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Knee Videos: Malalignment
Fresh Femoral Osteochondral Allograft Transplantation Using a Single-Plug Technique for Large Osteochondral Defects of the Knee
Osteochondral allograft (OCA) transplantation has been used to treat a wide spectrum of cartilage deficiencies in the knee, including spontaneous necrosis of the knee. Studies reporting outcomes after OCA transplantation have shown reliable improvement in pain and return to activities of daily living. We describe a single-plug, press-fit technique for OCA transplantation with concomitant high tibial osteotomy to treat femoral condyle chondral defects in a varus knee. Pearls and pitfalls of this technique are presented; attention should be paid to correction of concomitant joint pathology and malalignment to facilitate osseointegration and survivorship of the allograft plug into host bone.Flexion Contracture in Knee Osteoarthritis Can Be Fully Eliminated by Hybrid Closed Wedge High Tibial Osteotomy Using a Reduction-Insertion-Compression Handle
In conventional closed-wedge high tibial osteotomy (CWHTO) with preservation of the medial hinge, flexion contracture cannot be improved because of the two-dimensional correction. Conversely, in hybrid CWHTO, for which the name is derived from a hybrid of the lateral closing and medial opening, the medial cortex is intentionally disrupted. The medial hinge disruption enables three-dimensional correction, which helps eliminate flexion contracture by decreasing posterior tibial slope (PTS). The fine adjustment of the anterior closing distance and thigh-compression technique further facilitates PTS control.Augmentation of Patellar Tendon Repair With Autologous Semitendinosus Graft—Porto Technique
Patellar tendon ruptures can lead to significant functional deficiency of the extensor mechanism of the knee. These injuries, because of their inherent nature and associated complications, may require a complex treatment and remains a challenge for orthopaedic surgeons. Current surgical techniques present significant complications, including patellar fracture, damage to patellar articular cartilage, and abnormal patella height. This note describes a surgical technique to provide an additional reinforcement to the patellar tendon repair with a semitendinous autograft, without the necessity to perform any transosseous tunnels at the patella bone.Modified Elmslie-Trillat Procedure for Distal Realignment of Patella Tendon
Patellofemoral dysfunction, due to either a patellofemoral malalignment or patellar instability, is a complex and debilitating condition that significantly decreases the knee function. Conservative management may yield significant clinical outcomes; however, when morphologic anomalies are identified, the surgical approach should be employed. Hence, several surgical procedures have been described in the scientific literature aiming the correction of underlying extensor mechanism malalignments. Still, the rate of complications is higher than desirable.Open-Wedge Valgus High Tibial Osteotomy Technique With Inverted L-Shaped Configuration
High tibial osteotomy (HTO) is a useful alternative in the treatment of symptomatic varus malalignment. However, among its drawbacks is the tendency to decrease patellar height and increase the posterior tibial slope. The increased tibial slope increases anterior cruciate ligament tension and may compromise its function. On the other hand, patella baja often causes anterior knee pain and, over time, may favor degeneration of the patellofemoral joint. The aim of this study is to describe a technical modification of the standard open-wedge HTO.Opening Wedge High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction or Revision
High tibial osteotomy (HTO) is a valid treatment option for young active patients with medial tibiofemoral osteoarthrosis (OA) and varus deformity. Sometimes medial OA is combined with symptomatic anterior cruciate ligament (ACL) deficiency. Although isolated HTO (with possible delayed ACL reconstruction) might be indicated in the older population, young active patients may require combined HTO and ACL reconstruction. In addition, an abnormally increased tibial slope may predispose to ACL reconstruction failure and should be addressed for a successful ACL revision.Opening Wedge High Tibial Osteotomy Using Combined Computed Tomography-Based and Image-Free Navigation System
For opening wedge high tibial osteotomy (OWHTO), it is recommended that the osteotomy line is parallel to the medial tibial posterior slope (TPS) in the sagittal view and that the alignments are simultaneously controlled in the coronal and sagittal views. Here combined computed tomography (CT)-based and image-free navigation systems were used for intraoperative reference during OWHTO. Using the CT-based navigation, 2 entry points for insertion of Kirschner wires were preoperatively set up and an accurate osteotomy plane was intraoperatively duplicated.Joint Preservation Surgery for Medial Compartment Osteoarthritis
Single compartment osteoarthritis is a commonly encountered condition in the middle-aged population, with the medial compartment being the most commonly involved compartment. Medial compartment osteoarthritis becomes seriously disabling for these active patients, with a very few definitive solutions. These patients quickly stop responding to the conservative methods such as lifestyle modification, drugs, physiotherapy, and rehab programs. Less invasive procedures such as intra-articular injections or joint debridement also do not give a long-lasting relief.Medial Closing-Wedge Distal Femoral Osteotomy for Genu Valgum With Lateral Compartment Disease
Lateral compartment disease combined with valgus alignment can lead to progressive knee joint degeneration. In the symptomatic patient with isolated lateral compartment disease, a varus-producing distal femoral osteotomy can unload the diseased lateral compartment. This osteotomy may be combined with other cartilage or meniscal restorative techniques to optimize knee joint preservation and pain relief. The osteotomy can be performed with a medial closing-wedge or lateral opening-wedge technique.Autologous Osteophyte Grafting for Open-Wedge High Tibial Osteotomy
Osteophytes are physiological bony outgrowths that develop at the margins of the articular surfaces during the progression of osteoarthritis; they are associated with active endochondral bone formation processes and expressions of various growth factors. We believe they could be a source of bone grafts as a result of a potentially strong osteoinductive effect. Moreover, osteophytes can be easily harvested by arthroscopy in patients undergoing open-wedge high tibial osteotomy (OW-HTO) for medial unicompartmental knee osteoarthritis.Medial Opening Wedge Proximal Tibial Osteotomy
Genu varus malalignment can lead to medial compartment overload and progression of ipsilateral compartment osteoarthritis. To slow this process, a medial opening wedge proximal tibial osteotomy (PTO) can be performed. This type of PTO is indicated in patients with genu varus malalignment and isolated medial compartment osteoarthritis of the knee, prior to or concurrent with medial compartment cartilage procedures or meniscal transplants, chronic posterolateral corner deficiency, or chronic anterior cruciate ligament deficiency.Opening-Wedge Proximal Tibial Osteotomy
Varus knee malalignment caused by medial compartment arthritis results in progressive asymmetric wear of the tibiofemoral joint. This wear can cause progressively painful gonarthrosis. Surgical methods to address varus knee malalignment include lateral closing-wedge proximal tibial osteotomy, medial opening-wedge osteotomy, and arthroplasty. Medial opening-wedge proximal tibial osteotomy is an effective procedure for restoring proper coronal alignment and reducing knee pain. In this technical note, we present a reproducible technique for proximal tibial osteotomy.Anterolateral Biplanar Proximal Tibial Opening-Wedge Osteotomy
Proximal tibial anterolateral opening-wedge osteotomies have been reported to achieve successful biplanar lower-extremity realignment. Indications for a proximal tibial anterolateral osteotomy include symptomatic genu recurvatum with genu valgus alignment, usually in patients with a flat sagittal-plane tibial slope. The biplanar approach is able to simultaneously address both components of a patient's malalignment with a single procedure. The correction amount is verified with spacers and intraoperative imaging, while correction of the patient's heel height is simultaneously measured.Open-Wedge High Tibial Osteotomy Using a Protective Cutting System: Technical Advancement for the Accuracy of the Osteotomy and Avoiding Intraoperative Complications
Open-wedge high tibial osteotomy for medial unicompartmental arthritis of the knee joint is a successful treatment option but is associated with potential intraoperative complications such as tibial plateau fracture, dislocation of the osteotomy hinge, under- or over-correction of the posterior slope, and neurovascular injury. Therefore we devised a protective cutting system and describe our method for the prevention of these complications. The potential advantages of this system are protection of the posterior neurovascular structures using a curved protector, bone cutting along the natural tibial slope using a superior surface aligning with the natural tibial slope, and complete 1-plane sawing of the posterior wall before the lateral hinge.Medial Closing-Wedge Distal Femoral Osteotomy: Fixation With Proximal Tibial Locking Plate
Distal femoral varus osteotomy is a well-established procedure for the treatment of lateral compartment cartilage lesions and degenerative disease, correcting limb alignment and decreasing the progression of the pathology. Surgical techniques can be performed with a lateral opening-wedge or medial closing-wedge correction of the deformity. Fixation methods for lateral opening-wedge osteotomies are widely available, and there are various types of implants that can be used for fixation. However, there are currently only a few options of implants for fixation of a medial closing-wedge osteotomy on the market.Medial Patellofemoral Ligament Reconstruction Using a Femoral Loop Button Fixation Technique
Medial patellofemoral ligament (MPFL) reconstruction is a common procedure used to treat both acute and chronic patellar instability. Although many variations of MPFL reconstruction have been described, there is no consensus regarding the optimal surgical technique. We describe a technique for MPFL reconstruction with a looped gracilis tendon autograft using suture anchors to secure the graft to the patella and a suspensory loop button system for fixation to the femur. This technique replicates the native shape of the MPFL while minimizing the risk of patellar fracture and allowing for gradual tensioning of the graft.A Novel Closed-Wedge High Tibial Osteotomy Procedure to Treat Osteoarthritis of the Knee: Hybrid Technique and Rehabilitation Measures
High tibial valgus osteotomy (HTO) is an established treatment for medial-compartment osteoarthritis of the knee. We have combined medial open and lateral closed-wedge HTO (hybrid closed-wedge HTO) to overcome the limitations of traditional closed-wedge HTO. Our new hybrid procedure has the following advantages: (1) the bone block removed is smaller in size; (2) the procedure yields optimal geometric characteristics for bone healing; (3) there is no step-off at the lateral osteotomy site; (4) the lateral cortex of the proximal and distal fragments is attached firmly by the oblique osteotomy; and (5) early full weight-bearing walking is possible.Arthroscopic and Computer-Assisted High Tibial Osteotomy Using Standard Total Knee Arthroplasty Navigation Software
Opening-wedge high tibial osteotomy is an increasingly performed procedure for treatment of varus gonarthrosis and correction of malalignment during meniscal transplantation or cartilage restoration. Precise preoperative planning and meticulous surgical technique are required to achieve an appropriate mechanical axis correction. We describe our technique of arthroscopic and computer-assisted high tibial osteotomy using commonly available total knee arthroplasty navigation software as an intraoperative goniometer.
