High Complication Rate After Biplanar Open Wedge High Tibial Osteotomy Stabilized With a New Spacer Plate

(Position HTO Plate) Without Bone Substitute

Steffen Schrter, M.D., Christoph E. Gonser, M.D., Lukas Konstantinidis, M.D., Peter Helwig, M.D., and Dirk Albrecht, M.D.

Purpose: We performed a prospective clinical and radiographic evaluation after open wedge high tibial osteotomy (HTO) using the new Position HTO plate (Aesculap, Tuttlingen, Germany) without bone transplantation. Methods: Thirty-ve open wedge HTOs with the Position HTO plate were performed without bone wedges. The mean patient age was 44.6 9.2 years at the time of osteotomy, which was planned with mediCAD II software (Hectec, Niederviehbach, Germany). The Hospital for Special Surgery score, Lysholm-Gillquist score, Tegner activity level, and International Knee Documentation Committee subjective score were used for clinical assessment. We evaluated radiographs obtained preoperatively and at 2, 6, and 12 months postoperatively using fullweightbearing anteroposterior whole-leg views and anteroposterior and lateral views of the knee. For statistical analyses, JMP 8.0.1 (SAS, Cary, NC) was used. Results: We observed an overall complication rate of 34% and a plate-related complication rate of 23%. Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. A signicant difference in the mechanical tibiofemoral angle of 1.3 1.4 (P .001) was found between the follow-up at 2 and 6 months. The mean Hospital for Special Surgery score was 74.8 11.7 preoperatively, and it increased to 87.8 11.0 (P .001). The mean score on the Lysholm-Gillquist knee functional scoring scale was 55.5 21.7 preoperatively, and it improved to 73.0 23.9 (P .001). The Tegner activity level was 2.6 0.9 preoperatively, and it improved signicantly at nal follow-up to 3.7 1.8 (P .02). The International Knee Documentation Committee subjective score was 43.0 14.9 preoperatively, and it increased to 66.1 21 (P .001). Conclusions: We have shown a high plate-related complication rate and a signicant loss of correction between 2 and 6 months of follow-up after open wedge HTO using the new Position HTO plate without bone wedges. The preoperatively planned mechanical tibiofemoral angle was not achieved. Despite these complications, the clinical outcome improved signicantly. The Position HTO plate cannot be recommended with the presented technique. Level of Evidence: Level IV, therapeutic case series.

he high tibial osteotomy (HTO) is a wellestablished and commonly used treatment for younger patients and active older patients with medial

From the Department of Traumatology and Reconstructive Surgery, BG Traumacenter Tbingen (S.S., C.E.G., D.A.), Tbingen; and Department of Orthopaedics and Trauma Surgery, University Medical Centre (L.K., P.H.), Freiburg, Germany. Supported by DGUV (Deutsche Gesetzliche Unfallversicherung) FR150. The authors report no conict of interest. Received April 12, 2010; accepted January 7, 2011. Address correspondence to Dirk Albrecht, M.D., BG Traumacenter, Schnarrenbergstrasse 9572076, Tbingen, Germany. E-mail: publikationbg@googlemail.com 2011 by the Arthroscopy Association of North America 0749-8063/10232/$36.00 doi:10.1016/j.arthro.2011.01.008

unicompartmental osteoarthritis of the knee and varus malalignment. The aim of this technique is to shift the load to an intact lateral compartment to delay the total knee arthroplasty. Performing an open wedge HTO through a medial approach is a technique that avoids complications such as peroneal nerve lesion.1,2 In 1987 Hernigou et al.3 were the rst to describe this technique. Since then, specialized implants have been developed.2,4-7 These implants include short spacer plates with8 or without locking screws4 and locking plates without a spacer.2 The open wedge HTO with short plates and without bone transplantation has been shown to yield signicantly more mechanical complications.9,10 For example, Nelissen et al.9 noted a complication rate of

644

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 5 (May), 2011: pp 644-652

OPEN WEDGE HTO AND SPACER PLATE 45.8%, whereas Spahn10 reported a complication rate of 43.6% using a short spacer plate without locking screws (Puddu I; Arthrex, Naples, FL). However, complication rates with the new Position HTO plate (Aesculap, Tuttlingen, Germany) for HTO are not known. The purpose of this study was to examine the clinical and radiographic outcome after open wedge HTO using the new Position HTO plate without bone transplantation. We hypothesized that this technique may be a safe procedure that would lead to an improved clinical situation in patients with medial-compartment osteoarthritis. METHODS This study was performed with the approval of the local ethics committee and informed written consent from patients. Inclusion criteria were symptomatic medial osteoarthritis or articular cartilage lesions of the knee joint in active patients, varus limb malalignment, and a lateral joint compartment that was intact or whose cartilage lesions with an International Cartilage Repair Society grade of less than I. We included both smoking and nonsmoking patients. The gap size of the osteotomy was not limited. Exclusion criteria were clinically relevant disorders of bone metabolism (osteoporosis), body mass index (BMI) over 35 kg/m2, active infection, and range of motion of 100 or less. In total, 35 open wedge HTOs were performed (15 left side and 20 right side, 22 men and 13 women). The mean age at the time of the index operation was 44.6 9.2 years. The mean BMI was 27.6 4.4 kg/m2. Preoperative radiographs consisted of fullweight bearing long standing anteroposterior radiographs of the whole lower extremity, as well as anteroposterior and lateral views of the knee. In 23 cases the OrthoPilot navigation tool (B. Braun Aesculap, Tuttlingen, Germany) was used; in 12 cases the osteotomy was planned with mediCAD II planning software (Hectec, Niederviehbach, Germany). The radiographic examination included the mechanical tibiofemoral angle (mTFA) (varus deviation is indicated by negative values and valgus deviation by positive values, Fig 1) and the mechanical medial proximal tibial angle. Our preoperative goal was to achieve a 0 to 2 mTFA in cases with isolated cartilage defects and 2 to 4 overcorrection in cases of osteoarthritis. The mean gap size was 8 2 mm. The complication rate was analyzed retrospectively by use of patient charts. Plate-related complications were dened as loss of correction, postsurgical frac-

645

FIGURE 1.

Measurement of mTFA.

ture of the tibial plateau (fracture line through tibial plateau, beginning in osteotomy and ending in lateral tibial plateau), screw failure, malunion, and fracture of the lateral cortical bone. Other complications were dened as intraoperative tibial plateau fracture, early infection, postoperative hematoma, and arthrobrosis. Clinical Assessment The Hospital for Special Surgery (HSS) score,11,12 Lysholm-Gillquist score,13 Tegner activity score,14 and International Knee Documentation Committee (IKDC) subjective score15 were used for the clinical assessment. The HSS score (62% subjective and 38% objective) included 6 subscales with 7 items; the maximum score was 100 points. The Lysholm-Gillquist knee functional scoring scale (95% subjective and 5% objective) was used; it is a self-administered patient

646

S. SCHRTER ET AL. two-thirds of the cortical bone were cut; for anterior osteotomy, the tibial tuberosity bone was cut completely, with an angle of 130. The dorsal cortical bone of the tibial plateau was cut with chisels up to 1 cm to the lateral cortical bone. The osteotomy was slowly widened to achieve a gap size according to the preoperative plan or the navigation tool. The Position HTO plate was placed anteromedially under the pes anserinus and with a spacer according to the gap size. By use of two 6.5-mm spongiosa locking screws for proximal xation and two 4.5-mm cortical locking screws for the distal part, the xation was completed. The layers were closed, and a drain was placed. Postoperatively, the patients were allowed 20 kg partial weight bearing on the side of surgery using 2 crutches. Braces or casts were not used. Active physiotherapy was started after drain removal. In addition, patients used an active motion splint (CAMOped; OPED, Valley/Oberlaindern, Germany) for 6 weeks. After 6 to 8 weeks and X-ray control, full weight bearing was implemented. Follow-up examinations were performed after 2 months (lasting 6 to 8 weeks, range of 2 months), 6 months, and 12 months by the same examiner (S.S.). Radiographs at these time points included fullweight-bearing anteroposterior views of the whole leg, as well as anteroposterior and lateral views of the knee. The clinical and functional outcomes were assessed preoperatively and 12 months after surgery by use of the previously mentioned scores. Statistical Analysis JMP 8.0.1 (SAS, Cary, NC) was used for statistical analysis. Results for the HSS score, Tegner activity level, Lysholm-Gillquist knee functional scoring scale, and IKDC score that were assessed preoperatively and at 12 months follow-up were compared with the paired Student t test. Radiographic ndings were also analyzed with the paired Student t test. The mTFA was analyzed at the follow-up time points. Osteoarthritic patients were subdivided into 2 groups: mTFA less than 0 (group A) and mTFA greater than 0 (group B). The results of the clinical scores were evaluated by use of compared multivariance analyses 0.05. (ANOVA). The level of signicance was

questionnaire consisting of 8 items in which pain and instability each account for 30 of 100 points. The Tegner activity level was assessed by 1 examiner and covered activities of daily living, recreation, competitive sports, and work, with a maximum score of 10 points. The IKDC evaluation system was based on the patients subjective evaluation of knee functions such as symptoms and activity. Surgical Procedure Surgery was performed with the patient under spinal or general anesthesia. Single-shot antibiotics and prophylactic low-dose heparin were used. Arthroscopy was performed immediately before open wedge HTO, in 77.1% of patients, or a few weeks before surgery to assess the stage of lateral-compartment osteoarthritis. Additional surgery was necessary in 46% of cases (Fig 2). In 23 cases (66%) the OrthoPilot navigation tool was also used. For navigation, the femur and tibia were used as landmarks for the infrared-based navigation measuring the preoperative angle for open wedge HTO. The surgical technique consisted of a biplanar 130 L-shaped osteotomy without bone graft or bone substitute, as described by Staubli et al.1 and Lobenhoffer and Agneskirchner.2 In brief, a 4- to 6-cm longitudinal incision 5 cm distal to the knee joint line was made. With extension from the medial aspect, we positioned 2 K-wires parallel to the tibial slope above the pes anserinus, targeting the tibiobular joint under uoroscopic control. For transverse osteotomy,

FIGURE 2. Frequency of additional surgery. (ACT, autologous cartilage transplant; cartilage cells, harvest cartilage cells for ACT in further operation; me, partial meniscectomy; microfracture, microfracture according to Steadman in defect areal medial; microfracture me, microfracture according to Steadman in defect areal medial and partial meniscectomy; no, no further procedure during arthroscopy performed.)

RESULTS An overall complication rate of 34% and a platerelated complication rate of 23% were observed. Differences in gap size, BMI, and age between the

OPEN WEDGE HTO AND SPACER PLATE

647

In 1 case a TomoFix plate (Synthes, Oberdorf, Switzerland) was used. In the second case we had recommended a similar procedure but the patient disapproved of any surgical intervention. After 8 months, the osteotomy was consolidated. In 2 cases the early postoperative radiographs taken during the phase of partial weight bearing showed loss of correction and a medial dislocation of the tibial plateau. We performed a correction procedure. Furthermore, screw failure and loss of correction with malunion occurred (Fig 4) and were treated surgically. For xation, a TomoFix plate was used. Bone wedges for transplantation were harvested from the iliac crest. In 1 case, during metal removal, screw failure was found whereas the osteotomy was fully consolidated. In cases with complications, the gap size was 8.7 2.0 mm. In those without complications, the gap size was 8.0 1.8 mm. The difference was not signicant. Radiographic Results Preoperatively, the mTFA was 4.6 3.2 (range, 12.8 to 0.8). The mean mTFA was planned to be

FIGURE 3. (A) Intraoperative uoroscopic image with Position HTO plate after osteotomy. (B) Radiograph after 2 months followup. A tibial plateau fracture was seen.

group with plate-related complications and the group without complications were not observed. Signicant differences between the groups with and without navigation were not found for BMI, age, and mTFA. Complications An intraoperative lateral tibial plateau fracture occurred in 1 case (Table 1). As a salvage procedure, an additional tension screw and a Position HTO plate were used. No further operation was required. An early infection occurred after 10 days in 1 case. Two revision procedures and intravenous antibiotics were necessary. A postoperative hematoma developed in 1 case. Surgical revision included debridement, lavage, and drain insertion. Lateral tibial plateau fractures with a fracture line through the tibial plateau, beginning in the osteotomy and ending in the lateral tibial plateau, were seen in 2 cases after 2 months follow-up (Fig 3B). Retrospectively, no tibial plateau fracture was noted during intraoperative uoroscopy (Fig 3A).

FIGURE 4. Fullweight-bearing standing radiograph of whole leg, anterior-posterior, after 6 months, showing loss of correction and broken screw, as measured with mediCAD.

648
TABLE 1.

S. SCHRTER ET AL.
Summary of Complications
No. 1 1 1 1 2 2 3 1

Complication Intraoperative tibial plateau fracture Early infection Postoperative hematoma Loss of correction Postsurgical fracture of tibial plateau Screw failure and malunion Fractured lateral corticalis Arthrobrosis

groups was not signicant. After 6 months of followup, no further signicant loss of correction was found. Furthermore, no difference between the navigated and non-navigated groups was found. The mean mechanical medial proximal tibial angle was 86.2 2.9 (range, 78.3 to 93.9) preoperatively, it was 90.3 2.5 (range, 86.6 to 95.1) at 2 months after surgery, and it decreased after 12 months to 89.8 2.8 (range, 83.3 to 93.9). The mean difference was 1.2 1.7, which was signicant (P .004). Clinical Results

2.2 1.2 (range, 0 to 4). At the rst follow-up, the mean mTFA was 1.0 2.6 (range, 5.7 to 6.6). After 6 months, the mean mTFA was 0.3 2.5 (range, 6.3 to 4.9), and after 12 months, the mean mTFA was 0.7 3.1 (range, 9.3 to 3.9). Signicant differences between the navigated and non-navigated groups were not found. Between preoperatively and 2 months follow-up, radiographic measurements showed a signicant difference in the mTFA: 5.4 3.5 (P .001). Between 2 and 6 months, a signicant difference in the mTFA of 1.3 1.4 (P .001) was observed. No signicant differences between 6 and 12 months follow-up were seen (Table 2). A loss of correction was shown between 2 and 6 months follow-up (P .0002). The mTFA data were also analyzed regarding the presence or absence of complications (Table 2). Complications such as hematoma or infection without relation to the biomechanical alignment were assessed in the group with no (biomechanical) complications. Between 2 and 6 months, signicant differences in mTFA of 1.0 1.1 (P .001) and 2.2 2.0 (P .04) between the groups with and without complications were found. The difference between these
TABLE 2.

Concerning subjective and objective knee function, signicant improvements were found for all scores (Table 3). The mean HSS score was 74.8 11.7 (range, 51 to 99) preoperatively, and it increased to 87.8 11.0 (range, 61 to 99) after 12 months. The mean difference of 10.9 was signicant (P .001). According to the preoperative ratings, 23% of cases were excellent, 47% were good, 20% were fair, and 10% were poor. Postoperatively, 63% were excellent, 31% were good, and 6% were fair. The mean score on the Lysholm-Gillquist knee functional scoring scale was 55.5 21.7 (range, 17 to 94) preoperatively, and it increased to 73.0 23.9 (range, 21 to 100). The mean difference was 18.6 18.1 (P .001). The Tegner activity level was 2.6 0.9 (range, 1 to 4) preoperatively and 3.7 1.8 (range, 1 to 8) postoperatively. The mean difference was signicant (P .02). The IKDC subjective score was 43.0 14.9 (range, 13 to 71) preoperatively, and it increased postoperatively to 66.1 21 (range, 30 to 100). The mean difference was 23.7 14.8 (P .001). Signicant differences were not found between the navigated and non-navigated groups. Patients with osteoarthritis were divided into group

Radiographic Findings of All Cases

mTFA mTFA Without Complications 4.3 2.3 1.3 5.8 1.1 0.2 1.0 0.0 0.2 2.3 2.6 1.1 2.5 3.0 (P .0001) 2.6 (NS) 2.4 1.1 (P .001) 2.4 1.1 (NS) 2.6 (P .002) mTFA With Complications 5.4 2.0 0.2 4.2 2.2 2.1 2.2 3.0 0.2 5.7 4.7 1.5 2.7 4.7 (NS) 2.6 (NS) 2.1 2.0 (P .04) 0.7 0.8 (NS) 4.8 (NS)

Preoperative Planning 2 mo follow-up Mean difference between Mean difference between 6-mo follow-up Mean difference between 12-mo follow-up Mean difference between Mean difference between

2 mo and preoperative 2 mo and planning 6 mo and 2 mo 12 mo and 6 mo 12 mo and planning

4.6 2.2 1.0 5.4 1.3 0.3 1.3 0.7 0.2 2.8

3.2 1.2 2.6 3.5 (P 2.6 (P 2.5 1.4 (P 3.1 1.0 (NS) 3.1 (P

.0001) .008) .0002)

.0007)

Abbreviation: NS, not signicant.

OPEN WEDGE HTO AND SPACER PLATE

TABLE 3.
Lysholm-Gillquist Preoperative 12-mo follow-up Mean difference 55.5 73 18.6 21.7 23.9 18.1 (P 74.8 87.8 10.9

649

Clinical Scores
Tegner Activity Level 2.6 3.7 1.1 0.9 1.8 1.8 (P 43.0 66.1 23.7 IKDC 14.9 21.0 14.8 (P

HSS 11.7 11.0 11 (P

.0009)

.0001)

.02)

.0001)

A (mTFA 0) and group B (mTFA 0). Differences in HSS score, Lysholm-Gillquist knee functional scoring scale, Tegner activity level, and IKDC score were found between groups A and B (Table 4). These differences were not signicant. DISCUSSION We hypothesized that open wedge HTO using the Position HTO plate without bone transplantation may be a safe procedure that may improve the clinical function in patients with medial-compartment osteoarthritis. The open wedge HTO using the Position HTO plate was not safe, but, nevertheless, a signicant increase in the clinical outcome was observed. An overall complication rate of 34% and a plate-related complication rate of 23% were observed, which included screw failure and lateral tibial plateau fractures. Radiographic follow-up analysis showed a signicant loss of correction in the mTFA between 2 and 6 months follow-up in both the group with complications and the group without complications. After 6 months, no further signicant loss of correction was
TABLE 4. Clinical Scores According to Radiographic Outcome
Clinical Score Lysholm-Gillquist score Preoperatively 12-mo follow-up Difference HSS score Preoperatively 12-mo follow-up Difference Tegner activity level Preoperatively 12-mo follow-up Difference IKDC score Preoperatively 12-mo follow-up Difference Group A: mTFA 0 48.3 65.5 14.9 73.2 84.0 12.1 2.9 3.0 0.1 38.6 61.2 22.1 22.7 28.0 20.5 11.8 12.4 7.7 0.6 1.7 1.2 13.5 22.0 14.7 Group B: mTFA 0 59.4 86.6 27.2 83.4 92.6 9.2 2.8 5.0 2.2 50.3 81.6 31.3 23.4 15.8 13.6 9.7 5.9 9.6 0.4 1.9 2.3 13.5 13.72 17.1

measured compared with recent follow-up after 12 months. High rates of complications in open wedge HTO with short spacer plates were also noted by other authors and with a comparable surgical technique. For xation, short spacer plates without locking screws (Puddu; Arthrex) were used.9,10 Spahn10 recorded an implant failure rate of 16.4%. In cases with a correction angle greater than 12.5, a bone transplantation was carried out from the iliac crest. Nelissen et al.9 reported broken plates in 6.1% of cases and broken screws in 7.5%. The osteotomy gap was lled with -tricalcium phosphate (Vitoss; Stryker, Kalamazoo, MI). In our study we did not observe plate failure, but in 6% of cases, screw failure was observed. Such problems seem to be typical of short spacer plates because in studies using larger plate xators such as the TomoFix plate, these problems did not occur.1,4,16,17 In other reports, correlations between partial weight bearing or nonweight bearing were not found.9 The type of implant used determined the stability and the success of osteotomy. Various studies have reported the biomechanical properties of different implants.18-20 Agneskirchner et al.19 measured axial load and displacement and reported that less displacement was seen with rigid long medial tibial plate xators with locking bolts compared with short spacer plates. In a cadaveric study, Pape et al.18 showed a constant increase in creep failure at the opposite cortex and a constant increase in the plastic deformity after open wedge HTO with the Puddu plate. Most bone-implant constructs failed at 1,600 N. In contrast, the plate xator (TomoFix plate) had elastic deformity at 2,000 N and no failure of implant or construct. The TomoFix plate encompasses AO principles of internal xation while using a locking screw technology. The plate strength in combination with the angular and axial stability of 8 locking screws ensures maximum stability of the osteotomy maintaining the correction. Furthermore, the TomoFix implant is longer and thicker than the Position HTO plate. Only 4 locking screws are used for the Position HTO plate. A spacer lling the osteotomy gap may provide additional stability.5,7

650

S. SCHRTER ET AL. In other reports the rehabilitation protocol was more restrictive than in our study.9 Patients with short spacer plates had to avoid weight bearing for up to 10 weeks33 or 8 to 10 weeks.9 However, no data regarding the follow-up time points after 2 and 6 months without weight bearing are available. The mTFA recommended by Aglietti et al.25 was achieved with closed wedge osteotomy after 2 months but, during follow-up, a loss of correction between 2 and 6 months was observed, although they applied a cylinder cast for 4 weeks. After closed wedge HTO, loss of correction was also reported.34,35 Prospective studies with open wedge HTO and short spacer plates without bone transplantation were not available. Staubli et al.1 and Lobenhoffer et al.16 found that loss of correction with the TomoFix plate did not occur. Kolb et al.36 measured the mTFA after 6 weeks (2.1), after 12 months (2.0), and at most recent follow-up (1.3), but the differences were not signicant. Orsel et al.7 and Prix37 showed that loss of correction with the Puddu plate and additional application of allograft did not occur. Partial weight bearing was allowed after 3 weeks.37 These results implicate the need for autologous or allogeneic bone graft to avoid loss of correction after open wedge HTO with a short spacer plate. Intraoperative lateral tibial plateau fractures were found in 3% of patients in our study. Other studies reported a mean rate of 0.3% to 5%,5,6,17 with a maximum of 18.2%.10 This complication may depend partly on the experience of the surgeon. It can be avoided by enlarging the osteotomy very carefully. Therefore, after sawing of the corticalis bone, chisels of increasing widths may be used, respecting bone elasticity.10 Other authors reported an additional lateral external xation during opening the osteotomy.38 In cases of lateral tibial plateau fractures, additional xation with tension screws may be necessary. At follow-up examination, a 6% rate of lateral tibial plateau fractures was seen, which is a surprising nding. In these cases differences between BMI or wedge size did not exist. Reports assessing this problem were not found. It is possible that the apex of locking screws generates a new hinge point, with a maximum of load on the apex. Over time, cycles of axial load during partial weight bearing may have led to fracture of the tibial plateau. Infections after open wedge HTO and closed wedge HTO are reported in 2.3% to 33.6% of patients.5,6,35,39-43 In our study an infection rate of 3% was observed. No bone substitutes or bone grafts were used, possibly because perioperative single-shot antibiotics were administered. Furthermore, after osteot-

To avoid complications with screw or plate failure with short spacer plates, a bone transplantation or a bone substitute is necessary. Reports regarding the Puddu plate with additional bone grafts showed no complications.5,7 On the other hand, lling the gap with -tricalcium phosphate (Vitoss; Stryker) did not increase the mechanical stability.5,6,17,21,22 For increased stability in open wedge HTO, an anteromedial plate position is preferred. Blecha et al.,23 for example, showed that micromotions at the bone-wedge interface were of greater magnitude when the plate was positioned medially rather than anteromedially. Medial positioning of the plate was found to support smaller amounts of loading than an open wedge HTO with an anteromedial plate position, thus achieving lesser structural stability and safety. The exact leg alignment that leads to the best survival rate has not been determined,3,24-27 but achieving appropriate alignment with HTO determines whether success is achieved.28-30 The recommended postoperative alignment differs according to author. Aglietti et al.25 had the highest mean survival rate at an anatomical tibiofemoral angle (aTFA) of 8 to 14 (which equates to mTFA of 1 to 7 valgus). Cases of underor over-correction showed a mean survival rate of 10 years. When dividing osteoarthritic patients into group A (mTFA 0) and group B (mTFA 0), we found a signicantly better clinical outcome in group B for the Tegner activity level, HSS score, Lysholm-Gillquist knee functional scoring scale, and IKDC score. Akizuki et al.31 did not nd a correlation between the angle of correction and the long-term result. However, no correlation analyses between the postoperative mTFA or aTFA and the survivorship were performed. Other authors have used the mechanical axis as a reference. They recommended passing through a point 30% to 40% lateral to the midpoint.32 In our study an mTFA of 0 to 4 was aimed at, depending on the presence of osteoarthritis or an isolated cartilage lesion. The mean planned mTFA was 2.2 1.2 (range, 0 to 4), whereas after 2 months, we had achieved an mTFA of 1.0 2.6 (range, 5.7 to 6.6). The mean difference between planned and achieved angles was 1.3 2.6 (range, 7.7 to 5.6; P .008). However, between 2 and 6 months follow-up, a loss of correction of 1.3 1.4 had occurred. In the group without complications, a loss of correction of 1.0 1.1 was found, but no further signicant loss of correction was observed between 6 and 12 months follow-up. After 12 months, the mean mTFA was 0.73 3.11 (range, 9.3 to 3.9).

OPEN WEDGE HTO AND SPACER PLATE omy, closure of the fascia and periosteum was performed when possible. Afterward, the osteotomy underwent xation with the plate. These techniques may contribute to the low infection rate. Different scores to assess the clinical outcome after HTO are available. The HSS score,5,22,27,31,44,45 Lysholm-Gillquist score,6,7,17,45-47 Tegner activity level,6,45 and IKDC score17 are commonly used. Previous studies reported a preoperative HSS score of 60.7 to 69 and an improvement to 85 to 90.5,31,45 Others noted good and excellent results in 92% of cases after 5.7 years.48 In our study the HSS score increased from 74.8 11.7 (range, 51 to 99) to 87.8 11.0 (range, 61 to 99). The mean difference of 10.9 was signicant (P .0001). Other studies reported a preoperative Lysholm-Gillquist score of 42 to 56 and an improvement to 63 to 91.6,7,45,49 In our study this score increased from 55.5 21.7 (range, 17 to 94) to 73.0 23.9 (range, 21 to 100). The mean difference was 18.6 18.1 (P .0009). The Tegner activity level was 3 to 8 preoperatively and increased to 4 to 10 postoperatively.6,45 This study showed an improvement from 2.58 0.9 (range, 1 to 4) to 3.69 1.78 (range, 1 to 8). The mean difference was signicant (P .02). Niemeyer et al.17 reported improved IKDC scores after 12 and 24 months. Our results conrm this nding. Although all studies reported signicantly improved scores, the comparison of different studies is difcult because different grades of osteoarthritis or cartilage lesions were treated. Furthermore, the age at index surgery, the number and type of additional surgical procedures, and the follow-up times were different. The higher preoperative scores in our study may partially be explained by the inclusion criteria: varus malalignment and cartilage damage in younger patients in whom autologous cartilage transplant was indicated. For survivorship analysis, we used the KaplanMeier method.50 The HTO survival was ended by conversion to total knee arthroplasty or low scores.27,31,34,35,41 After closed wedge HTO or domeshape osteotomy, survival rates ranged from 75% to 99.3% after 5 years27,31,34,35,41; after 10 years, the survival rate decreased to a range of 28% to 97.6% according to previous authors.3,25,31,34 Aglietti et al.25 and Akizuki et al.31 reported survival rates of 57% and 90.4%, respectively, after 15 years. After open wedge HTO (with cement spacer), Hernigou et al.3 reported a survival rate of 85% after 10 years and 68% after 15 years. However, our resultswith a follow-up of 12

651

monthsare not comparable to this long-term outcome. The ndings of this study are limited because of the short period of follow-up and limited number of cases. Furthermore, this study included patients with cartilage defects, as well as patients with osteoarthritis. Any further subgrouping of patients was statistically not possible. CONCLUSIONS Our results show a high plate-related complication rate after open wedge HTO using the new Position HTO plate without bone wedges. A significant loss of correction between 2 and 6 months follow-up occurred. The preoperatively planned mTFA was not achieved postoperatively. Despite complications, the clinical outcome was signicantly improved. Overall, the Position HTO plate cannot be recommended with the presented technique. We consider the presented ndings important and hope that they will guide orthopaedic surgeons in implant selection.
Acknowledgment: The authors thank the participants who made this study possible.

REFERENCES
1. Staubli AE, De Simoni C, Babst R, Lobenhoffer P. TomoFix: A new LCP-concept for open wedge osteotomy of the medial proximal tibiaEarly results in 92 cases. Injury 2003;34:B55B62 (Suppl 2). 2. Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003;11:132-138. 3. Hernigou P, 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. 4. Stoffel K, Stachowiak G, Kuster M. Open wedge high tibial osteotomy: Biomechanical investigation of the modied Arthrex Osteotomy Plate (Puddu Plate) and the TomoFix Plate. Clin Biomech (Bristol, Avon) 2004;19:944-950. 5. Asik M, Sen C, Kilic B, Goksan SB, Ciftci F, Taser OF. High tibial osteotomy with Puddu plate for the treatment of varus gonarthrosis. Knee Surg Sports Traumatol Arthrosc 2006;14: 948-954. 6. Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G. The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch Orthop Trauma Surg 2005;125: 638-643. 7. Orsel S, Altun M, Bekmezci T, Tonbul M, Yalaman O. Early results of medial opening wedge osteotomy in varus gonarthrosis. Acta Orthop Traumatol Turc 2006;40:193-198 (in Turkish). 8. Kendoff D, Lo D, Goleski P, Warkentine B, OLoughlin PF, Pearle AD. Open wedge tibial osteotomies inuence on axial

652

S. SCHRTER ET AL.
30. Catani F, Marcacci M, Benedetti MG, et al. The inuence of clinical and biomechanical factors on the results of valgus high tibial osteotomy. Chir Organi Mov 1998;83:249-262. 31. Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H. The long-term outcome of high tibial osteotomy: A ten- to 20-year follow-up. J Bone Joint Surg Br 2008;90:592-596. 32. Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am 1979;10:585-608. 33. Spahn G, Wittig R. Primary stability of various implants in tibial opening wedge osteotomy: A biomechanical study. J Orthop Sci 2002;7:683-687. 34. Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 1993;75:196-201. 35. Hassenpug J, von Haugwitz A, Hahne HJ. Long-term results of tibial head osteotomy. Z Orthop Ihre Grenzgeb 1998;136: 154-161 (in German). 36. Kolb W, Guhlmann H, Windisch C, Kolb K, Koller H, Grutzner P. Opening-wedge high tibial osteotomy with a locked low-prole plate. J Bone Joint Surg Am 2009;91:25812588. 37. Prix R. Opening-wedge osteotomy of the proximal tibia. Acta Chir Orthop Traumatol Cech 2005;72:308-312 (in Czech). 38. Jacobi M, Wahl P, Jakob RP. Avoiding intraoperative complications in open-wedge high tibial valgus osteotomy: Technical advancement. Knee Surg Sports Traumatol Arthrosc 2009;18: 200-203. 39. Amendola A, Fowler PJ, Litcheld R, Kirkley S, Clatworthy M. Opening wedge high tibial osteotomy using a novel technique: Early results and complications. J Knee Surg 2004;17:164-169. 40. Brouwer RW, Bierma-Zeinstra SM, van Raaij TM, Verhaar JA. Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomised, controlled study. J Bone Joint Surg Br 2006;88:1454-1459. 41. Hernigou P, Ma W. Open wedge tibial osteotomy with acrylic bone cement as bone substitute. Knee 2001;8:103-110. 42. King-Martinez AC, Cuellar-Avaroma A, Perez-Correa J, Torres-Gonzalez R, Guevara-Lopez U. High tibial dome osteotomy complications in genu varum patients. Rev Med Inst Mex Seguro Soc 2007;45:111-116 (in Spanish). 43. Billings A, Scott DF, Camargo MP, Hofmann AA. High tibial osteotomy with a calibrated osteotomy guide, rigid internal xation, and early motion. Long-term follow-up. J Bone Joint Surg Am 2000;82:70-79. 44. Chiang H, Hsu HC, Jiang CC. Dome-shaped high tibial osteotomy: A long-term follow-up study. J Formos Med Assoc 2006;105:214-219. 45. Magyar G, Ahl TL, Vibe P, Toksvig-Larsen S, Lindstrand A. Open-wedge osteotomy by hemicallotasis or the closedwedge technique for osteoarthritis of the knee. A randomised study of 50 operations. J Bone Joint Surg Br 1999;81:444-448. 46. Marti CB, Gautier E, Wachtl SW, Jakob RP. Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 2004;20:366-372. 47. Miller BS, Joseph TA, Barry EM, Rich VJ, Sterett WI. Patient satisfaction after medial opening high tibial osteotomy and microfracture. J Knee Surg 2007;20:129-133. 48. Healy WL, Riley LH Jr. High tibial valgus osteotomy. A clinical review. Clin Orthop Relat Res 1986:227-233. 49. Zhang HN, Zhang J, Lv CY, et al. Modied biplanar openwedge high tibial osteotomy with rigid locking plate to treat varus knee. J Zhejiang Univ Sci B 2009;10:689-695. 50. Carr AJ, Morris RW, Murray DW, Pynsent PB. Survival analysis in joint replacement surgery. J Bone Joint Surg Br 1993;75:178-182.

9. 10. 11. 12. 13. 14. 15. 16. 17.

18.

19.

20. 21. 22.

23.

24. 25. 26. 27. 28.

29.

rotation and tibial slope. Knee Surg Sports Traumatol Arthrosc 2008;16:904-910. Nelissen EM, van Langelaan EJ, Nelissen RG. Stability of medial opening wedge high tibial osteotomy: A failure analysis. Int Orthop 2010;34:217-223. Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg 2004;124:649-653. Ranawat CS, Shine JJ. Duo-condylar total knee arthroplasty. Clin Orthop Relat Res 1973:185-195. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg Am 1976;58:754-765. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150-154. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985:43-49. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1:226-234. Lobenhoffer P, Agneskirchner J, Zoch W. Open valgus alignment osteotomy of the proximal tibia with xation by medial plate xator. Orthopade 2004;33:153-160 (in German). Niemeyer P, Koestler W, Kaehny C, et al. Two-year results of open-wedge high tibial osteotomy with xation by medial plate xator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy 2008;24:796-804. Pape D, Lorbach O, Schmitz C, et al. Effect of a biplanar osteotomy on primary stability following high tibial osteotomy: A biomechanical cadaver study. Knee Surg Sports Traumatol Arthrosc 2010;18:204-211. Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer P. Primary stability of four different implants for opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2006;14:291-300. Dorsey WO, Miller BS, Tadje JP, Bryant CR. The stability of three commercially available implants used in medial opening wedge high tibial osteotomy. J Knee Surg 2006;19:95-98. Engel GM, Lippert FG III. Valgus tibial osteotomy: Avoiding the pitfalls. Clin Orthop Relat Res 1981:137-143. Koshino T, Morii T, Wada J, Saito H, Ozawa N, Noyori K. High tibial osteotomy with xation by a blade plate for medial compartment osteoarthritis of the knee. Orthop Clin North Am 1989;20:227-243. Blecha LD, Zambelli PY, Ramaniraka NA, Bourban PE, Manson JA, Pioletti DP. How plate positioning impacts the biomechanics of the open wedge tibial osteotomy; a nite element analysis. Comput Methods Biomech Biomed Eng 2005;8:307-313. Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint Surg Am 2003;85:469-474. Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini A. High tibial valgus osteotomy for medial gonarthrosis: A 10- to 21-year study. J Knee Surg 2003;16:21-26. Rinonapoli E, Mancini GB, Corvaglia A, Musiello S. Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop Relat Res 1998:185-193. Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am 1984;66:1040-1048. Odenbring S, Egund N, Hagstedt B, Larsson J, Lindstrand A, Toksvig-Larsen S. Ten-year results of tibial osteotomy for medial gonarthrosis. The inuence of overcorrection. Arch Orthop Trauma Surg 1991;110:103-108. Madan S, Ranjith RK, Fiddian NJ. Intermediate follow-up of high tibial osteotomy: A comparison of two techniques. Bull Hosp Jt Dis 2002;61:11-16.