Name: Proximal Tibial Opening Wedge Osteotomy
Uploaded: 2012-05-17T00:00:00Z
Channel: Arthrex

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VCD-1030 | A | Proximal Tibial Opening Wedge Osteotomy

Ned Amendola

Human

Peter Fowler

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Proximal Tibial Opening Wedge Osteotomy

Arthrex presents a proximal tibial opening wedge osteotomy using the Arthrex opening wedge osteotomy system. The procedure is performed by Doctor Ned Amendola and Doctor Peter J. Fowler in London, Ontario. The young, active patient with early arthrosis of the knee and malalignment continues to be a very difficult management problem. Until recently, valgus closing wedge osteotomy has been the method of treatment for the malalignment. With the development of the opening wedge osteotomy technique designed in conjunction with Arthrex, surgeons are able to perform opening wedge osteotomies on either the femoral or tibial sides of the joint to correct either valgus or varus malalignment. Since 1996, we have performed 125 opening wedge osteotomies of the proximal tibia. The average age of these patients was 49 years. Our primary indications include malalignment with arthrosis and or instability of the knee. Ne. We refrain from performing this procedure in patients with profound loss of knee motion or compartmental osteoarthritis. The instrumentation has been specifically designed to predict the accuracy of the angle of the wedge osteotomy. Intraoperative adjustments can be achieved prior to the final plate fixation. Several other benefits favoring the opening wedge technique include. It's a procedure which can be performed through a small medial incision with minimal soft tissue disruption, avoiding the concern over neurovascular complications associated with the lateral approach to the knee joint. This technique also has a higher degree of precision, and alterations can be made intraoperatively without additional steps. The opening wedge osteotomy system allows the surgeon to correct malalignment while maintaining or altering the slope of the joint line surfaces, if necessary. In the proximal tibial opening. Wedge osteotomy, the articulation of the tibiofibular joint is left unaltered. Posterolateral knee dissection is avoided and therefore the neurovascular structures are avoided and the possible complication of compartment syndrome is avoided. Recently, in addition to the standard osteotomy plates designed by Arthrex, we have also utilized sloped osteotomy plates, which better account for the normal physiologic anterior to posterior slope of the tibia. The opening wedge osteotomy is easily performed along with anterior cruciate ligament reconstruction when necessary, and osteochondral resurfacing procedures in the knee. Pre-operative planning consists of full length radiographs as well as Rosenberg views to determine the amount of arthrosis and the appropriate correction. Our preoperative measurement is carried out in the following fashion. A line is drawn from the center of the femoral head to the center of the tibiotalar joint. This demonstrates the patient's mechanical axis. Another line is drawn from the center of the femoral head to a point midway in the lateral knee joint, that is 62.5% of the width of the tibial plateau. A second line is drawn from that point to the tibiotalar joint. The angle formed by the intersection of these two lines determines the degree of correction required to return the patient's mechanical axis to the point of intersection on the lateral side of the joint. Approximately one degree of correction is equal to one millimeter of opening of the osteotomy. Once the patient is prepped and draped, a diagnostic arthroscopy may be conducted to determine the status of the articular surfaces. Diagnostic arthroscopy is recommended prior to the osteotomy. Resurfacing procedures are considered and have proven effectiveness in combination with the opening wedge technique. Debridement is performed at this time if necessary. Once the arthroscopic portion is complete, the leg is exsanguinated and the tourniquet is inflated. A 6 to 7 centimeter vertical incision is made over the pars anserinus. Insertion midway between the medial border of the patellar ligament and the posterior margin of the tibia. The sartorius fascia is incised, exposing the hamstrings, and the hamstring tendons are retracted inferiorly, exposing the superficial medial collateral ligament. The medial lateral ligament can be managed in two ways. It can either be elevated subperiosteal and left intact, exposing the bone for the osteotomy, or if necessary, it can be divided transversely, one centimeter proximal to its insertion. However, if the osteotomy is being performed for instability concomitantly with ACL reconstruction with various thrust, the medial ligament may be elevated rather than sectioning it in order to avoid possible further instability. Retractors are then placed anteriorly to protect the patellar ligament and then posteriorly to protect the neurovascular structures. Extreme care must be taken when placing the posterior retractor to avoid compromise to the neurovascular structures with the aid of fluoroscopy, the three millimeter osteotomy guide pin is driven transversely across the proximal tibia, 1 to 2cm below the joint line, from medial to lateral and parallel to the joint. This pin is drilled to the lateral cortex but not penetrating the cortex. The tip of the pin is a reference of measurement to ensure that the osteotomy is directed to a point one centimeter medial to the tip. An anatomically correct AP view verifies the insertion depth. Next, the osteotomy guide assembly is inserted over the guide pin and positioned to the back of the guide, which meets the laser line on the pin. The parallel guide sleeve assembly is then placed onto the osteotomy guide over the central hub, and screwed down before advancing the two sleeves. The angle of the guide is set so that the two pins will be driven to a point that they will cross, just cephalad to the tibial tubercle. Once this angle is determined, the black knob is tightened and the two sleeves are advanced to bone. Note at this point, any adjustments to the AP slope of the tibial osteotomy can be accommodated by rotating the parallel guide sleeve assembly appropriately, but typically this angle is kept at zero degrees. Also, the eccentric holes in the drill sleeves may be rotated to accommodate variations in size and anatomy. The first of two osteotomy breakaway pins are drilled within one half to one centimeter of the lateral cortex, followed by the second pin driven in the same manner. The position of these two pins is then viewed under fluoro, and if the position is acceptable, the entire guide assembly in the three millimeter guide pin are removed. Next, the cutting guide is positioned over the remaining pins so that the cutting surface with the capture tags is facing inferiorly. The 22. four millimeter pins have breakaway scores along the length of the pin, and are shortened to accommodate a ten millimeter oscillating saw. A mallet is then used to drive the head stabilizing pin into bone. Position of the retractors are again verified before using the PowerOsteotome, using repeated confirmation with fluoroscopy. The saw is then advanced flush with the inferior surface of the cutting guide and used anteriorly, medially and posteriorly. This system is designed to produce a cut which intersects the initial guide pin one centimeter from its tip, leaving the lateral cortex intact as a hinge for the medial opening. Once the maximum depth of the saw blade is achieved, the acetone handle is loaded with either a ten, 25, or 35 millimeter blade and is used to complete the osteotomy. It is important that this stage of the procedure to advance the osteotomy in a manner as to avoid violating the lateral cortex. Once this oblique cut has been made with the appropriate one centimeter lateral hinge, the assembled osteotomy wedge and handle are inserted into the osteotomy and driven with a mallet to the predetermined depth. It is important at this point to allow the bone to plastically deform between impacts of the of the mallet while opening the osteotomy in order to prevent inadvertent fracturing into the tibial plateau or through the lateral cortex. On this patient, the depth is 15mm. Once the predetermined depth is reached, verified on the tines of the osteotomy wedge alignment verification is conducted using the assembled alignment rod from the hip to ankle under fluoroscopy, to ensure that the weight bearing axis is through the lateral compartment of the knee. Once the desired opening has been achieved, the wedge handle is removed, leaving the two tines in place. If only one of the tines remains secure within the osteotomy that is normal and is of no concern. Next, the ten millimeter tibial opening wedge osteotomy plate, determined to be the proper size for this patient, is brought up to the field. We consider a sloped plate based on our needs to reproduce the normal AP slope of the tibia. Normally, when performing a medial opening wedge osteotomy, there is a slight tendency to open the osteotomy more anteriorly than posteriorly. Therefore, using a slow plate will prevent that from happening. The plate is inserted between the tines, with the central tooth separating the osteotomy. Plate. Fixation is achieved approximately with 26.5 cancellous screws. Next, the two distal screws are placed using 4.5mm cortical screws. Taking advantage of the bicortical purchase of these screws in concert with the procedure, and the system may be harvesting bone from the iliac crest. Following the plate fixation, bone graft harvested from the iliac crest is packed into the defect for defects greater than 7.5mm, we recommend utilizing allograft autogenous or combined sources of tightly packed bone to the defect. Cortical rims should be reestablished with cortical pieces. Local tibial cancellous grafts may be used for defect 7.5mm or smaller by or. Cortical grafts should be used for defects one centimeter and larger. Once the bone graft is packed, a final alignment is checked. The tourniquet is released. The hemo vac place, then closure is conducted, avoiding violation of the newly packed bone graft. Well, to conclude, we found the opening wedge osteotomy technique to be safe and reproducible. We've I've done over 125 patients, and I've shown minimal morbidity and satisfactory outcome for patients with unicompartmental. Osteoarthrosis. Well, postoperatively we overnight tonight, he'll be in a knee immobilizer and be in hospital tomorrow morning. We'll put him in a hinge padded hinge brace where we won't restrict any motion on it, and then we'll get him up on crutches. We determine how much weight we're going to put on initially by how stable we think this is. So we'll have him On on partial weight bearing. Well, we'll see him in three weeks and then again at six weeks, but at six weeks, all going well, we'll put them on full protected weight bearing, but we still like it protected with a pair of crutches until it's been 12 weeks. During this time, there's no restriction of motion or no restriction of any physiotherapy modality to try and get the motion or work on the strength. We X-ray him at three weeks, six weeks and 12 weeks and six months and one year. For further information on the Arthrex Opening Wedge Osteotomy system and other Arthrex products, call Arthrex in Naples, Florida at 1-800-934-4404 or visit the Arthrex website at arthrex.com.

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Proximal Tibial Opening Wedge Osteotomy

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