Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system

Matsushita, Takehiko; Mori, Akiyoshi; Watanabe, Shu; Kataoka, Kunio; Oka, Shinya; Nishida, Kyohei; Nagai, Kazuo; Matsumoto, Tomoyuki; Hoshino, Yuichi; Kuroda, Ryosuke

doi:10.1007/s00402-022-04495-1

Cited by 8 publications

(10 citation statements)

References 39 publications

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“…The incidence of hinge fracture was significantly lower compared to the incidence of hinge fractures reported in literature [7, 16, 18, 20, 25]. Matsuhita et al reported a hinge fracture rate of 70% in 30 patients who underwent medial CWDFO whilst Rupp et al reported a hinge fracture rate of 48% in 79 patients who underwent lateral CWDFO [15, 20]. In this study, both medial and lateral CWDFO are included.…”

Section: Discussionmentioning

confidence: 87%

“…However, a significant complication of CWDFO limiting wider adoption is the occurrence of hinge fractures. The reported rates of hinge fracture in current literature are as high as 51% [15], an unacceptable risk for many surgeons and patients. Delayed and non‐unions, loss of correction, persistent pain and recurrence of symptoms are complications associated with hinge fractures [7, 8, 13, 20, 22].…”

Section: Introductionmentioning

confidence: 99%

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Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

Teo

Koh

Soong

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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Purpose Closing wedge distal femoral osteotomies (CWDFO) are attractive treatment options for unicompartmental knee osteoarthritis with coronal plane deformity. However, it has been traditionally associated with high rates of hinge fracture that can adversely impact recovery and patient outcomes. Appropriate siting of hinge point can be an efective method of reducing the incidence of hinge fractures. This study aims to illustrate a case series of CWDFO with low rates of hinge fracture utilising our preferred hinge point site. Methods A retrospective study of a cohort of 39 CWDFO was performed between May 2019 and May 2022. Both medial and lateral CWDFO were included. The hinge point in all cases was placed at the level of the inferior margin of the metaphyseal lare, and inferior to the gastrocnemius origin, with a hinge thickness of 10 mm. Post-operative radiographs were obtained at 2, 4 and 8 weeks after surgery to assess for hinge fracture and union. Results Thirty-nine cases of CWDFO were performed, consisting of eighteen cases of valgus malalignment that underwent medial CWDFO and twenty-one cases of varus malalignment that underwent lateral CWDFO. At surgery, the mean age was 47.6 (± 13.9) years and mean BMI was 29.4 (± 4.9). There were 23 men and 16 women. Three cases of hinge fractures occurred intraoperatively, translating into a hinge fracture rate of 7.69%. However, union was achieved in all three cases and all patients in this case series were able to progress to weight bear as tolerated at 2 months post-osteotomy. Conclusion Distal placement of the hinge at the level of the inferior metaphyseal lare margin with the use of a hinge wire can greatly reduce the rates of hinge fracture in CWDFO. Level of evidence Level III.

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Section: Discussionmentioning

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

Teo

Koh

Soong

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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“…Fujita et al 29 reported hinge fractures in 57% of patients after biplanar MCWDFO. Matsushita et al 22 reported a signi cantly higher incidence of hinge fractures after biplanar MCWDFO than after LCWDFO via DLO (70% vs. 30%). These reports showed a high incidence of hinge fractures in biplanar MCWDFO.…”

Section: Discussionmentioning

confidence: 99%

“…In biplanar DFO, careful attention is required to determine the osteotomy angle and thickness when creating the anterior ange. A higher incidence of hinge fractures occurs after MCWDFO than after LCWDFO via DLO 22 . Upon reviewing our previous cases of DFO, we observed a higher occurrence of hinge fractures in patients who underwent MCWDFO than in those who underwent LCWDFO due to an excessively thick anterior ange.…”

Section: Introductionmentioning

confidence: 88%

Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy

Sano,

Matsushita,

Nagata

et al. 2024

Preprint

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Distal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P < 0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P < 0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO.

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“…31 They can be even higher (60%) when measured using computed tomography. 29 The resulting instability and reduced stiffness of the bone-implant construct 3,25,30 may be one reason for delayed consolidation, as evidenced by the increased risk of malunions with associated rates of up to 6.7% and 7.3% after hinge fractures in MCW-DFO 26 and LOW-DFO, 23,24 respectively. Thus, several strategies have been reported to prevent these fractures, like the protective hinge wire 35 or positioning of the medial hinge distal to the adductor tubercle.…”

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confidence: 99%

Additional Plate Fixation of Hinge Fractures After Varisation Distal Femoral Osteotomies Provides Favorable Torsional Stability: A Biomechanical Study

Peez,

Grosse-Allermann,

Deichsel

et al. 2023

Am J Sports Med

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Background: Hinge fractures are considered risk factors for delayed or nonunion of the osteotomy gap in distal femoral osteotomies (DFOs). Limited evidence exists regarding the treatment of hinge fractures after DFO, which could improve stability and thus bone healing. Purpose: To (1) examine the effect of hinge fractures on the biomechanical properties of the bone-implant construct, (2) evaluate the biomechanical advantages of an additional fixation of a hinge fracture, and (3) test the biomechanical properties of different types of varisation DFOs. Study Design: Controlled laboratory study. Methods: A total of 32 fresh-frozen human distal femora equally underwent medial closing wedge DFO or lateral opening wedge DFO using a unilateral locking compression plate. The following conditions were serially tested: (1) preserved hinge; (2) hinge fracture along the osteotomy plane; (3) screw fixation of the hinge fracture; and (4) locking T-plate fixation of the hinge fracture. Using a servo-hydraulic materials testing machine, we subjected each construct to 15 cycles of axial compression (400 N; 20 N/s) and internal and external rotational loads (10 N·m; 0.5 N·m/s) to evaluate the stiffness. The axial and torsional hinge displacement was recorded using a 3-dimensional optical measuring system. Repeated-measures 1-way analysis of variance and post hoc Bonferroni correction were used for multiple comparisons. Statistical significance was set at P < .05. Results: Independent from the type of osteotomy, a fractured hinge significantly ( P < .001) increased rotational displacement and reduced stiffness of the bone-implant construct, resulting in ≥1.92 mm increased displacement and ≥70% reduced stiffness in each rotational direction, while the axial stiffness remained unchanged. For both procedures, neither a screw nor a plate could restore intact rotational stiffness ( P < .01), while only the plate was able to restore intact rotational displacement. However, the plate always performed better compared with the screw, with significantly higher and lower values for stiffness (+38% to +53%; P < .05) and displacement (–55% to −72%; P < .01), respectively, in ≥1 rotational direction. At the same time, the type of osteotomy did not significantly affect axial and torsional stability. Conclusion: Hinge fractures after medial closing wedge DFO and lateral opening wedge DFO caused decreased bone-implant construct rotational stiffness and increased fracture-site displacement. In contrast, the axial stiffness remained unchanged in the cadaveric model. Clinical Relevance: When considering an osteosynthesis of a hinge fracture in a DFO, an additional plate fixation was the construct with the highest stiffness and least displacement, which could restore intact hinge rotational displacement.

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Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system

Cited by 8 publications

References 39 publications

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy

Additional Plate Fixation of Hinge Fractures After Varisation Distal Femoral Osteotomies Provides Favorable Torsional Stability: A Biomechanical Study

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