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

Comparison of the indications for high tibial osteotomy and double-level osteotomy for the correction of diverse lower-leg deformities in an Asian population with medial compartment osteoarthritis: a retrospective observational study

PURPOSE

Double-level osteotomy (DLO) for knee osteoarthritis is becoming increasingly popular to achieve superior anatomical correction. This study aimed to compare the indication for open-wedge high tibial osteotomy (OWHTO) and DLO and to investigate preoperative bone morphology.

METHODS

Data of 166 knees treated with osteotomy were evaluated. The weight-bearing line ratio, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured. Bone deformity assessment and osteotomy simulation were conducted. Normal values of mLDFA and mMPTA were defined as 85-90°. Bone deformity was classified into four patterns: femoral, tibial, both, and no deformity. Simulation was performed to achieve a postoperative weight-bearing line ratio of 62%. Distal femoral osteotomy (DFO) or OWHTO was performed to achieve an mLDFA of 85° or mMPTA of up to 95°. If the postoperative parameter remained outside the correctable limit, DLO was performed. Cases were classified according to the corrective surgery performed, and those that could not be corrected after DLO were classified into the uncorrectable group.

RESULTS

Femoral, tibial, both, and no deformities were observed in 14.2%, 37.8%, 10.7%, and 33.9% of cases, respectively. No cases were classified into the DFO group; however, 53.6%, 38.1%, and 8.3% were classified into the OWHTO, DLO, and uncorrectable groups, respectively.

CONCLUSION

Bone deformity differed among cases, and only one-third had tibial deformity. OWHTO and DLO were indicated in approximately 50% and 40% of cases, respectively. Our study results reinforce the importance of evaluating leg morphology before surgical planning to achieve acceptable alignment.

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.

Meniscal allograft transplantation: A matched-pair analysis reveals worse sport activity level but similar clinical improvement and survival in women compared to men

PURPOSE

The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT).

METHODS

A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches.

RESULTS

Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences.

CONCLUSION

While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT.

LEVEL OF EVIDENCE

Level III, comparative study.

Effect of Medial Opening Wedge and External Rotational Humeral Osteotomies on Medial Elbow Compartment Pressure: An Ex Vivo Study

OBJECTIVE

 The aim of this study was to assess if the level of osteotomy (50 or 75% the length of the humerus), osteotomy angle (5, 10, or 20 degrees), direction of bone alteration (external rotational or medial opening wedge osteotomies), or orientation of osteotomy (perpendicular to the humeral long axis or perpendicular to the weight-bearing axis of the limb) affect pressure through the medial compartment of the elbow.

STUDY DESIGN

 Humeral osteotomies were performed at 50 and 75% the length of the humerus on 12 canine cadaver thoracic limbs and patient-specific three-dimensional (3D) printed plates applied to induce the desired alteration. Sensors were placed into the medial and lateral aspects of the elbow joint and the limb compressed to 90 N in a universal testing system.

RESULTS

 Increasing the angle of the induced change had a significant effect on the decreased load through the medial compartment. Performing the osteotomy at 75% of humeral length from proximal was significantly more effective at reducing the medial elbow load than performing it at 50%. Opening wedge osteotomies were more effective than external rotational osteotomies, but both were effective. Changing the direction of the osteotomy (comparing transverse to oblique) did not significantly affect the load reduction through the medial compartment.

CONCLUSION

 Performing an osteotomy at a more distal location along the humerus and increasing the angle of the induced change increased the effectiveness of load-shifting humeral osteotomies.

Osteotomy for treating knee osteoarthritis from 2012 to 2023: Bibliometric analysis and global trends

BACKGROUND

Numerous surgical interventions are available for the treatment of knee osteoarthritis (KOA). In recent years, knee-preserving surgery, specifically osteotomy, has gained significant attention from patients, particularly those who are young and physically active, as it not only effectively alleviates pain but also preserves bone integrity, thereby allowing for potential future joint replacement. This study aims to comprehensively analyze the global application trends of osteotomy for KOA and identify the current research hotspots.

METHODS

We conducted a literature search encompassing English-language studies on osteotomy for KOA published from 2012 to 2023 in the Web of Science Core Collection (WoSCC) database. Bibliometric analysis tools, including VOSviewer, CiteSpace, and R Studio, were employed to analyze global trends and research hotspots.

RESULTS

We analyzed 1520 eligible publications, comprising 1350 articles and 170 reviews. The number of articles on osteotomy for KOA has exhibited a consistent upward trend over the past decade. The top 3 contributing countries (South Korea, United States, and China) accounted for 45.98% of all published articles. U.S. scholars exhibited high productivity, prominence, and academic impact in this field. Seoul National University published the most papers on the relationship between osteotomy and KOA, while Sungkyunkwan University had the highest average citation rate. Among authors, Yong Seuk Lee from Korea and Steffen Schroeter from Germany had the highest number of publications and average citation values, respectively. Research interests were clustered into 5 categories: "High tibial osteotomy," "Biomechanics of osteotomy," "Osteotomy combined with cartilage repair techniques," "Postoperative prognosis and outcomes," and "Improvement of surgical techniques."

CONCLUSION

Recent years have witnessed notable rapid progress in the research on osteotomy for KOA. The field is poised for continued growth in terms of academic literature. The United States has emerged as a global leader in knee osteotomy research, while Korea demonstrates considerable potential in this domain. Future research hotspots may encompass high tibial osteotomies, osteotomies combined with cartilage repair techniques, and advancements in surgical techniques for KOA.

High tibial osteotomy versus unicompartmental knee arthroplasty for Kellgren-Lawrence grade 3-4 knee osteoarthritis in younger patients: comparable improvements in patient-reported outcomes, adjusted for osteoarthritis grade and sex

PURPOSE

Previous studies comparing high tibial osteotomy (HTO) with unicompartmental knee arthroplasty (UKA) have seldom accounted for differing patient characteristics between both groups. This study compared patient-reported outcomes (PROs) of HTO and UKA patients, adjusted for preoperative PROs, osteoarthritis grade and sex.

METHODS

A retrospective study was performed analysing prospectively collected PROs, namely the Oxford Knee Score (OKS) and pain/satisfaction scores, collected preoperatively and at 6 months, 12 months and 24 months postoperatively. Consecutive medial opening-wedge HTOs and medial UKAs from 2016-2019, with a preoperative Kellgren-Lawrence grade ≥ 3, aged 50-60 years, were included. Linear mixed model analyses, with the OKS over time as the primary outcome, were used.

RESULTS

We included 84 HTO patients (mean age 55.0 ± 3.0, 79% male, mean BMI 27.8 ± 3.4, 75% Kellgren-Lawrence grade 3) and 130 UKA patients (mean age 55.7 ± 2.8, 47% male, mean BMI 28.7 ± 4.0, 36% Kellgren-Lawrence grade 3). Response rates were ≥ 87% at all time points. Corrected for preoperative PROs, Kellgren-Lawrence grade and sex, the HTO group had a 2.5 (95% CI 1.0-4.0) points lower OKS over time than the UKA group (p = 0.001). The Numeric Rating Scale scores (NRS; 0-10) for pain at rest and during activity were higher (p < 0.01) in the HTO group. The EQ-5D-descriptive system (p < 0.01), NRS satisfaction (p < 0.01), anchor function and pain scores (p < 0.01) were lower over time in the HTO group.

CONCLUSION

UKA patients had better OKS scores, pain and satisfaction scores over time than HTO patients. However, the observed differences were below their established minimal clinically important differences. Therefore, from the patients' perspective, HTO did not appear to be inferior to UKA under the indications outlined in this study. Level of evidence Level IV.

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.

Effects of Lateral Opening-Wedge Distal Femoral Osteotomy on Meniscal Allograft Transplantation: A Biomechanical Evaluation

Background

Lateral meniscal deficiency with valgus malalignment increases the rate of lateral compartment osteoarthritis. Lateral meniscal allograft transplantation (LMAT) with a concomitant varus-producing opening-wedge distal femoral osteotomy (DFO) is an option yet to be evaluated biomechanically.

Purpose/Hypothesis

The purpose of this study was to clarify the biomechanical effects of the realignment procedure in the setting of LMAT. We hypothesized that (1) given the dependence of the lateral compartment on the lateral meniscus, a DFO and increasing degrees of varus would be insufficient to restore lateral compartment pressures to normal from a lateral meniscus-deficient state, and that (2) LMAT would restore lateral compartment pressures to the intact state while DFO would decrease lateral compartment pressures for any given state of the meniscus.

Study Design

Controlled laboratory study.

Methods

Ten cadaveric knees underwent opening-wedge varus-producing DFO secured by an external fixator. Anatomic alignment was standardized to 6° of mechanical valgus, and each joint was tested in full extension. Submeniscal placement of thin film pressure sensors allowed for the recording of contact pressure, peak contact pressure, and contact area. The specimens were loaded on a biaxial dynamic testing machine with loading angles between 9° valgus and 6° varus of mechanical alignment. Conditions tested included intact meniscus, meniscal deficiency, and meniscal transplantation.

Results

Isolated varus-producing DFO to 6° in the meniscus-deficient state failed to restore joint pressures and contact areas to the intact state, with significant changes in mean contact pressure (175%), mean peak contact pressure (135%), and contact area (-41%) (all P < .05 vs intact), while LMAT restored all outcome measures (all P > .05 compared with intact). After LMAT, every additional 1° of DFO correction contributed to a decrease in the mean contact pressure, peak pressure, and contact area of 5.6% (-0.0479 N/mm²), 5.9% (-0.154 N/mm²), and 1.4% (-6.99 mm²) for the lateral compartment and 7.3% (+0.034 N/mm²), 12.6% (+0.160 N/mm²), and 4.3% (+20.53 mm²) for the medial compartment, respectively.

Conclusion

Isolated DFO was inadequate to restore load distribution in meniscus-deficient knees, while concomitant LMAT restored near normal forces and improved the lateral compartment biomechanical profile.

Clinical Relevance

Our findings support the concomitant use of LMAT and varus-producing DFO in the setting of lateral meniscal deficiency with valgus malalignment. This study provides tools for the orthopaedic surgeon to individualize the correction for each patient.

Femoral-varus tibial-valgus osteotomy (FVTVO) for neutrally-aligned knee osteoarthritis with severe joint line obliquity enables return to sports activities: A case series study

Background

Re-alignment surgeries for uni-compartmental knee osteoarthritis, such as high tibial osteotomy (HTO) for varus knees or distal femoral osteotomy (DFO) for valgus knees, are recognized as standard strategies. However, the treatment strategy has not been established for patients with a neutrally-aligned osteoarthritic knee with severe joint line obliquity (JLO) owing to the combination of a valgus femur and a varus tibia; i.e., type II coronal plane alignment of the knee (CPAK). total knee arthroplasty (TKA) can be an option for CPAK type II-aligned osteoarthritis in older inactive patients. Here, we hypothesized that joint line horizontalization by femoral-varus tibial-valgus osteotomy (FVTVO), which may reduce the shear stress induced by JLO, could be a treatment option for CPAK type II-aligned osteoarthritis in young active patients who wish to return to sports (RTS) activity. Our aim in this study was to evaluate the postoperative results of FVTVO with RTS.

Methods

Our indications for FVTVO are as follows: JLO >5°; mechanical medial proximal tibial angle (mMPTA) < 87°; mechanical lateral distal femoral angle (mLDFA) < 87°; typical osteoarthritis patterns for CPAK type II on magnetic resonance images, namely osteoarthritic change of the lateral tibial spine, medial slip of the femur, and/or lateral meniscal extrusion from the lateral femoral condyle; and flexion contracture <10°. We enrolled patients who wished to RTS and who had a pre-symptom Tegner score ≥5 and had completed at least a 1-year follow-up. For FVTVO, closed-wedge DFO was performed in all femurs; both closed-wedge HTO and open-wedge HTO were used in the tibia, depending on the situation. Range of motion exercises began on the first postoperative day, and full weight-bearing was permitted 6 weeks postoperatively. Jogging was permitted 3 months postoperatively after confirming bone union, and patients could gradually return to their sports activity 6-12 months' postoperatively. The Japanese Orthopaedic Association (JOA) score and knee flexion range were assessed preoperatively and at the last follow-up. Tegner activity scale scores were assessed presymptom, preoperatively, and at the last follow-up. The hip-knee-ankle (HKA) angle, JLO, mMPTA, and mLDFA were evaluated radiologically, and meniscal extrusions, osteoarthritic change, and/or bone marrow edema were assessed on magnetic resonance images.

Results

One man and two women were included in this case series. Two were competitive athletes and one was a mountain climber. The patients' ages were 69, 46, and 57 years (Case 1, 2, and 3, respectively). All patients' CPAK type was converted from type II to type V; i.e., neutral-aligned knee with a neutral joint line, postoperatively. All patients returned to their presymptom sports activity level by the final follow-up. The presymptom/preoperative/final follow-up Tegner scale in Case 1, 2, and 3 were 6/1/6, 5/2/5, and 7/3/7, respectively.

Conclusion

Joint line horizontalization by FVTVO for patients with a neutral-aligned knee with severe JLO provided highly satisfactory clinical results and successfully led to RTS.

Clinical Effect of Isolated Lateral Closing Wedge Distal Femoral Osteotomy Compared to Medial Opening Wedge High Tibial Osteotomy for the Correction of Varus Malalignment: A Propensity Score-Matched Analysis

BACKGROUND

Recent evidence questions the role of medial opening wedge high tibial osteotomy (mowHTO) in the correction of femoral-based varus malalignment because of the potential creation of an oblique knee joint line. However, the clinical effectiveness of alternatively performing an isolated lateral closing wedge distal femoral osteotomy (lcwDFO), in which the mechanical unloading effect in knee flexion may be limited, is yet to be confirmed.

PURPOSE/HYPOTHESIS

The purpose of this article was to compare clinical outcomes between patients undergoing varus correction via isolated lcwDFO or mowHTO, performed according to the location of the deformity, in a cohort matched for confounding variables. It was hypothesized that results from undergoing isolated lcwDFO for symptomatic varus malalignment would not significantly differ from the results after mowHTO.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent isolated mowHTO or lcwDFO according to a tibial- or femoral-based symptomatic varus deformity between January 2010 and October 2019 were enrolled. Confounding factors, including age at surgery, sex, body mass index, preoperative femorotibial axis, and postoperative follow-up, were matched using propensity score matching. The International Knee Documentation Committee (IKDC) Subjective Knee Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively.

RESULTS

Of 535 knees assessed for eligibility, 50 knees (n = 50 patients, n = 25 per group) were selected by propensity score matching. Compared with preoperatively, both the mowHTO group (IKDC, 55.1 ± 16.5 vs 71.3 ± 14.7, P = .002; WOMAC, 22.0 ± 18.0 vs 9.6 ± 10.8, P < .001; Lysholm, 55.2 ± 23.1 vs 80.7 ± 16, P < .001; VAS, 4.1 ± 2.4 vs 1.6 ± 1.8, P < .001) and the lcwDFO group (IKDC, 49.4 ± 14.6 vs 66 ± 20.1, P = .003; WOMAC, 25.2 ± 17.0 vs 12.9 ± 17.6, P = .003; Lysholm, 46.5 ± 15.6 vs 65.4 ± 28.7, P = .011; VAS, 4.5 ± 2.2 vs 2.6 ± 2.5, P = .001) had significantly improved at follow-up (80 ± 20 vs 81 ± 43 months). There were no significant differences between the groups at baseline, at final follow-up, or in the amount of clinical improvement in any of the outcome parameters (P > .05; respectively).

CONCLUSION

Performing both mowHTO or lcwDFO yields significant improvement in clinical outcomes if performed at the location of the deformity of varus malalignment. These findings confirm the clinical effectiveness of performing an isolated lcwDFO in femoral-based varus malalignment, which is comparable with that of mowHTO in the correction of varus malalignment.

Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral-based symptomatic varus malalignment: an analysis at a mean 6-year follow-up

PURPOSE

To evaluate return to sport (RTS), work (RTW) and clinical outcomes following lateral closing wedge distal femoral osteotomy (LCW-DFO) for symptomatic femoral varus malalignment.

METHODS

Consecutive patients who underwent LCW-DFO for symptomatic varus malalignment between 12/2007 and 03/2018 were included. The International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analogue scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were assessed by questionnaire.

RESULTS

Thirty-two patients (mean age: 45.9 ± 12.3 years), who underwent LCW-DFO for femoral-based varus malalignment (6.4 ± 3.0°), were included at a mean follow-up of 72.7 ± 39.1 months. The patient collective significantly improved in IKDC (51.8 ± 12.3 to 61.8 ± 21.5, p = 0.010; 95% CI = 3-21), WOMAC (26.7 ± 17.6 to 12.5 ± 13.5; p < 0.001; 95% CI = 21-6) and Lysholm (46.5 ± 19.4 to 67.9 ± 22.8 points (p < 0.01; 95% CI = 9-31)) scores at final follow-up. The VAS for pain reduced significantly postoperatively (4.8 ± 2.3 points to 2.6 ± 2.3 points (p = 0.002; 95% CI = 0-3)). Following LCW-DFO, 96% of patients returned to sports at a mean of 5.3 ± 2.9 months. Yet, a shift to lower impact sports compared to one year preoperatively was observed, with patients participating in a significantly lower number of high-impact disciplines (p = 0.024) and fewer hours in high-impact sports (p = 0.034). Twenty-three out of 24 patients returned to work at a mean 11.4 ± 10.9 weeks, with 18 patients reporting a similar or superior working ability.

CONCLUSION

Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to RTS and RTW along with a significant functional improvement at mid-term follow-up. However, patients' expectations have to be adequately managed regarding a limited probability to return to high-impact sports and work after surgery.

LEVEL OF EVIDENCE

Retrospective case series; Level IV.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis

PURPOSE

The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis.

METHODS

Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol.

RESULTS

The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions.

CONCLUSION

Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers.

LEVEL OF EVIDENCE

Level II.

Clinical outcomes of hybrid closed wedge high tibial osteotomy for advanced osteoarthritis of the knee compared with total knee arthroplasty

PURPOSE

To evaluate clinical outcomes between hybrid closed wedge high tibial osteotomy (HCWHTO) and total knee arthroplasty (TKA) for advanced medial compartmental osteoarthritis of the knee (advanced knee OA).

METHODS

In more than grade 3 OA based on the Kellgren-Lawrence classification, when patients' age was less than 60 years or activity level was more than level 5 based on the UCLA activity score, 22 knees (18 patients) underwent HCWHTO. The other 22 knees (18 patients) that underwent TKA were evaluated retrospectively. Muscle strength was evaluated preoperatively and at 1 year postoperatively. The visual analogue scale (VAS) and Japanese version of the Knee injury and Osteoarthritis Outcome Score (J-KOOS) were used to evaluate clinical outcomes preoperatively and at a mean 66-months follow-up.

RESULTS

All postoperative muscle strength measures improved to preoperative equivalent levels in the HCWHTO group; they were significantly higher in the HCWHTO group than in the TKA group (p < .05). The VAS score and total J-KOOS significantly improved in both groups (HCWHTO, p = .001; TKA, p = .040); there were no significant differences in the scores between the groups at the final follow-up. Hybrid closed wedge HTO significantly improved the activities of daily living and sport/recreation scores, whereas TKA did not at the final follow-up.

CONCLUSIONS

In advanced knee OA, HCWHTO led to improved muscle strength, and its midterm clinical outcomes were equivalent to those of TKA. To postpone or even to avoid TKA, HCWHTO is considered an appropriate treatment for young and high-activity patients with advanced knee OA.

LEVEL OF EVIDENCE

Therapeutic Level III.

Around-knee osteotomy conversion for failed high tibial osteotomy: Re-correction high tibial osteotomy and additional distal femoral osteotomy may enable return to sporting activities

High tibial osteotomy (HTO) for knee osteoarthritis achieves excellent short- and long-term results. However, failure of HTO due to undercorrection or correction loss may necessitate conversion surgery. For patients with HTO failure who desire a return to sporting activities (RTS), non-prosthetic joint-preserving solutions such as conversion to around-knee osteotomies (AKO-conversion) may be more appropriate than total knee arthroplasty. The present study aimed to introduce potential non-prosthetic joint-preserving solutions for failed HTO and investigate the postoperative RTS. Among the patients who received non-prosthetic solutions for failed HTO from 2015 to 2020, this case series included those who were eager to RTS, were participating in a sporting activity with a Tegner activity scale score of ≥5 immediately before being affected by knee osteoarthritis, and had at least 2 years of follow-up. Deformity analysis for the preoperative planning of the AKO-conversion was based on the mechanical lateral distal femoral angle, joint line convergence angle, and mechanical medial proximal tibial angle. Four patients met the study inclusion criteria: two patients who underwent re-correction HTO and two who received additional distal femoral osteotomy (DFO). The average ages at primary HTO and AKO-conversion were 69.5 ± 11.8 years and 71.5 ± 10.9 years, respectively. The hip-knee-ankle angle was corrected from −2.8 ± 1.5° before conversion surgery to 3.3 ± 1.5° at 2 years after AKO-conversion. All four patients finally achieved a better sporting performance after AKO-conversion than preoperatively, and the Tegner activity scale score was improved from 2.5 ± 1.0 before AKO-conversion to 5.8 ± 0.5 at the 2-year follow-up. The duration between AKO-conversion and full RTS was 11.8 ± 6.7 months. In conclusion, two patients who underwent re-correction HTO and two who underwent additional DFO for undercorrection or correction loss after primary HTO achieved highly satisfactory clinical results, including RTS. The present findings suggest that non-prosthetic joint-preserving solutions using AKO for failed HTO should be considered as options to enable RTS.

Double level osteotomy for genu varum: Is a return to sport possible?

INTRODUCTION

A double level osteotomy (DLO) may be indicated in patients with genu varum when the deformity involves both the tibia and femur. These patients, who are often young and active, have a high functional demand and hope for a rapid return to sport. The purpose of our study was to assess return to sport and functional outcomes following DLO for symptomatic genu varum.

MATERIALS AND METHODS

A total of 40 patients (mean age 45.5±2 years) who underwent a DLO between 2018 and 2020, performed in 2 different hospitals, were reviewed after a minimum follow-up of 1-year. The mean initial varus was 11±2°. The type of sport and frequency of participation (UCLA activity score) as well as time to return to sport and level of activity recovered were defined as the primary endpoints. Functional scores were also assessed with the knee injury and osteoarthritis outcome score (KOOS).

RESULTS

At the last follow-up, 87.5% (n=35) of patients reported that they had returned to sport. The mean time to return to sport was 6±1 months with a significant difference (p<0.001) between the pre- and postoperative UCLA activity scores. There was a strong correlation between the presence of a joint line obliquity >3° and decreased functional outcomes (p<0.0001). The overall KOOS score improved (p<0.001) by a mean of 38.6 points after the correction. The 8 lateral cortical fractures (Takeuchi type I and II) and the 2 medial cortical fractures (Nakayama type 1) that were found had no impact on functional outcomes (p>0.05).

CONCLUSION

Our findings demonstrated that DLO provided rapid return to sport, thus making it possible to meet the functional demands and expectations of patients.

LEVEL OF EVIDENCE

IV; Retrospective study.

Risk Factors Affecting Return to Sports and Patient-Reported Outcomes After Opening-Wedge High Tibial Osteotomy in Active Patients

Background:

Although opening-wedge high tibial osteotomy (OWHTO) is favored for active patients who expect to return to sports, there is still a lack of robust evidence for factors affecting their recovery.

Purpose:

To identify (1) risk factors leading to a decreased level of return to preoperative sports after OWHTO and (2) patient characteristics and intraoperative factors influencing patient-reported outcomes after return to sports.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Included were 69 patients who underwent OWHTO and who expected to return to their preoperative level of sports, measured as a Tegner activity level ≥2. All included patients had a minimum of 1 year of follow-up data. Logistic regression analyses were performed to assess the effect of independent variables on the level of return to preoperative sports after surgery; the independent variables were age, sex, body mass index, preoperative Tegner score, preoperative Kellgren-Lawrence grade, preoperative percentage of mechanical axis (%MA), opening gap width, concomitant meniscal treatment, postoperative %MA, postoperative medial proximal tibial angle (MPTA), and postoperative posterior tibial slope. Univariate and multiple regression analyses were performed to assess for influencing factors on postoperative International Knee Documentation Committee (IKDC) subjective scores in patients who were able to return to sports.

Results:

Of the 69 patients, 51 (73.9%) returned to sports after OWHTO. High preoperative Tegner scores were statistically associated with a decrease in return to sports (odds ratio, 1.494; P = .033). Multiple regression analysis (n = 46 patients) identified that a higher postoperative MPTA was associated with a decreased IKDC subjective score after return to sports (r = –0.345; P = .019).

Conclusion:

Higher postoperative MPTA was associated with the worsening of patient-reported outcomes among those patients who did return to their preoperative sports after OWHTO. Also, participation in high-activity sports was confirmed to be a significant risk factor for a decreased rate of return to preoperative sports. These findings can support preoperative planning and intraoperative decision making, particularly for active patients.

Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

Knee joint distraction (KJD) is a novel technique for relatively young knee osteoarthritis (OA) patients. With KJD, an external distraction device creates temporary total absence of contact between cartilage surfaces, which results in pain relief and possibly limits the progression of knee OA. Recently, KJD showed similar clinical outcomes compared with high tibial osteotomy (HTO). Yet, no comparative data exist regarding return to sport (RTS) and return to work (RTW) after KJD. Therefore, our aim was to compare RTS and RTW between KJD and HTO. We performed a cross-sectional follow-up study in patients <65 years who previously participated in a randomized controlled trial comparing KJD and HTO. Out of 62 eligible patients, 55 patients responded and 51 completed the questionnaire (16 KJDs and 35 HTOs) at 5-year follow-up. The primary outcome measures were the percentages of RTS and RTW. Secondary outcome measures included time to RTS/RTW, and pre- and postoperative Tegner's (higher is more active), and Work Osteoarthritis or Joint-Replacement Questionnaire (WORQ) scores (higher is better work ability). Patients' baseline characteristics did not differ. Total 1 year after KJD, 79% returned to sport versus 80% after HTO (not significant [n.s.]). RTS <6 months was 73 and 75%, respectively (n.s.). RTW 1 year after KJD was 94 versus 97% after HTO (n.s.), and 91 versus 87% <6 months (n.s.). The median Tegner's score decreased from 5.0 to 3.5 after KJD, and from 5.0 to 3.0 after HTO (n.s.). The mean WORQ score improvement was higher after HTO (16 ± 16) than after KJD (6 ± 13; p = 0.04). Thus, no differences were found for sport and work participation between KJD and HTO in our small, though first ever, cohort. Overall, these findings may support further investigation into KJD as a possible joint-preserving option for challenging "young" knee OA patients. The level of evidence is III.

Improved Clinical Outcome and High Rate of Return to Low-Impact Sport and Work After Knee Double Level Osteotomy for Bifocal Varus Malalignment

PURPOSE

To evaluate return to sport (RTS) and work (RTW), as well as clinical outcomes following double level osteotomy (DLO) via combined medial open wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy for bifocal symptomatic varus malalignment, and to compare these outcome parameters between patients undergoing a single surgery and those undergoing a two-stage procedure.

METHODS

Consecutive patients who underwent DLO for symptomatic varus malalignment between 12/2007 and 03/2018 were enrolled. Patients converted to arthroplasty (n = 3) during follow-up were excluded. Outcome measures included the International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain, which were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were evaluated by questionnaire. Outcome measures were compared between DLO performed in a single- versus a two-stage surgery.

RESULTS

Thirty-two patients (mean age: 44.2 ± 12.6 years), who underwent DLO for varus malalignment (10.1° ± 2.9°) were included at a mean follow-up of 56.9 ± 35.3 months (range: 24-148). Compared to preoperatively, these patients significantly improved in IKDC (50.4 ± 13.9 to 66.1 ± 15.4; P < .001), WOMAC (29.7 ± 19.2 to 11.8 ± 13.5; P < .001) and Lysholm (53.6 ± 23.6 to 73.1 ± 23.6; P = .002) scores at final follow-up. For the WOMAC score, 78% of the patients included reached the minimally important clinical difference, along with a significant reduction of the VAS for pain (5.0 ± 3.0 to 2.5 ± 2.4; P < .001). Postoperatively, 96% of patients returned to sport after 7.7 ± 4.8 months, but at a lower frequency (P = .010) and to fewer disciplines (P = .005) with a shift to low-impact sports. 90% of the patients returned to work at a mean 5.9 ± 9.4 months, with 79% reporting a similar or superior working ability. Patients undergoing a two-stage procedure recovered to full physical working ability at a significantly longer duration, as compared to a single-stage procedure (9.8 ± 3.8 vs 9.0 ± 13.1 months; P = .047).

CONCLUSION

The majority of patients undergoing DLO for symptomatic varus malalignment, who were not converted to arthroplasty, experienced clinically significant functional improvement at mid-term follow-up. Return to sport and work rates in these patients were high; however, a shift to lower-impact sports disciplines was observed. Similar clinical outcomes can be expected when performing DLO in a single surgery or a two-stage procedure.

LEVEL OF EVIDENCE

Retrospective case series; Level IV.

Return to sport following distal femur osteotomy: a systematic review

INTRODUCTION

Distal femur osteotomies (DFOs) are well-accepted procedures in treating unicompartmental knee osteoarthritis associated with valgus malalignment. This study aims to investigate the Return to sport (RTS) after DFO.

MATERIALS AND METHODS

We conducted a systematic review of the literature according to the PRISMA guidelines, including all articles published in English, with no time limit, excluding double-level knee osteotomies.

RESULTS

Five articles were included for an overall cohort of 76 patients. The mean follow-up was 45.53 months. The mean age of the patients at the time of surgery was 33.87 years, and the mean malalignment was 5.59° in valgus. In 70 cases, patients received a lateral DFO, while in 6 cases, a medial closing-wedge DFO. An RTS of 86.1% was observed after DFO and a mean time to RTS of 12.3 months. 76.8% of patients recovered to a level equal to or higher than that practiced before the onset of symptoms. No statistically significant differences were observed in the RTS rate between those who performed lateral or medial DFO.

CONCLUSIONS

RTS after DFO is ubiquitous and occurs around one year after surgery. In most cases, patients report improved performance compared to what they experienced before the onset of symptoms. Unfortunately, while athletes often have RTS at a similar or better level, other patients often see a return to lower impact sports.

Return to Sport After Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-analysis

Background:

Patients undergoing unicompartmental knee arthroplasty (UKA) often want to return to sport (RTS) after surgery. However, the time taken to RTS and proportion of patients who RTS after UKA remain unknown.

Purpose:

To determine the time to RTS and proportion of patients who RTS after UKA.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A search was performed using PubMed, Medline, Embase, SPORTDiscus and the Cochrane Library databases for clinical trials reporting on RTS after UKA published between database inception and September 2021. In addition, a manual search was performed of relevant sports medicine and orthopaedic journals, and bibliographies were reviewed for eligible trials. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to undertake this study.

Results:

This meta-analysis included 11 studies (749 patients) that reported on RTS after UKA. The proportion of patients returning to sports increased over time: 6 studies (432 patients) demonstrated an overall pooled proportion of 48.1% (95% CI, 36.3%-60.2%) of patients who returned to sport at 3 months after surgery, while 7 studies (443 patients) demonstrated an overall pooled proportion of 76.5% (95% CI, 63.9%-87.1%) of patients who returned to sport at 6 months after surgery. Overall, 92.7% (95% CI, 85.8%-97.4%) of 749 patients were able to RTS at 4 years after surgery. Overall excellent patient-reported functional outcomes scores and low risk of complications with RTS after UKA were reported.

Conclusion:

The authors found that 48.1% of patients were able to RTS at 3 months after surgery and 76.5% were able to RTS at 6 months after UKA. Pooled proportion analysis showed that >90% of patients undergoing UKA were able to RTS at 48 months after surgery. The majority of patients who were able to RTS after UKA did so at a lower level of intensity than their preoperative level. RTS after UKA was associated with good patient-reported functional outcomes scores and a low risk of complications.

Work intensity and quality of life can be restored following double-level osteotomy in varus knee osteoarthritis

PURPOSE

The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term.

METHODS

Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: -11.0 ± 3.0° (-6.0 to -17.0), age: 49.1 ± 9.5 (31-65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5-43) months).

RESULTS

The duration that the patients were unable to work was 12.2 ± 4.4 (6-20) weeks. The PCS improved from 32.1 ± 11.3 (14.5-53.3) preoperatively to 54.6 ± 8.5 (25.2-63.7) (p < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1-67.7) to 57.2 ± 3.1 (47.3-61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population (p < 0.001), whereas the preoperative MCS was similar between the two groups (n.s.). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0-5.0) to 4.0 (2.0-7.0) (p < 0.001).

CONCLUSION

Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO.

LEVEL OF EVIDENCE

Study type: therapeutic, IV.

Return to Work Following Tibial Tubercle Osteotomy for Patellofemoral Osteoarthritis and Pain

PURPOSE

To evaluate the ability of patients to return to work following anteromedialization (AMZ) tibial tubercle osteotomy (TTO) due to isolated patellofemoral osteoarthritis or pain.

METHODS

Consecutive patients undergoing AMZ TTO were reviewed retrospectively at a minimum of 1 year postoperatively. Patients completed a subjective work questionnaire, a visual analog scale for pain, as well as a Kujala questionnaire and satisfaction questionnaire.

RESULTS

Fifty-seven patients (61 knees; average age: 32.7 ± 9.6 years) were contacted at an average follow-up of 4.86 ± 2.84 years postoperatively. The preoperative Kujala score improved from 55.7 ± 17.8 to 84.6 ± 15.8 at final follow-up (P < 0.001). Thirty-seven patients (64.9%) were employed within 3 years prior to surgery and 34 patients (91.9%) were able to return to work by 2.8 ± 2.6 months postoperatively. However, only 27 patients (73.0%) of patients were able to return to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations were able to return to work at a rate of 100.0%, 93.8%, 77.8%, and 100.0% by 2.2 months, 3.0 months, 3.1 months, and 4.0 months, postoperatively. No patients underwent revision TTO or conversion to arthroplasty by the time of final follow-up.

CONCLUSION

In patients with focal patellofemoral osteoarthritis or pain, AMZ TTO provides a high rate of return to work (91.9%) by 2.8 ± 2.6 months postoperatively. Patients with higher intensity occupations may take longer to return to work than those with less physically demanding occupations.

LEVEL OF EVIDENCE

III.

A 2021 consensus statement on osteotomies around the knee by the UK Knee Osteotomy consensus Group (KOG)

BACKGROUND

There are significant deficiencies in the evidence base of modern-day osteotomy which result in significant variation in practice between surgeons. The purpose of this statement was to develop a consensus statement on the practice of osteotomy so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined. The article is also intended to educate and inform the practice of individuals who are early in their experience and/or clinical practice.

METHOD

A group of 29 specialist knee surgeons who regularly perform osteotomy was convened to form the Knee Osteotomy consensus Group (KOG). Consensus was determined utilizing the consensus group technique described by List. A total of 37 questions were asked covering all aspects of clinical practice.

RESULTS

20 statements were generated and debated until a criterion level of 70% was met.

CONCLUSIONS

Consensus was achieved regarding 20 statements concerning Indications for surgery, decision making, surgical planning, technique, post-operative assessment and recovery.

Return to Work After Autologous Chondrocyte Implantation of the Knee in Patients with Workers Compensation Insurance

OBJECTIVE

This retrospective analysis aimed to evaluate patient and defect characteristics on return to work after autologous chondrocyte implantation (ACI) for all patients with workers compensation insurance in our clinic.

METHODS

Retrospective analysis of medical records of patients with workers compensation treated with ACI in our clinic over 10 years (August 2004 to November 2014). Data were collected on demographics, lesion size and location, number of defects, duration of symptoms, and outcomes.

RESULTS

A total of 28 patients with 30 ACI procedures were included in this analysis. Patients had a mean age of 40.0 years, were mostly male, and tended to be overweight (mean body mass index = 31.5 kg/m²). Most patients were employed in occupations with high physical demand (85.7%) compared with lower physical demand jobs (14.3%). The mean number of lesions per knee = 1.73. Overall, the mean total surface area of the defect was large (12.6 cm²), with large mean individual lesion size of 7.39 cm². All 28 patients returned to work in some capacity, with a total of 22 (79%) returning to full work, and 6 (21%) returning to modified work. There were no significant differences in the comparison of patients who returned to full versus modified work, in mean age, body mass index, high versus low physical demand occupation, or lesion characteristics (size, chronicity, or location).

CONCLUSIONS

Our results demonstrate that in a challenging workers compensation cohort, in patients with multiple large defects, treatment with ACI allows a high percentage of patients to return to their normal vigorous work activities within 9 months to 1 year following cartilage restoration. This study is a level IV retrospective case series.

Anterior Proximal-to-Posterior Distal Oblique Proximal Tibial Osteotomy

High tibial osteotomy is a common procedure to address unicompartment knee osteoarthritis and other conditions. Regarding the specific surgical methods, medial open wedge osteotomy and lateral close wedge osteotomy are the most used. Both methods have a common disadvantage in that they are not so suitable to correct a severe deformity. Thus, we would like to introduce an anterior proximal-to-posterior distal oblique proximal tibial osteotomy technique, which is especially suitable to correct severe tibial deformity. The most critical point of this technique is to create an osteotomy plane from the most proximal posterior site of the tibial tubercle posteriorly and distally to the posterior cortex of the tibia, with each horizontal osteotomy maneuver in the coronal plane. Combined fibular osteotomy is always needed, and better results can be obtained when it is combined with arthroscopic debridement of the knee. We consider the introduction of this technique will provide a useful option when tibial osteotomy is needed to preserve the knee, especially for a great deformity correction.

Return to Work Following Isolated Opening Wedge High Tibial Osteotomy

PURPOSE

Patients with isolated medial compartment osteoarthritis and varus deformity may undergo high tibial osteotomy (HTO) to reduce the contact pressure in the medial compartment. The purpose of this investigation is (1) examine the timeline of return to work (RTW) following HTO and (2) evaluate RTW stratified by occupational intensity.

METHODS

Consecutive patients undergoing HTO were reviewed retrospectively at a minimum of 2-years postoperatively. Patients completed a subjective work questionnaire, a visual analogue scale for pain, Single Assessment Numerical Evaluation, and a satisfaction questionnaire.

RESULTS

Thirty-eight patients were included at an average of 9.0 ± 3.3 years postoperatively. Thirty-seven patients (average age 43.4 ± 7.8 years, 91.9% with a Kellgren-Lawrence grade of III/IV) were employed within 3 years prior to surgery. Eighteen patients (48.6%) underwent subsequent surgery with 14 patients (37.8%) receiving a salvage knee arthroplasty at an average of 6.1 ± 3.5 years following HTO. Thirty-five patients (94.5%) returned to work at an average of 2.9 ± 2.0 months. The rate of RTW for sedentary, light, moderate, and heavy duties were 87.5%, 100%, 100%, and 93.3%, respectively, while the duration until RTW was 1.0 months, 1.1 months, 2.4 months, and 3.3 months, respectively.

CONCLUSION

In a young and active population with osteoarthritis or varus deformity, an HTO allows patients to return to work; however, patients with high-intensity occupations may be absent from work longer than those with lesser physically demanding occupations. HTO is not a definitive treatment option as nearly 40% of patients underwent knee arthroplasty by 6.1 years postoperatively.

LEVEL OF EVIDENCE

IV, case series.

Return to sports activity after opening wedge high tibial osteotomy in patients aged 70 years and older

BACKGROUND

The purpose of this study was to evaluate return to sports (RTS) after opening wedge high tibial osteotomy (OWHTO) in elderly patients and associated factors affecting RTS.

METHODS

Seventy-four patients (mean age 68 years) who underwent OWHTO were enrolled. Clinical outcomes were evaluated using the Knee Society Score (KSS). Patients were asked regarding types of sports activities and their levels of participation within preoperative 1 year and postoperative 1 year. Levels of participation in sports and recreational activities were examined using the Tegner activity scale. The outcomes were compared between two age groups (≥ 70 years vs. < 70 years).

RESULTS

Of the 74 patients overall, 59 participated in at least one sport preoperatively, and 55 returned to sports postoperatively (RTS 93%). The KSS knee score and function score were significantly improved after surgery in both age groups (P < 0.05), but no significant differences were found between the age groups. The Tegner activity scales for ≥ 70 years and < 70 years were 2.9 ± 1.1 and 4.0 ± 1.9 preoperatively (P < 0.01) and 2.7 ± 1.2 and 3.3 ± 1.4 postoperatively (P = 0.16), respectively. RTS was reported by 24 of 25 (96.0%) in the age < 70 years group and 31 of 34 (91.2%) in the age ≥ 70 years group. Majority of age ≥ 70 years participated in low-impact sports preoperatively and returned to the same impact level postoperatively.

CONCLUSIONS

The rate of RTS after OWHTO was high in patients aged 70 years and older with low-impact level. OWHTO is a preferred surgical option for elderly patients who desire RTS.

Good Validity and High Internal Consistency of the Forgotten Joint Score-12 in Patients After Medial Opening Wedge High Tibial Osteotomy

BACKGROUND

The Forgotten Joint Score-12 (FJS-12) was originally developed to assess awareness of an artificial joint. Medial opening wedge high tibial osteotomy (MOWHTO), an alternative surgical method of knee replacement, is a joint-preservation surgery; therefore, joint awareness should be used to evaluate its clinical results. However, FJS-12 has not been validated as a tool to evaluate the postoperative results of MOWHTO. This study aimed to validate FJS-12 in MOWHTO.

METHODS

Patients with bilateral knee surgery, previous knee surgery, flexion contracture >15°, varus alignment >20°, and patients without plate removal surgery were excluded. Finally, 71 knees of 71 patients were analyzed, with a mean follow-up of 34.5 months. The FJS-12 score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained, and the floor and ceiling effect of each score was investigated. Cronbach's α was calculated to determine the internal consistency of FJS-12. Spearman's correlation coefficients between FJS-12 and KOOS were calculated to assess convergent validity.

RESULTS

There were ceiling effects in 3 KOOS subscales (symptoms [25.4%], pain [15.5%], and activities of daily living [25.4%]) but not in FJS-12 (8.5%). No floor effect was noted in any patient-reported outcome measures. The total Cronbach's α was 0.9457 in FJS-12. FJS-12 showed moderate-to-strong positive correlations with all KOOS subscales (r = 0.64-0.72).

CONCLUSION

FJS-12 showed a lower ceiling effect than KOOS and high internal consistency and convergent validity in patients following MOWHTO. With its low ceiling effect, FJS-12 was found to be useful for evaluating patients following MOWHTO.

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.

Good clinical outcomes and return to sports after hybrid closed-wedge high tibial osteotomy

PURPOSE

This study aimed to investigate preoperative sports participation and postoperative clinical outcomes including a return to sports (RTS) after hybrid closed-wedge high tibial osteotomy (CWHTO) for medial compartment osteoarthritis of the knee. Characteristic of Hybrid CWHTO was defined as extra-articular lateral closed and medial open wedge osteotomy.

METHODS

The patients who underwent hybrid CWHTO from January 2016 to December 2018 were retrospectively reviewed and divided them into sports and non-sports groups. The preoperative demographic and radiographic characteristics were compared in both groups. And the clinical outcomes including the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS), Lysholm score, University of California at Los Angeles (UCLA) activity score, and RTS in the sports group were also investigated. Statistical analysis was performed for comparisons among the preoperative factors between the two groups. Influence of sports impact and bone union of fibular osteotomy was also statistically investigated for RTS.

RESULTS

Of the 161 knees (129 patients; 46 males, 83 females), 20 knees (16 patients; 13 males, 3 females; 12.3%) belonged to sports group. Although there were no significant differences regarding the age and radiographic parameters, there were significant differences in the body mass index and proportion of males between both groups. The JOA, VAS, Lysholm, and UCLA activity scores significantly improved after surgery. RTS was 80% at a mean duration of 7.2 ± 3.1 months. RTS in the high-impact sports group was significantly lower than that in the low-impact sports group (high-impact 60% vs. low-impact 100%, p = 0.043). There was no significant difference in RTS regarding bone union after fibular osteotomy.

CONCLUSION

The clinical outcomes including RTS were satisfactory in patients with hybrid CWHTO.

LEVEL OF EVIDENCE

IV.

Return to sports rate after opening wedge high tibial osteotomy in athletes

PURPOSE

We hypothesized that patient treated with OWHTO who participate in high-impact sports would attain satisfactory outcome. The purpose of this study was to examine the clinical and radiological outcomes in a consecutive series of opening-wedge high tibial osteotomy (OWHTO) in highly active patients.

METHODS

Seventy-seven consecutive patients who underwent OWHTO with varus osteoarthritic knees were included in the study. The mean age of the study population was 56.1 years. All patients were followed for a minimum of 2 years. Clinical and radiological evaluations were performed at 12 and 24 months after surgery. The clinical results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) Subjective Score. In regards to radiological assessment, the following parameters were measured in full-length weightbearing radiographs both pre- and postoperatively; mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA), and weight bearing line (WBL) ratio.

RESULTS

Fifty-eight patients (75.3%) returned to the same high-impact sports activities as before surgery, with a mean time to return of 8.7 ± 2.7 months (6-14 months). In the clinical assessments, the IKDC subjective score and KOOS both improved from the mean preoperative scores of 38.4 and 217.4 points to the mean postoperative scores of 74.5 and 421.6 points, respectively. The mean pre-symptomatic Tegner activity scale was 5.3 ± 0.6 and significantly decreased to 4.8 ± 1.2 at 2 years postoperative (p < 0.05). In the radiological evaluation, the postoperative mTFA, mMPTA, and WBL ratio values averaged 1.3° ± 2.2° valgus, 90.7° ± 2.9°, and 51.6% ± 8.4°, respectively, at 24 months after surgery.

CONCLUSIONS

Clinical outcomes based on postoperative patient-reported outcome measures and rate of return to high-impact sports activities were favorable after OWHTO in patients with knee OA who desired to continue sporting activities with the Tegner activity score of  ≥ 5 points.

LEVEL OF EVIDENCE

Retrospective case series, IV.

Recommendations for Patients with High Return to Sports Expectations after TKA Remain Controversial

(1) Background: Improved surgical techniques and implants in total knee arthroplasty (TKA) have led to broader indications for surgical interventions of osteoarthritis of the knee. There is a growing young and active patient subgroup with high return to sports (RTS) expectations after TKA. The current lack of evidence regarding RTS capacity in this patient cohort, requires the consolidation of experts' opinions and experiences to address the special needs among these patients. The aim of this study was to assess current expert opinions in regard to preoperative patient assessment, surgical technique and decision-making and patient counseling for these patients. (2) Methods: We performed a survey among surgeons specialized in arthroplasty with a questionnaire designed to assess current recommendations, surgical techniques, and implant preferences as well as patient counseling in patients with high expectations for RTS after TKA. (3) Results: The majority of surgeons are in favor of return to low-impact sports after TKA within 3 to 6 months. Some even recommend return to high-impact sports. Despite improvement of surgical techniques and implants, we observed no clear preference for a single surgical technique or implant specification in active patients. (4) Conclusions: Current evidence for sports-associated complications after TKA is scarce. Despite a growing array of surgical techniques and implants, the available literature is still controversial with no single surgical technique or TKA design distinguishing itself clearly from others. Surgeons' recommendations are mostly based on their experience and training. Nonetheless, we observed growing faith in modern implants with some surgeons even recommending high-impact sports after TKA.

Return to Work After Distal Femoral Varus Osteotomy

Background

Distal femoral varus osteotomy (DFVO) is a well-described procedure to address valgus deformity of the knee. There is a paucity of information available regarding patients' ability to return to work (RTW) after DFVO.

Purpose

To report the objective findings for RTW rates and times for patients receiving a DFVO for lateral compartment osteoarthritis secondary to valgus deformity of the knee.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective study of patients who received a lateral-wedge opening DFVO. Patients must have worked within 3 years before their operation to be included for analysis. Patients were contacted at a minimum of 2 years postoperatively for interview and questionnaire evaluation, including a subjective work questionnaire, visual analog scale (VAS) for pain, Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire.

Results

Overall, 32 patients were contacted at a mean follow-up of 7.1 ± 4.1 years (range, 2.2-13.3 years). The mean ± SD age at the time of surgery was 30.8 ± 8.8 years (range, 17.2-46.5 years), and 65.6% of patients were female. Eleven patients (34.4%) received a concomitant meniscal allograft transplant, and 12 (37.5%) received a cartilage grafting procedure. The average VAS pain score decreased significantly from 6.1 preoperatively to 3.2 postoperatively (P = .03). All patients were able to RTW, at a mean time of 6.0 ± 13.2 months postoperatively (range, 0-72 months). When stratified by work intensity, the average time to return was 13.8, 3.1, 2.7, and 2.9 months for high, moderate, light, and sedentary occupations, respectively. There was no significant difference between these RTW times (P = .16), although this analysis may have been limited by the small sample size. Four patients whose work was classified as heavy work (50%) and 3 whose work was classified as moderate work (18.8%) either switched jobs or kept the same job with lighter physical duties as a result of their procedures.

Conclusion

In a young and active population, DFVO for valgus deformity reliably afforded the ability to RTW within a relatively short time for patients with sedentary, light, and moderate occupational demands. However, patients with moderate- to high-intensity occupational demands may be unable to RTW at their preoperative level.

Opening wedge high tibial osteotomy allows better outcomes than unicompartmental knee arthroplasty in patients expecting to return to impact sports

PURPOSE

Prior studies have compared unicompartmental knee arthroplasty (UKA) with high tibial osteotomy (HTO) suggesting that both procedures had good functional outcomes. But none had established the superiority of one of the two procedures for patients with high expectation including return to impact sport. The aim of this study was to compare functional outcomes and ability to return to impact sport of active patients defined with a pre-arthritis University of California and Los Angeles activity (UCLA) score > 8, after UKA or HTO procedures.

METHODS

A retrospective review of patients with a pre-arthritis UCLA score > 8 operated between January 2014 and September 2017 has identified 91 patients with open-wedge HTO and 117 patients with UKA. A matching process based on age (± 3 years) and gender allowed to include 50 patients in each group for comparative analysis. Patient reported outcomes included Knee Osteoarthritis Outcomes Score (KOOS), UCLA Score, Knee Society Score (KSS) and time to return to sport or previous professional activities at 3, 6, 12 and 24 months following surgery.

RESULTS

Mean time to return to sport activities or previous professional activities were significantly lower for the HTO group than for UKA group [respectively, 4.9 ± 2.2 months for HTO group vs 5.8 ± 6.2 months for UKA group (p = 0.006) and 3 ± 3 months for HTO group vs 4 ± 3 months for UKA group (p = 0.006)]. At 24-month follow-up, UCLA score, KOOS Sports Sub-score and KSS activity score were significantly higher for HTO group than for UKA group (Δ: 2 CI 95% (1.3-2.5 points) p < 0.0001, (Δ: 10.9 CI 95% (2.9-18.9 points) p = 0.04 and Δ: 7.8 CI 95% (2.4-13.4 points) p = 0.006, respectively) and 31 patients (62%) were practicing impact sport in the HTO group versus 14 (28%) in the UKA group (odd-ratio 4.2 CI 95% (1.8-9.7) p < 0.0001).

CONCLUSION

HTO offers statistically significant quicker return to sport activities and previous professional activities with a higher rate of patients able to practice impact activity (62% for HTO vs 28% for UKA) and better sports related functional scores at two years after surgery compared to UKA.

LEVEL OF EVIDENCE

III retrospective case-control study.

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.

Return to Sports After High Tibial Osteotomy Using the Opening Wedge Technique

Objective  The present paper evaluates the resuming of physical activities by young, active patients who practiced some sport modality and underwent a high tibial osteotomy (HTO) using the opening wedge technique.

Methods  A total of 12 patients submitted to HTO using the opening wedge technique were prospectively analyzed. All patients were not playing sports at that time. Pre- and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, visual analog scale for pain and performance level were compared. The average follow-up time was of 12 months.

Results  One patient resumed sporting activities at a performance level significantly lower compared to the preoperative level, while eight patients returned at a slightly below level, two returned at the same level and one patient returned at a higher level in comparison with the preoperative period.

Conclusion  For isolated medial osteoarthrosis treatment, HTO using the opening wedge technique has favorable clinical and functional results, allowing patients to resume their sporting activities.

Integrated care programmes for sport and work participation, performance of physical activities and quality of life among orthopaedic surgery patients: a systematic review with meta-analysis

Objectives

Orthopaedic surgery is primarily aimed at improving function and pain reduction. Additional integrated care may enhance patient’s participation in sports and work, possibly improving performance of physical activities and quality of life (QoL). We aimed to assess the effectiveness of integrated care among orthopaedic surgery patients.

Design

Systematic review with meta-analysis.

Data source

Medline, EMBASE and CINAHL (until 17 June 2019).

Eligibility for selecting studies

We searched for controlled studies on integrated care interventions consisting of active referral to case managers, rehabilitation with participation-based goals and/or e/mHealth, with outcomes of sports and work participation, performance of physical activities and/or QoL. Outcomes were normalised to 0–100 scales and statistically pooled.

Results

Seventeen articles (n=2494) of moderate quality were included reporting on patients receiving back, upper limb, knee or hip surgery. Only one study reported on return to sports and found no significant benefit. For return to work, one study did (90% vs 82%) and one did not (relative risk=1.18 (0.80 to 1.70)) observe significant benefits. Integrated care showed small effects for improving performance of physical activities (2.69 (–0.20 to 5.58); eight studies, n=1267) and QoL (2.62 (1.16 to 5.05); nine studies, n=1158) compared with usual care.

Summary/Conclusion

We found insufficient and inconsistent evidence for the effectiveness of integrated care for orthopaedic surgery patients regarding sport and work participation. Small effects were found for performance of physical activities and QoL. High quality research on integrated care focusing on sports and work participation is needed before integrated care can be implemented for orthopaedic surgery patients.

Medial Opening Wedge High Tibial Osteotomy Decreases Medial Meniscal Extrusion and Improves Clinical Outcomes and Return to Activity

Background:

Medial meniscal extrusion (MME) is defined as displacement of the meniscus that extends beyond the tibial margin. Knee varus malalignment increases MME.

Purpose/Hypothesis:

The purpose of this study was to quantify MME before and after medial opening wedge high tibial osteotomy (HTO) and to correlate the reduction of MME with clinical outcomes and return to activity. It was hypothesized that MME would decrease after HTO and that patients with lower MME after surgery would have improved clinical outcomes and return to activity at short-term follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 66 patients who underwent HTO to correct the anatomic axis with a minimum follow-up of 2 years. MME was measured using magnetic resonance imaging preoperatively and 6 weeks after surgery (study protocol). Patients were assessed preoperatively and postoperatively with the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) score for pain, and Tegner score.

Results:

The mean ± SD preoperative and postoperative MME values were 3.9 ± 0.6 mm and 0.9 ± 0.5 mm, respectively. At 2 years after surgery, KOOS, pain VAS, and Tegner scores were higher than those found preoperatively (P < .001). Patients with less than 1.5 mm of MME after surgery had better clinical outcomes and return to activity compared with patients who had MME of 1.5 mm or more (P < .05).

Conclusion:

Medial opening wedge HTO decreased MME after 6 weeks and improved clinical outcomes and return to activity at a minimum 2-year follow-up. Additionally, patients with postoperative MME of less than 1.5 mm had better clinical outcomes and return to activity compared with patients who had postoperative MME of 1.5 mm or more.

Combined ACL reconstruction and opening wedge high tibial osteotomy at 10-year follow-up: excellent laxity control but uncertain return to high level sport

PURPOSE

The purpose of this study was to report the long-term outcomes of a continuous series of patients who underwent simultaneous anterior cruciate ligament (ACL) reconstruction and opening wedge high tibial osteotomy (HTO) for varus-related early medial tibio-femoral osteoarthritis. It was hypothesized that this combined surgery sustainably allowed return to sport with efficient clinical and radiological results.

METHODS

From 1995 to 2015, all combined ACL reconstruction (bone-patellar tendon-bone graft) and opening wedge HTO for anterior laxity and early medial arthritis were included. Clinical evaluation at final follow-up used Tegner activity score, Lysholm score, subjective and objective IKDC scores. Radiologic evaluation consisted in full-length, standing, hip-to-ankle X-rays, monopodal weight-bearing X-rays and skyline views. AP laxity assessment used Telos™ at 150 N load. Student's t test was performed for matched parametric data, Wilcoxon for nonparametric variables and Friedman test was used to compare small cohorts, with p < 0.05.

RESULTS

35 Patients (36 knees) were reviewed with a mean follow-up of 10 ± 5.2 years. The mean age at surgery was 39 ± 9. At final follow-up 28 patients (80%) returned to sport (IKDC ≥ B): 11 patients (31%) returned to sport at the same level and 6 (17%) to competitive sports. Mean subjective IKDC and Lysholm scores were 71.8 ± 14.9 and 82 ± 14.1, respectively. The mean decrease of the Tegner activity level from preinjury state to follow-up was 0.8 (p < 0.01). Mean side-to-side difference in anterior tibial translation was 5.1 ± 3.8 mm. Three patients were considered as failures. The mean preoperative mechanical axis was 4.2° ± 2.6° varus and 0.8° ± 2.7° valgus at follow-up. Osteoarthritis progression for medial, lateral, and femoro-patellar compartments was recorded for 12 (33%, p < 0.05), 6 (17%, p < 0.001), and 8 (22%, p < 0.05) knees, respectively. No femoro-tibial osteoarthritis progression was observed in 22 knees (61%).

CONCLUSIONS

Combined ACL reconstruction and opening wedge HTO allowed sustainable stabilization of the knee at 10-year follow-up. However, return to sport at the same level was possible just for one-third of patients, with femoro-tibial osteoarthritis progression in 39% of cases.

LEVEL OF EVIDENCE

III.

Predictors of Return to Work After High Tibial Osteotomy: The Importance of Being a Breadwinner

Background

Limited evidence exists on patient-relevant outcomes after high tibial osteotomy (HTO), including return to work (RTW). Furthermore, prognostic factors for RTW have never been described.

Purpose

To investigate the extent and timing of RTW in the largest HTO cohort investigated for RTW to date and to identify prognostic factors for RTW after HTO.

Study Design

Cohort study; Level of evidence, 3.

Methods

Consecutive patients who underwent HTO between 2012 and 2015 were included. Patients received a questionnaire at a mean follow-up of 3.6 years. Questions were asked pre- and postoperatively regarding work status, job title, working hours, preoperative sick leave, employment status, and whether patients were their family's breadwinner. The validated Work Rehabilitation Questionnaire (WORQ) was used to assess difficulty with knee-demanding activities. Prognostic factors for RTW were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph.

Results

We identified 402 consecutive patients who underwent HTO, of whom 349 were included. Preoperatively, 299 patients worked, of whom 284 (95%) achieved RTW and 255 (90%) returned within 6 months. Patients reported significant postoperative improvements in performing knee-demanding activities. Being the family's breadwinner was the strongest predictor of RTW (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.27-6.69). In contrast, preoperative sick leave was associated with lower odds of RTW (OR, 0.20; 95% CI, 0.08-0.46).

Conclusion

After HTO, 95% of patients were able to RTW, of whom 9 of 10 returned within 6 months. Breadwinners were more likely to RTW, and patients with preoperative sick leave were less likely to RTW within 6 months. These findings may be used to improve preoperative counseling and expectation management and thereby enhance work-related outcomes after HTO.

Return to Sport and Outcomes After Concomitant Lateral Meniscal Allograft Transplant and Distal Femoral Varus Osteotomy

PURPOSE

To evaluate the time and rate of return to sport (RTS), as well as outcomes, in young and active patients receiving concomitant lateral meniscal allograft transplantation (MAT) and distal femoral varus osteotomy (DFVO) for lateral meniscal deficiency and valgus malalignment.

METHODS

This was a retrospective study of consecutive patients who underwent concomitant MAT and DFVO by a single surgeon. The exclusion criteria were any concomitant procedures other than cartilage restoration procedures for focal full-thickness cartilage defects of the lateral femoral condyle and less than 2 years of follow-up. At final follow-up, patients were asked to complete a subjective sports questionnaire, the Marx Activity Rating Scale, a visual analog scale (VAS), the Single Assessment Numeric Evaluation, and a satisfaction questionnaire. Changes in patient-reported outcome measures were assessed using nonparametric statistical testing.

RESULTS

A total of 21 patients met the inclusion criteria, of whom 17 were included for analysis at an average follow-up of 7.5 years (range, 2.2-13.3 years). The average age at the time of surgery was 23.3 years (range, 16.9-36.2 years), and 76.5% of patients were female patients. The average VAS score decreased from 5.7 preoperatively to 2.6 postoperatively (P = .02). Of the 15 patients who participated in sports within 3 years prior to their surgical procedure, 14 (82.4%) returned to 1 or more sports at an average of 16.9 months (range, 6-36 months); however, only 46.7% were able to return to their preinjury level of participation or higher. Furthermore, 88.2% of patients reported being satisfied with their sport-related outcomes. Direct rates of sport-specific return were as follows: weightlifting, 100%; skiing, 100%; running, 66.7%; and basketball, 50%.

CONCLUSIONS

In our study population, concomitant MAT and DFVO afforded a high rate of RTS at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores. These findings are essential to note when counseling patients receiving these procedures who wish to resume sports and physical activities so that they may expect an extensive recovery process before they can RTS.

LEVEL OF EVIDENCE

Level IV, case series.

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.

High tibial osteotomy solely for the purpose of return to lifelong sporting activities among elderly patients: A case series study

Knee osteoarthritis (KOA) is a common joint disease among older individuals, associated with increased mortality rates. The current study was conducted to examine whether open wedge high tibial osteotomy (OWHTO) is an effective treatment for elderly patients with a desire to return to sporting activities (RTS) who do not report inconvenience or pain in activities of daily living. We examined a case series of 9 KOA patients (12 knees) aged 50 or above with a desire for RTS, who underwent HTO. We assessed patients before surgery and 2 years after surgery to evaluate surgical outcomes and RTS. The results revealed that patients’ average Japanese Orthopaedic Association score was significantly improved at 2 years after surgery (97.5 ± 4.5), compared with the preoperative score (87.9 ± 7.2; p = 0.008). In addition, the average Tegner activity level score was significantly improved at 2-year follow-up (5.8 ± 1.1) compared with the preoperative score (2.8 ± 1.1; p < 0.001). Eight of nine cases except a marathon runner returned to pre-symptom sporting performance levels. Overall, the current findings suggest that OWHTO provides an appropriate treatment for older KOA patients with a desire for RTS.

Closing-Wedge Distal Femoral Osteotomies-Retrospective Study

Objective  To describe the surgical technique of distal closing-wedge femoral osteotomy and a cases series submitted to this technique.

Methods  A total of 26 patients submitted to medial closing-wedge distal femoral osteotomy from 2002 to 2013 were evaluated. All of the patients had their medical files and imaging exams reviewed to evaluate the degree of correction and their current state.

Results  Out of the 26 patients, 12 were male and 14 were female. Their mean age was 47.15 years old. In all of the cases, a neutral alignment related to the anatomical axis was achieved. Most of the patients presented bone healing at 6 weeks. There were no cases of bleeding during the surgery. One patient presented with delayed bone healing. One patient complained of plaque-related discomfort, requiring the removal of the device. One patient had a superficial infection, but no osteotomy revision was needed. There were no cases of deep venous thrombosis or of pulmonary thromboembolism. To date, there has been no conversion to total knee replacement.

Conclusion  Treatment with medial closing-wedge distal femoral osteotomy sustained the proposed correction in patients with up to 15 years of follow-up.

Prognostic Factors for Return to Sport After High Tibial Osteotomy: A Directed Acyclic Graph Approach

BACKGROUND

High tibial osteotomy (HTO) is increasingly used in young and physically active patients with knee osteoarthritis. These patients have high expectations, including return to sport (RTS). By retaining native knee structures, a return to highly knee-demanding activities seems possible. However, evidence on patient-related outcomes, including RTS, is sparse. Also, time to RTS has never been described. Furthermore, prognostic factors for RTS after HTO have never been investigated. These data may further justify HTO as a surgical alternative to knee arthroplasty.

PURPOSE

To investigate the extent and timing of RTS after HTO in the largest cohort investigated for RTS to date and to identify prognostic factors for successful RTS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Consecutive patients with HTO, operated on between 2012 and 2015, received a questionnaire. First, pre- and postoperative sports participation questions were asked. Also, time to RTS, sports level and frequency, impact level, the presymptomatic and postoperative Tegner activity score (1-10; higher is more active), and the postoperative Lysholm score (0-100; higher is better) were collected. Finally, prognostic factors for RTS were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph.

RESULTS

We included 340 eligible patients of whom 294 sufficiently completed the questionnaire. The mean follow-up was 3.7 years (± 1.0 years). Out of 256 patients participating in sports preoperatively, 210 patients (82%) returned to sport postoperatively, of whom 158 (75%) returned within 6 months. We observed a shift to participation in lower-impact activities, although 44% of reported sports activities at final follow-up were intermediate- or high-impact sports. The median Tegner score decreased from 5.0 (interquartile range [IQR], 4.0-6.0) presymptomatically to 4.0 (IQR, 3.0-4.0) at follow-up (P < .001). The mean Lysholm score at follow-up was 68 (SD, ± 22). No significant differences were found between patients with varus or valgus osteoarthritis. The strongest prognostic factor for RTS was continued sports participation in the year before surgery (odds ratio, 2.81; 95% CI, 1.37-5.76).

CONCLUSION

More than 8 of 10 patients returned to sport after HTO. Continued preoperative sports participation was associated with a successful RTS. Future studies need to identify additional prognostic factors.

Improved Methods to Measure Outcomes After High Tibial Osteotomy

Observational studies suggest high tibial osteotomy produces substantial improvements in knee loading and stability that can limit the progression of joint damage; decrease pain; improve function and quality of life; and delay the need for knee replacement surgery. It can be cost-effective in knee osteoarthritis. However, systematic reviews and clinical practice guidelines are unable to provide strong recommendations, because limited high-level evidence supports its therapeutic value versus other treatments. We describe findings suggesting it can improve outcomes important to knee joint structure and function, patient quality of life, and health care systems. Future clinical trials are warranted and required.

High Tibial Osteotomy: Review of Techniques and Biomechanics

High tibial osteotomy becomes increasingly important in the treatment of cartilage damage or osteoarthritis of the medial compartment with concurrent varus deformity. HTO produces a postoperative valgus limb alignment with shifting the load-bearing axis of the lower limb laterally. However, maximizing procedural success and postoperative knee function still possess many difficulties. The key to improve the postoperative satisfaction and long-term survival is the understanding of the vital biomechanics of HTO in essence. This review article discussed the alignment principles, surgical technique, and fixation plate of HTO as well as the postoperative gait, musculoskeletal dynamics, and contact mechanics of the knee joint. We aimed to highlight the recent findings and progresses on the biomechanics of HTO. The biomechanical studies on HTO are still insufficient in the areas of gait analysis, joint kinematics, and joint contact mechanics. Combining musculoskeletal dynamics modelling and finite element analysis will help comprehensively understand in vivo patient-specific biomechanics after HTO.

The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis

Background

Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking.

Objectives

Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW.

Methods

We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle–Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics.

Results

A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks.

Conclusion

A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-0924-2) contains supplementary material, which is available to authorized users.