Advertisement

Opposite hinge fractures in high tibial osteotomy: a displacement subtype is more critical than a fracture type

  • Anton DorofeevEmail author
  • Alfred Tylla
  • Martin Benco
  • Wolf Drescher
  • Richard Stangl
Original Article • KNEE - FRACTURES
  • 14 Downloads

Abstract

Purpose

Analysis of the structure of the fractures of opposite hinge (FOH) after angle-stable closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO), and their influence on the development of tibial pseudarthrosis.

Methods

187 CW and 94 OWHTOs were analyzed retrospectively. The FOHs in the OWHTO were classified according to Takeuchi, and in the CWHTO—according to the own classification with two types (depending on the direction of FOH). FOHs in both techniques were also subdivided into three subtypes according to displacement (A—non-displaced, B—primarily displaced, C—secondarily displaced). The statistical analysis included correlation analysis and logistic regression.

Results

FOHs were found in 81 (43.3%) CW and 39 (41.2%) OWHTOs. The stable type 1 fractures predominated in OWHTO (76.9 vs. 42%, p < 0.001), the unstable type 2 FOHs prevailed in CWHTO (58 vs. 17.9%, p < 0.001). The tibial pseudarthrosis rate was higher with type 1 (20 vs. 12.9%, n.s.) and subtype A (16.7 vs. 6.8%, p = 0.048) FOHs in OWHTO, and with type 2 (20 vs. 0%, p < 0.001) and subtypes B (25 vs. 0%, p < 0.001) and C (29.4 vs. 25%, n.s.) in CWHTO (without FOHs 0.9% in CW and 1.8% in OWHTO, n.s.). Relevant correlations were detected between the pseudarthrosis rate and fracture type only in CWHTO (ρs = 0.298, p < 0.001, OR 24.87 for type 2) and displacement subtype in both groups (for subtype C: ρs = 0.345, p < 0.001, OR 43.75 and ρs = 0.231, p = 0.02, OR 18.0, respectively).

Conclusions

The unstable FOH types were more common in CWHTO. The displacement subtype was more predictive for the development of tibial pseudarthrosis than the fracture type, especially in OWHTO. The secondarily displaced FOHs (subtype C) represented the highest risk for the occurrence of pseudarthrosis in both techniques.

Keywords

Osteotomy Classification Hinge fracture CWHTO OWHTO Pseudarthrosis 

Notes

Author’s contribution

AD contributed to design and objectives of this study, data collection, statistical analysis and writing. AT is a surgeon and contributed to the data collection and preparing the manuscript. MB contributed to the data collection and radiological evaluation. WD is a senior surgeon and contributed to design of this study and edition of the manuscript. RS is a senior surgeon and contributed to design of this study, statistical analysis and supervision of the study. All authors read and approved the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures were performed with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

In this study, formal informed consent was obtained from all participants.

References

  1. 1.
    Gstottner M, Pedross F, Leidensteiner M, Bach C (2008) Long-term outcome after high tibial osteotomy. Arch Orthop Trauma Surg 128:111–115CrossRefGoogle Scholar
  2. 2.
    Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H (2008) The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br 90(5):592–596CrossRefGoogle Scholar
  3. 3.
    Amendola A, Bonasia DE (2010) Results of high tibial osteotomy: review of the literature. Int Orthop 34(2):155–160CrossRefGoogle Scholar
  4. 4.
    Schallbereger A, Jacobi M, Wahl P, Maestretti G, Jakob RP (2011) High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years. Knee Surg Sports Traumatol Arthrosc 19:122–127CrossRefGoogle Scholar
  5. 5.
    Staubli AE, De Simoni C, Babst R, Lobenhoffer P (2003) TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia—early results in 92 cases. Injury 34(Suppl 2):B55–B62CrossRefGoogle Scholar
  6. 6.
    van Raaij TM, Brouwer RW, de Vlieger R, Reijman M, Verhaar JA (2008) Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening-wedge technique. Acta Orthop 79(4):508–514CrossRefGoogle Scholar
  7. 7.
    Weng PW, Chen CH, Luo CA, Sun JS, Tsuang YH, Cheng CK, Lin SC (2017) The effects of tibia profile, distraction angle, and knee load on wedge instability and hinge fracture: a finite element study. Med Eng Phys 42:48–54.  https://doi.org/10.1016/j.medengphy.2017.01.007 CrossRefGoogle Scholar
  8. 8.
    Kessler OC, Jacob HA, Romero J (2002) Avoidance of medial cortical fracture in high tibial osteotomy: improved technique. Clin Orthop Relat Res 395:180–185CrossRefGoogle Scholar
  9. 9.
    Meidinger G, Imhoff AB, Paul J, Kirchhoff C, Sauerschnig M, Hinterwimmer S (2011) May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union. Knee Surg Sports Traumatol Arthrosc 19(3):333–339CrossRefGoogle Scholar
  10. 10.
    Miller BS, Dorsey WO, Bryant CR, Austin JC (2005) The effect of lateral cortex disruption and repair on the stability of the medial opening wedge high tibial osteotomy. Am J Sports Med 33(10):1552–1557CrossRefGoogle Scholar
  11. 11.
    Tunggal AW, Higgins GA, Waddel JP (2010) Complications of closing wedge high tibial osteotomy. Int Orthop 34(2):255–261CrossRefGoogle Scholar
  12. 12.
    Ogawa H, Matsumoto K, Akiyama H (2017) The prevention of a lateral hinge fracture as a complication of a medial opening wedge high tibial osteotomy: a case control study. Bone Joint J 99(7):887–893CrossRefGoogle Scholar
  13. 13.
    Han SB, Lee DH, Shetty GM, Hae DJ, Song JG, Nha KW (2013) A “safe zone” in medial open-wedge high tibia osteotomy to prevent lateral cortex fracture. Knee Surg Sports Traumatol Arthrosc 21:90–95CrossRefGoogle Scholar
  14. 14.
    Nelissen EM, van Langelaan EJ, Nelissen RG (2010) Stability of medial opening wedge high tibial osteotomy: a failure analysis. Int Orthop 34(2):217–223CrossRefGoogle Scholar
  15. 15.
    Spahn G (2004) Complications in high tibial (medial opening wedge) osteotomy (2004). Arch Orthop Trauma Surg 124(10):649–653CrossRefGoogle Scholar
  16. 16.
    Bae DK, Park CH, Kim EJ, Song SJ (2016) Medial cortical fractures in computer-assisted closing-wedge high tibial osteotomy. Knee 23(2):295–299CrossRefGoogle Scholar
  17. 17.
    Nakamura R, Komatsu N, Fujita K, Kuroda K, Takahashi M, Omi R et al (2017) Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy. Bone Joint J 99(10):1313–1318CrossRefGoogle Scholar
  18. 18.
    Pape D, Adam F, Rupp S, Seil R, Kohn D (2004) Stability, bone healing and loss of correction after valgus realignment oft he tibial head. A roentgen stereometry analysis. Orthopade 33(2):208–217CrossRefGoogle Scholar
  19. 19.
    Rossi R, Bonasia DE, Amendola A (2011) The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg 19:590–599CrossRefGoogle Scholar
  20. 20.
    Fujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am 10:585–608Google Scholar
  21. 21.
    Lee DC, Byun SJ (2012) High tibial osteotomy. Knee Surg Relat Res 24(2):61–69CrossRefGoogle Scholar
  22. 22.
    Takeuchi R, Ishikawa H, Kumagai K, Yamaguchi Y, Chiba N, Akamatsu Y et al (2012) Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fracture. Arthroscopy 28(1):85–94CrossRefGoogle Scholar
  23. 23.
    Dorofeev A, Tylla A, Drescher W, Stangl R (2019) Opposite cortical fractures in closed-wedge HTO: New classification and treatment algorithm. The Knee.  https://doi.org/10.1016/j.knee.2019.07.014 Google Scholar
  24. 24.
    Atrey A, Morison Z, Tosounidis T, Tunggal J, Waddell JP (2012) Complications of closing wedge high tibial osteotomies for unicompartmental osteoarthritis of the knee. Bone Joint Res 1(9):205–209CrossRefGoogle Scholar
  25. 25.
    Reyle G, Lorbach O, Diffo Kaze A, Hoffmann A, Pape D (2017) Prevention of lateral cortex fractures in open wedge high tibial osteotomies. The anteroposterior drill hole approach. Orthopade 46(7):610–616CrossRefGoogle Scholar
  26. 26.
    Lee YS, Won JS, Oh WS, Park HG, Lee BK (2014) Lateral tibial bone mineral density around the level of the proximal tibiofibular joint. Knee Surg Sports Traumatol Arthrosc 22(7):1678–1683CrossRefGoogle Scholar
  27. 27.
    Dexel J, Fritzsche H, Beyer F, Harman MK, Lützner J (2017) Open-wedge high tibial osteotomy: incidence of lateral cortex fractures and influence of fixation device on osteotomy healing. Knee Surg Sports Traumatol Arthrosc 25(3):832–837CrossRefGoogle Scholar
  28. 28.
    van Houten AH, Heesterbeek PJ, van Heerwaarden RJ, van Tienen TG, Wymenga AB (2014) Medial open wedge high tibial osteotomy: can delayed or nonunion be predicted? Clin Orthop Relat Res 472(4):1217–1223CrossRefGoogle Scholar
  29. 29.
    Böhler M, Fuss FK, Schachinger W, Wölfl G, Knahr K (1999) Loss of correction after lateral closing wedge high tibial osteotomy—a human cadaver study. Arch Orthop Trauma Surg 119(3–4):232–235Google Scholar
  30. 30.
    Jacobi M, Wahl P, Jakob RP (2010) Avoiding intraoperative complications in open-wedge high tibial valgus osteotomy: technical advancement. Knee Surg Sports Traumatol Arthrosc 18(2):200–203CrossRefGoogle Scholar
  31. 31.
    Slocum DB, Larson RL, James SL, Grenier R (1974) High tibial osteotomy. Clin Orthop Relat Res 104:239–243CrossRefGoogle Scholar
  32. 32.
    Song EK, Seon JK, Park SJ, Jeong MS (2010) The complications of high tibial osteotomy: closing-versus opening-wedge methods. J Bone Joint Surg Br 92(9):1245–1252CrossRefGoogle Scholar
  33. 33.
    Lee OS, Lee YS (2018) Diagnostic value of computed tomography and risk factors for lateral hinge fracture in the open wedge high tibial osteotomy. Arthroscopy 34(4):1032–1043CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgerySana Klinikum RummelsbergSchwarzenbruckGermany
  2. 2.Department of OrthopaedicsRWTH University HospitalAachenGermany

Personalised recommendations