Biomaterials 29 (2008) 3497–3502

Contents lists available at ScienceDirect

Biomaterials
journal homepage: www.elsevier.com/locate/biomaterials

Leading Opinion

Do we need synthetic osteotomy augmentation materials for

opening-wedge high tibial osteotomyq
Sebastian Aryee a, Andreas B. Imhoff a, *, Tim Rose a, Thomas Tischer a, b
a
Department of Orthopaedic Sport Medicine, Technical University of Munich, Germany
b
Department of Anatomy, Ludwig-Maximillians University of Munich, Germany

a r t i c l e i n f o a b s t r a c t

Article history: High tibial osteotomy (HTO) is an increasing popular method to treat unicompartimental osteoarthritis
Received 22 March 2008 of the knee in younger, active patients. In so doing one tries to delay the need for total or uni-
Accepted 11 May 2008 compartimental joint replacement. The augmentation of HTO opening gaps with supporting material is
Available online 16 June 2008
discussed controversially, especially after the introduction of locking plates, which contribute to the
decline of the non-union rate. Currently, we do not recommend synthetic augmentation, when using
Keywords: locking plates in HTO with opening angles less than 10 . In our recent randomized study we could
Osteoarthritis of the knee
histologically and radiologically demonstrate the complete rebuilding of lamelliform bone in patients
High tibial osteotomy
Open wedge osteotomy
without synthetic augmentation, whilst bony ingrowth into the hydroxyapatite/tricalcium phosphate
Supporting material (HA/TCP) wedge of augmented osteotomies just slowly progressed. In contrast to unaugmented os-
Hydroxyapatite teotomies, there was no advantage in using HA/TCP wedges or the combination of HA/TCP wedges and
Synthetic augment platelet rich plasma (PRP) as supporting material after 12 months. In osteotomies where an opening
angle bigger than 7.5 is chosen, rigid locking plates should be used. In our opinion, autologous iliac crest
graft should be used in the high-risk patients (obese, smoker, opening angle bigger than 10 ). Whether
synthetic augmentation combined with PRP is equal or even superior to autologous iliac crest graft in
openings bigger than 10 has not been proven yet.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction perform the osteotomy and which fixation material is most bene-
ficial [11,13,14].
Since Jackson and Waugh first described tibial osteotomy for In our department we prefer the high tibial opening-wedge
osteoarthritis of the knee in 1961 [1] a lot of research have been osteotomy with a weight bearing line shift to 62.5% of the lateral
carried out to improve this method and the materials used. High knee compartment as Noyes and colleagues recommended [15]. In
tibial osteotomy (HTO) is an acknowledged surgical intervention contrast to the closed wedge osteotomy, the open wedge osteotomy
method to treat unicompartimental degenerative arthritis of the avoids lateral muscle detachment, dissection of the peroneal nerve
knee with varus deformity in selected patients [2–8]. Tibial and osteotomy of the fibula [16]. Biplanar osteotomy increases
osteotomy underwent several variations in terms of location and rotational stability. Disadvantages of this method are the possibility
surgical technique of the osteotomy as well as the fixation tech- of osteotomy collapse and loss of correction, especially when using
nique and possible augmentation with supporting material [9–13]. non-locking plates [2,10,17], as well as donor-site morbidity after
Several research studies dealt with the question where and how to retrieval of iliac crest graft [18]. Allograft to avoid donor side mor-
bidity was successfully applied in HTO by Yacobucci and Cocking
[19]. However, the use of allograft increases additional risks like
disease transmission, immunologic reactions and slow remodel-
ling. After opening-wedge HTO was broadly accepted, many re-
q Editor’s Note: This paper is one of a newly instituted series of scientific articles
search teams have suggested that the use of supporting material
that provide evidence-based scientific opinions on topical and important issues in
biomaterials science. They have some features of an invited editorial but are based could protect against collapse of the osteotomy opening and
on scientific facts, and some features of a review paper, without attempting to be accelerate bony healing without causing any disadvantages for the
comprehensive. These papers have been commissioned by the Editor-in-Chief and patients [20–23]. Unfortunately, these studies had no unaugmented
reviewed for factual, scientific content by referees. control group. In fact, to our knowledge there are no reports which
* Corresponding author. Department of Orthopaedic Sport Medicine, Technical
University of Munich, Connollystrasse 32, D-80809 Munich, Germany. Tel.: þ49 89
compare unaugmented with augmented medial opening-wedge
289 24462; fax: þ49 89 289 24484. high tibial osteotomy in patients with medial arthritis of the knee.
E-mail addresses: [email protected], [email protected] (A.B. Imhoff). The purpose of this review is to give the reader an overview of

0142-9612/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.biomaterials.2008.05.027
3498 S. Aryee et al. / Biomaterials 29 (2008) 3497–3502

recent developments in high tibial osteotomy and to present the After skin incision the insertion site of the hamstring tendons
role of supporting material and/or growth factors, as well as the and the patellar tendon are visualized. To protect the tibial nerve,
influential role of locking plates in HTO in current clinical practice. artery and vein a curved Hohmann’s retractor is placed around the
Our experience is based on over 900 osteotomies performed during dorsal tibial edge before sawing. The osteotomy is performed, using
the last 10 years, both closed and open wedges using different previously drilled k-wires as guide rail, stopping 15 mm ahead of
plates and various supporting materials when necessary. the lateral tibia. To preserve the patellar tendon, the tibial tuber-
osity is omitted by sawing in a 135 angle to the tibial osteotomy
(Fig. 2). This biplanar osteotomy increases rotational stability and
2. Operative technique
improves bony surface area for bony healing. The final opening is
achieved by insertion of osteotoms and slow, gradual widening of
Preoperative planning includes accurate measurement of the
the opening without the breakage of the lateral cortical bone. By
lower limb axial alignment using standing long-leg radiographs to
opening more ventrally or posteriorly, the tibial slope can also be
determine the extent of varus deformity and to calculate the degree
influenced [8]. The medial side of the opening is fixed with a lock-
of valgisating osteotomy (Fig. 1) [15].
ing plate (e.g. Arthrex, Naples, FL, USA or Synthes, West Chester, PA,
USA). If the lateral cortex breaks, the axial stiffness and torsional
stiffness are reduced over 50% [24], and a rigid long locking plate
should be used. In cases where augmentation is performed, either
autologous spongious iliac bone graft or an HA/TCP wedge (Fig. 3)
of appropriate size is inserted into the osteotomy opening and
pushed laterally until it is firmly aligned to the tibial bone. In cases
where a combination of HA/TCP and PRP is used, the wedges
are soaked for 20 min with the PRP and then inserted into the
osteotomy. The rest of the PRP is injected directly into the osteomy
site. PRP was prepared in the operating theatre from 60 ml of
anticoagulated blood (anticoagulated with dextrose citric acid)
drawn from the patient [25]. In the first step PRP and platelet-poor
plasma were separated from the red blood cell fraction by centri-
fugation for 3 min at 2.4000 U/min. In the next step, the PRP was
separated from the platelet-poor plasma by centrifugation for
12 min at 3.000 U/min. The resulting PRP (about 6 ml) was then

Fig. 1. Preoperative planning. Line a illustrates the weight bearing line, preoperatively
on the left side and after correction on the right side. Line b shows the projected
weight bearing line after correction to 66% on the lateral tibial plateau in this case.
Next line c is drawn parallel to the upper ankle joint. The correction angle for opening Fig. 2. After sawing the bone the final opening could be achieved by successive
high tibial osteotomy is then constructed, beginning at the hinge of the opening insertion of chisels into the osteotomy and slow, gradual widening of the opening. In
osteotomy and proceeding to the intersection of line a and c and line b and c. This advance to the plate fixation the osteotomy opening was kept open with an osteotomy
angle alpha is then used as the operative correction angle. retractor. * marks the tibial tuberosity. Note the 130 osteotomy.
 S. Aryee et al. / Biomaterials 29 (2008) 3497–3502 3499

Fig. 3. Commercially available HA/TCP wedges of various thicknesses. Note the visible
macroporosity. Inset shows microscopic picture of HA/TCP wedge. (Macroscopic HA/
TCP picture by courtesy of Arthrex, Naples, FL, USA.)
Fig. 4. Puddu plate (Arthrex), a short locking plate. Arrow shows the locking mecha-
nism, by which the angle of the screw can be adjusted 30 in every direction. (Picture
by courtesy of Arthrex, Naples, FL, USA.)
mixed with 2 ml 10% calcium chloride and applied to the HA/TCP
after 10 min. To avoid increased medial intercompartimental
pressure by tensioning of the medial collateral ligament (mcl) not maintain stability of the osteotomy sufficiently. If the lateral
during medial opening, the posterior oblique band of the mcl is cortical bone breaks, stability of the osteotomy depends solely on
incised arthroscopically using a special curved knife [26]. The par- the used plate and a long locking plate should be used.
tial mcl release leads neither to decreased joint stability nor As our own results show, the Puddu plate is a reliable implant,
restrictions in postoperative treatment. suitable for complaint, non-overweight patients without osteo-
Postoperative management basically depends on the plate used. porotic bone or other risk factors for bony healing like smoking.
If a massive locking plate like Tomofix (Synthes) is used, which is In patients with risk factors for bony consolidation or openings
designed to bear full weight, the patient should be allowed to greater than 7.5 , the long rigid locking plates should be used.
mobilise and walk directly after surgery with partial weight bearing
for six weeks. When other plates are used, weight bearing should
4. Synthetic augmentation material
be avoided until bony consolidation is visible on plain radiographs.
As a result of limited autologous bone availability and to mini-
3. Plate fixation mise the problem of donor-site morbidity, many efforts have been
made to find adequate supporting material for augmentation after
The primary stability of the plate used is of major importance for osteotomy [30,31]. In the literature hydroxyapatite [12,21,22],
complete bony consolidation after HTO [5,11,27,28]. In the past, one b-tricalcium phosphate [20,23,32] or the combination of both (HA/
major complication after open wedge osteotomy was the failure of TCP) [33] was the most commonly used synthetic augments in high
the implant with potential loss of correction [10,27]. To avoid this, tibial osteotomy. The use of bone cement as a temporary spacer for
the stability of the osteotomy can be increased using bony aug- bone defects has been described, but secondary biological re-
mentation, the insertion of spacers or the use of rigid locking plates construction was performed after cement removal [34,35]. In one
[28]. Reasonable advantages have been achieved using newer study, however, permanent acrylic bone cement has been used as
locking plates, which are much more stable than the previously an interface in the postero-medial part of high tibial osteotomy to
used implants [11,14,28,29]. The non-union rate is much lower in maintain the opening angle and good results have been achieved
these cases compared to previously used plates. Furthermore, the [36]. However, due to the different biomechanical features between
necessity of bony augmentation is lowered [5]. bone and bone cement and missing bony remodelling and in-
The two most common used locking plates are the Tomofix plate corporation, in our opinion, the use of bone cement as a permanent
(Synthes) and the Puddu plate (Arthrex) (Fig. 4). In a biomechanical spacer is not recommendable, if one aims to achieve biological
study, Agneskirchner and colleagues showed the advantage of regeneration.
a long locking plate over a short spacer plate with multidirectional One of the major problems of synthetic wedges is the generally
locking screws on primary stability [11]. These results have been low resistance of macroporous ceramics to compressive strength as
confirmed by Stoffel et al. [14]. Thereby, the incidence of lateral a result of, among other factors, high porosity percentage and big
cortical failure as well as mal-union or non-union can be reduced pore size. A compromise is adopted between high porosity, re-
greatly and the use of augmentation material can be avoided in quired for a good osseous integration, and high material density
many cases. One disadvantage of the long locking plate is its cor- which increases the mechanical strength. TCP alone exhibits rapid
pulent design, which can cause discomfort for the patients and degradation and weak mechanical properties, which has limited its
plate removal is necessary in almost every case (not before 18 application as bone graft substitutes, though it has good bio-
months after implantation). Further, implant costs are higher. We compatibility and osteoconductivity [37]. The combination of HA
therefore occasionally recommend the use of the short Puddu and TCP is supposed to feature a high initial stability and a good
plates, in cases where opening angles up to 7.5 are achieved biodegradability. However, the mechanical strength of HA/TCP is
without complications, even if they are not as strong as the longer not able to bear full weight after opening-wedge high tibial
plates [13,28]. If openings of 10 or bigger were accomplished, we osteotomy [38].
observed immediate or delayed breakage of the lateral cortical The results of research studies using synthetic supporting
bone, especially when short locking plates were used, which could material in a solid or granulate fashion have been fairly diverse.
3500 S. Aryee et al. / Biomaterials 29 (2008) 3497–3502

Recently, Jensen and colleagues, described that rapid resorption of

b-tricalcium phosphate might impair the regenerative ability of
local bone, especially in the initial stage of bone healing [39]. The
microstructure of the used b-TCP has important influence on the
osteogenic effects [40]. This has recently been confirmed by Fellah
and colleagues. HA/TCP with different micropores was evaluated in
a goat critical-defect model [41]. Ceramics sintered at 1050  C
showed superior results when compared to ceramics sintered at
1200  C regarding bony ingrowth.
Recent in vivo human studies from van Hemert, investigating on
tricalcium phosphate granules and rigid wedges, Koshino, using
a porous hydroxyapatite wedge and Gaasbeek, using b-tricalcium
phosphate, concluded that the use of HA alone or in combination
with TCP is recommendable [20–23]. In these studies the histo-
logical and radiographical findings showed a good resorption of the
supporting material with complete incorporation and remodelling
into new bone with increasing bony consolidation during follow up
between 6 and 25 months. Specimens of b-tricalcium phosphate
received by biopsy at different times showed increased osteogenic
features with vascular formation and prominent bone formation
[42]. Unfortunately these studies have no unaugmented control
group to compare the time range needed for bone remodelling
between augmented and unaugmented osteotomies.
The high caseload with HTO patients in our department gave us
more experience and follow up results regarding the convenience
of supporting material, especially of HA/TCP and PRP. The HA/TCP
wedge utilised by us consists of 60% micro–macroporous biphasic
hydroxyapatite and 40% tertiary b-phosphate (Fig. 3). The average
total porosity is 65–75%, whilst two different sizes of porosity are
found within this material. The microporous part consists of pores
with a diameter less than 10 mm. The macroporous part consists of
pores with a diameter between 300 mm and 600 mm (same as
autograft macropores).
In our patient population, systematically followed-up (ran-
domized controlled study; n ¼ 60 patients, three groups: no aug-
mentation, HA/TCP, HA/TCP þ PRP), we found that all patients,
irrespective of treatment, with or without supporting material, had
considerable relief of knee joint pain and improved essentially in
walking ability after an average correction of the femurotibial angle
from 5.3  0.8 varus to 1.9  0.4 valgus. No significant clinical
Fig. 5. Radiographs of the right (A) and left (B) knees of a 54-year-old woman who had
differences were observed between augmented and non- painful bilateral medial osteoarthritis of the knee and was operated on the right side
augmented patients after one year. The visual-analog-pain scale without augmenting material and on the left side using a 7.5 mm HA/TCP wedge. (A, a)
(VAS) and the lysholm knee score improved significantly. If no Six weeks after surgery bony union begins at the osteotomy site with trabecular
augmentation was performed, partial bony union was observed continuity noted laterally and posteriorly. (b) Twelve months after surgery complete
bony union and trabecular bone formation within the osteotomy are visualized. (B, a)
roentgenographically at the site of osteotomy on average after six to Anteroposterior X-ray of the right knee six weeks after HTO with HA/TCP augmenta-
eight weeks, with callus formation noted lateral and posterior. tion (without PRP). Partial bony union with trabecular continuity laterally and poste-
Twelve months after surgery complete bony union within the riorly beside the HA/TCP wedge is visualized. (b) Twelve months after surgery the HA/
osteotomy was registered in all specimens (Fig. 5A). If supporting TCP wedges could be identified clearly with sharp bordered edges. No clear trans-
formation from HA/TCP to bone could be found radiographically.
material was used, union with callus formation lateral and poste-
rior beside the hydroxyapatite wedge was noted after six weeks
equally to unaugmented osteotomies. After 12 months the hy-
droxyapatite wedges could still be clearly identified with sharp not significant, we did not observe any screw breakage in patients
bordered edges (Fig. 5B). The histological examination after 12 with unaugmented osteotomies. From our experience we recom-
months during plate removal presented varying stages of bony mend augmentation for openings greater than 10 . Brouwer et al.
consolidation. The samples taken from unaugmented osteotomies too recommend augmentation with iliac crest for openings equal or
showed mature, lamelliform bone in full depth. In samples taken greater than 7.5 [13].
out of augmented osteotomies, the HA/TCP wedge remained un-
dissolved, presenting the same histological composition as on the 5. Platelet rich plasma/growth factors
date of insertion with partial bony ingrowth in between (Fig. 6).
Whilst no significant disadvantages regarding clinical outcome Another possibility to increase bony consolidation is the appli-
could be found between augmented and unaugmented osteoto- cation of growth factors. Over the last years, platelet rich plasma
mies, complications in terms of HA/TCP dislocation (one case) and (PRP) has been found out as a source of various growth factors [43].
screw breakage (two cases) were observed when supporting ma- PRP can be prepared in the operating theatre from 60 ml of anti-
terial was used. The collective of our recent study was too small to coagulated blood drawn from the patient as described in the
say decisively that the usage of supporting material causes cumu- operative technique. Before inserting the HA/TCP into the osteot-
lative difficulties. Even though the number of screw breakage was omy opening it is allowed to absorb the prepared PRP in a small
 S. Aryee et al. / Biomaterials 29 (2008) 3497–3502 3501

Fig. 6. (a) The specimens taken from unaugmented osteotomies show mostly newly formed cancellous bone. No fibrous ingrowth or signs of pseudoarthrosis could be detected
(specimen thickness 5 mm). (b) Showing a specimen from augmented osteotomy with HA/TCP. Prominent remnants of HA/TCP contained in newly formed bone and fibrous tissue
can be seen (specimen thickness of 5 mm). (c) Specimen showing HA/TCP soaked with platelet rich plasma (specimen thickness of 100 mm). Bony as well as fibrous ingrowth can be
seen. Compare picture to empty HA/TCP wedge (inlet in Fig. 2, same magnification) to see missing resorption of the wedge after 12 months. (d) Ultra high power view showing
osteoclast activity in specimens treated with HA/TCP soaked in platelet rich plasma (specimen thickness of 5 mm). All images were stained with May-Gruenwald giemsa. * marks
newly formed bone; arrow marks fibrous tissue. Bar size: (a) and (b) 1000 mm, (c) 400 mm, and (d) 100 mm.

dish. The remaining PRP is injected into the opening prior to the replacement. Our and other results showed that the high tibial
application of the HA/TCP wedge. The main active components of opening-wedge osteotomy with locking plate fixation, for selected
PRP are autologous growth factors contained in the platelets like patients with osteoarthritis, is a reproducible and highly recom-
PDGF, TGF-a, TGF-b, FGF and EGF [43,44]. Some studies have shown mendable method, leading to significant improvements in clinical
beneficial effects on bone regeneration [45,46]. Okuda and col- outcome [3–5,16,51]. We favour the high tibial opening-wedge
leagues concluded that the combination of HA and PRP leads to osteotomy instead of the closing-wedge osteotomy. The former
better outcome in the treatment of intrabony periodontal defects in method allows multiplanar correction, possible damage to the
humans than HA alone, although both groups improved signifi- peroneal nerve is decreased and lateral muscle detachment avoi-
cantly over 12 months [45]. In a randomized human study, the ded. The use of locking plates reduced the non-union or mal-union
application of PRP to lyophilized bone graft increased osteogenic rate so that high tibial opening-wedge osteotomy became more
potential six weeks after high tibial osteotomy. However, one year convenient to a broader range of patients. Our radiological and
after the operation all patients showed complete clinical and histological findings demonstrate that HA/TCP scaffolds were able
functional evidences of healing [47]. We also observed this in our to promote bone ingrowth but showed no faster bony consolidation
study group. The addition of PRP did not affect the overall outcome or any other additional benefits compared to the non-augmented
after 12 months. Rai and colleagues noted improved outcome of osteotomy site after a period of time of 12 months. On the contrary,
PRP and tricalcium phosphate for segmental bone repair [25]. although if not significant, we observed slightly more complica-
There are, however, some potential drawbacks. As different tions after the usage of HA/TCP. The addition of PRP to HA/TCP
studies have shown, the addition of PRP to b-TCP [48], HA/TCP [49] scaffolds accelerated resorption and new bone formation of the
or collagen sponges [50] in different animal models did not induce wedge only insignificantly. In conclusion, the use of HA/TCP wedges
significantly more bone formation than controls alone. Further it is with or without PRP in opening-wedge osteotomy with an opening
difficult to retain enough PRP at the site of surgery to achieve high angle less than 10 is currently not a recommendable procedure
concentrations of growth factors. More research has to be done and must be precisely questioned in every case. More importantly,
before this method can be accepted universally in the operating one should seriously think of the advantages of stable osteosyn-
theatre outside controlled studies. thesis using the newer rigid locking plates, which led to signifi-
cantly improved outcome with less complication rate.
6. Conclusion
Acknowledgments
High tibial opening-wedge osteotomy as treatment for medial
osteoarthritis of the knee, especially for younger patients is The experimental results used to develop this leading opinion
a valuable alternative to total or unicompartimental knee joint paper were partly from the thesis of Dominik Stauber.
3502 S. Aryee et al. / Biomaterials 29 (2008) 3497–3502

References [27] Warden SJ, Morris HG, Crossley KM, Brukner PD, Bennell KL. Delayed- and
non-union following opening wedge high tibial osteotomy: surgeons’ results
from 182 completed cases. Knee Surg Sports Traumatol Arthrosc 2005;13:
[1] Jackson JP, Waugh W. Tibial osteotomy for osteoarthritis of the knee. J Bone
34–7.
Joint Surg Br 1961;43-B:746–51.
[28] Spahn G, Muckley T, Kahl E, Hofmann GO. Biomechanical investigation of
[2] Koshino T, Yoshida T, Ara Y, Saito I, Saito T. Fifteen to twenty-eight years’
different internal fixations in medial opening-wedge high tibial osteotomy.
follow-up results of high tibial valgus osteotomy for osteoarthritic knee. Knee
Clin Biomech (Bristol Avon) 2006;21:272–8.
2004;11:439–44.
[29] Dorsey WO, Miller BS, Tadje JP, Bryant CR. The stability of three commercially
[3] Bauer GC, Insall J, Koshino T. Tibial osteotomy in gonarthrosis (osteo-arthritis
available implants used in medial opening wedge high tibial osteotomy. J Knee
of the knee). J Bone Joint Surg Am 1969;51:1545–63.
Surg 2006;19:95–8.
[4] Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical
[30] De Long Jr WG, Einhorn TA, Koval K, McKee M, Smith W, Sanders R, et al. Bone
long-term study of eighty-seven cases. J Bone Joint Surg Am 1993;75:196–201.
grafts and bone graft substitutes in orthopaedic trauma surgery. A critical
[5] Staubli AE, De Simoni C, Babst R, Lobenhoffer P. TomoFix: a new LCP-concept
analysis. J Bone Joint Surg Am 2007;89:649–58.
for open wedge osteotomy of the medial proximal tibia – early results in 92
[31] Bauer TW, Muschler GF. Bone graft materials. An overview of the basic science.
cases. Injury 2003;34(Suppl. 2):B55–62.
Clin Orthop Relat Res 2000:10–27.
[6] Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP. Opening
[32] Tanaka T, Kumagae Y, Saito M, Chazono M, Komaki H, Kikuchi T, et al. Bone
wedge high tibial osteotomy: an operative technique and rehabilitation pro-
formation and resorption in patients after implantation of beta-tricalcium
gram to decrease complications and promote early union and function. Am J
phosphate blocks with 60% and 75% porosity in opening-wedge high tibial
Sports Med 2006;34:1262–73.
osteotomy. J Biomed Mater Res B Appl Biomater 2008.
[7] Imhoff AB, Linke RD, Agneskirchner J. Corrective osteotomy in primary varus,
[33] Gutierres M, Dias AG, Lopes MA, Hussain NS, Cabral AT, Almeida L, et al.
double varus and triple varus knee instability with cruciate ligament
Opening wedge high tibial osteotomy using 3D biomodelling bonelike mac-
replacement. Orthopade 2004;33:201–7.
roporous structures: case report. J Mater Sci Mater Med 2007;18:2377–82.
[8] Hohmann E, Bryant A, Imhoff AB. The effect of closed wedge high tibial
[34] DeSilva GL, Fritzler A, DeSilva SP. Antibiotic-impregnated cement spacer for
osteotomy on tibial slope: a radiographic study. Knee Surg Sports Traumatol
bone defects of the forearm and hand. Tech Hand Up Extrem Surg 2007;11:
Arthrosc 2006;14:454–9.
163–7.
[9] Coventry MB. Proximal tibial varus osteotomy for osteoarthritis of the lateral
[35] Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm
compartment of the knee. J Bone Joint Surg Am 1987;69:32–8.
after trauma: treatment with cement spacer and delayed cancellous bone
[10] Spahn G. Complications in high tibial (medial opening wedge) osteotomy.
grafting. J Trauma 1995;38:910–4.
Arch Orthop Trauma Surg 2004;124:649–53.
[36] Hernigou P, Ma W. Open wedge tibial osteotomy with acrylic bone cement as
[11] Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer P. Primary stability of
bone substitute. Knee 2001;8:103–10.
four different implants for opening wedge high tibial osteotomy. Knee Surg
[37] Dong J, Uemura T, Shirasaki Y, Tateishi T. Promotion of bone formation using
Sports Traumatol Arthrosc 2006;14:291–300.
highly pure porous beta-TCP combined with bone marrow-derived osteo-
[12] Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G. The high tibial osteotomy,
progenitor cells. Biomaterials 2002;23:4493–502.
open versus closed wedge, a comparison of methods in 108 patients. Arch
[38] Daculsi G Bone substitute with controlled bioactivity. Arthrex General
Orthop Trauma Surg 2005;125:638–43.
Information; 1999.
[13] Brouwer RW, Bierma-Zeinstra SM, van Raaij TM, Verhaar JA. Osteotomy for
[39] Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and
medial compartment arthritis of the knee using a closing wedge or an opening
graft resorption of autograft, anorganic bovine bone and beta-tricalcium
wedge controlled by a Puddu plate. A one-year randomised, controlled study. J
phosphate. A histologic and histomorphometric study in the mandibles of
Bone Joint Surg Br 2006;88:1454–9.
minipigs. Clin Oral Implants Res 2006;17:237–43.
[14] Stoffel K, Stachowiak G, Kuster M. Open wedge high tibial osteotomy: bio-
[40] Okuda T, Ioku K, Yonezawa I, Minagi H, Kawachi G, Gonda Y, et al. The effect of
mechanical investigation of the modified Arthrex osteotomy plate (Puddu
the microstructure of beta-tricalcium phosphate on the metabolism of
plate) and the TomoFix plate. Clin Biomech (Bristol Avon) 2004;19:944–50.
subsequently formed bone tissue. Biomaterials 2007;28:2612–21.
[15] Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament re-
[41] Fellah BH, Gauthier O, Weiss P, Chappard D, Layrolle P. Osteogenicity of
construction in varus angulated, anterior cruciate ligament-deficient knees. A
biphasic calcium phosphate ceramics and bone autograft in a goat model.
two- to seven-year follow-up study. Am J Sports Med 1993;21:2–12.
Biomaterials 2008;29:1177–88.
[16] Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of
[42] Ogose A, Kondo N, Umezu H, Hotta T, Kawashima H, Tokunaga K, et al. His-
valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003;11:
tological assessment in grafts of highly purified beta-tricalcium phosphate
132–8.
(OSferion) in human bones. Biomaterials 2006;27:1542–9.
[17] Jackson JP, Waugh W. The technique and complications of upper tibial
[43] Anitua E, Sanchez M, Orive G, Andia I. The potential impact of the preparation
osteotomy. A review of 226 operations. J Bone Joint Surg Br 1974;56:236–45.
rich in growth factors (PRGF) in different medical fields. Biomaterials 2007;28:
[18] Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of an-
4551–60.
terior and posterior iliac crest bone grafts in terms of harvest-site morbidity
[44] van den Dolder J, Mooren R, Vloon AP, Stoelinga PJ, Jansen JA. Platelet-rich
and functional outcomes. J Bone Joint Surg Am 2002;84-A:716–20.
plasma: quantification of growth factor levels and the effect on growth and
[19] Yacobucci GN, Cocking MR. Union of medial opening-wedge high tibial
differentiation of rat bone marrow cells. Tissue Eng 2006;12:3067–73.
osteotomy using a corticocancellous proximal tibial wedge allograft. Am J
[45] Okuda K, Tai H, Tanabe K, Suzuki H, Sato T, Kawase T, et al. Platelet-rich plasma
Sports Med 2008.
combined with a porous hydroxyapatite graft for the treatment of intrabony
[20] van Hemert WL, Willems K, Anderson PG, van Heerwaarden RJ, Wymenga AB.
periodontal defects in humans: a comparative controlled clinical study. J
Tricalcium phosphate granules or rigid wedge preforms in open wedge high
Periodontol 2005;76:890–8.
tibial osteotomy: a radiological study with a new evaluation system. Knee
[46] Aghaloo TL, Moy PK, Freymiller EG. Evaluation of platelet-rich plasma in
2004;11:451–6.
combination with anorganic bovine bone in the rabbit cranium: a pilot study.
[21] Koshino T, Murase T, Saito T. Medial opening-wedge high tibial osteotomy with
Int J Oral Maxillofac Implants 2004;19:59–65.
use of porous hydroxyapatite to treat medial compartment osteoarthritis of
[47] Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, et al. En-
the knee. J Bone Joint Surg Am 2003;85-A:78–85.
hanced tibial osteotomy healing with use of bone grafts supplemented with
[22] Koshino T, Murase T, Takagi T, Saito T. New bone formation around porous
platelet gel or platelet gel and bone marrow stromal cells. J Bone Joint Surg
hydroxyapatite wedge implanted in opening wedge high tibial osteotomy in
Am 2007;89:2413–20.
patients with osteoarthritis. Biomaterials 2001;22:1579–82.
[48] Tamura K, Sato S, Kishida M, Asano S, Murai M, Ito K. The use of porous beta-
[23] Gaasbeek RD, Toonen HG, van Heerwaarden RJ, Buma P. Mechanism of bone
tricalcium phosphate blocks with platelet-rich plasma as an onlay bone graft
incorporation of beta-TCP bone substitute in open wedge tibial osteotomy in
biomaterial. J Periodontol 2007;78:315–21.
patients. Biomaterials 2005;26:6713–9.
[49] Plachokova AS, van den Dolder J, Stoelinga PJ, Jansen JA. Early effect of
[24] Miller BS, Dorsey WO, Bryant CR, Austin JC. The effect of lateral cortex dis-
platelet-rich plasma on bone healing in combination with an osteoconductive
ruption and repair on the stability of the medial opening wedge high tibial
material in rat cranial defects. Clin Oral Implants Res 2007;18:244–51.
osteotomy. Am J Sports Med 2005;33:1552–7.
[50] Sarkar MR, Augat P, Shefelbine SJ, Schorlemmer S, Huber-Lang M, Claes L, et al.
[25] Rai B, Oest ME, Dupont KM, Ho KH, Teoh SH, Guldberg RE. Combination of
Bone formation in a long bone defect model using a platelet-rich plasma-
platelet-rich plasma with polycaprolactone–tricalcium phosphate scaffolds for
loaded collagen scaffold. Biomaterials 2006;27:1817–23.
segmental bone defect repair. J Biomed Mater Res A 2007;81:888–99.
[51] Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus
[26] Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus
gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint
medial opening wedge high tibial osteotomy on articular cartilage pressure of
Surg Am 2003;85-A:469–74.
the knee: a biomechanical study. Arthroscopy 2007;23:852–61.