An Alternative Technique for Prevention of Lateral Tibial Plateau Fractures During The Proximal Tibial Medial Opening Wedge Osteotomy: An Experimental Study At Calf Tibiae

Abstract

Aim: Aim of this study is to define a simple method for preventing lateral tibial plateau fractures performing proximal tibia medial opening wedge osteotomy. Materials ve Methods: 30 calf tibiae in the same age and weight group were used for the experiments. They were assigned randomly into two groups. Of the 30 specimens, 15 were selected randomly as Group A. Five of them were divided in two equal parts on frontal plane with a large saw in order to observe the efficiancy of the procedures. Others were undivided. In this group, one or two provisional Kirschner wires or Schanz screws were applied 1.5-2 cm below and paralel to the articular surface. Later, oblique or nearly oblique osteotomies were performed medio-laterally 2 cm medial to the lateral cortex and 1.5 cm and 3 cm below the lateral tibial plateau. Following osteotomy, distractionwas made with angle-scale distractor. Of the 30 specimens, 15 were selected randomly as Group B. Five of them were divided in two equal parts on the frontal plane with a large saw. Others were again undivided. Oblique or nearly oblique osteotomies were performed medio-laterally 2 cm medial to the lateral cortex and 1,5 cm and 3 cm below the lateral tibial plateau. Following osteotomy, distraction was made with angle-scale distractor. Results: In Group A where the osteotomies were more distant from the articular surface and lateral cortex, no problem was seen during the first stage where the angle of distraction was mean 9.0º. Application above the mean angle of 9.0º of distraction created fracture line proximally but these lines could not pass the level of provisional Kirschner wires or Schanz screws. The fracture lines extended to the lateral cortex under the Kirshner wires or Schanz screws. Tibial plateau fracture was not observed. However in Group B osteotomy was made 3 cm distally from the articular surface and 2 cm medially from the lateral cortex, no problem was seen during the first stage where the mean angle of distraction was 9.1º. In these specimens fractures reached tibial plateau or lateral cortex above the mean of 9.1º of distraction manoeuvres. Conclusion: K-wires or Schanz screws applied paralel to the articular surface of tibial plateau guide the fracture line the lateral cortex and prevent intraarticular fracture formation on the plateau. Key words: Proximal tibial osteotomy, High tibial osteotomy, Complications, Experimental study, Lateral tibial plateau fractures, Technical trick

Keywords

• Proximal tibial osteotomy, High tibial osteotomy, Complications, Experimental study, Lateral tibial plateau fractures, Technical trick

Proksimal Tibia Medial Açık Kama Osteotomisinde Lateral Plato Kırığı Oluşumunu Önlemek İçin Alternatif Uygulama: Dana Tibialarında Deneysel Çalışma+

Öz

Amaç: Proksimal tibia medial açık kama osteotomi uygulamalarında lateral plato kırığı oluşumunu önlemek için alternatif bir yöntem tanımlamak. Gereç ve Yöntem: Bu çalışma için yaklaşık aynı yaş grubunda ve ağırlığındaki danalara ait 30 tibia kullanıldı. Rastgele iki gruba ayrıldılar; 30 tibianın 15 tanesi rastgele seçilerek Grup A'yı oluşturdular. Bunlardan 5 tanesi, yöntemin etkinliğini ve sonuçlarını göstermek için hizar ile frontal planda iki eşit parçaya ayrıldı. Kalan 10 tibia bölünmeden kullanıldı. Bu grupta, eklem yüzeyine paralel ve 1.5-2 cm distalinden bir veya iki adet Kirshner teli veya Schanz çivisi uygulandı. Sonra, lateral korteksin 2 cm mediali ile lateral tibia platosu eklem yüzeyinin 1.5 ile 3 cm distaline olmak üzere medio-lateral doğrultuda oblik veya hafif oblik osteotomiler yapıldı. Osteotomi sonrası açı skalalı distraktör ile distraksiyon uygulandı. Kalan 15 tibia Grup B'yi oluşturdu. Bunlarda 5 tanesi yöntemin etkinliğini ve sonuçlarını göstermek için hizar ile frontal planda iki eşit parçaya ayrıldı. Kalan 10 tibia bölünmeden kullanıldı. Sonra, lateral korteksin 2 cm mediali ile lateral tibia platosu eklem yüzeyinin 1.5 ile 3 cm distalinden olmak üzere medio-lateral doğrultuda oblik veya hafif oblik osteotomiler yapıldı. Osteotomi sonrası açı skalalı distraktör ile distraksiyon uygulandı. Bulgular: Grup A'da eklem yüzeyinden ve lateral korteksten daha uzak olan osteotomilerde distraksiyonun ortalama ilk 9 derecesini uygularken problem oluşmadı. Ortalama 9 derecenin üzerinde distraksiyon uygularken proksimale doğru uzanan kırık hattı oluştu. Kırık hatları Kirshner telleri veya Shanz çivileri seviyesini daha proksimale doğru aşamadılar, tel ve çivilerin altından lateral kortekse doğru yönlendiler. Tibial plato kırığı gözlenmedi. Buna karşılık Grup B'yi oluşturan osteotomilerden eklem yüzeyinin 3 cm distalinden ve lateral korteksin 2 cm medialinden yapılan osteotomilerde ortalama ilk 9.1 derece distraksiyona kadar problem oluşmadı. Bu değerlerin üzerinde ise lateral tibial plato veya lateral kortekse uzanan kırıklar saptandı. Sonuçlar: Eklem yüzeyine paralel olarak uygulanan Kirshner telleri veya Schanz çivileri oluşan kırık hattının lateral kortekse yönlenmesini sağlayarak platoda eklem içi kırık oluşumunu önlemektedir. Anahtar kelimeler: Proksimal tibial osteotomi, Yüksek tibial osteotomi, Komplikasyonlar, Deneysel çalışma, Lateral tibial plato kırığı, Teknik incelik

Anahtar Kelimeler

• Proksimal tibial osteotomi, Yüksek tibial osteotomi, Komplikasyonlar, Deneysel çalışma, Lateral tibial plato kırığı, Teknik incelik

Kaynakça

1. Franco V, Cerullo G, Cipolla M, Gianni E, Puddu G. Open wedge high tibial osteotomy. Tech Knee Surg 2002; 1: 43-53.
2. Hernigou Ph, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity: A ten to thirteen-year follow-up study. J Bone Joint Surg [Am] 1987; 69: 332-354.
3. Hofmann AA, Wyatt RWB, Beck SW. High tibial osteotomy: Use of an osteotomy jig, rigid fixation, and early motion versus conventional surgical technique and cast immobilization. Clin Orthop 1991; 271: 212-217.
4. Koshino T, Murase T, Saito T. Medial opening-wedge high tibial osteotomy with use of porous hydroxyapatite to treat medial compartment osteoarthritis of the knee. J Bone Joint Surg [Am] 2003; 85: 78-85.
5. Lobenhoffer P, De Simoni C, Staubli AE. Open-wedge high-tibial osteotomy with rigid plate fixation. Tech Knee Surg 2002; 1: 93-105.
6. Paccola CAJ, Fogagnolo F. Open-wedge high tibial osteotomy: a technical trick to avoid loss of reduction of the opposite cortex. Knee Surg Sports Traumatol Arthrosc 2005 Jan; 13(1): 19-22. Epub 2004 Mar 16.
7. Puddu G. High tibial osteotomy (The arthritic knee in the young athlete, SYM 15) In: Abstracts Book of 11 th ESSKA 2000 Congress and 4 th World Congress on Sports Trauma , May 5-8, 2004, Athens-Greece, pp: 446-447.
8. Staubli AE, 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: S-B55-S-B62.

9. Coventry MB. Osteotomy about the knee for degenerative and rheumatoid arthritis: Indications, operative technique, and results. J Bone Joint Surg [Am] 1973; 55: 23-48.
10. Insall J, Shoji H, Mayer V. High tibial osteotomy: A five-year evaluation. J Bone Joint Surg [Am] 1974; 56: 1397-1405.
11. Maquet P. Valgus osteotomy for osteoarthritis of the knee. Clin Orthop 1976; 120: 143- 148.
12. Nakhostine M, Friedrich NF, Müller W, Kentsch A. A special high tibial osteotomy technique for treatment of unicompartmental osteoarthritis of the knee. Orthopedics 1993; 16: 1255-1258.
13. Esenkaya I. Fixation of medial opening wedge osteotomy for medial osteoarthrosis of the knee using the buttress plate with wedge. In: Abstracts Book of Second Annual International Conference of SICOT/SIROT 2003, Cairo-Egypt: P1KNE-15.
14. Esenkaya I. Fixation of medial opening wedge osteotomy for medial osteoarthrosis of the knee using the buttress plate with wedge. In: Abstracts Book of 7th Congress of the Turkish Society of Sports Traumatology Arhroscopy and Knee Surgery Combined With The 3rd Congress of Asia-Pacific Knee Society, November 1-4, 2004, Ankara-Turkey, FP-083, pp: 115-118.
15. Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003; 11: 132-138.
16. Magyar G, Toksvig-Larsen S, Lindstrand A. Open wedge tibial osteotomy by callus distraction in gonarthrosis: Operative technique and early results in 36 patients. Acta Orthop Scand 1998; 69: 147-151.
17. 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.
18. Esenkaya İ. Dizin medial osteoartritinde medial açık kama osteotomisinin tespitinde kamalı destek plağı kullanımı. XVIII. Milli Türk Ortopedi ve Travmatoloji Kongresi, 18- 23 Ekim 2003, İstanbul, Ed. Kuzgun Ü, Kongre Kitabı, Cilt 1, SS: 124, pp: 271-272.
19. Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma 2004 Dec; 124(10): 649-653. Epub 2003 Sep 30.
20. Esenkaya I. A new distractor with angle-scale for open-wedge proximal tibial osteotomy. In: Abstracts Book of 7th Congress of the Turkish Society of Sports Traumatology Arhroscopy and Knee Surgery Combined With The 3rd Congress of Asia-Pacific Knee Society, November 1-4, 2004, Ankara-Turkey, PP-012, pp: 237-238.