proximal fragment slips with gravity because of the oblique osteotomy. The slipping force (red arrow) may be converted to a compressive force between the proximal and distal parts of the osteotomy (black arrow) by the stopping effect of the lateral plate.
Table 1.
Advantages and Disadvantages of the Hybrid Closed-Wedge High Tibial Osteotomy
| Advantages |
|---|
| - Mechanically more stable than conventional closed wedge high tibial osteotomy because of the following reasons. |
|
|
|
|
| -The intentionally created medial hinge disruption enables three-dimensional correction, such as extension/flexion osteotomy or rotational osteotomy. |
| -A use of a micro-oscillating saw provides an extra margin of safe osteotomy. |
| Disadvantages |
|---|
|
|
MCL, medial collateral ligament.
Fig 2.
An example of the coronal and sagittal preoperative planning to eliminate flexion contracture for a case of medial osteoarthritis with flexion contracture of 5°. (A) The coronal preoperative planning of the closing angle when the postoperative weight-bearing line is set at 65% of the width of the tibial plateau. The white line and the white dashed line indicate the preoperative and planned postoperative weight-bearing lines, respectively. The yellow, white, and green circles represent the hinge point, preoperative ankle center, and planned postoperative ankle center, respectively. The correction angle corresponds to the angle between the yellow line and the green dashed line (14°). (B) The coronal preoperative planning of the closing distance using three-dimensional computed tomography without changing the posterior tibial slope. The proximal oblique osteotomy (yellow dashed line) begins 40 mm distal to the lateral joint line (green double-arrow line) and ends 20 mm distal to the medial joint line (green dashed double-arrow line). Drawing the distal oblique osteotomy line from the hinge point using a dashed black line with the correction angle of 14°, which corresponds to 9 mm of the lateral (i.e., posterior) closing distance (white double-arrow line). The yellow line represents the coronal plane osteotomy, i.e., the margin of the anterior flange. When the thickness of the flange base is set at 15 mm, the anterior closing distance is estimated at 7 mm. (C) The sagittal preoperative planning of the closing distance using three-dimensional computed tomography. The flange thickness is set at 15 mm (yellow line). The proximal oblique osteotomy line on the lateral cortex (yellow dashed line) is made parallel to the joint line (yellow arrow). If the anterior closing distance is set at 9 mm (red double-arrow line); i.e., the same distance as the posterior closing distance (white double-arrow line), the posterior tibial slope can be decreased by approximately 5° (blue circle with the blue line), which is equivalent to the degree of flexion contracture. (D) Preoperative lateral radiograph. The posterior tibial slope (8° in this patient) is defined as the angle between the medial joint line (yellow line) and a perpendicular line (white line) to the posterior cortex of the tibia (yellow dashed line). (E) The postoperative slope was decreased to 3°; meaning that 5° of flexion contracture was eliminated by the decreased slope angle. (F) Postoperative whole-leg radiograph showing the appropriately corrected weight-bearing line (preoperative to postoperative change: 25% to 65%, respectively; white dashed line).
Fig 3.
The characteristics of the Reduction-Insertion-Compression Handle (RICH) and how to use it; (RICH for the right knee). (A) The insertion guide for the less invasive stabilization system (LISS; Synthes; Solothurn, Switzerland) has 10 more holes in the distal section than the number in the RICH device (red double-arrow line). (B) The RICH is quite a bit shorter than the insertion guide for the LISS to fit the shorter plate. A large hole is present in the middle of the handle of the RICH device compared with the LISS to reduce the weight of the handle (yellow dashed line). (C) The compression screw with a nut (Pull Reduction Instrument) for hole 1 to provide a compressive force to the osteotomized site. (D) The TomoFix Lateral High Tibia plate (Johnson and Johnson; New Brunswick, NJ) is connected to the RICH device. Valgus stress to close the wedge can be applied by the right hand (blue arrow), and a counter force against the valgus stress is provided through the foot part of the handle (yellow arrow), while controlling the plate position using the left hand. Compressive forces to the oblique osteotomy plane and the coronal osteotomy plane can be applied using the surgeon’s abdomen (red arrow) and bone forceps (green arrows), respectively. The reduction is completed by tightening the nut of the Pull Reduction Instrument with a wrench (black arrow). (E) Arrangement of the doctors and nurse relative to the patient for the right hybrid closed wedge high tibial osteotomy. The patient’s leg shown in red indicates the operated leg. The lead surgeon stands distal to the foot of the operated leg to hold the RICH and confirm the alignment. The first assistant inserts the Kirschner wires and screws, and the second assistant applies a downward force on the patient’s thigh to eliminate the flexion contracture.
Table 2.
Pearls and Pitfalls of the Reduction-Insertion-Compression Handle
| Pearls |
|---|
|
|
|
| Pitfalls |
|---|
|
Indications
The indications for OWHTO/CWHTO are as follows3: 1) no or mild lateral compartment osteoarthritis; 2) varus knee (hip-knee-ankle angle <0° and/or weight-bearing line ratio <50%); 3) deformity center around the proximal tibia (medial proximal tibial angle11 <90°); and 4) flexion contracture <10°. H-CWHTO was chosen when a patient met at least one of the following additional criteria: 1) correction angle ≥12°; 2) smoking ≥20 cigarettes per day; 3) flexion contracture ≥5°; or 4) presence of patellofemoral osteoarthritis.
Surgical Technique
Preoperative Planning
Figure 2 illustrates a target postoperative weight-bearing line ratio of 60%–70%, and the angle is fine-tuned to achieve a hip-knee-ankle angle of 2°–5° valgus (Fig 2, A and F). In two-dimensional PTS-preserving CWHTO, the anterior closing distance is smaller than the posterior closing distance because the former is located more medially than the latter in the coronal plane (Fig 2, B and C). In three-dimensional PTS-reducing H-CWHTO, to eliminate the flexion contracture (Fig 2, D and E), the anterior closing distance is larger than that in PTS-preserving H-CWHTO (Fig 2C).
Osteotomy
The operation (Video 1) is performed in the supine position under general anesthesia. After arthroscopic meniscal resection/repair through anterolateral and anteromedial portals, the fibula is segmentally resected at its midportion, according to ankle-angle-adjusting (triple-A) fibular osteotomy.12 Through a 12-cm anterolateral curved incision, the tibialis anterior muscle is subperiosteally detached using a Cobb elevator. With the knee flexed, the posterior muscles are detached from the posterior tibial aspect as for the tibialis anterior, and a radiolucent retractor is inserted. With the knee extended, the lateral patellar retinaculum is incised along the patellar tendon edge, and the infrapatellar fat pad is gently retracted without cutting.
Ascending and proximal oblique (transverse) osteotomies are performed under the guidance of two Kirschner wires (K-wires) with sufficient retraction. For gentle osteotomy without an unexpected fracture, we use a light-weight cordless micro-oscillating saw with a thin blade (Hall MicroFree Cordless Small Bone Power System; CONMED, Largo, FL). The medial cortex is completely cut with a chisel during the proximal oblique osteotomy, taking care not to damage the superficial medial collateral ligament (Table 3). The two K-wires are then removed, which enables the identification of the proximal oblique osteotomy line confidently on the fluoroscopic view. A 3.0-mm K-wire is then inserted from anterior to posterior at the hinge point, which divides the proximal oblique osteotomy line in a 2 to 1 ratio.10
Table 3.
Risks and Limitations of the Hybrid Closed-Wedge High Tibial Osteotomy Using the Reduction-Insertion-Compression Handle
| Risks |
|---|
| Special care not to damage the superficial MCL should be taken during the complete-cut of the medial cortex with a chisel. The superficial MCL tear may highly destabilize the osteotomized site and make the reduction difficult. |
|
|
| Limitations |
|---|
|
|
MCL, medial collateral ligament.
The knee is then flexed, and the distal oblique osteotomy line is drawn on the lateral aspect of the tibia using an electrosurgical knife in accordance with the preoperative plan. The line is cut toward the K-wire at the hinge using a micro-oscillating saw. After fenestration of the lateral tibial aspect,13 the posterior cortices in the proximal and distal oblique osteotomy lines are cut toward the K-wire using the micro-reciprocating saw. The wedge is removed, and the remaining posteromedial cortex beyond the hinge is completely cut using a chisel under fluoroscopic control.
Plate Fixation
Once the osteotomy is completed, the varus deformity is corrected by applying a valgus stress. The TomoFix Lateral High Tibia plate (Johnson and Johnson, New Brunswick, NJ), connected to the RICH device, is placed on the lateral aspect of the tibia (Video 1, Figs 3 and 4). The lead surgeon stands distal to the foot of the operated leg and holds the RICH in the left hand for the right knee or the right hand for the left knee (Fig 3E). The surgeon’s hand on the lateral side of the knee serves as a leverage point for applying the valgus stress and the hand on the medial side provides a valgus stress (Fig 4A). Axial pressure is added by the surgeon’s abdomen. The first assistant inserts K-wires and screws through the RICH (Figs 3E and 4B), and the second assistant applies a downward force on the patient’s thigh (Figs 3E and 4B) to eliminate the flexion contracture.
Fig 4.
Fixation and closure (right knee). (A) The TomoFix PLT plate (Johnson and Johnson; New Brunswick, NJ) fixed with the Reduction-Insertion-Compression Handle (RICH; Depuy Synthes, Tokyo, Japan) is attached on the tibial anterolateral aspect, and the plate position is adjusted using the handle of the RICH device. The second assistant applies a compressive force to the femur to achieve full extension (blue arrow). The surgeon’s hand on the lateral side of the knee serves as a leverage point for applying the valgus stress (black arrow). The hand on the medial side provides a valgus stress (yellow arrow). When the compressive force to the osteotomy site is inadequate, compression can be provided using the surgeon’s abdomen. (B) The proximal side of the plate is temporarily fixed with two K-wires through the guide sleeves. The proximal K-wire is bent (the black arrow shows the direction of the bend) to prevent floating of the plate head from the proximal tibia. (C) After temporary fixation of the distal fragment using a K-wire, a compressive force is applied to the ascending osteotomy plane using bone forceps (black arrows). (D) The Pull Reduction Instrument with a compression nut (yellow arrow) is inserted into the most proximal drill sleeve (hole 1 of the RICH; Fig 3B) in the distal osteotomy fragment. (E) The nut is tightened with a wrench (green arrow) to reduce the closed wedge appropriately and to apply a compressive force to the oblique osteotomy site. (F) The remaining locking screws are inserted through the drill sleeves in the handle. (G) Proximal screws above the handle are inserted after removing the handle. Compression to the femur and valgus stress to the knee are still required to prevent under-correction and persistent postoperative flexion contracture. (H) The fascia of the tibialis anterior muscle is closed using a running suture with STRATAFIX Symmetric PDS Plus 3-0 suture (Ethicon, Somerville, NJ). (I) The crural fascia of the fibular osteotomy site is closed using a running suture with STRATAFIX Spiral PDS Plus 3-0 suture (Ethicon). K-wire, Kirschner wire.
Following temporary fixation with three K-wires (two in the proximal fragment and one in the distal fragment), a compressive force to the coronal osteotomy is applied using bone forceps (Fig 4C). The Pull Reduction Instrument (Fig 3C) is then inserted into hole 1 (Fig 3B) in the RICH through an insertion sleeve, and a compressive force to the oblique osteotomy plane is applied by tightening the nut until the proximal and distal oblique osteotomy lines are in maximal contact (Figs 3D and 4E). After confirming the limb alignment on the monitor,14 the remaining locking screws are inserted through the drill sleeves in the RICH. The temporary K-wire fixations and the compression screw are replaced with locking screws (Fig 4F), and the RICH is removed. Finally, proximal screws are inserted (Fig 4G) except in hole B because this hole tends to be too close to the oblique osteotomy line. The fascia of the tibialis anterior muscle and the crural fascia of the fibular osteotomy site are closed using a running suture (Fig 4, H and I) before skin closure.
Postoperative Rehabilitation
Full weight-bearing walking exercise, as well as range-of-motion exercises are allowed on the first postoperative day, and these are advanced gradually, as tolerated.
Discussion
The most commonly performed knee osteotomies, such as OWHTO, C-CWHTO, and distal femoral osteotomy, accept only two-dimensional correction because three-dimensional correction may induce an unstable opposite cortical hinge fracture. In contrast, H-CWHTO can accept an intentional medial cortical fracture for the following reasons (Table 1): First, the superficial medial collateral ligament functions as a medial tension band structure thanks to the tensioning effect caused by the medial opening (Fig 1G).15 Second, in C-CWHTO with a parallel proximal cut to the joint line (Fig 1A), the transverse diameter of the proximal fragment is much larger than that of the distal fragment (Fig 1B).7 Therefore, a displaced medial hinge fracture with lateral displacement (Fig 1C) may cause an unstable impaction phenomenon; i.e., “shaft-in-condyle”, which can result in undercorrection and/or correction loss (Fig 1D).8 In H-CWHTO, the oblique osteotomies may provide almost equivalent diameters of the proximal and distal oblique osteotomy lines (Fig 1, E and F), which increases the lateral contact area.10 Additionally, the oblique osteotomy creates a lateral slip of the proximal fragment, which can be converted to a compressive force at the lateral contact area by the buttress effect of the locking plate (Fig 1H).
Through the use of this particular structure, the PTS can be changed at lower risk in H-CWHTO compared with other osteotomy techniques. Although PTS control by only the intentionally created difference in the anterior and posterior gaps (Fig 2C) is not necessarily easy, thigh compression facilitates PTS control. Assuming that flexion contracture and PTS are α° and β°, respectively, thigh compression automatically reduces α° to 0°, and the postoperative PTS can be calculated as (β° − α°). As the anterior tibial slope may cause anterior femoral slip during walking, care should be taken not to create a minus value for the PTS (β° − α°) (Table 3).
Freedom of the proximal fragment during the correction process owing to the intentional hinge disruption may be a risk and limitation of this procedure (Table 3). In conclusion, H-CWHTO using the RICH device with thigh compression facilitates accurate improvement of flexion contracture. Sufficient compressive forces to stabilize the osteotomy site can be provided by both thigh compression and valgus pressure using the RICH device.
Acknowledgments
The authors thank Murakami Y, and Kumabe T, and Nanbo H for editing the video transcript and filming the video, respectively.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: R.N. reports consulting fees from OlympusTerumo Biomaterials. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
This video shows the method to improve flexion contracture in knee osteoarthritis with hybrid closed-wedge high tibial osteotomy using a Reduction-Insertion-Compression Handle. One of the authors has a consultancy agreement with Olympus Terumo Biomaterials. Herein, we demonstrate the surgical procedure on the right knee. This case had a flexion contracture of 10° in the right knee. First, the torn medial meniscus is arthroscopically resected through anterolateral and anteromedial portals. Through a longitudinal incision, the fibula is resected at its mid-portion. Gauze is packed, and the wound is wrapped to further secure hemostasis. The tibial skin incision begins 1 cm proximal to the fibular head, runs through Gerdy’s tubercle, and passes 1 cm lateral to the tibial anterior margin. After making the skin incision, the proximal part of the tibialis anterior muscle is detached using an electrosurgical knife. The fascia of the tibialis anterior muscle is then sharply dissected 1.5 cm from the anterior margin of the tibia. Elevating the incised fascia, the muscle is separated from the fascial backside from distal to proximal using an electrosurgical knife. The muscle is then subperiosteally detached using a Cobb elevator. The knee is flexed to create room for posterior retraction, and the tibial posterior aspect is detached using a Cobb elevator as for the tibialis anterior. The lateral patellar retinaculum is incised along the edge of the patellar tendon. Retracting the fat pad, the starting point of the proximal oblique osteotomy is determined using a 4-cm gauge, and two K-wires are inserted. The ascending osteotomy is performed using a micro-oscillating saw and a chisel. The proximal oblique osteotomy line is cut with the micro-oscillating saw, and the medial cortex is completely disrupted using a chisel. After removing the two initial K-wires, a new K-wire is inserted for the hinge point, which divides the oblique osteotomy line in a 2:1 ratio. The knee is flexed, and the distal osteotomy line is drawn in accordance with the preoperative slope-decreasing plan. The line is cut toward the K-wire using the micro-oscillating saw, and additional anterior and posterior cuts are made to create a cortical window. The posterior cortices are cut from the window using a micro-reciprocating saw, and the wedge is removed. Removing the hinge K-wire, the posteromedial cortex is cut using a chisel under fluoroscopic control. The wedge can be easily closed by applying valgus stress through the handle of the RICH device fixed to the plate. During temporary fixation using K-wires, the assistant applies downward force on the patient’s thigh to eliminate the flexion contracture. An additional compressive force is applied to the flange using forceps. A drill with a compression nut is inserted through a drill sleeve and gently tightened with three fingers. The distal K-wire sleeve is removed, and the nut is tightened with a wrench until the proximal and distal oblique osteotomy lines are in maximal contact. The alignment is confirmed using a measurement radiograph on the monitor before locking screw insertion. The assistant continues to apply thigh compression, while the locking screws are inserted through the handle in sequential order. Dismounting the handle, a sleeve for proximal fixation is installed, and the clamp is removed. During the proximal locking fixation, the assistant does not relax the hand applying thigh compression, and the lead surgeon does not relax the valgus stress, to maintain alignment. Using fluoroscopy, the surgeon confirms the anteroposterior and lateral views of the fixation. Finally, the fascia of the tibialis anterior muscle is closed using a running suture without closing the plate head portion. The crural fascia of the fibular osteotomy site is also closed using a running suture.
References
- 1.Staubli A.E., De Simoni C., Babst R., Lobenhoffer P. TomoFix: A new LCP-concept for open wedge osteotomy of the medial proximal tibia—Early results in 92 cases. Injury. 2003;34(Suppl 2):B55–B62. doi: 10.1016/j.injury.2003.09.025. [DOI] [PubMed] [Google Scholar]
- 2.Takeuchi R., Ishikawa H., Kumagai K., et al. Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: A new classification of lateral hinge fracture. Arthroscopy. 2012;28:85–94. doi: 10.1016/j.arthro.2011.06.034. [DOI] [PubMed] [Google Scholar]
- 3.Nakamura R., Komatsu N., Murao T., et al. The validity of the classification for lateral hinge fractures in open wedge high tibial osteotomy. Bone Joint J. 2015;97-B:1226–1231. doi: 10.1302/0301-620X.97B9.34949. [DOI] [PubMed] [Google Scholar]
- 4.Nakamura R., Komatsu N., Fujita K., et al. Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy. Bone Joint J. 2017;99-B:1313–1318. doi: 10.1302/0301-620X.99B10.BJJ-2017-0103.R1. [DOI] [PubMed] [Google Scholar]
- 5.Goshima K., Sawaguchi T., Shigemoto K., et al. Large opening gaps, unstable hinge fractures, and osteotomy line below the safe zone cause delayed bone healing after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2019;27:1291–1298. doi: 10.1007/s00167-018-5334-3. [DOI] [PubMed] [Google Scholar]
- 6.Nakamura R, Komatsu N, Fujita K, et al. Anteromedial plating without filling the gap in open wedge high tibial osteotomy may increase the risk of screw breakage, which can be reduced by medial plating and bone-substitute insertion. J Orthop Sci In press. doi:10.1016/j.jos.2021.12.017. [DOI] [PubMed]
- 7.Coventry M.B. Osteotomy about the knee for degenerative and rheumatoid arthritis. J Bone Joint Surg Am. 1973;55:23–48. [PubMed] [Google Scholar]
- 8.Nakamura R., Nishimura H., Katsuki Y. Re-correction osteotomy with osteophyte graft for correction loss with non-union after high tibial osteotomy. BMJ Case Rep. 2017;2017 doi: 10.1136/bcr-2017-221870. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.van Raaij T.M., Brouwer R.W., de Vlieger R., Reijman M., Verhaar J.A. Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening-wedge technique. Acta Orthop. 2008;79:508–514. doi: 10.1080/17453670710015508. [DOI] [PubMed] [Google Scholar]
- 10.Takeuchi R., Ishikawa H., Miyasaka Y., Sasaki Y., Kuniya T., Tsukahara S. A novel closed-wedge high tibial osteotomy procedure to treat osteoarthritis of the knee: Hybrid technique and rehabilitation measures. Arthrosc Tech. 2014;3:e431–e437. doi: 10.1016/j.eats.2014.04.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Paley D., Herzenberg J.E., Tetsworth K., McKie J., Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25:425–465. [PubMed] [Google Scholar]
- 12.Nakamura R., Amemiya M., Kawashima F., Okano A. Ankle-angle-adjusting fibular osteotomy in closed wedge high tibial osteotomy. Arthrosc Tech. 2022 doi: 10.1016/j.eats.2022.08.018. In press. doi: 10.1016/j.eats.2022.08.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ogata K. Interlocking wedge osteotomy of the proximal tibia for gonarthrosis. Clin Orthop Relat Res. 1984;186:129–134. [PubMed] [Google Scholar]
- 14.Nakamura R., Kuroda K., Takahashi M., Katsuki Y. Open wedge high tibial osteotomy with pes anserinus preservation and insertion of bone-substitute. Arthrosc Tech. 2021;11:e69–e78. doi: 10.1016/j.eats.2021.09.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Saito H., Saito K., Shimada Y., et al. Short-term results of hybrid closed-wedge high tibial osteotomy: A case series with a minimum 3-year follow-up. Knee Surg Relat Res. 2018;30:293–302. doi: 10.5792/ksrr.18.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
This video shows the method to improve flexion contracture in knee osteoarthritis with hybrid closed-wedge high tibial osteotomy using a Reduction-Insertion-Compression Handle. One of the authors has a consultancy agreement with Olympus Terumo Biomaterials. Herein, we demonstrate the surgical procedure on the right knee. This case had a flexion contracture of 10° in the right knee. First, the torn medial meniscus is arthroscopically resected through anterolateral and anteromedial portals. Through a longitudinal incision, the fibula is resected at its mid-portion. Gauze is packed, and the wound is wrapped to further secure hemostasis. The tibial skin incision begins 1 cm proximal to the fibular head, runs through Gerdy’s tubercle, and passes 1 cm lateral to the tibial anterior margin. After making the skin incision, the proximal part of the tibialis anterior muscle is detached using an electrosurgical knife. The fascia of the tibialis anterior muscle is then sharply dissected 1.5 cm from the anterior margin of the tibia. Elevating the incised fascia, the muscle is separated from the fascial backside from distal to proximal using an electrosurgical knife. The muscle is then subperiosteally detached using a Cobb elevator. The knee is flexed to create room for posterior retraction, and the tibial posterior aspect is detached using a Cobb elevator as for the tibialis anterior. The lateral patellar retinaculum is incised along the edge of the patellar tendon. Retracting the fat pad, the starting point of the proximal oblique osteotomy is determined using a 4-cm gauge, and two K-wires are inserted. The ascending osteotomy is performed using a micro-oscillating saw and a chisel. The proximal oblique osteotomy line is cut with the micro-oscillating saw, and the medial cortex is completely disrupted using a chisel. After removing the two initial K-wires, a new K-wire is inserted for the hinge point, which divides the oblique osteotomy line in a 2:1 ratio. The knee is flexed, and the distal osteotomy line is drawn in accordance with the preoperative slope-decreasing plan. The line is cut toward the K-wire using the micro-oscillating saw, and additional anterior and posterior cuts are made to create a cortical window. The posterior cortices are cut from the window using a micro-reciprocating saw, and the wedge is removed. Removing the hinge K-wire, the posteromedial cortex is cut using a chisel under fluoroscopic control. The wedge can be easily closed by applying valgus stress through the handle of the RICH device fixed to the plate. During temporary fixation using K-wires, the assistant applies downward force on the patient’s thigh to eliminate the flexion contracture. An additional compressive force is applied to the flange using forceps. A drill with a compression nut is inserted through a drill sleeve and gently tightened with three fingers. The distal K-wire sleeve is removed, and the nut is tightened with a wrench until the proximal and distal oblique osteotomy lines are in maximal contact. The alignment is confirmed using a measurement radiograph on the monitor before locking screw insertion. The assistant continues to apply thigh compression, while the locking screws are inserted through the handle in sequential order. Dismounting the handle, a sleeve for proximal fixation is installed, and the clamp is removed. During the proximal locking fixation, the assistant does not relax the hand applying thigh compression, and the lead surgeon does not relax the valgus stress, to maintain alignment. Using fluoroscopy, the surgeon confirms the anteroposterior and lateral views of the fixation. Finally, the fascia of the tibialis anterior muscle is closed using a running suture without closing the plate head portion. The crural fascia of the fibular osteotomy site is also closed using a running suture.