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Aspects of Current Management: J.-M. Brinkman, P. Lobenhoffer, J. D. Agneskirchner, A. E. Staubli, A. B. Wymenga, and R. J. van Heerwaarden Osteotomies around the knee: PATIENT SELECTION, STABILITY OF FIXATION AND BONE HEALING IN HIGH TIBIAL OSTEOTOMIES J Bone Joint Surg Br 2008; 90-B: 1548-1557 [Abstract] [Full text] [PDF]

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Osteotomies around the knee - stimulation of bone healing in opening-wedge osteotomies

A. Ludwig Meiss   (14 January 2009)

Osteotomies around the knee - stimulation of bone healing in opening-wedge osteotomies 14 January 2009
A. Ludwig Meiss, Orthopaedic Surgeon, Professor emeritus University Medical Center Hamburg-Eppendorf, Germany Send letter to journal: Re: Osteotomies around the knee - stimulation of bone healing in opening-wedge osteotomies meiss{at}uke.uni-hamburg.de A. Ludwig Meiss	Sir, In the article by Brinkman et al the details of opening-wedge osteotomies with fixation by an angle-stable locking plate are well described. Due to the gap a period of bone healing up to one year is expected. Accordingly, removal of the implant is not advised before one and a half years after osteotomy. The question arises as to how the bone healing can be promoted. The authors mention the option of filling the defect with porous tri-calcium phosphate or autologous grafts, in particular in gaps of more than 20 mm. However, no prospective randomised trials have yet been published that compare the various filling materials with no filling at all. Standard autologous cancellous bone grafting is not being considered for routine use. May I suggest the following: In this particular situation for which Lexer1 coined the term "ersatzkräftiges Lager" (site/bed of high osteogenic potency) the following ancillary procedures can help to stimulate bone healing and reduce the time needed for consolidation by many months: 1. Moving pieces of cancellous bone from the proximal and the distal osteotomy surface into the wider part of the gap. 2. Filling of the gap with thin chips/slivers/shavings of cortical bone (optimal thickness 0.5 - 1.0 mm) obtained with an osteotome from the adjacent meta- and diaphyseal cortex. These procedures are less laborious than standard cancellous bone grafting and, of course, can be favourably combined. The second procedure is supported by my studies in the past on the osteogenic potential of cortical bone particles,2,3 and also by a recent study published in this journal.4 A.L. Meiss, Orthopaedic Surgeon, Professor Emeritus, University Medical Center, Hamburg-Eppendorf, Germany. 1. Lexer E. Die freien Transplantationen. II. Teil. Neue Deutsche Chirurgie, 26b, Enke, Stuttgart, 1924. 2. Meiss L, Delling G. Stimulation of bone regeneration by fragmented cortical bone and porous calcium phosphate ceramics (tricalcium phosphate and hydroxyapatite) - An experimental study and preliminary clinical results. In: Willert H-G, Heuck FHW, eds. Neuere Ergebnisse in der Osteologie. Heidelberg: Springer-Verlag, 1989:619-31. 3. Meiss L. Experimentelle Untersuchungen und klinische Ergebnisse zur Stimulation der Knochenregeneration mit zerkleinerter Kortikalis und porösen Kalziumphosphatkeramiken (Trikalziumphosphat und Hydroxiapatit). Hefte zur Unfallheilkunde, A.H. Huggler/E.H. Kuner (Hrsg.), Berlin Heidelberg: Springer-Verlag, 1991;216:85-97. 4. Hammer TO, Wieling R, Green JM, et al. Effect of re-implanted particles from intramedullary reaming on mechanical properties and callus formation: a laboratory study. J Bone Joint Surg [Br] 2007;89-B:1534-8.