Skip to main content

Advertisement

SpringerLink
Log in

Medially and distally inserted tuberosity screw fixation of the osteotomized tubercle is safe and effective in retro-tubercular bi-planar opening-wedge high tibial osteotomy

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study was to develop a safe and effective method of inserting one tuberosity screw and to determine whether retro-tubercular (RT)-Open-wedge high tibial osteotomy (OWHTO) with tuberosity screw fixation can be conducted to overcome the problem of osteotomized tubercle and produce favorable outcomes compared to RT-OWHTO without tuberosity screw fixation.

Methods

From 2018 to 2020, patients who underwent bi-planar RT-OWHTO were allocated as two groups (RT-OWHTO without tuberosity screw fixation as group I and with screw fixation as group II). Computed tomography (CT) was used to analyze osteotomy configurations such as RT gap and tip distance, and union of the main and second plane osteotomy sites. The RT gap distance was measured as the length of the osteotomy gap. The RT tip distance was measured as the length of the gap at the tip of the tibial tubercle. Post-operative complications were analyzed also. To evaluate the neurovascular (NV) approximity of screw fixation group, the pre-operative magnetic resonance imaging (MRI) images were referenced on the post-operative CT for the assessment of the safe zone.

Results

In total, 44 knees in group I and 46 knees in group II were enrolled. The RT gap distance (2.58 ± 0.69 mm vs. 0.57 ± 0.57 mm; p < .001) and RT tip distance (4.31 ± 1.60 mm vs. 1.48 ± 1.42 mm; p < .001) were significantly larger in group I than in group II. The sum of union grade in the second plane osteotomy site (17.93 ± 2.18 points vs. 22.24 ± 2.57 points; p < .001) was statistically different between two groups at three months post operatively. Post-operative tuberosity prominence occurred in five knees only in group I (p = 0.025), although tibial tuberosity fracture developed in seven cases in group II compared with two cases in group I with no statistical significance. NV was safe when the screw was inserted medially.

Conclusion

RT-OWTHO with one-screw fixation for the tuberosity was effective in terms of tuberosity prominence and the union of the second plane osteotomy site. However, it also produced another problem, such as tuberosity fracture. In addition, a tuberosity screw was safe when it was inserted in the medial–distal direction.

Level of evidence

Cohort study; level III.

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
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Bin SI, Kim HJ, Ahn HS, Rim DS, Lee DH (2016) Changes in patellar height after opening wedge and closing wedge high tibial osteotomy: a meta-analysis. Arthroscopy 32:2393–2400

    Article  PubMed  Google Scholar 

  2. Choi CH, Lee WS, Jung M, Moon HS, Lee YH, Oh J et al (2020) Adequate protection rather than knee flexion prevents popliteal vascular injury during high tibial osteotomy: analysis of three-dimensional knee models in relation to knee flexion and osteotomy techniques. Knee Surg Sports Traumatol Arthrosc 28:1425–1435

    Article  PubMed  Google Scholar 

  3. Chun KC, So BJ, Kang HT, Chun CH (2018) Pseudoaneurysm formation due to popliteal artery injury caused by drilling during medial opening wedge high tibial osteotomy. Knee Surg Relat Res 30:364–368

    Article  PubMed  PubMed Central  Google Scholar 

  4. Clement ND, Bardgett M, Weir D, Holland J, Gerrand C, Deehan DJ (2018) What is the minimum clinically important difference for the WOMAC index after TKA? Clin Orthop Relat Res 476:2005–2014

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ding T, Tan Y, Tian X, Xue Z, Ma S, Hu Y et al (2022) Patellar height after high tibial osteotomy of the distal tibial tuberosity: a retrospective study of age stratification. Comput Math Methods Med 2022:7193902

    Article  PubMed  PubMed Central  Google Scholar 

  6. El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S (2010) Patellar height and posterior tibial slope after open- and closed-wedge high tibial osteotomy: a radiological study on 100 patients. Am J Sports Med 38:323–329

    Article  PubMed  Google Scholar 

  7. Erquicia J, Gelber PE, Perelli S, Ibanez F, Ibanez M, Pelfort X et al (2019) Biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy, radiological and clinical analysis with minimum follow-up of 2 years. J Exp Orthop 6:10

    Article  PubMed  PubMed Central  Google Scholar 

  8. Gaasbeek R, Welsing R, Barink M, Verdonschot N, van Kampen A (2007) The influence of open and closed high tibial osteotomy on dynamic patellar tracking: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 15:978–984

    Article  PubMed  Google Scholar 

  9. Gaasbeek RD, Sonneveld H, van Heerwaarden RJ, Jacobs WC, Wymenga AB (2004) Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera: a new technique. Knee 11:457–461

    Article  CAS  PubMed  Google Scholar 

  10. Hernigou J, Chahidi E, Kashi M, Moest E, Dakhil B, Hayek G et al (2018) Risk of vascular injury when screw drilling for tibial tuberosity transfer. Int Orthop 42:1165–1174

    Article  PubMed  Google Scholar 

  11. Jiang X, Xie K, Han X, Ai S, Wu H, Wang L et al (2022) HKA angle-a reliable planning parameter for high tibial osteotomy: a theoretical analysis using standing whole-leg radiographs. J Knee Surg 35:54–60

    Article  PubMed  Google Scholar 

  12. Jo IH, Lee OS, Lee SH, Kim KW, Lee YS (2019) Retro-tubercular gap widening can be caused by inappropriate anterior osteotomy and large opening gap in the medial biplanar open-wedge HTO. Knee Surg Sports Traumatol Arthrosc 27:2910–2916

    Article  PubMed  Google Scholar 

  13. Kang BY, Lee DK, Kim HS, Wang JH (2022) How to achieve an optimal alignment in medial opening wedge high tibial osteotomy? Knee Surg Relat Res 34:3

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kang T, Lee DW, Park JY, Han HS, Lee MC, Ro DH (2020) Sawing toward the fibular head during open-wedge high tibial osteotomy carries the risk of popliteal artery injury. Knee Surg Sports Traumatol Arthrosc 28:1365–1371

    Article  PubMed  Google Scholar 

  15. Kim JS, Lee JI, Choi HG, Yoo HJ, Jung YS, Lee YS (2021) Retro-tubercle biplanar opening wedge high tibial osteotomy is favorable for the patellofemoral joint but not for the osteotomized tubercle itself compared with supra-tubercle osteotomy. Arthroscopy 37:2567–2578

    Article  PubMed  Google Scholar 

  16. Kline AJ, Gonzales J, Beach WR, Miller MD (2006) Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer. Am J Orthop (Belle Mead NJ) 35:30–32

    PubMed  Google Scholar 

  17. Krause M, Drenck TC, Korthaus A, Preiss A, Frosch KH, Akoto R (2018) Patella height is not altered by descending medial open-wedge high tibial osteotomy (HTO) compared to ascending HTO. Knee Surg Sports Traumatol Arthrosc 26:1859–1866

    Article  PubMed  Google Scholar 

  18. LaPrade RF, Oro FB, Ziegler CG, Wijdicks CA, Walsh MP (2010) Patellar height and tibial slope after opening-wedge proximal tibial osteotomy: a prospective study. Am J Sports Med 38:160–170

    Article  PubMed  Google Scholar 

  19. Lee OS, Ahn S, Lee YS (2017) Effect and safety of early weight-bearing on the outcome after open-wedge high tibial osteotomy: a systematic review and meta-analysis. Arch Orthop Trauma Surg 137:903–911

    Article  PubMed  Google Scholar 

  20. Lee OS, Lee ES, Lee YS (2019) Disparity between preoperative target correction amount and postoperative correction amount in open wedge high tibial osteotomy. Knee Surg Relat Res 31:126–131

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lee YS, Kang JY, Lee MC, Oh WS, Elazab A, Song MK (2016) Effect of the osteotomy length on the change of the posterior tibial slope with a simple distraction of the posterior gap in the uni- and biplanar open-wedge high tibial osteotomy. Arthroscopy 32:263–271

    Article  PubMed  Google Scholar 

  22. Lee YS, Kim MK, Byun HW, Kim SB, Kim JG (2015) Reliability of the imaging software in the preoperative planning of the open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:846–851

    Article  CAS  PubMed  Google Scholar 

  23. Lee YS, Lee MC, Kang SG, Elazab A, Oh WS (2016) Open-wedge high tibial osteotomy using a protective cutting system: technical advancement for the accuracy of the osteotomy and avoiding intraoperative complications. Arthrosc Tech 5:e7–e10

    Article  PubMed  PubMed Central  Google Scholar 

  24. Lee YS, Lee SB, Oh WS, Kwon YE, Lee BK (2016) Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 24:129–133

    Article  PubMed  Google Scholar 

  25. Lee YS, Moon GH (2015) 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 20:129–136

    Article  CAS  PubMed  Google Scholar 

  26. Longino PD, Birmingham TB, Schultz WJ, Moyer RF, Giffin JR (2013) Combined tibial tubercle osteotomy with medial opening wedge high tibial osteotomy minimizes changes in patellar height: a prospective cohort study with historical controls. Am J Sports Med 41:2849–2857

    Article  PubMed  Google Scholar 

  27. Martimbianco AL, Calabrese FR, Iha LA, Petrilli M, Lira Neto O, Carneiro Filho M (2012) Reliability of the “American Knee Society Score” (AKSS). Acta Ortop Bras 20:34–38

    Article  PubMed  PubMed Central  Google Scholar 

  28. Nha KW, Kim HJ, Ahn HS, Lee DH (2016) Change in posterior tibial slope after open-wedge and closed-wedge high tibial osteotomy: a meta-analysis. Am J Sports Med 44:3006–3013

    Article  PubMed  Google Scholar 

  29. Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP (2006) Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med 34:1262–1273

    Article  PubMed  Google Scholar 

  30. Ogawa H, Matsumoto K, Yoshioka H, Sengoku M, Akiyama H (2020) Distal tibial tubercle osteotomy is superior to the proximal one for progression of patellofemoral osteoarthritis in medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 28:3270–3278

    Article  PubMed  Google Scholar 

  31. Seo H, Lim D, Jang YW, Kang KS, Lee MC, Lee OS et al (2020) Distribution of the force in the knee joint during daily activities after open wedge high tibial osteotomy: a rationale for the proper postoperative management. J Knee Surg 33:158–166

    Article  PubMed  Google Scholar 

  32. Shetty AA, Tindall AJ, Nickolaou N, James KD, Ignotus P (2005) A safe zone for the passage of screws through the posterior tibial cortex in tibial tubercle transfer. Knee 12:99–101

    Article  CAS  PubMed  Google Scholar 

  33. Shin YS, Sim HB, Yoon JR (2017) Tibial nerve neuropathy following medial opening-wedge high tibial osteotomy-case report of a rare technical complication. Eur J Orthop Surg Traumatol 27:563–567

    Article  PubMed  Google Scholar 

  34. Song IH, Song EK, Seo HY, Lee KB, Yim JH, Seon JK (2012) Patellofemoral alignment and anterior knee pain after closing- and opening-wedge valgus high tibial osteotomy. Arthroscopy 28:1087–1093

    Article  PubMed  Google Scholar 

  35. van Hemert WL, Willems K, Anderson PG, van Heerwaarden RJ, Wymenga AB (2004) Tricalcium phosphate granules or rigid wedge preforms in open wedge high tibial osteotomy: a radiological study with a new evaluation system. Knee 11:451–456

    Article  PubMed  Google Scholar 

  36. Yang JH, Lee SH, Nathawat KS, Jeon SH, Oh KJ (2013) The effect of biplane medial opening wedge high tibial osteotomy on patellofemoral joint indices. Knee 20:128–132

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) No.2021R1A2C1092657.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea

    Sung Bae Park, Joo Sung Kim, Ho Won Jeong, Seung Jae Shim, Seong Yun Park, Jung Guel Kim & Yong Seuk Lee

Authors
  1. Sung Bae Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joo Sung Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ho Won Jeong
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Seung Jae Shim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Seong Yun Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jung Guel Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yong Seuk Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yong Seuk Lee.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

The article does not contain any studies involving human participants or animals performed by any of the authors. Institutional Review Board approval was obtained before performing the study (B-2205-757-101).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (XLSX 97 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Park, S.B., Kim, J.S., Jeong, H.W. et al. Medially and distally inserted tuberosity screw fixation of the osteotomized tubercle is safe and effective in retro-tubercular bi-planar opening-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 31, 1571–1582 (2023). https://doi.org/10.1007/s00167-022-07009-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-07009-z

Keywords

Search

Navigation