Posterior Aspect Fracture of Tibia after Open Wedge Distal Tuberosity Osteotomy: A Case Report.

Introduction: Open wedge distal tuberosity osteotomy (OWDTO) was the surgical treatment in which tibial tuberosity was attached proximal fragment to avoid an increase in patellofemoral joint pressure. The current paper reported a case of post-operative posterior aspect fracture of the tibia as a rare complication after OWDTO. Case Report: A 52-year-old Asian man had been performing OWDTO for medial knee osteoarthritis. The patient was injured by the tibial posterior aspect fracture due to minor trauma 2 months after surgery. Bone union was completed by transient unloading and ultrasound therapy, but the anteroposterior screw remained in the bone due to screw breakage during removal. Conclusion: Post-operative posterior aspect fracture of the tibia is a complication specific to OWDTO. It is difficult to detect the fracture on X-ray; therefore, the evaluation with computed tomography is recommended. It is possible that removal of the anteroposterior screw has become difficult in the event that this fracture occurs.

More negative sagittal tibial tuberosity-trochlear groove distances are correlated with larger patellofemoral chondral lesion size.

PURPOSE: The purpose of this study is to assess the association between sagittal tibial tuberosity-trochlear groove (sTT-TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures. METHODS: A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix-induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high-grade lesions, magnetic resonance imaging (MRI) and minimum 2-year follow-up. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT-TG and lesion size. RESULTS: A total of 80 patients (50 females) with a mean age of 31.5 ± 10.4 years, body mass index of 27.0 ± 5.9 kg/m2 and follow-up of 61.5 ± 21.4 months were included. A total of 107 lesions were present: 63 patients with unipolar (patella = 41, trochlea = 22) and 22 with bipolar lesions. The mean MRI defect size was 1.6 ± 1.0 cm2 and the mean intraoperative defect size was 3.8 ± 2.4cm2. Intra- (ICC: 0.99,0.98) and inter-rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT-TG measurements. The mean sTT-TG was -4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (-0.45, p < 0.01), intraoperative patellar lesion size (-0.32, p = 0.01), total lesion area (-0.22, p = 0.04), but not trochlear lesion size (-0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT-TG remained an independent variable correlated with larger MRI-measured patellofemoral defect sizes and intraoperative patellar lesions. CONCLUSION: A more negative sTT-TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration. LEVEL OF EVIDENCE: Level III, Diagnostic.

Tensionable lesser tuberosity osteotomy repair for anatomic total shoulder arthroplasty.

A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Postoperative onset lateral hinge fracture is a risk factor for delayed union of the tibial tuberosity in medial opening wedge distal tibial tuberosity osteotomy.

Background: This study aimed to evaluate bone union of the tibial tuberosity in patients undergoing medial opening wedge distal tibial tuberosity osteotomy (OWDTO). It was hypothesized that bone union of the tibial tuberosity could be associated with lateral hinge fractures (LHFs), but not thickness of the tibial tuberosity osteotomy. Methods: Data of 61 consecutive patients who underwent OWDTO were retrospectively reviewed. Radiographic parameters of the lower limb and LHFs were evaluated. Thickness of the tibial tuberosity osteotomy and bone union of the tibial tuberosity were assessed at 1, 2, 3, 4, and 5 cm distal to the most proximal part of the tibial tuberosity on computed tomography. Bone union was assessed. Factors related to bone union of the tibial tuberosity were analyzed. Results: There were 13 postoperative onset LHFs: all healed with conservative treatments within 6 months after surgery. The total score of bone union of the tibial tuberosity was 8.4 ± 2.1 points, which correlated with age, postoperative medial proximal tibial angle (MPTA), correction angle, and postoperative onset LHF (r = 0.307, 0.388, 0.275, and -0.624, respectively; p = 0.016, 0.002, 0.033, and <0.001, respectively). Regression coefficient for postoperative onset LHF, postoperative MPTA, and body mass index were -0.619 (p < 0.001), 0.285 (p = 0.003), and -0.227 (p = 0.021), respectively. Conclusion: Postoperative onset LHFs, but not thickness of the tibial tuberosity osteotomy, were a risk factor for delayed union of the tibial tuberosity following OWDTO. Furthermore, to prevent delayed union of the tibial tuberosity, postoperative onset LHFs should be prevented. Level of evidence: LEVEL III, Case-control study.

Sulcus-Deepening Trochleoplasty With Medial Patellofemoral Ligament Reconstruction: Outcomes at 10 to 20 Years.

BACKGROUND: Recent systematic reviews on the outcomes of sulcus-deepening trochleoplasty with adjuvant medial patellofemoral ligament (MPFL) reconstruction at a follow-up of 2 to 6 years have found that the procedure grants good clinical outcomes with low redislocation rates. However, there is a lack of evidence in the literature regarding mid- and long-term follow-ups. PURPOSE: To evaluate the radiographic and clinical outcomes of thick-flap sulcus-deepening trochleoplasty with MPFL reconstruction at a minimum follow-up of 10 years to assess the signs of patellofemoral arthritis, incidence of recurrent dislocation, and grade of patient satisfaction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors evaluated a retrospective series of 43 patients (48 knees) who underwent sulcus-deepening trochleoplasty between 2003 and 2013. All patients underwent thick-flap sulcus-deepening trochleoplasty with additional MPFL reconstruction. All patients were assessed at a minimum follow-up of 10 years by an independent clinician who noted any patellar redislocation or reoperations in the operated knee and collected the International Knee Documentation Committee (IKDC), Kujala, and satisfaction scores. Furthermore, a radiographic examination was performed to assess patellar height using the Caton-Deschamps index and patellofemoral arthritis using the Iwano classification. RESULTS: At a mean follow-up of 14.8 ± 2.1 years (range, 10-20 years), 4 patients (4 knees) were lost to follow-up (8.3%). The satisfaction, Kujala, and IKDC scores were 8.2 ± 1.6, 77.5 ± 14.4, and 65.7 ± 13.5, respectively. Only 1 patient reported a traumatic patellar dislocation (2%). Radiographs at the final follow-up were available for 34 knees, which revealed Iwano grade 1 in 14 knees (41%), Iwano grade 2 in 7 knees (21%), and no patellofemoral arthritis in 13 knees (38%). CONCLUSION: Sulcus-deepening trochleoplasty with MPFL reconstruction provides satisfactory results and prevents patellar redislocations with no or minimal patellofemoral arthritis.

Incidence and risk factors for lateral hinge fractures in medial opening wedge high tibial osteotomy and medial opening wedge distal tibial tuberosity osteotomy.

BACKGROUND: The aims of this study were (1) to compare the incidence of lateral hinge fractures (LHFs) in medial opening-wedge high tibial osteotomy (OWHTO) and medial opening-wedge distal tibial tuberosity osteotomy (DTO), and (2) to investigate the risk factors for LHFs. The incidence of LHFs was hypothesized to be higher in the DTO group than the OWHTO group. The DTO procedure is also a risk factor for LHFs. METHODS: A total of 167 knees that underwent OWHTO (n = 65) and DTO (n = 102) were subjected to propensity score matching for the comparison of the groups. The matched variables were sex, preoperative hip-knee-ankle (HKA) angle, and preoperative medial proximal tibial angle. Forty-one matched pairs were enrolled for comparative analysis. Logistic regression analysis was performed to investigate risk factors for LHFs. RESULTS: The incidence of LHFs was not significantly different between the groups (34.1% vs. 26.8%, respectively; p = 0.631). Logistic regression analysis showed that age (odds ratio: 1.074, 95% confidence interval (CI): 1.020-1.131, p = 0.007), BMI (odds ratio: 1.150, 95% CI: 1.049-1.260, p = 0.003), and preoperative HKA angle (odds ratio: 1.150, 95% CI: 1.049-1.260, p = 0.035) were significant risk factors for LHFs. The difference in surgical technique between OWHTO and DTO was not a risk factor for LHFs (p = 0.204). CONCLUSIONS: The incidence of LHFs is similar in DTOs and OWHTOs, and the DTO procedure is not a risk factor for LHFs. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Isolated Medial Patellofemoral Ligament Reconstruction in Patellar Instability: Does the Distance Between Tibial Tuberosity-Trochlear Groove Make a Difference?

Introduction: Medial patellofemoral ligament reconstruction (MPFLR) is used in most patellar instability surgeries, there is controversy on adding a tibial tuberosity osteotomy (TTO). Objective: To describe the results of isolated MPFLR in patellar instability according to the Tibial Tuberosity-Trochlear Groove distance (TT-TG). Methods: Retrospective study of patients with patellar instability with a mature skeleton in one center between 2016 and 2021, using isolated MPFLR. Patients with incomplete clinical and/or radiological records and less than one year follow-up were excluded. Pre-surgical demographic and radiological data (TT-TG, Caton-Deschamps (CD) index, patellar tilt, trochlear dysplasia) were recorded. Patients were divided into three groups according to TT-TG distance (Group 1: < 17 mm, Group 2: 17-19, Group 3: ≥ 20 mm). A pre and post-surgical Kujala score was performed. Local complications, satisfaction, recurrence and/or reintervention were recorded. Pre-surgical variables between groups, intra and inter-group Kujala differences were compared using Bartlett's test. Consent from the patients and approval from the local ethics committee were obtained. Results: 67 patients met the selection criteria, mean age of 23 years, 70% were women. There were no pre surgical, radiological nor follow-up differences between the groups (average 27 months). Pre and post-surgical Kujala score, respectively: Group 1: 37-78, Group 2: 37-78, Group 3: 39-79. All groups had a significant improvement (p < 0.05), there were no significant differences in improvement between groups (p > 0.05). There were three patients with a redislocation episode, all in group 1. One patient had a mobilization under anesthesia due to an arthrofibrosis (Group 2). 97% of all cases reported being satisfied. Conclusion: Isolated MPFLR in patellar instability presents a functional improvement, with a low rate of complications and failure, regardless of the pre surgical TT-TG. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00906-6.

Effect of medial opening wedge distal tibial tuberosity osteotomy on possible neuropathic pain in patients with osteoarthritis of the knee.

BACKGROUND: There is a paucity of literature regarding the changes and features of neuropathic pain (NP) in knee osteoarthritis (OA) following medial opening wedge distal tibial tuberosity osteotomy (OWDTO). This study aimed to investigate the effect of OWDTO on NP in knee OA; we hypothesized that OWDTO improves knee symptoms and functions and also meets patient satisfaction in those with knee OA with possible NP or without NP. METHODS: Fifty-two consecutive patients who underwent OWDTO were categorized into the unlikely NP and possible NP groups using the painDETECT questionnaire. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) score and the Knee Society Score 2011 (KSS 2011) were compared between the groups preoperatively and at the 1-year follow-up. RESULTS: The number of patients having possible NP significantly decreased from 12 (23.1%) preoperatively to one (1.9%) postoperatively (p < 0.001). The patient with postoperative possible NP also had possible NP preoperatively. All preoperative sub-scores of WOMAC were significantly higher in the possible NP group than in the unlikely NP group (p = 0.018, 0.013, 0.004, and 0.005, respectively); however, the postoperative scores did not differ between the two groups. Regarding the KSS 2011, the preoperative scores for symptom and functional activities were significantly lower in the possible NP group than in the unlikely NP group (p = 0.031 and 0.024, respectively). CONCLUSIONS: OWDTO is an effective surgery for patients with possible NP; it improves symptoms and knee function as well as meets patient satisfaction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Efficacy of intravenous tranexamic acid administration in medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO) for varus knee osteoarthritis: a randomized control trial.

BACKGROUND: This randomized controlled study was undertaken to investigate the efficacy of intravenous tranexamic acid (TXA) administration in reducing perioperative blood loss in patients undergoing medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO). It was hypothesized that TXA would reduce perioperative blood loss in MOWDTO. METHODS: A total of 61 knees in 59 patients who underwent MOWDTO during the study period were randomly assigned to either of the groups with intravenous TXA administration (TXA group) or without TXA administration (control group). In the TXA group, patients received 1000 mg of TXA intravenously before skin incision and 6 h after the first dose. The primary outcomes was the volume of perioperative total blood loss which calculated using the blood volume and hemoglobin (Hb) drop. The Hb drop was calculated as the difference between preoperative Hb and postoperative Hb at days 1, 3, and 7. RESULTS: The perioperative total blood loss was significantly lower in the TXA group (543 ± 219 ml vs. 880 ± 268 ml, P < 0.001). The Hb drop was significantly lower at postoperative days 1, 3 and 7 in the TXA group than in the control group (day 1: 1.28 ± 0.68 g/dl vs. 1.91 ± 0.69 g/dl, P = 0.001; day 3: 1.54 ± 0.66 g/dl vs. 2.69 ± 1.00 g/dl, P < 0.001; day 7: 1.74 ± 0.66 g/dl vs. 2.83 ± 0.91 g/dl, P < 0.001). CONCLUSION: Intravenous TXA administration in MOWDTO could reduce the perioperative blood loss. Trial registration The study was approved by the institutional review board. (Registered on 26/02/2019 Registration Number 3136). Level of Evidence Level I, randomized controlled trial.

Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use.

BACKGROUND: This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing. METHODS: An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively. RESULTS: A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037). CONCLUSION: A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The rate and predictors of healing of repaired lesser tuberosity osteotomy in reverse total shoulder arthroplasty.

Background: Evidence is building that a functional subscapularis improves function-specifically internal rotation tasks-following reverse total shoulder arthroplasty (rTSA). However, the optimal method for subscapularis repair during rTSA remains unknown with variable healing rates reported. This study aims to investigate the rate of and predictors for healing a lesser tuberosity osteotomy (LTO) following rTSA. Methods: Following local institutional review board approval, patients with at least one-year follow-up for rTSA managed with an LTO and subsequent repair between March, 2017 and March, 2020 were retrospectively identified. Shoulders were selected for LTO repair based upon preoperative imaging and intraoperative assessment of subscapularis quality. All patients were implanted with a system consisting of a 150° or 155° (constrained) humeral neck-shaft angle and 2.5 to 4.5 millimeters (mm) of glenoid lateralization (Trabecular Metal Reverse Shoulder System; Zimmer Biomet, Warsaw, IN, USA). At a minimum of six months, radiographs were reviewed for an assessment of LTO healing by three independent reviewers. Healing was classified as displaced, fibrous union, or ossified union. For assessing predictors, the repair was considered intact if the LTO fragment was not displaced (fibrous union or ossified union). Results: Sixty-five rTSA with LTO repair were performed in 64 patients. These patients had an average age of 67.2 years (range, 31-81) and 36 (55.4%; 36/65) were female. At an average follow-up of 15.2 months (range, 8-38), 50 cases (76.9%; 50/65) were classified as having an ossified union. The radiographic healing could not be assessed in a single case. Of the 14 cases without ossific union, 8 (12.3%; 8/65) were displaced and 6 (9.2%; 6/65) were classified as a fibrous union. In logistic regression, only combined humeral liner height predicted LTO displacement (odds ratio = 1.4 [95% confidence interval = 1.1-1.8]; P = .01). Humeral loosening was not found in any cases following LTO. Conclusion: This analysis demonstrates that radiographic healing of LTO repair is more favorable than published rates of healing after subscapularis tenotomy or peel in the setting of rTSA. Subscapularis management with LTO provides the ability to monitor repair integrity with plain radiographs and a predictable radiographic healing rate. The integrity of subscapularis repair may be influenced by the use of thicker humeral liners. Further investigation is needed to determine the functional impact of a healed subscapularis following rTSA.

Revision lateralization osteotomy of the tibial tubercle has excellent outcomes in patients suffering from previous medial tibial tubercle overcorrection.

INTRODUCTION: Tibial tubercle osteotomy (TTO) is a common procedure used to treat patients with patellofemoral instability (PFI) and osteoarthritis (PFOA). Medial patellar maltracking due to previous excessive medialization of the tibial tubercle has rarely been reported. Therefore, the goal of this study was to assess patient-reported outcome measures (PROMs) after revision osteotomy with lateralization of the tibial tubercle (RL-TTO) to correct medial patellofemoral maltracking. MATERIALS AND METHODS: Between 2017 and 2021, a series of 11 patients (male/female 1/10; age 35.8 ± 10.5 years) were treated by RL-TTO, of whom 8 patients could be retrospectively evaluated after a mean of 32.4 ± 15.1 months (range 18-61 months) postoperatively. The Kujala anterior knee pain scale, the patellofemoral subscale of the Knee Osteoarthritis and Outcome Score (KOOS-PF), and a numeric analog scale (NAS; 0-10) regarding anterior knee pain (AKP) at rest and during activity were assessed from pre- to postoperatively. RESULTS: The preoperative mean tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances were - 6.5 ± 6.5 mm and 0.7 ± 4.6 mm, respectively. The intraoperatively determined amount of tibial tubercle lateralization averaged 10.7 ± 3.6 mm. The Kujala score and KOOS-PF improved significantly from 33.6 ± 10.1 (23-51) points to 94.4 ± 6.2 points (82-100) (p < 0.001) and from 20.6 ± 13.2 points (0-43.3) to 87.3 ± 9.9 points (72.8-100) (p < 0.001) from pre- to postoperatively, respectively. Pain at rest decreased from 5.8 ± 1.9 to 0.8 ± 0.9 (p < 0.001), and pain during activity decreased from 8.6 ± 1.3 to 1.6 ± 1.5 (p < 0.001). CONCLUSION: RL-TTO significantly improved subjective knee function and AKP in patients suffering from medial patellar maltracking due to previous excessive tibial tubercle medialization osteotomy at short-term follow-up.

Thinner tuberosity osteotomy is more resistant to axial load in medial open-wedge distal tuberosity proximal tibial osteotomy: A biomechanical study.

BACKGROUND: The purpose of this study was to investigate axial load resistance of the tibia depending on the thickness of tibial tuberosity osteotomy in medial open-wedge distal tuberosity proximal tibial osteotomy (OWDTO). The hypothesis is that a thin tibial tuberosity osteotomy shows high axial load resistance of the tibia. METHODS: The OWDTO model was constructed from imitation bones of the tibia. Distal tibial tuberosity osteotomy was performed with thicknesses of 7, 14, and 21 mm (n = 5 for each group). Cyclic axial-load fatigue tests were performed to investigate the strain at five measurement points on the OWDTO model. An axial-load failure test was also performed to investigate the maximum strain for failure. RESULTS: The 7-mm OWDTO model showed a significantly lower stain range than the 14-mm model at the middle part of the lateral hinge (P = 0.0263, mean difference: -852.6 µÎµ), posterior part (P = 0.0465, mean difference: -1040.0 µÎµ), posterior tibial cortex (P < 0.0001, mean difference: -583.4 µÎµ), and plate (P = 0.0029, mean difference: -121.6 µÎµ). There were no significant differences in the strain at the tibial tuberosity between the groups. The axial load for complete failure was significantly higher in the 7-mm model than in the 21-mm model (P = 0.0010, mean difference: 2577.0 N). The failure points were at the lateral hinges. CONCLUSIONS: Thinner distal tibial tuberosity osteotomy is more resistant to axial load and may be recommended for the prevention of tibial and lateral hinge fractures after OWDTO.

Analysis of popliteal artery location for high tibial and distal tuberosity osteotomy using contrast-enhanced computed tomography.

BACKGROUND: Our objective was to evaluate the location of popliteal artery (PA) in osteotomy planes during high tibial osteotomy (HTO) and to determine a safer angle for screw drilling to the tibial tuberosity during distal tuberosity osteotomy (DTO). METHODS: Twenty knees in 20 patients who underwent contrast-enhanced computed tomography for cardiovascular diseases were examined. Osteotomy planes for open-wedge HTO (OWHTO) and hybrid closed-wedge HTO (hybrid CWHTO) were created using three-dimensional bone models. The distance from the posterior cortex of the tibia to the PA (dPC-PA) in the osteotomy planes was measured in the virtual osteotomy planes. The dangerous point (Point D1) was defined as the point 17.5 mm away from PA, setting the working length of the bone saw as 35 mm. The distance between the most medial point of the tibial cortex (Point M) and Point D1 in OWHTO and the most lateral point (Point L) and Point D1 in hybrid CWHTO were examined (dM-D1 and dL-D1, respectively). The location of Point D1 to the osteotomy line (%D1) was expressed as percentage, setting the start and end of the osteotomy line as 0% and 100%, respectively. To determine the safe angle for screw drilling in DTO, the angle between the line tangential to the medial cortex of the tibia and that passing through the center of the tibial tuberosity and PA were measured. RESULTS: In OWHTO and hybrid CWHTO, the mean dPC-PA was 10.6 mm (6.9-16.5 mm) and 10.2 mm (7.3-15.4 mm), respectively. The mean dM-D1 in OWHTO was 25.9 mm (24.6-27.2 mm) and dL-D1 in hybrid CWHTO was 5.1 mm (2.9-7.4 mm). The mean %D1 was 47.6 ± 3.7% in OWHTO and 9.3 ± 4.1% in hybrid CWHTO, respectively. The minimal angle between the two lines in DTO was 35.2°. CONCLUSION: PAs could run within 10 mm from the posterior cortex in the osteotomy planes of HTO. Therefore, proper posterior protection is necessary when cutting posterior cortex. An angle of less than 35° against the medial cortex line would be safe for screw fixation to avoid vascular injury in DTO.

Functional internal rotation is similar between lesser tuberosity osteotomy and subscapularis peel in total shoulder arthroplasty: short-term follow-up.

INTRODUCTION: Lesser tuberosity osteotomy (LTO) and subscapularis peel (Peel) are 2 common techniques used to mobilize the subscapularis tendon during anatomic total shoulder arthroplasty (TSA). The literature is inconclusive over which technique is optimal; thus, controversy exists over which technique should be performed. The purpose of this study was to compare specific functional internal rotation tasks and general outcome scores in TSA patients who received either an LTO or Peel. METHODS: A retrospective review of 563 patients treated with primary TSA using either an LTO (n = 358) or Peel (n = 205) with a minimum 2-year follow-up was performed. Subjective internal rotation, active internal rotation, and specific questions related to functional internal rotation isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons functional questionnaires were reviewed. Other outcome scores including visual analog scale pain and function, Single Assessment Numerical Evaluation, SST, American Shoulder and Elbow Surgeons, and revision rates were compared between the 2 groups. RESULTS: The study found no difference in postoperative functional internal rotation and range of motion between LTO and Peel. Patients who received a Peel were shown to have a slightly greater improvement in the ability to perform toileting and a higher average change in SST score that did not reach clinical significance. There was no difference in the percentage of maximal improvement, revision rate, or need for revision between the 2 groups. CONCLUSION: No difference was found between the LTO and Peel techniques in regard to functional tasks of internal rotation at short-term follow-up.

Tibial shaft fracture after medial open-wedge distal tibial tuberosity osteotomy: A case report.

We report a case of tibial shaft fracture after open-wedge distal tibial tuberosity osteotomy (OWDTO). The use of a lag screw for a lateral hinge fracture in OWDTO requires careful postoperative rehabilitation and follow-up. We discuss concerns related to the mechanical strength at the osteotomy site after OWDTO to prevent fracture.

Three-dimensional transfer of tibial tuberosity for patellar instability with patella alta preserves patellar position and clinical outcomes: A minimum 3-year follow-up study.

BACKGROUND: The three-dimensional (3D) transfer of tibial tuberosity has been reported to improve patellofemoral congruity and showed good clinical outcomes during the short follow-up, however, little is known about whether the patellar position and clinical outcomes are preserved at longer follow-ups and the risk factors for poor clinical outcomes. HYPOTHESIS: We hypothesized that patellar position and clinical outcomes would be preserved and the predisposing factors were associated with poor clinical outcomes after the 3D transfer of tibial tuberosity. PATIENTS AND METHODS: Thirty-nine patients, with a mean age of 27.9 (15-52) years, who underwent the 3D transfer of the tibial tuberosity were enrolled. Patellar position was evaluated using the Caton-Deschamps index and patellar tilt. Clinical outcomes were evaluated with Lysholm and Kujala scores pre- and postoperatively. Age, body mass index (BMI), radiographic measurements, and range of motion (ROM) were compared between the poor group (defined as <80 points on Kujala score) and the good group (≥80 points). The mean follow-up period was 54.1 (36-100) months. RESULTS: Patellar position decreased from 1.32 (1.21-1.53) preoperatively to 0.99 (0.84-1.07) at the final follow-up, according to the Caton-Deschamps index (p < 0.01). The mean patellar tilt decreased from 26.0° (21-40°) to 15.1° (5-28°) (p < 0.01). Kujala and Lysholm scales improved from 59.1 to 54.2 to 90.1 and 91.8 at final follow-up, respectively (p < 0.01). Increased BMI, lower femorotibial angle, limited ROM, and poor preoperative clinical outcomes were the predicting factors for poor postoperative clinical outcomes (p < 0.05). CONCLUSION: The 3D transfer for patellar instability with patella alta preserved the patellar position and clinical outcomes for at least 3 years. Predisposing factors that may potentially affect postoperative clinical outcomes of the 3D transfer of tibial tuberosity include an increased BMI, valgus knee, limited ROM, and poor preoperative clinical outcomes.

Fracture of the tibial tubercle does not affect clinical outcomes in medial opening wedge high tibial osteotomy with distal tibial tubercle osteotomy.

PURPOSE: To investigate whether tibial tubercle fracture affected clinical outcomes and bony union in medial opening wedge high tibial osteotomy with distal tibial tubercle osteotomy (DTO) and to determine the anatomical risk factors for tibial tubercle fracture. MATERIALS AND METHODS: All patients who underwent DTO were retrospectively reviewed, and 104 successive patients were included. The Knee Society Score and complications including tibial tubercle fracture were recorded. On radiographs and computed tomography scans, the length, thickness, width, height, and bony union of the osteotomized tibial tubercle and the posterior tibial slope were statistically analysed. RESULTS: Fracture of the tibial tubercle occurred intraoperatively in 11 patients (10.6%) and in the postoperative period in 1 (1.0%). The case of postoperative fracture showed non-union. There was no significant difference in the Knee Society Score between the non-fracture and fracture groups. There were significant differences in the posterior tibial slope and the height of the tibial tubercle between the groups (p < 0.0001 for each comparison). The logistic regression analysis showed that the height of the tibial tubercle was associated with a higher risk of the fracture of the tibial tubercle (p < 0.01; OR, 1.548; 95% CI, 1.149-2.085). However, there were no significant differences in the bony union rate of the tibial tubercle at 6 months after surgery between the groups. CONCLUSIONS: Tibial tubercle fracture did not affect the clinical outcome and bony union in spite of the relatively high occurrence rate. Anatomical risk factors for the fractures was a lower tibial tubercle position. LEVEL OF EVIDENCE: Level IV.

Distal tibia allograft glenoid reconstruction for shoulder instability: outcomes after lesser tuberosity osteotomy.

BACKGROUND: Distal tibia allograft reconstruction of the glenoid in shoulder instability has garnered significant attention over the last decade. Prior studies demonstrate significant improvement in all reported patient outcomes albeit the approach is through a subscapularis split. There have not been prior studies evaluating outcomes after lesser tuberosity osteotomy which provides excellent exposure to the anterior glenoid.We hypothesize there is significant improvement in functional outcomes and no deleterious effects after lesser tuberosity osteotomy for distal tibia allograft reconstruction of the glenoid for shoulder instability. METHODS: A retrospective review was performed from 2016 of 2019 of patients undergoing distal tibia allograft reconstruction of the glenoid through a lesser tuberosity osteotomy. Patients were indicated if they had recurrent anterior shoulder instability with >20% glenoid bone loss and evidence of an off-track lesion. Clinical, imaging, and operative data were evaluated. Objective follow-up data evaluated at minimum 2 years included radiographs, range of motion, DASH, SANE, VAS, SST, ASES, and Constant scores. RESULTS: A total of 12 patients were available with average follow-up 28 months, average age 26 years old, and average glenoid bone loss of 33%. The patients demonstrated significant improvement in their clinical outcomes at final follow-up: DASH 42.9-8.9 (P = .004), SANE 32.2-85 (P = .00005), VAS 4.6-1.1 (P = .003), SST 7-11.4 (P = .01), ASES 50.2-90.5 (P = .001), and Constant 37.6-86.2 (P = .01). Range of motion at final follow-up was forward flexion to 161.4° (135-170°), external rotation 49.5° (40-65°), and internal rotation to T12-L1 (T7-L2) vertebral body. CONCLUSION: The present study demonstrates the effectiveness of a lesser tuberosity osteotomy in exposure of the glenoid for reconstruction with a distal tibia allograft. The functional integrity of the subscapularis is maintained and the patient-reported outcomes are comparable with current literature.