|Year : 2016 | Volume
| Issue : 2 | Page : 94-101
Can fixator-assisted plating of focal dome osteotomy accurately correct varus deformity in medial compartment osteoarthritis?
Milind M Chaudhary
Department of Orthopaedic Surgery, Centre for Ilizarov Techniques, Chaudhary Hospital, Akola, Maharashtra, India
|Date of Submission||12-Sep-2016|
|Date of Acceptance||14-Sep-2016|
|Date of Web Publication||16-Sep-2016|
Milind M Chaudhary
Centre for Ilizarov Techniques, Chaudhary Hospital, Civil Lines, Akola - 444 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Large varus deformities in medial compartment osteoarthritis are difficult to correct with lateral closing-wedge or medial opening-wedge osteotomies. They are easier to correct gradually with opening-wedge or dome osteotomies with external fixation. A focal dome osteotomy can support a large angular correction and yet retains good bony contact. It creates a large proximal fragment that allows for better fixation. However, external fixation devices are cumbersome and not well tolerated by older women and those who cannot follow-up over long distances. Fixator-assisted plating of the focal dome osteotomy combines the advantages of the fixator for accuracy of correction and the convenience of the locking plate. We retrospectively analyzed 34 focal dome high-tibial osteotomies in 31 patients performed over 6 years. Preoperative mechanical axis deviation was −19% (−150%-28%) which improved to 55% (3%-108%). The average preoperative medial proximal tibial angle was 79.8° (88°-63°) which improved to 93° (84°-107°). The average preoperative hip-knee-ankle angle was 195.2° (185°-225°) which improved to 177.5° (166°-204°). Femorotibial angle was 184.6° (182°-220°) which improved to 172° (158°-184°). The tibial slope reduced from 76.9° to 81.1°. Average follow-up was 70 months (45-113). Large varus deformities could be corrected safely with reasonable accuracy in this study.
Keywords: Fixator-assisted plating, focal dome osteotomy, high-tibial osteotomy, medial compartment osteoarthritis, varus deformity
|How to cite this article:|
Chaudhary MM. Can fixator-assisted plating of focal dome osteotomy accurately correct varus deformity in medial compartment osteoarthritis?. J Limb Lengthen Reconstr 2016;2:94-101
|How to cite this URL:|
Chaudhary MM. Can fixator-assisted plating of focal dome osteotomy accurately correct varus deformity in medial compartment osteoarthritis?. J Limb Lengthen Reconstr [serial online] 2016 [cited 2020 May 25];2:94-101. Available from: http://www.jlimblengthrecon.org/text.asp?2016/2/2/94/190711
| Introduction|| |
Accurately correcting the varus deformity and preserving valgus alignment is most important in achieving long-term relief of pain in medial compartment osteoarthritis (OA) of the knee.  Lateral closing-wedge and medial opening-wedge osteotomies are popular but may have many complications including lack of accuracy and inadvertent secondary problems. , Lee et al.  described a fixator-assisted medial opening-wedge osteotomy fixed with a minimally invasive locking plate. However, the deformities were not large. Paley  described Ilizarov focal dome high-tibial osteotomy at the upper tibial meta-diaphyseal junction, just distal to the tibial tuberosity. It can correct large deformities and has many advantages over the dome osteotomy described by Maquet.  Maquet's dome method is performed above the tibial tuberosity with its convexity facing proximally. This creates a small proximal fragment difficult to fix reliably. It causes medial translation of distal fragment which mitigates the effect of lateral translation of mechanical axis achieved by the valgus.
The focal dome is performed just below the tuberosity with its convexity downward. It creates a large proximal tibial fragment which is fixed adequately with a circular fixator or a locking plate. The dome osteotomy retains bony contact even after large angular correction. Acute and sustained compression by a fixator allows reliable union. Fixator hinges allow gradual and accurate correction of the deformity which can be fine-tuned to the gait of the patient. Early full-weight bearing mobilization and resumption of activities are great advantages.
Its performance in distal harder bone delays union compared with a supratuberosity osteotomy. Younger patients tolerate longer fixator durations quite well, but it tests the patience of older ones. Older women with large deformities are reluctant to accept an external fixator and refuse surgery if it is the only option offered to them. Patients may be unable to travel longer distances for mandatory follow-up care of the fixator. This was our experience after performing Ilizarov focal dome high-tibial osteotomies over 15 years.
For these patients, we chose to combine the benefits of the focal dome osteotomy aligned with an Ilizarov fixator with the convenience of locked plating fixation. The Ilizarov fixator was applied during surgery to accurately hold the correction of the focal dome osteotomy. A TomoFix (DePuy Synthes, Mumbai, Maharashtra, India) or locking plate (Uma Surgicals, Mumbai, Maharashtra, India) applied laterally fixed the osteotomy and allowed mobilization. The fixator is removed thereafter, in the theater, increasing the comfort and convenience of the patient. We retrospectively analyzed the accuracy of correction of large varus deformities in medial compartment OA knee achieved by fixator-assisted plating.
| Materials and Methods|| |
We treated 34 limbs in 31 patients [Table 1] suffering from medial compartment OA of the knee between 2007 and 2013 using the focal dome osteotomy with the fixator-assisted plating (FAP) method. Of 31 patients, 21 were women who did not need the external fixator treatment. Of 31 patients, 24 were above the age of 55 years (33-70 years). There were 17 right and 17 left knees. The average preoperative mechanical axis deviation (MAD) as measured on full-length X-rays was -19%. In only 12 of the 34 limbs, the mechanical axis passed through the knee joint. In the remaining 22 limbs, the Mikulicz line passed from 0% to -150% [Figure 1].
|Figure 1: Severe displacement of mechanical axis preoperatively. In many patients it is not passing through the knee joint at all|
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The average preoperative medial proximal tibial angle (MPTA) was 79.8° (88°-63°). The average preoperative hip-knee-ankle (HKA) angle was 195.2° (185°-225°) and femorotibial angle (FTA) was 184.6° (182°-220°).
Three patients had Grade 2 Kellgren-Lawrence (KL), 15 had Grade 3, and 17 had Grade 4 KL arthritis on radiological scoring.  Of 34 patients, 23 had patellofemoral arthritis. The patients were all given a trial of conservative therapy for a minimum of 3 months before they were offered surgery. They were all treated with a focal dome osteotomy fixed with a Lateral TomoFix plate assisted by a hybrid Ilizarov external fixator. The average duration of follow-up was 70.9 months since surgery (45-113 months).
The patient is placed supine on a radiolucent table. We start by approaching the fibula laterally and by resecting a 10-15 mm segment. We use a hybrid Ilizarov or external fixator as an intraoperative alignment tool for the dome osteotomy.
Two 4 mm × 3 mm pins are inserted in the distal tibia and attached to a ring. The tourniquet is inflated. Retinacular release , on both sides of the patella helps control patellafemoral pain. A longitudinal incision from top of the patella extending to 10 cm below the tibial tuberosity helps achieve retinacular release and the dome osteotomy. Electrocautery achieves hemostasis. It also helps achieve partial denervation of the patellofemoral joint by damaging the cutaneous nerves coming from lateral and medial sides. 
Two 4 mm × 3 mm half pins fix the proximal fragment. The first pin is anteroposterior, parallel to tibial slope, close to the joint. The second one is inserted posteromedially in the tibial head. These are attached to a carbon fiber ring at joint level which does not block visualization of the osteotomy on X-rays.
We expose the upper tibia by subperiosteal dissection. A jig is used to drill holes in a small arc with a 2 mm or 3.2 mm drill bit. The center of rotation of angulation is above the tibial tuberosity, and the arc has its center on it. Convexity of the arc faces distally at lower part of the tuberosity. The medial and lateral borders of the arc are just above the tuberosity. A thin, sharp osteotome connects these holes to complete the arcuate osteotomy. Take care not to cause comminution of the posterior cortex.
Manually translate the distal fragment laterally by a single cortex width. Connect the rings with multiplane hinges, distract the medial, and compress the lateral connections to achieve valgus. A cautery cord test or long leg X-rays are done. Adjustments ensure the mechanical axis passes at outer border of lateral tibial spine. Aim for 62% of the joint width if long leg films can be exposed and measured.
When alignment is satisfactory, the hinges are locked. The osteotomy is held stably by the fixator. Apply a TomoFix plate on the lateral side with 4 screws in the proximal fragment and 3 in the distal. Partial weight bearing is started on the 2 nd day [Figure 2].
|Figure 2: (a) 65 year old lady with a large varus deformity. Patient unwilling for external fixation treatment, unable to travel long distances for follow-up. (b) Mechanical Axis Deviation at -4.5%. HKA 192, FTA 188 degrees. Needs minimum 17.6 degrees of correction. (c) Total angular correction achieved 18 degrees. Mechanical axis at 68%. HKA at 177 and FTA at 180 degrees. (d) Post Op clinical photo showing early ambulation. High comfort levels and ability to bear almost full weight within a few weeks. (e) AP xray showing a Lateral tomofix plate with three distal and four proximal scres fixing the focal dome osteotomy. The focal dome retains very good bony contact and there is minimal lateral translation of distal fragment. Upper third fibulectomy is seen. (f) Lateral xray showing a mild posterior translation of the distgal fragment. This is due to a small amount of external rotation of the distal fragment intentionally created. This increases the lateral shift of the mechanical axis in the frontal plane|
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| Results|| |
All osteotomies united. There were no fixation failures. None needed bone grafting or graft substitutes. One patient developed a fracture distal to the plate 1 year after the osteotomy united. This was fixed with a plate which developed an infection after the fracture healed. The plate was removed, and debridement and antibiotic cement beads were inserted. One patient developed partial wound dehiscence due to prominence of the plate which healed with daily dressings.
The average post-operative MAD [Table 2] was 55% (3% to 108%). 14 of 34 (41.1%) were within 50 to 70% of width of the joint. (presuming that some patients had dynamic varus, which needed more than the usual target of 62% of the joint width). 6/34 (17.6%) were mildly undercorrected till 40% joint width. 2/34 (5.8%) were mildly overcorrected to between 70% and 80% joint width. 6 of 34 (17.6%) were significantly overcorrected (>80% joint width). 6 of 34 (17.6%) were significantly undercorrected to less than 40% joint width [Figure 3].
|Figure 3: Comparison of mechanical axis deviation before and after surgery|
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The postoperative MPTA averaged 93° (84°-107°).
Hip Knee Ankle angle HKA [Table 3] averaged 177.5° (166 to 204°). However, 10 of 34 patients had undercorrection of HKA less than 177° and eight of 34 had overcorrection of more than 6°HKA angle (174°). Hence only 16/34 or 47% had the ideal correction.
The average Femoro-Tibial Angle [Table 4], FTA was 172°(158 to 184°). Considering 8 to 12° of valgus (FTA of 172 to 168) as ideal, only 8/34 (23.5%) had an excellent correction. Considering 12 to 16° valgus FTA (168-164°) 10/34 (29.4%) had mild overcorrection. 2/34 (5.8%) had significant overcorrection. Considering 4 to 8° as mild undercorrection (FTA=176 to 172°), 10/34 (29.4%) had mild undercorrection. Considering 4° valgus to 4° varus (FTA 176 to 184), 5 of 34 patients (14.7%) had moderate undercorrection. 2/34 (5.8%) were severely undercorrected.
The mean Femoro Tibial (FTA) deformity corrected was 17.3° (9.4 to 36°). The mean HKA (Hip Knee Ankle) angle was corrected to a mean of 18.5 degrees (8 to 35°). There was a 4.12° change in the tibial slope (95%CI=-5.89 to -2.49). Preop Posterior Proximal Tibial Angle (PPTA) was a mean of 76.90° and Post Op was 81.1° (two tailed P < 0.0001). (calculated using Instat GraphPad Prism3.0, La Jolla, Ca. USA) [Figure 4]. All P values are given in [Table 5].
|Figure 4: Graph shows change in the PPTA. Most patients had a mild increase in PPTA or a reduction in the slope signifying a correction of fixed flexion deformity|
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| Discussion|| |
Upper tibial varus deformity contributes to medial compartment OA. Many osteotomies and fixation methods have been described in the literature. Smaller deformities are easily corrected using closing or opening-wedge osteotomy. Correcting larger deformities with either has problems. ,,
Opening a large wedge will increase the pressure in the medial collateral ligament (despite releasing it at its distal insertion) and increase pressure in the medial compartment. Correcting a large deformity lengthens the limb. It tensions the patellar ligament and causes patella baja. The large gap takes longer to heal and may need bone grafting or substitutes. These increase morbidity, costs, and operative time. 
Closing a large wedge deformity causes limb shortening, overhang at the osteotomy with potential difficulties during future knee replacement. There are higher chances of neurovascular deficit, undercorrection and recurrence of deformity, delayed and nonunion of the osteotomy. 
Bone neither needs to be removed nor a wedge opened with a dome osteotomy. A large deformity can be corrected while retaining bony contact. The Maquet dome osteotomy  done above the tuberosity can correct a large deformity but results in a very small proximal fragment that is difficult to fix adequately. It also results in medial translation of the distal fragment, which partially negates the lateral translation of the mechanical axis achieved by valgus angulation.
The focal dome osteotomy ,, overcomes all of these problems. The osteotomy translates the distal fragment laterally. This aids the mechanical axis translation toward the lateral compartment. There is enough bony stock for stable fixation either with an external fixator or with a locked plate. Gradual correction of upper tibial varus is popular but fixator time can be long and can inconvenience the patient. Gradual correction of varus in adolescents using the Ilizarov fixator took an average of 24 weeks for Park.  Older patients have less tolerance to the fixator. A dome osteotomy can correct a large varus acutely and without losing bony contact. We did achieve the objective of correcting large varus deformities with the convenience of locked plating. However, the accuracy of correction was moderately good.
The use of a Lateral Tomofixγ or a locking plate has not been described for a dome osteotomy. The dome osteotomy creates lateral translation and a step. Using a locking plate gives stable fixation and retains this desirable translation. Only three screws may fix the distal fragment stably to allow full weight bearing mobilization.
We have experienced a few disadvantages of this method. The upper fibular osteotomy is an additional step compared with the medial opening-wedge osteotomy and it prolongs operative time. The Ilizarov fixator application needs 30 min in our experience. The cautery cord test or X-rays take an additional 15-20 min. A cautery cord test is prone to error caused by inadvertent movement of the hand holding the cord. A bump under the trochanter internally rotates the limb. A thigh tourniquet pushes the cautery cord or alignment rod away from the thigh and can force an error. Flexion of the knee during surgery can underestimate the varus or overestimate the valgus achieved. 
A full-length cassette and portable X-ray machine with a large tube to film distance could help accurately measure the correction and achieve more accuracy. However, there are difficulties in implementing this system as it needs a very long tube head to film distance. Operation Theatre ceilings are not high enough and portable X-ray machine tube head height rarely exceeds seven feet. The operation table rarely goes below 34". We did get a custom-made X-ray machine with a tube height of 10 feet. However, we did not have a portable long irridescent phosphor (IP) or computerized radiography cassette. All our preoperative and postoperative full-length X-rays were taken on a Carestream Kodak wall mounted system since 2010. Long leg radiography was performed in the operation theatre with the older film radiography 14" × 51" cassette on 5 patients. Two of the five patients had a correction within 10% of the ideal mechanical axis. The difficulties enumerated above forced us to go back to the cautery cord test. We did obtain a 34" long IP cassette in 2013, but the 100 mA portable X-ray machine was unable to generate the factors needed for proper exposure of the film.
After the analysis of these patients, we are pursuing long leg radiography in the operation theatre by trying to obtain a 300 mA portable X-ray machine with a 10 foot tube height as well as an operation table that can go significantly below 34".
These errors may have caused overcorrection of more than 12° of femorotibial valgus in 10 of the 34 segments (29.4%). More than 15° of valgus was seen in 3 of the 34 limbs (8.8%).
More than 15° valgus may be unacceptable and may lead to early degeneration of the lateral compartment.  However, progression of arthritis in lateral compartment is multifactorial and is accelerated by preexisting meniscal damage.  Koshino et al.  recommends 10° of FTA as ideal. Many patients have dynamic varus  which needs correction. Externally rotating the distal fragment aids in lateral translation of the mechanical axis.
Hinterwimmer showed internal rotation of 4.4° ± 2.8° seen in medial opening-wedge osteotomies.  This internal rotation negates the desired lateral shift of mechanical axis. A dome osteotomy which creates a mild external rotation is possibly more beneficial.
Undercorrection is widely accepted as the factor that gives unacceptable results as well as early recurrence of symptoms.  In our series, an average correction of 172° FTA, i.e., 8° valgus, was achieved (4° varus to 22° valgus). This may seem inadequate unless one recognizes that the average preoperative FTA was 184° (182°-220°, i.e., 2°-40° varus)
A Taylor spatial frame (TSF) fixator can help avoiding some errors.  However, positioning for radiography and programming can lead to excess tourniquet time. Our results could have improved with the TSF fixator, albeit at a higher cost. However, during the study, the TSF Fixator (Smith and Nephew, Gurgaon, India) was not commercially available.
We found a 4.2° ± 4.9° increase in the PPTA, i.e., a reduction in the tibial slope. Correction of a fixed flexion deformity of the knee is easy to perform with the Ilizarov fixator: By compressing anterior struts and distracting posterior ones. The reduction in slope reflects the correction of any mild flexion deformities. 
In a medial opening-wedge osteotomy where lateral shift of mechanical axis is achieved by angulation, large varus corrections can have deleterious effects on ankle joint contact pressures.  The dome osteotomy achieves the lateral translation of the mechanical axis without placing angular stresses on the ankle.
Our study has several limitations. We have not measured patient-reported outcome measures. That will be the subject of future study, especially to analyze if the results are long lasting and if there is a correlation between radiological results and patient-reported outcome measures. There is no control. However, an earlier study compared the radiological results of the dome osteotomy treated with lateral locked plating versus the dome osteotomy treated with the Ilizarov fixator.  There were more women, older patients and larger varus deformities in the group treated with plating (FAP) [Table 6]. The Ilizarov fixator group achieved more valgus (68% MAD vs. 53.1% MAD in the FAP group). This could be a reflection of better correction of dynamic varus. No blood transfusions were needed in the ilizarov group. There were no re-fractures and no deep infections. Fixator duration was an average of 14 weeks (12-18 weeks).
|Table 6: Differences between Ilizarov and Fixator assisted plating methods in previous study* |
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Many studies with plating of medial opening-wedge osteotomies have shown more accurate results.  However, the deformities were smaller. Other studies have achieved accuracy with gradual correction.  Our patient cohort refused external fixation and we had to attempt accuracy despite the lack of having a TSF fixator or proper long leg radiography.
Our study may not have universal appeal as we treated much older patients with higher KL grades of OA with corrective osteotomies. This reflects the choices made by patients in our geographical location, based on financial and cultural considerations.
Another limitation of our study is that we could not distinguish between large varus caused by intra-articular or extra-articular deformity. Since 2013, we have discovered newer methods to correct large varus deformities in medial compartment OA of the knee. Tibial condylar valgus osteotomy, proposed by Teramoto  corrects intra-articular deformities and can be fixed conveniently with locking and nonlocking plates. We have several of these and gathered experience in treating intra- and extra-articular combined deformities using the Ilizarov external fixator. 
For large extra-articular deformities, the FAP of focal dome osteotomies offers moderately good accuracy with convenience of definitive internal fixation. The accuracy of this method could be improved using a TSF fixator and using long leg radiography in the operation theatre.
| Conclusions|| |
Fixator assisted plating enables correction of large varus deformities in medial compartment osteoarthritis. A focal dome osteotomy performed at the level of the tibial tuberosity allows large corrections aided by an intra-operatively placed fixator. A lateral Tomofix or locking plate holds the fixation till reliable union. Accuracy of correction can be improved by using a TSF or similar fixator or by long leg radiography in the operation theatre.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The author would like to acknowledge the contributions made by Madhavi Modak in the preparation of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]