High tibial osteotomy: evolution of research and clinical applications--a Canadian experience

Midterm Outcomes After Simultaneous Hip Arthroscopic Surgery for Bilateral Femoroacetabular Impingement

BACKGROUND

Bilateral hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) has demonstrated good outcomes at short-term follow-up, with significant improvements in pain, hip function, and patient-reported outcomes, coupled with a complication rate similar to that of unilateral surgery.

PURPOSE

To investigate whether, in patients with bilateral symptomatic FAI, simultaneous bilateral hip arthroscopic surgery is an efficacious option that produces effective midterm outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective database of patients who underwent primary hip arthroscopic surgery between August 2012 and October 2020 was used to collect clinical data on 2 groups. Group 1 consisted of patients who underwent simultaneous bilateral hip arthroscopic surgery for the treatment of FAI. Group 2 represented a matched-pair control group of patients selected based on sex and age with signs and symptoms of unilateral FAI and in whom a single side was evaluated and treated. Differences in the International Hip Outcome Tool-12 and Non-Arthritic Hip Score scores were evaluated up to 5 years postoperatively.

RESULTS

In total, 171 patients (235 hips) were included, of whom 64 underwent simultaneous bilateral hip arthroscopic surgery (128 hips) and a control group of 107 patients (107 hips) underwent unilateral hip arthroscopic surgery. No significant differences were observed in International Hip Outcome Tool-12 scores between the 2 groups at 6 weeks, 3 months, 1 year, 2 years, and 5 years postoperatively. No significant differences were observed in Non-Arthritic Hip Score scores between the simultaneous bilateral and control groups at 6 weeks, 3 months, 6 months, 1 year, 2 years, and 5 years postoperatively. Overall, 18% of hips in the simultaneous bilateral group reported lateral femoral cutaneous nerve palsy at 2-week follow-up in comparison to 16% of hips in the control group.

CONCLUSION

Simultaneous bilateral hip arthroscopic surgery for the treatment of FAI represents a safe treatment option, producing effective midterm outcomes in appropriately selected patients.

Is single-stage bilateral medial opening wedge high tibial osteotomy advisable?

PURPOSE

To validate the safety and clinical results of single-stage bilateral versus unilateral medial opening wedge high tibial osteotomy (HTO).

METHODS

A propensity-matched cohort study was performed from March 2020 to March 2021 in our medical center. Data were prospectively collected. Including 34 patients who underwent single-stage bilateral medial opening HTO(SSBHTO), and 68 cases in the unilateral group. Propensity-matched ration was 2:1 based on age, sex, and body mass index using R software. Comparisons of the length of hospital stay, operative time, blood loss, postoperative adverse events, 90-day readmission rate, conversion to TKA rate, self-reported VAS and WOMAC scores were made to investigate the safety and clinical results of bilateral HTO.

RESULTS

The mean length of hospital stay was 7.36 ± 2.23 days for SSBHTO and 7 days (IQR, 3 days; range, 4 to 23 days) for the unilateral group (P = 0.219). The mean operative time was 144 ± 47 min for bilateral HTO and 105(37.5) mins for a unilateral OWHTO (P < 0.001). The mean blood loss was 150(100) ml for SSBHTO and 100(50) ml for unilateral OWHTO (P < 0.001). There were no significant difference of the adverse events and 90-day readmission rate between two groups. No failed HTO or conversion to knee arthroplasty were observed at the end of follow-up. VAS, pain, stiffness, and functional scores of the WOMAC scale were essentially comparable of two groups one year after surgery (P > 0.05).

CONCLUSIONS

A single-stage bilateral medial opening wedge high tibial osteotomy is advisable for patients with knee osteoarthritis. Patients benefit from avoiding secondary anesthesia, postoperative complications, and substantial cost savings.

LEVEL OF EVIDENCE

Therapeutic Level III.

Editorial Commentary: Locking Plate Removal Is Safe and May Improve Function 1 Year After Medial Opening Wedge High Tibial Osteotomy

The development of angular stable locking late fixation in realignment osteotomy has resulted in the ability to be more aggressive with weight bearing and rehabilitation after high tibial osteotomy. One of the downsides of some of these plate fixators is the degree of soft-tissue irritation and discomfort that can be experienced by many patients, resulting in the need for hardware removal. Studies have shown greater than 50% of patients requiring hardware removal with no resulting loss of correction, although there may be cultural reasons for the higher number, not solely attributable to the symptom profile. It is encouraging to see that after 1 year postoperatively, hardware removal after high tibial osteotomy not only is safe but also results in a clinically important improvement in pain and function, with progressive bone healing out to 2 years.

Effect of Meniscal Tear Patterns and Preoperative Cartilage Status on Joint Space Width After Medial Opening-Wedge High Tibial Osteotomy

BACKGROUND

Medial opening-wedge high tibial osteotomy (MOWHTO) is performed to treat young adults with medial compartment knee osteoarthritis associated with varus deformity. However, factors influencing joint space width (JSW) vary according to the type of medial meniscal tear and have not yet been completely elucidated.

PURPOSE

To examine changes in JSW according to the type of medial meniscal tear after MOWHTO and analyze the influencing factors.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study was conducted on 134 patients who underwent MOWHTO for medial osteoarthritis and were followed up for >2 years. The patients were classified into 3 groups based on medial meniscal status: intact, nonroot tear, and root tear. The authors then measured the JSW preoperatively and at 3 months, 6 months, 1 year, and >2 years postoperatively; analyzed whether the change in JSW varied according to meniscal status; and determined the association of these changes with the preoperative cartilage grade of the medial femoral condyle (MFC) and medial tibial plateau (MTP). International Knee Documentation Committee (IKDC) scores were used to evaluate clinical function.

RESULTS

Of the 134 patients, the medial meniscus was intact in 29 patients, a nonroot tear was observed in 58 patients, and a root tear was observed in 47 patients. Postoperatively, JSW increased for all groups, but the timing of the increase varied between the groups (P < .001). JSW increased the most 6 months postoperatively in the intact group and 3 months postoperatively in the nonroot tear and root tear groups (P < .001). Additionally, the increase in JSW was the greatest in the root tear group. Preoperatively, MFC and MTP cartilage status differed among the groups; MTP status did not affect the JSW, but MFC status did (P < .001). The IKDC score increased from the preoperative to postoperative time point in all groups, but there was no significant difference between groups.

CONCLUSION

The authors observed that the amount and timing of increase in JSW were dependent on the pattern of medial meniscal tear observed when MOWHTO was performed. In addition, the cartilage grade of MFC before surgery was associated with changes in JSW. The IKDC score was not significantly different between groups. However, a longer follow-up period is needed to analyze the correlation with the meniscal tear pattern and JSW.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies

PURPOSE

This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO).

METHODS

A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests.

RESULTS

An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees.

CONCLUSION

In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered.

LEVEL OF EVIDENCE

Level Ⅳ, retrospective case-control study.

Effect of Varus-Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area at Varying Degrees of Knee Flexion

Background

In patients with valgus alignment and degenerative changes in the lateral compartment, both distal femoral osteotomy (DFO) and high tibial osteotomy (HTO) can be used to unload the lateral compartment. Prior studies have shown that in valgus knees, the tibial wear is posterior and DFO exerts the greatest effect in extension; however, its effect is decreased as flexion angle rises.

Hypothesis

Medial closing-wedge (MCW) HTO would significantly decrease contact area, mean contact pressure (MCP), and peak contact pressure (PCP) in the lateral knee compartment through knee flexion to a greater extent compared with lateral opening-wedge (LOW) DFO.

Study Design

Controlled laboratory study.

Methods

MCWHTO and LOWDFO were performed, correcting a mean of 8° of valgus alignment, in 10 cadaveric knees using plate fixation. Tibiofemoral contact pressure of the medial and lateral compartments was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors and load applied through an Instron device. PCP, MCP, and contact area were measured for each condition.

Results

The lateral MCP was significantly decreased in the HTO state compared with the native state in 30° (P = .015), 60° (P = .0199), and 90° (P < .0001) of flexion. The lateral MCP was also significantly decreased in the HTO state when compared with the DFO state in 60° (P = .0093) and 90° of flexion (P < .0001). After DFO, the lateral MCP returned to that of the native state in 60° (P > .999) and 90° (P > .999) of flexion. The lateral PCP decreased for all test states in all degrees of flexion; the HTO state was significantly decreased when compared with the native state in 60° (P < .0001) and 90° (P < .0001).

Conclusion

With varus corrections of 8°, MCWHTO was more effective at unloading the lateral compartment than LOWDFO. This effect was significant as the knee flexion angle increased. This study should be considered as one aspect of the surgical decision-making process.

Clinical Relevance

In patients with mild to moderate valgus deformity without hypoplastic lateral femoral condyle and without significant joint line obliquity, MCWHTO may improve offloading of the lateral compartment in flexion.

Bilateral Inverted V-shaped High Tibial Osteotomy: A Case Report

The article describes the case of a young patient with bilateral genu varum deformity, limiting her mobility. The therapeutic decision was a staged reverse V-shaped tibial osteotomy on both knees at a six-month interval. The surgery faced infectious complications on the left side, requiring additional treatment. Despite this, the patient achieved successful correction, with wound healing and bone consolidation. Preoperative planning was crucial, determining specific correction angles for each knee. The reverse V-shaped osteotomy demonstrated satisfactory functional outcomes compared to other techniques. The conclusion emphasizes the effectiveness of reverse V-shaped high tibial osteotomy (HTO) in addressing varus tibial deformities, providing an alternative before considering total knee arthroplasty. Multicenter studies and long-term evaluations are recommended to refine this surgical procedure.

Assessment of return to sport and functional outcomes following distal femoral, double level and high tibial osteotomies for active patients with symptomatic varus malalignment

PURPOSE

This study indicated the outcomes of three surgical techniques for the treatment of symptomatic unicompartmental knee osteoarthritis (UKOA) with varus malalignment in younger, active patients: distal femoral osteotomy (DFO), double-level osteotomy (DLO) and high tibial osteotomy (HTO). The outcomes measured included the return to sport, sport activity and functional scores.

METHODS

A total of 103 patients (19 DFO, 43 DLO, 41 HTO) were enrolled in the study and were divided into three groups based on their oriented deformity, each undergoing one of the three surgical techniques. All patients underwent pre- and post-operative evaluations including X-rays, physical exams and functional assessments.

RESULTS

All three surgical techniques were effective in treating UKOA with constitutional malalignment. The average time to return to sport was similar among the three groups (DFO: 6.4 ± 0.3 [5.8-7] months, DLO: 4.9 ± 0.2 [4.5-5.3] months, HTO: 5.6 ± 0.2 [5.2-6] months). The sport activity and functional scores improved significantly for all three groups, with no significant differences observed among the groups.

CONCLUSION

Various knee osteotomy procedures, DFO, DLO, and HTO, result in high RTS rates and quick RTS times with satisfactory functional scores. Despite pre- to post-operative improvements in sport activities following DFO and DLO, pre-symptom levels were not reached following all evaluated procedures.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

The benefits of a percutaneous supplemental screw to reinforce the hinge of a medial open wedge tibial osteotomy

INTRODUCTION

Our earlier studies reported that an additional lag screw placed from the opposite side increases the stability of the fixation construct in medial open wedge high tibia osteotomy (MOWHTO). The aim of the study was to evaluate the clinical relevance of the use of a supplemental screw with immediate post-operative full weight-bearing and its benefits in terms of functional outcome, radiographic outcome and complications.

MATERIALS AND METHODS

A retrospective study was performed comparing the historical cohort (MOWHTO without opposite screw) (group A) with the current cohort (MOWHTO with opposite screw) (group B). The patients underwent clinical and radiological assessments. We evaluated the WOMAC (The Western Ontario and McMaster Universities) score, IKDC (International Knee Documentation Committee) scores, and Lysholm knee score. Patients' return to sports and work were also recorded.

RESULTS

We included 123 knees receiving MOWHTO alone (group A) with 114 knees (group B) receiving MOWHTO with an opposite screw. A shorter bone union time (18.3 ± 2.1 weeks v.s. 11.5 ± 2.6 weeks, p < 0.001), earlier return to sports (6.1 months vs. 4.6 months, p < 0.001) and return to works (3.2 months vs. 2.3 months, p < 0.001) and better 6-month functional outcomes were found in group B (p < 0.001). The complications were similar in both groups. One patient experienced irritation at the site of the screw entrance and the screw was removed after union.

CONCLUSION

The current study evaluated the clinical efficacy of a supplemental lag screw placed from the opposite side in MOWHTO. Comparing to the plate alone, the additional opposite screw improved the implant and fixation stability under immediate weight-bearing without causing complications. A shorter time for returning to sports and work was noted, and a better functional outcome at 6-month follow-up was registered.

An Abnormal Presentation of Pediatric Genu Varum, Managed by Bilateral Tibial and Fibular Osteotomies With External Spatial Frame Placement: A Case Report

Genu varum is a common finding in the pediatric population with a large differential, including but not limited to Blount’s disease, rickets, and physiologic bowing of the legs. Here we report a case of a 12-year-old Caucasian male who presented for an atraumatic stress fracture of the fifth metatarsal after an athletic event. Further evaluation showed significant genu varum with a Q angle of 9 degrees and medial knee joint space narrowing. The patient was unable to undergo conservative management due to early completion of puberty with relatively premature skeletal maturity. A bilateral tibial and fibular osteotomy with external spatial frame placement was performed successfully followed by six months of minor activity complicated by subclinical enoxaparin-induced purpura. The unique presentation of a stress fracture caused by compensatory mechanisms for the severe varus deformity, as well as the rarity of this procedure being performed on both legs simultaneously with good outcomes was the primary reason for the publication of this paper.

Radiographic Evaluation of Medial Opening-Wedge High Tibial Osteotomy Using a New Internal Fixator with a Wedge-Shaped Spacer Block

We developed a new internal fixator: a rigid T: -shaped plate with locking screws and wedge-shaped spacer block for high tibial osteotomy. The purpose of the present study was to evaluate the radiographic outcome of opening-wedge high tibial osteotomy (OWHTO) using this new internal fixator. Sixty OWHTOs were performed in patients with medial compartment osteoarthritis and varus deformity (28 males and 23 females). Patients' mean age was 60.4 years. Preoperative and postoperative radiographs were obtained. The paired t-test was used to evaluate the differences over time with respect to radiographic variables. Union of the osteotomy gap was obtained in all patients, and no implant breakage was found. On anterior-posterior radiographs, a significant difference was observed (p < 0.01) between the preoperative and postoperative mean values of femorotibial angles (179.6 ± 3.2 vs. 170.6 ± 2.5 degrees), weight-bearing line ratios (23.8 ± 13.5 vs. 60.5 ± 11.5%), anatomical medial proximal tibial angles (84.8 ± 2.5 vs. 91.0 ± 2.6 degrees), and joint line coverage angles (3.6 ± 2.0 vs. 2.4 ± 1.7 degrees). On lateral radiographs, posterior tibial slopes were 11.5 ± 3.9 degrees preoperatively and 12.2 ± 4.0 degrees postoperatively (p < 0.01), and Insall-Salvati ratios were 1.04 ± 0.12 preoperatively and 1.06 ± 0.13 postoperatively (p = 0.24). Performing OWHTO using a new internal fixator with a wedge-shaped spacer achieves adequate correction of lower limb alignment without implant-related complications. This is a Level IV, case series study.

Proximal Tibiofibular Dislocation in Closing-Wedge High Tibial Osteotomy Increases the Risk of Medium and Long-Term Total Knee Replacement

Proximal tibiofibular dislocation in closing-wedge high tibial osteotomy increases the risk of medium and long-term total knee replacement. Background: High tibial osteotomy is an effective treatment for medial osteoarthritis in young patients with varus knee. The lateral closing-wedge high tibial osteotomy (CWHTO) may be managed with tibiofibular dislocation (TFJD) or a fibular head osteotomy (FHO). TFJD may lead to lateral knee instability and thereby affect mid- and long-term outcomes. It also brings the osteotomy survival rate down. Objective: To compare the CWHTO survival rate in function of tibiofibular joint management with TFJD or FHO, and to determine whether medium and long-term clinical outcomes are different between the two procedures. Material & Methods: A retrospective cohort study was carried out that included CWHTO performed between January 2005 to December 2018. Those patients were placed in either group 1 (FHO) or Group 2 (TFJD). Full-leg weight-bearing radiographs were studied preoperatively, one year after surgery and at final follow-up to assess the femorotibial angle (FTA). The Rosenberg view was used to assess the Ahlbäck grade. The Knee Society Score (KSS) was used to assess clinical outcomes and a Likert scale for patient satisfaction. The total knee replacement (TKR) was considered the end of the follow-up and the point was to analyze the CWHTO survival rate. A sub-analysis of both cohorts was performed in patients who had not been FTA overcorrected after surgery (postoperative FTA ≤ 180°, continuous loading in varus). Results: A total of 230 knees were analyzed. The follow-up period ranged from 24-180 months. Group 1 (FHO) consisted of 105 knees and group 2 (TFJD) had 125. No preoperative differences were observed in terms of age, gender, the KSS, FTA or the Ahlbäck scale; neither were there any differences relative to postop complications. The final follow-up FTA was 178.7° (SD 4.9) in group 1 and 179.5° (SD 4.2) in group 2 (p = 0.11). The Ahlbäck was 2.21 (SD 0.5) in group 1 and 2.55 (SD 0.5) in group 2 (p = 0.02) at the final follow-up. The final KSS knee values were similar for group 1 (86.5 ± 15.9) and group 2 (84.3 ± 15.8). Although a non-significant trend of decreased HTO survival in the TFJD group was found (p = 0.06) in the sub-analysis of non-overcorrected knees, which consisted of 52 patients from group 1 (FHO) and 58 from group 2 (TFJD), 12.8% of the patients required TKR with a mean of 88.8 months in group 1 compared to 26.8% with a mean of 54.9 months in the case of group 2 (p = 0.005). However, there were no differences in clinical and radiological outcomes. Conclusion: TFJD associated with CWHTO shows an increase in the conversion to TKR at medium and long-term follow-up with lower osteotomy survival than the CWHTO associated with FHO, especially in patients with a postoperative FTA ≤ 180° (non-overcorrected). There were no differences in clinical, radiological or satisfaction results in patients who did not require TKR. Level of evidence III. Retrospective cohort study.

Return to sport and work after medial open wedge high tibial osteotomy : a case series

Data on return to work and sport following open wedge high tibial osteotomy (HTO) have been underreported. Furthermore, there is no clear consensus in literature about the postoperative alignment goals following HTO. A retrospective case series was performed to evaluate return to sport and work following open wedge HTO. The University of California, Los Angeles scale, the German classification system according to the Reichsausschuß für Arbeitszeitermittlung, the Tegner score and the Knee injury and Osteoarthritis Outcome Score were used to asses the employment status, sport status and clinical outcome at the time of surgery and at final follow-up, minimum 2 years after surgery. The pre- and postoperative hip knee ankle angle (HKA) were documented. The desired postoperative alignment target was 0°-2° valgus mechanical axis. 30 open wedge HTOs were performed of which 27 patients were retrospectively included in the study. 25 out of 26 patients returned to work and 15 out of 17 patients returned to sport following surgery. Outcome scores were significantly higher after surgery. The mean postoperative HKA was 0,9° of valgus mechanical axis. This study shows excellent outcome in sport and work activity and clinical outcome after open wedge HTO. We furthermore suggest that these outcomes can be obtained with a postoperative alignment of 0°-2° of valgus mechanical axis.

A Right Angle Guide for Distal Tuberosity Osteotomy With Medial Open Wedge High Tibial Osteotomy for Varus Knee Osteoarthritis

Medial open wedge high tibial osteotomy (OWHTO) is usually performed with proximal tuberosity osteotomy or setting the osteotomy line proximal to the tuberosity. However, OWHTO can result in patellofemoral complications due to postoperative patella infera. A new OWHTO technique, biplanar osteotomy with a distal tuberosity osteotomy, was reported in 2004 to prevent postoperative patella infera. To ensure that the 2 osteotomy lines maintain perpendicular, we describe the OWHTO procedure with a distal tuberosity osteotomy technique using a TriS Medial HTO Plate System (Olympus Terumo Biomaterials Corp., Tokyo, Japan) and a right angle guide we developed. In this Technical Note, we describe the procedure and advantages, risks, and limitations, as well as the pearls and pitfalls based on our experience.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors

BACKGROUND

An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it.

METHODS

We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery.

RESULTS

Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%-7%) at 5 years and 21% (95% CI 17%-26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12-3.45), pain (adjusted HR 0.85, 95% CI 0.75-0.96)], female sex (adjusted HR 1.67, 95% CI 1.08-2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17-1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12-1.53).

INTERPRETATION

We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

Combination of Cylindrical Autologous Bone Grafting Technique With a Metallic Block Insertion in Open-Wedge High Tibial Osteotomy

Open-wedge high tibial osteotomy (OW-HTO) is an effective surgical intervention for medial-compartment knee osteoarthritis. However, the osteotomized gap might be a disadvantage in OW-HTO because it can cause problems such as delayed bone union or loss of correction. These issues can be minimized by using autologous bone graft in the osteotomized gap, which is known to be the fastest and most clinically satisfactory gap filler. The primary mechanical stability of the osteotomy site in OW-HTO is essential for early weight bearing after surgery. Therefore, we introduce the combination of a cylindrical autologous bone grafting technique and a metallic block insertion for faster bone union and better primary stability of the site in OW-HTO. We expect that the described procedure will enable early postoperative weight bearing and, thereby, allow an early return to normal function.

Application of external osteosynthesis in correction of varus deformation of lower extremities in patients with gonarthrosis

Background. Arthrosis of the knee joint is one of the most common diseases in elderly patients with the varus deformity. One of the treatment methods is corrective osteotomy. Aims: optimization of the diagnosis of deformities in patients with gonarthrosis, improvement of the technique of operation and postoperative control of the main reference lines and angles, assessment of the correction results, analysis of complications. Methods. A retrospective clinical study was conducted. 39 patients were observed, in whom 78 operations were performed on both legs simultaneously. In all the cases, tibia osteotomies and osteosynthesis with the Ilizarov apparatus were used. All the patients underwent an X-ray study of the legs along the entire length with the identification of the main reference lines and angles. Results. In all the cases, it was possible to normalize the position of the mechanical axis and the angle of orientation of the knee joint. After the surgery, the wounds were not sutured to prevent compartment syndrome. The correction was performed in a single-stage manner in elderly patients, gradually in young patients. The period of fixation with the Ilizarov apparatus was 16.6 3.1 weeks. Conclusions. The Ilizarov method has significant advantages: low invasiveness, stable fixation, absence of foreign bodies to the end of treatment. This allows us to recommend it for a wider use in patients with gonarthrosis and varus deformity.

Research trends and hotspots of high tibial osteotomy in two decades (from 2001 to 2020): a bibliometric analysis

BACKGROUND

The purpose of this study is to comprehensively analyze the global application trend of high tibial osteotomy (HTO) and identify promising research hotspots of HTO based on bibliometrics and visual analysis.

METHODS

Publications (articles and reviews) related to HTO from 2001 to 2020 were retrieved from the Web of Science Core Collection database (WOSCC). The country, institution, year, author, journal, average citations per item, H index, title, abstract, keywords of publication, and the top 10 cited articles were extracted and analyzed in detail. The VOSviewer software was used to analyze theco-occurrence of keywords to predict the hotspots of HTO.

RESULTS

A total of 1883 articles were included. In the past 20 years, the number of HTO articles has shown an increasing trend in general. The top 3 countries (the USA, Germany, and South Korea) accounted for 49.547% of all articles published. The USA has the largest number of publications. The University of Western Ontario is the largest contributor. The Knee Surgery Sports Traumatology Arthroscopy is the most influential journal. Professors Saito T and Imhoff AB are the leading scholars who made great achievements in the HTO field. The research direction can be divided into the following 5 clusters: "prognosis and outcome", "HTO combined with cartilage restoration techniques", "animal experimental research", "study on bone union and plate fixation at osteotomy", and "surgical technique research".

CONCLUSION

In terms of the trend of previous years, an increasing number of literatures related to HTO will be published in the future. The USA is a world leader in the field of HTO. South Korea presented great potential in this area. HTO combined with cartilage restoration techniques, postoperative prognosis and outcome, and surgical technique research may be the future hotspots in the field of HTO research.

Medical Comorbidities and Functional Dependent Living Are Independent Risk Factors for Short-Term Complications Following Osteotomy Procedures about the Knee

OBJECTIVE

To characterize rates and risk factors for adverse events following distal femoral osteotomy (DFO), high tibial osteotomy (HTO), and tibial tubercle osteotomy (TTO) procedures.

DESIGN

Patients undergoing DFO, HTO, or TTO procedures during 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Rates of adverse events were characterized for each procedure. Demographic, comorbidity, and procedural factors were tested for association with occurrence of any adverse events.

RESULTS

A total of 1,083 patients were identified. Of these, 305 (28%) underwent DFO, 273 (25%) underwent HTO, and 505 (47%) underwent TTO. Mean ages for patients undergoing each procedure were the following: DFO, 51 ± 23 years; HTO, 40 ± 13 years; and TTO, 31 ± 11 years. The most common comorbidities for DFO were hypertension (34%) and smoking (17%); for HTO, hypertension (22%) and smoking (21%); and for TTO, smoking (20%) and hypertension (11%). Independent risk factors for occurrence of any adverse event were age ⩾45 years for DFO (odds ratio [OR] = 3.1, P < 0.001) and HTO (OR = 2.3, P = 0.029), and body mass index >30 for HTO (OR = 2.5, 95% confidence interval = 1.1-5.7, P = 0.031). When all osteotomy procedures were analyzed collectively, additional variables including diabetes mellitus (OR = 2.2, P = 0.017), chronic obstructive pulmonary disease (OR = 5.5, P = 0.003), and dependent functional status (OR = 3.0, P = 0.004) were associated with adverse events.

CONCLUSIONS

The total rate of adverse events was not independently associated with the type of osteotomy procedure. In addition, patients with age >45, diabetes mellitus, chronic obstructive pulmonary disease, and dependent functional status have greater odds for adverse events and should be counseled and monitored accordingly.

Proximal tibiofibular joint changes after closed-wedge high tibial osteotomy. Are they relevant?

BACKGROUND

There is some controversy about how the proximal tibiofibular joint (PTFJ) capsulotomy changes PTFJ anatomy in closed-wedge high tibial osteotomy (CW-HTO) and about how this affects ankle and knee mobility and the onset of lateral knee pain. The aim of this study is to evaluate changes in PTFJ after CW-HTO, and its possible clinical significance.

METHODS

This study includes 50 patients who underwent CW-HTO with tibiofibular capsulotomy from 2000 to 2018 in our hospital. A clinical evaluation was conducted to evaluate pain location. The degrees of osteoarthritis and the proximal fibular subluxation were evaluated on radiographs. A dynamic analysis of the PTFJ was also performed comparing proximal fibular head subluxation on anteroposterior knee radiographs with the ankle placed in neutral position and dorsiflexed.

RESULTS

The clinical evaluation revealed that two patients had a sore scar, five had pain on the PTFJ with manual compression, and none referred lateral compartment pain. The radiological analysis revealed an average proximal subluxation of the fibular head after the osteotomy of 9.64 (range: 0-29) mm, which was greater in oblique PTFJ (p < 0.05). After the surgery, all the patients developed some degree of PTFJ arthritis. There was no correlation between lateral pain and proximal fibular subluxation, tibiofibular arthritis, or lateral compartment arthritis. The dynamic analysis revealed no significant changes.

CONCLUSIONS

After CW-HTO all the patients developed proximal subluxation of the fibular head and a variable degree of PTFJ osteoarthritis, but these changes seem to be unrelated with lateral knee pain.

Patient-specific prediction of joint line convergence angle after high tibial osteotomy using a whole-leg radiograph standing on lateral-wedge insole

PURPOSE

To assess the usefulness of a whole-leg radiograph standing on lateral-wedge insole (LWI) for predicting the change in joint line convergence angle (JLCA) before vs. after high tibial osteotomy (HTO).

METHODS

Forty knees with medial osteoarthritis underwent open-wedge HTO. Pre-operatively, all patients had whole-leg radiographs taken in three different conditions: supine, standing, and standing on LWI inclined at 20°. A standing whole-leg radiograph was also obtained post-operatively. Radiological measurements including JLCA and percentage of mechanical axis (%MA) were compared. Using pre-operative radiographs, correction angles were calculated with the target %MA at 62.5%. Correlations between the difference in calculated correction angle among the three pre-operative conditions and the change in JLCA before vs. after HTO were assessed.

RESULTS

In the pre-operative standing conditions, the mean JLCA of 3.8° was significantly decreased to 3.2° using LWI, which did not differ from post-operative JLCA of 3.1°. Mean %MA significantly shifted laterally from 20.6 to 24.8% using LWI, and was strongly correlated with the change in JLCA (coefficient, 0.83). Calculated correction angles differed significantly among the three pre-operative conditions. The difference in calculated correction angle between standing with and without LWI was strongly correlated to the change in standing JLCA before vs. after HTO (coefficient, 0.73).

CONCLUSION

Larger differences in calculated correction angles between pre-operative radiographs standing with and without LWI predicted larger changes in JLCA after HTO. Whole-leg radiograph standing on LWI is a promising modality for correct pre-operative planning considering patient-specific changes in JLCA before vs. after HTO.

LEVEL OF EVIDENCE

IV.

Anterior cruciate ligament reconstruction with anterior closing wedge osteotomy for failed high tibial osteotomy-A case report

•

High posterior tibial slope is a risk factor for anterior cruciate ligament deficiency.

•

Knee instability from increased posterior tibial slope is not a reported complication after open wedge high tibial osteotomy.

•

Anterior cruciate ligament reconstruction using the quadriceps tendon and tibial anterior closing wedge osteotomy is a good treatment option.

Background

Increased posterior tibial slope (PTS) is considered a risk factor for anterior cruciate ligament (ACL) injury. Previous studies revealed that medial opening wedge high tibial osteotomy (OWHTO) tends to increase PTS. However, knee instability from increased PTS is not a reported complication after OWHTO, and the treatment strategy is unclear.

Methods

A 55-year-old woman who complained of left knee pain underwent OWHTO for early-stage medial compartment osteoarthritis by another doctor. After the first surgery, her left knee pain decreased; however, 1 year after OWHTO, she began to feel left knee instability, and the primary doctor consulted our clinic. Physical examination revealed a positive Lachman's test, and radiographs showed that PTS had increased from 8 degrees to 15 degrees. According to these findings, we diagnosed an aggravated symptomatic knee instability secondary to increased PTS after OWHTO. We then performed ACL reconstruction using the quadriceps tendon and tibial anterior closing wedge osteotomy (ACWO), which is a newly-developed technique to correct PTS for revision ACL reconstruction.

Results

Postoperatively, PTS was corrected from 15 degrees to 7 degrees, and the patient's Lysholm score improved from 39 to 95, 1 year postoperatively.

Conclusions

ACL reconstruction with ACWO is a possible treatment option for the PTS-increased knee after OWHTO.

Proximal Tibiofibular Dislocation in a Closing-Wedge High Tibial Osteotomy Causes Lateral Radiological Gapping of the Knee: A Prospective Randomized Study

BACKGROUND

To determine whether a proximal tibiofibular joint dislocation (TFJD) increases lateral compartment gapping more than a fibular head osteotomy (FHO) during a closing-wedge high tibial osteotomy (CWHTO). The second objective was to determine whether lateral compartment gapping affects clinical outcomes.

METHODS

A prospective randomized clinical study was carried out that included 18 patients in Group 1 (FHO) and 18 in Group 2 (TFJD). Varus-stress radiographs of all the patients with both knees at full extension and at 30 ° of flexion were studied pre-operatively and 12 months post-operatively. Lateral compartment gapping was measured in millimeters. The Knee Society Score (KSS) was used to assess clinical stability.

RESULTS

The difference between the pre- and post-operative measurements relative to gapping in the lateral knee compartment at 0 ° of knee flexion was 1.3 mm (SD 1.8) in Group 1 and 4.5 mm (SD 2.4) in Group 2 (p = 0.006). At 30 ° of knee flexion, this difference was 1.9 mm (SD 1.2) in Group 1 and 5.2 mm (SD 3.1) in Group 2 (p = 0.01). No differences were observed in the pre- and post-operative period relative to gapping in healthy knees. Pre-operatively, both groups presented similar KSS knee values: Group 1 with 54.7 (SD 11.7), Group 2 with 54.8 (SD 11.1) (n.s.). Post-operatively, these values were also similar: Group 1 with 93.2 (SD 7.4), Group 2 with 93.5 (SD 5.5) (n.s.).

CONCLUSIONS

In patients who have undergone a CWHTO, TFJ dislocation increases knee lateral compartment gapping when compared to an FHO at 0 ° and 30 ° of knee flexion. However, this fact seems to have no repercussion on the functional status of the knees as measured with the KSS at the one-year follow-up.

Day-Case Opening Wedge High Tibial Osteotomy With Intraosseous PEEK Implant

Purpose

To evaluate the short-term clinical outcomes, complications, hospitalization time, and readmission rate related to day-case opening wedge high tibial osteotomy (OWHTO) with intraosseous PEEK (polyether ether ketone) implant, in the treatment of knee osteoarthritis.

Methods

An observational study on patients treated with OWHTO using intraosseous PEEK implant was performed with a period of 12 months follow-up. Grade of Knee Injury and Osteoarthritis Outcome Score (KOOS) was assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to analyze the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered.

Results

In the period from 2016 to 2017, a consecutive group of 40 patients (13 female, 27 male) with symptomatic medial knee osteoarthritis and varus malalignment were included in the study. The average age of the patients was 54.9 (± 7.6) years. In total, 30 (77%) patients met the criterion for minimal clinically important difference in KOOS scores. The KOOS symptoms improved from 58.1 ± 20 to 78.5 ± 16.5 (P < .0001), pain from 48.1 ± 18.2 to 78.6 ± 18.5 (P < .0001), activities of daily living from 59.0 ± 19.5 to 84.1 ± 15.2 (P < .0001), sport from 23.2 ± 17.6 to 55.6 ± 26.3 (P < .0001), and quality of life from 28.4 ± 12.8 to 61.5 ± 22.5 (P < .0001) at 1-year follow-up. The average hospitalization time at the Day Surgery Unit was 5.6 ± 0.7 hours, and 4 (10%) patients had to be readmitted to the hospital within 2 weeks postoperatively. The overall complication rate was 18%. Complications that required revision surgery were registered in 4 patients (10%), including 2 non-unions and 2 progressions of osteoarthritis.

Conclusions

The day-case OWHTO with intraosseous PEEK implant was a success in 77% of the cases. The results and complications were comparable with other published studies. Despite a short hospitalization time, the readmission rate was low.

Level of Evidence

IV, therapeutic case series.

Open Versus Closing Wedge Osteotomy and Application to Mandibular Reconstruction

PURPOSE

To review the specific techniques of closing wedge osteotomy and open osteotomy, compare their clinical and radiographic outcomes, and apply these findings to mandibular reconstruction.

METHODS

A thorough review of the otolaryngology, facial plastic and reconstructive surgery, oral and maxillofacial surgery, and orthopedic surgery literature was conducted in the Ovid MEDLINE, EMBASE, and Google Scholar databases using the terms 'osteotomy' and 'mandibular reconstruction.'

RESULTS

Traditionally, open osteotomies were thought to result in greater rates of malunion. However, multiple meta-analyses within the orthopedic literature have refuted this. Closing wedge osteotomies, on the other hand, may increase the chance of damaging a perforator. Again, no studies have evaluated the relationship between type of osteotomy and flap survival or wound healing. The particular type of osteotomy performed often depends on the type of osseous flap being utilized.

CONCLUSIONS

Open osteotomies are a viable and even preferred alternative, particularly in flaps without consistent perforators, such as scapular free flaps.

Ankle joint pressure change in varus malalignment of the tibia

BACKGROUND

Varus malalignment of the tibia could alter ankle biomechanics, and might lead to degenerative changes of the ankle joint. However, previous studies failed to report the detailed changes of ankle biomechanics in varus malalignment of the tibia. The aim of this biomechanical study was to evaluate how the ankle joint pressure would change in response to the incremental increases in varus malalignment of the tibia.

METHODS

Eight fresh-frozen human cadaver legs were tested in this study. Varus malalignment of the tibia and a total of 600 N compressive force was simulated using a custom made fixture. Intra-articular sensors (TeckScan) were inserted in the ankle joint to collect the ankle joint pressure data. The testing sequence was 0°, 2°,4°,6°,8°,10°,12°,14°,16°,18°,20° of tibial varus.

RESULTS

As the tibial varus progressed, the center of force (COF) shifted laterally both for the medial and lateral aspect of the ankle joint. For the medial aspect of the ankle joint, the lateral shift reached its maximum at 8° [2.76 (1.62) mm, p = 0.002] of tibial varus, while for the lateral aspect of the ankle joint, the lateral shift reached its maximum at 12° [2.11 (1.19) mm, p = 0.002] of tibial varus. Thereafter, the COF shifted medially as the tibial varus progressed. For the lateral aspect of the ankle joint, The P_mean increased from 2103.8 (625.1) kPa at 0° to 2295.3 (589.7) kPa at 8° of tibial varus (p = 0.047), significant difference was found between the P_mean at 0° and 8° (p = 0.047) of tibial varus. Then as the tibial varus progressed, the P_mean decreased to 1748.9 (467.2) kPa at 20° of tibial varus (p = 0.002). The lateral joint pressure ratio also increased from 0.481 (0.125) at 0° to 0.548 (0.108) at 10° of tibial varus (p = 0.002), then decreased to 0.517 (0.101) at 20° of tibial varus (p = 0.002) .

CONCLUSIONS

For mild tibial varus deformities, there was a lateral shift of COF and lateral stress concentration within the ankle joint. However, as the tibial varus progressed, the COF shifted medially and the lateral stress concentration decreased.

Return to sport following isolated opening wedge high tibial osteotomy

BACKGROUND

The purposes of the study are as follows: (1) examine the timeline of return to sport (RTS) following isolated high tibial osteotomy (HTO), (2) evaluate the degree of participation and function upon RTS and (3) identify reasons that patients do not return or discontinue participation in sport activity.

METHODS

Patients undergoing isolated HTO were reviewed retrospectively at a minimum of two years post-operatively. Patients completed a subjective sports questionnaire, a visual analog scale for pain, Single Assessment Numerical Evaluation, and a satisfaction questionnaire.

RESULTS

Thirty-eight patients (70.4%) were included at an average of 9.0 ± 3.3 years. Thirty-four patients (average age 42.7 ± 7.2 years, 90.0% with a Kellgren-Lawrence grade of III/IV) participated in sports within three years prior to surgery. Eighteen patients (52.9%) returned to the operating room by the time of final follow-up, including 13 patients (38.2%) who underwent salvage arthroplasty by 6.1 ± 3.6 years following HTO. Thirty patients (88.2%) returned to ≥1 sport at an average of 7.5 ± 5.0 months; however only 41.2% were able to return to preinjury level of participation.

CONCLUSIONS

In patients with medial osteoarthritis and varus deformity, isolated high tibial osteotomy provides a high rate (88.2%) of return to sport by 7.5 months postoperatively, yet only a fraction of patients returned to their preinjury level. HTO is not a definitive treatment option as nearly 40% of patients underwent knee arthroplasty by 6.1 years post-operatively. Patient expectations regarding return to sport can be appropriately managed with adequate preoperative patient education.

LEVEL OF EVIDENCE

IV.

The importance of costing perspective: an example evaluating the cost-effectiveness of a locking versus nonlocking plate in medial opening wedge high tibial osteotomy

Summary

High tibial osteotomy (HTO) fixation can be achieved using various plate designs. Compared with nonlocking plates, the stability of locking plates allows patients to return to weight-bearing and work sooner and may also decrease postoperative complications, introducing the potential for overall cost savings. However, material costs for locking plates are higher, and the plate bulkiness may lead to additional surgery to remove the plate. We conducted a retrospective study to evaluate the cost-effectiveness of a locking versus a nonlocking plate in HTO from both the health care payer and societal perspectives up to 12 months postoperative. We observed that from a health care payer perspective, the locking plate was not cost-effective. However, the locking plate was cost-effective from the societal perspective (addition of indirect costs, such as time off work). These findings highlight the importance of considering costing perspective in economic evaluations for chronic conditions, particularly in publicly funded health care systems.

Assessment of valgus laxity after release of the medial structure in medial open-wedge high tibial osteotomy: an in vivo biomechanical study using quantitative valgus stress radiography

Background

To perform medial open-wedge high tibial osteotomy (OWHTO), surgeons expose the medial-proximal tibia by releasing or cutting the superficial layer of the medial collateral ligament (sMCL). Biomechanically, the sMCL provides primary restraint against valgus forces. Therefore, any release of the sMCL can cause valgus instability of the knee joint. The purpose of this study was to assess valgus laxity after release of the medial structure of the knee during OWHTO.

Methods

Between 2009 and 2015, 84 consecutive patients (93 knees) who underwent OWHTO using a locking plate were enrolled in this study. All patients underwent radiological examinations before surgery, during surgery, 1 year after surgery, and after plate removal to objectively assess valgus laxity. The medial joint space (MJS) and the joint line convergence angle (JLCA) of the knee were evaluated using quantitative valgus stress radiography. Clinical evaluation was performed 2 years after surgery.

Results

The mean functional knee score improved significantly, from 65.5 to 91.1 points (p < 0.0001). The mechanical axis percentage shifted to pass through a point 69.7% lateral from the medial edge of the tibial plateau. The MJS and JLCA increased significantly during OWHTO surgery (11.0 mm, 7.4 °, p < 0.0001). However, no significant differences were noted in the MJS and JLCA among preoperative, 1-year postoperative periods and after plate removal.

Conclusion

Valgus laxity was significantly greater after release of the sMCL. However, no significant differences were noted in valgus laxity in preoperative, 1-year postoperative periods and after plate removal. Complete release of the sMCL did not cause postoperative valgus laxity after OWHTO surgery.

Trial registration

Trial registration number: No.012–0360.

Patient Evaluation and Indications for Osteotomy Around the Knee

Osteotomy is recognized as a knee joint-preserving surgical procedure to treat frontal and/or sagittal plane malalignment with or without associated instability. This article outlines the preoperative clinical and imaging assessments of prospective patients undergoing osteotomy. In addition, indications and contraindications as well as surgical planning are presented.

Hybrid closed wedge high tibial osteotomy improves patellofemoral joint congruity compared with open wedge high tibial osteotomy

PURPOSE

To evaluate clinical outcomes and radiographic changes in patellofemoral (PF) joint congruity between open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge HTO (HCWHTO).

METHODS

From 2011 to 2013, 36 knees in 31 patients who underwent OWHTO and 21 knees in 17 patients who underwent HCWHTO were evaluated in this retrospective study with a minimum 5-year follow-up. Radiological outcomes including hip-knee-ankle angle (HKA), femoral patellar height index (FPHI), preoperative PF osteoarthritis (OA) grade, medial and lateral joint spaces of the PF joint, and congruence angle were measured. Clinical parameters including the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee Score (OKS) were also evaluated. Preoperative and final follow-up values for each procedure were compared in outcome analyses.

RESULTS

Mean preoperative HKA and the degree of PF-OA were significantly more severe for patients treated with HCWHTO compared with those treated with OWHTO (p = 0.001, p = 0.0001). Mean postoperative FPHI was significantly decreased with proximalization of the patella in HCWHTO (p = 0.01) but showed no significant change in OWHTO (n.s.). Regarding PF joint congruity after HCWHTO, lateral joint space and congruence angle were significantly improved (p = 0.0001, p = 0.005), while medial joint space was not significantly changed (n.s.). After OWHTO, congruence angle showed no significant difference (n.s.), but medial and lateral joint spaces were significantly decreased (p = 0.0001, p = 0.018). There were no significant differences in KOOS and OKS between the groups (n.s., n.s.).

CONCLUSIONS

Although degrees of varus knee and PF-OA were more severe in HCWHTO than those in OWHTO, HCWHTO led to improved PF joint congruity, and its mid-term clinical outcomes were equivalent to those of OWHTO. Therefore, in patients with varus knee combined with PF-OA preoperatively, HCWHTO is a more effective treatment than OWHTO.

LEVEL OF EVIDENCE

Therapeutic level III.

Distal Femoral Medial Opening Wedge Osteotomy for Post-Traumatic, Distal Femoral Varus Deformity

Restoration of neutral mechanical alignment of the lower limb is an important factor in the treatment of unicompartmental arthrosis. Traditionally, medial opening wedge high tibial osteotomy has been widely performed to correct varus malalignment with unicompartmental arthrosis. However, an ideal indication for the high tibial osteotomy is the knee with metaphyseal tibial varus malalignment. The basic principle of corrective osteotomy is performing an osteotomy at the center of the deformity to prevent abnormal joint line obliquity. If pathologic distal femoral varus deformity is the cause of genu varum, the osteotomy should be performed in the distal femur. Reports of medial opening wedge distal femoral osteotomy (DFO) to correct varus malalignment are rare. We present a case of this very rare and challenging condition in a 47-year-old male, which was successfully treated by medial opening wedge DFO.

Intra- and Extra-Articular Deformity of Lower Limb: Tibial Condylar Valgus Osteotomy (TCVO) and Distal Tibial Oblique Osteotomy (DTOO) for Reconstruction of Joint Congruency

Osteotomies are the established surgical procedure for the deformity of the lower limb induced by osteoarthritis (OA) of the knee and ankle. Closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO) are extra-articular surgery, which aim to shift the mechanical axis from medial to slightly lateral and reduce the overload in the medial compartment of the varus deformed knee by extra-articular correction. However, varus deformity of the knee with the teeter effect, which could be accompanied with subluxation and thrust due to the medial-lateral soft tissue imbalance, is not resolved only by the shift of mechanical axis. The depression of the medial tibia plateau, so-called pagoda deformity, is the intra-articular deformity, which could potentially cause the teeter effect and involves intra-articular incongruency. In such case, the osteotomy with novel concept should be developed to overcome the issues, both the imbalance of soft tissue and intra-articular deformity. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy, which improves the joint congruency of the medial-compartment knee OA with subluxation and/or intra-articular deformity and also provides better joint stability. A similar argument is raised in the treatment of the ankle OA. Low tibial osteotomy (LTO) is an extra-articular surgery to correct malalignment of lower leg. Distal tibial oblique osteotomy (DTOO) is a novel surgery to improve the bony congruency of the ankle OA. In DTOO, the distal tibia is cut obliquely from the proximal medial to the distal lateral in the coronal plane and towards the center of the tibiofibular joint to improve the bony congruency of the ankle joint. Tibial condylar valgus osteotomy (TCVO) and distal tibial oblique osteotomy (DTOO) can correct intra-articular deformity of knee and ankle, respectively. The rationale and indication of TCVO and DTOO for the treatment of the lower limb by reconstructing the joint congruency are discussed.

Gait biomechanics after combined HTO-ACL reconstruction versus HTO alone: A matched cohort study

The purpose of the present study was to compare bilateral external knee moments during gait in patients with concomitant medial compartment knee OA, varus alignment and chronic anterior cruciate ligament (ACL) deficiency who underwent either medial opening-wedge high tibial osteotomy alone (HTO) or simultaneous HTO and ACL reconstruction (HTO-ACLR). Fifty-two patients (26 matched pairs) completed 3D gait analysis preoperatively and at a minimum 5 years postoperatively. Patients were matched for preoperative age, sex, body mass index and magnitude of correction. Primary outcomes selected a priori were the peak knee adduction moment (KAM) and knee flexion (KFM) moment during stance. Moments were compared using mixed model repeated measures analysis of variance (ANOVA). For the peak KAM, there was a significant time by limb interaction. For both groups, there were similar reductions in the peak KAM 5 years postoperatively in the surgical limb only [-1.34 %BW × Ht (-1.71, -0.96) and -1.72 %BW × Ht (-1.99, -1.44) for HTO and HTO-ACLR, respectively]. For the peak KFM, there was a significant time by group by limb interaction. There was a decrease in the peak KFM 5 years postoperatively in the HTO group [-0.88 %BW × Ht (-1.45, -0.31)] but not in the HTO-ACLR group [0.03 %BW × Ht (-0.43, 0.48)]. These results suggest that individuals with medial knee OA, varus alignment and chronic ACL deficiency who undergo simultaneous medial opening-wedge HTO and ACL reconstruction may not experience the same long-term (5 year) changes in sagittal plane knee biomechanics observed in patients undergoing HTO alone. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy

PURPOSE

High tibial osteotomy (HTO) has gained more importance in the treatment of cartilage damage or osteoarthritis of the medial compartment with concurrent varus deformity. Concerning the extent of axis correction, various different views exist. The aim of this study was to evaluate the effect of the size of axis correction on functional outcome in patients undergoing a valgus HTO.

METHODS

From 2005 to 2013, 156 patients with an underlying varus deformity and cartilage damages or unicompartimental osteoarthritis of the medial compartment were treated by HTO. Retrospectively patients were allocated into three different groups according to the degree of axis correction. For this purpose, three adjacent areas, respectively, comprising 5% of the tibial plateau were defined. Limits of those areas were set as follows: with the medial border representing the 0% point and the lateral border representing the 100 point, the three areas were separated according to their limiting intersection points (group A 50-55%, group B 55-60%, group C > 60%). For comparison of the functional outcomes, standardized measures and scores were used (pre-OP: VAS, Lysholm; post-OP: VAS, Lysholm, KOOS). Analysis of the pre- and post-operatively recorded X-rays was effected by means of a planning software (mediCAD, Hectec GmbH, Germany), and statistical analysis was carried out using SPSS Statistics 21.0 (IBM Corp., Armonk, USA). A p value of 0.05 was considered statistically significant.

RESULTS

Thirty-nine patients were allocated to group A, 50 patients to group B and 67 to group C. Pre-operatively, patients in each group were of a homogenous constitution. In the groups A-C, HTO proved to reduce the VAS score and to increase the Lysholm score (p < 0.001). Regarding outcome parameters, group A showed significantly better results in terms of increased Lysholm (p = 0.049) and KOOS pain score (p = 0.043). In patients treated by HTO and ACI implantation for medial compartment lesions, the best results were achieved in group A which was of statistical significance in comparison of the Lysholm (p = 0.006) and VAS score (p = 0.045) of groups A and C. In this subgroup, the size of the post-operative valgus angle significantly correlated with the final VAS score (PC 0.364; p = 0.013), final Lysholm score (PC - 0.390; p = 0.007) and KOOS4 (PC - 0.356; p = 0.014).

CONCLUSION

HTO for varus deformity in patients with concomitant cartilage damage or osteoarthritis of the medial compartment is a reliable treatment option with satisfying functional outcome. Precise pre-operative planning regarding individual factors in each patient is mandatory; a pathology-based extent of correction leads to a favourable clinical outcome and to a significant reduction in pain.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Longitudinal changes in subchondral bone structure as assessed with MRI are associated with functional outcome after high tibial osteotomy

OBJECTIVES

The primary objective of this study was to evaluate the effects of high tibial osteotomy (HTO) on subchondral bone structure assessed with magnetic resonance (MR)-based trabecular bone imaging and the correlations of these effects with functional outcome and clinical symptoms.

METHODS

Patients with varus malalignment (6.2±2.2°) and without a history of knee surgery (n=22; 3 women; 48.7±10.3 years) were included into this prospective study. 1.5T MR imaging was performed before and on average 1.5 years after HTO (amount of correction 4.7±2.5°) and histomorphometric parameters of the trabecular bone were calculated for the medial/ lateral tibia and femur. Functional outcome was assessed with validated scores focusing on sports activity including the Lysholm Score, Tegner Activity Scale and the adapted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score.

RESULTS

Apparent trabecular number significantly decreased in all compartments of the tibiofemoral joint when comparing values before and on average 1.5 years after HTO (P<0.05 for all). Decrease in apparent trabecular number was significantly higher within the medial tibia compared to the lateral compartment (mean difference -0.24 mm^-1 (95% confidence interval (CI): -0.33, -0.14 mm^-1); P<0.001). Apparent trabecular bone thickness significantly increased within 1.5 years after HTO in the lateral femur (P=0.002) and tibia (P <0.001). The Lysholm Score and Tegner Scale demonstrated an improvement of functional outcome, and the adapted WOMAC demonstrated an improvement of pain, stiffness and physical function within 1.5 years after HTO (P<0.01), with the improvement of WOMAC correlating significantly with changes in trabecular bone thickness within the medial tibia (r= -0.48; P=0.01).

CONCLUSION

These findings indicate a reversal of the previous subchondral bone alterations in patients with varus malalignment after undergoing HTO, while pronounced subchondral changes were associated with a better functional outcome.

LEVEL OF EVIDENCE

3.

[Effectiveness of medial open wedge high tibial osteotomy combined with posterior slope angle of tibial plateau correction in treatment of osteoarthritis of limited flexion knee with varus deformity]

Objective

To explore the short-term effectiveness of medial open wedge high tibial osteotomy (OWHTO) combined with posterior slope angle of tibial plateau correction to treat the osteoarthritis of limited flexion knee with varus deformity.

Methods

The data of 18 cases (18 knee) with osteoarthritis of limited flexion knee with varus deformity between January 2014 and July 2016 were analyzed retrospectively. There were 6 males and 12 females with an average age of 54.9 years (range, 48-64 years). There were 8 cases of left knee and 10 cases of right knee. The varus of knee ranged from 7.45 to 15.52° (mean, 10.63°). According to Kellgren-Lawrence grading standard, there were 4 cases of grade Ⅱ and 14 of grade Ⅲ. OWHTO was used to adjust the varus deformity, and the posterior slope angle of tibial plateau was adjusted to solve the limited flexion.

Results

The thickness of osteotomy was 10-19 mm (mean, 14.91 mm). The operation time was 1.2-2.0 hours (mean, 1.4 hours). All incisions healed by first intension. All patients were followed up 1.0-2.5 years, with an average of 1.5 years. At last follow-up, the range of knee flexion and Lysholm score, Hospital for Special Surgery (HSS) score, and International Knee Documentation Committee (IKDC) score were significantly higher than preoperative ones, showing significant differences ( P<0.05). X-ray films showed that the osteotomy healed at 3- 7 months (mean, 3.6 months) after operation. At last follow-up, the limb alignment by the relative position of tibial plateau and the posterior slope angle of tibial plateau were significantly improved, showing significant differences when compared with preoperative ones ( P<0.05).

Conclusion

The OWHTO combined with posterior slope angle of tibial plateau correction can significantly improve the range of flexion and functional score in short-term.

A critical appraisal of medial open wedge high tibial osteotomy for knee osteoarthritis

A medial open wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure to correct varus deformity related to Knee Osteoarthritis. It consistently provides relief in knee pain and improves knee function. This technique is recommended for active, middle and old aged individuals with an isolated medial compartment knee OA. The MOWHTO scores several advantages over lateral closed wedge osteotomy and hence is now a preferred choice of HTO.

Changes in biomechanical risk factors for knee osteoarthritis and their association with 5-year clinically important improvement after limb realignment surgery

OBJECTIVE

To evaluate 5-year outcomes after lower limb realignment and test the hypothesis that surgery-induced changes in selected biomechanical risk factors for medial knee osteoarthritis (OA) are associated with clinically important improvements.

DESIGN

We prospectively evaluated patient-reported outcomes, full-limb standing radiographs and gait biomechanics before, 6 months (surgery-induced change) and 5 years after medial opening wedge high tibial osteotomy (HTO) in 170 patients (46.4 ± 8.9 years, 135 males) with knee OA and varus alignment. Logistic regression tested the associations of 6-month changes in mechanical axis angle and knee adduction moment with achieving an increase of ≥10 points in the Knee injury and Osteoarthritis Outcome Score (KOOS)4 at 5 years, with and without adjusting for covariates. Gait data were also compared to existing data from healthy controls.

RESULTS

Mean 5-year changes (95% confidence interval (CI)) were: KOOS4: +14.2 (10.8, 17.6); mechanical axis angle: +8.21° (7.58, 8.83); knee adduction moment: -1.49 %BW*Ht (-1.35, -1.63). The postoperative knee adduction moments were typically lower than values for healthy controls. When divided into quartiles, although all strata improved significantly, patients with reductions in knee adduction moment of 1.14-1.74 %BW*Ht (neither largest nor smallest changes) had highest 5-year KOOS4 scores. The 6-month change in knee adduction moment (odds ratios (OR) = 0.38; 95% CI: 0.22, 0.67), preoperative KOOS4 (OR = 0.96; 95% CI: 0.94, 0.99) and preoperative medial tibiofemoral narrowing grade (OR = 0.62; 95% CI: 0.37, 1.00) were negatively associated with having a 5-year clinically important improvement (C-statistic = 0.70).

CONCLUSIONS

Substantial improvements in biomechanical risk factors and patient-reported outcomes are observed 5 years after medial opening wedge HTO. The surgery-induced change in load distribution during walking is significantly associated with long-term clinically important improvement.

High Rates of Return to Sports Activities and Work After Osteotomies Around the Knee: A Systematic Review and Meta-Analysis

BACKGROUND

Knee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce.

OBJECTIVES

Our aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW.

METHODS

We systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled.

RESULTS

We included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders.

CONCLUSION

Eight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload.

Conventional plate and screws in medial opening-wedge high tibial osteotomy: are they sufficiently stable? A retrospective study

Objective

Opening-wedge osteotomy of the proximal tibia is a widely performed procedure for treating medial gonarthrosis in active patients and in the presence of varus malalignment of the lower limb. The fixation method is controversial, and the use of conventional implants has been abandoned in favor of implants with more modern locking screws. The aim of the present clinical study was to assess the maintenance of the correction achieved in cases wherein fixation was performed using conventional implants.

Methods

This retrospective study included 51 patients who underwent opening-wedge high tibial osteotomy wherein fixation was performed using conventional implants (4.5-mm DCP plate and non-locking screws). Radiological findings regarding patellar height, tibial slope, and varus correction postoperatively and after consolidation were analyzed to assess the maintenance of the correction achieved by osteotomy.

Results

The mean loss of correction angle, calculated by the difference between the correction angle in the immediate postoperative period and that after consolidation, was 0.92° ± 0.9°. In addition, changes in patellar height determined by the Blackburne–Peel method and in the sagittal slope of the tibial plateau were not significant or clinically relevant.

Conclusions

The use of conventional plates and screws is viable in the fixation of opening-wedge high tibial osteotomy because they provide enough stability to maintain the achieved correction until consolidation, without significant changes.

The use of factor Xa inhibitors following opening-wedge high tibial osteotomy for venous thromboembolism prophylaxis

PURPOSE

This study aimed to investigate the incidence of venous thromboembolism (VTE) after medial opening-wedge high tibial osteotomy (OWHTO) and evaluate the efficacy and safety of edoxaban for the prevention of VTE in patients undergoing OWHTO.

METHODS

A total of 139 patients with osteoarthritis or osteonecrosis undergoing OWHTO were enrolled in this prospective, randomized study. Four patients were excluded because of preoperatively diagnosed VTE, and 135 patients were divided into two groups-an edoxaban group and a non-edoxaban group-and underwent computed tomography venography on day 7 to check for postoperative VTE. Blood samples were taken on the day before OWHTO and on postoperative days 1, 3, 7, and 14.

RESULTS

Treatment with edoxaban reduced the incidence of VTE after OWHTO; however, there was no statistically significant difference between the two groups. No major bleeding was noted in the edoxaban group. There were significant differences in the D-dimer level, prothrombin time, fibrinogen level, and thrombin antithrombin complex levels between the groups.

CONCLUSIONS

Edoxaban is an oral, once-daily, selective, direct factor Xa inhibitor that is safe and easy to handle. It may offer a new option for preventing VTE after OWHTO.

LEVEL OF EVIDENCE

I.

Valgus Stress Radiographs Predict Lateral-Compartment Cartilage Thickness but Not Cartilage Degeneration in Varus Osteoarthritis

BACKGROUND

Intact cartilage in the lateral compartment is an important requirement for medial unicompartmental knee arthroplasty. This study sought to determine how measurements of joint space width in the lateral compartment on valgus stress radiographs compare to cartilage thickness as measured with a precise needle test, and whether cartilage thickness is a predictor of cartilage degeneration.

METHODS

A consecutive series of 100 knees undergoing total knee arthroplasty for end-stage varus osteoarthritis was studied. Twenty-eight knees were retrospectively excluded because not all data were available, leaving 72 knees (61 patients; mean age, 67 years [49-87]). On calibrated valgus stress radiographs, lateral-compartment joint space width was measured. During surgery, osteochondral samples of the distal lateral femur and the lateral tibia plateau were harvested. Cartilage thickness and histology were assessed. Cartilage thickness of tibia and femur was defined as lateral-compartment cartilage thickness.

RESULTS

Lateral-compartment joint space width on valgus stress radiographs and lateral-compartment cartilage thickness correlated well (r_s = 0.671, P < .001). However, no correlation of cartilage histology according to the osteoarthritis cartilage histopathology assessment system, and cartilage thickness on the lateral tibia plateau (r_s = -0.060, P = .614) and cartilage thickness on the distal lateral femur (r_s = -0.128, P = .282) was observed.

CONCLUSION

Valgus stress radiographs can assess combined cartilage thickness in the lateral compartment of the knee. Cartilage thickness, however, is a poor predictor of cartilage degeneration.

Medial compartment knee osteoarthritis: age-stratified cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy

PURPOSE

To compare the age-based cost-effectiveness of total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO) for the treatment of medial compartment knee osteoarthritis (MCOA).

METHODS

A Markov model was used to simulate theoretical cohorts of patients 40, 50, 60, and 70 years of age undergoing primary TKA, UKA, or HTO. Costs and outcomes associated with initial and subsequent interventions were estimated by following these virtual cohorts over a 10-year period. Revision and mortality rates, costs, and functional outcome data were estimated from a systematic review of the literature. Probabilistic analysis was conducted to accommodate these parameters' inherent uncertainty, and both discrete and probabilistic sensitivity analyses were utilized to assess the robustness of the model's outputs to changes in key variables.

RESULTS

HTO was most likely to be cost-effective in cohorts under 60, and UKA most likely in those 60 and over. Probabilistic results did not indicate one intervention to be significantly more cost-effective than another. The model was exquisitely sensitive to changes in utility (functional outcome), somewhat sensitive to changes in cost, and least sensitive to changes in 10-year revision risk.

CONCLUSIONS

HTO may be the most cost-effective option when treating MCOA in younger patients, while UKA may be preferred in older patients. Functional utility is the primary driver of the cost-effectiveness of these interventions. For the clinician, this study supports HTO as a competitive treatment option in young patient populations. It also validates each one of the three interventions considered as potentially optimal, depending heavily on patient preferences and functional utility derived over time.

Good functional results following high tibial opening-wedge osteotomy of knees with medial osteoarthritis: A prospective study with a mean of 8.3years of follow-up

BACKGROUND

To report time dependent functional improvement and predictive risk factors for failure when the load in varus knees with medial osteoarthritis is shifted from the medial to the lateral knee compartment.

METHODS

Forty-nine consecutive patients (52 knees), mean age 47 (31-64) years, underwent a high tibial opening-wedge valgus osteotomy stabilized with a Puddu plate and bone grafting. The patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at three and six months, one, two, five and 10years postoperatively with a mean follow-up time of 8.3years (2.0-10.6).

RESULTS

Mean angular correction was 8.0° (four to 12). The five subscores of KOOS increased significantly during the first year by 40-131% from preoperative values, the good results remaining throughout the 10-year follow-up for those with a surviving osteotomy. The outcome was related to the grade of preoperative osteoarthritis. Seven knees were converted to total knee arthroplasty (TKA) mean 6.2years (two to nine) post-operatively, and had a lower KOOS preoperatively than those of surviving osteotomies. The osteotomy survival rate at five years was 94% and at 10years 83%. Patients with KOOS subscore quality of life (QoL) <44 at the two-year follow-up had a 11.7 times higher risk for later TKA than those with QoL ≥44 (P=0.017).

CONCLUSION

High tibial opening-wedge osteotomy for medial knee osteoarthritis resulted in good functional recovery after one year and favorable mid-term results. It may be a good treatment option for middle-aged patients with varus knees and medial osteoarthritis in order to prevent or postpone TKA.