A preference-based single-item measure of quality of life following medial opening wedge high tibial osteotomy: large improvements similar to arthroplasty

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.

Economic evaluation of high tibial osteotomy: Closing wedge is more cost-effective than open wedge technique when analysing the KOOS-12 improvement

PURPOSE

The purpose of this study was to compare the cost-effectiveness of two techniques for performing a knee valgus osteotomy: opening wedge high tibial osteotomy (OW-HTO) vs closing wedge high tibial osteotomy (CW-HTO).

METHODS

In this economic evaluation study, a cost-effectiveness analysis from the perspective of the Spanish public healthcare system was performed, comparing OW-HTO with CW-HTO. All patients with medial knee osteoarthritis who underwent one of these procedures between 2018 and 2020 in our institution were included. The cost analysis included operating room, implant, graft and hospital admission costs. Functional outcomes (KOOS-12, Tegner activity scale, pain and satisfaction) and radiological outcomes (hip-knee-ankle angle, medial proximal tibial angle, tibial slope and patellar height) were analysed. The cost-effectiveness ratio was obtained by calculating the cost of improving the minimal clinically important difference (MCID) of KOOS-12 for each procedure. All costs are expressed in 2020 euros.

RESULTS

Fifty-one patients met the inclusion criteria (27 OW-HTO and 24 CW-HTO). Good to excellent functional outcomes, significant pain reduction (>6 points) and high patient satisfaction (>9/10) were observed in both groups. Both techniques yielded excellent radiological outcomes. N.s. differences in functional or radiological outcomes improvements between both procedures were found. However, the OW-HTO group presented a higher total cost than the CW-HTO group (4612.1 ± 765.6€ vs. 1827.1 ± 701.9€; p < 0.001). The cost-effectiveness ratio was 818.1 ± 46.8 €/MCID for the CW-HTO procedure and 2414.3 ± 115.2 €/MCID for the OW-HTO procedure (p = 0.025).

CONCLUSION

The CW-HTO procedure presented a cost-effectiveness ratio almost three times lower than the OW-HTO procedure. Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis.

LEVEL OF EVIDENCE

Level III; economic study.

The Relationships between Coronal Plane Alignments and Patient-Reported Outcomes Following High Tibial Osteotomy: A Systematic Review

OBJECTIVE

This systematic review aimed to determine whether coronal angular corrections correlate with patient reported outcomes following valgus-producing high tibial osteotomy (HTO).

DESIGN

Ovid MEDLINE, Embase, and Web of Science were systematically searched. Studies that reported hip-knee-ankle angles (HKA) or femorotibial angles (FTA), and the Oxford Knee Score (OKS), visual analogue scale (VAS) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), or EQ-5D before and after valgus-producing HTO were eligible. Correlation analyses were performed where appropriate to investigate the relationships between variables. PROSPERO ID: CRD42019135467.

RESULTS

This study included 39 articles including 50 cohorts. VAS was reported in 22 studies, OKS in 9, KOOS in 12 and EQ-5D in 2. The HKA angle was corrected from 7.1° ± 1.7° varus to 2.3° ± 1.7° valgus at final follow-up. The FTA changed from 3.0° ± 2.0° varus to 7.7° ± 1.3° valgus. Outcome scores improved with clinical and statistical significance postoperatively. Spearman correlations for nonparametric data revealed greater changes in knee alignment were moderately associated with larger improvements in VAS scores (r = 0.50). Furthermore, those who experienced greater changes in alignment showed larger improvements in the KOOS Activity and Quality of Life domains (r = 0.72 and r = 0.51, respectively).

CONCLUSION

On average, patients did not achieve the "ideal correction" of 3° to 6° valgus postoperatively. Nevertheless, statistical and clinical improvements in patient-reported outcome measure scores were consistently reported. This suggests that the "ideal correction" may be more flexible than 3° to 6°.

Total Knee Arthroplasty Is Superior to Open Wedge High Tibial Osteotomy in Terms of Pain Relief for Patients With Osteoarthritis

Background

Globally, total knee arthroplasty (TKA) is widely performed on patients with osteoarthritis. Meanwhile, open wedge high tibial osteotomy (OWHTO) has garnered attention in our country as a joint-preserving procedure. This study aimed to retrospectively compare the postoperative clinical outcomes of TKA and OWHTO for patients with osteoarthritis.

Methods

We selected 94 patients (106 knees) who underwent OWHTO or TKA between 2013 and 2018, had complete clinical data, and were followed up for >2 years. Patients were classified into 2 groups depending on the procedure (TKA: n = 49; OWHTO: n = 45). Patients in the A (= arthroplasty) group were significantly older, with a worse range of motion (ROM) than those in the O (osteotomy) group. There were no significant differences regarding sex and body mass index between groups. Operative time, perioperative blood loss, knee ROM, and Japanese Knee Injury and Osteoarthritis Outcome Score (J-KOOS) were compared between the groups.

Results

Significant differences were found between the A and O groups regarding operative time (120 ± 27.2 vs 80.3 ± 23.3 minutes), perioperative blood loss (505.4 ± 271.8 vs 322.6 ± 196.1 mL), knee ROM (flexion; 123.4 ± 16.3° vs 133.7 ± 12.8°), and J-KOOS for pain (87.4 ± 12.5 vs 78.1 ± 15.2 points) and symptoms (86.6 ± 12.3 vs 79.1 ± 13.3 points). There were no significant differences regarding other J-KOOS subscales.

Conclusions

OWHTO involved shorter operative times and less blood loss. However, the O group reported less pain relief. The A group represents an older, likely less active patient population. Therefore, OWHTO is a possible joint-preserving treatment options in younger active patients who may not be interested in arthroplasty.

Complications, Additional Surgery, and Joint Survival Analysis After Medial Open-Wedge High Tibial Osteotomy

The reported incidence of complications following medial open-wedge high tibial osteotomy (MOWHTO) varies. The authors sought to assess the complications, additional surgeries, and joint survival following MOWHTO in patients with isolated medial compartment arthrosis during a mean follow-up of 10 years. This retrospective study involved patients implanted with spacer plates, angle adjustable plates, or inverse L-type plates with wedges between 2000 and 2010. A total of 504 knees from 441 patients were examined. Mean age of the study population was 52.6±7.0 years, with 56 (11.1%) knees from men and 448 (88.9%) from women. The 10-year Kaplan-Meier joint survival rate was 94.8%. Overall complication rate for MOWHTO was 63.7%, with complications in 20.3% of treated knees requiring additional surgery. In this population, although the overall complication rate and the need for additional surgery were high, the need for additional surgery resulting from serious complications was low (2.6%). The high joint survival rate and low rate of additional surgery for serious complications indicate that MOWHTO can be safely applied in patients with isolated medial gonarthrosis. [Orthopedics. 2020;43(5):303-314.].

Health-Related Quality of Life - an Underestimated Factor to Evaluate the Treatment Success after Open Wedge HTO Surgery: Prospective 6-Years Follow-Up

BACKGROUND

The subjective health related quality of life in patients with degenerative joint diseases is an important variable to evaluate the treatment outcome. In this study, mid-term results of open wedge HTO were analysed and compared to the subjective quality of life (SF 36) of the general population. Furthermore, the relationships of preoperative assessed subscales of the health-related quality of life (SF 36) and the conversion to knee arthroplasty were analysed.

METHODS

The cohort consisted of 120 patients who were prospectively followed-up after open wedge HTO. At five follow-up points of time, patients were examined and asked about their subjective, health-related quality of life using the SF 36 score.

RESULTS

104 patients were included and evaluated until the last follow-up (mean: 81.2 ± 11.3 months after open wedge HTO; follow-up rate: 86.7%). Six years after open wedge HTO, similar values in several psychologic subscales of the SF 36 (BP, GH, V, MH) and the mental health component summary score (MCS) compared to the general population were found. The physical health component summary score (PCS) showed a significant improvement relative to the preoperative values. Nine out of 104 patients (8.7%) received a knee arthroplasty (50.1 ± 25.0 months). Low preoperative values of the subscales "physical functioning" (PF) and "bodily pain" (BP) were identified as risk factors in terms of conversion to a total knee arthroplasty.

CONCLUSIONS

Patients with medial unicompartimental knee osteoarthrosis treated with open wedge HTO showed very good results. The health-related quality of life was nearly as high as in the general population. Patients with preoperative low physical function and high pain values have a higher risk to have a conversion to knee arthroplasty. Surgeons should be aware of these factors if an open wedge HTO is considered.

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.

Short-term functional outcomes of computer assisted navigated high tibial osteotomy

Purpose

High tibial osteotomy (HTO) is a surgical procedure performed on patients with knee osteoarthritis (OA). Computer assisted navigated high tibial osteotomy (CAN-HTO) may result in improved outcomes for patients undergoing this procedure.

Methods

Retrospective study involving patients undergoing CAN-HTO.

Results

Surveyed thirty-three patients. Average follow-up: 2.3 years. 97% patients reported they would have this procedure performed again, if indicated. Re-operation rate: 6.1% and complication rate: 12.1%. Patients had decreased KOOS for symptoms when compared to non-navigation based HTO (p = 0.000).

Conclusion

There may be merit with the use of CAN-HTO, with demonstrated patient-reported benefits at 2-year follow-up.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health-related quality of life after open-wedge high tibial osteotomy

PURPOSE

(1) To monitor longitudinal changes in health-related quality of life (HRQOL), pain, knee function, and return to work (RtW) following high tibial osteotomy (HTO) for medial compartment osteoarthritis (OA), and (2) to investigate the influences of psychopathological comorbidities on preoperative impairment and post-operative course.

METHODS

Sixty-four patients were prospectively followed for 24 months after HTO to determine HRQOL, pain, functional outcome, and RtW. Psychopathological comorbidities (e.g. depression) were determined preoperatively. Patients with no psychological distress (ND) were compared to patients with psychological distress (PD) in order to investigate the influence of psychopathological comorbidities on outcome.

RESULTS

There was a significant increase in HRQOL and decrease in pain from 6 month follow-up on. Functional outcomes increased significantly from 12 month follow-up on. In general, there was a steady state of outcomes from 6- to 12-month follow-up on. At final follow-up, 90 % returned to their previous occupation without limitations. Mental component summary (MCS) and functional outcome showed a positive correlation with RtW, while depression had a negative one. A significantly inferior outcome of group PD versus ND was observed at baseline and early follow-up. RtW was significantly prolonged in group PD (8.9 ± 7.6 vs. 3.9 ± 3 months; p < 0.001). At final follow-up, both groups presented with comparable outcomes.

CONCLUSION

HTO for medial compartment OA significantly improves HRQOL, pain, and knee function. Time to RtW is high and critically depends on PD. Further, extend of preoperative impairments, an initially inferior course, and inferior MCS outcome was influenced by PD. However, otherwise no significant differences were observed between groups PD and ND at final follow-up.

LEVEL OF EVIDENCE

Prospective case series, II.

Knee joint distraction compared with high tibial osteotomy: a randomized controlled trial

PURPOSE

Both, knee joint distraction as a relatively new approach and valgus-producing opening-wedge high tibial osteotomy (HTO), are knee-preserving treatments for knee osteoarthritis (OA). The efficacy of knee joint distraction compared to HTO has not been reported.

METHODS

Sixty-nine patients with medial knee joint OA with a varus axis deviation of <10° were randomized to either knee joint distraction (n = 23) or HTO (n = 46). Questionnaires were assessed at baseline and 3, 6, and 12 months. Joint space width (JSW) as a surrogate measure for cartilage thickness was determined on standardized semi-flexed radiographs at baseline and 1-year follow-up.

RESULTS

All patient-reported outcome measures (PROMS) improved significantly over 1 year (at 1 year p < 0.02) in both groups. At 1 year, the HTO group showed slightly greater improvement in 4 of the 16 PROMS (p < 0.05). The minimum medial compartment JSW increased 0.8 ± 1.0 mm in the knee joint distraction group (p = 0.001) and 0.4 ± 0.5 mm in the HTO group (p < 0.001), with minimum JSW improvement in favour of knee joint distraction (p = 0.05). The lateral compartment showed a small increase in the knee joint distraction group and a small decrease in the HTO group, leading to a significant increase in mean JSW for knee joint distraction only (p < 0.02).

CONCLUSION

Cartilaginous repair activity, as indicated by JSW, and clinical outcome improvement occurred with both, knee joint distraction and HTO. These findings suggest that knee joint distraction may be an alternative therapy for medial compartmental OA with a limited mechanical leg malalignment.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Health-related quality of life and clinical outcomes following medial open wedge high tibial osteotomy: a prospective study

Background

Open wedge high tibial osteotomy (HTO) is an established method for the treatment of patients with varus malalignment and medial compartment osteoarthritis. In these patients, health-related quality of life (HRQL) can be improved by using this procedure. The purpose of the present study consisted in evaluating HRQL up to 18 months after HTO, comparing the results to values of the German normal population, and in analyzing the impact of preoperative HRQL on the postoperative clinical result. It was hypothesized that normal values in physical and mental health can be achieved within 18 months after operation. Study design: Prospective case series. Level of evidence: IV.

Methods

120 patients were included in this prospective case series from 12/2008 to 12/2011. All patients underwent open wedge HTO without a bone graft using the TomoFix^TM plate. HRQL was assessed by using the SF-36 questionnaire, preoperatively, as well as 6, 12, and 18 months postoperatively. Regular scoring, norm-based scaling, and the physical and mental component summary scores (PCS and MCS) were evaluated. Clinical outcome was assessed by using Lequesne, Lysholm, HSS and IKDC Score.

Results

HRQL could be described in 96 patients. The PCS of HRQL showed a statistically significant pre- to postoperative improvement (30.2 ± 13.4 to 45.9 ± 13.5 after 18 months). A reduced preoperative mental component summary score (MCS) resulted in lower values of each clinical score (p < 0.05) and in a prolonged duration of incapacity for work (MCS < 50:15.0 ± 12.8 weeks, vs. MCS ≥ 50: 9.1 ± 4.8 weeks, p < 0.05). MCS values improved from the pre- to postoperative measurements and comparable values to the normal population were reached already within 6 months after surgery (46.0 ± 14.9 pre-operatively and 48.5 ± 13.7 after 6 months), and after 18 months even a score of 49.5 ± 12.4 was achieved.

Conclusion

Lower preoperative mental component score results in reduced postoperative clinical outcome and prolonged duration of incapacity for work after HTO. In contrast to PCS, MCS showed comparable values to the normal population within 6 months after HTO.

Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases

PURPOSE

We report intermediate-term outcomes of a large consecutive series of medial opening-wedge tibial osteotomies.

METHODS

One hundred consecutive patients who underwent medial high tibial osteotomy from 2004-2013 were retrospectively reviewed. Charts were reviewed for patient age and gender, knee pain and range of motion, smoking status, and body mass index. Operative reports were reviewed for bone graft type, degree of correction, and osteotomy fixation method. Radiographs were evaluated for lateral cortical or intra-articular fracture, osteotomy healing, and preoperative and postoperative tibiofemoral angles.

RESULTS

Eighty-nine osteotomies (89%) in 83 patients were included in the study. Most procedures were performed for medial knee arthritis. The mean age at surgery was 48.1 years, and the mean follow-up period was 4.0 years. The mean tibiofemoral alignment was 3.2° of varus preoperatively and 6.4° of valgus postoperatively. Plate and screw fixation was used in all cases. Bone grafting methods included autograft, allograft, iliac crest aspirate, platelet-rich plasma, and demineralized bone matrix. Of the osteotomies, 83 (93%) healed uneventfully. Five nonunions and 1 delayed union occurred. Allograft combined with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion (P = .02). Lateral cortical fracture was associated with repeat surgery for nonunion or alignment loss (P = .02). Pain was minimal or mild in 65% of patients, moderate in 16%, and severe in 19%. Osteotomy fixation with a small 4-screw plate was associated with increased postoperative pain (P = .01). Seven patients underwent arthroplasty an average of 5 years after osteotomy. The need for arthroplasty was associated with longer follow-up (P = .02) and use of a smaller plate (P = .04).

CONCLUSIONS

Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. Allograft mixed with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion. At intermediate follow-up, 65% of patients had minimal or mild pain. Seven patients had undergone arthroplasty. Fixation with a smaller plate was associated with increased postoperative pain and the need for subsequent arthroplasty.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.