The Medial Opening Wedge Osteotomy in Which The Tibial Tubercle Remains Attached to the Proximal Fragment: An Anatomıc Study

Öz

Objectives: Aim of this study is to perform and to evaluate the medial opening wedge osteotomy technique in which the tibial tubercle remains attached to the proximal fragment of osteotomy on plastic tibial models and human cadaveric and amputated tibiae. Material and Methods: The medial opening wedge osteotomy in which the tibial tubercle (tuberositas tibiae, tibial tuberosity), the area of insertion of the patellar ligament, remains attached to the proximal fragment were applied on 10 plastic tibial models and six human cadaveric and four amputated tibiae. The level of the osteotomy was planned which should be started 4 centimeters distal to the medial joint line and obliquely directed laterally and proximally 1.5 centimeters distal to the lateral joint line and 1 centimeter medial to the lateral cortex. Medial cortex, anterior cortex around the tibial tubercle and posterior cortex were cut in which the tibial tubercle remains attached to the proximal fragment Results: When the medial opening wedge osteotomy in which the tibial tubercle remains attached to the proximal fragment was carried out at human cadaveric tibiae, fracture of tibial tubercle was observed in the first application. The reason of this complication was determined that not to have been noticed posterior angulation of proximal tibia metaphyseal region during the drilling to weaken the bone and later to cut the bone from medial to lateral. We didn't have another fracture in the other bone specimens which was cut 120°-125° angulated anterior cut around and behind the tuberosity. Conclusıons: Distal tuberosity osteotomy in open wedge proximal osteotomy can prevent patella infera because of the patellar ligament and its insertion area tibial tubercle were not exposed to the stretching. Application of these osteotomies on human cadaver or amputated tibiae and plastic tibial models were also diffucult than other classic osteotomy techniques. It must remember that tibial tubercle may be broken during the application of the technique. Key words: Proximal Tibial Osteotomy, High Tibial Osteotomy, Retrotubercle Osteotomy, Patella İnfera, Patella Baja, Anatomic Experiment

Anahtar Kelimeler

• Proximal Tibial Osteotomy, High Tibial Osteotomy, Retrotubercle Osteotomy, Patella İnfera, Patella Baja, Anatomic Experiment

Tibial Tüberkülün Proksimal Fragmanda Bırakıldığı Proksimal Tibia Medial Açık Kama Osteotomisi: Anatomik Çalışma+

Öz

Amaç: Proksimal tibia medial açık kama osteotomisinde tibial tüberkülün proksimal fragmanda bırakıldığı retrotüberkül osteotomi tekniğini plastik tibia örnekleriyle insan kadavra ve amputat tibialarında uygulamak ve değerlendirmek. Gereç ve Yöntem: 10 plastik tibia örneğiyle altı insan kadavra ve dört amputat tibiasında, patellar tendonun yapıştığı tibial tüberkül (tuberositas tibia) proksimal fragmanda kalacak şekilde proksimal tibia medial açık kama osteotomisi uygulandı. Medialden açık kama osteotomisi eklem seviyesinin 4 cm distalinden başlayarak lateralde eklem seviyesinin 1.5 cm distaline ve lateral korteksin 1 cm medialine uzanacak şekilde planlandı. Tibial tüberkül geniş bir tabanla proksimal fragmanda kalacak şekilde medial korteks, tibial tüberkül etrafından anterior korteks ve posterior korteks kesildi. Sonuçlar: Tibial tüberkül etrafından yapılan osteotomilerde insan kadavrasına ait tibia örneklerinde ilk uygulamada tibial tükerkül kırıldı. Bu komplikasyon, medialden laterale kemiği zayıflatmak için yapılan drilizasyon ve sonrası osteotomi esnasında proksimal tibia metafizer bölgesinin posteriora yaptığı eğimi hesaplamama sonrası oluştuğu saptandı. Bu eğim göz önüne alınarak yapılan ve tibial tüberkülün proksimal fragmana geniş bir tabanla tutunduğu ve yaklaşık 120-125 derecelik bir açıyla kesildiği örneklerde benzer komplikasyonla karşılaşılmadı. Çıkarımlar: Tibial tüberkülün proksimal fragmanda bırakıdığı medial açık kama osteotomilerinde patellar tendon ve yapışma yeri gerilmeye maruz kalmayacağı için patella infera oluşumu önlenecektir. Ancak, özellikle tibial tüberkül etrafından yapılan osteotomi uygulamasının klasik açık kama osteotomi yöntemlerine kıyasla teknik zorluklar içerdiği ve uygulama esnasında tibial tüberkülün kırılabileceği hatırlanmalıdır. Anahtar kelimeler: Proksimal tibial osteotomi, Yüksek tibial osteotomi, Tuberositas tibia arkasından yapılan osteotomi, Patella/Patellar tendon Oranının azalması, Anatomik çalışma

Anahtar Kelimeler

• Proksimal tibial osteotomi, Yüksek tibial osteotomi, Tuberositas tibia arkasından yapılan osteotomi, Patella/Patellar tendon Oranının azalması, Anatomik çalışma

Kaynakça

1. Agarwala S, Sinha M, Parasnis RN. Box osteotomy- a new technique of proximal tibial osteotomy for osteoarthritis of the knee. Orthop Traumatol 2001; 3. 218-227.
2. Franco V, Cerullo G, Cipolla M, Gianni E, Puddu G. Open wedge high tibial osteotomy. Tech Knee Surg 2002; 1: 43-53.
3. Hernigou P, Ma W. Open wedge tibial osteotomy with acrylic bone cement as bone substitute. Knee 2001; 8: 103-110.
4. Hernigou Ph, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. J Bone Joint Surg [Am] 1987; 65: 332-354.
5. Kitson J, Weale AE, Lee AS, MacEachern AG. Patellar tendon length following opening wedge high tibial osteotomy using an external fixator with particular reference to later total knee replacement. Injury 2001; 32 Suppl 4: SD140-143.
6. Koshino T, Morii T, Wada J, Saito H, Ozawa N, Noyori K. High tibial osteotomy with fixation by a blade plate for medial compartment osteoarthritis of the knee. Orthop Clin North Am 1989; 20: 227-243.
7. Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003; 11: 132-138. Epub 2003 Jan 11.
8. Lobenhoffer P, De Simoni C, Staubli AE. Open-wedge high tibial osteotomy with rigid plate fixation. Tech Knee Surg 2002; 1: 93-105.

9. Maquet P. Valgus osteotomy for osteoarthritis of the knee. Clin Orthop 1976; 120: 143- 148.
10. Maquet P. The treatment of choice in osteoarthritis of the knee. Clin Orthop 1985; 192: 108-112.
11. Backstein D, Meisami B, Gross AE. Patella baja after modified Coventry-Maquet high tibial osteotomy. J Knee Surg 2003; 16: 203-208.
12. Kaper BP, Bourne RB, Rorabeck CH, MacDonald SJ. Patella infera after high tibial osteotomy. J Arthroplasty 2001; 16: 168-173.
13. Nakamura E, Mizuta H, Kudo S, Takagi K, Sakamoto K. Open-wedge osteotomy of the proximal tibia with hemicallotasis. J Bone Joint Surg [Br] 2001; 83: 1111-1115.
14. Ogata K. Interlocking wedge osteotomy of the proximal tibia for gonarthrosis. Clin Orthop 1984; 186: 129-134.
15. Saito T, Takeuchi R, Ara Y, Yoshida T, Koshino T. High tibial osteotomy with anterior advancement of distal fragment for medial and patellofemoral compartmental osteoarthritis of the knee. Knee 2002; 9: 127-132.
16. Tigani D, Ferrari D, Trentani P, Barbanti-Brodano G, Trentani F. Patellar height after high tibial osteotomy. Int Orthop 2001; 24: 331-334.
17. Westrich GH, Peters LE, Haas SB, Buly RL, Windsor RE. Patella height after high tibial osteotomy with internal fixation and early motion. Clin Orthop 1998; 354: 169-174.
18. Cullu E, Aydoğdu S, Sur H. Does patellar ligament length chance after dome-type high tibial osteotomy? Bull Hosp Jt Dis 2000; 59: 140-143.
19. Esenkaya I, Elmali N, Misirlioglu M. Fixation of medial opening wedge osteotomy for medial osteoarthritis of the knee using buttress plate with wedge.7th Congress of the Turkish Society of Sports Traumatology Artroscopy and Knee Surgery Combined With The 3rd Congress of Asia-Pacific Knee Surgery Abstract Book; November 01-04 2004; Ankara, Turkey: FP: 083, pp: 115-118.
20. Sonneveld H, Wymenga AB, Lelivelt ABM, Jacobs WCH (2002) Distal tuberosity osteotomy in open wedge high tibial osteotomy prevents patella baja; A new technique.In: 10 th ESSKA 2000 Congress Abstracts, April 23-27, 2002, Rome, P-118, pp: 300.
21. Gaasbeek RDA, Sonneveld H, Van Heerwaarden RJ, Jacobs WCH, Wymenga AB. Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera; a new technique.In: 11th ESSKA 2000 Congress 4th World Congress on Sports Trauma, Abstracts&Presentations, May 5-8, 2004, Athens-Greece, OP-43, pp: 26.
22. Scuderi GR, Windsor RE, Insall JN. Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg [Am] 1989; 71: 245-248.
23. Murphy SB. Tibial osteotomy for genu varum: Indications, preoperative planning, and technique. Orthop Clin North Am 1994; 25: 477-482.
24. Esenkaya I, Misirlioglu M, Atasever A. The posterior slope angle of proximal tibial metaphysis region. 7th Congress of the Turkish Society of Sports Traumatology Artroscopy and Knee Surgery Combined With The 3rd Congress of Asia-Pacific Knee Surgery Abstract Book; November 01-04 2004; Ankara, Turkey: PP: 020, pp: 247-249.
25. Closkey RF, Windsor RE. Alterations in patella after a high tibial or distal femoral osteotomy. Clin Orthop 2001; 389: 51-56.