|Year : 2015 | Volume
| Issue : 3 | Page : 160-162
A report of nonunion at medial wedge high tibial osteotomy site and its management
Sanjay Agarwala, Anshul Sobti, Pranshu Agrawal
Department of Orthopaedics, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||28-Sep-2015|
Dr. Anshul Sobti
Department of Orthopaedics, P.D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai - 400 016, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
High tibial osteotomy (HTO) is an accepted treatment option for correcting deformities and reducing pain in the treatment of uni-compartment osteoarthritis of the knee. The principle is to redistribute the weight-bearing load. Medial open wedge HTO (MOWHTO) has gained popularity over lateral closed wedge osteotomy due to its decreased incidence of complications. MOWHTO surgical techniques have many variations in fixation techniques and in the use of bone grafts or bone substitute augmentation. In spite of the existing guidelines, there are no clear indications of grafting at the osteotomy site. Delayed union and nonunion although are possible complications, nonunion is especially rarely reported. Thus authors in this case report, like to point attention towards this under-reported complication and its management.
Keywords: High tibial osteotomy complication, medial open wedge high tibial osteotomy, nonunion high tibial osteotomy
|How to cite this article:|
Agarwala S, Sobti A, Agrawal P. A report of nonunion at medial wedge high tibial osteotomy site and its management. J Nat Sc Biol Med 2015;6, Suppl S1:160-2
|How to cite this URL:|
Agarwala S, Sobti A, Agrawal P. A report of nonunion at medial wedge high tibial osteotomy site and its management. J Nat Sc Biol Med [serial online] 2015 [cited 2020 Aug 13];6, Suppl S1:160-2. Available from: http://www.jnsbm.org/text.asp?2015/6/3/160/166128
| Introduction|| |
High tibial osteotomy (HTO) was introduced as early in 1961  and later popularized by Coventry in 1985.  It gained popularity for correcting deformities and reducing pain in the treatment of uni-compartmental osteoarthritic knee. The principle is to redistribute the weight-bearing load from the arthritic portion to the noninvolved articular cartilage portion of the knee. Use of medial opening wedge HTO (MOWHTO) has increased over the lateral closing wedge technique, for the treatment of varus knees because it offers improvements, it is easier to perform, corrects the deformity close to its origin, provides more predictable corrections and better preservation of the bone stock, and avoids injuries to the peroneal nerve and proximal tibiofibular joint. However, many complications, such as nonunion, infection, penetrating osteotomy cuts or screws into the tibiofemoral joint, tibial plateau fracture, and the loss of correction angle, have been reported in the literature. ,, MOWHTO surgical techniques have many variations in fixation techniques and in the use of bone grafts or bone substitute augmentation. ,,,
Authors have reported two different methods of fixation. The first method involves the use of a T-buttress plate with use of autologous tricortical iliac bone graft augmentation.  This method involves the issues of donor site morbidities, chronic pain, infections, and paresthesia.  Second method, which uses a locking compression plate without any bone grafts or bone substitutes, has been described.
Although autologous iliac bone grafts are considered to be the gold standard, , donor site morbidity with these grafts is unavoidable. The use of synthetic bone substitutes is an alternative. However, it has been reported to have several disadvantages, including delayed incorporation into bone, soft tissue irritation, and infections. 
It was noted that the rate of delayed and nonunion following MOWHTO for medial compartment arthritis of the knee was relatively low and comparable to that reported for traditional closed wedge HTO.  Zorzi et al.  has also described that the use of autologous bone graft in MOWHTO <12.5 mm is unnecessary Meidinger et al.  reported 5.4% rate of nonunion. Risk factors influencing the development of a nonunion included smoking, body mass index and fracture of the lateral cortical hinge. No influence was detected for the degree of correction.
Nonunion although is a known complication, is rarely reported. The authors in this case report, like to point attention toward this complication, its management.
| Case Report|| |
A 42-year-old female with medial compartment osteoarthritis, varus alignment of the right knee [Figure 1] underwent MOWHTO [Figure 2] for the same. Intra-operatively the medial osteotomy wedge was opened to 12° and the desired correction was achieved. The patient was advised nonweight-bearing mobilization with a walker during the rehabilitation. On subsequent follow-up postoperatively patient complained of persistent pain and clinically had tenderness at the medial osteotomy site. Radiographs showed that the osteotomy gap persisted with sclerosis of the osteotomy margins [Figure 3]. The patient was subsequently planned for bone grafting of the HTO site. Cancellous autogenous graft from right iliac crest mixed with bone graft substitute was used [Figure 4]. Postoperatively at subsequent follow-up the osteotomy site had completely healed and filled up radiologically [Figure 5] and clinically she had no tenderness at the osteotomy site.
|Figure 2: Postoperative X-ray after medial open wedge high tibial osteotomy|
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|Figure 3: Seven months postoperative X-ray showing nonunion at osteotomy site|
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| Discussion|| |
HTO is a valuable operation in a young and active population with medial compartment osteoarthritis and a varus knee deformity. The key to success depends on maintaining correction as well as the stability of the osteotomy. Medial opening wedge osteotomy creates a defect, which is inherently unstable. Although, the original technique suggested that no graft was required to fill the defect, recently Zorzi et al.  has shown that the complication rates, including delayed union and loss of correction, were higher in patients where the graft was not used.  Technique modification have been described, use of grafts have been termed unnecessary for defects <13 mm.
Pornrattanamaneewong et al. found that all osteotomies in their series became united within 8-12 weeks, regardless of patient demographics, including age, smoking status, or body weight.  Warden et al. in a study of 188 MOWHTO cases reported the occurrence of 6.6% delayed and as low as 1.6% nonunion cases following MOWHTO for medial compartment arthritis of the knee.  Hooper et al. reported a 2.8% nonunion rate when no osteoinductive agents were added. 
Our case report highlights the possibility of nonunion at the osteotomy with MOWHTO, with a small defect, its recognition, a timely line of management and its results.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Jackson JP, Waugh W. Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br 1961;43-B:746-51.
Coventry MB. Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am 1985;67:1136-40.
Chae DJ, Shetty GM, Wang KH, Montalban AS Jr, Kim JI, Nha KW. Early complications of medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation. Knee 2011;18:278-84.
Matthews LS, Goldstein SA, Malvitz TA, Katz BP, Kaufer H. Proximal tibial osteotomy. Factors that influence the duration of satisfactory function. Clin Orthop Relat Res 1988;Apr:193-200.
Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy 2009;25:639-46.
Asik M, Sen C, Kilic B, Goksan SB, Ciftci F, Taser OF. High tibial osteotomy with Puddu plate for the treatment of varus gonarthrosis. Knee Surg Sports Traumatol Arthrosc 2006;14:948-54.
Brinkman JM, Lobenhoffer P, Agneskirchner JD, Staubli AE, Wymenga AB, van Heerwaarden RJ. Osteotomies around the knee: Patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg Br 2008;90:1548-57.
Chae DJ, Shetty GM, Lee DB, Choi HW, Han SB, Nha KW. Tibial slope and patellar height after opening wedge high tibia osteotomy using autologous tricortical iliac bone graft. Knee 2008;15:128-33.
Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP. Opening wedge high tibial osteotomy: An operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med 2006;34:1262-73.
Pornrattanamaneewong C, Numkanisorn S, Chareancholvanich K, Harnroongroj T. A retrospective analysis of medial opening wedge high tibial osteotomy for varus osteoarthritic knee. Indian J Orthop 2012;46:455-61.
Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989;3:192-5.
Warden SJ, Morris HG, Crossley KM, Brukner PD, Bennell KL. Delayed- and non-union following opening wedge high tibial osteotomy: Surgeons′ results from 182 completed cases. Knee Surg Sports Traumatol Arthrosc 2005;13:34-7.
Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 1987;69:332-54.
Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg 2004;124:649-53.
Zorzi AR, da Silva HG, Muszkat C, Marques LC, Cliquet A Jr, de Miranda JB. Opening-wedge high tibial osteotomy with and without bone graft. Artif Organs 2011;35:301-7.
Meidinger G, Imhoff AB, Paul J, Kirchhoff C, Sauerschnig M, Hinterwimmer S. May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union. Knee Surg Sports Traumatol Arthrosc 2011;19:333-9.
Hooper NM, Schouten R, Hooper GJ. The outcome of bone substitute wedges in medial opening high tibial osteotomy. Open Orthop J 2013;7:373-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]