A new double level osteotomy procedure to restore a joint line and joint angles in severe varus osteoarthritis. - Double level osteotomy associated with tibial condylar valgus osteotomy (DLOTO)

Comparison of short-term clinical outcomes between open-wedge high tibial osteotomy and tibial condylar valgus osteotomy

BACKGROUND

This study aimed to compare radiological features and short-term clinical outcomes between open-wedge high tibial osteotomy (OWHTO) and tibial condylar valgus osteotomy (TCVO), to provide information facilitating decision-making regarding those two procedures.

METHODS

Twenty-seven cases involving 30 knees that had undergone OWHTO (HTO group) and eighteen cases involving 19 knees that had undergone TCVO (TCVO group) for medial compartment knee osteoarthritis (OA) were retrospectively evaluated. Patient characteristics, severity of knee OA, lower limb alignment, joint congruity and instability were measured from standing full-length leg and knee radiographs obtained before and 1 year after surgery. Range of motion in the knee joint was measured and Knee Injury and Osteoarthritis Outcome Score (KOOS) was obtained to evaluate clinical results preoperatively and 1 year postoperatively.

RESULTS

Mean age was significantly higher in the TCVO group than in the HTO group. Radiological features in the TCVO group included greater frequencies of advanced knee OA, varus lower limb malalignment, higher joint line convergence angle, and varus-valgus joint instability compared to the HTO group before surgery. However, alignment of the lower limb and joint instability improved to comparable levels after surgery in both groups. Maximum flexion angles were significantly lower in the TCVO group than in the HTO group both pre- and postoperatively. Mean values in all KOOS subscales recovered similarly after surgery in both groups, although postoperative scores on three subscales (Symptom, Pain, and ADL) were lower in the TCVO group (Symptom: HTO, 79.0; TCVO, 67.5; Pain: HTO, 80.5; TCVO, 71.1; ADL: HTO, 86.9; TCVO, 78.0).

CONCLUSIONS

Both osteotomy procedures improved short-term clinical outcomes postoperatively. TCVO appears preferable in cases of advanced knee OA with incongruity and high varus-valgus joint instability. An appropriate choice of osteotomy procedure is important to obtain favorable clinical outcomes.

Outcomes of Distal Medial Collateral Ligament Release During Opening-Wedge High Tibial Osteotomy

Background

During opening-wedge, high-tibial osteotomy (OWHTO), various methods of managing the superficial medial collateral ligament (sMCL) can be performed to obtain a sufficient medial side opening.

Purpose/Hypothesis

The purpose of this study was to evaluate the outcomes of distal sMCL release during OWHTO. It was hypothesized that distal sMCL release would not cause valgus instability.

Study Design

Case series; Level of evidence, 4.

Methods

This retrospective study included 77 patients who underwent OWHTO between January 1, 2018, and October 31, 2019, and completed serial radiological assessments including weightbearing line ratio (WBLR), medial proximal tibial angle (MPTA), coronal translation, total tibial plateau inclination (TTPI), valgus medial joint-space width (valgus-MJSW), valgus joint-line convergence angle (valgus-JLCA), varus lateral joint-space width (varus-LJSW), and varus joint-line convergence angle (varus-JLCA) on standing whole-leg and varus-valgus stress radiographs. Subgroup analysis of pre- to postoperative changes in radiologic parameters was performed according to TTPI (group 1: <25th percentile, group 2: 25th-75th percentile, group 3: >75th percentile) and Ahlbäck osteoarthritis classification (group 1: Ahlbäck grade 1, group 2: Ahlbäck grades 2 and 3).

Results

The mean time to final follow-up was 34.6 ± 6.4 months. The WBLR and coronal translation did not change significantly over the follow-up period. The valgus-MJSW at 6 months postoperatively was significantly wider than that preoperatively and at 1 year postoperatively (P < .001). The varus-LJSW at 6 months postoperatively was significantly wider compared with preoperatively and 1 year postoperatively (P < .001), and the varus-LJSW at 1 year postoperatively was wider than that found preoperatively. Coronal translation was significantly more reduced for patients in TTPI group 1 versus group 3 (P = .019). There was no significant differences according to the Ahlbäck groups. All clinical outcomes improved at final follow-up compared with preoperative values (P ≤ .002).

Conclusion

The study findings indicated that sMCL release did not cause valgus instability or valgus overcorrection at 1 year postoperatively, and improved clinical outcomes were seen at the final follow-up compared with preoperative status after OWHTO with sMCL release.

Tibial condylar valgus osteotomy for the treatment of intra-articular varus deformity of the knee

The increasing incidence and distribution of primary and post-traumatic knee osteoarthritis (OA) in the young, active population has renewed interest in joint-preserving procedures. High tibial osteotomy (HTO) represents the most common treatment for medial knee OA associated with varus tibial deformity. However, deformities may also be related to intra-articular defects that an extra-articular procedure could not correct. The tibial condylar valgus osteotomy (TCVO) represents an intra-articular surgical technique for treating advanced medial knee OA with lateral joint subluxation. Currently, only a few papers with small samples and limited follow-up report the use of TCVO for the treatment of intra-articular deformities. Indications and operative techniques are various and not standardized. After an extensive search of PubMed, Scopus and Cochrane library, the main purpose of this paper is to summarize and discuss the indications, surgical techniques, and outcomes of intra-articular osteotomies while also reporting the preoperative planning and surgical procedure performed at our institution. These characteristics allow earlier weight-bearing and faster complete recovery. TCVO is an effective procedure to correct lower limbs' intra-articular defects from degenerative conditions developmental and post-traumatic deformities. This surgical technique, working at the intra-articular level, leads to some benefits related to restoring joint congruence and stability by realigning the axis of the lower limb and reducing the lateral joint subluxation. Moreover, the improved valgisation and lateralization of the mechanical axis and the limitation of the osteotomy to the medial condyle led to a better load distribution to the not osteotomy-involved compartment.