Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology

Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review

CONTEXT

Knee injury and subsequent surgery are widespread in the military setting. Associations between knee surgery and expected outcomes over time have not been consolidated and characterized systematically by procedure type across the body of literature, and the temporal expectations of these outcomes remain unclear.

OBJECTIVE

To summarize common postoperative follow-up times and associated outcomes that determine clinical or surgical failure in US service members after elective knee surgery.

DATA SOURCES

A systematic search was conducted with 3 bibliographic databases of published research reports from 2010 through 2021.

STUDY SELECTION

Studies in US military service members undergoing elective knee surgery, with a minimum of 1-year follow-up, and reporting on a functional/occupational outcome were included. Three reviewers screened all abstracts and full-text articles to determine eligibility.

STUDY DESIGN

Systematic review of longitudinal cohort studies.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

Extracted data included military demographics, surgical procedure variables, surveillance period, and outcome measures. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development, and Evaluation approach were used to determine study quality and risk of bias.

RESULTS

A total of 22 studies (mean follow-up time of 40.7 months) met the inclusion criteria. For cruciate ligament repair, approximately one-third of patients required a second surgery or were medically separated from military service by 2 years from surgery; 100% were reinjured by 4 years, and 85% sustained a new injury within 5 years of surgery. For meniscal repair, nearly one-third of patients were medically separated, and half were placed on activity restrictions within 3 years of surgery. For articular cartilage repair, within 5 years, 39% of patients required a second surgery, 30% were placed on activity restrictions, and 36% were medically separated. For patellar repair, 37% of patients were medically separated and over half were placed on activity restrictions within 5 years.

CONCLUSION

Common knee surgeries can have long-term implications for military careers that may not become apparent with shorter follow-up periods (<2 years). When longer surveillance periods are used (eg, up to 5 years), additional surgical procedures are more common and the likelihood of being injured or medically separated from military service is higher.

Change in quality of life and return to work and sports after isolated closing-wedge distal femoral osteotomy

PURPOSE

To analyze return to work and sports, and health-related quality of life (HRQoL) after closing-wedge distal femoral osteotomy (CWDFO) for valgus deformity and lateral compartmental osteoarthritis.

METHODS

Thirty-three patients underwent isolated CWDFO in our center between January 2018 and June 2020 were enrolled, of whom 32 and 23 patients were included in the return-to-work and return-to-sports analyses, respectively. Short Form-36 (SF-36), Tegner score, Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) pain score were compared preoperatively and postoperatively. And postoperative complications were recorded.

RESULTS

Overall, 33 patients were contacted at a mean follow-up of 37.94 ± 6.68 months, with a median age of 35 years (range: 26-63 years) at the surgery time. The physical component summary of SF-36 (p < 0.001) increased significantly at 1 year postoperatively. All patients returned to work, including 96.86% who returned to the same level of work in 1.89 ± 0.98 months, and to sports, including 78.26% who returned to the same sport level in 6.50 ± 2.05 months. Rates of returning to work (p = 0.215) and sports (p = 0.165) did not differ with work/sports intensity. Tegner scores (p = 0.025) and VAS pain scores (p < 0.001) decreased, and KOOS (p < 0.001) increased at 1 year postoperatively. Revision/conversion surgery was not required. In all, 30.43% patients reported a subjective decrease in sports ability; 82.61% patients considered their sports ability acceptable.

CONCLUSION

Patients returned to work/sports after isolated CWDFO, and had increased HRQoL. Patients playing high-impact sports had lower rates of returning to the same sport level, and may require preoperative counseling.

LEVEL OF EVIDENCE

IV, Case series.

Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome

INTRODUCTION

The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications.

METHODS

Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications.

RESULTS

The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal.

CONCLUSION

DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.

Return to Sport and Work Following Distal Femoral Varus Osteotomy: A Systematic Review

Background: Distal femoral varus osteotomy (DFVO) is an effective surgical intervention for the management of symptomatic valgus malalignment of the knee. Because it preserves the native knee joint and its ligamentous stability, DFVO is preferred to total knee arthroplasty (TKA) in the young, active population. Purpose: We sought to assess return to work (RTW) and return to sport (RTS) rates following DFVO for valgus malalignment of the knee. Methods: For this systematic review, we searched EMBASE, MEDLINE, and Web of Science from inception through December 31, 2020. English language studies of all levels of evidence explicitly reporting on RTS and RTW rates following DFVO for valgus malalignment of the knee were eligible for inclusion. Results: Seven studies and 127 patients were included in our analysis. Mean age was 32.4 ± 8.8 years with men comprising 46.7% ± 22.3% of study populations. The mean RTS rate was 87.2% ± 10.7%, with a return to preoperative activity levels rate of 65.4% ± 26.8%. The mean RTW rate was 81.8% ± 23.3%, with a return to preoperative activity levels of 72.8% ± 18.1%. The mean reoperation rate was 35.6% ± 18.8% within a mean follow-up period of 5.5 ± 1.9 years. Conclusions: This systematic review of low-level studies found DFVO to be a safe and effective procedure for the management of genu valgum in young, active populations, with most patients returning to sport and/or work, although not all at their preoperative activity levels. A paucity of data surrounds RTS and RTW rates following DFVO. Future studies should explicitly report both return to activity rates and whether patients returned to their preoperative activity levels.

Is Self-reported Return to Duty an Adequate Indicator of Return to Sport and/or Return to Function in Military Patients?

BACKGROUND

In the military, return-to-duty status has commonly been used as a functional outcome measure after orthopaedic surgery. This is sometimes regarded similarly to return to sports or as an indicator of return to full function. However, there is variability in how return-to-duty data are reported in clinical research studies, and it is unclear whether return-to-duty status alone can be used as a surrogate for return to sport or whether it is a useful marker for return to full function.

QUESTIONS/PURPOSES

(1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)?

METHODS

Preoperative and postoperative self-reported physical profile status (mandated physical limitation), physical activity status, work status, deployment status, military occupation specialty changes, and medical evaluation board status were retrospectively reviewed for all active-duty soldiers who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty and general orthopaedic clinics. Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). A total of 89% (1175) were excluded since they did not have survey data at the 1 year mark. Of the remaining 144 patients, 9% (13) were excluded due to the same patient having undergone multiple procedures, and 2% (3) were excluded for incomplete data. This left 10% (128) of the original group available for analysis. Ninety-eight patients reported not having a physical profile at their latest postoperative visit; however, 14 of these patients also stated they were retired from the military, leaving 84 patients in the return-to-duty group. Self-reported "full-time duty with no restrictions" was originally used as the indicator for return to duty; however, the authors felt this to be too vague and instead used soldiers' self-reported profile status as a more specific indicator of return to duty. Mean length of follow-up was 13 ± 3 months. Eighty-three percent (70 of 84) of patients were men. Mean age at the preoperative visit was 35 ± 8 years. The most common surgery types were sports shoulder (n = 22) and sports knee (n = 14). The subgroups were too small to analyze by orthopaedic procedure. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery. Return to sport was determined by asking patients how their level of physical activity compared with their level before their injury (higher, same, or lower). We identified the number of other indicators that may suggest decreased function by investigating change in work type/level, self-reported nondeployability, or medical evaluation board. This was performed with a simple survey.

RESULTS

Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity. Twenty-seven percent (23) reported not returning to the same work level, 32% (27) reported being nondeployable, 23% (19) reported undergoing a medical evaluation board (evaluation for medical separation from the military), and 11% (9) reported a change in military occupation specialty (change of job description).

CONCLUSION

Return to duty is commonly reported in military orthopaedics to describe postoperative functional outcome. Although self-reported return to duty may have value for military study populations, based on the findings of this investigation, surgeons should not consider return to duty a marker of return to sport or return to full function. However, further investigation is required to see to what degree this general conclusion applies to the various orthopaedic subspecialties and to ascertain how self-reported return to duty compares with specific outcome measures used for particular procedures and subspecialties.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Return to Work and Sport After Distal Femoral Osteotomy: A Systematic Review

CONTEXT

Distal femoral osteotomy (DFO) is a joint preservation procedure that corrects genu valgum deformities and patellofemoral maltracking, thereby restoring kinematics and unloading contact pressures in the lateral tibiofemoral and patellofemoral compartments.

OBJECTIVE

To evaluate the rates of return to work (RTW) and return to sport (RTS) after DFO for valgus malalignment and lateral compartment osteoarthritis through a systematic review of the literature.

DATA SOURCES

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on the PubMed, Cochrane, and Embase databases.

STUDY SELECTION

The search terms femoral osteotomy AND (sports OR work) were used. Studies in which patients underwent concomitant total knee arthroplasty were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4 (systematic review of level 4 studies).

DATA EXTRACTION

Data included the number of patients, age, gender, laterality of operation, time to follow-up, rate of RTW and RTS, time to RTS, activity level on return, and activity level scores (Tegner, Marx, Lysholm, and the International Knee Documentation Committee). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Seven articles with 194 patients were included. The average age ranged from 19 to 49 years with a mean postoperative follow-up range of 36 to 90 months. RTW data were available for 125 patients, of whom 42.1% to 91.3% returned by final follow-up. Data on RTS were available for 149 patients, of whom 70% to 100% returned at a range of 8.3 to 16.9 months postoperatively, and 41.6% to 100% returned to the same or greater level of sports activity. The Tegner and Marx activity level scores ranged from 3 to 4 and from 5 to 11, respectively, at final follow-up.

CONCLUSION

Patients treated with DFO reported high rates of RTW and RTS, with most patients being able to return to recreational sport after surgery.

Technique for Biplanar Lateral Opening Wedge Distal Femoral Osteotomy in the Valgus Knee

Valgus malalignment can be corrected with a biplanar lateral opening wedge distal femoral osteotomy (bLOWDFO) in patients with symptomatic lateral compartment disease. Advantages of a lateral opening wedge technique over the medial closing wedge technique include avoidance of vascular structures and theoretically better control of the amount of correction. The advantages of a bLOWDFO over a uniplanar osteotomy are that it creates a larger surface area for healing, and provides inherent stability to control the osteotomy intraoperatively. The purpose of this article is to present a reproducible technique for bLOWDFO and review the indications, preoperative planning, rationale, and clinical outcomes.