Skip to main content

Advertisement

SpringerLink
Log in

A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy

  • Original Article
  • Published:
HSS Journal ®

Abstract

Background

Medial opening-wedge high tibial osteotomy (HTO) is one of the most common and effective HTO techniques, in which the proximal tibia is cut medially, leaving an intact lateral hinge of bone that can be opened to a variable amount for the desired correction, but the technical complications of lateral cortex fracture and intra-articular fracture are well described. The lateral bone hinge for medial opening-wedge HTO is crucial. If the hinge is too small, the tibia can fracture and become unstable, requiring further fixation. If the hinge is too large, the osteotomy can propagate into the joint as an intra-articular fracture when opening the osteotomy.

Purpose

We propose a new technique that utilizes digital preoperative templating to improve the accuracy of the cut. Preoperative digital templating may allow the surgeon to reproducibly obtain a lateral bone hinge of 10 mm, while also reducing radiation exposure relative to the traditional fluoroscopically assisted technique.

Methods

Ten cadaver extremities from five cadavers were matched into pairs and randomized into two groups: those with and without preoperative templating. The templating protocol measures the distance between two points on the medial and lateral cortices, and 20 mm is subtracted to determine the depth of the saw cut (10 mm for the hinge and another 10 mm because the proximal tibia is oval in shape). The control method was done by making the cut using fluoroscopy with tactile feedback. Postoperative computed tomography scans were obtained of all legs to measure the width of the lateral bone hinge. Intraoperative fluoroscopy used during both techniques and the numbers of fluoroscopy shots were recorded.

Results

We found neither the treatment group with preoperative planning nor the control group with the conventional technique had bone hinge widths that were different from the ideal 10 mm. The average hinge widths for the treatment and control groups were 11.2 and 11.5 mm, respectively. However, the treatment group was exposed to significantly less intraoperative fluoroscopy during the osteotomy cut. The average total number of fluoroscopy shots was 2.2 in the treatment group versus 6.3 for the control group.

Conclusions

This new preoperative planning technique achieves similar accuracy of the lateral bone hinge when compared to current methods but exposes the patient, surgeon, and staff to significantly less intraoperative radiation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Badawy M, Fenstad AM, Indrekvam K, Havelin LI, Furnes O. The risk of revision in total knee arthroplasty is not affected by previous high tibial osteotomy. Acta Orthop. 2015;86(6):734–739. https://doi.org/10.3109/17453674.2015.1060402

    Article  PubMed  PubMed Central  Google Scholar 

  2. Badman BL. Radiation exposure with use of the mini-c-arm for routine orthopaedic imaging procedures. J Bone Joint Surg. 2005;87(1):13. https://doi.org/10.2106/JBJS.D.02162

    Article  PubMed  Google Scholar 

  3. Bar-On E, Weigl DM, Becker T, Katz K, Konen O. Intraoperative C-arm radiation affecting factors and reduction by an intervention program. J Pediatr Orthop. 2010;30(4):320–323. https://doi.org/10.1097/BPO.0b013e3181d98f06

    Article  PubMed  Google Scholar 

  4. Blattert TR, Fill UA, Kunz E, Panzer W, Weckbach A, Regulla DF. Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures: a clinical study. Arch Orthop Trauma Surg. 2004;124(10):659–664. https://doi.org/10.1007/s00402-004-0743-9

    Article  PubMed  Google Scholar 

  5. Bode G, von Heyden J, Pestka J, et al. Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):1949–1955. https://doi.org/10.1007/s00167-013-2762-y

    Article  PubMed  Google Scholar 

  6. Botchu R, Ravikumar K. Radiation exposure from fluoroscopy during fixation of hip fracture and fracture of ankle: Effect of surgical experience. Indian J Orthop. 2008;42(4):471–473. https://doi.org/10.4103/0019-5413.43398

    Article  PubMed  PubMed Central  Google Scholar 

  7. Brinkman J-M, Lobenhoffer P, Agneskirchner JD, et al. Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg [Br]. 2008;90:1548–1557. https://doi.org/10.1302/0301-620X.90B12

    Article  Google Scholar 

  8. Chou LB, Cox CA, Tung JJ, Harris AHS, Brooks-Terrell D, Sieh W. Prevalence of cancer in female orthopaedic surgeons in the United States. J Bone Joint Surg Am. 2010;92(1):240–244. https://doi.org/10.2106/JBJS.H.01691

    Article  PubMed  Google Scholar 

  9. Chou LB, Lerner LB, Harris AHS, Brandon AJ, Girod S, Butler LM. Cancer Prevalence among a Cross-sectional Survey of Female Orthopedic, Urology, and Plastic Surgeons in the United States. Womens Health Issues. 2015; 25(5):476–481. https://doi.org/10.1016/j.whi.2015.05.005

    Article  PubMed  Google Scholar 

  10. DeMeo PJ, Johnson EM, Chiang PP, Flamm AM, Miller MC. Midterm follow-up of opening-wedge high tibial osteotomy. Am J Sports Med. 2010;38(10):2077–2084. https://doi.org/10.1177/0363546510371371

    Article  PubMed  Google Scholar 

  11. Dexel J, Fritzsche H, Beyer F, Harman MK, Lützner J. Open-wedge high tibial osteotomy: incidence of lateral cortex fractures and influence of fixation device on osteotomy healing. Knee Surg Sports Traumatol Arthrosc. 2015. https://doi.org/10.1007/s00167-015-3730-5

  12. Domholdt E. Physical Therapy Research. Philadelphia: W.B. Saunden Company; 1993.

    Google Scholar 

  13. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P. Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):170–180. https://doi.org/10.1007/s00167-012-2087-2

    Article  PubMed  Google Scholar 

  14. Giordano BD, Grauer JN, Miller CP, Morgan TL, Rechtine GR. Radiation exposure issues in orthopaedics. J Bone Joint Surg Am. 2011;93(12):e69(1)-e69(10). https://doi.org/10.2106/JBJS.J.01328

    Article  Google Scholar 

  15. Giuseffi SA, Replogle WH, Shelton WR. Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases. Arthroscopy. 2015;31(11):2128–2137. https://doi.org/10.1016/j.arthro.2015.04.097

    Article  PubMed  Google Scholar 

  16. Greene DJ, Tenggadjaja CF, Bowman RJ, Agarwal G, Ebrahimi KY, Baldwin DD. Comparison of a reduced radiation fluoroscopy protocol to conventional fluoroscopy during uncomplicated ureteroscopy. Urology. 2011;78(2):286–290. https://doi.org/10.1016/j.urology.2010.11.020

    Article  PubMed  Google Scholar 

  17. Hui C, Salmon LJ, Kok A, et al. Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med. 2011;39(1):64–70. https://doi.org/10.1177/0363546510377445

    Article  PubMed  Google Scholar 

  18. Kessler OC, Jacob HAC, Romero J. Avoidance of medial cortical fracture in high tibial osteotomy: improved technique. Clin Orthop Relat Res. 2002;(395):180–185.

    Article  Google Scholar 

  19. Khan IA, Kamalasekaran S, Fazal MA. Risk of ionising radiation to trainee orthopaedic surgeons. Acta Orthop Belg. 2012;78(1):106–110.

    PubMed  Google Scholar 

  20. Kolb W, Guhlmann H, Windisch C, Kolb K, Koller H, Grützner P. Opening-wedge high tibial osteotomy with a locked low-profile plate. J Bone Joint Surg Am. 2009;91(11):2581–2588. https://doi.org/10.2106/JBJS.H.01047

    Article  PubMed  Google Scholar 

  21. Lee YS, Moon GH. Comparative analysis of osteotomy accuracy between the conventional and devised technique using a protective cutting system in medial open-wedge high tibial osteotomy. J Orthop Sci. 2015;20(1):129–136. https://doi.org/10.1007/s00776-014-0663-7

    Article  CAS  PubMed  Google Scholar 

  22. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond). 2005;55(6):498–500. https://doi.org/10.1093/occmed/kqi048

    Article  PubMed  Google Scholar 

  23. Miller ME, Davis ML, MacClean CR, Davis JG, Smith BL, Humphries JR. Radiation exposure and associated risks to operating-room personnel during use of fluoroscopic guidance for selected orthopaedic surgical procedures. J Bone Joint Surg Am. 1983;65(1):1–4.

    Article  CAS  Google Scholar 

  24. Nelson EM, Monazzam SM, Kim KD, Seibert JA, Klineberg EO. Intraoperative fluoroscopy, portable X-ray, and CT: patient and operating room personnel radiation exposure in spinal surgery. Spine J. 2014;14(12):2985–2991. https://doi.org/10.1016/j.spinee.2014.06.003

    Article  PubMed  Google Scholar 

  25. Poignard A. Revisiting high tibial osteotomy: fifty years of experience with the opening-wedge technique. J Bone Joint Surg. 2010;92(Supplement_2):187. https://doi.org/10.2106/JBJS.I.00771

    Article  PubMed  Google Scholar 

  26. Riley SA. Radiation exposure from fluoroscopy during orthopedic surgical procedures. Clin Orthop Relat Res. 1989;(248):257–260.

    Google Scholar 

  27. Saragaglia D, Blaysat M, Inman D, Mercier N. Outcome of opening wedge high tibial osteotomy augmented with a Biosorb® wedge and fixed with a plate and screws in 124 patients with a mean of ten years follow-up. Int Orthop. 2011;35(8):1151–1156. https://doi.org/10.1007/s00264-010-1102-9

    Article  PubMed  Google Scholar 

  28. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005; 13(1):69–76.

    Article  Google Scholar 

  29. 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 Suppl 2:B55–62.

    Article  Google Scholar 

  30. W-Dahl A, Toksvig-Larsen S, Lindstrand A. Ten-year results of physical activity after high tibial osteotomy in patients with knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2015. https://doi.org/10.1007/s00167-015-3693-6

Download references

Author information

Authors and Affiliations

  1. Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Elad Spitzer MD, Joseph J. Ruzbarsky MD, John B. Doyle BA, Kaitlyn L. Yin BA & Robert G. Marx MD, MSc, FRCS

Authors
  1. Elad Spitzer MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joseph J. Ruzbarsky MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John B. Doyle BA
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kaitlyn L. Yin BA
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Robert G. Marx MD, MSc, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert G. Marx MD, MSc, FRCS.

Ethics declarations

Conflict of Interest

Elad Spitzer, MD, Joseph J. Ruzbarsky, MD, John B. Doyle, BA, Kaitlyn L. Yin, BA, declare they have no conflict of interest. Robert G. Marx, MD, MSc, FRCS, reports receiving research funding from DePuy Synthes to support this work, as well as book royalties from Springer and Demos Health and Deputy and Associate Editorships at Journal of Bone and Joint Surgery outside this work.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

N/A

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Electronic supplementary material

ESM 1

(PDF 1224 kb)

ESM 2

(PDF 1224 kb)

ESM 3

(PDF 1224 kb)

ESM 4

(PDF 1224 kb)

ESM 5

(PDF 1225 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Spitzer, E., Ruzbarsky, J.J., Doyle, J.B. et al. A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy. HSS Jrnl 14, 251–257 (2018). https://doi.org/10.1007/s11420-017-9591-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11420-017-9591-3

Keywords

Search

Navigation