The advantages of circular external fixation used in high tibial osteotomy (average 6 years follow-up)

Salvage Algorithm for Deep Surgical Site Infections after HTO with Unstable Bone Situation Using a Hexapod System - Primary Results

The incidence of deep surgical site infections following high tibial osteotomy (HTO) ranges between 0.4 to 4.7%. It is a severe complication with a high risk for poor clinical outcome. The aim of this study was to proof that a salvage algorithm for infected HTO with unstable bone situation leads to an infection-free status and bone union of the osteotomy and that correct limb alignment can be restored with good knee function.The study included seven patients with peri-implant infections following HTO. Infections occurred 83 ± 58.9 days (range: 24-191) after HTO. All patients underwent the "RESTORE" algorithm: patients received (1) REmoval of the HTO hardware and extensive debridement; (2) the osteotomy was STabilized with a hexapod external fixator (Taylor Spatial Frame, TSF); (3) the osteotomy gap was Opened; and (4) the alignment was REconstructed using the TSF, aiming for the intended limb alignment of the initial HTO. Patient-reported outcomes were assessed 22-36 months after removal of the TSF.After 24 weeks (range: 11-35), an infection-free status and bone healing were achieved. In all cases, the limb was saved, and the previously targeted mechanical axis of the lower limb was restored. All patients reached full extension of the knee joint and at least 110° of flexion. For KOOS: Symptoms 67.86 ± 18.1, Pain 73.41 ± 16.58, ADL 78.99 ± 21.32, Sports 52.14 ± 25.96, and QoL 41.96 ± 24.66. OKS 35.71 ± 8.8, SF-12 Physical Health 38.89 ± 10.3, and SF-12 Mental Health 46.86 ± 13.76.The "RESTORE" algorithm is a safe and effective salvage procedure. The concept allows for saving the limb and obtaining the previously planned limb alignment. Patient-reported outcome measures showed slightly lowered values than healthy samples, but substantially better values than patients awaiting HTO. Due to the possibility of initial full weight-bearing, the risk of higher morbidity caused by immobilization is minimized.

Lateral closing wedge high-tibial osteotomy is a long-lasting option for patients under the age of 55 with medial compartment osteoarthritis

Purpose

Assess the survival of the closing wedge high tibial osteotomy (CWHTO) with failure defined as progression to total knee arthroplasty (TKA) and perioperative complications.

Methods

Patients undergoing CWHTO in a single centre were included in this study. The patient's demographics, operative data and patient-reported outcome measures were collected from the medical records. The outcomes assessed were progression to TKA, complications and patient-reported outcome measures. The Australian joint registry was used to assess which patients progressed to TKA. A binary logistics regression is used to determine if any of the collected factors increase the likelihood of conversion to arthroplasty. Survival analysis is conducted using a Kaplan-Meier survivorship analysis with failure defined as progression to TKA.

Results

Three hundred and fifty-four (244 males and 110 females) patients were included in the study. The average age of the group was 51 years with an average follow-up of 18 years. Patients under the age of 55 had a lower rate of progression to TKA. At 15 years, the rate of progression to TKA was 64% and 85% for those under the age of 55 and over 55, respectively. The complication rate was 6% without any peroneal nerve palsies.

Conclusion

CWHTO is a good surgical option particularly when indicated in patients under the age of 55. Additionally, this technique results in a low overall complication rate with an absence of the often-feared complication of peroneal nerve palsy.

Level of Evidence

Level III, Retrospective study.

High Tibial Osteotomies for the Treatment of Osteoarthritis of the Knee

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A high tibial osteotomy (HTO) is a joint-preserving procedure that can be used to treat symptomatic unicompartmental cartilage disorders in the presence of limb malalignment.

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Appropriate patient selection and careful preoperative planning are vital for optimizing outcomes.

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Based on past literature, correction of varus malalignment to 3° to 8° of valgus appears to lead to favorable results. Recently, there has been growing awareness that it is important to consider soft-tissue laxity during preoperative planning.

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Although there has been a recent trend toward performing opening-wedge rather than closing-wedge or dome HTOs for unicompartmental osteoarthritis, current data suggest that all 3 are acceptable techniques with varying complication profiles.

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Based on current evidence, an HTO provides pain relief, functional improvement, and a high rate of return to sport, with reported survivorship ranging from 74.7% to 97.6% and 66.0% to 90.4% at 10 and 15 years, respectively.

Long-term results of the subtubercle tibial osteotomy using the circular external fixator for medı̇al compartment osteoarthrı̇tı̇s of knee

BACKGROUND

We evaluated the long-term clinical and radiographic outcomes of patients who underwent subtubercular tibial osteotomy (STO) with Ilizarov external fixation used for high tibial osteotomy for medial knee osteoarthritis (MKOA).

METHODS

Between October 2003 and December 2011, 42 knees of 40 patients who had undergone STO with Ilizarov external fixator with a diagnosis of MKOA were evaluated. Survival analysis was performed by examining the duration of total knee arthroplasty (TKA). Clinical and radiological variables were collected at the time of admission after removal of the fixator and at outpatient follow up.

RESULTS

Mean age was 49.3 ± 5.68 (range 37-61) years, mean postoperative follow up time was 14.22 ± 2.93 (range 9-18) years, and mean fixator duration was 14.6 (range 13-20) weeks. Survival analysis showed 100% at 5 years, 95.2% at 10 years and 88.1% at 15 years. Clinical examination of the patients showed significant improvement in American Knee Society score (KSS), KSS functional score and Oxford Knee Score (OKS) score (P = 0.005). In the study, it was observed that the patients' knee osteoarthritis had progressed over time. On examination, radiographic measurements including mechanical axis deviation, medial proximal tibial angle, femorotibial angle, and joint line alignment angle improved significantly after deformity correction (P = 0.001).

CONCLUSION

STO using the Ilizarov method offers long-term survival. It provides effective treatment in young patients with isolated MKOA. Achieving the desired amount of correction in the coronal and sagittal planes can be presented as a surgical technique for the treatment of MKOA as an effective method in clinical and radiological correction.

Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis

Osteoarthritis causes joint pain and functional disorder, of which knee osteoarthritis is the most common. Nowadays, clinically effective treatments mainly include conservative treatment, arthroplasty, and osteotomy. However, conservative treatment only offers symptomatic relief and arthroplasty is limited to the patients with a moderate to severe degree of osteoarthritis. For relatively young patients who require greater knee preservation, a surgical treatment with low operation trauma and revision rate is needed. Osteotomy around the knee, based on the notion of “knee preservation,” has been chosen as an alternative surgical treatment. Cutting and realigning the bones corrects the mechanical line of lower limb force bearing. As such, osteotomy around the knee retains normal anatomical structure and obtains good functional recovery of the knee joint. The techniques of osteotomy around the knee includes anti‐varus deformity and anti‐valgus deformity osteotomy, aiming to reallocate the force bearing in the compartment of the knee joint. By choosing the surgical section of the lower limbs, the osteotomy around the knee can achieve the correction of mechanical axis, such as the high tibial osteotomy (HTO), proximal fibular osteotomy (PFO), and distal femur osteotomy (DFO). Numerous modified techniques have been developed to meet the demands of patients based on traditional methods. These modified osteotomy have their own advantages and indications. This paper aims to guide clinical treatment by reviewing different types of osteotomies, and their effects, that have been studied and applied widely in clinical practices.

Dome-shaped high tibial osteotomy with semi-circular Ilizarov pin fixator: Mid- to long-term results of a novel technique

BACKGROUND

The aim of this study was to assess the clinical and radiological results of the dome-shaped high tibial osteotomy (HTO) which was fixed with a novel construct comprised of semi-circular Ilizarov frames and pins.

METHODS

The patients with at least five years of follow-up were evaluated. One-hundred and thirty-two knees of 114 patients were included in the final analysis. The clinical evaluation included range of motion and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Anatomical femorotibial angle (aFTA), anatomical medial proximal tibial angle (aMPTA), tibial slope and Insall-Salvati ratio were calculated on standard weight-bearing radiographs.

RESULTS

The average aFTA was improved from 1.6° varus to 8.7° valgus (P < 0.001). The average WOMAC score (P < 0.001) and flexion value (P = 0.014) were improved at the latest follow-up (WOMAC: 17.2, flexion: 142.5) compared with the preoperative period (WOMAC: 59.6, flexion: 129.2). The sagittal radiological parameters were not significantly affected. The five-year survival was 96.2%, and 10-year survival was 83.3%.

CONCLUSIONS

The semi-circular Ilizarov pin construct provided satisfactory outcomes both clinically and radiologically at mid- to long-term follow-up.

Changes in lower limb alignment and their effect on the functional outcome after treatment of varus degenerative OA knee by hemicallotasis using modular dynamic HTO fixator

OBJECTIVE

High tibial osteotomy (HTO) is an established procedure to treat medial compartmental osteoarthritis (OA) knee associated with varus deformity. It is well documented that precise correction of deformity and maintenance of correction achieved is important to ensure long term good results. This study was undertaken to record changes in radiological parameters and its effect on the functional outcomes in first two years following HTO done for varus degenerative OA kneeby hemicallotasis technique using HTO fixator.

METHODS

31 patients meeting our inclusion-exclusion criteria who underwent HTO by hemicallotasis method using self-adjusting unilateral HTO fixator were included in the study. Their femoro tibial angle (FTA), mechanical axis %, Insall- Salvati ratio, proximal tibial antero-posterior slope and knee injury and osteoarthritis outcome Score (KOOS) were recorded preoperatively, postoperatively at the time of removal of fixator, at 1 year and at 2 years.

RESULTS

The FTA and mechanical axis significantly improved from a mean of 183.12⁰ and -3.26% respectively preoperatively to 173.38⁰ and 61.81% at the time of removal of fixator but subsequently showed significant deterioration to 176.06⁰ and 57.96% at 1 year and further insignificant deterioration to 176.16⁰ and 57.74 at 2 years. The KOOS improved from mean 56.61 preoperatively to 70.48 at the time of fixator removal and further improved significantly to 85.68 at 1 year but significantly deteriorated to 84.54 at 2 years. The Insall-Salvati ratio, tibial slope showed no significant change throughout the study. Conclusion: Though desired alignment can be achieved by using the fixator, we found a significant deterioration in achieved radiological parameters after removal of fixator adversely affecting the functional outcome which is a matter of concern.

[Clinical application of Taylor spatial frame in adjustment of lower extremity force line of knee medial compartmental osteoarthritis]

OBJECTIVE

To explore the safety and effectiveness of Taylor spatial frame (TSF) in the treatment of medial compartmental osteoarthritis (MCOA) of the knee and the adjustment of the lower extremity force line at the same time.

METHODS

The clinical data of 30 patients with MCOA who underwent high tibial osteotomy (HTO) between October 2016 and April 2017 were retrospectively analyzed. According to the different fixation methods, they were divided into external fixation group (TSF external fixation, 16 cases) and internal fixation group (locking steel plate internal fixation, 14 cases). There was no significant difference between the two groups in gender, age, side, disease duration, mechanical femur tibia angle (MFTA), and other general data ( P>0.05). The operation time and intraoperative blood loss of the two groups were recorded and compared; MFTA was used to evaluate the recovery of the lower extremity force line at last follow-up; Hospital for Special Surgery (HSS) score was used to evaluate the clinical effecacy before operation and at 2 weeks, 1 month, and 3 months after operation.

RESULTS

The operation time and intraoperative blood loss of external fixation group were significantly less than those of internal fixation group ( P<0.05). All patients were followed up 9-16 months, with an average of 12 months. There were 2 cases of delayed healing in the internal fixation group and 1 case of delayed healing in the external fixation group, and all healed after symptomatic treatment. All patients in the two groups had no complication such as needle infection, nonunion at osteotomy, osteomyelitis, and so on. At last follow-up, MFTA standard was used to evaluate the recovery of force line. The results of external fixation group were all excellent, while the results of internal fixation group were excellent in 10 cases and good in 4 cases. The difference between the two groups was significant ( Z=-2.258, P=0.024). The HSS scores in the two groups were significantly improved at each time point after operation, and gradually improved with time after operation ( P<0.05). The HSS score of the external fixation group was significantly higher than that of the internal fixation group ( t=2.425, P=0.022) at 3 months after operation; and there was no significant difference between the two groups at other time points ( P>0.05).

CONCLUSION

TSF has unique advantages in HTO treatment of MCOA patients and correction of lower extremity force line, such as shorter operation time, less bleeding, firm fixation, and less complications. It can accurately adjust the lower extremity force line after operation and has good effectiveness. It is an effective and safe fixation method.

Biomechanical and Functional Improvements Gained by Proximal Tibia Osteotomy Correction of Genu Varum in Patients with Knee Pain

BACKGROUND

Mechanical axis malalignment contributes to abnormal forces across the knee joint. Genu varum, or increased medial mechanical axis deviation (MAD), increases force transmission and contact pressures to the medial compartment. With increasing MAD and femoral-tibial mechanical axis angle (MAA), contact forces within the medial or lateral compartment of the knee significantly increase with increasing deformity. This may lead to knee pain, further deformity, and medial compartment degenerative joint disease, which can interfere with participation in sports and diminish quality of life.

PURPOSES/QUESTIONS

We sought to evaluate patients with knee pain with bilateral genu varum and determine the effect of bilateral proximal tibial osteotomies on knee biomechanics, deformity correction, and functional outcomes.

METHODS

This was a single-center, prospective study of eight limbs in four patients. Consecutive patients presenting with knee pain and bilateral genu varum originating from the proximal tibia were included. All patients underwent staged bilateral proximal tibial osteotomies with gradual deformity correction with an external fixator. Subjects underwent a three-dimensional (3D) instrumented motion analysis during level walking. A 3D lower extremity model was built and bilateral knee frontal plane kinematics and kinetics during the stance phase of gait were determined. Radiographic analysis was performed including assessment of MAD, MAA, and medial proximal tibial angle (MPTA). Functional outcomes were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the 36-item Short-Form Survey (SF-36), the Lower Limb Questionnaire (LLQ), and a visual analog scale (VAS) for pain.

RESULTS

The average time in the external fixator for a single limb was 97 days. The average follow-up period was 310 days. All biomechanical outcomes significantly improved, including knee adduction angle (7.8° to 1.8°), knee adduction moments (first peak, - 0.450 to - 0.281 nm/kg, and second peak, - 0.381 to - 0.244 nm/kg), and knee adduction moment impulse (- 0.233 to - 0.150 nm s/kg). There was a significant improvement in MAA, MAD, and MPTA. All patients showed qualitative improvement in mean scores on VAS (11.8 to 0.0), LLQ (77 to 93), KOOS (64 to 84), and SF-36 (71 to 88).

CONCLUSION

These findings suggest that bilateral proximal tibial osteotomy may be effective in improving knee biomechanics during gait and correcting mechanical alignment in patients with bilateral genu varum. Patients also demonstrated improvement in functional outcome scores. This technique should thus be considered in patients with varus knee osteoarthritis in the setting of genu varum to alleviate symptoms and potentially decrease further clinical deterioration.

Clinical and radiological outcomes of high tibial osteotomy with combined fixator-assisted nailing and subtubercle tibial osteotomy

OBJECTIVE

The aim of this study was to assess the clinical and radiological results of our high tibial osteotomy technique combining fixator-assisted nailing and subtubercle tibial osteotomy in varus malalignment.

METHODS

This was a retrospective study of a consecutive series of 32 knees in 32 patients ('2 follow-up loss' 12 males and 18 females; mean age at the time of operation: 50.6±7.8 (36-62) years) operated on between 2014 and 2016. Radiographic and clinical measurements were assessed pre- and postoperatively. Kolmogorov-Smirnov, paired t and Wilcoxon rank tests were used in the statistical analyses.

RESULTS

The mean follow-up period was 36.1±8.15 (31-53) months, the mean duration of the hospital stay was 3.6±0.1 (2-6) days, and the mean Kellgren-Lawrence score was 2.4±0.6 (2-4). Time to bony union was an average of 16.17 (12-29) weeks. Compared to the preoperative mechanical medial proximal tibial angle, femorotibial angle and mechanical axis deviation measurements, all the postoperative values showed significant changes (p<0.01). However, there was no statistical difference between the preoperative and postoperative tibial slopes (p>0.05), and the postoperative Caton-Deschamps index did not show a meaningful change (p>0.05). The postoperative visual analog scale, Knee Society Score, and Modified Hospital for Special Surgery Knee Scoring System measures showed significant improvement compared to the preoperative values (p<0.01). The postoperative walking distance increased to 1137.50±845.1 meters, from 359.4±306.2 meters (p<0.01).

CONCLUSION

This percutaneous technique is minimally invasive, corrects the alignment in two planes, and does not affect patellar height. We believe that this technique could be a promising alternative to other knee preserving surgeries in correcting varus malalignment.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Evaluation of the external fixator TrueLok Hexapod System for tibial deformity correction in children

BACKGROUND

Tibial deformities are common in paediatric orthopaedic practice. Correcting multiplanar tibial deformities associated with lower limb length discrepancy can be challenging. Hexapod external fixation with gradual correction has been proven effective in this situation.

OBJECTIVE

To assess clinical and radiological outcomes of gradual tibial deformity correction using the external fixator TL-HEX™ (Orthofix) in children.

HYPOTHESIS

TL-HEX™ is effective in correcting tibial deformities in children.

PATIENTS AND METHODS

This multicentre retrospective study collected data from the medical files of 26 patients with 31 tibial deformities treated by gradual correction using TL-HEX™. The tibial deformities were due to congenital defects in 11 (35%) cases, Blount's disease in 9 (29%) cases, pseudo-achondroplasia in 4 (13%) cases, and other causes in 7 (23%) cases. Mean age at surgery was 11.9 years. In each patient, antero-posterior long leg radiographs obtained pre-operatively and at last follow-up were used to measure parameters including the mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), and leg length discrepancy (LLD).

RESULTS

The mean healing index was 39.3 days/cm (range, 32-58 days/cm). The overall complication rate was 61%, with 11 unplanned visits. Superficial pin tract infection was the most common complication. Significant decreases between the pre-operative and post-operative assessments occurred in mean MAD (from 32.1mm to 10.2mm, P<0.001) and mean LLD (from 36.8mm to 9.1mm, P<0.001). Patients who underwent proximal tibial osteotomy had a significant improvement in MPTA, from 80.6° to 88.5° (P=0.006).

DISCUSSION

This is the first clinical study specifically designed to assess outcomes of TL-HEX™ limb lengthening and deformity correction. MAD, MPTA, and LLD were significantly improved at last follow-up. MAD was greater than 10mm at last follow-up in only 11patients. The complication rate was similar to those reported with other external fixators. TL-HEX™ is effective in the management of tibial deformities in children.

LEVEL OF EVIDENCE

IV (retrospective study).

Opening wedge high tibial osteotomy using a monoaxial dynamic external fixator

PURPOSE

To prospectively assess midterm results in 37 patients (41 knees) who were treated with opening wedge high tibial osteotomy (OW-HTO) with the use of a monoaxial dynamic external fixator (MDEF) for medial knee osteoarthritis.

METHODS

Clinical and subjective evaluations were performed using the IKDC and KOOS evaluation forms and the modified Knee Society Clinical Rating System (KSS). Pin tract infections were evaluated according to Checketts-Otterburns classification. Radiographic evaluation included long-standing AP lower limb, standard lateral, Rosenberg and Merchant views.

RESULTS

Thirty-six patients (40 knees) were evaluated at a mean follow-up period of 7 years. Ten patients (25 %) developed a minor pin tract infection. Subjective KOOS and IKDC scores showed statistically significant improvement. Clinical evaluation with IKDC and KSS forms showed no patient with instability or a range-of-motion deficit worst than pre-operatively. At MDEF removal, the mechanical axis was on average 4.5° valgus; anatomical axis 6.8° valgus; the Mikulicz' line crossed the tibial plateau on average at 64 % of the width of the tibial plateau measured from medial; the posterior slope 5°; the metaphyseal varus 4.3°; and the Insall/Salvati ratio 1.02. At latest follow-up, five patients had a loss of correction of 1°-2° on mechanical axis and one patient had a loss of correction of 3° on mechanical axis and 4 % of mechanical axis on tibial plateau.

CONCLUSIONS

The use of a MDEF to perform an OW-HTO showed a good maintenance of correction achieved with satisfactory midterm outcome results in all patients but three who underwent total knee replacement. The only severe post-operative complication was one case of non-union in a heavy smoker.

LEVEL OF EVIDENCE

Prospective and therapeutic study, Level IV.

High Tibial Osteotomy for Medial Compartment Osteoarthritis: A Comparison of Clinical and Radiological Results from Closed Wedge and Focal Dome Osteotomies

This study aimed to evaluate the clinical and radiological results of closed wedge osteotomy (11 knees) and focal dome osteotomy (14 knees) in cases of high tibial osteotomy undertaken for varus knee with medial compartment osteoarthritis. Clinical evaluation was performed using the Knee Society Score and no significant difference was seen between the two groups at final follow-up. Radiological evaluation was made on the basis of the pre- and postoperative mechanical axis, postoperative movement of the tibial axis, loss of correction at final follow-up and patellar height measured using the Insall-Salvati index. Statistically significant differences were seen with focal dome osteotomy compared with closed wedge osteotomy in the Insall-Salvati index at final follow-up, the amount of correction loss and the change in tibial axis location. It is concluded that, in the treatment of medial compartment osteoarthritis by high tibial osteotomy, focal dome osteotomy is more beneficial than closed wedge osteotomy in not creating any additional deformity.

Comparison between results of high tibial osteotomy above and below tibial tubercle in relation to future total knee arthroplasty

This prospective study included 50 patients with medial compartment osteoarthritis and varus knees. Twenty-five patients had high tibial closed wedge osteotomy above the tibial tubercle (TT) (group I), and the other 25 had the osteotomy just below it (group II). The two groups were matched. The osteotomies in both groups were fixed with plates and screws. All patients were followed up radiographically and clinically for more than 12 months. Clinical and radiographic results of both groups are comparable. Regarding factors that will affect future knee arthroplasty (TKA), osteotomies below TT are more advantageous. That is because soft tissues and bony changes of the knees in group II are minimal, and the issue of slower union rates can be diminished by using rigid plate fixation.

Patella infera or patellar tendon adherence after high tibial osteotomy

PURPOSE

Alterations in patellar height after high tibial osteotomy are found in many instances. Fibrosis of the tendon is implicated as the cause of the mechanism of patella lowering. This study aimed to determine the relationship between the position of the patella and the histopathological findings at the patellar tendon after high tibial osteotomy.

METHODS

Nineteen knees in seventeen patients who were consecutively hospitalised for implant extraction are studied. All of the patients had previously undergone closing wedge osteotomy by the same surgeon at the same department. The median follow-up time is 15 months (range: 11-35). Five patients who all underwent high tibial osteotomy at the same time are also included in the study as a control group for histopathological evaluation. All of the patients are evaluated radiologically, patellar tendon biopsies are taken during the operation, and histopathological analyses are performed.

RESULTS

The shortening of the patellar tendon is statistically significant (P < 0.05). The severity of the vascularisation, inflammation, and fibrotic change observed at the distal part of the tendon is evident. However, there is no statistically significant correlation between these findings and the degree of shortening.

CONCLUSIONS

The shortening of the tendon occurs as a result of adherence in the distal part of the tendon. It would appear that it is this shortening that causes the difficulties encountered during arthroplasty surgery of osteotomy patients, and not patella infera.

Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction

PURPOSE

We sought to determine survival and clinical outcomes of high tibial osteotomy (HTO) with or without articular cartilage surgery and/or meniscal allograft transplantation in patients with medial compartment chondral pathology, varus malalignment, and/or meniscal deficiency, whether there is any difference in survival or clinical outcome between these patient cohorts, and whether there is any difference between opening- (OWHTO) and closing-wedge (CWHTO) techniques.

METHODS

A systematic review of multiple medical databases was performed using PRISMA guidelines. Study quality was assessed via modified Coleman Methodology Scores (MCMS).

RESULTS

Sixty-nine studies were included (4557 subjects). MCMS rating was overall poor. Mean follow-up was 7.1 years. Mean subject age was 53 years. Survival of isolated HTO was 92.4%, 84.5%, 77.3%, and 72.3% at 5, 10, 15, and 20 years of follow-up. At 5 years of follow-up, HTO with articular cartilage surgery had significantly greater survival (97.7%) than either isolated HTO (92.4%) or HTO with MAT (90.9%). Isolated HTO, HTO with articular cartilage surgery, and HTO with MAT all significantly improved subjective and objective clinical outcome scores. At two years of follow-up, survival was significantly greater following OWHTO (98.7%) versus CWHTO (96.7%). However, at all other time points with or without combined articular cartilage surgery and/or MAT, there was no significant survival difference between the techniques.

CONCLUSIONS

Survival and clinical outcomes of isolated HTO were excellent at short- and mid-term follow-ups, but deteriorated with time. HTO with concomitant procedures also demonstrated excellent early survival and clinical outcomes that deteriorated with time (up to 10 years).

The impact of a high tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis

PURPOSE

Both high tibial valgus osteotomy (HTO) and unicompartmental medial knee arthroplasty (UKA) are established methods for the treatment for moderate stages of OA. This is the first global meta-analysis to compare the long-term effects of both methods regarding survival, outcomes and complications of total arthroplasty.

METHODS

Literature research was performed using established medical databases: MEDLINE (via PubMed), EMBASE (via OVID) and the Cochrane register. Criteria for inclusion were as follows: English or German papers, a clinical trial with a clear description of survival, an outcome evaluation using a well-described knee score and a follow-up >5 years. Statistical analysis was performed using the special meta-analysis software called "Comprehensive Meta Analysis" (version 2.0; Biostat, Englewood, NJ, USA).

RESULTS

Final meta-analysis after the full-text review included 46 studies about valgus HTO and 43 studies about medial UKA. There were no significant differences between valgus HTO and medial UKA in terms of the number of total required replacements. After a 5- to 8-year follow-up, 91.0% of the valgus HTO patients and 91.5% of medial UKA patients did not need a total replacement. This value was 84.4% for valgus HTOs and 86.9% for medial UKAs after a 9- to 12-year follow-up. Mean survival time to TKA was 9.7 years after valgus HTO and 9.2 years after medial UKA. Clinical outcome was significantly better after medial UKA in a 5- to 12-year follow-up. After more than 12 years, results were comparable in both groups. No significant differences were seen in the complication rates.

CONCLUSIONS

This meta-analysis aimed to find the advantages and disadvantages of two established methods for the treatment for medial compartment knee osteoarthritis. Valgus HTO is more appropriate for younger patients who accept a slight decrease in their physical activity. Medial UKA is appropriate for older patients obtaining sufficient pain relief but with reduced physical activity.

LEVEL OF EVIDENCE

II.

The treatment of high tibial osteotomy non-union with the Ilizarov external fixator

To evaluate the results of the Ilizarov external fixator in the treatment of non-union post-high tibial osteotomy (HTO). Five non-unions, in four patients, following HTO were treated by Ilizarov fixation. Clinical outcome was assessed pre- and post-operatively by the Knee Society Clinical Rating System (KSCRS). Radiological analysis assessed bone healing pre- and post-operatively and measured proximal tibial alignment. All cases healed with a mean time of 25 ± 3 weeks (Mean ± SD) (range, 24-30 weeks) in the fixator. The clinical and radiological outcome improved in all cases. Four knees were initially in excessive varus and underwent correction of alignment, as measured by medial proximal tibial angle (MPTA), from 75.5° ± 8.4° (mean ± SD) to 90.2° ±  2.7° (normal range, 85°-90°). One patient was in excessive valgus and had a correction of MPTA from 100° to 87°. The KSCRS knee score improved from 35.6 ± 10.8 to 86.6 ± 13.9 (mean ± SD) (normal score = 100) and the functional score from 37.8 ± 11.8 to 85.4 ± 10.5 (mean ± SD) (normal score = 100). The Ilizarov technique is a minimally invasive method that produces excellent clinical, radiological and functional outcomes.

Does Langenskiold staging have a good prognostic value in late onset tibia vara?

BACKGROUND

Although many literature studied the effect of many factors on the prognosis of the early-onset Blount disease, studies that were written on the prognostic factors affecting late onset tibia vara are still limited.

PURPOSE

The aim of this study is to evaluate the prognostic value of the Langenskiold classification system for late onset tibia vara.

METHODS

Twenty children from the Sporting Health Insurance Student Reference Hospital-Alexandria, with a diagnosis of late onset tibia vara were evaluated for the effect of the Langenskiold staging system on the prognosis after they all had been treated by gradual correction by Ilizarov technique using the so called "juxta-articular hinge assembly" after a mean follow-up period of 4.9 years (range : 4-6, SD 0.75).

RESULTS

The difference in varus recurrence rates between the "low grade group" and "high grade group" was found to be statistically significant (p = 0.008) as will be discussed later. There was no statistically significant relation between the age of the patients at the time of operation, sex, length of the follow up period and the degree of pre-operative varus deformity angle (DA) and the recurrence (p > 0.05).

CONCLUSION

We concluded that Langenskiold staging system is a reliable, reproducible and a good prognostic factor for late onset tibia vara.

Proximal tibial osteotomies for the medial compartment arthrosis of the knee: a historical journey

Several proximal tibial osteotomy techniques for the medial compartment arthrosis of the knee are described and traced in their development. These techniques are of the closed wedge, dome and open wedge types. We detail the differences in planning and surgery as well the need for different fixation devices. This historical and technical description will benefit those surgeons wishing to undertake the procedure as an alternative to joint replacement strategies.

High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results

We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9 patients with medial compartment OA and varus deformity underwent TSF application and medial opening wedge HTO. Pre- and post-operative Oxford knee scores, SF-12 and visual analogue pain scores were recorded along with radiographic outcomes. Median follow-up was 19 months (range 15–35). Mean age at operation was 49 years (range 37–59). The median time spent in the frame was 18 weeks (range 12–37). The mean preoperative Oxford knee score was 28.7. This improved to a mean of 35.4 post-operatively (P = 0.0142). 6 (67%) patients had a documented pin-site infection. With TKR as an end point, the survival rate of HTOs was 88.9% at a median of 19 months follow-up. This study demonstrates that in selected patients the TSF provides a viable treatment option for performing HTO in medial compartment OA with varus deformity.

Does the Taylor Spatial Frame accurately correct tibial deformities?

BACKGROUND

Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) and the Ilizarov method enable gradual realignment of angulation and translation in the coronal, sagittal, and axial planes, therefore, the term six-axis correction.

QUESTIONS/PURPOSES

We asked whether this approach would allow precise correction of tibial deformities.

METHODS

We retrospectively reviewed 102 patients (122 tibiae) with tibial deformities treated with percutaneous osteotomy and gradual correction with the TSF. The proximal osteotomy group was subdivided into two subgroups to distinguish those with an intentional overcorrection of the mechanical axis deviation (MAD). The minimum followup after frame removal was 10 months (average, 48 months; range, 10-98 months).

RESULTS

In the proximal osteotomy group, patients with varus and valgus deformities for whom the goal of alignment was neutral or overcorrection experienced accurate correction of MAD. In the proximal tibia, the medial proximal tibial angle improved from 80 degrees to 89 degrees in patients with a varus deformity and from 96 degrees to 85 degrees in patients with a valgus deformity. In the middle osteotomy group, all patients had less than 5 degrees coronal plane deformity and 15 of 17 patients had less that 5 degrees sagittal plane deformity. In the distal osteotomy group, the lateral distal tibial angle improved from 77 degrees to 86 degrees in patients with a valgus deformity and from 101 degrees to 90 degrees for patients with a varus deformity.

CONCLUSIONS

Gradual correction of all tibial deformities with the TSF was accurate and with few complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Patellar height relevance in opening-wedge high tibial osteotomy

INTRODUCTION

The decrease of patellar height following opening-wedge proximal tibial osteotomy can affect function, and subsequent total knee arthroplasty may be more difficult and give poorer results.

HYPOTHESIS

Pre-operative patellar height is an objective predictor of functional result in opening-wedge osteotomy.

PATIENTS AND METHODS

The effect of opening-wedge high tibial osteotomy (HTO) and internal fixation on patellar height and its functional outcome were assessed. Forty supra-tuberosity medial opening wedge osteotomies were performed in 36 patients presenting with medial femorotibial osteoarthritis and varus deformity. Mean age was 55 years. Mean varus was 9 degrees and mean opening 11 degrees. Minimum follow-up was 22 months, with a mean of 4.2 years. Clinical results were assessed on the International Knee Society (IKS) scale. X-ray measurements (HKA angle, tibial slope, and patellar height as per Caton-Deschamps [CD], Insall-Salvati [IS] and Blackburne-Peel [BP]) were taken pre-operatively, postoperatively and on follow-up.

RESULTS

Patellar height decreased by 10 to 15% (p < 0.0001), depending on the selected ratio. Mean CD index was 0.85 preoperatively (S.D. = 0.12), 0.76 postoperatively (S.D. = 0.14) and 0.75 at follow-up (S.D. = 0.14). Mean IS index was 0.95 preoperatively (S.D. = 0.11), 0.86 postoperatively (S.D. = 0.12) and 0.87 at follow-up (S.D. = 0.12). Mean BP index was 0.68 preoperatively(S.D. = 0.10) and 0.58 postoperatively and at follow-up (S.D. = 0.12). Tibial slope was altered by a mean of 1.5 degrees (range: -4 to + 9 degrees). There was no correlation between opening angle and patellar lowering. Patellar height decrease did not affect functional results whether height remained normal or became low (total IKS score, 179 and 170, respectively); the poorest functional results, however, were associated with patella infera (total score, 147).

DISCUSSION

Medial opening-wedge HTO is an established treatment for unicompartmental varus knee osteoarthritis. We do not, however, recommend it in case of preoperative patellar height of less than 0.6 on the CD ratio.

LEVEL OF EVIDENCE

Retrospective, level IV.

Rigid stepped plate for internal fixation for high tibial osteotomy

High tibial osteotomy is regarded as an effective treatment for unicompartmental arthrosis of the knee, but the optimal fixation method has not yet been devised. The purpose of this study was to confirm the superior strength of a rigid stepped plate as compared to a 4-hole L-plate device. Lateral closing-wedge high tibial osteotomy was performed on 30 ten-month-old porcine tibiae. Fifteen tibiae were fixed using a rigid stepped plate and 15 were fixed with a 4-hole L-plate. Three types of deforming force-compression, valgus bending, and varus bending-were each applied to 5 pair of tibiae fitted with either the rigid stepped plate or the L-plate using a mechanical testing apparatus. Values of load, displacement, and stiffness were analyzed to compare the fixation powers. Mean stiffness in the rigid stepped plate and L-plate groups were 977.8 (SD 230.3) and 836.2 (SD 248.4) N/mm for compression testing (P=.465), 38.7 (SD 12.9) and 21.6 (SD 9.6) N/mm for valgus bending (P=.047), and 62.3 (SD 18.1) and 29.8 (SD 9.7) N/mm for varus bending (P=.009), respectively. The rigid stepped plate has greater fixation strength than the conventional 4-hole L-plate. Given this improved level of fixation with the rigid stepped plate, immobilization duration after high tibial osteotomy could be shortened and complications reduced.

'Fine-tuned' correction of tibial slope with a temporary external fixator in opening wedge high-tibial osteotomy

The authors describe a surgical procedure to 'fine-tune' the tibial slope during high-tibial osteotomy. Fifteen consecutive patients were treated for medial compartment osteoarthritis of the knee using a temporary unilateral external fixator and accompanying internal fixator composed of two plates (with different sized space). All 15 patients were evaluated by measuring femoro-tibial angles (FTAs) in the frontal plane, and using the proximal tibial anatomical axis (PTAA) and the posterior tibial cortex (PTC) methods to assess tibial slope in the sagittal plane. FTA, PTAA, and PTC angles were measured using: (1) radiographs taken before surgery, (2) fluoroscopic images taken after inserting the first plate during surgery, (3) fluoroscopic images taken after tibial slope restoration using an external fixator system during surgery, and finally using, (4) radiographs taken after surgery. In all patients, preoperative PTAA and PTC angles increased significantly after inserting the first plate posteromedially at osteotomy site. After tibial slope had been accurately restored using the external fixator system, PTAA and PTC angles decreased to the preoperative tibial slope level without changing femorotibial angles in the coronal plane. The authors were able to acquire a consistent and reproducible natural tibial slope using tibial slope "fine tuning" using an external fixator and a stable internal fixator.

Quality of life in patients with varus gonarthrosis treated with high tibial osteotomy using the circular external fixator

Generally, surgeon-driven musculoskeletal evaluation systems are used for evaluating outcomes of patients who are treated with high tibial osteotomy. In this study, we investigated the effects of high tibial osteotomy using circular external fixator on quality of life. Twenty-one high tibial osteotomy of 19 patients were evaluated. Quality of life assessment was made using Short Form -36 at preoperative, before fixator removal and 6 months after fixator removal. After applying fixator, the physical function and physical role scores of Short Form-36 decreased and emotional role score did not improve. In other categories, significant improvements were observed when fixator in place. At the sixth month after fixator removal, significant improvements were dedected in all categories of Short Form-36. Although there was a decrease in physical functions after fixator application in patients who were treated with high tibial osteotomy using circular external fixator, significant improvement occurred in quality of life after fixator removal.

Tibial slope and high tibial osteotomy using the circular external fixator

Alteration of tibial slope is one of the important anatomical changes of the proximal tibia after high tibial osteotomy. Increased or decreased tibial slope can effect further total knee prosthesis procedure. In this retrospective study, 18 knees of 17 patients (17 female, mean age 51 range 43-61, mean BMI is 33.6 +/- 4.6 kg/m2) who were applied high tibial osteotomy using circular external fixator due to medial compartment arthrosis of the knee were evaluated in terms of tibial slope changes. While mean correction about 12.3 degrees in mechanical femoro-tibial angle was obtained in frontal plan (P = 0.0001), significant change in tibial slope was not determined in sagittal plan (P = 0.127). The mean posterior proximal femoral angle values were measured as 79.5 +/- 2.1 degrees preoperatively and as 80.3 +/- 2.7 degrees postoperatively and found to fall into the normal range (80.4 +/- 1.6 degrees). As there is no significant alteration in tibial slope after high tibial osteotomy performed with the Ilizarov system, complications due to alteration in tibial slope will not be experienced in follow-up or in further total knee prosthesis procedure.

The oblique high tibial osteotomy technique without bone removal and with rigid blade plate fixation for the treatment of medial osteoarthritis of the varus knee: medium and long-term results

Several high tibial osteotomy (HTO) surgical techniques for the treatment of medial osteoarthritis of the varus knee have been reported. Their main objectives are the achievement of the precise correction that is necessary for the lower limb mechanical axis realignment and the alleviation of the medial joint space. Early or late recurrence of the varus deformity must be avoided and various methods of fixation have been proposed to obtain this. We present a method of single level oblique HTO with no bone removal and with blade plate fixation for the treatment of medial osteoarthritis of the knee. One hundred seventeen patients (136 knees) were operated using this technique during a 12.2-year period. In 4.5 years follow-up there were 73.8% satisfactory results while in 8.4 years follow-up there were 61.1% satisfactory results. There were 11 complications: five patients with deep vein thrombosis, four with superficial wound infection and two with temporary peroneal nerve dysfunction. This study presents the operative technique in details, evaluates the results and assesses the advantages and disadvantages of the method in relation to other techniques described in the literature.

High tibial osteotomy with Puddu plate for the treatment of varus gonarthrosis

In this study, the results of open-wedge osteotomy with Puddu plate for the treatment of varus gonarthrosis have been evaluated prospectively. This study assessed 65 knees of 60 patients with varus gonarthrosis who underwent high tibial osteotomies. Our study population consisted of 13 male and 47 female patients with a mean age of 54 (range 39-76) years. For the clinical evaluation of the patients Hospital of Special Surgery (HSS) score, American Knee Society and Oxford knee scores, and for the radiological assessment mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), femorotibial angle and Insall-Salvati index were basically taken into consideration. Our patients were followed up for an average of 34 (range 18-60) months. In the last assessments of our cases, mean improvements detected in HSS scores, Oxford knee scores, knee and functional scores of Knee Society were 26.72, 19.18, 49.9, and 30 points, respectively. The radiological examinations revealed that their mechanical axes on the average passed 5.09 mm laterally achieving an average of 6.5 degrees genu valgum, and a mean Insall-Salvati index of 1.09. As complications, superficial wound infection in two patients (3%), implant infections in one patient (1.5%), deep vein thrombosis in two patients (3%), peroperative lateral tibial plateau fracture in one patient (1.5%), and postoperative lateral tibial plateau fracture due to a falling down were encountered. According to the results obtained, postoperative pain resolves promptly and a significant degree of improvement of knee functions of the patients are achieved. Therefore, we believe that high tibial osteotomy with a Puddu plate is a valuable alternative to total knee arthroplasty in cases with varus gonarthrosis. Although early results are satisfactory, long-term follow-up studies are required especially in the middle aged and elderly patient populations.

Proximal tibia medial open-wedge osteotomy using plates with wedges: early results in 58 cases

We evaluated in this study indications, surgical technique, and results of wedge plates for fixation in proximal tibia medial opening wedge osteotomy. Fifty-eight knees in 56 consecutive patients (9 men, 47 women; mean age 52 years; ranging between 36 and 66 years) with medial compartment osteoarthrosis were treated with proximal tibia medial open-wedge osteotomy. For fixation, plates which were designed by the first author and which support the osteotomy surface with wedge-shaped projections were used. The plates were either rectangular in shape with two or four holes or had an inverse "L" shape with four holes, and had bearing metal wedges of varying heights from 5 to 15 mm. Tricortical (n=8) and bicortical (n=43) iliac bone autografts and allografts (n=7) were used. The average follow-up time was 21 months (ranging between 6 and 44 months). The mean preoperative tibiofemoral angle was 4.6 degrees varus (0 degrees -11 degrees ) while it was 5.6 degrees valgus (2 degrees -11 degrees ) postoperatively. The mean preoperative HSS score was 58 (range 51-75) and it was found 89 (range 79-96) postoperatively. As complications, lateral tibial plateau fracture in 5 knees (8.6%) and lateral cortex fracture in 15 knees (25.8%) were encountered during surgery. Deep vein thrombosis in two cases (3.4%) and nonfatal pulmonary embolism in one case (1.7%), delayed wound healing in two knees (3.4%), and delayed union as well as breakdown of a distal screw in one knee (1.7%) were encountered postoperatively. In conclusion, using wedge plates for fixation of proximal tibia medial opening wedge osteotomy in the treatment of medial osteoarthritis with unicompartmental involvement of the knee, provides adequate stabilization to allow early movement for functional rehabilitation and keeps the obtained correction level.

High tibial osteotomy for medial compartment osteoarthritis

Unicompartmental osteoarthritis of the knee is often a difficult management problem in the younger age group. A high tibial osteotomy has been found to be quite an effective procedure for this condition in the past. A better understanding of the principles of this technique and innovations in the instrumentation has renewed interest in this procedure. This article provides an overview of the principles, biology, indications, contraindications, planning and execution, postoperative care, results and complications of high tibial osteotomy. An attempt has been made to incorporate important technical considerations, recent developments and other treatment options in this condition.

The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients

INTRODUCTION

One hundred and eight patients with varus gonarthrosis were treated with high tibial osteotomy (HTO) in 2001. Fifty one patients received an open wedge osteotomy by using the 'Puddu' plate and 57 patients received a Coventry-type closing wedge osteotomy. For both groups the follow-up examination period was 22.5 months (253-1009 days).

MATERIAL AND METHODS

To evaluate the study, radiological and subjective criteria as well as the Lysholm and the Tegner Activity Score were used. Altogether 84 % of the patients were included in the follow-up examination study.

RESULTS

In both groups a significant improvement of both scores were achieved. Both methods obtained safe and reproducible results for the correction considering the different operation techniques. There were no differences in outcome between the two methods. Satisfactory results were also achieved for early arthrosis of the femoropatellar and the lateral compartment.

CONCLUSION

Open and closed wedge HTOs obtain significant improvement in patients with medial osteoarthritis of the knee. Using the right technique is very important for good results. For stabilization of the medial ligament we recommend the open wedge osteotomy. The patient should be informed about the routine removal of the metal plate.