The Effects of Valgus Medial Opening Wedge High Tibial Osteotomy on Articular Cartilage Pressure of the Knee: A Biomechanical Study

      Purpose: The objective of this study was to quantify the effect of different loading axes and of a valgus opening wedge high tibial osteotomy (HTO) on tibiofemoral cartilage pressure. Methods: Six human knee specimens were tested with a load of 1000N in extension in a materials testing machine using a specially designed fixture. Pressure in the medial and lateral joint compartment was recorded using pressure-sensitive films. Different loading alignments (varus, straight, and valgus) were simulated. A medial opening wedge HTO was performed adjusting the loading axis to slight valgus. The first measurement was performed with intact medial collateral ligament (MCL). Then the MCL was dissected gradually and the cartilage pressure again analyzed. Results: There was a significant correlation of the load distribution with the position of the loading axis. The medial compartment was predominantly loaded in the varus setting. The more lateral the loading line intersected the knee, the more pressure was redistributed laterally. The opening wedge HTO without the MCL release resulted in a significant increase of the pressure medially (P = .002). Only after a complete release of the MCL was a significant decrease of pressure medially observed after opening wedge HTO (P = .003). Conclusions: The position of the loading axis in the frontal plane has a strong effect on the tibiofemoral cartilage pressure distribution of the knee. The medial compartment is predominantly loaded in a varus knee; a neutral mechanical axis slightly loads the lateral more than the medial compartment. In valgus alignment, the main load runs through the lateral compartment. Clinical Relevance: A medial opening wedge HTO maintains high medial compartment pressure despite the fact that the loading axis has been shifted into valgus. Only after complete release of the distal fibers of the MCL does the opening wedge HTO produce a decompression of the medial joint compartment.

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        • Coventry M.B.
        Osteotomy about the knee for degenerative and rheumatoid arthritis.
        J Bone Joint Surg Am. 1973; 55: 23-48
        • Coventry M.B.
        Upper tibial osteotomy for gonarthrosis.
        Orthop Clin North Am. 1979; 10: 191-210
        • Coventry M.B.
        Proximal tibial osteotomy.
        Orthop Rev. 1988; 17: 456-458
        • Lobenhoffer P.
        • Agneskirchner J.D.
        Improvements in surgical technique of valgus high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2003; 11: 132-138
        • Lootvoet L.
        • Massinon A.
        • Rossillon R.
        • et al.
        [Upper tibial osteotomy for gonarthrosis in genu varum. Apropos of a series of 193 cases reviewed 6 to 10 years later.].
        Rev Chir Orthop Reparatrice Appar Mot. 1993; 79: 375-384
        • Hernigou P.
        • Medevielle D.
        • Debeyre J.
        • et al.
        Proximal tibial osteotomy for osteoarthritis with varus deformity.
        J Bone Joint Surg Am. 1987; 69: 332-354
        • Odenbring S.
        • Egund N.
        • Knutson K.
        • et al.
        Revision after osteotomy for gonarthrosis.
        Acta Orthop Scand. 1990; 61: 128-130
        • Dugdale T.W.
        • Noyes F.R.
        • Styer D.
        Preoperative planning for high tibial osteotomy.
        Clin Orthop. 1992; 274: 248-264
        • Goutallier D.
        • Hernigou P.
        • Medevielle D.
        • et al.
        [Outcome at more than 10 years of 93 tibial osteotomies for internal arthritis in genu varum (or the predominant influence of the frontal angular correction)].
        Rev Chir Orthop Reparatrice Appar Mot. 1986; 72: 101-113
        • Engel G.M.
        • Lippert F.G.
        Valgus tibial osteotomy: Avoiding the pitfalls.
        Clin Orthop. 1981; 160: 137-143
        • Kettelkamp D.B.
        • Wenger D.R.
        • Chao E.Y.
        • et al.
        Results of proximal tibial osteotomy.
        J Bone Joint Surg Am. 1976; 58: 952-960
        • Koshino T.T.
        • Moril J.
        • Wada H.
        • et al.
        High tibial osteotomy with fixation by a blade plate for medial compartment osteoarthritis of the knee.
        Orthop Clin North Am. 1989; 20: 227-243
        • Hernigou P.
        • Ovadia H.
        • Goutallier D.
        [Mathematical modelling of open-wedge tibial osteotomy and correction tables.].
        Rev Chir Orthop Reparatrice Appar Mot. 1992; 78: 258-263
        • Fujisawa Y.
        • Masuhara K.
        • Shiomi S.
        The effect of high tibial osteotomy on osteoarthritis of the knee.
        Orthop Clin North Am. 1979; 10: 585-608
        • Miniaci A.
        • Ballmer F.T.
        • Ballmer P.M.
        • et al.
        Proximal tibial osteotomy.
        Clin Orthop. 1989; 246: 250-259
        • Noyes F.R.
        • Barber S.D.
        • Simon R.
        High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees.
        Am J Sports Med. 1993; 21: 2-12
        • Paley D.
        Normal lower limb alignment and joint orientation.
        in: Paley D. Principles of Deformity Correction. Springer Verlag, Berlin, Heidelberg2002: 1-17
        • Stukenborg-Colsman C.
        • Ostermeier S.
        • Hurschler C.
        • et al.
        Tibiofemoral contact stress after total knee arthroplasty: Comparison of fixed and mobile-bearing inlay designs.
        Acta Orthop Scand. 2002; 73: 638-646
        • Agneskirchner J.D.
        • Hurschler C.
        • Stukenborg-Colsman C.
        • et al.
        Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: A biomechanical study in human cadaveric knees.
        Arch Orthop Trauma Surg. 2004; 124: 575-584
        • Lobenhoffer P.
        • De Simoni C.
        • Staubli A.E.
        Open wedge high-tibial osteotomy with rigid plate fixation.
        Techniques in Knee Surgery. 2002; 1: 93-105
        • Agneskirchner J.D.
        • Freiling D.
        • Hurschler C.
        • et al.
        Primary stability of four different implants for opening wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 291-300
        • Lobenhoffer P.
        • Agneskirchner J.
        • Zoch W.
        [Open valgus alignment osteotomy of the proximal tibia with fixation by medial plate fixator.].
        Orthopade. 2004; 33: 153-160
        • Riegger-Krugh C.
        • Gerhart T.N.
        • Powers W.R.
        • et al.
        Tibiofemoral contact pressures in degenerative joint disease.
        Clin Orthop. 1998; 348: 233-245
        • McKellop H.A.
        • Sigholm G.
        • Redfern F.C.
        • et al.
        The effect of simulated fracture-angulations of the tibia on cartilage pressures in the knee joint.
        J Bone Joint Surg Am. 1991; 73: 1382-1391
        • Bachus K.N.
        • DeMarco A.L.
        • Judd K.T.
        • et al.
        Measuring contact area, force, and pressure for bioengineering applications: Using Fuji Film and TekScan systems.
        Med Eng Phys. 2006; 28: 483-488
        • Shelburne K.B.
        • Torry M.R.
        • Pandy M.G.
        Contributions of muscles, ligaments, and the ground-reaction force to tibiofemoral joint loading during normal gait.
        J Orthop Res. 2006; 9: 9