International
International Orthopaedics (SICOT) (1992) 16:407
Orthopaedics © Springer-Verlag 1992
Letters to the editor The Editorial Board of International Orthopaedics has decided to publish "Letters to the Editor", in order to enable correspondence between orthopaedic surgeons from all over the world. It is hoped that our readers will not hesitate to send to the Editor their frank opinions on papers published in the Journal. A. Trias, Editor
S. Bhan and P. K. Dave: High valgus tibial osteotomy for osteoarthritis of the knee International Orthopaedics (SICOT) (1992) 16:13-17
Dear Sir,
Author's reply
The article by Bhan and Dave stresses some important aspects of knee surgery. Joint replacement is widely used and although it has its merits it should not overshadow the more conservative techniques. The beneficial effects of high tibial osteotomy are indisputable, even though the mechanism which leads to its success is ill understood, as the authors correctly point out. The surgical technique of osteotomy is critical [2]. Closing wedge procedures are more commonly used than open wedge techniques, which require a bone graft. Internal fixation of the osteotomy is associated with a high instance of complications [3]. However, external fixation allows compression and can be re-used many times. The dome, or barrel-vault, osteotomy [1] allows correction after operation and deserves more popularity. Bhan and Dave have excised the head of the fibula. This interferes with the biomechanics of the leg, as was clearly shown by Wagner [4]. An oblique osteotomy of the fibula at the level of its middle and lower thirds is easy to perform, can'ies no risk of damage to the peroneal nerve, and heals well. Dome osteotomy with external fixation and oblique fibular osteotomy is the treatment of choice in both the developing world and the Northern Hemisphere. Upper tibial osteotomy remains the preferred treatment for unicompartmental arthritis, and should always be considered as it relieves the symptoms and delays further joint degeneration.
Dear Sir, We would like to thank Dr. Gunzburg for his thoughtful comments and agree with his observation that joint replacement surgery should not overshadow the more conservative techniques. We wanted to highlight this aspect in our paper. Having used dome osteotomy of the proximal tibia in the last two years, we are also convinced that this is a better procedure, especially with respect to reduction in operative time and ability to control postoperative alignment. Since we were more familiar with the technique of closing wedge osteotomy, this was used in all the cases on which our paper was based. Excision of the head of the fibula gives a better exposure and makes the operation easier, particularly for the less experienced surgeon. It also gives protection against development of a compartment syndrome, and protects the lateral popliteal nerve, which can be visualised and isolated as described by Coventry [ 1]. The procedure may interfere with the biomechanics of leg function, as pointed out by Wagner [2], but clinically we have not observed any such problems. Reattachment of the biceps tendon and lateral collateral ligament to the neck of the fibula under physiological tension may counterbalance the mechanical disadvantage of excision of the head. We have also seen two cases in which retaining the head of the fibula resulted in complete closure of the wedge.
R. Gunzburg
Yours sincerely,
Department of Orthopaedics, Brugmalm University Hospital, Brussels, Belgium
S. Bhan and P. K. Dave Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Dehli- 110029, India
References I. Blaimont P e t al. (1971) Contribution biom6canique ~ l'6tude des conditions d'Equilibre dans le genou normal et pathologique. Application au traitement de l'arthrose varisante. Acta Orthop Belg 37: 573-591 2. Coventry MB (1985) Upper tibial osteotomy for osteoarthritis J Bone Joint Surg 67:1136-1140 3. Lemaire R (1982) Etude comparative de deux sdries d'ost6otomies tibiales avec fixation par lame-plaque ou par cadre de compression. Acta Orthop Belg 48:157-171 4. Wagner J (1983) Contribution ~ l'6tude du cadre tibio-p6ronier. Thesis, Free University of Brussels
References 1. Coventry MB (l 985) Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg [Am] 67-A: 1136-1140 2. Wagner J (1983) Contribution ~ l'6tude du cadre tibio-p6ronier. Thesis, Free University of Brussels
International Orthopaedics (SICOT) (1992) 16:407
Orthopaedics © Springer-Verlag 1992
Letters to the editor The Editorial Board of International Orthopaedics has decided to publish "Letters to the Editor", in order to enable correspondence between orthopaedic surgeons from all over the world. It is hoped that our readers will not hesitate to send to the Editor their frank opinions on papers published in the Journal. A. Trias, Editor
S. Bhan and P. K. Dave: High valgus tibial osteotomy for osteoarthritis of the knee International Orthopaedics (SICOT) (1992) 16:13-17
Dear Sir,
Author's reply
The article by Bhan and Dave stresses some important aspects of knee surgery. Joint replacement is widely used and although it has its merits it should not overshadow the more conservative techniques. The beneficial effects of high tibial osteotomy are indisputable, even though the mechanism which leads to its success is ill understood, as the authors correctly point out. The surgical technique of osteotomy is critical [2]. Closing wedge procedures are more commonly used than open wedge techniques, which require a bone graft. Internal fixation of the osteotomy is associated with a high instance of complications [3]. However, external fixation allows compression and can be re-used many times. The dome, or barrel-vault, osteotomy [1] allows correction after operation and deserves more popularity. Bhan and Dave have excised the head of the fibula. This interferes with the biomechanics of the leg, as was clearly shown by Wagner [4]. An oblique osteotomy of the fibula at the level of its middle and lower thirds is easy to perform, can'ies no risk of damage to the peroneal nerve, and heals well. Dome osteotomy with external fixation and oblique fibular osteotomy is the treatment of choice in both the developing world and the Northern Hemisphere. Upper tibial osteotomy remains the preferred treatment for unicompartmental arthritis, and should always be considered as it relieves the symptoms and delays further joint degeneration.
Dear Sir, We would like to thank Dr. Gunzburg for his thoughtful comments and agree with his observation that joint replacement surgery should not overshadow the more conservative techniques. We wanted to highlight this aspect in our paper. Having used dome osteotomy of the proximal tibia in the last two years, we are also convinced that this is a better procedure, especially with respect to reduction in operative time and ability to control postoperative alignment. Since we were more familiar with the technique of closing wedge osteotomy, this was used in all the cases on which our paper was based. Excision of the head of the fibula gives a better exposure and makes the operation easier, particularly for the less experienced surgeon. It also gives protection against development of a compartment syndrome, and protects the lateral popliteal nerve, which can be visualised and isolated as described by Coventry [ 1]. The procedure may interfere with the biomechanics of leg function, as pointed out by Wagner [2], but clinically we have not observed any such problems. Reattachment of the biceps tendon and lateral collateral ligament to the neck of the fibula under physiological tension may counterbalance the mechanical disadvantage of excision of the head. We have also seen two cases in which retaining the head of the fibula resulted in complete closure of the wedge.
R. Gunzburg
Yours sincerely,
Department of Orthopaedics, Brugmalm University Hospital, Brussels, Belgium
S. Bhan and P. K. Dave Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Dehli- 110029, India
References I. Blaimont P e t al. (1971) Contribution biom6canique ~ l'6tude des conditions d'Equilibre dans le genou normal et pathologique. Application au traitement de l'arthrose varisante. Acta Orthop Belg 37: 573-591 2. Coventry MB (1985) Upper tibial osteotomy for osteoarthritis J Bone Joint Surg 67:1136-1140 3. Lemaire R (1982) Etude comparative de deux sdries d'ost6otomies tibiales avec fixation par lame-plaque ou par cadre de compression. Acta Orthop Belg 48:157-171 4. Wagner J (1983) Contribution ~ l'6tude du cadre tibio-p6ronier. Thesis, Free University of Brussels
References 1. Coventry MB (l 985) Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg [Am] 67-A: 1136-1140 2. Wagner J (1983) Contribution ~ l'6tude du cadre tibio-p6ronier. Thesis, Free University of Brussels
