Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: a biomechanical study in human cadaveric knees. Winner of the AGA-DonJoy Award 2004.

INTRODUCTION: Valgus high tibial osteotomy is an established treatment for unicompartmental varus osteoarthritis. However, only little is known about the effect of osteotomy in the sagittal plane on biomechanical parameters such as cartilage pressure and joint kinematics. This study investigated the effects of high tibial flexion osteotomy in a human cadaver model.
MATERIALS AND METHODS: Seven fresh human cadaveric knees underwent an opening wedge osteotomy of the proximal tibia in the sagittal plane. The osteotomy was opened anteriorly, and the tibial slope of the specimen was increased gradually. An isokinetic flexion-extension motion was simulated in a kinematic knee simulator. The contact pressure and topographic pressure distribution in the medial joint space was recorded using an electronic pressure-sensitive film. Simultaneously the motion of the tibial plateau was analyzed three-dimensionally by an ultrasonic tracking system. The traction force to the quadriceps tendon which was applied by the simulator for extension of the joint was continuously measured. The experiments were carried out with intact ligaments and then after successively cutting the posterior and anterior cruciate ligaments.
RESULTS: The results demonstrate that tibial flexion osteotomy leads to a significant alteration in pressure distribution on the tibial plateau. The tibiofemoral contact area and contact pressure was shifted anteriorly, which led to decompression of the posterior half of the plateau. Moreover, the increase in the slope resulted in a significant anterior and superior translation of the tibial plateau with respect to the femoral condyles. Posterior subluxation of the tibial head after cutting the posterior cruciate ligament was completely neutralized by the osteotomy. The increase in slope resulted in a significant higher quadriceps strength which was necessary for full knee extension.
CONCLUSIONS: We conclude from these results that changes in tibial slope have a strong effect on cartilage pressure and kinematics of the knee. Therapeutically a flexion osteotomy may be used for decompression of the degenerated cartilage in the posterior part of the plateau, for example, after arthroscopic partial posterior meniscectomy. If a valgus osteotomy is combined with a flexion component of the proximal tibia, complex knee pathologies consisting of posteromedial cartilage damage and posterior and posterolateral instability can be addressed in one procedure, which facilitates a quicker rehabilitation of these patients.