Valgus tibial osteotomy with "wedge" plate of Puddu: technique presentation

Abstracts

O objetivo do presente trabalho é apresentar os resultados iniciais, obtidos com a osteotomia valgizante de adição de tíbia, fixada com placa calço descrita por Puddu. Foram operados 29 joelhos em 27 pacientes para correção de geno-varo, sendo que, em apenas um paciente o procedimento bilateral teve objetivo profilático. O seguimento foi de 3 a 28 meses com média de 14 meses. A osteotomia proximal de tíbia foi feita de forma oblíqua iniciando na inserção distal do ligamento colateral medial em direção ao tubérculo de Gerdy. A osteotomia foi aberta e fixada com uma placa calço de Puddu. O espaço aberto da osteotomia foi preenchido por enxerto autólogo de ilíaco. A carga total era dada com 45 dias de pós-operatório. Os resultados obtidos mostraram que entre 4 a 6 meses os pacientes tiveram uma significativa melhora na sintomatologia indutora do procedimento cirúrgico. A avaliação final mostrou 27 resultados satisfatórios e apenas 2 regulares. Como conclusão essa técnica tornou a osteotomia de tíbia um procedimento reprodutível com resultados previsíveis com excelente manutenção no pós-operatorio da correção obtida no trans-operatório.

Osteoartrose; Geno-varo; Osteotomia

ARTIGO DE REVISAO

Valgus tibial osteotomy with "wedge" plate of Puddu: technique presentation^*

João Luiz Ellera Gomes^I; Roberto Petersen Ruthner^II; Luiz Roberto Stigler Marczyk^III

^IProfessor Assistente de Ortopedia e Traumatologia da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul

^IIMédico Ortopedista da Sbot, fazendo mestrado em Cirurgia na Faculdade de Medicina da Universidade Federal do Rio Grande do Sul

^IIIProfessor Titular de Ortopedia e Traumatologia da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul

^{Endereço dos autores do trabalho}

SUMMARY

The objective of this paper is to present the initial results obtained with the valgus tibial osteotomy, fixed with the wedge plate described by Puddu. This surgery was performed in 29 knees, in 27 patients, for correction of genu-varum, and as a profilatic measure in only one patient. The follow up time was from 3 to 28 months with average of 14 months. The proximal tibial osteotomy was done in an oblique way with start in the distal insertion of the colateral medial ligament and directed to the Gerby tubercle. The osteotomy was opened and fixed with a wedge plate of Puddu. The space opened by the osteotomy was filled with autologous iliac graft. Total weightbearing was allowed 45 days after surgery. The results show that in 4 to 6 months patients had a significant improvement of symptoms which induced to the surgical procedure. The final evaluation shows 27 satisfactory results and only 2 regular. Concluding, this technique made the tibial osteotomy a reproducible procedure with predictable results and excellent mantainance in the post-surgery of the correction obtained during surgery.

Key-words: Osteoartrosis, Genu-varum. Osteotomy

INTRODUCTION

The medial femoro-tibial degeneration of the knee often brings doubts to the orthopedist upon which would be the better technique to be choosen⁵. All surgical tecniques described have the objective of shifting the weight load present in the medial compartment, due to a varum deformity, to the lateral side, at least partially, aiming a better distribution of pressure^5,6,9,10. Although having the same objective, these several techniques are different with respect to the simplicity of its execution, results obtained, complications during surgery and care after surgery^{2,3,4,8,9,10,12,13,15,16,17,18}. Due to these differences of techniques and results, alternative solutions appeared, from solely video-arthroscopic techniques⁷ to new models of unicompartimental prosthesis^5,14.

We were reluctant to indicate the tibial osteotomies until we learned from Dr. Giancarlo Puddu (Rome, Italy) a technique developed by him, the proximal osteotomy with opening fixed with wedge plaque, what appeared to be a simple and logic idea^1,11. The objective of this paper is to present the results obtained with this technique in the surgical treatment of 29 patients with varum deformity of the knee.

MATERIAL AND METHODS

From July/97 to August/99, 29 knees from 27 patients bearing a varum deformity were treated with the technique of proximal osteotomy with tibial opening fixed with plaque wedge fixed with two screws, one spongiosus and one cortical.

The age of our patients ranged from 17 to 79 years old, with average of 52 years and 6 months. Sixteen patients were male and 11 female. The average age of male patients was 44 years and 3 months and for female patients was 60 years and 9 months.

All candidates to the procedure had a X-ray standing, with mono and bipodal support, with complete extension of the knees. The varum angle was measured for evaluation of final result obtained after surgery, since the correction of the deformity during surgery was based solely in the visual appearance.

Surgical Technique

The initial procedure was a surgical video-artroscopy^7,13, with the objective of wash the articulation from cartilagenous debris, ressect the menisc lesions and treat the cartilagenous lesions trough curetage, perforations and abrasion^7,18. Following started the osteotomy^1,11 itself, with a longitudinal incision with circa 5 cm in the skin, in the medial side os the tibial metaphisis, 4 cm away from the articular interline. The colateral medial superficial ligament was identified and transversaly cut 1 cm above its tibial insertion. In this point a thread of Kirschner was introduced and oriented to the Gerdy tubercle (Fig. 2.2). Its orientation was evaluated with the image amplifier, and modified if necessary. When the orientation was acceptable, the thread was cut 1 cm above its entry in the tibia. The objective of this thread was to act as a guide to the disk of the bone sewer. The tibial cut was started below and close to this thread of Kirschner (Fig. 2.3). The progression of this cut, transversal to the tibial axis, was also monitored with help from the image amplifier. Once the tibial cut was finished (Fig. 2.4), the osteotomy was completed with the diapason, that has the shape of a wedge (Fig. 2.5), graded in its extension. This instrument is the key of the whole procedure, because at the same time it completes the osteotomy, it permits a variation for more or for less in the correction up to the desired point, being the size of the plaque chosen according to the graduation externally visible in the lateral side of the diapason-wedge (Fig. 1).

The degree of clinical correction was evaluated with the foot of the patient placed against the abdomen of the surgeon. If considered insufficient, the diapason-wedge was pushed inside the tibial cut, increasing the correction. If the correction was considered too great, the diapason-wedge was pulled outside, decreasing instantly the degree of correction. When the correction was considered as ideal, a plaque corresponding to the lateral number in the diapason-wedge was put in place. This number ranges from 7,15 to 15 mm, and the plaque was placed inside the diapason, in a way that when it was displaced, the plaque would keep the same correction achieved. Proximally the plaque was fixed with a long spongiosus screw, pratically standing parallel to the osteotomy line. Distally, the plaque was fixed with a cortical screw (Fig. 2.6) The stabilization during surgery was excellent in all cases. In this moment the bone defect was filled with autologous iliac bone graft. In all patients was used a aspiration device for 24 hours. The wound was closed layer by layer and the knee was protected with a long imobilizer with aluminum fins. The imobilizer was kept for 3 weeks, but patients were encouraged to do flexo-extension exercises starting in the 10^th postoperative day. Partial weightbearing started in the 15^th day and total weightbearing in the 45^th postop day. All patients were monitored radiologically after surgery (Fig. 3 and 4).

Criteria for Assessment of Results

The evaluation criteria that appear in Table 1³ were used review the cases

RESULTS

To evaluate the results the subjective classification in satisfactory, regular and non-satisfactory, was used. Table 1 ³

According to our evaluation we classified 27 knees as satisfactory, 1 knee as regular and 1 knee as non-satisfactory result. As complication we had one case of superficial infection that required surgical cleaning, with good outcome after antibiotic treatment and bandages. It was not necessary the outplacement of the plaque with screws and autologous bone graft placed to fill the bone imperfections. This patient presented with moderate pain and partial limitation of knee flexion non-satisfactory result). In all cases occurred complete integration of the autologous bone graft (Fig. 5)

DISCUSSION

The surgical correction with plaque of Puddu^1,11 is a procedure that, in our opinion, will considerably change the treatment of the varum deformities of knee, with or without degenerative disease of the medial compartment. The reasons for this are many, but here are those we judge as the most important. We will start with the analysis of the surgical procedure methodology. It is specially efficient in the profilatic correction of the varum deformities in young patients. It is enough that the plaque size used in one side be similar to the one used in the other side to have a totally symetric correction We consider particularly atractive the transsurgery reversibility of the obtained correction. This flexibility is achieved by pulling inside or pushing outside the diapason-wedge, to obtain more or less correction, without compromising the final result. No additional bone cut is necessary. All is solved by the initial tibial cut. The stabilization transsurgical of the osteotomy is excellent, but the the most important is that this correction is kept unchanged in the postoperative time.

Another interesting aspect is the low local morbidity, not only due to the reduced tissular mobility, but also due to the mantainance of the fibular and proximal tibiofibular articulation integrity. As the fibula is not touched, it works as a biological stabilizer increasing the stability of the osteotomy. This low local morbidity decreases the chance of complications very frequent in the conventional osteostomies¹⁶, mainly in elderly patients. Certainly one will say that this surgery requires collection of bone graft from iliac, and we are obliged to agree. However, considering the anatomical distance of both procedures, there is no superimposed local morbidity, and both procedures are perfectly tolerated by patients. Moreover, exists the possibility of the tibial bone defect be filled in by methods other than the autologous graft, what would decrease additionally the global morbidity. In our hospital, we started a study with 3 groups of patients treated with liophilized graft, frozen homologous graft and tablets of hidroxiapatite. No nosso hospital, já iniciamos um protocolo que inclui 3 grupos de pacientes tratados com enxerto liofilizado, enxerto homólogo congelado e pastilhas de hidroxiapatite.

Maybe the major difficulty faced in this whole procedure, was how to name the plaque that fixes the osteotomy.

We could simply call it plaque of Puddu, name of surgeon who developed this procedure. It happens that such plaques are sold by Artrex®, factory of orthopedic material, that together with Dr. Peter Fowler and Dr. A. Amendola¹, will introduce several modifications to the original model, shown to us by Dr. Giancarlo Puddu¹¹ some years ago. Thus, the confusion is created, because we would have the Puddu original plaque and the Artrex® plaque, ou who knows, the plaque Puddu-Fowler. from what we could observe up to now, the changes intrduced are more cosmetics than conceptual, that means, changes in the format and not in the content. Due to these reasons we prefer stick to concept of plaque with variable protuberance. We have thought initially in plaque of addition ou plaque step, but concluded that these are designations that do not express in a satisfactory way the function of the plaque. Our option was in favor of plaque-wedge, that in spite of phonetically disagreable, is an expression that naturally translates the objective and format of the plaque in question.

Regardless of the chosen name, what really counts, as far as tibial osteotomy is concerned, it is that the ways are so important as the end. Under this aspect, the tibial valgisant osteotomy with wedge-plate of Puddu reached its final objective, that is, correction of the deformity and a postoperative time very easy for patients in spite of all structural changes of this procedure. As last words, we would like to tranquilize the more skepticals saying that, regardless of the fact that osteotomies usually supratuberositary have ocasionally become transtuberositary, we had no case of committment of the extensor aparatus.

CONCLUSION

The quality of the results obtained up to this moment, besides the transoperative simplicity, the safety of the postoperative handling and the low number of complications led us to conclude that the technique used rescued the proximal tibial osteotomy from the shadow brought by the total knee prosthesis turning once more its indication as one attractive alternative to the treatment of varum knee due to unicompartimental medial ostheoarthrosis.

REFERENCES

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• 2. Camargo, O.P.A., Severino, N.R., Aihara, T., Cury, R.P.L., Souza, D.G., Palomino, E.M. & Cillo, M.S.P.: Osteotomia tibial alta: estudo comparativo entre os métodos de fixação por "agrafes" e aparelho de Ilizarov. Rev Bras Ortop 30: 305-310, 1995.
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• 8. Miniaci, A., Ballmer, F.T., Ballmer, P.M. & Jakob, R.P.: Proximal tibial osteotomy: a new fixation device. Clin Orthop 246: 250-259,1989.
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• 12. Stetson, W.B., Friedman, M.J., Fulkerson, J.P., Cheng, M. & Buuck, D.: Fracture of the proximal tibia with immediate weightbearing after a Fulkerson osteotomy. Am J Sports Med 25: 570-574,1997.
• 13. Vidal, P.C., Brandt, C., Paulo, H., Gomes, M.M. & Tavares,S.: Tratamento da osteoartrose do joelho com artroscopia e osteotomia valgizante tibia empregando o aparelho de Ilizarov. Rev Bras Ortop 30: 523-527,1995.
• 14. Weale, A.E. & Newman, J.H.: Unicompartmental arthroplasty and high tibial osteotomy for osteoarthosis of the knee. A comparative study with a 12 to 17 year follow-up period. Clin Orthop 302: 134-137,1994.
• 15. Wildner, M., Peters, A., Hellich, J. & Reichelt, A.: Complications of high tibial osteotomy and internal fixation with staples. Arch Orthop Trauma Surg 111: 210-212,1992.
• 16. Wootton, J.R., Ashworth, M.J. & Maclaren, C.A.: Neurological complications of high tibial osteotomy - the fibular osteotomy as a causative factor: a clinical and anatomical study. Ann R Coll Surg Engl 77: 31-34,1995.
• 17. Zaidi, S.H., Cobb, A.G. & Bentley, G.: Danger to the popliteal artery in high tibial osteotomy. J Bone Joint Surg [Br] 77: 384-386,1995.
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Endereço dos autores do trabalho:

Av. itaqui, nº 45, Petrópolis, Porto Alegre, RS, BRASIL.

Cep: 90460-140 Tel/Fax: (0xx-51) 332-4101

^*

Work done at Serviço de Ortopedia e Traumatologia do Hospital de Clinicas de Porto Alegre, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul.

Publication Dates

• Publication in this collection
  07 May 2007
• Date of issue
  Sept 2000