Midterm follow-up of opening-wedge high tibial osteotomy.

BACKGROUND: High tibial osteotomy is a valuable option for patients with varus gonarthrosis. To avoid difficulties with closing-wedge osteotomies, medial opening-wedge high tibial osteotomies have been advocated. HYPOTHESIS: Opening-wedge high tibial osteotomy is a good option in highly active patients with varus gonarthrosis who would like to delay or prevent progression to total knee arthroplasty without activity restrictions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty consecutive patients with varus gonarthrosis were treated with a medial opening-wedge high tibial osteotomy using the Puddu plate and allograft bone graft for a prospective study (14 men and 6 women; average age, 49.4 years [range, 36-67 years]). Gait analysis was performed preoperatively and at 6 months postoperatively. Preoperative radiographs, subjective ratings, and knee scores (Lysholm and Hospital for Special Surgery [HSS] scores) were obtained. At 2 years postoperatively and at the latest follow-up visit (average, 8.3 years), the subjective ratings and knee scores were repeated. RESULTS: Gait analysis revealed an abnormal weightbearing pattern preoperatively with the vertical ground-reaction force. The postoperative vertical ground-reaction force revealed a normal double peak pattern. The preoperative adduction moment was 29% greater than the 6-month postoperative adduction moment. The preoperative varus averaged 3.6° and was corrected to an average of 7.5° of valgus postoperatively. All patients subjectively rated their preoperative knee as poor. At 2 years postoperatively, most patients (14) rated their knee as good, with 5 excellent and only 1 fair rating. The average preoperative Lysholm and HSS knee scores were 54.2 and 75.9, respectively, compared with the 2-year postoperative averages of 89.1 and 92.7, respectively. At 8 years postoperatively, there was 70% survivorship with 42% of patients rating their knees as good or excellent. Five patients (25%) had undergone total knee arthroplasty. Lysholm and HSS knee scores were 83.0 and 86.8, respectively, for the surviving knees at 8 years postoperatively. CONCLUSION: Medial opening-wedge high tibial osteotomy produces good results in the midterm. After the osteotomy, a more normal appearing weightbearing pattern with double peaks was seen. The adduction moment significantly decreased, resulting in less contact pressure through the medial degenerative compartment of the knee. The authors recommend medial opening-wedge high tibial osteotomy for young patients with varus alignment and medial compartment arthritis to allow this patient population to remain highly active and delay progression to total knee arthroplasty without activity restrictions.

Isolated acetabular revision through the posterior approach: short-term results after revision of a recalled acetabular component.

Isolated acetabular revision is commonly associated with high rates of postoperative dislocation. We hypothesize that the dislocation rate in a series of isolated acetabular revisions for loosening of recalled acetabular components is low when strict intraoperative stability testing is coupled with re-repair of the piriformis tendon. Twenty-six isolated revisions of aseptic, loose recalled acetabular components were performed through the posterior approach by a single surgeon. All piriformis tendon and posterior capsular repairs from the index operation were considered intact at the time of revision. The piriformis tendon was re-repaired in each revision case. The average revision acetabular component was 3 mm larger than the index component. In this select group of isolated acetabular revisions, strict intraoperative stability testing and re-repair of the piriformis tendon yielded zero dislocations.

Osteolysis of the pelvis: evaluation and treatment.

Osteolysis of the pelvis is a common and well-recognized complication associated with total hip arthroplasty. The diagnosis and treatment of osteolysis of the pelvis is a challenging and controversial problem. Osteolysis of the pelvis often is asymptomatic and does not present with symptoms until considerable bone loss and loosening of the acetabular socket occur. Radiographs are the most common way to detect and monitor osteolysis around an implant. However, lesions viewed radiographically usually are underestimations of the lesions found intraoperatively. Moreover, some advocate computed tomography scanning to evaluate these lesions. The indications for treatment of osteolysis with cemented acetabular components are defined more clearly than with a cementless component. If the cemented or cementless acetabular component is loose, then revision is necessary. However, it is less clear when to intervene surgically with a well-fixed cup with osteolysis. Many early reports advocated the removal of a well-fixed socket during revision surgery for osteolysis and polyethylene wear. However, the removal of a well-fixed socket has the potential for significant damage and loss of the surrounding bone resulting in loss of integrity of a column or pelvic discontinuity, which may compromise placing another acetabular component. Recently, a new treatment strategy of retaining a well-fixed socket, exchanging the liner, and grafting lesions has proven successful. Without the removal of the acetabular shell, different techniques are needed to graft the osteolytic lesions. Osteolysis is a difficult problem; however, with radiographic surveillance to monitor patients for lesions, proper indications, and good surgical techniques, the treatment of osteolysis of the pelvis can result in a well-functioning total hip arthroplasty.

Failure of a retinacular flap to prevent dorsal wrist pain after titanium Pi plate fixation of distal radius fractures.

Patients with distal radius fractures that had been treated with a dorsal Pi plate and retinacular flap covering the transverse limb of the Pi plate were evaluated clinically and radiographically. Nine of 20 patients (45%) required plate removal for dorsal wrist pain. Three of the remaining 11 who retained the plate had dorsal tenderness over the wrist extensors. There were no differences evident between the 2 groups in plate size, position, or number of screws used. In addition there were no significant differences between the groups in either radial height or inclination. The palmar tilt did show a trend toward statistical significance: those patients who required plate removal had an average of 4.1 degrees of dorsal tilt, patients whose plate was not removed averaged 2.8 degrees of palmar tilt. Our results show that the retinacular flap covering the distal transverse limb of the Pi plate did not prevent the occurrence of dorsal wrist pain. Dorsal wrist pain remained a problem with dorsal plating of distal radius fractures.