Osteotomy of the Tibia and Fibula in the Treatment of Chronic Osteoarthritis of the Knee.

Nihil Scriptun Miraculi Causa OSTEOTOMY of the tibia alone as an operation simply to correct deformity at the knee was described and performed by Volkmann as long ago as 1875; at about the same time as Lister and MacEwan (1878) gave their description of the first supracondylar osteotomy. This operation is also mentioned in Orthopaedic Surgery (Jones & Lovett, 1929) in relation to the treatment of knock-knee and bow-leg deformity in adult patients who had suffered from rickets in childhood. This procedure, modified in that the bone is divided horizontally through the inner tuberosity just distal to the articular surface, has been advocated within quite recent years by Smillie (1946). It is also mentioned by Judet, Judet, Lagrange and Dunoyer (1954). My colleague G. E. Thomas (1964) also regards it as correct practice in patients whose painful arthritic knees show a valgus deformity and maintains that this deformity can be corrected by a tibial osteotomy alone. Osteotomy of the tibia combined with division of the fibula was first performed, to my knowledge, at the Royal Southern Hospital, Liverpool, from 1928 onwards. The surgeons who practised it at that time had usually to deal with deformity of the knee in adults, the result of childhood rickets. This was common in those times. They pointed out that correction of this deformity in adult life by femoral osteotomy, which was so successful in children, invited the rapid onset of pain and chronic degenerative change in the knee joint. They gave the reason that correction of the deformity above the knee joint altered the inclination of the axis of movement of that joint to the line of weightbearing in the leg as a whole; and that whereas a growing child could accommodate to this, an adult could not. Osteotomy below the knee makes no such alteration but corrects the position by the production of an equal and opposite deformity below the original one and leaves the axis of movement of the knee joint at the same inclination to the weight bearing line of the limb. The application of this procedure to the treatment of chronic osteoarthritis of the knee is of later date. It is described by Steindler (1940). As far as the series of patients quoted in this article is concerned the operation was first performed in 1941 with the single objective of correction of increasing deformity in painful and progressive degeneration of the knee. At that time certain authorities regarded this operation as dangerous because of the possibility of vascular complications and even gangrene of the limb, which had been observed to occur in certain fractures involving the tuberosities of the tibia and the proximal shaft of the fibula. This catastrophe need not be anticipated provided proper care is exercised. The rapid relief of pain observed in patients treated in this manner led to the increasing use of the operation. It is now also advocated by other authors (Jackson & Waugh, 1961) and a proportion of the patients described here have previously been reported elsewhere (Wardle, 1962).