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The Knee 15 (2008) 242–245

Short communication

Bilateral non-union of high tibial osteotomies treated by total kneearthroplasty: A case report

Rajiv Gandhi a,⁎, Abdullah Alomran b, Nizar Mahomed c

a Division of Orthopedic Surgery, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8b Department of Surgery, University of Toronto, Division of Orthopedic Surgery, Toronto Western Hospital, Canada

c Department of Surgery, University of Toronto, Toronto Western Hospital, Canada

Received 26 December 2007; received in revised form 29 January 2008; accepted 29 January 2008

Abstract

Non-union following high tibial osteotomy (HTO) is very uncommon. We present a case of bilateral non-union of HTOs with end-stage kneearthritis treated with staged, bilateral, posterior stabilized knee replacements. A 77-year-old female presented to our clinic with complaints ofdebilitating knee pain. She used a frame to get about in her home, she was unable to get up stairs, and she rarely went outside. Simple radiographsrevealed bilateral non-unions of her osteotomies, subluxation of the tibial plateauxs and severe knee osteoarthritis. At the time of surgery, the non-unions were found to be fibrous stable. We took a minimal tibial plateaux resection and used long stem tibial stems with offset couplers to bypassthe non-unions. At minimum 1 year follow-up, she was walking pain free with full knee range of motion. We found that primary total kneereplacement (TKR) using tibial stems and without treating the tibial non-union gave satisfactory results.© 2008 Elsevier B.V. All rights reserved.

Keywords: Osteotomy; Non-union; Knee arthroplasty; Arthritis

1. Introduction

High tibial valgus osteotomy (HTO) is a treatment option formedial compartment osteoarthritis (OA) of the knee [1,2]. Theincidence of non-union after HTO has been reported to be ashigh as 5.7% [3,4]. The options for treatment of a non-unionfollowing osteotomy includes internal fixation and bonegrafting [5,6] or external fixation and grafting [7–9].

The treatment of a non-union of a HTO with knee A has notbeen well established. Yoshino et al. advocated using iliac crestbone grafting to obtain union of the osteotomy at the time oftotal knee replacement (TKR) [10]. Their implant of choice wasa posterior stabilized knee design with a long stemmed tibialcomponent. Other authors described a similar case treated witha constrained condylar design implant and no attempt to obtainunion at the fracture site [8].

⁎ Corresponding author. Tel.: +1 416 603 5642; fax: +1 416 603 3437.E-mail address: Rajiv.gandhi@uhn.on.ca (R. Gandhi).

0968-0160/$ - see front matter © 2008 Elsevier B.V. All rights reserved.doi:10.1016/j.knee.2008.01.011

We describe the first case of bilateral non-unions of previousHTOs with end stage knee osteoarthritis treated with a staged,bilateral, posterior stabilized total knee arthroplasty. With thisdiagnosis in an elderly patient, our goal was to minimize themorbidity of potentially multiple operations while maximizingher function and pain relief.

2. Case report

A 77-year-old lady underwent bilateral lateral closing wedgeHTOs in 1984 for isolated medial compartment OA. Theseoperations were done at another hospital and staged 6 weeksapart. She presented for examination at our hospital in March2006, stating she had 3 pain-free years after the operations buthad been experiencing increasing pain ever since. At the time ofour examination, she was using a walker in her home, unable towalk up the stairs, and she seldom walked outside. Heralignment was in significant varus bilaterally with a range ofmotion of 0 to 80°. Her X-rays revealed bilateral Grade IVosteoarthritis [11] with non-unions of her osteotomy sites. The

Fig. 1. AP and lateral views of right knee showing non-union of the HTO, severe medial compartment OA, and subluxation of the tibial plateau.

243R. Gandhi et al. / The Knee 15 (2008) 242–245

tibial plateaux were subluxed relative to the tibial shaft and thelateral staples were still in place (Figs. 1 and 2). Herpreoperative WOMAC [12] scores were 67 on the right and72 on the left.

The patient underwent staged bilateral TKRs with posteriorstabilized inserts and tibial stems to bypass the non-union sites(Genesis II, Smith and Nephew, Memphis, Tennessee). For bothknees, we took a minimal resection of the proximal tibia andexamined the non-union sites. They were both found to befibrous stable and as such we left them alone. We did not use

Fig. 2. AP and Lateral view of left knee showing non-union of th

bone graft and made no attempt to obtain union at the site. Weneeded offset couplers on both tibial stems to ensure the stemwas centered in the tibial canal. The retained staples wereremoved through the midline incision.

At 1 year follow-up, the patient was pain free and walkingwithout any aids. She had a range of motion of both knees from0 to 120°. Her WOMAC scores were 9 on the right side and 13on the left side. Her 1 year follow-up X-rays showed bothimplants in satisfactory alignment and the non-union sitesappeared unchanged (Figs. 3 and 4).

e HTO with severe OA, and subluxation of the tibial plateau.

Fig. 4. Post-operative X-ray of left total knee arthroplasty with long stemmed tibial component.

Fig. 3. Post-operative X-ray of right total knee arthroplasty with long stemmed tibial component.

244 R. Gandhi et al. / The Knee 15 (2008) 242–245

245R. Gandhi et al. / The Knee 15 (2008) 242–245

3. Discussion

Non-union is an uncommon complication of HTO, [3,4] andto our knowledge bilateral non-union has not been reported.

In discussion with this patient, one option was to first try andobtain bony union of her osteotomies and then subsequentlyperform staged knee replacements. We felt that it would bedifficult to obtain union of the osteotomies since they have beenun-united for 22 years and to perform bilateral operations in anelderly woman risked significant morbidity. Moreover, shedescribed her pain at the level of the joint line rather than beingmore distal at the site of the osteotomy.

Another option would have been to primarily resect theentire non-united plateaux and use a rotating hinge prosthesis atthe time of joint replacement. We elected for a posteriorstabilized knee replacement with a long stemmed tibialcomponent. We emphasize the need for offset couplers on thetibia to ensure the stem is centered in the tibial canal. The non-union site was found to be very stable intra-operatively.

In a case of bilateral non-union and severe knee OA,addressing the non-union first and then treating the OA wouldrequire four operations. This may be too much for an elderlypatient. We found that primary TKR using tibial stems andwithout treating the tibial non-union gave satisfactory results.

References

[1] Dowd GSE, Somayaji HS, Uthukuri M. High tibial osteotomy for medialcompartment osteoarthritis. The Knee 2006;13:87–92.

[2] Koshino T, Yoshida T, Ara Y, Saito I, Saito T. Fifteen to twenty-eightyears' follow-up results of high tibial valgus osteotomy for osteoarthriticknee. The Knee 2004;11:439–44.

[3] Billings A, Scott DF, Camargo MP, Hofmann AA. High tibial osteotomywith a calibrated osteotomy guide, rigid internal fixation, and early motion.J Bone Jt Surg Am 2000;82:70–9.

[4] Naudie D, Bourne RB, Roraback CH, Bourne TJ. Survivorship of the hightibial valgus osteotomy: a 10-to-22 year followup study. Clin Orthop RelatRes 1999;367:18–27.

[5] Wolff AM, Krackow KA. The treatment of nonunion of proximal tibialosteotomy with internal fixation. Clin Orthop Relat Res 1990;250:207–15.

[6] Cameron HU, Welsh RP, Jung Y-B, Noftall F. Repair of nonunion of tibialosteotomy. Clin Orthop Relat Res 1993;287:167–9.

[7] Schatzker J, Burgess RC, Glynn MK. The management of nonunionsfollowing high tibial osteotomy. Clin Orthop Relat Res 1985;193:230–3.

[8] Tjornstrand B, Hagstedt B, Persson BM. Results of surgical treatment fornon-union after high tibial osteotomy in osteoarthritis of the knee. J Bone JtSurg Am 1978;60:973–7.

[9] Rozbruch SR, Herzenberg JE, Tetsworth K, Tuten HR, Paley D.Distraction osteogenesis for nonunions after high tibial osteotomy. ClinOrthop Relat Res 2002;394:227–35.

[10] Yoshino N, Takai S, Watanabe Y, Nakamura S, Kubo T. Total kneearthroplasty with long stem for treatment of nonunion after high tibialosteotomy: a case report. J Arthroplast 2004;19:528–31.

[11] Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis.Ann Rheum Dis 1957;16:494–502.

[12] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW.Validation study of WOMAC: a health status instrument for measuringclinically important patient relevant outcomes to antirheumatic drugtherapy in patients with osteoarthritis of the hip or knee. J Rheumatol1988;5:1833–40.