POSTGRAD. MED. J. (1964), 40, 536

OSTEOTOMY OF THE TIBIA AND FIBULAIN THE TREATMENT OF

CHRONIC OSTEOARTHRITIS OF THE KNEEE. N. WARDLE, M.Ch.(Orth.), F.R.C.S.

Consulting Orthopadic Surgeon, United Liverpool Hospitals.

Nihil Scriptun Miraculi CausaOSTEOTOMY of the tibia alone as anoperation simply to correct deformity at theknee was described and performed byVolkmann as long ago as 1875; at aboutthe same time as Lister and MacEwan (1878)gave their description of the first supracondylarosteotomy. This operation is also mentionedin Orthopaedic Surgery (Jones & Lovett, 1929)in relation to the treatment of knock-knee andbow-leg deformity in adult patients who hadsuffered from rickets in childhood. This pro-cedure, modified in that the bone is dividedhorizontally through the inner tuberosity justdistal to the articular surface, has beenadvocated within quite recent years bySmillie (1946). It is also mentioned by Judet,Judet, Lagrange and Dunoyer (1954). My col-league G. E. Thomas (1964) also regards it ascorrect practice in patients whose painfularthritic knees show a valgus deformity andmaintains that this deformity can be correctedby a tibial osteotomy alone.Osteotomy of the tibia combined with

division of the fibula was first performed, tomy knowledge, at the Royal Southern Hospi-tal, Liverpool, from 1928 onwards. Thesurgeons who practised it at that time hadusually to deal with deformity of the knee inadults, the result of childhood rickets. Thiswas common in those times. They pointed outthat correction of this deformity in adult lifeby femoral osteotomy, which was so suc-cessful in children, invited the rapid onset ofpain and chronic degenerative change in theknee joint. They gave the reason that cor-rection of the deformity above the knee jointaltered the inclination of the axis ofmovement of that joint to the line of weight-bearing in the leg as a whole; and thatwhereas a growing child could accommodateto this, an adult could not. Osteotomy below theknee makes no such alteration but correctsthe position by the production of an equal andopposite deformity below the original one

and leaves the axis of movement of the kneejoint at the same inclination to the weightbearing line of the limb.The application of this procedure to the

treatment of chronic osteoarthritis of the kneeis of later date. It is described by Steindler(1940). As far as the series of patients quotedin this article is concerned the operation wasfirst performed in 1941 with the single objectiveof correction of increasing deformity in pain-ful and progressive degeneration of the knee.At that time certain authorities regarded thisoperation as dangerous because of the pos-sibility of vascular complications and evengangrene of the limb, which had beenobserved to occur in certain fractures involvingthe tuberosities of the tibia and the proximalshaft of the fibula. This catastrophe need notbe anticipated provided proper care is exercised.The rapid relief of pain observed in patientstreated in this manner led to the increasinguse of the operation. It is now also advocatedby other authors (Jackson & Waugh, 1961)and a proportion of the patients described herehave previously been reported elsewhere(Wardle, 1962).MaterialThe majority of the 35 patients (Table 1) reported

here presented with osteoarthritic knees in whichvarus deformity was associated with persistent andintractable pain which suddenly increased beyondthat which they had been accustomed to bear foryears with the aid of analgesics and physiotherapy.It is plain from other authors that as many patientsmay present with valgus deformity. Their ages haveranged from 42 to 75; 19 of them were men and16 women. Pain and deformity were constantlyassociated with gross synovial thickening, periodiceffusion of fluid in the joints and coarse creaking.The range of active movement present before treat-ment has rarely been less than 90 degrees of flexionfrom the extended position. The radiographs (Fig. 1)illustrate a typical knee joint at the time of operation.

TechniqueTwo skin incisions are used. The first com-

mences just distal to the tibial tubercle and

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September, 1964 WARDLE: Osteotomy of Tibia & Fibula 537

TABLE 1

Age at Period of Post-operativeName Operation Deformity Immobilisation Rangeof Knee of Movement

Mrs. T. 63 Varus 8 Weeks 900Miss L. 50 Varus 12 Weeks 900Mrs. B. 65 Varus 8 Weeks FullMr. P. 70 Varus 8 Weeks FullMr. B. 60 Varus 8 Weeks FullMr. W. 68 None 8 Weeks 900Mr. B. 65 Varus 12 Weeks FullMr. W. 43R: 51L Varus: Varus 12 Weeks : 7 Months Full : FullMr. D. 63 Varus 12 Weeks 900Mrs. M. 62 Varus 12 Weeks 900Mrs. N. 71 Varus 16 Weeks FullMr. B. 42 Varus 12 Weeks FullMrs. C. 66 Valgus 12 Weeks 900Mr. K. 50 Varus 12 Weeks 900 Coronary IncidentMr. A. 61L: 62R Varus: Varus 8 Weeks::OWeeks 700: 900Mr. McP. 59 Varus 8 Weeks 900Mrs. H. 54 Valgus 12 Weeks 1000Mr. D. 50 Varus 12 Weeks 900Mr. L. 50 Varus 10 Weeks FullMr. K. 62L : 63R Varus : Varus 12 Weeks : 8 Weeks 700: 1000Mrs. B. 73 Varus 12 Weeks 700Mrs. A. B. 60 Valgus 8 Weeks 900Mrs. C. 72 Varus 8 Weeks 450Mr. P. 61 Varus 8 Weeks Less than 90' Coronary IncidentMiss P. 54 None 8 Weeks None RheumatoidMrs. K. 61 None 8 Weeks FullMr. H. 58 Varus 8 Weeks FullMr. T. 67 Varus 8 Weeks 450 Death from CoronaryMr. W. 49 Varus thrombosisMrs. C. 67 Varus 8 Weeks Less than 900 ThrombosisMrs. R. 56 None 8 Weeks Less than 900Mrs. McD. 55 Varus 8 Weeks 90°Mr. H. J. 75 None 10 Weeks Full ..Mrs. P. D. 74 Varus _ Paget's OstetlsMr. E. Y. 60 Varus 12 Weeks 900 Wearing caliper

extends distally for three inches, curving alittle laterally so that at no time does it liedirectly over the suibcutaneous border of thetibia. The flap thus marked is reflected mediallyto expose the crest of the tibia and itssubcutaneous surface at a point two inchesdistal to the tibial tubercle. The lateral sur-face of the tibia is cleared of muscle by arougine and a bone lever inserted until itstip passes around the posterior border of thebone. A second bone lever is inserted at themedial border of the subcutaneous surface ofthe tibia in a similar manner. The line ofosteotomy is then notched out of the hardcortical bone, particularly at the subcutaneousborder, to prevent splintering and the tibiais then divided. The second incision is made onthe lateral surface of the leg directly over theshaft of the fibula and at the same level asthe first. The fascia is divided in the sameline and the peroneal muscles are separatedby blunt dissection to avoid damage to the

branches of the peroneal nerve; bone leversare inserted and the fibula divided a littledistal to the site of the tibial osteotemy. Theoperation can be performed easily without atourniquet in elderly patients. After closureof the incisions any deformity present is cor-rected and a long leg plaster cast is applied.Clinical union may be expected in six toeight weeks and can be expedited by encourag-ing the patient to bear weight on the cast.A below knee plaster is substituted whenunion is present. Internal fixation may beused to avoid plaster fixation but it is doubtfulwhether patients achieve weight bearing anyearlier or recover their movement any morequickly by this method.

Immcedite ResultsAll patients in this series have reported

complete relief of their pain, in particular oftheir intractable night pain, within a few days

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'R' .....

FIG. I.-Two radiographs. Antero-posterior andoperation, to illustrate diminution of jointbone architecture.

of operation and there has been no recur-rence. Twenty-seven of these patients hadrecovered the minimum range of 90 degrees ofactive flexion in the knee joint by six monthsfrom the time of operation, many of them atthree months. A considerable proportion haveachieved a full range although movement waslimited before operation. At an interval oftwo years the disappearance of synovialthickening is a striking feature and crepitusis marked.ly diminished. Later, radiologicalchanges occur in the proximal part of the

lateral views of an osteoarthritic knee beforespacing, osteophyte formation and changes in

tibia. Normal bone architecture and densityre-appear and cysts disappear (Fig. 2).ComplicationsThere have been no immediate complications

in any of these patients during the first fourpost-operative weeks, which is in keeping witha simple operation. The advanced age of manypatients would lead one to expect a numberof coronary thromboses and pulmonaryemboli. However there have been only threesuch events, in patients numbered 14, 18 and29, all of them comparatively young men.

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(a) (b)FIG. 2.-Two radiographs. Antero-posterior views of a knee joint.

(a) 31.7.61-before operation. (b) 17.12.62-the same knee joint eighteen monthslater, to illustrate the change in joint spacing, bone architecture and density.

Non-UnionThis has been observed once. The patient,

young in years but with advanced degenerativechanges in his knee joints, presented in 1949.Osteotomy of the tibia and fibula was per-formed on the left leg at that time. Theresult was sufficiently successful to return himto work and to bring him back requesting thesame procedure for his right knee in 1957.When observed in 1962 there was non-unionof the right tibia at the site of the osteotomy,but he was pain free and had a range of 120degrees of active flexion from full extensionin both knees. He was at work and walkedwithout sticks.

Oedema of the LegAll patients have shown this in the first

few weeks following removal of all externalsupport from the limb. A firm bandage,remedial exercises, periodic elevation of the

limb and effleurage together with a graduatedincrease in the period of weight bearing haveusually been sufficient to remove the swellingrapidly. The three patients with cardio-vascular complications were notable exceptions.Wound Infection: This has not occurred in thisseries.

Muscle Hernia: There have been twoexamples of this. Both patients had grossdeformity and were obese, and it was foundimpossible to close the fascial envelope of theperoneal muscles at the fibular incision withoutgross tension.

Late ResultsIn patients examined more than five years

from the time of operation certain pheno-mena have been consistently observed. Clinic-ally there is a striking reduction in soft-tissue

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FIG. 3.-Two radiographs. Antero-posteriorthe medullary barrier.

synovial swelling. Radiologically the archi-tecture of the tibial bone proximal to thesite of the osteotomy tends to return to normaland joint spacing increases. The most suc-cessful cases, in which there has been restora-tion of full movement, are associated with theappearance of a medullary barrier in the tibiaat the site of osteotomy (Fig. 3).The lasting success of such a simple opera-

tion as osteotomy in the treatment of chronicosteoarthritis of the hip and knee raises theinevitable question-in what way does anosteotomy relieve pain and what are thephysiological changes set in motion whichrepair the joint? No satisfactory explanationhas yet appeared but certain observationswhich have been made, particularly in rela-

and lateral views of a tibia and fibula illustrating

tion to osteotomy of the tibia and fibula,have lead to investigations which may beuseful.

Investigations and DiscussionThe rapid relief of pain in chronic

osteoarthritis of the hip which follows inter-trochanteric osteotomy has become acommonplace. The same phenomenon occursin chronic osteoarthritis of the knee follow-ing osteotomy of the tibia and fibula. In thisarea of bone however, it is more easilyobserved that division of the tibia is constantlyassociated with the out-pouring of dark venousblood from the medulla; this is particularly soin elderly patients in whom the operation hasbeen performed without a tourniquet. This

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k"t)

FIG. 4.-Two radiographs. Lateral views of the tibia following intra-osseus venography.(a) The appearance in the tibia of an osteo-arthritic knee.(b) The appearance in the tibia of an unaffected knee joint from a patient 70 years old.

appearance of venous blood suggested thatthe relief of intra-medullary venous pressuremight be associated with they relief of pain.

In practice no reliable method of estimatingthe intra-medullary venous pressure has beenfound. Nevertheless, venous engorgement doesexist within the medullae of bones distal tochronic osteoarthritic knee joints in manypatients, and certain observations (Brookes,Elkin, Harrison and Heald, 1961), which showthat no valvular obstruction exists betweenthe bone medulla and the main venous trunksof the limb, suggested that simple venous stasismight have some bearing on the matter.

This has been investigated clinically andradiolQgically (Helal, 1962). In all patientstreated for chronic osteoarthritis of the kneeat the David Lewis Northern Hospital during1962 there was a greater percentage withassociated varicose veins in the affected legthan in a comparable number of patientstreated for other conditions.

Radiologically the possibilities of intra-osseous venography (Schobinger, 1960) havebeen explored. This is a technique originally

described for the delineation of main venouschannels in a limb. It has been modified toproduce a pattern of the venous networkwithin bone. The procedure has proved safeand useful. The patient is tested for sensi-tivity by the injection of 1 cc. 45 per centHypaque six hours before operation. Underanaesthesia, before the osteotomy is commenced,a self-tapping cannula (Helal, 1962) is screwedinto the tibial medulla and the backflow ofmedullary blood is noted. 10 ccs. of 45 percent Hypaque are then injected into the tibiaand an X-ray taken just as the injection iscompleted. Fig. 4 shows the type of venogramobtained in an established osteoarthritic kneecontrasted with that obtained from the tibiaof a patient from whose knee a largeganglion was being removed. This latterpicture can probably be regarded as a normalintraosseous venogram. Provided that theradiograph is taken immediately the injectionis completed this venous pattern in the bonecan be obtained, although it does not appearin any of Schobinger's illustrations, whereradiography was delayed. Undoubtedly, there

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542 POSTGRADUATE MEDICAL JOURNAL September, 1964

is evidence of venous sinusoidal engorgementin the tibia subjacent to an osteoarthriticknee.At an interval such as two years from the

time of operation the radiographs of thetibia of many patients subjected to osteotomyshow a medullary block (Fig. 3). The appear-ance of this barrier suggests that somealteration in the pattern of venous flow, or inthe amount of venous blood contained in thebone occurs, which has a relationship with therelief of symptoms and the late changes inbone produced by the operation of osteotomy.It is interesting to observe that several yearsafter osteotomy the venogram obtained from

the tibia of an osteoarthritic knee returns tothe pattern regarded as normal.

It would seem, therefore, that in orderto relieve the pain of an osteoarthritic kneejoint it is necessary to open the medullarycavity of the tibia distal to that joint. Tomaintain this relief of pain it is necessary tocreate a barrier across the medulla isolatingits proximal part from any connection with themain venous outflow from the shaft of thebone as a whole. Osteotomy of the tibiaproduces this block naturally by bone as inthe healing of any fracture. When theosteoarthritis of the knee joint is associatedwith deformity it is necessary to add anosteotomy of the fibula to correct thisdeformity as well as to relieve the pain.

REFERENCESBROOKES, M., ELKIN, A. C. HARRISON, R. G., and HEALD, C. B. (1961): A new Concept of Capillary Circulation

in Bone Cortex, Lancet. i, 1078.HELAL, B. (1962): Osteoarthritis of the Knee Joint-submitted as Thesis for the degree of M.Ch. (Orth.) of

Liverpool University.JACKSON, J. P., and WAUGH, W. (1961): Tibial Osteotomy for Osteoarthritis of the Knee, J. Bone Jt. Surg., 43-B,

746.JONES, SIR. R., and LOVETr, R. W. (1929): 'Orthopadic Surgery', p. 321, 328. London: Oxford University Press.JUDET, J., JUDET, R., LAGRANGE, J., and DUNOYER, J. (1954): 'Resection Reconstruction of the Hip; Arthro-

plasty with an Acrylic Prosthesis'. Edinburgh and London: E. & S. Livingstone.LISTER and MAOEWAN (1878): Osteotomy, Lancet, ii, 912.SCHOBINGER, R. A. (1960): 'Intraosseous Venography', New York and London: Grune and Stratton.SMILLIE, I. S. (1946): 'Injuries of the Knee Joint', Edinburgh and London: E. & S. Livingstone. Baltimore:

Williams and Wilkins.STEINDLER, A. (1940): 'Orthopaedic Operations'. Springfield, Illinois: Charles C. Thomas.THOMAS, G. E. (1964): Personal Communication.VOLKMANN, R. (1875): Osteotomy for Knee Joint Deformity, Edinb. med. J., translation from the Berl. Klin.

Wschr. p. 794.WARDLE, E. N. (1962): Osteotomy of the Tibia and Fibula, Surg., Gynec. Obstet., 115, 61.

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