Malalignment: A Requirement for Cartilage and Organ Restoration

High tibial osteotomy combined with cartilage restoration: A systematic review of clinical outcomes and prognostic factors

Background

Focal chondral defects are often treated with cartilage restoration procedures. Malalignment often accompanies chondral defects. High tibial osteotomy (HTO), classically utilized to treat uni-compartmental knee osteoarthritis, corrects malalignment. HTO combined with cartilage restoration procedures can treat uni-compartmental osteoarthritis and focal chondral defects.

Purpose

To assess outcomes of combined HTO and cartilage restoration procedures and review prognostic factors that may assist in preoperative planning and patient counseling.

Study design

Systematic Review of published literature.

Methods

A systematic review of PubMed and Scopus was performed following PRISMA guidelines. Thirty-four papers were included in qualitative considerations.

Results

Thirty-four papers that reported the combined outcome of HTO and cartilage repair were included. Twenty of the 34 included papers reported prognostic factors that affected the success or failure of combined HTO and cartilage repair surgery for focal articular defect and uni-compartmental knee osteoarthritis. Cartilage repair techniques that were combined with HTO and included in this review are bone marrow stimulation, allograft transplantation, osteochondral autograft transplantation, autologous chondrocyte implantation, and mesenchymal stem cell implantation.

Conclusions

HTO with adjunctive cartilage repair procedures improve clinical outcome scores and restore alignment in patients with medial compartment osteoarthritis and isolated focal chondral defects. HTO with adjunctive cartilage procedures produces optimal results in younger, non-obese patients with focal chondral defects and varus malalignment, without significant lateral compartment and patellofemoral involvement.

The effect of smoking on union rates following corrective osteotomies around the knee: A systematic review and meta-analysis

BACKGROUND

Distal femur osteotomies (DFO) and high tibial osteotomies (HTO), are well-established treatment options for joint preservation in active patients with uni-compartmental osteoarthritis. Optimal outcomes are contingent on adequate preoperative evaluation of patient-specific factors. This systematic review and meta-analysis aims to explore the difference in union rates between smokers and non-smokers following corrective osteotomies around the knee.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in accordance with the PRISMA guidelines to identify studies reporting smoking status in adults who developed delayed and/or non-union following HTO or DFO. Studies were pooled using a random effect model [Review Manager (RevMan) software, V.5.4] and heterogeneity was estimated using I2.

RESULTS

Data for meta-analysis was available for 1,406 osteotomies from 10 studies, performed in patients with mean age ranging from 38-54 years, and 65% were male. The union rate among non-smokers was 97.3% (1100/1131) compared with 89.5% (246/275) among smokers; OR 4.59 [95% CI 1.99 to 10.62], p-value < 0.001. Subgroup analysis revealed that the risk of non-union in smokers after opening wedge osteotomy was almost double (OR 4.8) that of closing wedge osteotomies (OR 2.9).

CONCLUSION

Smoking increases the risk of non-union during elective knee osteotomy surgery. Our findings also suggest that smokers have a better chance of achieving union with closing wedge osteotomy compared to open wedge osteotomy.

Cartilage repair strategies in the knee according to Dutch Orthopedic Surgeons: a survey study

BACKGROUND

This study surveyed Dutch orthopedic surgeons on the management of cartilage defects in the knee and the adherence to the recently updated Dutch knee cartilage repair consensus statement (DCS).

METHODS

A web-based survey was sent to 192 Dutch knee specialists.

RESULTS

The response rate was 60%. Microfracture, debridement and osteochondral autografts are performed by the majority, 93%, 70% and 27% of respondents, respectively. Complex techniques are used by < 7%. Microfracture is mainly considered in defects 1-2 cm² (by > 80%) but also in 2-3 cm² (by > 40%). Concomitant procedures, e.g., malalignment corrections, are performed by 89%. Twenty-one percent of surgeons treat patients aged 40-60 years. Microfracture, debridement and autologous chondrocyte implantation are not considered to be highly affected by age > 40 years by any of the respondents (0-3%). Moreover, for the middle-aged there is a large spread in treatments considered. In case of loose bodies, the majority (84%) only performs refixation in the presence of attached bone.

CONCLUSION

Small cartilage defects in ideal patients may be well treated by general orthopedic surgeons. The matter becomes complicated in older patients, or in case of larger defects or malalignment. The current study reveals some knowledge gaps for these more complex patients. Referral to tertiary centers might be indicated, as is stated by the DCS, and this centralization should enhance knee joint preservation. Since the data from present study are subjective, registration of all separate cartilage repair cases should fuel objective analysis of clinical practice and adherence to the DCS in the future.

After Chondroplasty, Patient Election to Proceed With Cartilage Transplantation Is Closely and Additively Associated With Preoperative AMADEUS (Area Measurement And DEpth Underlying Structure) Grade, Condylar Involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score

Purpose

To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty.

Methods

This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population.

Results

Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (P < .01) and an overall AUC of 0.906 (P < .01).

Conclusions

Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score.

Clinical Relevance

Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.

A 2021 consensus statement on osteotomies around the knee by the UK Knee Osteotomy consensus Group (KOG)

BACKGROUND

There are significant deficiencies in the evidence base of modern-day osteotomy which result in significant variation in practice between surgeons. The purpose of this statement was to develop a consensus statement on the practice of osteotomy so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined. The article is also intended to educate and inform the practice of individuals who are early in their experience and/or clinical practice.

METHOD

A group of 29 specialist knee surgeons who regularly perform osteotomy was convened to form the Knee Osteotomy consensus Group (KOG). Consensus was determined utilizing the consensus group technique described by List. A total of 37 questions were asked covering all aspects of clinical practice.

RESULTS

20 statements were generated and debated until a criterion level of 70% was met.

CONCLUSIONS

Consensus was achieved regarding 20 statements concerning Indications for surgery, decision making, surgical planning, technique, post-operative assessment and recovery.

Patient-Reported Outcomes for Large Bipolar Osteochondral Allograft Transplantation in Combination with Realignment Osteotomies for the Knee

Effective treatment for bipolar articular cartilage lesions in the knee remains a clinical challenge. Lower extremity malalignment is a risk factor for treatment failures, which can be addressed by tibial or femoral osteotomy. The purpose of this study was to compare outcomes among patients who underwent knee joint restoration by osteochondral allograft (OCA) transplantation with concurrent or staged realignment osteotomy. With Institutional Review Board approval, patients undergoing bipolar OCA transplantation with concurrent or staged distal femoral osteotomy (DFO) or high tibial osteotomy (HTO) were analyzed. Patients were categorized by osteotomy type (DFO and HTO) and timing (concurrent and staged). Patient-reported outcome measures (PROMs), revisions, failures, and complications were examined preoperatively (baseline), 3, 6, 12, and 24 months after OCA transplantation; change scores from preoperative values were used for analysis. A total of 23 patients met inclusion criteria (15 males); 13 (56.5%) received HTO (5 concurrent), while 10 (43.5%) received DFO (5 concurrent). There were no significant differences in complication rates between concurrent and staged osteotomies. Primary bipolar OCA transplantation with osteotomy was associated with successful outcomes in 70% of patients; four patients underwent revision (17.4%) and three (13.0%) failed and were treated by total knee arthroplasty. Further, the four patients undergoing revision met functional criteria for success at final follow-up, resulting in a 2-year functional survival rate of 87.4%. Aside from Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, all PROMs for concurrent and staged osteotomies improved from baseline to 2 years postoperatively. Concurrent osteotomies of both types were associated with significantly lower pain scores at 12 months (p = 0.04), compared with staged osteotomies. Apart from Single Assessment Numerical Evaluation (SANE), more PROM improvement was observed for concurrent osteotomies at 2 years. Improvements in PROMs for patients undergoing OCA transplantation combined with osteotomy were observed at 2-year follow-up. PROMs for concurrent osteotomy were consistently greater than staged osteotomy, lending support to addressing lower extremity malalignment with bipolar OCA transplantation in the knee during a single surgery when possible.