Proximal Tibia Medial Open Wedge Osteotomy Using Puddu Plate for Treatment of Genu Varum in Adolescent and Young Patients

Mohammed Elattar*

Citation: Proximal Tibia Medial Open Wedge Osteotomy Using Puddu Plate for Treatment of Genu Varum in Adolescent and Young Patients. American Research Journal of Orthopedics and Traumatology. 2018; 3(1): 1-7.

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Purpose: Medial open wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure for patients who have medial compartmental osteoarthritis of the knee with varus deformity of the limb. The abnormal load on the medial compartment of the knee is directed to the lateral compartment with this procedure. A gap occurs on the proximal tibia while providing adequate correction. Filling this gap with bone grafts or synthetic materials has gained wide acceptance for preventing bone union problems or osteotomy site collapse. The aim of this study is to report our results of MOWHTOs performed without any bone graft or any other synthetic materials.

Patients and Methods: We evaluated 20patients MOWHTOs that have been performed between 2014 and 2018. Age of the patients ranged from 18 to 40. Fifteenpatients were females and five of them were males. The follow-up time was 12 months.

Results: All osteotomies united without loss of correction. The meanbone union time was 12.8 weeks. We did not have any major complication regarding the technique.

Conclusion: The results of our study have shown that we can achieve satisfactory and good results by performing MOWHTO procedure without using any bone grafts or synthetic materials.

Keywords: High tibial osteotomy, medial, open- wedge,puddu plate


High tibial osteotomy is a procedure for young and active patients who have medial unicompartmental osteoarthritis of the knee and varus malalignment of the limb [1]. The aim of this procedure is to relocate the abnormal weight- bearing load from the medial arthritic compartment to the healthy lateral compartment. Medial opening-wedge technique is one of the high tibial osteotomy procedures [2]. There are numerous fixation techniques, bone grafts or augmentation materials for filling the gap on the osteotomy site [3–7]. Stable fixation is necessary for healing of the osteotomy and reducing the risk of non-union and loss of correction [8]. Stainless steel plates with conventional screws are first-generation plating systems. Current systems that provide more mechanical stability are locking titanium plates and locking screw designs [9– 12]. It has been theoretically thought that bone union problems or correction loss due to osteotomy defect are the disadvantages of medial opening-wedge high tibial osteotomy (MOWHTO) [13]. Filling the osteotomy defect with bone grafts or any other materials for preventing these theoretical disadvantages has gained wide acceptance. There are various materials for filling the osteotomy defect (autograft, allograft, xenograft, bone substitute, acrylic cement and ceramic spacer) [14, 15]. Autologous bone graft has been accepted as ‘gold standard’ for this purpose [16].

The aim of this study was to report our results of MOWHTO performed without any bone graft or any other synthetic materials.

Our study includes 20 MOWHTOs of 38 patients that have been performed between June 2014 and February 2018. The same surgeon performed all osteotomies. There were 15 females and five males aged ranging from 18 to 40. The inclusion criteria was patients to whom MOWHTO was performed for genu varum without any bone grafts and any synthetic materials. The indication for surgery was genu varum deformity and pain localized on medial knee compartment of the knee. The preoperative exclusion criteria were symptomatic osteoarthritis of the lateral or patellofemoral compartments, severe osteoarthritis, varus deformity of more than 15, range of motion less than 90 and flexion contracture of more than 10. We evaluated clinical and radiologic process of each patient. Follow-up clinical and radiologic examinations were performed at the third week, sixth week, third month, sixth month, and 1 year.

Surgical Procedure
The patient was placed in a supine position on the operative table. The C-arm of an image intensifier was set up on the same side of the knee and opposite to the surgeon.The osteotomy procedure is performed through a vertical anteromedial incision extending 7 to 8 cm distally and parallel to the tibial axis (Fig. 1B).

Sharp dissection is carried out beneath the skin incision to the pes anserinus and superficial medial collateral ligament (MCL), and detached from the tibia using Cobb elevator. Then, both pes anserinus and superficial MCL are retracted posteriorly and the posterior surface of the tibia at the level of the osteotomy is exposed. A retractor is placed dorsally in the osteotomy line (Fig. 3). This procedure provides complete exposure of the anteromedial surface of the tibia. The anterosuperior attachment site of the patellar tendon is exposed and a radiolucent retractor is placed under the patellar tendon.


Under fluoroscopic control, a guide pin is drilled from the medial attachment site of the patellar tendon to the point 1.5 cm below the lateral joint line, and 1 cm medial to the lateral cortex. This guide pin is roughly directed toward the fibular head. Another guide pin is drilled parallel to the first pin and tibial posterior slope.

A cutting plate is placed through 2 guide pins, and the osteotomy is started 1 mm above the attachment site of the patellar tendon. A radiolucent retractor is used to protect the patellar tendon. A bone saw is used to cut 2 to 3 cm of the medial site of the tibia. Then, osteotomes are used to cut the tibia 1 cm medial to the lateral cortex (Figs. 1C). If the osteotomy is completed, it will easily open the osteotomized site. If not, anterior and/or posterior cortex is not completely cut. Next, the opener is inserted and gradually opened until desired correction. A Puddu plate (Arthrex Inc., Naple, FL) is placed into the osteotomy site (Figs. 1D). Plate positioning is important; if a plate is placed anteriorly, the tibial posterior slope will be increased.5

Postoperative Period

Early postoperative AP and lateral X-rays were taken (Fig. 3). Isometric quadriceps and active ankle exercises were started on the same day. Straight leg raising was started on the first day after surgery. For the next 3 weeks, patients were only allowed to move their knee from 0 to 30 of flexion in the hinge brace without weightbearing: After the first control at the end of the third week, patients were allowed to flex their knees up to 90 in the brace and also partial weight-bearing with crutches or walker was allowed as tolerated. Brace was removed and full flexion was stimulated after the second control that has been per- formed at the end of the sixth week, and also, radiologic evaluation was performed. Full weight-bearing was allowed after radiographic evaluation at the second control. Another patient’s radiographs demonstrating the full union of the bone without loss of correction at the sixth month (Figs. 3).


All osteotomies united without early loss of correction at the end of the sixth month (Fig. 3). Mean time for bone union was 16.8 weeks (14-24). There was not any major complication. All of our patients were able to stand and walk on their operated legs 6 months after the procedure.