Osteotomy Around the Knee: Evolution, Principles and Results
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Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-012-2206-0 KNEE Osteotomy around the knee: evolution, principles and results J. O. Smith • A. J. Wilson • N. P. Thomas Received: 8 June 2012 / Accepted: 3 September 2012 Ó Springer-Verlag 2012 Abstract to other complex joint surface and meniscal cartilage Purpose This article summarises the history and evolu- surgery. tion of osteotomy around the knee, examining the changes Level of evidence V. in principles, operative technique and results over three distinct periods: Historical (pre 1940), Modern Early Years Keywords Tibia Osteotomy Knee Evolution Á Á Á Á (1940–2000) and Modern Later Years (2000–Present). We History Results Principles Á Á aim to place the technique in historical context and to demonstrate its evolution into a validated procedure with beneficial outcomes whose use can be justified for specific Introduction indications. Materials and methods A thorough literature review was The concept of osteotomy for the treatment of limb defor- performed to identify the important steps in the develop- mity has been in existence for more than 2,000 years, and ment of osteotomy around the knee. more recently pain has become an additional indication. Results The indications and surgical technique for knee The basic principle of osteotomy (osteo = bone, tomy = osteotomy have never been standardised, and historically, cut) is to induce a surgical transection of a bone to allow the results were unpredictable and at times poor. These realignment and a consequent transfer of weight bearing factors, combined with the success of knee arthroplasty from a damaged area to an undamaged area of joint surface. from the 1980s onward, led to knee osteotomy being With the advent and subsequent success of knee regarded as an irrelevant surgical option by many surgeons. arthroplasty surgery, especially in low demand and older Despite its fluctuating reputation, this article demonstrates patients, there has been a relative neglect of osteotomy as a the reasons for the enduring practice of osteotomy, not valid treatment modality in many healthcare services least because achieving the appropriate alignment is now [5, 16, 73, 94]. However, less favourable results have been recognised as the foundation step when planning any sur- reported for knee arthroplasty in younger, more active gical intervention. patients [30, 43], causing some clinicians to pause and Conclusions With appropriate patient selection, accurate question this extended indication and search for another pre-operative planning, modern surgical fixation tech- solution. The relegation of osteotomy around the knee to niques and rapid rehabilitation, osteotomy around the knee ‘historic’ status, due to a reputation of poor and unpre- is now an effective biological treatment for degenerative dictable outcomes, has recently been challenged following disease, deformity, knee instability and also as an adjunct evidence from several centres, which have both refined and redefined the entire process from patient selection to post- operative rehabilitation [57, 64]. With appropriate indica- J. O. Smith (&) A. J. Wilson N. P. Thomas Á Á tions, planning and a standardised operative technique, we Department of Orthopaedic Surgery, Basingstoke and North will show that osteotomy around the knee can be a highly Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK effective procedure, resulting in reproducible and enduring e-mail: [email protected] functional and symptomatic improvement. 123 Knee Surg Sports Traumatol Arthrosc Materials and methods A PubMed search conducted during November 2011 using the search terms ‘osteotomy’ and ‘tibial’ or ‘femoral’ produced 3,312 results in the English language. After the evaluation of each abstract, 352 full text articles were retrieved, based upon their relevance to the history, evo- lution, principles and results of osteotomy around the knee. The authors’ critical analysis of each paper was required to select the most pertinent articles for inclusion in the final review based upon three main historical periods: Historical (pre 1940), Modern Early Years (1940–2000) and Modern Later Years (2000–Present). History and evolution Historical osteotomy (pre 1940) The concept of deformity correction has been established since the time of Hippocrates (460–370 BC) with the Hippocratic Scamnum, a traction device used to set bones [36] (Fig. 1). The prequel to osteotomy in the sixteenth century was osteoclasia, where malalignment was treated Fig. 1 The Hippocratic Scamnum was a traction device used for by breaking a deformed bone, before immobilising it in the deformity correction over two millennia ago. Reproduced with correctly aligned position as it healed. Bosch and Lorenz permission and copyrightÓ of the British Editorial Society of Bone separately developed apparatus derived from a book- and Joint Surgery [36] maker’s press, which were used for the correction of static deformities including varus, valgus, recurvatum and flexion contractures, to improve function [4]. Advances were slow during the subsequent three cen- turies—poor antisepsis, limited understanding of the underlying biological principles, little dissemination of new techniques and rudimentary operating equipment were significant obstacles. The first successful surgical osteotomy about the knee is attributed to John Rhea Barton from Pennsylvania, USA Fig. 2 A gimlet, such as the one pictured was used during the (1794–1871), who performed a supracondylar wedge ‘subcutaneous’ osteotomy technique by Prof. Pancoast to create femoral osteotomy for an ankylosed knee in 1835 [57, 59]. multiple femoral perforations at the osteotomy site (image from He reported success in 12 of 14 procedures, noting of the Wikipedia) remaining two that they ‘perished…of hectic irritation and exhaustion’ post-operatively. USA reported using a ‘stout gimlet’ to create multiple per- Langenbeck, using techniques adapted from his experi- forations at a femoral osteotomy site through a single small ences in the Schleswig–Holstein war in Germany, per- incision before applying a corrective force [1] (Fig. 2). formed several osteotomies about the knee for rachitic Despite these measures, infection still ensued, although a deformity and ankylosis in the 1850s [1]. He drilled an good eventual recovery is recorded in this patient. aperture and inserted a small saw to almost complete the The technique was adapted by Professor Gross of Phil- osteotomy before applying lateral force. Unfortunately, adelphia, USA, who used a custom-made chisel to com- infection rates were high, attributed initially to a ‘foreign plete the drill holes with good results in four cases [1]. At body reaction’ to the created bone sawdust. Other surgeons around this time, Louis Little, a surgeon in London, UK, in Germany, including Billroth, Mayer, Wernher and used a carpenter’s chisel to correct a post-infective (stru- Volkmann, pioneered the use of modified instruments, mous) knee ankylosis in a 14-year-old girl [56]. which made ‘subcutaneous’ osteotomy possible, improving Several further osteotomy procedures were reported in aseptic practice [87]. In 1859, Professor Pancoast in the Europe by Volkmann, Ogsten, Barwell and Lister, although 123 Knee Surg Sports Traumatol Arthrosc Fig. 3 Pre- and post-operative images of a patient with a genu valgum and b genu varum, treated by William Macewen [59] at the end of the nineteenth century William Macewen from Glasgow Royal Infirmary in the 75 years, osteotomies were performed regularly for wide- UK was probably most prolific at this time. In 1879, he ranging indications, although techniques still varied dra- reported on a transverse femoral osteotomy technique to matically. Some surgeons advocated the creation of the correct genu valgum and ‘anterior tibial curves’, which he osteotomy by means of driving a chisel straight in through used in 50 cases [58] (Fig. 3). He described a medial the skin, as described to one of the senior authors (NPT) by femoral approach that avoids significant vascular compli- Karl Nissen (personal communication). Results remained cation and warned against correcting with ‘a quick jerk’, mixed, particularly as there was no internal fixation or rather advising ‘the bending ought to be performed radiographic analysis of correction, and only rudimentary gradually’. post-operative immobilisation was practiced. In 1880, Macewen [59] published the first book devoted In 1934, Brett performed the first osteotomy immedi- to osteotomy, in which he presented his series of 1,800 ately distal to the tibial plateau in a case of genu recurv- cases without major complications. With good antisepsis atum [15]. Following an incomplete anteroposterior and improved operative techniques, osteotomy gained osteotomy, he elevated the anterior tibia as an opening rapid acceptance throughout Europe [87]. For the next wedge, filling it with bone chips and adding screws for 123 Knee Surg Sports Traumatol Arthrosc support (Fig. 4). One year post-operatively, the patient was femoral osteotomy for two groups of patients with genu pain free, had returned to work and no longer suffered valgum: in children, resistant to conservative corrective hyperextension (Table 1). measures; and in adults with lateral compartment knee OA as a consequence of unbalanced loading [17]. He described an opening-wedge distal femoral osteotomy and argued Historical osteotomy (pre 1940) against High Tibial Osteotomy (HTO) following his Early osteotomies had highly variable