Incidence and Factors Affecting the Occurrence of Lateral Hinge Fracture After Medial Opening-Wedge High Tibial Osteotomy

Sang-June Lee, Jae-Hwa Kim, Eugene Baek, Han-Seung Ryu, Donghun Han, Wonchul Choi, Sang-June Lee, Jae-Hwa Kim, Eugene Baek, Han-Seung Ryu, Donghun Han, Wonchul Choi

Abstract

Background: Few clinical studies have reported the predictors of lateral hinge fracture (LHF) after medial opening-wedge high tibial osteotomy (MOWHTO).

Purpose/hypothesis: The purpose was to compare the incidence of LHF on plain radiographs versus computed tomography (CT) scans and to investigate the factors related to the development of LHF after MOWHTO. We hypothesized that (1) a higher LHF detection rate would be seen on CT scans versus plain radiographs and (2) LHF incidence would be related to opening gap width and hinge position.

Study design: Cohort study (diagnosis); Level of evidence, 3.

Methods: A total of 97 MOWHTO cases were included. The presence and types of LHF were determined from plain radiographs and CT scans. Radiographic parameters were measured on plain radiographs taken 6 weeks postoperatively. Anterior and posterior opening gap widths, coronal and sagittal osteotomy slopes, and fibular height were calculated from CT scans. The wedge-hinge relationship and the zone of hinge position were assessed, and the patient and radiographic factors related to LHF occurrence were evaluated.

Results: Seventeen LHF cases (20.5%) were detected on plain radiographs, while significantly more (37 cases; 44.6%) were found on CT scans (P = .001). Based on Takeuchi classification, 28 LHF cases were considered type 1, 7 were type 2, and 2 were type 3. Logistic regression analysis revealed that opening gap width (odds ratio, 1.615; 95% confidence interval, 1.232-2.118; P = .001) and posterior opening gap width (odds ratio, 3.731; 95% confidence interval, 1.642-4.351; P = .008,) differed significantly between patients with versus without LHF. Other patient and radiographic factors were not significantly related to LHF occurrence. Receiver operating characteristic curve analysis identified the opening gap width cutoff values for LHF as 11.0 mm (area under the curve, 0.81; sensitivity, 78.4%; specificity, 73.9%).

Conclusion: The incidence of LHF after MOWHTO can be underestimated on plain radiographs compared with CT scans. Only large opening gap width, especially posterior gap width, was found to have a statistically significant relationship with occurrence of LHF. Therefore, special caution for possible LHF may be needed if a large correction is planned.

Keywords: biplane osteotomy; lateral hinge fracture; medial compartment osteoarthritis; opening-wedge high tibial osteotomy.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: W.C. received support from the National Research Foundation of Korea grant funded by the Korean government (No. 2020R1F1A1050436). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

© The Author(s) 2021.

Figures

Figure 1.
Figure 1.
Flowchart of the study population that had open wedge HTO and CT scans. CT, computed tomography; HTO, high tibial osteotomy.
Figure 2.
Figure 2.
Takeuchi classification of lateral hinge fracture. The arrow indicates the fracture site. Type 1, the fracture reaches just proximal to or within the tibiofibular joint; type 2, the fracture reaches the distal portion of the proximal tibiofibular joint; and type 3, a lateral plateau fracture.
Figure 3.
Figure 3.
(A) The safe zone (SZ) on radiograph, defined as the distance from the circumference line of the fibular head to the fibular tip. The asterisk indicates the medial opening gap width, measured as the distance between the 2 medial edges of the osteotomy margin. (B) The fibular height (FH) on CT scan, calculated as the distance from the circumference line of the fibular head to the lateral tibial plateau. (C) Coronal slope (CS; left) and sagittal slope (SS; right), assessed as the angle between a line perpendicular to the tibial shaft axis and the distal osteotomy margin on the appropriate CT view. (D) Anterior gap (AG) and posterior gap (PG) widths. On the image slice showing the anteromedial osteotomy edge in sagittal view, anterior and posterior gap widths were measured between the edges of the 2 osteotomy margins. CT, computed tomography.
Figure 4.
Figure 4.
Classification of wedge-hinge relationship. Type A, both anterior and posterior osteotomies extend over the lateral zone; type B, only the anterior osteotomy extends; type C, only the posterior osteotomy extends; and type D, neither osteotomy extends.
Figure 5.
Figure 5.
Zone classification of hinge position. The hinge level was classified according to the height of the endpoints, with levels high (H), mid (M), and low (L) based on the proximal and distal margin of the proximal tibiofibular joint.

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