Tuberosity-Sparing Anterior Opening-Wedge Tibial Osteotomy for Correcting Recurvatum: Effects on Functional Scores, Lower Limb Coronal Alignment, and Patellar Height

Abstract

Background: Symptomatic genu recurvatum (GR) continues to be a challenge for clinicians. Patients may present with pain, weakness, and instability, which can lead to significant functional impairment. Currently, there are few reports discussing the treatment options and clinical outcomes of patients with symptomatic GR.

Purpose/hypothesis: The main objective of this study was to present the radiographic and functional outcomes of tuberosity-sparing anterior opening-wedge tibial osteotomy (TAOWTO) for symptomatic GR. It was hypothesized that TAOWTO can adequately correct the deformity and allow patients to have symptomatic relief after the procedure without compromising patellofemoral joint function.

Study design: Case series. Level of evidence, 4.

Methods: This retrospective study was performed at a single, tertiary referral center. All patients underwent a TAOWTO performed by a single surgeon between January 2016 and January 2021. Pre- and postoperative radiographs were analyzed for posterior proximal tibial angle (PPTA), recurvatum angle, pertinent lower extremity alignment parameters, and patellar height. All patients were clinically evaluated pre- and postoperatively for the Knee injury and Osteoarthritis Outcome Score (KOOS).

Results: After exclusions, 30 patients were included in the study. The mean age at the time of surgery was 22.6 ± 3.5 years, and the mean follow-up duration was 25.2 ± 7.8 (median, 35; range, 20.1-27.5) months. The causes of recurvatum were posttraumatic (53.3%), posterior cruciate ligament insufficiency (16.7%), anterior epiphysiodesis (6.7%), and soft tissue laxity (23.3%). The PPTA (in degrees) before and after the surgery was 94.2 ± 2.7 and 85.8 ± 1.8, respectively (P < .0001). There were no significant changes in hip-knee angle, medial proximal tibial angle (in degrees) and Caton-Deschamps index. In addition, the recurvatum angle was significantly reduced (12.0 ± 2.9 vs 2.9 ± 1.7; P < .0001). All domains of KOOS (Pain, Symptoms, Activities of Daily Living, Quality of Life, and Sport and Recreation) were significantly improved after the surgery (P < .0001).

Conclusion: TAOWTO was an effective surgical procedure for patients with symptomatic GR. It reliably corrected the PPTA and recurvatum angle, while maintaining the native coronal alignment and patellar height. Patients also had significant symptomatic relief and functional improvement in both daily and sports activities.

Keywords: anterior opening-wedge tibial osteotomy; genu recurvatum; high tibial flexion osteotomy; hyperextension; slope-correcting osteotomy.

Figure 1.

Patient inclusion diagram. TAOWTO, tuberosity-sparing anterior opening-wedge tibial osteotomy; DLO, double-level osteotomy.

Figure 2.

Radiographs before and after correction. (A) Preoperative lateral view of the left tibia, showing estimation of the posterior proximal tibial angle based on the best-fit circle method using the full anatomic axis of the tibia. (B) Postoperative lateral view of the left tibia, showing anterior opening-wedge tibial osteotomy fixed with the plate (Newclip Technics) and staples (Dupuy Synthes) as well as estimation of the posterior proximal tibial angle based on the best-fit circle method.

Figure 3.

The surgical approach in a left knee. (A) The knee position before surgery. The patient had a posterior sag sign, which raised concerns for posterior cruciate ligament insufficiency. (B) A 10-cm incision was planned starting just proximal to the tibial tuberosity (black star indicates patellar tendon). (C) The patellar tendon (black star) was dissected from the medial and lateral capsule. Then, subperiosteal flaps were raised to expose the proximal tibia medially and laterally.

Figure 4.

Anterior opening-wedge osteotomy cuts. (A) Fluoroscopic image, showing 2 guide wires inserted to template high tibial osteotomy under fluoroscopy and directed from distal to proximal toward the hinge point. The posterior hinge was distal to the insertion of the posterior cruciate ligament on the tibia. (B) The osteotomy cut was performed under the guide of the pins, the black star indicated the hinge protective wire. (C) A fluoroscopic image shows the cuts guided by the pins. The hinge protective wire (black star) was inserted from the distal tibial tuberosity to the hinge point.

Figure 5.

Intraoperative fluoroscopic images of osteotomy and plate fixation. (A) The opening of the osteotomy site with a metal block. (B) Insertion of an allograft bone block into the gap. (C) The locked plate fixation was applied on the medial side and staple fixation on the lateral side.

Figure 6.

(A, B) Anteroposterior and lateral radiographs of a single patient preoperatively. (C, D) Six months postoperatively; and (E, F) 18 months postoperatively after hardware removal.