Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up

An Update on Emerging Techniques and Considerations in Revision Anterior Cruciate Ligament Reconstruction

» The rate of primary anterior cruciate ligament reconstruction (ACLR) failure in at-risk populations remains unacceptably high and necessitates thorough evaluation of native alignment and concomitant injuries.» Posterior tibial slope of >12° is a substantial risk factor of ACLR failure and should be corrected through anterior closing wedge osteotomy.» Varus malalignment of >5° exacerbates stress on the ACL graft, increases ACLR failure risks, and should be considered for correction through high tibial osteotomy at the time of revision ACLR.» Injuries to the anterolateral ligamentous complex are prevalent in ACL ruptures, and high-risk patients have shown benefit from anterolateral ligament reconstruction or lateral extra-articular tenodesis in the revision setting.» Addressing posterolateral corner, collateral ligament, and meniscal injuries, during revision ACLR, is vital to mitigate increased graft forces and optimize knee stability and functional outcomes.

Total knee arthroplasty post-high tibial osteotomy, results of an early experience from a North African arthroplasty unit, and a comprehensive review of the literature

PURPOSE

To report an early experience after converting HTO to TKA by reporting the incidence of functional, radiological, and complications in a single surgeon case series from a North African specialized arthroplasty unit.

METHODS

Between 2010 and 2020, 33 knees in 31 patients (two bilateral) were operated upon, 24 females and seven males, had a mean age of 65 ± 4.5 years; 17 (51.5%) knees had medial wedge opening (WMO), while 16 (48.5%) had lateral wedge closure (LWC) osteotomies. The mean time from HTO to TKA was 8.1 ± 3.3 years. A posterior stabilized (PS) implant was used in 31 (93.9%), while in 2 (6.1%), a varus-valgus constrained (VVC) implant was used. A tibial stem was needed in 13 (39.4%) knees. The functional assessment was performed according to the Knee Society Scoring System (KSS). The radiographic assessment included the anatomical femorotibial angle (aFTA) for alignment, the medial proximal tibial angle (MPTA), and the tibial slope (TS).

RESULTS

After a mean follow-up of 4.3 ± 1.1 years, the KSS knee and function sub-scores improved from a preoperative mean of 41 ± 8.9 (26 to 57) and 37.7 ± 9.2 (25 to 55) points to 91.3 ± 3.8 (81 to 94) and 85.5 ± 5 (80 to 95) points at the last follow-up, respectively (P < 0.05). The preoperative knee flexion improved from a mean of 84.5° ± 15.9 (55 to 110) to 110.6° ± 9.3 (95 to 125) (P < 0.05). The aFTA improved from a preoperative mean of 182.2° ± 10.3 (164 to 205) to a postoperative mean of 186° ± 2.6 (179 to 190) (P < 0.05). The MPTA changed from a preoperative mean of 88.4° ± 6.7 (77 to 102) to a postoperative (tibial component alignment) mean of 90° ± 1.7 (85 to 94) (P < 0.05). The mean preoperative TS changed from 80.9° ± 7.3 (68 to 96) to a mean postoperative of 86.9° ± 1.3 (83 to 89) (P < 0.05). Non-progressive radiolucent lines were detected at the tibial component in four (12%) knees. Complications were reported in seven (21.2%) knees; no revision was needed in any knee.

CONCLUSIONS

The authors' early experience showed improved functional and radiological outcomes; however, the complication incidence was relatively high, but no knees required revision. A longer follow-up is mandatory to prove the consistency of the results.

Medial unilateral knee arthroplasty after high tibial osteotomy: A retrospective study of 41 cases

INTRODUCTION

When medial knee osteoarthritis continues to get worse after a high tibial osteotomy (HTO) procedure, a subsequent total knee arthroplasty (TKA) is typically warranted. Medial unilateral knee arthroplasty (UKA) is not recommended. The aim of this study was to evaluate the outcomes of patients who underwent medial UKA after HTO.

HYPOTHESIS

Good results can be obtained with this procedure, as long as the postoperative valgus is not excessive.

MATERIALS AND METHODS

This was a retrospective, single-center study of patients operated between January 2005 and June 2019. The primary endpoint was the Oxford Knee Scale (OKS). The Knee injury and Osteoarthritis Outcome Score (KOOS) and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), range of motion and complications were the secondary endpoints. The average follow-up was 79 months.

RESULTS

Forty-one knees in 38 patients were analyzed. Four revisions with implant exchange (10%) were needed. Thirty-seven knees had a mean OKS of 20/60±8 (12-39). The mean flexion and extension amplitude were 123°±8° (110-140) and -1.5°±4 (-15-0), respectively. Eight patients had flexion and/or extension contractures.

DISCUSSION

Good functional and clinical outcomes in the medium term were achieved for the patients in this study who underwent UKA after HTO. These findings reinforce the good results reported in recent studies of UKA after HTO.

LEVEL OF EVIDENCE

IV, Retrospective study.

Treatment of periprosthetic knee infection and coexistent periprosthetic fracture: A case report and literature review

BACKGROUND

Periprosthetic joint infection (PJI) and periprosthetic fracture (PPF) are among the most serious complications following total knee arthroplasty. Herein, we present one patient with these two complications with details on the characteristics, treatment strategy, and outcome.

CASE SUMMARY

A 69-year-old female patient who suffered from PJI and PPF following total knee arthroplasty was treated by a two-stage revision surgery. After thorough foreign material removal and debridement, we used a plate that was covered with antibiotic-loaded bone cement to link with a hand-made cement spacer to occupy the joint space and fix the fracture. Although the infection was cured, the fracture did not heal and caused bone defect due to the long interval between debridement and revision. In the revision surgery, a cemented stem and cortical allogenic splints were used to reconstruct the fracture and bone defect. At the final follow-up 27 mo after revision, the patient was satisfied with postoperative knee functions with satisfactory range of motion (104º) and Hospital for Special Surgery knee score (82 points). The radiographs showed no loosening of the prosthesis and that the bone grafts healed well with the femur.

CONCLUSION

Our two-stage revision surgery has proved to be successful and may be considered in other patients with PJI and PPF.

Higher knee survivorship in young patients with monocompartmental osteoarthritis and constitutional deformity treated by high tibial osteotomy then total knee arthroplasty compared to an early total knee arthroplasty : a comparative study at a minimum follow-up of ten years

AIMS

The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group).

METHODS

This was a case-control study of consecutive patients receiving a posterior-stabilized TKA for OA between 1996 and 2010 with previous HTO. A total of 73 TKAs after HTO with minimum ten years' follow-up were included. Cases were matched with a TKA without previous HTO for age at the time of the HTO. All revisions were recorded. Kaplan-Meier survivorship analysis was performed using revision of metal component as the endpoint. The Knee Society Score, range of motion, and patient satisfaction were assessed.

RESULTS

Mean follow-up was 13 years (SD 3) after TKA in both groups. The 20-year Kaplan-Meier survival estimate was 98.6% in TKA post-HTO group (HTO as timing reference) and 81.4% in control group (TKA as timing reference) (p = 0.030). There was no significant difference in clinical outcomes, radiological outcomes, and complications at the last follow-up.

CONCLUSION

At the same delay from index surgery (HTO or TKA), a strategy of HTO followed by TKA had superior knee survivorship compared to early TKA at long term in young patients.Level of evidence: IIICite this article: Bone Jt Open 2023;4(2):62-71.

Outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity. A systematic review

Background: When correcting severe genu varus deformity, knee surgeons must choose between performing a single or double-level osteotomy. This systematic review aims to provide this equipoise with some clarity. Patients and methods: We conducted this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Studies evaluating the effect of the double level osteotomy (DLO) or those comparing it to high tibial osteotomy (HTO) from all regions and written in any language were included. Results: Six studies were included in this systematic review. They were prepared and analysed using Review Manager V5.0 [Computer Program] (RevMan5). Performing DLO resulted in restoring patellar height, joint-line convergence angle (JLCA), and mMPTA to normal values. DLO was also more successful at avoiding joint line obliquity (JLO) in severe varus deformity when compared to HTO (P < 0.001). No significant difference was reported between the two cohorts regarding the mLPTA. DLO resulted in satisfactory short term KOOS and IKDC scores. The complication rate after DLO was 2.28%. Conclusions: DLO showed a low complication rate and satisfactory short term KOOS and IKDAC scores. Randomised control trials with long term follow-up comparing the DLO and HTO are recommended.

Tibial metaphyseal sleeves in primary total knee arthroplasty following high tibial osteotomy and tibial plateau fracture; preliminary mid-term survival and outcome

BACKGROUND

Previous high tibial osteotomy (HTO), and tibial plateau fractures (TPF) may cause problems in subsequent total knee arthroplasty (TKA) due to altered metaphyseal bone structure. Higher rates of loosening of the tibial component have been described. In post-HTO and TPF cases, a more durable fixation could be achieved by tibial sleeves. This study investigates the preliminary short-to-midterm clinical and radiographic results in a cohort of these cases.

METHODS

A cohort of 28 patients was selected, 11 following HTO, and 17 following TPF. Standard clinical and radiologic follow-up was performed at 6 weeks, and one and two years. Revision with removal of primary prosthesis for any reason was the primary outcome. Patient reported pre- and postoperative pain, satisfaction and general health scores were collected at one and two years. Postoperative radiographs were analyzed for radiolucent lines.

RESULTS

There were no cases of aseptic loosening. Survival for all reasons was 96.4% (CI 77.2%-99.5%). One progressive radiolucent line was seen. Numerical rating scale (NRS) for pain with and without weightbearing at 2-year follow-up improved from 8 to 3 and from 5 to 2 points respectively. Overall general health scores improved with a median of 70 at ≥ 2 years, compared to 63 pre-operatively.

CONCLUSION

With no revision for aseptic loosening the use of tibial sleeves in primary TKA seems a safe and reliable method for fixation of the tibial component in metaphyseal bone with altered bone structure at short and mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, cohort study.

Conversion Total Knee Arthroplasty

»

Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA).

»

Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates.

»

There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA.

»

By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.

Closing-wedge high tibial osteotomy, a reliable procedure for osteoarthritic varus knee

PURPOSE

The purpose of this study was to analyze the long-term clinical and radiological outcomes of patients who underwent closing-wedge High Tibial Osteotomy (HTO) for the treatment of medial compartment osteoarthritis and to evaluate the conversion rate to knee arthroplasty.

METHODS

A retrospective, non-randomized, monocentric study was performed in our Institution considering 166 patients between 1989 and 2012. The final population was composed by 82 patients (94 knees), median age at time of operation was 53 (range 45-73) years. All patients were evaluated clinically (HSS Score, Tegner Scale, VAS and Crosby-Insall Grading) and radiographically (osteoarthritis staging, hip-knee-ankle (HKA) angle, tibial slope and metaphyseal varus).

RESULTS

Mean follow-up was 11.9 ± 7.2 years. HSS Score increased significantly from 70.8 ± 10 to 93.2 ± 9.1 (p < 0.05) instead Tegner Scale increased from 1.3 ± 0 (range 1-4) to 2.8 ± 0.7 (range 2-6) at the last control (n.s.); VAS score significantly decreased from 7.9 ± 1.4 to 1.6 ± 1.1 (p < 0.05) at last follow-up. According to the Crosby-Insall Grading System, 80 patients (97.4%) reported excellent-good results. HKA angle decreased from 6.9° ± 3.5 to 2.6° ± 2.6 (p < 0.01), tibial slope decreased from 10.1° ± 1.4 to 6.8° ± 2.1 (p < 0.05) and finally the metaphyseal varus decreased from 4.2° ± 0 to 2.1° ± 1.2 (n.s.) at the last follow-up. Adverse events were reported in 4.8%. Osteotomy survivorship rate resulted 92% at 10 years, 82% at 15 years and 80% at 20 years. Sixteen revisions (9.6%) were reported at a mean period of 12.8 years.

CONCLUSIONS

CW-HTO is a valid option for medial osteoarthritis treatment, with successful results in both clinical and radiological outcomes.

LEVEL OF EVIDENCE

IV.

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern

BACKGROUND

Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI).

METHODS

About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA.

RESULTS

Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups.

CONCLUSION

The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.

High Midterm Survival Rate of Uncemented Total Knee Arthroplasty After High Tibial Osteotomy: A Case-Control Study

BACKGROUND

Total knee arthroplasty (TKA) following high tibial osteotomy (HTO) is technically more demanding than TKA in a native knee. Studies have reported increased intraoperative and postoperative complication of TKA with previous HTO. The aim of this study is to compare the survival and complication rates and functional outcomes of uncemented TKA with previous HTO to primary TKA at our institution over a decade.

METHODS

This case-control study included 41 uncemented TKA after HTO between 2002 and 2012. For each case, 2 control patients were matched based on age and gender without previous HTO. The 2 groups were comparable for body mass index, as well as preoperative functional scores.

RESULTS

The mean follow-up was 7.8 ± 2.4 (range, 5-13.6) years. At last follow-up, there was no significant difference in functional outcomes or radiological imaging, particularly the rate of radiological loosening. There was no significant difference in complications (9; 22%) in the group of TKA after HTO vs the control group (14; 17%). One revision was performed in the group of TKA after HTO for septic loosening, and no revisions in the control group. The survival rate at a mean follow-up of 8 years was 97.6% in the group TKA after HTO vs 100% in the control group.

CONCLUSION

Uncemented TKAs following HTO have no significant difference in functional and radiological outcomes and survivorship compared to uncemented primary TKA at midterm follow-up.

High tibial osteotomy in obese patients: Is successful surgery enough for a good outcome?

INTRODUCTION

Knee osteoarthritis is the most common articular pathology. High tibial osteotomy (HTO) is a frequently used treatment procedure in medial osteoarthritis of the knee joint. We aimed to reveal factors that affect clinical and radiologic outcomes by evaluating the efficacy of HTO in patients with BMI ≥30 kg/m2 who were not appropriate for prostheses considering their activity, degree of pain, and age.

MATERIAL AND METHOD

HTO was performed using the medial open wedge technique who presented to the orthopedics polyclinic with symptoms of knee pain, whose BMI was over 30 kg/m2. All patients were diagnosed as having mechanical axis deviation and isolated medial compartmental arthrosis between 2013 and 2015.The clinical and radiologic follow-ups of patients were performed on day 45, at month 3, month 6, and after 1 year. The knee scoring system from the American Knee Society (AKS), and range of motion (ROM) were used in the functional evaluation of the patients.

RESULT

Eighteen patients were included in the study. Thirteen patients (72.2%) were women and 5 (27.8%) were men. Preop axis score was found significantly lower compared with the axis scores at postop month 6 and in final follow-up, the postoperative final follow-up axis score was found significantly lower than the axis score at month 6 (p < 0.05).

CONCLUSION

We anticipated in our study that the better outcomes obtained in the early period might be maintained for longer in parallel with weight loss and decreased BMI in the postoperative period. We believe that it is important to perform complication-free HTO with the correct technique, and by organizing a rapid and systematic weight loss process.

Medial Opening-Wedge High Tibial Osteotomy for Medial Compartment Arthrosis/Overload

Medial opening-wedge high tibial osteotomy has become increasingly popular for treating isolated, medial compartment arthrosis in younger, more active patients. Relative indications include age younger than 55 to 60 years, normal weight, preserved range of motion, and isolated medial compartment osteoarthritis or overload. Several surgical techniques exist for stabilization of the osteotomy with similar outcomes. Complication rates after medial opening-wedge high tibial osteotomy vary from 29% to 37%, with highest risk of nonunion, fracture, stiffness, and loss of correction. Good long-term outcomes can be achieved, with 5- and 10-year survivorship rates ranging from 75% to 98.7% and 51% to 97.6%, respectively.

Total Knee Arthroplasty After High Tibial Osteotomy Results in Excellent Long-Term Survivorship and Clinical Outcomes

BACKGROUND

Some prior reports of total knee arthroplasty after high tibial osteotomy have shown high rates of aseptic loosening. As such, the goal of this study was to analyze the outcomes of contemporary total knee arthroplasty after high tibial osteotomy, with particular emphasis on survivorship free from aseptic loosening, any revision, and any reoperation; complications; radiographic results; and clinical outcomes.

METHODS

We retrospectively reviewed 207 patients who underwent 231 total knee arthroplasties using cemented prostheses after high tibial osteotomy from 2000 to 2012 through our total joint registry: 87% were after a closing-wedge osteotomy and 13% were after an opening-wedge osteotomy. The mean follow-up from total knee arthroplasty was 8 years. At the time of the total knee arthroplasty, the mean age was 64 years and the mean body mass index was 31 kg/m. The majority of total knee arthroplasties had a posterior-stabilized design (93%), and 4% had a varus-valgus constraint design. Tibial stems were utilized in 8% of cases. Bivariate and multivariate Cox regression analyses were utilized to analyze risk factors for poorer survival.

RESULTS

At 10 years, survivorship free from aseptic loosening was 97%, survivorship free from any revision was 90%, and survivorship free from any reoperation was 85%. Fifteen patients (15 total knee arthroplasties [6%]) underwent aseptic revision, most commonly for instability (3%), aseptic loosening (2%), and periprosthetic fracture (1%). On bivariate analysis, patient age of <60 years was a significant risk factor for poorer revision-free survival (hazard ratio, 2.9; p = 0.02); on multivariate analysis, younger age was the only significant risk factor for revision (p = 0.04). There were 14 complications (6%), the most common being a manipulation under anesthesia in 9 cases (4%). No unrevised total knee arthroplasties had definitive radiographic evidence of loosening. Knee Society scores improved from a mean preoperative score of 59 points to a mean postoperative score of 93 points (p < 0.001).

CONCLUSIONS

Contemporary total knee arthroplasty with a cemented prosthesis after high tibial osteotomy demonstrated excellent long-term durability, with 10-year survivorship free from aseptic loosening of 97%. There was reliable improvement in clinical outcomes, but perfect knee balance was sometimes challenging, as reflected by a 4% prevalence of manipulation under anesthesia and a 3% prevalence of revision for instability.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ten-year survival and complications of total knee arthroplasty for osteoarthritis secondary to trauma or surgery: A French multicentre study of 263 patients

BACKGROUND

Previous surgical procedures raise technical challenges in performing total knee arthroplasty (TKA) and may affect TKA outcomes. Survival rates of TKA done after trauma or surgery to the knee have not been accurately determined in large populations. The objectives of this retrospective study in 263 patients with TKA after knee trauma or surgery and a follow-up of 10 years were to assess survival, functional outcomes, and the nature and frequency of complications.

HYPOTHESIS

Knee trauma or surgery before TKA increases the risk of complications and decreases implant survival.

MATERIAL AND METHODS

Two hundred and sixty-three patients (122 [47%] females and 141 [53%] males) underwent TKA between 2005 and 2009 at nine centres in France. Mean age at surgery was 61 years. The patients had knee osteoarthritis secondary to a fracture (n=66), osteotomy (n=131), or ligament injury (n=66). Mean time from trauma or surgery to TKA was 145 months (range, 72-219 months).

RESULTS

Major complications were infection (n=12, 4.5%), skin problems (n=8, 3%), and stiffness (n=8, 3%). Ten-year survival to implant exchange for any reason was 89%±2.8%. Flexion range increased by 2.5°±17° (p=0.02) to a mean of 110° (range, 30° to 140°); extension range increased by 4°±7° (p<0.001) to a mean of -1.19 (range, -20° to 0°). Of the 263 patients, 157 (60%) reported little or no pain at last follow-up. Mean postoperative hip-knee-ankle angle was 179°±3.2° (range, 171°-188°).

CONCLUSION

TKA performed after knee injury or surgery carries a risk of specific complications (infection, skin problems, and stiffness) and may have a lower survival rate compared to primary TKA.

LEVEL OF EVIDENCE

IV, retrospective cohort study.