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Acta Ortopédica Brasileira

Print version ISSN 1413-7852On-line version ISSN 1809-4406

Acta ortop. bras. vol.11 no.1 suppl.1 São Paulo Jan./Mar. 2003 



Valgus osteotomy of the tibia with a Puddu plate combined with anterior cruciate ligament reconstruction



Roberto Freire da Mota e AlbuquerqueI; Marcos Cristian BorgesII; Milton Luiz da RochaII; Eduardo Ienny AkiyamaII; Marcos de Amorim AquinoIII; Sandra Umeda SasakiIII; Alexandre Pagotto PachecoIV; Marco Martins AmatuzziV

IArthroscopy Laboratory Coordinator, IOT, HC, FMUSP
IITrainee Doctors at Arthroscopy Lab., IOT,  HC, FMUSP
IIIPost Graduate Students, IOT, HC, FMUSP
IVAssistant Doctor, IOT, HC, FMUSP
VChairman, IOT, HC, FMUSP





Anterior knee instability associated with a varus deformity is a complex condition with several treatment possibilities. Among these, anterior cruciate ligament (ACL) associated to a simultaneous valgus tibial osteotomy is a increasing indication. This simultaneous procedure adds technical issues to those related to the isolated surgeries. Thus, the osteotomy plane and location of fixation hardware shouldn’t conflict with tibial tunnel and ACL graft fixation.

Authors analyze the relations between a opening tibial valgus osteotomy stabilized with a Puddu plate and ACL reconstruction with a patellar tendon graft fixated with interference screws in 10 human cadaver knees. A straight oblique tibial osteotomy starting on the medial tibial cortex and oriented laterally and proximally was performed on all knees with a 10mm opening medially and stabilized with a Puddu plate on the most posterior aspect of the medial tibia, and a tibial tunnel drilled 50° to tibial plateau. With this technique there was no intersection between tibial tunnel or interference screw and the osteotomy or the plate fixation screws.

Key Words: Knee; Osteotomy; Tibia; Anterior cruciate ligament/surgery/injury.




Association of anterior knee instability to varus deviation is a complex situation. When the axial alignment of the limb is an important issue in the instability pattern, it is mandatory to understand that a single ligament reconstruction is a partial treatment, and will fail if the misalignment is not corrected(6). In these cases, surgeries over soft tissues as Anterior Cruciate Ligament (ACL) should be performed together with the osteotomies, or in a second moment if the instability remains after axial correction(5,6). The combined surgery is indicated for patients with chronic symptomatic injury of ACL that developed a misalignment in varus of the knee joint, with a narrowing of the medial tibiofemoral compartment. It is characteristic that these patients have an asymmetrical varus in comparison to the opposite side knee, and the misalignment is produced by the ligamental lesion itself with time, being progressive and eventually aggravated by meniscectomy, frequently previously performed(5).

Several surgical techniques of tibial osteotomy were described for knee varus deformity correction(5,8,9,12,18). All of them aim to move laterally, even though partially, the existing overload at medial side, allowing a better load distribution over the knee. However, in the instable knee, there is another primary objective. The axis alignment aims to compensate the adductor moment helping neutralization of the instability due to lateral compartment slackness or, more specifically, of the posterolateral corner of the knee.

The association of valgus tibial osteotomy to reconstruction of the anterior cruciate ligament at the same surgery demands an osteotomy technique that allows a feasible rehabilitation of the ligamental reconstruction.

Thus, osteotomies without a rigid fixation, demanding a long postoperative immobilization are not suitable for this situation. It has to be considered as well that in these cases the knee usually already presents a moderate degree of osteoarthrosis, so, it is desirable a technique preserving the bone reserve and that does not significantly changes the anatomy of the proximal portion of the tibia, due to the possibility of an eventual knee arthroplasty.

Opening osteotomies are efficacious in correcting the tibial varus deformity, sparing bone tissue, avoiding deformities, sometimes coarse, caused by osteotomies with bone wedge resection(5,9,14,15).

An important question is the technical viability of association of the osteotomy to ACL reconstruction, once it should not have any interference of the tibial tunnel with the osteotomy plane or with the fixation screws eventually used.

Puddu et al.(17) presented a proximal tibia osteotomy technique with a medial wedge opening, stabilized by means of a plate with a metallic chock interposed in the osteotomy plane, avoiding it to close. Proximally, the plate is fixated with one or two long screws for cancellous bone, placed in parallel to the osteotomy line and, distally, the plate is fixated to the tibial shaft by means of one or two cortical screws.

This technique has been frequently used among us and, when adequately performed demonstrates to be an efficient surgery for correcting the mechanical axis of the varus knee, providing stability and pain relief(6,7,17). Were not reported, to this moment, studies evaluating the technical suitability of ACL reconstruction combined with this osteotomy technique.

Thus, we aim to study and standardize the positioning of the tibial tunnel and of the fixation plate in the ACL reconstruction associated to valgus tibial osteotomy by means of an opening wedge and fixation with a "chock" plate as described by Puddu et al.(17). In performing simultaneously both procedures, there are some questions to be answered. It was not, for instance, established the position where the "chock" plate should be placed during the valgus osteotomy, or the angle that should be used for drilling the tibial tunnel in the ACL reconstruction so that there is not an intersection between this and the proximal spongeous screw used for fixation of the plate. The complexity of the surgery lead us to draw an osteotomy model in an such an angle that does not disturbs the drilling of the tibial tunnel which will get a graft, neo ACL.



Obtaining, preparing and preserving the anatomical piece

There were used in our study ten anatomical knee pieces, removed from fresh human corpses, from the Serviço de Verificação de Óbitos da Capital (City Morgue), with causa mortis other than consumptive diseases. The pieces were removed as a block, including all tissues but skin and subcutaneous, through a median anterior longitudinal approach, from the medium third of the thigh to the median third of the leg. After removed, all pieces were packed in plastic bags, kept frozen at -20º C up to the moment of the procedures. Previously to the experiment, the pieces were defrosted by immersion in saline solution at room temperature (1,11,16).

Surgical Technique

The Authors, at the Arthroscopy Laboratory of IOT from Hospital das Clínicas da FMUSP, performed all the procedures. All anatomical pieces underwent valgus osteotomy of the tibia with a Puddu(17) "chock" plate along with an ACL arthroscopic reconstruction as standardized by Dejour(2,3,4) which derived from the original technique by Jones(10) using a patellar tendon graft fixated to the tibia and femur by means of interference screws.

The first performed procedure was the drilling of the tibial tunnel. For this it was used a conventional 50º angulated norm and positioned with a 15º inclination in relation to the sagittal plane; the cortical tunnel entry hole at the metaphyseal tibial region was placed 0.5 cm to 1.0 cm proximally to pes anserinus tendons. Following, it was drilled a femoral tunnel according to usual procedures. After the tunnels were drilled, the 1 cm width graft was taken from the central part of the patellar tendon and following the pes anserinus tendons were identified. The fascia of the sartorius was divided parallel to its fibers, proximal to gracile tendon. The pes anserinus tendons were retracted allowing the view of the medial superficial collateral ligament, divided transversely 1 cm above its tibial insertion, exposing the posterior-medial tibial aspect. At is anterior aspect, after retropatellar bursa was identified, a blunt retractor was placed under the patellar tendon, exposing the tibia. Next step was to introduce a Kirschner wire obliquely oriented, towards the Gerdy tuberculum, starting from a point 1 cm below the entry level of tibial tunnel, with this wire working as a guide for the bone saw. The tibial cut was carefully performed, close to the Kirschner wire, keeping the fibular head as a reference, aiming to preserve as much as possible the lateral tibial cortical (the osteotomy ended 1 cm before the lateral cortical). After the tibial osteotomy was finished, it was opened by means of a wedge shaped norm, graded in its extension, with a clinical correction of 10 mm through the placement of a plate with a chock of the same size inside the norm, so that it could be removed and the correction preserved. Proximally, the plate was fixated with one long spongeous screw, quite parallel to the osteotomy line, and distally, fixated by a cortical screw(7,17). The plate was placed 1 cm posterior-laterally to the tibial tunnel entry, so avoiding the intersection of the tibial tunnel and the spongeous screw. Finished the osteotomy fixation, it was crossed through the tibial and femoral tunnels, and fixated with interference screws at both sides(2,3,4). Bony grafting finally, fulfilled the bony defect.



Finished each valgus tibial osteotomy with a "chock" Puddu plate, combined with ACL reconstruction, a radiographic evaluation of the knee was performed through Anterior (Figure 1), Lateral (Figure 2), Internal Oblique and External Oblique (Figure 3) views.








None of the ten evaluated pieces had any intersection between the tibial tunnel drilled for ACL reconstruction and the screws used for fixation of the "chock" Puddu plate as well as there was no rupture or collapsing of the tibial tunnel after the valgus osteotomy was performed.



We decided to drill the tibial and femoral tunnels before the valgus osteotomy for understanding that this makes the procedure easier, reducing the surgery time (specially important in this technique, for being a combined procedure). It was used an angulated 50º tibial norm positioned with a 15º inclination, in relation to the sagittal plane, what is fully supported by the literature(2,6,8,14,15).

The osteotomy trace should start about 1 cm below the entry of the tibial tunnel, in order to avoid the risk of this to collapse. By observing these procedures, the tunnel, positioned isometrically, in a 50º angulation will lead the osteotomy to be performed about 4 cm from the joint line, at the level of the distal insertion of the medial collateral ligament, that is, in a suitable position for a Puddu osteotomy.

In our study we had no problem in drilling the tunnels nor in defining the start point of the osteotomy.

The tibial cut during the valgus osteotomy shoud be performed under radiographic control. This was not possible due to not having an immage intensifier available at the laboratory. With help of an anatomical piece without skin and subcutaneous, we so performed carefully the osteotomy, taking the fibular head as a reference. For better precision, anterior and posterior corticals had the osteotomy performed by thin osteotomes, using the electric saw only for starting the osteotomy.

In our study we had no problem in drilling the tunnels nor is defining the start point of the osteotomy.

The tibial cut during the valgus osteotomy shoud be performed under radiographic control. This was not possible due to not having an immage intensifier available at the laboratory. With help of an anatomical piece without skin and subcutaneous, we so performed carefully the osteotomy, taking the fibular head as a reference. For better precision, anterior and posterior corticals had the osteotomy performed by thin osteotomes, using the electric saw only for starting the osteotomy.

A 10 mm "chock" Puddu plate was used. Only one size of plate was used for, independently of its size, the spongeous screw was allways positioned parallel to the osteotomy line, not changing the surgical technique.

The plate was placed 1 cm posterior-medially to the tibial tunnel entry. We chose this position due to, when the plate is placed more posteriorly there is a trend to a reduction of the posterior inclination of the tibia, reducing as well the anterior-posterior aspect of the contact force of the joint, contributing for reducion of the anterior translation of the tibia(6). As we understand, this mechanism would be interesting in patients with a recently reconstructed ACL, for reducing the tension over this ligament. With this positioning, also, the spongeous screw, responsible for the proximal fixation of the plate, remains at the same level of the entry of the tibial tunnel, however without possibility of intersection between both of them, for having different paths.

The patellar tendon graft was fixated to the tibia by means of an interference screw, routinelly used in reconstructions without osteotomy, and that, in this technique minimizes the risk of tunnel, or screw or other fixation material to crossover, for using the same tunnel as the graft.

Thus, this looks to us a suitable and safe option for those cases where it is indicated to add a valgus tibial osteotomy to ACL reconstruction at the same surgical time, an increasingly frequent situation.



Valgus tibial osteotomy with "chock" Puddu plate, combined with ACL reconstruction of the knee was shown to be technically possible with the described standardization, without interference of complications due to the procedures being performed together.



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Correspondence to
Av. Nove de Julho, 5.519 cj.41
São Paulo, SP, CEP 01407-200

Trabalho recebido em 12/09/2002
Aprovado em 07/11/2002
Work performed at Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP

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