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

Jesse Chieh-Szu Yang, Cheng-Fong Chen, Chu-An Luo, Ming-Chau Chang, Oscar K Lee, Ye Huang, Shang-Chih Lin, Jesse Chieh-Szu Yang, Cheng-Fong Chen, Chu-An Luo, Ming-Chau Chang, Oscar K Lee, Ye Huang, Shang-Chih Lin

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.

Figures

Figure 1
Figure 1
Schematic diagrams of surgical parameters for HTO with a medial opening wedge. (a) Cutting position, lateral hinge, sawing direction, and sawing depth in the coronal plane. (b) 3D diagram of the lateral hinge and distraction angle. The symbols are defined in the content.
Figure 2
Figure 2
(a) Schematic diagram of the 2D preoperative planning for WBL percentage and distraction angle. (b) Fujisawa's point is adopted as a preplanning guide in the limb radiograph.
Figure 3
Figure 3
(a) Flow chart of the preoperative planning strategy. (b) Simulation of the biplanar cut. (c) Valgus correction of the 3D tibial model.
Figure 4
Figure 4
Schematic diagrams of (a) the PSI guide for medial opening wedge HTO and (b) intraoperative usage before and after distraction.
Figure 5
Figure 5
Intraoperative photograph with the PSI guide.
Figure 6
Figure 6
Postoperative photographs of a patient in standing and squatting positions three months after surgery.
Figure 7
Figure 7
Pre- and postoperative comparisons of (a) the WBL percentage, with the negative value indicating that the WBL passes outside medially of the entire joint, and (b) the tibial slope.
Figure 8
Figure 8
Pre- and postoperative data of ten HTO patients: (a) WBL percentage and (b) tibial slope.

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