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Lateral hinge fractures (LHF) are one of the most common complications of medial opening wedge high tibial osteotomy (MOWHTO), and are the leading cause of construct instability displacement, non-union, and varus recurrence after this procedure. To date, Takeuchi's classification is the most popular classification to describe this complication, and it can help surgeons to make intra and postoperative decisions. Opening medial gap width is the most recognized factor related to LHF occurrence. Recognizing the implications of LHF in patients' clinical and radiographic results has led many authors to propose surgical tips and the use of osteosynthesis materials such as K-wires and screws for its prevention, which should be considered when identifying risk factors for LHF during preoperative planning. The evidence for determining the optimal management of LHF is scarce and mostly supported by experts' opinions and recommendations; therefore, studies are still needed to identify the most appropriate behavior when dealing with such a complication.

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Con la osteotomía en un solo nivel, se puede lograr la corrección del eje de la extremidad en pacientes con deformidades combinadas femoral y tibial, pero de forma simultánea generará una alteración patológica de oblicuidad de la interlínea articular, lo que conducirá a elongación ligamentaria, inestabilidad, degeneración condral y, en última instancia, comprometerá su sobrevida y los resultados funcionales. En virtud del análisis de la literatura más reciente, podemos concluir que existe un número significativo de pacientes que requieren de un procedimiento combinado para lograr un objetivo biomecánico óptimo. La finalidad de una osteotomía en doble nivel alrededor de la rodilla consiste en restablecer la anatomía normal, descargar el compartimiento afectado, normalizar los ángulos mecánicos y la orientación de la interlínea articular. Los ejes fisiológicos pueden restablecerse a través de un análisis preoperatorio exhaustivo, respetando principios biomecánicos y fijación estable con placas bloqueadas. Es un procedimiento demandante y con indicaciones en evolución, que progresivamente se ha instaurado como una alternativa de tratamiento justificada en estudios clínicos y biomecánicos para el manejo de deformidades severas alrededor de la rodilla.

With single-level osteotomy, correction of the limb axis in patients with combined femoral and tibial deformities can be achieved. This correction, however, will generate a pathological alteration in the joint line oblicuity, leading to ligament elongation, instability, joint degeneration and, ultimately, it will compromise the longevity and functional results of the correction. By analyzing the most recent literature, we can conclude that there is a significant number of patients who require a combined procedure to achieve an optimal biomechanical goal. The purpose of a double-level osteotomy around the knee is to restore normal anatomy, unload the affected compartment, normalize the mechanical angles and the orientation of the joint line. Physiological axes can be reestablished by means of a thorough preoperative analysis, observing the biomechanical principles and stable fixation with locked plates. It is a demanding procedure with increasing indications, which has progressively been established in clinical and biomechanical studies as a justified treatment alternative for the management of severe deformities around the knee.

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PURPOSE: To describe the short-term and long-term results of patients who underwent a medial opening wedge high tibial osteotomy (MOW-HTO) for unicompartmental medial knee joint osteoarthritis. METHODS: A retrospective review was conducted of patients with MOW-HTO using a Puddu plate®, with more than ten year follow-up. The degree of correction, initial chondral damage, number of meniscal lesions, preoperative and 1-year postoperative functional scale scores (IKDC and Lysholm), and arthroplasty conversion rates at the ten year follow-up were registered. We assumed early indication when patients underwent the operation before they were 40 years old and delayed ≥ 40. Functional outcomes were analyzed by adjusting for pre-operative values. Fisher's exact test was used to study the association between the arthroplasty conversion rates and the timing of indication. RESULTS: Fifty-five patients were included, 37 of whom were male (67%). Twenty-nine patients had early indications for surgery (53%). All patients completed ten year follow-up. All patients improved IKDC (p < 0.01) and Lysholm (p < 0.01) scores compared to their presurgical scores at the one year post-operative evaluation. We had six minor complications, none requiring revision surgery. We had three conversions to arthroplasty, all in the late indication group, not statistically significant different. Linear regression showed that early indication was associated with a higher IKDC score when adjusting for the Outerbridge chondral damage score, the number of meniscal lesions, and sex (p < 0.01). CONCLUSION: All patients improved functional scores one year after surgery. Early indication (i.e., younger than 40 years of age) was independently associated with better functional outcomes than late indication at one year follow-up.

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BACKGROUND: Medial meniscal extrusion (MME) is defined as displacement of the meniscus that extends beyond the tibial margin. Knee varus malalignment increases MME. PURPOSE/HYPOTHESIS: The purpose of this study was to quantify MME before and after medial opening wedge high tibial osteotomy (HTO) and to correlate the reduction of MME with clinical outcomes and return to activity. It was hypothesized that MME would decrease after HTO and that patients with lower MME after surgery would have improved clinical outcomes and return to activity at short-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 66 patients who underwent HTO to correct the anatomic axis with a minimum follow-up of 2 years. MME was measured using magnetic resonance imaging preoperatively and 6 weeks after surgery (study protocol). Patients were assessed preoperatively and postoperatively with the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) score for pain, and Tegner score. RESULTS: The mean ± SD preoperative and postoperative MME values were 3.9 ± 0.6 mm and 0.9 ± 0.5 mm, respectively. At 2 years after surgery, KOOS, pain VAS, and Tegner scores were higher than those found preoperatively (P < .001). Patients with less than 1.5 mm of MME after surgery had better clinical outcomes and return to activity compared with patients who had MME of 1.5 mm or more (P < .05). CONCLUSION: Medial opening wedge HTO decreased MME after 6 weeks and improved clinical outcomes and return to activity at a minimum 2-year follow-up. Additionally, patients with postoperative MME of less than 1.5 mm had better clinical outcomes and return to activity compared with patients who had postoperative MME of 1.5 mm or more.

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INTRODUCTION: The complications of the open-wedge osteotomy technique (slope, hypo- and hypercorrection and fractures) are related to difficulties in the control of the open-wedge angle during surgery. MATERIALS AND METHODS: In this cadaveric study, we evaluated the safety and precision of a novel system, the Realignment High Control System (RHC), in the correction of knee mechanical axis and slope. The RHC has a fixation plate coupled to a dynamic device that opens the osteotomy continuously, allowing plate fixation before osteotomy wedge opening. RESULTS: All procedures were easily performed, with no fractures. The openings equaled the indicated by the navigation system for 7.5° and 10°, and for 5°, there was a statistically, although not clinically significant, difference of 0.6°. The slope shown by the RHC setting and in the navigation system was significantly different for the 10° setting only, with a mean difference of 0.563°. CONCLUSIONS: RHC facilitates the surgical technique of high tibial osteotomy, with gradual wedge opening, precise correction of the mechanical axis, and appropriate control of the tibial slope, even with larger openings.

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Los pacientes con mal alineamiento en varo pueden ser difíciles de tratar cuando tienen una lesión crónica de la esquina posterolateral (EPL), resultando en doble o triple varo y subsecuentemente varus thrust durante la marcha. Una osteotomía tibial alta es un procedimiento útil y necesario particularmente en el estadío crónico. Este artículo revisa los fundamentos de la planificación preoperatoria en una lesión crónica de la EPL.

Patients with varus malalignment can be difficult to manage when they have a chronic injury to the posterolateral corner (PLC), resulting in double or triple varus and subsequent varus thrust during gait. A high tibial osteotomy is a useful and necessary procedure particularly in the chronic setting. This article reviews the basics of preoperative planning in a chronic injury of the PLC.

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Introducción: La lesion del ligamento cruzado anterior (LCA) es una de las patologias musculoesqueleticas mas frecuentes. Numerosos factores predisponentes han sido identificados intrinsecamente en la articulacion. El objetivo de este trabajo es analizar la relacion existente entre una hipomotilidad de cadera y la presencia concomitante de una lesion de LCA en deportistas recreacionales. Materiales y Método: Se incluyo en forma prospectiva a pacientes deportistas recreacionales entre 18 y 40 anos (48 con una lesion primaria de LCA confirmada por RMN y 53 controles voluntarios). Se midieron ambas rotaciones en decubito supino y los resultados fueron analizados estadisticamente con la prueba de t test. Resultados: Se analizaron los datos y resultaron estadisticamente significativos en cuanto a una disminucion de movilidad en la cadera homolateral a la rodilla afectada por la lesion del ligamento, tanto para la rotacion interna [RI] (p=0.001) como para la rotacion externa [RE] (p=0.016). El analisis comparativo con el grupo control mostro que existe una asociacion entre rotura de LCA y una hipomotilidad de cadera a expensas en mayor medida de una disminucion en la RI (p=0,002), puesto que la comparacion de la RE en ambos grupos no resulta estadisticamente significativa (p=0.936). Conclusión: Existe una fuerte asociacion entre la lesion del LCA y hipomotilidad de la cadera, principalmente a expensas de la rotacion interna en deportistas recreacionales. No solo encontramos esta asociacion entre voluntarios y pacientes con la lesion sino tambien en el miembro contralateral a la lesion LCA. Por tal motivo creemos de vital importancia el cribado de factores de riesgo para asi implementar planes de prevencion. Nivel de Evidencia: II. Tipo de Estudio: Prospectivo...(AU)

Introduction: Numerous intrinsic predisposing factors have been identified within the knee joint in ACL injuries. However, several studies have showed the influence of the hip on the knee biomechanics. The aim of this paper is to analyze the relationship between a hip hypomotility and the concomitant presence of an ACL injury in recreational athletes. Method: We prospectively evaluated 48 recreational athletes with ACL injury confirmed with MRI and 53 volunteer controls without ACL injuries between 18 and 40 years of age. Internal rotation [IR] and external rotation [ER] were measured and analyzed. Results: A significant decrease in hip range of motion was found in the ipsilateral hip, both for IR (p=0.001) and ER (p=0.016). Comparative analysis with the control group showed an association between ACL tear and hypomotility hip mainly because of IR lessening (p=0.002), since the comparison of the ER in both groups was not statistically significant (p=0.936). Conclusion: There is a strong association between ACL injury and hip hypomotility , not only but mainly due to a decrease in IR. Moreover, we found not only this association between volunteers and patients, but in the same patient compared to the unaffected side. Therefore, we believe that is especially important to identify risk factors in order to prevent these lesions. Level of Evidence: IV. Type of study: Case Series. Retrospective...(AU)

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Introducción: La lesion del ligamento cruzado anterior (LCA) es una de las patologias musculoesqueleticas mas frecuentes. Numerosos factores predisponentes han sido identificados intrinsecamente en la articulacion. El objetivo de este trabajo es analizar la relacion existente entre una hipomotilidad de cadera y la presencia concomitante de una lesion de LCA en deportistas recreacionales. Materiales y Método: Se incluyo en forma prospectiva a pacientes deportistas recreacionales entre 18 y 40 anos (48 con una lesion primaria de LCA confirmada por RMN y 53 controles voluntarios). Se midieron ambas rotaciones en decubito supino y los resultados fueron analizados estadisticamente con la prueba de t test. Resultados: Se analizaron los datos y resultaron estadisticamente significativos en cuanto a una disminucion de movilidad en la cadera homolateral a la rodilla afectada por la lesion del ligamento, tanto para la rotacion interna [RI] (p=0.001) como para la rotacion externa [RE] (p=0.016). El analisis comparativo con el grupo control mostro que existe una asociacion entre rotura de LCA y una hipomotilidad de cadera a expensas en mayor medida de una disminucion en la RI (p=0,002), puesto que la comparacion de la RE en ambos grupos no resulta estadisticamente significativa (p=0.936). Conclusión: Existe una fuerte asociacion entre la lesion del LCA y hipomotilidad de la cadera, principalmente a expensas de la rotacion interna en deportistas recreacionales. No solo encontramos esta asociacion entre voluntarios y pacientes con la lesion sino tambien en el miembro contralateral a la lesion LCA. Por tal motivo creemos de vital importancia el cribado de factores de riesgo para asi implementar planes de prevencion. Nivel de Evidencia: II. Tipo de Estudio: Prospectivo...

Introduction: Numerous intrinsic predisposing factors have been identified within the knee joint in ACL injuries. However, several studies have showed the influence of the hip on the knee biomechanics. The aim of this paper is to analyze the relationship between a hip hypomotility and the concomitant presence of an ACL injury in recreational athletes. Method: We prospectively evaluated 48 recreational athletes with ACL injury confirmed with MRI and 53 volunteer controls without ACL injuries between 18 and 40 years of age. Internal rotation [IR] and external rotation [ER] were measured and analyzed. Results: A significant decrease in hip range of motion was found in the ipsilateral hip, both for IR (p=0.001) and ER (p=0.016). Comparative analysis with the control group showed an association between ACL tear and hypomotility hip mainly because of IR lessening (p=0.002), since the comparison of the ER in both groups was not statistically significant (p=0.936). Conclusion: There is a strong association between ACL injury and hip hypomotility , not only but mainly due to a decrease in IR. Moreover, we found not only this association between volunteers and patients, but in the same patient compared to the unaffected side. Therefore, we believe that is especially important to identify risk factors in order to prevent these lesions. Level of Evidence: IV. Type of study: Case Series. Retrospective...

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Introducción: El relleno de la brecha producido por una osteotomía tibial proximal valguizante de apertura (OTA), se encuentra en constante discusión, dado los resultados dispares obtenidos por los distintos autores. El objetivo del siguiente trabajo fue comparar los resultados tanto radiológicos como clínicos con el uso de sustituto óseo y aloinjerto. Materiales y Método: Entre 2009 y 2012, se realizaron 34 OTA. La muestra fue dividida en dos grupos, 15 pacientes en los cuales se había utilizado sustituto óseo (SO) y 19 pacientes en los que se colocó aloinjerto óseo estructural (AI). El grado de artrosis fue estadificado preoperatoriamente según la clasificación de AhlbÒck e intraoperatoriamente estadificamos las lesiones de cartílago según la clasificación de Outerbridge. El análisis clínico se realizó mediante la Escala de la Sociedad de Rodilla (Knee Society Score) y la Escala de Oxford. El seguimiento del tiempo de consolidación, eje anatómico, eje mecánico y mantenimiento de la corrección (diferencia en milímetros) se realizó mediante radiografías con un seguimiento mínimo de un año. Resultados: La unión ósea ocurrió en la totalidad de las osteotomías, siendo el tiempo de consolidación ósea de 4,3 meses (50 días û 6 meses) en el grupo SO y de 3,2 meses (40 días û 5 meses) en el grupo AI (p=0,7). Se obtuvo una mejoría promedio del Knee Score y del Knee function de 20,3 y de 14,8 puntos respectivamente en el grupo SO y de 21,3 y 19,1 puntos en el grupo AI. La evaluación con el Oxford Score evidencio una mejoría promedio en el grupo SO de 21 puntos y de 29 puntos en el grupo AI. Por lo referido anteriormente no encontramos diferencias significativas entre ambos grupos en la evaluación funcional de los pacientes. Tuvimos dos casos descriptos de perdida de corrección que ocurrieron en el grupo SO, a diferencia del grupo AI en el que no apareció ninguna perdida de corrección no siendo esta una diferencia estadísticamente significativa (p=0,09). Conclusión: Ambos materiales tienen resultados clínicos e índices de consolidación comparables, pero con un mayor riesgo de pérdida de corrección de las osteotomías con sustituto óseo. Nivel de Evidencia: IV (AU)

Introduction: Given the disparate results obtained by different authors concerning the material to fill the bone gap produced by an opening high tibial osteotomy (HTO) the decision remains controversial. Good and very good results have been reported with bone substitute wedges and allograft, which avoid the inconveniences of autologous grafts use. The purpose of this study was to compare both radiological and clinical results using allograft and bone substitute. Material and Methods: We retrospectively analyzed 34 opening wedge HTO filled with allograft or bone substitute (from 2009 to 2012). We divided the sample into two groups: BS (Bone substitute) group was conformed by 15 patients and the AG (Allograft) group with 19 patients. The degree of osteoarthritis was staged preoperatively and intraoperatively we stratified condral lesions according to the classification of AhlbÒck and Outerbridge respectively. The clinical analysis was performed using the Knee Society Score and Oxford Knee Score. We analyzed time to consolidation, anatomical and mechanical axis and loss of correction (measured in millimeters) using X-rays. Results: Union occurred in every osteotomy, mean time was of 4,3 months in the BS group and 3,2 months in the AG group (p: 0,7). The knee society score (Knee Score and Knee function) were 20,3 and 14,8 points respectively in the BS group, and 21,3 and 19,1 in the AG group. The evaluation with the Oxford Score was 21 points in the BS group and 29 in the AG Group. As mentioned above, we did not found significant differences between groups in the functional assessment of patients. We had two cases of loss of correction in the BS group, and none in the AG group (p = 0.09). Conclusion: The results shows that there was no statistical difference between the two groups for overall complications. However, clinical results filling with bone substitute was less tolerated and increased the risk of loss of correction. Level of Evidence: IV (AU)

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Introducción: El relleno de la brecha producido por una osteotomía tibial proximal valguizante de apertura (OTA), se encuentra en constante discusión, dado los resultados dispares obtenidos por los distintos autores. El objetivo del siguiente trabajo fue comparar los resultados tanto radiológicos como clínicos con el uso de sustituto óseo y aloinjerto. Materiales y Método: Entre 2009 y 2012, se realizaron 34 OTA. La muestra fue dividida en dos grupos, 15 pacientes en los cuales se había utilizado sustituto óseo (SO) y 19 pacientes en los que se colocó aloinjerto óseo estructural (AI). El grado de artrosis fue estadificado preoperatoriamente según la clasificación de Ahlbãck e intraoperatoriamente estadificamos las lesiones de cartílago según la clasificación de Outerbridge. El análisis clínico se realizó mediante la Escala de la Sociedad de Rodilla (Knee Society Score) y la Escala de Oxford. El seguimiento del tiempo de consolidación, eje anatómico, eje mecánico y mantenimiento de la corrección (diferencia en milímetros) se realizó mediante radiografías con un seguimiento mínimo de un año. Resultados: La unión ósea ocurrió en la totalidad de las osteotomías, siendo el tiempo de consolidación ósea de 4,3 meses (50 días – 6 meses) en el grupo SO y de 3,2 meses (40 días – 5 meses) en el grupo AI (p=0,7). Se obtuvo una mejoría promedio del Knee Score y del Knee function de 20,3 y de 14,8 puntos respectivamente en el grupo SO y de 21,3 y 19,1 puntos en el grupo AI. La evaluación con el Oxford Score evidencio una mejoría promedio en el grupo SO de 21 puntos y de 29 puntos en el grupo AI. Por lo referido anteriormente no encontramos diferencias significativas entre ambos grupos en la evaluación funcional de los pacientes. Tuvimos dos casos descriptos de perdida de corrección que ocurrieron en el grupo SO, a diferencia del grupo AI en el que no apareció ninguna perdida de corrección no siendo esta una diferencia estadísticamente significativa (p=0,09). Conclusión: Ambos materiales tienen resultados clínicos e índices de consolidación comparables, pero con un mayor riesgo de pérdida de corrección de las osteotomías con sustituto óseo. Nivel de Evidencia: IV

Introduction: Given the disparate results obtained by different authors concerning the material to fill the bone gap produced by an opening high tibial osteotomy (HTO) the decision remains controversial. Good and very good results have been reported with bone substitute wedges and allograft, which avoid the inconveniences of autologous grafts use. The purpose of this study was to compare both radiological and clinical results using allograft and bone substitute. Material and Methods: We retrospectively analyzed 34 opening wedge HTO filled with allograft or bone substitute (from 2009 to 2012). We divided the sample into two groups: BS (Bone substitute) group was conformed by 15 patients and the AG (Allograft) group with 19 patients. The degree of osteoarthritis was staged preoperatively and intraoperatively we stratified condral lesions according to the classification of Ahlbãck and Outerbridge respectively. The clinical analysis was performed using the Knee Society Score and Oxford Knee Score. We analyzed time to consolidation, anatomical and mechanical axis and loss of correction (measured in millimeters) using X-rays. Results: Union occurred in every osteotomy, mean time was of 4,3 months in the BS group and 3,2 months in the AG group (p: 0,7). The knee society score (Knee Score and Knee function) were 20,3 and 14,8 points respectively in the BS group, and 21,3 and 19,1 in the AG group. The evaluation with the Oxford Score was 21 points in the BS group and 29 in the AG Group. As mentioned above, we did not found significant differences between groups in the functional assessment of patients. We had two cases of loss of correction in the BS group, and none in the AG group (p = 0.09). Conclusion: The results shows that there was no statistical difference between the two groups for overall complications. However, clinical results filling with bone substitute was less tolerated and increased the risk of loss of correction. Level of Evidence: IV

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