Satisfactory long-term survival, functional and radiological outcomes of open-wedge high tibial osteotomy for managing knee osteoarthritis: Minimum 10-year follow-up study

Fixation of Takeuchi Type II/III lateral hinge fractures provides favourable stability of a medial open wedge high tibial osteotomy-A biomechanical study

PURPOSE

To investigate the biomechanical consequences of osteosynthesis of lateral hinge fractures (LHFs) in medial open wedge high tibial osteotomy (MOWHTO).

METHODS

Sixteen fresh-frozen human cadaveric proximal tibiae underwent MOWHTO fixed with an ipsilateral locking compression plate. The specimens were assigned to two clusters simulating LHFs according to the Takeuchi classification: (1) Type II fracture; and (2) Type III fracture. The following conditions were serially tested: (1) intact hinge; (2) fractured hinge; (3) screw fixation of the LHF; (4) staple fixation of the LHF; and (5) locking T-plate fixation of the LHF. Each specimen was subjected to 10 cycles of axial compression load (720 N; 36 N/s), and internal and external rotational loads (10 N m; 1 N m/s), while capturing the interfragmentary movements via motion tracking.

RESULTS

In Takeuchi Type II fractures, osteosynthesis of the fractured hinge with staples or a plate significantly reduced fracture site displacement (p < 0.05) and significantly increased construct stiffness (p < 0.05) under axial and torsional loading, while only the plate restored intact torsional displacement (n.s.). For Takeuchi Type III fractures, both screw and plate fixation significantly reduced fracture site displacement (p < 0.05) and significantly increased construct stiffness (p < 0.05) under axial and torsional loading. Both techniques restored torsional stiffness in each rotational direction and torsional displacement in internal rotation (n.s.).

CONCLUSION

Additional plate fixation of Takeuchi Type II fractures was the construct with the highest stiffness, restoring the axial and torsional stability to a MOWHTO with an intact hinge. Screw and plate fixation of Takeuchi Type III fractures provided equivalent stability and restored the torsional and axial stability of the MOWHTO. In case of a Takeuchi Type II or III fracture, surgeons should consider additional plate or screw osteosynthesis of the fractured hinge to best restore the stability of the MOWHTO, which may potentially reduce the risk of loss of correction and impaired bone healing.

LEVEL OF EVIDENCE

There is no level of evidence as this study was an experimental laboratory study.

An increased medial proximal tibial angle of greater than 95 degrees after opening wedge high tibial osteotomy is not associated with deterioration of minimum 10-year clinical outcomes

PURPOSE

The purpose of this study was to assess whether an excessively increased medial proximal tibial angle (MPTA) resulted in the deterioration of long-term clinical outcomes after opening wedge high tibial osteotomy (OWHTO) for patients with knee osteoarthritis (OA).

METHODS

A total of 69 OA knees that underwent OWHTO, with follow-up for a minimum of 10 years, were retrospectively reviewed. The knee and function scores of the Knee Society Score were assessed separately, and cases with a score decline greater than or equal to the minimal clinically important difference from postoperative 1 to 10 years were defined as showing clinical deterioration. Cartilage status was assessed with arthroscopy at the time of osteotomy (first-look) and plate removal (second-look) according to the International Cartilage Repair Society grading system. The outcomes were compared between knees with MPTA ≤ 95° (n = 27) and MPTA > 95° (n = 42).

RESULTS

The mean knee and function scores at postoperative 10 years in MPTA ≤ 95° knees (86.8 ± 9.6 and 90.4 ± 13.1) were not significantly different from those in MPTA > 95° knees (85.8 ± 11.5 and 86.9 ± 14.2). The rate of clinical deterioration in knee and function scores was not significantly different between MPTA ≤ 95° knees (26% and 26%) and MPTA > 95° knees (21% and 36%). No significant differences were found between the MPTA ≤ 95° and MPTA > 95° groups in the cartilage status of all compartments at both first-look and second-look (postoperative 21 months) arthroscopies.

CONCLUSIONS

Increased MPTA > 95° after OWHTO is not associated with deterioration of minimum 10-year clinical outcomes.

Decreased Elastic Modulus of Knee Articular Cartilage Based on New Macroscopic Methods Accurately Represents Early Histological Findings of Degeneration

OBJECTIVE

Ex vivo nanoindentation measurement has reported that elastic modulus decreases as cartilage degenerates, but no method has been established to macroscopically evaluate mechanical properties in vivo. The objective of this study was to evaluate the elastic modulus of knee joint cartilage based on macroscopic methods and to compare it with gross and histological findings of degeneration.

DESIGN

Osteochondral sections were taken from 50 knees with osteoarthritis (average age, 75 years) undergoing total knee arthroplasty. The elastic modulus of the cartilage was measured with a specialized elasticity tester. Gross findings were recorded as International Cartilage Repair Society (ICRS) grade. Histological findings were graded as Mankin score and microscopic cartilage thickness measurement.

RESULTS

In ICRS grades 0 to 2 knees with normal to moderate cartilage abnormalities, the elastic modulus of cartilage decreased significantly as cartilage degeneration progressed. The elastic modulus of cartilage was 12.2 ± 3.8 N/mm for ICRS grade 0, 6.3 ± 2.6 N/mm for ICRS grade 1, and 3.8 ± 2.4 N/mm for ICRS grade 2. Similarly, elastic modulus was correlated with Mankin score (r = -0.51, P < 0.001). Multiple regression analyses showed that increased Mankin score is the most relevant factor associated with decreased elastic modulus of the cartilage (t-value, -4.53; P < 0.001), followed by increased histological thickness of the cartilage (t-value, -3.15; P = 0.002).

CONCLUSIONS

Mechanical properties of damaged knee cartilage assessed with new macroscopic methods are strongly correlated with histological findings. The method has potential to become a nondestructive diagnostic modality for early cartilage damage in the clinical setting.

Cartilage regeneration and long term survival in medial OA knee patients treated with HTO and OATS

Background

Osteoarthritis (OA) of the knee, in most instances primarily, affects medial compartment of knee. Combining Osteochondral Autologous Transfer System (OATS) with Medial Open-Wedge High Tibial Osteotomy (MOWHTO) may represent an integrated approach to sustaining long-term knee functionality in OA patients.

Materials and methods

From 2009 to 2016, combined OATS and MOWHTO was performed in 66 knees of 63 patients with medial compartment knee OA. Cartilage regeneration was assessed by 2nd look arthroscopy and Knee function was assessed by knee society scoring (KSS) pre-operatively and post-operatively. The survival rate of MOWHTO plus OATS was assessed. Failure is characterized by the need to convert into total knee replacement.

Results

The KSS knee score (from 48.3 to 90.4) and function score (from 42.6 to 88.7) showed a statistically significant improvement (p-value of <0.0001) at a mean follow-up period of 9.49 years. Second look arthroscopy done at the time of implant removal showed 100 % cartilage regeneration with even hyaline cartilage regeneration in 49 out of 57 knees assessed and partial regeneration in 8 knees. The Kaplan Meier survivorship analysis was 96.7 % at the mean 9.49 years after surgery. Only 2 patients needed TKA conversion in follow-up.

Conclusion

Combining OATs and valgus MOWHTO provides good option to successfully manage patients of OA and varus malalignment. This resulted in significant improvement in knee function, lowering pain intensity, good cartilage regeneration, and a high survivorship rate for 10 years postoperatively.

Intraoperative radiographic analysis and adjustment of the optimal position of plate in high tibial osteotomy

BACKGROUND

When high tibial osteotomy is performed for genu varus deformity, it is not easy to determine the accurate placement of the plate.

PURPOSE

To determine a simple way to assess the position of the plate, to provide more effective mechanical support and to reduce the risk of implant rupture and vascular injury.

MATERIAL AND METHODS

Two human anatomical marks, the patellar ligament and semimembranosus, were connected and divided into four parts to identify points Ⅰ, Ⅱ, and Ⅲ. These points determined the areas for Tomofix placement: anterior, anterolateral, and lateral. Simulated internal fixation placed hole B of Tomofix at points Ⅰ (anterior), Ⅱ (anterolateral), and Ⅲ (lateral). We analyzed the pointing direction of the locking screws in Tomofix holes on MRI to assess potential injury risk to the popliteal neurovascular bundle.

RESULTS

In the X-ray: holes B and C appeared as the plate in the anterior, only hole C appeared as the plate in the anterolateral, and none of the holes appeared as the plate in the lateral. In the general view of the sawbones, the screw pointed towards the popliteal neurovascular bundle when the plate was in the anterior.

CONCLUSION

If a small number of holes on the plate is visible under fluoroscopy, then several lateral positions of the plate can be obtained; the direction of the screw tunnel tends to deviate from the popliteal neurovascular bundle with the posterior position of the plate.

Combined knee osteotomy and cartilage procedure for varus knees: friend or foe? A narrative review of the literature

Varus knees with associated cartilage pathologies are not uncommon scenarios that present to orthopaedic surgeons. There is no agreement on the ideal management of varus knees with concomitant cartilage pathology. Through a literature review, the authors tried to answer three main questions: On October 2022, OVID MEDLINE, EMBASE, and COCHRANE databases were searched. Clinical studies reporting on clinical, radiologic, or macroscopic cartilage regeneration following either isolated knee osteotomy or concomitant osteotomy and a cartilage procedure were reviewed. Despite controversies, the literature demonstrated favourable outcomes of combined knee osteotomy and a cartilage procedure in patients with substantial deformity and cartilage defects. Isolated high tibial osteotomy may induce cartilage regeneration in several scenarios and severities of concomitant malalignment and cartilage defects. There are recommendations that knee osteotomy should be added to a cartilage procedure when an extra-articular deformity of > 5° is detected. Some studies report good outcomes for combining a knee osteotomy with cartilage grafting, but they lack a control group of isolated osteotomy. There is still scarce of evidence on the influence of osteotomies on cartilage regeneration and the outcomes of concomitant osteotomy and different cartilage procedures vs isolated osteotomies. With advanced statistical evaluation (artificial intelligence, machine learning) of big datasets, more answers and better results will be delivered.

Cartilage Degeneration of the Lateral Compartment of the Knee at Second-Look Arthroscopy Is Associated With Deterioration of 10-Year Clinical Outcomes After Opening-Wedge High Tibial Osteotomy

PURPOSE

To identify the arthroscopic findings associated with deterioration of 10-year clinical outcomes after opening-wedge high tibial osteotomy (OWHTO) in patients with knee osteoarthritis.

METHODS

A total of 114 consecutive knees of 91 patients with knee osteoarthritis who underwent OWHTO between 2007 and 2011 were retrospectively reviewed. Of these patients, those who underwent second-look arthroscopy and were followed up for a minimum of 10 years were enrolled. The Knee Society Score (KSS) and hip-knee-ankle angle were assessed. Cartilage status was graded at the time of osteotomy (first look) and plate removal (second look) according to the International Cartilage Repair Society (ICRS) grading system. The KSS knee subscale score and function subscale score were assessed separately, and on the basis of the changes in each of these scores from 1 to 10 years postoperatively and the minimal clinically important difference (MCID), the patients were divided into 2 groups: deteriorated (deterioration of score ≥ MCID) and non-deteriorated (deterioration of score < MCID).

RESULTS

Sixty-nine knees were included in this study. The mean knee score improved continuously from 48.7 ± 11.3 preoperatively to 86.8 ± 10.3 at 1 year (P < .001), 87.5 ± 9.9 at 5 years (P < .001), and 86.5 ± 10.5 at 10 years (P < .001) postoperatively. The mean function score also improved continuously from 62.5 ± 12.1 preoperatively to 90.7 ± 12.9 at 1 year (P < .001), 91.6 ± 12.1 at 5 years (P < .001), and 88.5 ± 13.1 at 10 years (P < .001) postoperatively. Three knees underwent conversion to total knee arthroplasty within 10 years postoperatively. The deteriorated KSS group showed significantly progressed ICRS grades in the lateral compartment compared with the non-deteriorated KSS group. The ICRS grade in the lateral compartment at second-look arthroscopy was identified as the only significant factor associated with both knee score deterioration (odds ratio, 4.89; P = .03) and function score deterioration (odds ratio, 3.91; P = .03) on multivariable logistic regression analysis.

CONCLUSIONS

The presence of cartilage degeneration of the lateral compartment of the knee at second-look arthroscopy is associated with deterioration of long-term clinical outcomes after OWHTO.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The Role of Neutrophil to Lymphocyte Ratio in the Assessment and Rehabilitation of Knee Osteoarthritis Patients

Osteoarthritis (OA) is considered to be a real problem for many people. The last decade is characterized through an increased interest in using a non-specific, simply and readily available marker of inflammation-neutrophil to lymphocyte ratio (NLR)-to predict various chronic diseases (gastrointestinal and colorectal cancers, lung cancer, cardiovascular events, sarcoidosis, arthritis). The aim of our study is to establish the correlation between NLR and other parameters of clinical and functional status in KOA patients and to compare the NLR values before and after rehabilitation program. 90 patients, aged 40 to 82 years, diagnosed with mild (8 patients), moderate (70 patients) and severe (12 patients) KOA, in accordance with Kellgren and Lawrence score. Statistical assessment showed different values for the erythrocyte sedimentation (ESR) rate at 1-hour, Visual Analogue Scale (VAS), and Lequesne index in the studied group. NLR regression was significant for ESR at 1 and 2 hours. As an independent diagnostic marker, NLR has limited value, however it can be considered an inexpensive additional biomarker for the diagnosis of KOA and for monitoring the rehabilitation program.

The novel hyaluronic acid granular hydrogel attenuates osteoarthritis progression by inhibiting the TLR-2/NF-κB signaling pathway through suppressing cellular senescence

In patients with mild osteoarthritis (OA), two to four monthly injections are required for 6 months due to the degradation of hyaluronic acid (HA) by peroxidative cleavage and hyaluronidase. However, frequent injections may lead to local infection and also cause inconvenience to patients during the COVID-19 pandemic. Herein, we developed a novel HA granular hydrogel (n-HA) with improved degradation resistance. The chemical structure, injectable capability, morphology, rheological properties, biodegradability, and cytocompatibility of the n-HA were investigated. In addition, the effects of the n-HA on the senescence-associated inflammatory responses were studied via flow cytometry, cytochemical staining, Real time quantitative polymerase chain reaction (RT-qPCR), and western blot analysis. Importantly, the treatment outcome of the n-HA with one single injection relative to the commercial HA product with four consecutive injections within one treatment course in an OA mouse model underwent anterior cruciate ligament transection (ACLT) was systematically evaluated. Our developed n-HA exhibited a perfect unification of high crosslink density, good injectability, excellent resistance to enzymatic hydrolysis, satisfactory biocompatibility, and anti-inflammatory responses through a series of in vitro studies. Compared to the commercial HA product with four consecutive injections, a single injection of n-HA contributed to equivalent treatment outcomes in an OA mouse model in terms of histological analysis, radiographic, immunohistological, and molecular analysis results. Furthermore, the amelioration effect of the n-HA on OA development was partially ascribed to the attenuation of chondrocyte senescence, thereby leading to inhibition of TLR-2 expression and then blockade of NF-κB activation. Collectively, the n-HA may be a promising therapeutic alternative to current commercial HA products for OA treatment.

Superior survivorship and plate-related results of TomoFix compared to Puddu plate fixation for opening-wedge high tibial osteotomy: A systematic review of the literature

PURPOSE

This systematic review aimed to compare survivorship and plate-related results of Puddu and TomoFix plates in opening-wedge high tibial osteotomy (OWHTO).

METHODS

PubMed, Scopus, EMBASE, and CENTRAL databases were searched from January 2000 until September 2021 for clinical studies involving patients with medial compartment knee disease and varus deformity undergoing OWHTO using the Puddu or TomoFix plating systems. We extracted survival data, plate-related complications, and functional and radiological outcomes. The risk of bias assessment had been carried out using Cochrane Collaboration's quality assessment tool for randomised controlled trials (RCTs) and Methodological Index for Non-Randomised Studies (MINORS).

RESULTS

Twenty-eight studies were included. The total number of knees was 2568 in 2372 patients. The Puddu plate was used in 677 knees, while the TomoFix plate was used in 1891. The follow-up ranged from 5.8 to 147.6 months. Both plating systems were able to delay conversion to arthroplasty at different follow-up intervals. However, osteotomies fixed by the TomoFix plate achieved higher survival rates, especially at mid-term and long-term follow-ups. In addition, fewer complications were reported with the TomoFix plating system. Although both implants achieved satisfactory functional outcomes, high scores could not be maintained throughout long-term intervals. Regarding radiological results, TomoFix plate was able to achieve and maintain larger degrees of varus deformity, while preserving the posterior tibial slope.

CONCLUSIONS

This systematic review demonstrated the superiority of the TomoFix over the Puddu system as a safer and more effective fixation device in OWHTO. Nevertheless, these results should be interpreted with caution due to the lack of comparative evidence through high-quality RCTs.

Gait analysis and knee kinematics before, and 6 and 18 months after corrective valgus osteotomy

BACKGROUND

The study objective was to assess clinical outcomes and gait biomechanics in patients after 6 and 18 months after varus deformity (VD) surgical correction at knee joint (KJ).

METHOD

The study included 20 patients with medial osteoarthritis (OA) of the knee of grade 2-3 and a VD of >4°. A total of 21 surgeries were performed on the patients. Full length weight bearing (FLWB) X-ray and KJ assessments were done using the KSS, KOOS and VAS scoring systems were obtained from all the patients. Biomechanical gait parameters were captured using an inertial sensor system at timepoints before, and 6 and 18 months after surgery. Temporal and kinematic parameters of walking were analyzed.

RESULTS

The radiological parameters showed a stable VD correction. According to the KOOS, KS and VAS scores, there was a moderate dynamic improvement in the operated knee function during the study. The biomechanical parameters remained virtually unchanged throughout the entire follow-up period. In the following year, there were some subjective improvements but without any significant changes in gait biomechanics or knee kinematics.

CONCLUSIONS

Thus, the main changes in the joint clinical condition and function occur in the first 6 months after surgery. According to the study data-assessments by VAS, KOOS, and KSS-there was a moderate clinical improvement during the long-term follow-up period, however, the biomechanical changes were minor.

A novel image-based machine learning model with superior accuracy and predictability for knee arthroplasty loosening detection and clinical decision making

Background

Loosening is the leading cause of total knee arthroplasty (TKA) revision. This is a heavy burden toward the healthcare system owing to the difficulty in diagnosis and complications occurring from the delay management. Based on automatic analytical model building, machine learning, may potentially help to automatically recognize the risk of loosening based on radiographs alone. The aim of this study was to build an image-based machine-learning model for detecting TKA loosening.

Methods

Image-based machine-learning model was developed based on ImageNet, Xception model and a TKA patient X-ray image dataset. Based on a dataset with TKA patient clinical parameters, another system was then created for developing the clinical-information-based machine learning model with random forest classifier. In addition, the Xception Model was pre-trained on the ImageNet database with python and TensorFlow deep learning library for the prediction of loosening. Class activation maps were also used to interpret the prediction decision made by model. Two senior orthopaedic specialists were invited to assess loosening from X-ray images for 3 attempts in setting up comparison benchmark.

Result

In the image-based machine learning loosening model, the precision rate and recall rate were 0.92 and 0.96, respectively. While for the accuracy rate, 96.3% for visualization classification was observed. However, the addition of clinical-information-based model, with precision rate of 0.71 and recall rate of 0.20, did not further showed improvement on the accuracy. Moreover, as class activation maps showed corresponding signals over bone-implant interface that is loosened radiographically, this confirms that the current model utilized a similar image recognition pattern as that of inspection by clinical specialists.

Conclusion

The image-based machine learning model developed demonstrated high accuracy and predictability of knee arthroplasty loosening. And the class activation heatmap matched well with the radiographic features used clinically to detect loosening, which highlighting its potential role in assisting clinicians in their daily practice. However, addition of clinical-information-based machine-learning model did not offer further improvement in detection. As far as we know, this is the first report of pure image-based machine learning model with high detection accuracy. Importantly, this is also the first model to show relevant class activation heatmap corresponding to loosening location.

Translational potential

The finding in this study indicated image-based machine learning model can detect knee arthroplasty loosening with high accuracy and predictability, which the class activation heatmap can potentially assist surgeons to identify the sites of loosening.

Surgeons' expectations of osteotomies around the knee

INTRODUCTION

High tibial osteotomy (HTO) is a valid and joint preserving surgical technique to treat medial degenerative osteoarthritis (OA) in young and active patients. A recent study shows that patients' expectations of osteotomy around the knee are high, but OA progression and potential conversion to a total knee arthroplasty (TKA) were underestimated. The aim of this study was to investigate surgeons' expectations of HTO and to compare the results to the patients' expectations and actual outcomes reported in the literature.

METHODS

461 surgeons were questioned online using the 'Hospital for Special Surgery Knee Surgery Expectations Survey (HFSS-KSES)' and a ten-item non-validated questionnaire to investigate the expectations of HTO. Two subgroups were formed to investigate differences regarding the surgeons' experience. Statistical analysis was performed using IBM SPSS Statistics.

RESULTS

Surgeons' expectations of HTO were rated between very and little important with pain reduction being the most important item on the HFSS-KSES. Furthermore, 'improving the ability to walk', 'to perform daily activities', 'having confidence in the knee', and 'avoiding future degeneration' were rated of high importance. An important difference regarding the experience was the lower expectations on delay/prevention of TKA of less-experienced surgeons.

CONCLUSION

Surgeons' expectations of HTO are high but nevertheless different to the patients' expectations reported in the literature. Also, expectations for the delay/prevention of TKA differed regarding the experience of surgeons. While pain reduction represents one of the most important items for surgeons and patients, the expected outcome regarding the delay/prevention of a TKA and returning to sports differs to the patients' expectations and to the actual outcome reported in the literature. This should be considered when performing the preoperative informed consent.

Evaluation of postoperative orientation of the knee and ankle joint after open wedge high tibial osteotomy

Background

Cases with varus knee osteoarthritis (OA) often present concomitant ankle joint deformity and poor tibial plafond inclination (TPI) in the coronal plane. Although changes to the TPI with respect to the ground after open wedge high tibial osteotomy (OWHTO) have been described, reports on the relationship between the correction angle and severity of knee joint line obliquity (KJLO) are scarce. This study aimed to examine the correlation between the correction angle after OWHTO and the change in knee and ankle inclination with respect to the floor.

Methods

Between January 2016 and December 2019, 39 knees in 39 patients (mean age, 58.3 ± 9.7 years; male, 14 knees; female, 25 knees) underwent OWHTO for varus knee OA. The mean duration of follow up was 30.1 ± 9.8 months. Radiological severity of OA was evaluated for those with Kellgren-Lawrence grade 1-3. Preoperative and 1-year postoperative radiographs were used to examine the postoperative femorotibial angle, hip-knee angle, KJLO, TPI, talar tilt (TT), position of weight bearing line of the tibial plateau width (WBL ratio; %), and the relationship between the pre-to postoperative changes in each measured value and intraoperative correction angle. The relationship between the pre-to postoperative changes in each measured value and intraoperative correction angle were evaluated. Clinical evaluations were conducted before and 2 years after OWHTO using the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale of pain.

Results

The mean pre-to post-operative changes were 3.2 ± 2.2 for KJLO and 3.1 ± 2.5 for TPI, both demonstrating significant differences as well as significant correlations with the correction angle. The knee joint demonstrated postoperative changes in the valgus direction and none in the varus direction with respect to the floor in all cases. Furthermore, the sum of changes to the KJLO and TPI showed a positive correlation that approximates the change in the correction angle. The mean pre- and postoperative 2-year KOOS subscale of pain were 50.2 ± 10.2 and 82.3 ± 9.1. There were no correlations between preoperative TPI, pre-to postoperative change in TPI, and 2-year postoperative of KOOS subscale of pain.

Conclusion

For those who underwent OWHTO for varus OA, the knee joint changed from a preoperative varus malalignment to mild valgus malalignment, and the ankle joint tended to improve from a preoperative valgus malalignment to the postoperative neutral alignment with respect to the floor. Although a positive correlation was found in which the correction angle approximates the sum of changes to the KJLO and TPI, no significant difference was found between changes in KJLO and TPI nor in the ratio between the correction angle and changes in each measured value.

10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy

Background:

Good-to-excellent midterm results after high tibial osteotomy (HTO) to treat medial compartment cartilage defects or osteoarthritis (OA) have been published, but little is known about long-term survival rates in terms of conversion to total knee arthroplasty (TKA) using angular stable internal plate fixation.

Purpose:

To determine TKA-free survival rates and functional and radiological outcomes at 10 years after HTO. A subgroup analysis of patients who underwent combined HTO and autologous cartilage implantation (ACI) was also performed.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 125 patients with a mean follow-up of 9.90 ± 2.25 years; 90 patients underwent HTO for medial OA, and 35 patients underwent ACI and HTO for medial focal cartilage defects. Functional outcome measures included visual analog scale (VAS) for pain, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and KOOS₄ (average of 4 KOOS subscales: Pain, Symptoms, Sport, and Quality of Life). Radiological outcomes included lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle.

Results:

Overall, 16 patients required conversion to TKA at a mean 86.75 ± 25.73 months (10-year survival rate, 87.2%). Only 2 patients in the HTO+ACI subgroup required a conversion to TKA (10-year survival rate, 94.3%). The complication rate for all patients was 8.8%. In both the HTO and HTO+ACI subgroups, VAS pain levels decreased and Lysholm scores increased significantly from pre- to postoperatively (P < .001). A higher preoperative Tegner score led to a significantly lower risk for conversion to TKA (P = .001), and a preoperative body mass index of ≥35 was associated with a significantly higher risk (P = .019), as was female sex (P = .046). Radiological parameters remained within physiological ranges. The postoperative joint line conversion angle did correlate with postoperative functional outcome but not with TKA conversion.

Conclusion:

Long-term results of HTO for medial compartment OA or cartilage defects with underlying varus deformity were good to excellent. In particular, patients who underwent HTO+ACI presented excellent long-term survival rates. HTO, therefore, delays or prevents TKA implantation, especially in young, active patients with medial compartment damage.

[Clinical and functional outcomes of valgus osteotomy in patients with medial gonarthrosis (preliminary results)]

OBJECTIVE

To analyze gait biomechanics before and after corrective osteotomies around the knee joint in patients with medial gonarthrosis.

MATERIAL AND METHODS

The study recruited 5 patients (6 surgeries) with medial gonartrosis and varus knee deformity. Gait biomechanics was analyzed in preoperative period and 6 months later. The control group consisted of 20 healthy people.

RESULTS

Knee joint biomechanics was almost normal in postoperative period. Amplitude of knee joint flexion was increased. Moreover, hip joint flexion-extension amplitude was increased on both sides and often exceeded normal values. Clinical results showed significant increase in IKS (from 55 to 89.6) and VAS score (from 7.7 to 2.3). Postoperative correction angle varied within 1.5-2° of valgus.

CONCLUSION

Corrective osteotomy around the knee joint is effective for medial gonarthrosis. We obtained favorable clinical results and limb axis correction after surgery without significant hypercorrection. Gait biomechanics was also improved.

[Comparison of two osteotomies in the treatment of medial compartment osteoarthritis]

OBJECTIVE

To compare the effectiveness of modified distal tibial tubercle-high tibial osteotomy (DTT-HTO) and open-wedge HTO (OWHTO) in the treatment of medial compartment osteoarthritis.

METHODS

A clinical data of 80 patients with medial compartment osteoarthritis treated with HTO between January 2016 and January 2019 was retrospectively analyzed, including 40 patients treated with DTT-HTO (DTT-HTO group) and 40 patients treated with OWHTO (OWHTO group). There was no significant difference in gender, age, body mass index, affected side, disease duration, Kellgren-Lawrence grading of osteoarthritis, and preoperative knee society score (KSS), Hospital for Special Surgery (HSS) score, knee joint visual analogue scale (VAS) score, hip-knee-ankle angle (HKA), posterior tibial slope (PTS), weight-bearing line ratio (WBL), Blackburne-Peel index (BPI), Caton-Deschamps index (CDI), and Insall-Salvati index (ISI) between the two groups ( P>0.05). The operation time, incision length, bleeding volume, hospital stay, and complications in both groups were recorded. The KSS, HSS, and VAS scores were used to evaluated the effectiveness. A self-made questionnaire was used to evaluate the recovery of low-impact sports ability of the knee. X-ray films were used to observe the osteotomy healing and measure the HKA, PTS, WBL, and the patellar height indexes (BPI, CDI, ISI).

RESULTS

All operations successfully completed in both groups. The OWHTO group operated longer than the DTT-HTO group ( P<0.05). There was no significant difference in the incision length, bleeding volume, and hospital stay between the two groups ( P>0.05). All incisions healed by first intention in both groups. There were 2 cases of lateral hinge fractures in the OWHTO group, and 1 case of lateral hinge fracture and 2 cases of tibial plateau fractures in the DTT-HTO group. No other complications occurred. The patients in both groups were followed up 2-4 years with an average of 2.8 years. The HSS, KSS, and VAS scores in both groups significantly improved after operation when compared with preoperative scores ( P<0.05). All scores gradually improved with the time and there were significant differences between different time points ( P<0.05). The HSS, KSS, and VAS scores were significantly better in the DTT-HTO group than in the OWHTO group at 3 months after operation ( P<0.05). There was no significant difference between the two groups at 6 months, 1 year, and 2 years ( P>0.05). At 1 year, the low-impact sports ability of the OWHTO group was rated as excellent in 8 cases, general in 25 cases, and poor in 7 cases, and as excellent in 7 cases, general in 26 cases, and poor in 7 cases of the DTT-HTO group. There was no significant difference between the two groups ( Z=-0.715, P=0.475). X-ray film reexamination showed that the osteotomies healed in both groups. The healing time was (4.52±1.23) months in the OWHTO group, and (4.23±1.56) months in the DTT-HTO group, showing no significant difference ( t=0.923, P=0.359). At immediate after operation, the HKA and WBL of the two groups significantly improved when compared with the preoperative values ( P<0.05). However, the pre- and post-operational difference was not significant between the two groups ( P>0.05). The PTS of the OWHTO group was significantly higher than preoperative value ( P<0.05), while the PTS of the DTT-HTO group was lower than preoperative value ( P>0.05). The pre- and post-operational difference between the two groups was significant ( P<0.05). BPI and CDI in the OWHTO group were significantly lower than preoperative values ( P<0.05), but there was no significant difference in ISI when compared with preoperative value ( P>0.05). There was no significant difference in the BPI, CDI, and ISI of the DTT-HTO group between pre- and post-operation ( P>0.05). The pre- and post-operational differences of BPI and CDI between the two groups were significant ( P<0.05), and there was no significant difference in the pre- and post-operational difference of ISI ( P>0.05).

CONCLUSION

The two osteotomies in the treatment of medial compartment osteoarthritis can significantly change the varus deformity and achieve satisfactory effectiveness. The early functional recovery of DTT-HTO is faster, which can avoid the increased PTS and patellar baja of traditional OWHTO. However, neither of the two surgical procedures can restore the patient's ideal low-impact sports ability of the knee.

Joint Space Width Increases Medially and Decreases Laterally at Different Time Points After Medial Open-Wedge High Tibial Osteotomy

PURPOSE

To evaluate the serial changes in the joint space width (JSW) of the medial and lateral compartments after medial open-wedge high tibial osteotomy (MOWHTO) and its associated factors.

METHODS

The medial and lateral weight-bearing JSWs were measured on serial radiographs and analyzed preoperatively and postoperatively within 2 weeks, as well as at 3 months, 6 months, 1 year, and 2 years. Associations between the medial and lateral JSWs and age, body mass index, mechanical axis, correction angle, lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle (JLCA), JLCA on stress radiographs, and arthroscopic cartilage status were examined. Clinical outcome was measured according to the Knee Society objective and functional scores.

RESULTS

Seventy-one patients who underwent MOWHTO with locking-plate fixation were analyzed. The respective mean medial and lateral JSWs on serial radiographs were as follows: 3.08 mm and 5.14 mm preoperatively, 3.10 mm and 4.63 mm postoperatively, 3.37 mm and 4.57 mm at 3 months, 3.40 mm and 4.59 mm at 6 months, 3.44 mm and 4.57 mm at 1 year, and 3.42 mm and 4.64 mm at 2 years. At 3 months, the medial JSW increased (P < .001), whereas the lateral JSW decreased immediately (P < .001). JSW showed no significant differences at other time points. Preoperative and postoperative JLCAs and medial femoral and tibial cartilage grades were associated with medial JSW changes (P = .021). However, no significant parameters were associated with decreases in the lateral JSW (P > .05). The postoperative Knee Society objective and functional scores improved and were maintained.

CONCLUSIONS

After MOWHTO, the medial JSW increased at 3 months postoperatively and the lateral JSW decreased immediately. The preoperative and postoperative JLCAs and the medial femoral and tibial cartilage grades were associated with the change in the medial JSW. However, no significant parameters were associated with the decrease in the lateral JSW.

LEVEL OF EVIDENCE

Level IV, case series of therapeutic study.

Role of high tibial osteotomy in medial compartment osteoarthritis of the knee: Indications, surgical technique and outcomes

Knee osteoarthritis (OA) is the most common joint disorder worldwide. In particular, primary knee OA often presents with a varus malalignment. This increases the loads going through the medial compartment resulting in cartilage degeneration and symptomatic arthritis. High tibial osteotomy (HTO) is the workhorse surgical procedure for treating medial knee OA. When performed precisely in the hands of an experienced surgeon, HTO can delay or avoid knee arthroplasty. Of note, outcomes of knee arthroplasty are at best unpredictable in patients of younger age. Hence, there is a growing need for joint preservation procedures for younger patients presenting with knee OA, of which HTO is one. Through this article, the authors of whom all are joint preservation surgeons with a special interest in osteotomy hope to share from their experience as well as the available literature on the indications, perioperative planning, surgical technique, outcomes as well as pearls and pitfalls of HTO.

High-risk factors for subjective discomfort due to lower limb discrepancy after medial open wedge high tibial osteotomy

BACKGROUND

Medial open wedge high tibial osteotomy (OWHTO) may result in lower limb discrepancy (LLD), and some patients experience uncomfortable symptoms. Studies have found that the degree of LLD is one but not the only high-risk factor for inducing symptoms. The main purpose of this study is to explore the risk factors for symptomatic LLD.

METHODS

Sixty-four patients who underwent OWHTO in our hospital between June 2018 and January 2020 were included in the study. Changes in tibia length, lower limb length, femorotibial angle (FTA), LLD, and KOOS score were evaluated before and 1 year after surgery. Questionnaire was used to investigate whether patients had uncomfortable symptoms of LLD after surgery. Binary logistic regression was applied to analyze the risk factors of symptomatic LLD.

RESULTS

There were 18 patients with subjective LLD uncomfortableness, 13 of them were occasional and 5 were frequent. Patients had a mean correction angle of 11.7° ± 4.6°, with a mean increase in tibial length of 6.0 ± 3.5 mm, lower limb length of 7.5 ± 2.3 mm, and LLD of 6.9 ± 4.2 mm at 1 year post-operation. Preoperative and postoperative changes in tibia length and lower limb length were statistically significant (P < 0.0001).There were statistically significant differences in pain, symptoms, ADL, sports/recreations, QOL of KOOS subclassification before and after surgery (P < 0.0001). Binary logistic regression revealed that age ≥ 55, BMI ≥ 28, and LLD ≥ 10 mm were high-risk factors for symptomatic LLD (P = 0.031, OR = 4.82; P = 0.012, OR = 6.251; P = 0.006, OR = 6.836).

CONCLUSION

Patients with age ≥ 55, BMI ≥ 28, and postoperative LLD ≥ 10 mm are more likely to develop symptomatic LLD. Older or heavier patients, who are expected to have an LLD greater than 10 mm after OWHTO should be fully informed of the possibility of postoperative LLD symptoms.

Patient-specific instrumentation (PSI) Referencing High Tibial Osteotomy Technological Transfer and Education: protocol for a double-blind, randomised controlled trial (PROTECTED HTO Trial)

INTRODUCTION

High tibial osteotomy (HTO) is a treatment of choice for active adult with knee osteoarthritis. With advancement in CT imaging with three-dimensional (3D) model reconstruction, virtual planning and 3D printing, patient-specific instrumentation (PSI) in form of cutting jigs is employed to improve surgical accuracy and outcome of HTO. The aim of this randomised controlled trial (RCT) is to explore the surgical outcomes of HTO for the treatment of medial compartment knee osteoarthritis with or without a 3D printed patient-specific jig.

METHODS AND ANALYSIS

A double-blind RCT will be conducted with patients and outcome assessors blinded to treatment allocation. This meant that neither the patients nor the outcome assessors would know the actual treatment allocated during the trial. Thirty-six patients with symptomatic medial compartment knee osteoarthritis fulfilling our inclusion criteria will be invited to participate the study. Participants will be randomly allocated to one of two groups (1:1 ratio): operation with 3D printed patient-specific jig or operation without jig. Measurements will be taken before surgery (baseline) and at postoperatively (6, 12 and 24 months). The primary outcome includes radiological accuracy of osteotomy. Secondary outcomes include a change in knee function from baseline to postoperatively as measured by three questionnaires: Knee Society Scores (Knee Scores and Functional Scores), Oxford Knee Scores and pain visual analogue scale (VAS) score.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Joint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee (CREC no. 2019.050), in accordance with the Declaration of Helsinki. The results will be presented at international scientific meetings and through publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04000672; Pre-results.