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      Clinical Experience Using a 3D-Printed Patient-Specific Instrument for Medial Opening Wedge High Tibial Osteotomy

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          Abstract

          Purpose

          High tibial osteotomy (HTO) has been adopted as an effective surgery for medial degeneration of the osteoarthritis (OA) knee. However, satisfactory outcomes necessitate the precise creation and distraction of osteotomized wedges and the use of intraoperative X-ray images to continually monitor the wedge-related manipulation. Thus HTO is highly technique-demanding and has a high radiation exposure. We report a patient-specific instrument (PSI) guide for the precise creation and distraction of HTO wedge.

          Methods

          This study first parameterized five HTO procedures to serve as a design rationale for an innovative PSI guide. Preoperative X-ray and computed tomography- (CT-) scanning images were used to design and fabricate PSI guides for clinical use. The weight-bearing line (WBL) of the ten patients was shifted to the Fujisawa's point and instrumented using the TomoFix system. The radiological results of the PSI-guided HTO surgery were evaluated by the WBL percentage and tibial slope.

          Results

          All patients consistently showed an increased range of motion and a decrease in pain and discomfort at about three-month follow-up. This study demonstrates the satisfactory accuracy of the WBL adjustment and tibial slope maintenance after HTO with PSI guide. For all patients, the average pre- and postoperative WBL are, respectively, 14.2% and 60.2%, while the tibial slopes are 9.9 and 10.1 degrees. The standard deviations are 2.78 and 0.36, respectively, in postoperative WBL and tibial slope. The relative errors of the pre- and postoperative WBL percentage and tibial slope averaged 4.9% and 4.1%, respectively.

          Conclusion

          Instead of using navigator systems, this study integrated 2D and 3D preoperative planning to create a PSI guide that could most likely render the outcomes close to the planning. The PSI guide is a precise procedure that is time-saving, radiation-reducing, and relatively easy to use. Precise osteotomy and good short-term results were achieved with the PSI guide.

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          Most cited references36

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          Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients.

          Stephanie Floerkemeier, Alex E Staubli, Steffen Schroeter … (2013)
          Open-wedge valgus high tibial osteotomy is a well-established procedure in the management of medial osteoarthritis of the knee. In recent years, improved osteotomy and fixation methods have led to an increased use of this technique. The aim of this study was to identify predictive parameters for the clinical outcome after valgus high tibial osteotomy.
          Article 0 comments Cited 80 times – based on 0 reviews     Review now
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            Proximal tibial osteotomy. A new fixation device.

            P E Ballmer, Anthony Miniaci, F Ballmer … (1989)
            A new internal fixation device was applied to 41 proximal tibial osteotomies to ensure against loss of postoperative correction. An oblique osteotomy was stabilized by two screws and a five-hole one-half tubular plate. Thirty-six patients with 41 proximal tibial osteotomies were reviewed for an average roentgenographic follow-up time of 22.6 months (range, six to 48 months) with no loss of correction. In addition, 16 patients with 19 osteotomies and a minimum clinical follow-up time of two years were reviewed using the Hospital for Special Surgery knee scoring system; these early results demonstrated a similar outcome to previously published series. The new fixation device is simple to use, permits early postoperative motion, and maintains the exact correction obtained at the time of surgery.
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              Opening wedge tibial osteotomy: the 3-triangle method to correct axial alignment and tibial slope.

              Frank R. Noyes, John West, S Goebel (2005)
              Although a change in tibial slope may occur during a medial opening wedge osteotomy, calculations have not been defined to address this problem. The authors investigated geometric factors important to correct axial alignment and tibial slope during osteotomy. To calculate, through 3-dimensional analysis of the proximal tibia, how the angle of the opening wedge along the anteromedial tibial cortex influences the tibial slope (sagittal plane) and valgus correction (coronal plane) during osteotomy, and to analyze the different radiographic methods reported in the literature to measure medial and lateral tibial slope. The authors postulated that differences in reported normal values of tibial slope in the sagittal plane were technique dependent. Descriptive laboratory study. The proximal anteromedial tibial cortex obliquity on magnetic resonance imaging was measured in 35 knees. Serial computed tomography images of the proximal tibia were digitized, allowing a series of virtual opening wedge osteotomies to be performed. Algebraic calculations defined the effect of an opening wedge osteotomy on the anteromedial tibial cortex opening wedge angle, sagittal tibial slope angle, and coronal valgus alignment. The anteromedial tibial cortex oblique angle at the medial osteotomy site was 45 degrees +/- 6 degrees and determined, along with the degrees of valgus correction, the degrees of the opening wedge angle in the oblique plane. The anterior osteotomy gap at the tibial tubercle was generally one half of the posteromedial gap to maintain the normal sagittal tibial slope. Every millimeter of gap error at the tibial tubercle resulted in approximately 2 degrees of change in the tibial slope. The width of the buttress plate along the anteromedial tibial cortex was 2 to 3 mm less than the computed coronal valgus posteromedial osteotomy gap to achieve tibiofemoral valgus correction. A series of measurements preoperatively and intraoperatively are required to obtain the desired correction of tibial slope and valgus alignment.
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                Author and article information

                Contributors
                Shang-Chih Lin:
                ORCID: http://orcid.org/0000-0002-9135-5469
                Journal
                Journal ID (nlm-ta): Biomed Res Int
                Journal ID (iso-abbrev): Biomed Res Int
                Journal ID (publisher-id): BMRI
                Title: BioMed Research International
                Publisher: Hindawi
                ISSN (Print): 2314-6133
                ISSN (Electronic): 2314-6141
                Publication date Collection: 2018
                Publication date (Electronic): 8 May 2018
                Volume: 2018
                Electronic Location Identifier: 9246529
                Affiliations
                1Department of Orthopedic & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
                2Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
                3Department of Orthopedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
                4Graduate Institute of Biomedical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
                5Institute of Anatomy and Cell Biology, National Yang-Ming University, Taipei, Taiwan
                6Department of Orthopedic Surgery, Taipei City Hospital and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
                7Adult Orthopedic Department, Beijing JST Hospital, Beijing, China
                Author notes

                Academic Editor: Despina Deligianni

                Author information
                http://orcid.org/0000-0002-9135-5469
                Article
                DOI: 10.1155/2018/9246529
                PMC ID: 5964591
                PubMed ID: 29854810
                SO-VID: 65cedbd9-30ce-4f3f-99b0-5df6f30d2a38
                Copyright © Copyright © 2018 Jesse Chieh-Szu Yang et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 12 September 2017
                Date revision received : 10 February 2018
                Date accepted : 25 February 2018
                Categories
                Subject: Research Article

                Data availability:

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