Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system

A morphology of the distal medial femoral surface that should be considered when performing coronal osteotomy in medial closed wedge distal femoral varus osteotomy

AIMS

The aim of the present study was to evaluate the morphology of the distal medial femoral surface during coronal osteotomy in medial closed wedge distal femoral varus osteotomy (MCWDFO) using plain CT.

METHODS

Twenty knees (mean age, 55.3 years) were included. Preoperative CT images were obtained prior to MCWDFO for valgus OA. In the cross-section depicting the starting position of the transverse cut, a curve was drawn that passed through the centre of the femoral cortex, and lines parallel and perpendicular to the surgical epicondylar axis (SEA) were drawn to analyse the medial side. Inflection points on the medial line were defined as P1-P4. The radii of circles passing through P1-P3 (PR, posterior radius) and P2-P4 (AR, anterior radius) were drawn. Values for the PR, AR, and radius ratio (PR/AR) were measured.

RESULTS

Based on the PR/AR, the cross-sectional morphologies were classified into 5 triangular types (PR/AR < 0.5), 4 flat types (PR/AR > 0.8), and 11 convex types (PR/AR 0.6 to 0.7).

CONCLUSION

The medial anteroposterior width and flange thickness were easier to assess in the flat type; however, these were difficult to assess in the triangular type with a gentle anterior slope. Surgeons should consider the differences in the anterior slope according to cross-sectional morphologies when performing coronal osteotomy in MCWDFO.

Small changes of femoral torsion in varus or valgus distal femoral osteotomy using patient-specific instruments

PURPOSE

Hinge fractures show a relatively high incidence in varus and valgus distal femoral osteotomy (DFO) and can lead to delayed- or non-union. Another observed complication of a hinge fracture is an unintentional change of the postoperative femoral torsion of up to + 9.5° in conventionally performed DFO. We hypothesize that the change of femoral torsion in case of a hinge fracture is less pronounced when DFO is performed using patient-specific instruments (PSI) compared to the literature of conventionally performed DFO.

METHODS

All patients who underwent varus or valgus DFO using PSI from January 2014 to September 2023 were included. Radiographs and computed tomography (CT) scans were used to screen for hinge fractures. Pre- and postoperative femoral torsion was measured in CT.

RESULTS

Thirty-five medial closing-wedge DFO (MCW-DFO), 27 lateral closing-wedge DFO (LCW-DFO), and 27 lateral opening-wedge DFO (LOW-DFO) were included, resulting in a total of 89 included osteotomies. A total of 55 hinge fractures (61.8%) were observed. The femoral torsion changed significantly from 20.5° ± 7.7° to 15.5° ± 8.1° (p < 0.001) in LOW-DFO with a hinge fracture, whereas the other two techniques showed no significant change of femoral torsion.

CONCLUSION

The use of PSI in varus and valgus DFO showed only small changes of the postoperative femoral torsion, even in case of a hinge fracture. The change of femoral torsion was depending on the type of DFO and was only significant in LOW-DFO, however, not exceeding a mean change of 5°.

Radiographic Assessment of Bone Union in Proximal Tibia and Distal Femur Osteotomies: A Systematic Review

Background

Osteotomies around the knee are a well-established treatment option for early and moderate unicompartmental osteoarthritis combined with a lower extremity malalignment. Moreover, osteotomies are often combined with cartilage treatment. Current image-based bone union assessments lack an accepted definition despite widespread use in research and clinical settings. The aim of this systematic review was to identify definitions and classification systems for bone union on radiographs after a proximal tibia or distal femur osteotomy.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE and Embase database, applying specific inclusion and exclusion criteria. Two independent reviewers screened abstracts and full-texts. The modified Cochrane Risk of Bias Tool and Risk of Bias in Nonrandomized Studies of Interventions tool were used. Data extraction included study characteristics, imaging modality, bone union definition, classification systems, assessment of gap fillers, use of modifiers, and osteotomy type.

Results

Of the 1,180 screened titles and abstracts, 105 studies were included, with the majority (69 studies [65.7%]) using a retrospective design. Fifty-five studies (52.4%) defined bone union based on one or more criteria, while 50 studies (47.6%) used a classification system. There were 13 different criteria for bone union and 9 different classification systems. Interestingly, none of the classification systems incorporated negative criteria, such as hardware failure. Notably, 137 studies (49.1%) described bone union as either a primary or secondary outcome but do not describe a system for assessing bone union.

Conclusion

This systematic review highlights the lack of consensus in the literature in defining bone union after a proximal tibia or distal femur osteotomy, revealing many criteria and different classifications. None of the classification systems were applicable to osteotomies with and without gap filler. This systematic review shows the need for a straightforward, reproducible, and accurate method to assess bone union after a proximal tibia or distal femur osteotomy.

Level of Evidence

Level III. See Instructions for Authors for a complete description of levels of evidence.

Hinge screw or no hinge stabilization provides decreased stability compared to hinge plate in a biomechanical evaluation of distal femoral derotational osteotomies

PURPOSE

Derotational distal femoral osteotomy (DFO) is the causal treatment for patients with femoral torsional deformity. The fixation is achieved by a unilateral angle-stable plate. Delayed- or non-unions are one of the main risks of the procedure. An additional contralateral fixation may benefit the outcome. Therefore, we hypothesize that primary stability in DFO can be improved by an additional fixation with a hinge screw or an internal plate.

METHODS

Derotational DFO was performed in 15 knees and fixed either with an angle-stable plate only (group 'None'), with an additional lateral screw (group 'Screw') or with an additional lateral plate (group 'Plate'). Biomechanical evaluation was carried out under axial loading of 150 N (partial weight bearing) and 800 N (full weight bearing), followed by internal and external rotation. After linear axial loading in step 1, a cyclic torsional load of 5 Nm was applied under constant axial load in step 2. In step 3, the specimens were unloaded. Micromovements between the distal and proximal parts of the osteotomy were recorded at each step for all specimens.

RESULTS

In step 1, the extent of micromovements was highest in group 'None' and lowest in group 'Plate' without being significantly different. In step 2, group 'Plate' showed significantly higher stability, reflected by less rotation and lower micromovements. Increasing the axial load from 150 to 800 N at step 2 resulted in increased stability in all groups but only reached significance in group 'None'.

CONCLUSION

An additional contralateral plate significantly increased stability in derotational DFO compared to the unilateral angle-stable plate only. Contrary, a contralateral hinge screw did not provide improved stability.

STUDY DESIGN

Experimental study.

LEVEL OF EVIDENCE

IV.

Morphological analysis of the distal femur as a surgical reference in biplane distal femoral osteotomy

Distal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P < 0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P < 0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO.

Setting hinge position distal to the proximal margin of the distal lateral femur reduces the maximum principal strains of the hinge area and risk of hinge fractures

Purpose

The optimal hinge position to prevent hinge fractures in medial closing wedge distal femoral osteotomy (MCWDFO) based on the biomechanical background has not yet been well examined. This study aimed to examine the appropriate hinge position in MCWDFO using finite element (FE) analysis to prevent hinge fractures.

Methods

Computer-aided design (CAD) models were created using composite replicate femurs. FE models of the MCWDFO with a 5° wedge were created with three different hinge positions: (A) 5 mm proximal to the proximal margin of the lateral epicondylar region, (B) proximal margin level and (C) 5 mm distal to the proximal margin level. The maximum and minimum principal strains in the cortical bone were calculated for each model. To validate the FE analysis, biomechanical tests were performed using composite replicate femurs with the same hinge position models as those in the FE analysis.

Results

In the FE analysis, the maximum principal strains were in the order of Models A > B > C. The highest value of maximum principal strain was observed in the area proximal to the hinge. In the biomechanical test, hinge fractures occurred in the area proximal to the hinge in Models A and B, whereas the gap closed completely without hinge fractures in Model C. Fractures occurred in an area similar to where the highest maximal principal strain was observed in the FE analysis.

Conclusion

Distal to the proximal margin of the lateral epicondylar region is an appropriate hinge position in MCWDFO to prevent hinge fractures.

Level of Evidence

Level V.

Additional Plate Fixation of Hinge Fractures After Varisation Distal Femoral Osteotomies Provides Favorable Torsional Stability: A Biomechanical Study

BACKGROUND

Hinge fractures are considered risk factors for delayed or nonunion of the osteotomy gap in distal femoral osteotomies (DFOs). Limited evidence exists regarding the treatment of hinge fractures after DFO, which could improve stability and thus bone healing.

PURPOSE

To (1) examine the effect of hinge fractures on the biomechanical properties of the bone-implant construct, (2) evaluate the biomechanical advantages of an additional fixation of a hinge fracture, and (3) test the biomechanical properties of different types of varisation DFOs.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 32 fresh-frozen human distal femora equally underwent medial closing wedge DFO or lateral opening wedge DFO using a unilateral locking compression plate. The following conditions were serially tested: (1) preserved hinge; (2) hinge fracture along the osteotomy plane; (3) screw fixation of the hinge fracture; and (4) locking T-plate fixation of the hinge fracture. Using a servo-hydraulic materials testing machine, we subjected each construct to 15 cycles of axial compression (400 N; 20 N/s) and internal and external rotational loads (10 N·m; 0.5 N·m/s) to evaluate the stiffness. The axial and torsional hinge displacement was recorded using a 3-dimensional optical measuring system. Repeated-measures 1-way analysis of variance and post hoc Bonferroni correction were used for multiple comparisons. Statistical significance was set at P < .05.

RESULTS

Independent from the type of osteotomy, a fractured hinge significantly (P < .001) increased rotational displacement and reduced stiffness of the bone-implant construct, resulting in ≥1.92 mm increased displacement and ≥70% reduced stiffness in each rotational direction, while the axial stiffness remained unchanged. For both procedures, neither a screw nor a plate could restore intact rotational stiffness (P < .01), while only the plate was able to restore intact rotational displacement. However, the plate always performed better compared with the screw, with significantly higher and lower values for stiffness (+38% to +53%; P < .05) and displacement (-55% to -72%; P < .01), respectively, in ≥1 rotational direction. At the same time, the type of osteotomy did not significantly affect axial and torsional stability.

CONCLUSION

Hinge fractures after medial closing wedge DFO and lateral opening wedge DFO caused decreased bone-implant construct rotational stiffness and increased fracture-site displacement. In contrast, the axial stiffness remained unchanged in the cadaveric model.

CLINICAL RELEVANCE

When considering an osteosynthesis of a hinge fracture in a DFO, an additional plate fixation was the construct with the highest stiffness and least displacement, which could restore intact hinge rotational displacement.

Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome

INTRODUCTION

The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications.

METHODS

Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications.

RESULTS

The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal.

CONCLUSION

DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.

Optimal additional support screw position for prevention of hinge fracture in biplanar closed wedge distal femoral osteotomy

Background

The purpose of this study was to examine the biomechanical significance of supplemental fixation using a positional screw in prevention of the hinge fracture in lateral closed-wedge distal femoral osteotomy (LCW-DFO) by means of a three-dimensional finite element analysis.

Methods

The three-dimensional numerical knee models with LCW-DFO were developed. To assess the mechanical efficacy of the positional screw and determine its optimal position and orientation, in total, 13 screwing methods were analyzed. In the first four methods, the screw was supported by the cortical bone only on the medial surface (mono-cortical). In the other 9 models, the screw was supported by both medial and lateral cortical bones (bi-cortical). Under 1000 N of vertical force and 5 Nm of rotational torques, the highest shear stress value around the medial hinge area was adopted as an analytical parameter.

Results

In mono-cortical methods, with the cancellous bone support, all methods were able to reduce the highest stress value compared to the value without the screw, while the efficacy was rather inferior when the screw was in horizontal direction. Without the cancellous bone support, however, all methods were not able to reduce the stress value. In bi-cortical methods, with the cancellous bone support, almost all screw augmentation methods were able to reduce the stress value. When screwing from the medial to the lateral, it only gets worse when going extremely posterior. Without the cancellous bone support, all methods were able to reduce the stress value.

Conclusion

The mechanical efficacy of the bi-cortical method was proven regardless of the quality of the local cancellous bone.

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

PURPOSE

Closing wedge distal femoral osteotomies (CWDFO) are attractive treatment options for unicompartmental knee osteoarthritis with coronal plane deformity. However, it has been traditionally associated with high rates of hinge fracture that can adversely impact recovery and patient outcomes. Appropriate siting of hinge point can be an effective method of reducing the incidence of hinge fractures. This study aims to illustrate a case series of CWDFO with low rates of hinge fracture utilising our preferred hinge point site.

METHODS

A retrospective study of a cohort of 39 CWDFO was performed between May 2019 and May 2022. Both medial and lateral CWDFO were included. The hinge point in all cases was placed at the level of the inferior margin of the metaphyseal flare, and inferior to the gastrocnemius origin, with a hinge thickness of 10 mm. Post-operative radiographs were obtained at 2, 4 and 8 weeks after surgery to assess for hinge fracture and union.

RESULTS

Thirty-nine cases of CWDFO were performed, consisting of eighteen cases of valgus malalignment that underwent medial CWDFO and twenty-one cases of varus malalignment that underwent lateral CWDFO. At surgery, the mean age was 47.6 (± 13.9) years and mean BMI was 29.4 (± 4.9). There were 23 men and 16 women. Three cases of hinge fractures occurred intraoperatively, translating into a hinge fracture rate of 7.69%. However, union was achieved in all three cases and all patients in this case series were able to progress to weight bear as tolerated at 2 months post-osteotomy.

CONCLUSION

Distal placement of the hinge at the level of the inferior metaphyseal flare margin with the use of a hinge wire can greatly reduce the rates of hinge fracture in CWDFO.

LEVEL OF EVIDENCE

Level III.

Effect of implant composition on periprosthetic bone mineral density after total hip arthroplasty

BACKGROUND

The severity of bone mineral density (BMD) loss after total hip arthroplasty (THA) depends on both implant- and patient-related factors. While implant fixation type is an important factor, but few studies have considered the effect of material composition on the same implant fixation type. In particular, differences in mechanical stiffness due to material composition are of great interest. Here, we compared changes in periprosthetic BMD after THA using proximal fixation concept stems comprising different titanium alloys, i.e., β titanium alloys stem and α + β titanium alloys stem.

METHODS

This retrospective cohort included 122 patients (β titanium alloys stem, 61 cases; α + β titanium alloys stem, 61 cases) who underwent primary THA between January 2009 and December 2019. The primary outcome was the change in periprosthetic BMD from base line. Age, body mass index, diagnosis, stem size, canal flare index, surgical approach, pre-operative lumbar BMD, and pre-operative activity scores were reviewed and changes in periprosthetic BMD between the two groups were compared using analysis of covariance. The secondary outcome was radiographic response after THA.

RESULTS

There was significant difference in periprosthetic BMD in zone 6 and 7 at 2 years (p < 0.05) between the two groups. There was no significant difference in other zones. A significant difference in radiographic response was noted only for the Engh classification.

CONCLUSION

α + β titanium alloys stem resulted in a significantly higher rate of BMD loss in zones 6 and 7 compared with the β titanium alloys stem. These results may be due to differences in mechanical stiffness due to the different titanium alloy composition of the prosthetics.