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Letters to the Editor to:

Scientific Articles:
Javad Parvizi, Arlen D. Hanssen, and Mark J. Spangehl
Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure
J Bone Joint Surg Am 2004; 86: 474-479 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Not all Osteotomies are the Same
S. Robert Rozbruch, MD, Assistant Professor Orthopedic Surgery, Weill Medical College of Cornell University   (7 April 2004)
[Read Letter to the Editor] Dr. Spangehl responds:
Mark J. Spangehl, Javad Parvizi, Arlen D. Hanssen   (7 April 2004)

Not all Osteotomies are the Same 7 April 2004
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S. Robert Rozbruch, MD,
Director, Institute for Limb Lengthening and Reconstruction
Hospital for Special Surgery;,
Assistant Professor Orthopedic Surgery, Weill Medical College of Cornell University

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Re: Not all Osteotomies are the Same

rozbruchsr{at}hss.edu S. Robert Rozbruch, MD, et al.

To the Editor:

I read with interest “Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure” (volume 86-A, number 3, March 2004) by J. Parvizi, A. Hanssen, and M. Spangehl. The authors review a group of 166 cemented condylar knee replacements done in 118 patients that had previously had a proximal tibia osteotomy. These knee replacements had relatively inferior results, and the authors identified risk factors for early failure.

The problems cited by the authors were mal-alignment, patella baja, instability, periarticular scarring, proximal tibia bone deficiency, and retained hardware. The great detail about knee arthroplasty, long follow- up, and meticulous study design are all severely compromised by the absence of any detail regarding the technique of osteotomy. Were these opening or closing wedge corrections? Was the fibula osteotomized or was the proximal tibia-fibula joint sprung? Was there internal, external, or no fixation? Were patients casted or allowed to move their knees? Were the corrections done acutely or gradually?

Do the authors suggest that these techniques are all the same? That would be as ludicrous as clumping together a group of knee replacements to include revision total knee replacements, cemented and uncemented primary total knee replacements, PCL sparing and retaining, and unicondylar knee replacements.

Presumably, this was predominantly a group of closing wedge Coventry- type high tibial osteotomies. Today, this technique has been largely abandoned because of its association with patella baja, decreased metaphyseal bone stock, lateral knee laxity, and altered proximal tibia anatomy.

Modern techniques of proximal tibia osteotomy including opening wedge corrections, stable fixation that allows early weight-bearing and knee range of motion, gradual corrections with external fixation after percutaneous osteotomy, and adjunctive ligament tensioning techniques should not be associated with the specific problems cited by the authors.

The authors have suggested that proximal tibial osteotomy in general will compromise future total knee replacement. This is a dangerous and inaccurate message that is not supported by their data or lack thereof. The authors should give the readers specific information about the osteotomy techniques used. Sincerely, S. Robert Rozbruch, MD Director, Institute for Limb Lengthening and Reconstruction Hospital for Special Surgery Assistant Professor of Orthopedic Surgery Weill Medical College of Cornell University
Dr. Spangehl responds: 7 April 2004
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Mark J. Spangehl,
Orthopaedic Surgeon
Mayo Foundation,
Javad Parvizi, Arlen D. Hanssen

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Re: Dr. Spangehl responds:

spangehl.mark{at}mayo.edu Mark J. Spangehl, et al.

To the Editor:

We wish to thank Dr. Rozbruch for his comments regarding “Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure" (volume 86-A, number 3, March,2004) by J. Parvizi, A. Hanssen, and M. Spangehl.

Dr. Rozbruch is certainly correct that not all osteotomies are the same. Details of the osteotomies were not included in the study. The osteotomies that were preformed prior to the total knee replacements in this series were lateral closing wedge osteotomies as popularized by Conventry. They were performed by different surgeons, who, while using the same basic technique and principles certainly had small variations in the surgical technique and post-operative management. Unfortunately, detailed data regarding the exact technique of each osteotomy procedure was not available. The authors acknowledge that this is an inherent problem, common to many retrospective studies. The authors do agree that various differences in technique (eg. management of the proximal fibula, early range of motion vs casting, amount of bone resected, etc) could influence the result of the osteotomy and potentially the result of subsequent total knee replacement, but we believe that the results are valid for closing wedge osteotomies, and can be generalized to apply such patients.

The authors are in agreement with Dr. Rozbruch that newer techniques of osteotomy, such as opening wedge osteotomy, the use of stable fixation allowing for early range of motion, or other techniques as cited by Dr. Rozbruch may make the results of total knee replacement after proximal tibial osteotomy more favorable. The authors are also hopeful that with newer techniques, the results of knee replacement will be more favorable and that the concerns cited in the article will be less of a problem. However, to date, there is insufficient data to support this claim, and further study is now needed on total knee replacement after newer techniques of proximal tibial osteotomy.