Total knee arthroplasty after high tibial osteotomy. A systematic review

High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review

INTRODUCTION

The role of valgus producing high tibial osteotomy (HTO) for the treatment of advanced knee osteoarthritis (OA) is still controversial. The aim of the current systematic review was to assess survivorship and patient-reported outcomes (PROMs) of high tibial osteotomy in patients with radiological advanced medial knee OA.

METHODS

A systematic search of PubMed, Cochrane and EMBASE database was performed in July 2023 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Inclusion and exclusion criteria were applied to identify studies investigating the survivorship rate and PROMs of valgus-producing high tibial osteotomy in patients with advanced knee OA at x-ray assessment in the medial compartment at minimum-two-years follow up. Advanced radiological OA was defined as Kellgren Lawrence (K-L) ≥ 3 or Ahlbäch ≥ 2. Survivorship was defined as percentage of patients free of total knee arthroplasty (TKA) at follow-up. Clinical interpretation of provided PROMs were performed according to minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) target values reported in literature. Survivorship data and PROMs scores were extracted, and studies were stratified based on selected study features. The quality of included studies was assessed with modified Coleman score.

RESULTS

A total of 18 studies, totalling 1296 knees with a mean age between 46.9 and 67 years old, were included. Average survivorship was of 74.6% (range 60 - 98.1%) at 10-years follow up. The subjective scoring systems showed good results according to MCID and PASS, and postoperative improvements were partially maintained until final follow-up.

CONCLUSION

HTO is worth considering as treatment choice even in patients affected by radiological advanced medial knee osteoarthritis. Long term survivorship and good patient reported clinical outcomes could be expected in this population.

LEVEL OF EVIDENCE

IV; systematic review of level III-IV studies.

Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review

BACKGROUND

High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure.

PURPOSE

To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded.

RESULTS

A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%).

CONCLUSION

Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure.

Higher survival rate in total knee arthroplasty after high tibial osteotomy than that after unicompartmental knee arthroplasty

PURPOSE

The objective of this study was to evaluate the survival rates and complications in TKA after UKA and HTO as compared with primary TKA using national health data. It was hypothesized that survival and complication rates would be worse in patients with a history of UKA or HTO compared to primary TKA.

METHODS

Based on a list of patients who underwent TKA from Korean National Health Insurance database, 315,071 underwent primary TKA (group A); 2177 TKA after HTO (group B); and 1284 TKA after UKA (group C). Revision rates were compared between the groups using log-rank tests and adjusted hazard ratios (HR) of groups B and C were compared with those of the reference group (group A). A total of 1000 TKA matched patients were assigned to groups B and C according to propensity score for comparing revision rates after TKA and perioperative complication rates between TKA after HTO and UKA.

RESULTS

The overall revision rate was 2.1% in group A, 2.0% in group B, and 4.2% in group C. The revision rate until 10 years after TKA was significantly higher in group B (p = 0.03) or C (p < 0.0001) than in group A. The hazard ratios for revision was significantly higher in group A than in groups B and C at 10 years after index TKA (1.4 in group B and 3.7 in group C). The result of the comparison using PSM between TKA after HTO and UKA showed that TKA after HTO had lower risk of revision than TKA after UKA (HR: 0.41 at 10 years). However, no statistically significant differences in the perioperative complication rate between the two groups were found. (NS, not significant) CONCLUSIONS: TKA after UKA or HTO showed a significantly higher risk of revision than primary TKA. While TKA after HTO showed lower risk of revision than TKA after UKA, no significant differences in complications between TKA after UKA and HTO were found. Thus, surgeons must be aware of the low survival rate in TKA after UKA or HTO, especially in TKA after UKA.

LEVEL OF EVIDENCE

III (Retrospective cohort study).

High Tibial Osteotomies for the Treatment of Osteoarthritis of the Knee

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A high tibial osteotomy (HTO) is a joint-preserving procedure that can be used to treat symptomatic unicompartmental cartilage disorders in the presence of limb malalignment.

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Appropriate patient selection and careful preoperative planning are vital for optimizing outcomes.

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Based on past literature, correction of varus malalignment to 3° to 8° of valgus appears to lead to favorable results. Recently, there has been growing awareness that it is important to consider soft-tissue laxity during preoperative planning.

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Although there has been a recent trend toward performing opening-wedge rather than closing-wedge or dome HTOs for unicompartmental osteoarthritis, current data suggest that all 3 are acceptable techniques with varying complication profiles.

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Based on current evidence, an HTO provides pain relief, functional improvement, and a high rate of return to sport, with reported survivorship ranging from 74.7% to 97.6% and 66.0% to 90.4% at 10 and 15 years, respectively.

[Are the results of total knee arthroplasty after high tibial osteotomy worse?]

Hintergrund

Bei einem Teil der Patienten nach Tibiakopfumstellungsosteotomie (HTO) wird die Implantation einer Knietotalendoprothese (Knie-TEP) notwendig. Durch die HTO kann die Anatomie ungünstig verändert und die Knie-TEP-Operation erschwert sein. Ziel dieser Studie war es zu untersuchen, ob Patienten nach HTO gegenüber denjenigen mit primärer Gonarthrose in gleichem Maße von einer Knie-TEP profitieren.

Material und Methoden

Im lokalen Register konnten insgesamt 44 Patienten nach HTO und 1703 Patienten mit primärer Gonarthrose identifiziert werden. Zur Reduktion von Confoundern erfolgte eine 1:1 „propensity score matched-pair“-Analyse (Alter, Geschlecht, BMI, Komorbiditäten) bei Patienten mit einem 5‑Jahres-Follow-up. Es resultierten 35 gematchte Paare, welche hinsichtlich Kniefunktion, Schmerzniveau, Zufriedenheit mit dem Operationsergebnis sowie perioperativen Daten (Schnitt-Naht-Zeit, Implantattyp, Komplikationen) und Revisionen verglichen wurden.

Ergebnisse

Patienten mit vorangegangener HTO hatten prä- und 5 Jahre postoperativ eine vergleichbare Kniefunktion, jedoch ein signifikant höheres prä- und postoperatives Schmerzniveau. Trotz des höheren Schmerzniveaus zeigte sich eine vergleichbare Zufriedenheit mit dem Operationsergebnis. Die Schnitt-Naht-Zeit für die Knie-TEP nach HTO war signifikant länger und es wurden signifikant häufiger modulare Endoprothesen mit Stielverankerung implantiert. Hinsichtlich postoperativer Komplikationen innerhalb der ersten 3 Monate nach Operation unterschieden sich beide Kohorten nicht signifikant. Die Revisionsrate innerhalb von 5 Jahren war bei Patienten nach HTO nicht erhöht.

Schlussfolgerung

Fünf Jahre nach der Knie-TEP zeigten Patienten mit vorangegangener HTO eine vergleichbare Kniefunktion wie Patienten mit primärer Gonarthrose. Jedoch war bei Patienten nach HTO ein höheres Schmerzniveau zu verzeichnen. Der Operationsaufwand der Knie-TEP nach HTO war deutlich höher.

Return to Physical Activity After High Tibial Osteotomy or Unicompartmental Knee Arthroplasty: A Systematic Review and Pooling Data Analysis

BACKGROUND

The 2 most common definitive surgical interventions currently performed for the treatment of medial osteoarthritis of the knee are medial opening wedge high tibial osteotomy (HTO) and medial unicompartmental knee arthroplasty (UKA). Research exists to suggest that physically active patients may be suitably indicated for either procedure despite HTO being historically indicated in active patients and UKA being more appropriate for sedentary individuals.

PURPOSE

To help consolidate the current indications for both procedures regarding physical activity and to ensure that they are based on the best information presently available.

STUDY DESIGN

Systematic review.

METHODS

A search of the literature via the MEDLINE, Embase, and PubMed databases was conducted independently by 2 reviewers in accordance with the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies that reported patient physical activity levels with the Tegner activity score were eligible for inclusion. Patient demographics, operative variables, and patient-reported outcome scores were abstracted from the included studies.

RESULTS

Thirteen eligible studies were included, consisting of 401 knees that received HTO (399 patients) and 1622 that received UKA (1400 patients). The patients' mean age at surgery was 48.4 years for the HTO group and 60.6 years for the UKA group. Mean follow-up was 46.6 months (HTO) and 53.4 months (UKA). All outcome scores demonstrated an equal or improved score for activity and knee function regardless of the operation performed. Operative variables during HTO had a larger effect on outcome than during UKA.

CONCLUSION

Patients who underwent HTO were more physically active pre- and postoperatively, but patients undergoing UKA experienced an overall greater increase in their physical activity levels and knee function according to Tegner and Lysholm scores. Activity after HTO may be influenced by operative factors such as the implant used and the decision to include a graft material in the osteotomy gap, although this requires further research. Some studies found that patients were able to return to physical activity postoperatively despite having an age or body mass index that would traditionally be a relative contraindication for HTO or UKA.

An Increase in Medial Joint Space Width After Medial Open-Wedge High Tibial Osteotomy Is Associated With an Increase in the Postoperative Weight-Bearing Line Ratio Rather Than With Cartilage Regeneration: Comparative Analysis of Patients Who Underwent Second-Look Arthroscopic Assessment

PURPOSE

To investigate relevant factors influencing increases in medial joint space width (JSW) after medial open-wedge high tibial osteotomy (MOWHTO).

METHODS

Between January 2010 and December 2018, the electronic medical records of consecutive patients who underwent MOWHTO and subsequent second-look arthroscopic assessment at least 12 months after MOWHTO were retrospectively evaluated. The patients were classified into 2 groups according to changes in the medial JSW of the knee at the time of the second-look operation compared with that at baseline before the initial surgical procedure. Various radiographic parameters, arthroscopic findings, and clinical scores were compared between the groups, and regression analysis was performed to identify factors related to increases in medial JSW.

RESULTS

A total of 114 patients were analyzed. In a bivariate analysis, patients who experienced an increase in medial JSW showed a significantly higher postoperative weight-bearing line ratio (WBLR) (P = .008) and a greater proportion of severe preoperative cartilage lesions in the medial compartment of the knee compared with patients with a maintained or reduced medial JSW (P = .035). In terms of clinical scores, patients with an increased medial JSW showed relatively favorable clinical outcomes at the time of the second-look operation. Regression analysis indicated only postoperative WBLR as a relevant factor associated with an increase in medial JSW after MOWHTO (odds ratio, 1.057; P = .01). Additional analysis with patients reclassified according to the postoperative WBLR showed that as the postoperative WBLR increased, the medial JSW increased, without a significant change in the lateral JSW.

CONCLUSIONS

An increase in the medial JSW of the knee joint after MOWHTO appears to be associated with an increase in the postoperative WBLR, not with cartilage regeneration. Obtaining adequate correction so that the postoperative WBLR is within 60% to 70% would be desirable in terms of postoperative changes in the medial JSW, as well as clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Prevalence of femoro-acetabular impingement in non-arthritic patients with hip pain: a meta-analysis

PURPOSE

As the prevalence of femoro-acetabular impingement syndrome (FAIS) in symptomatic patients who lack evidence of hip osteoarthritis (OA) remains to be described, the purpose of this study was to calculate the prevalence of FAIS in this patient population.

METHODS

Libraries of PubMed, Embase, and Ovid were systematically reviewed for all studies between 2009 and 2019, investigating femoro-acetabular impingement and hip pain. Level I-IV studies delineating patients with hip pain who do not have OA (Tonnis or Outerbridge grades < three) were included. Demographics, outcomes, radiographic parameters, and criteria were entered into a meta-analysis to calculate the incidence of FAIS in non-arthritic symptomatic hips.

RESULTS

In total, 2264 patients (2758 hips) were included in the pooled analysis. Weighted mean age was 31 years. The incidence of FAIS in patients with no evidence of osteoarthritis but who complain of hip pain is 61% (47.3-74.4%). In total, 1483 hips were diagnosed with FAIS. Of the studies that described the rates of all three of the various subtypes of FAIS in their reports, 37% had a combined-type, 38% had a cam-type, and 25% had a pincer-type FAIS.

CONCLUSION

Femoroacetabular impingement should be suspected in 47 to 74% of patients with hip pain and without arthritis. Physicians must maintain a high index of suspicion for FAIS in young patients presenting with hip pain, as FAIS is a common and treatable condition that, if left alone, may lead to hip degeneration.

Functional Outcome of High Tibial Osteotomy in Patients with Medial Compartment Osteoarthritis Using Dynamic Axial Fixator -a prospective study

INTRODUCTION

Medial Compartment Osteoarthritis of the knee is becoming a widespread problem. The surgical options include high tibial osteotomy, unicompartmental knee replacement, and total knee replacement. Replacement surgeries are not advised in the younger age group, so in these patients, high tibial osteotomy is the only option. In this study, we have assessed the functional and radiological outcomes of high tibial osteotomy done by hemicallostasis method.

METHOD

We report the outcome of 30 patients (30 knees) who underwent hemicallostasis with a dynamic external fixator for medial compartment osteoarthritis of the knee. The radiological assessment was done with the help of Hip Knee Ankle angle. The functional scoring was done via Oxford knee score, IKDC, KOOS, and WOMAC score.

RESULTS

At a mean follow up of 35 months, the preoperatively mean HKA angle was 172 ± 30. The mean HKA angle postoperatively was 184 ± 10. Appropriate correction of the HKA angle was achieved in 24 of 30 patients (80%). Whereas, there was under correction in 3 patients (10%) and overcorrection in 3 (10%) patients. All the functional scores showed significant improvement in the postoperative scores. There was a positive correlation between the HKA angle and oxford, IKDC, KOOS, and WOMAC Score. Complications like superficial pin tract infection were seen in 3 (10%) patients, deep infection in 1 (3%), and early union of osteotomy in 1 (3%) patient leading to revision of the osteotomy. .

CONCLUSION

HTO is effective in improving pain, function, activity of daily living, and quality of life in patients suffering from medial compartment Osteoarthritis of the knee. Hip Knee Ankle Angle is an important parameter to restore for better functional outcomes. The Advantage of using a dynamic axial fixator is the precision in achieving calculated correction without any implant in the bone once the correction is achieved along with good healing rates.

Cartilage Quality (dGEMRIC Index) Following Knee Joint Distraction or High Tibial Osteotomy

OBJECTIVE

High tibial osteotomy (HTO) and knee joint distraction (KJD) are treatments to unload the osteoarthritic (OA) joint with proven success in postponing a total knee arthroplasty (TKA). While both treatments demonstrate joint repair, there is limited information about the quality of the regenerated tissue. Therefore, the change in quality of the repaired cartilaginous tissue after KJD and HTO was studied using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC).

DESIGN

Forty patients (20 KJD and 20 HTO), treated for medial tibiofemoral OA, were included in this study. Radiographic outcomes, clinical characteristics, and cartilage quality were evaluated at baseline, and at 1- and 2-year follow-up.

RESULTS

Two years after KJD treatment, clear clinical improvement was observed. Moreover, a statistically significant increased medial (Δ 0.99 mm), minimal (Δ 1.04 mm), and mean (Δ 0.68 mm) radiographic joint space width (JSW) was demonstrated. Likewise, medial (Δ 1.03 mm), minimal (Δ 0.72 mm), and mean (Δ 0.46 mm) JSW were statistically significantly increased on radiographs after HTO. There was on average no statistically significant change in dGEMRIC indices over two years and no difference between treatments. Yet there seemed to be a clinically relevant, positive relation between increase in cartilage quality and patients' experienced clinical benefit.

CONCLUSIONS

Treatment of knee OA by either HTO or KJD leads to clinical benefit, and an increase in cartilage thickness on weightbearing radiographs for over 2 years posttreatment. This cartilaginous tissue was on average not different from baseline, as determined by dGEMRIC, whereas changes in quality at the individual level correlated with clinical benefit.

Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization

BACKGROUND

Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA.

METHODS

Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups.

RESULTS

One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes.

CONCLUSION

Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.

Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy

BACKGROUND

The primary aim was to assess survival of opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early conversion to total knee arthroplasty (TKA).

METHODS

During the 18-year period (1994-2011) 111 opening wedge HTO were performed at the study centre. Mean age was 45 years (range 18-68) and the majority male (84%). Mean follow-up was 12 (range six to 21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed.

RESULTS

Forty (36.0%) HTO failed at a mean of 6.3 years (range one to 15). By Kaplan-Meier analysis, the five-year survival rate was 84% (95% confidence interval (CI) 82.6-85.4), 10-year rate 65% (95% CI 63.5-66.5) and 15-year rate 55% (95% CI 53.3-56.7). Cox regression analysis identified older age (hazard ratio (HR) 1.07 for each additional year, 95% CI 1.03-1.11, p b 0.001) and female gender (HR 2.37, 95% CI 1.06-5.33, p = 0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62-0.81, p b 0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26-4.91, p = 0.01) risk of failure in patients aged 47 years old or more.

CONCLUSION

The risk of early conversion to TKA is significantly increased in females and those older than 47. These risk factors should be considered pre-operatively when planning intervention for isolated medial compartment osteoarthritis.

The Utility of Biologics, Osteotomy, and Cartilage Restoration in the Knee

The management of complex cartilage and meniscal pathology in young, athletic patients is extremely challenging. Joint preservation surgery is most difficult in patients with concomitant knee pathologies, including cartilage defects, meniscal deficiency, malalignment, and/or ligamentous insufficiency. Clinical decision making for these patients is further complicated by articular cartilage lesions, which often are incidental findings; therefore, treatment decisions must be based on the confirmed contribution of articular cartilage lesions to symptomatology. Surgical management of any of the aforementioned knee pathologies that is performed in isolation typically results in acceptable patient outcomes; however, concomitant procedures for the management of concomitant knee pathologies often are essential to the success of any single procedure. The use of biologic therapy as an alternative to or to augment more conventional surgical management has increased in popularity in the past decade, and indications for biologic therapy continue to evolve. Orthopaedic surgeons should understand knee joint preservation techniques, including biologic and reconstructive approaches in young, high-demand patients.

Does a Previous High Tibial Osteotomy (HTO) Influence the Long-term Function or Survival of a Total Knee Arthroplasty (TKA)?

High tibial osteotomy (HTO) is a well established technique for the treatment of medial osteoarthritis of the knee with varus malalignment. The outcome of total knee arthroplasty (TKA) after HTO remains uncertain. The aim of this paper is to revise the literature with the aim of answering the following question: Does a previous (HTO) influence the long-term function or survival of a TKA?. The search engine was MedLine. The keywords used were: total knee arthroplasty after high tibial osteotomy. One hundred and ten articles were found. Of those, only 19 were selected and reviewed because they were strictly focused on the topic and the question of this article. The reports published so far have a low grade of evidence (levels III and IV). Most of them are prospective case series (level IV). One is a systematic review of level III studies reported in 2009. Two recent studies based in a great number of cases (registers) showed similar survival in the 2 groups: around 92% at 10 years, and 88% at 15 years. The review of the literature suggests that a previous HTO does not influence the function or survival of a TKA in the long-term. Level of evidence: III.

Better clinical outcomes after unicompartmental knee arthroplasty when comparing with high tibial osteotomy

BACKGROUND

Both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are well-established treatments for medial knee osteoarthritis (OA). However, it is unclear whether HTO or UKA leads to better clinical outcomes and lower complication rates. This meta-analysis compared the clinical outcomes and complications of HTO and UKA in patients with medial knee OA.

METHODS

All studies comparing the functional outcome, postoperative pain, revision rate to total knee arthroplasty (TKA), postoperative complications, postoperative velocity, and postoperative range of motion (ROM) as assessed with various measurement tools in patients with medial knee OA treated with HTO or UKA were included.

RESULTS

Sixteen studies were included in the meta-analysis. The proportion of patients who underwent revision to TKA (OR 1.56, 95% CI: 0.61-3.98; P = .35) did not differ significantly between HTO and UKA. In contrast, functional outcome (OR 0.47, 95% CI: 0.24 to 0.95; P = .04), postoperative pain (OR 0.28, 95% CI: 0.12 to 0.62; P = .002), postoperative complications (OR 2.48, 95% CI: 1.26 to 4.90; P = .009), postoperative velocity (95% CI: -0.11 to -0.00; P = .03), and postoperative ROM (95% CI: 2.02 to 15.23; P = .01) were significantly different between the 2 groups.

CONCLUSIONS

There were no significant differences in the revision rate to TKA between HTO and UKA. However, results from subgroup analyses suggested that opening-wedge HTO resulted in a lower revision rate to TKA than did UKA, whereas closing-wedge HTO resulted in a higher revision rate to TKA than did UKA. In addition, UKA resulted in significantly better functional outcomes and postoperative velocity, along with less postoperative pain, fewer postoperative complications, and lower postoperative ROM. Based on the findings of current meta-analysis, UKA appears to be as efficacious and safe as HTO in the treatment of medial knee OA.

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

INTRODUCTION

High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO.

MATERIAL AND METHOD

A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110°; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO.

RESULTS

Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5°. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05).

DISCUSSION

The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group.

LEVEL OF EVIDENCE

III; comparative retrospective study.

Single-stage total knee arthroplasty and osteotomy as treatment of secondary osteoarthritis with severe coronal deviation of joint surface due to extra-articular deformity

PURPOSE

Severe extra-articular deformities can be treated with single-stage total knee replacement (TKA) and osteotomy. Aim of this study was to examine the patient-reported outcome measures (PROMs) and the complications after single-stage TKA and osteotomy. We hypothesized patients achieve good outcome after single-stage TKA and osteotomy, which is comparable to outcome after primary TKA without deformity.

METHODS

Twenty-one patients with severe extra-articular deformity who underwent single-stage TKA and deformity-correcting osteotomy were reviewed and invited to fill in PROMs including the Oxford Knee Score, the Short Form-12, a Visual Analogue Scale for pain, and questions about satisfaction and quality of life.

RESULTS

The mean follow-up period was 64 months. Ten patients were treated with TKA and supracondylar femoral osteotomy. Although PROMs showed good results (mean quality of life score was 85 out of 100), two patients had a revision of the osteotomy due to non-union. Eleven patients were treated with TKA and high tibial osteotomy. Patients were satisfied with the results (mean quality of life score was 81 out of 100). Two patients developed infection requiring debridement, resulting in one arthrodesis and one gastrocnemius transfer for wound closure.

CONCLUSION

In general, patients were satisfied with the postoperative result. Outcome was comparable to patients after primary TKA in the literature. However, serious complications need to be taken into account.

LEVEL OF EVIDENCE

III.

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.

History of previous knee surgery does not affect the clinical outcomes of primary total knee arthroplasty in an Asian population

BACKGROUND

Patients with a history of previous knee surgeries, such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO), often have a higher likelihood of requiring a subsequent total knee arthroplasty (TKA). However, there is relatively limited data, especially in the Asian population, on how previous knee surgery could affect the clinical outcomes of TKA. Therefore, this study aims to evaluate the impact of previous knee surgeries on the clinical outcomes of future TKA.

METHODS

We reviewed the prospectively-collected data of 303 patients who underwent TKA by a single surgeon from a total joint registry of a tertiary hospital over a period of 5 years. Those with a history of previous knee surgery were identified. The SF-36 Health Survey, Oxford Knee Score (OKS) and Knee Society Score (KSS) were used to evaluate clinical outcomes pre-operatively, at 6 months and 2 years.

RESULTS

Previous knee surgery did not have a significant impact on the patients' pre-operative baseline clinical scores and body mass index (BMI). Patients with a history of knee surgery undergo TKA at a significantly younger age (mean of 6.6 years younger). On follow-up, patients with a history of knee surgery have similar post-operative outcome scores as those without previous knee surgery. Also, a high proportion of these patients are satisfied with their post-operative results and feel that their expectations have been met.

CONCLUSIONS

Patients with previous knee surgery had TKA at a significantly younger age than those without. But these patients have similar clinical and quality of life outcomes after TKA. In addition, a high proportion of these patients are satisfied with the results of surgery and feel that their expectations of TKA are met. This is important for clinicians when counselling patients pre-operatively.

Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus closed wedge osteotomy

PURPOSE

Medial opening wedge high tibial osteotomy (HTO) has become increasingly popular as an alternative to lateral closing wedge osteotomy for the treatment of medial compartment knee osteoarthritis with varus deformity. The present systematic review was conducted to provide an objective analysis of total knee arthroplasty (TKA) outcomes following previous knee osteotomy (medial opening wedge vs. lateral closing wedge).

METHODS

A literature search of online databases (MEDLINE, EMBASE, Cochrane Library database) was made, in addition to manual search of major orthopaedic journals. The methodological quality of each of the studies was assessed on the Newcastle-Ottawa Scale and Effective Practice and Organization of Care. A total of ten studies were included in the review. There were eight studies with Level IV and two studies with Level III evidence.

RESULTS

Eight studies reported clinical and radiologic scores. Comparative studies between TKA following medial opening and lateral closing wedge HTO did not demonstrate statistically significant clinical and radiologic differences. The revision rates were similar. However, more technical issues during TKA surgery after lateral closing wedge HTO were mentioned than the medial open wedge group. The quadriceps snip, tibial tubercle osteotomy, and lateral soft tissue release were more frequently needed in the lateral closing wedge HTO group. In addition, because of loss of proximal tibia bone geometry in the lateral closing wedge HTO group, concerns such as tibia stem impingement in the lateral tibial cortex was noted.

CONCLUSION

The present systematic review suggests that TKA after medial opening and lateral closing wedge HTO showed similar performance. Clinical and radiologic outcome including revision rates did not statistically differ from included studies. However, there are more surgical technical concerns in TKA conversion from lateral closing wedge HTO than from the medial opening wedge HTO group.

LEVEL OF EVIDENCE

IV.

Open wedge high tibial osteotomy (HTO) versus mobile bearing unicondylar medial joint replacement: five years results

INTRODUCTION

Aim of this study was to compare clinical results after open wedge HTO (OW-HTO and medial unicondylar joint replacement (UKA) in patients aged between 55 and 65.

MATERIALS AND METHODS

Fifty-four patients aged between 55 and 65 years with medial OA and varus malalignement who had been treated by either OW-HTO or UKA could be included. Minimum follow up was 5 years. The HSS knee score and the KOOS were used to evaluate clinical outcome.

RESULTS

There was no difference in the revision rate, the HSS knee score and the KOOS subscales Sports/Rec and ADL between the OW-HTO and UKA group. However, the KOOS subscales pain, Symptoms and QoL were significantly better in the UKA group compared to the OW-HTO.

CONCLUSIONS

The results of this study showed that 5 years after surgery patients after UKA had less residual pain and symptoms than patients after UKA. These advantages might result in a higher quality of life.

High tibial osteotomy in the ACL-deficient knee with medial compartment osteoarthritis

High tibial osteotomy (HTO) has traditionally been used to treat varus gonarthrosis in younger, active patients. Varus malalignment increases the risk of progression of medial compartment osteoarthritis and an HTO can be performed to realign the mechanical axis of the lower limb towards the lateral compartment, thereby decreasing contact pressures in the medial compartment. Anterior cruciate ligament (ACL) insufficiency may lead to post-traumatic arthritis due to altered joint loading and associated injuries to the menisci and articular cartilage. Understanding the importance of posterior tibial slope and its role in sagittal knee stability has led to the development of biplane osteotomies designed to flatten the posterior tibial slope in the ACL deficient knee. Altering the alignment in both the sagittal and coronal planes helps improve stability as well as alter the load in the medial compartment. Detailed history, physical exam and radiographic analysis guide treatment decisions in this high demand patient population. Lateral closing wedge (LCW) and medial opening wedge (MOW) HTOs have been performed and their potential advantages and disadvantages have been well described. Given the triangular shape of the proximal tibia, it is imperative that the surgeon pay close attention to the geometry of the osteotomy “gap” when performing MOW HTO to avoid inadvertently increasing the posterior tibial slope. Simultaneous ACL reconstruction may require technique modifications depending on the type of HTO and ACL graft chosen. With appropriate patient selection and good surgical technique, it is reasonable to expect patients to return to activities of daily living and recreational sports without debilitating pain or instability.

Conversion Total Knee Arthroplasty after Failed High Tibial Osteotomy

Clinical results of high tibial osteotomy (HTO) deteriorate over time despite the initial satisfactory results. Several knees may require a conversion to total knee arthroplasty (TKA) because of failure such as the progression of degenerative osteoarthritis and the loss of the correction angle. It is important to know the long-term survival rate and common reason of failure in HTO to inform patients of postoperative expectations before surgery and to prevent surgical errors during surgery. In addition, it has been reported that clinical and radiological results, revision rate, and complication rate were poorer than those in patients without a previous HTO. There are few review articles that describe why conversion TKA after HTO is surgically difficult and the results are poor. Surgeons have to avoid the various complications and surgical errors in this specific situation. We would like to present the considering factors and technical difficulties during conversion TKA after HTO with a review of the literature. We could conclude through the review that the correction of deformity, lower amount of tibial bone resection, and sufficient polyethylene insert thickness, restoration of the joint line height, and adequate ligament balancing can be helpful in overcoming the technical challenges encountered during TKA following HTO.

Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy

PURPOSE

The objectives of this study were (1) to evaluate the clinical and radiologic outcomes of open-wedge high tibial osteotomy focusing on patellofemoral alignment and (2) to search for correlation between variables and patellofemoral malalignment.

METHODS

A total of 46 knees (46 patients) from 32 females and 14 males who underwent open-wedge high tibial osteotomy were included in this retrospective case series. Outcomes were evaluated using clinical scales and radiologic parameters at the last follow-up. Pre-operative and final follow-up values were compared for the outcome analysis. For the focused analysis of the patellofemoral joint, correlation analyses between patellofemoral variables and pre- and post-operative weight-bearing line (WBL), clinical score, posterior slope, Blackburn Peel ratio, lateral patellar tilt, lateral patellar shift, and congruence angle were performed.

RESULTS

The minimum follow-up period was 2 years and median follow-up period was 44 months (range 24-88 months). The percentage of weight-bearing line was shifted from 17.2 ± 11.1 to 56.7 ± 12.7%, and it was statistically significant (p < 0.01). Regarding the clinical results, statistical significance was observed using all scores (p < 0.01). In the radiologic evaluation, patellar descent was observed with statistical significance (p < 0.01). Last follow-up lateral patellar tilt was decreased with statistical significance (p < 0.01). In correlation analysis between variables of patellofemoral malalignment, the pre-operative weight-bearing line showed an association with the change in lateral patellar tilt and lateral patellar shift (correlation coefficient: 0.3).

CONCLUSION

After open-wedge high tibial osteotomy, clinical results showed improvement, compared to pre-operative values. The patellar tilt and lateral patellar shift were not changed; however, descent of the patella was observed. Therefore, mild patellofemoral problems should not be a contraindication of the open-wedge high tibial osteotomy.

LEVEL OF EVIDENCE

Case series, Level IV.

The difficult primary total knee arthroplasty: a review

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cruciate retaining versus posterior stabilized total knee arthroplasty after previous high tibial osteotomy

PURPOSE

This study aimed to investigate the clinical outcome of total knee arthroplasty (TKA) after previous high tibial osteotomy (HTO) using cruciate retaining (CR) versus posterior stabilized (PS) prostheses.

METHODS

Between 2001 and 2010, 133 patients who underwent TKA after previous HTO were included in this study and prospectively followed up for two years. Two independent assessors recorded the range of motion of the operated knee, anterior-posterior (AP) laxity, medial-lateral (ML) laxity, Oxford Knee Score (OKS), Knee Society Function Score (KSFS) and Knee Society Knee Score (KSKS).

RESULTS

Thirty-three patients received CR prostheses, while 100 patients received PS prostheses. The median (inter-quartile range) knee flexion at 6 months and 2 years post-TKA was 101° (90, 116) and 110° (90, 118), respectively for the CR group, compared to 115° (100, 121) and 118° (108, 125) for the PS group (p = 0.010 and p = 0.009, respectively). AP and ML laxities were comparable in both groups of patients. While both groups of patients showed improvement in OKS, KSFS and KSKS at 6 months and 2 years post-TKA, there was no significant difference in these clinical scores between the two groups at both time points of follow-up. None of the 133 patients required revision surgery.

CONCLUSIONS

Although PS prostheses offer better knee flexion in TKA after previous HTO, the knee stability, clinical scores and revision rate at 6 months and 2 years post-TKA are comparable between CR and PS prostheses. The authors conclude that CR is an alternative to PS prostheses in patients undergoing TKA after previous HTO.

LEVEL OF EVIDENCE

III.

The risk of revision in total knee arthroplasty is not affected by previous high tibial osteotomy

BACKGROUND AND PURPOSE

Previous studies have found different outcomes after revision of knee arthroplasties performed after high tibial osteotomy (HTO). We evaluated the risk of revision of total knee arthroplasty with or without previous HTO in a large registry material.

PATIENTS AND METHODS

31,077 primary TKAs were compared with 1,399 TKAs after HTO, using Kaplan-Meier 10-year survival percentages and adjusted Cox regression analysis.

RESULTS

The adjusted survival analyses showed similar survival in the 2 groups. The Kaplan-Meier 10-year survival was 93.8% in the primary TKA group and 92.6% in the TKA-post-HTO group. Adjusted RR was 0.97 (95% CI: 0.77-1.21; p = 0.8).

INTERPRETATION

In this registry-based study, previous high tibial osteotomy did not appear to compromise the results regarding risk of revision after total knee arthroplasty compared to primary knee arthroplasty.

What Host Factors Affect Aseptic Loosening After THA and TKA?

BACKGROUND

Aseptic loosening is the most common cause for revisions after lower-extremity total joint arthroplasties, however studies differ regarding the degree to which host factors influence loosening.

QUESTIONS/PURPOSE

We performed a systematic review to determine which host factors play a role in the development of clinical and/or radiographic failure from aseptic loosening after (1) THA and (2) TKA.

METHODS

Two searches on THA and TKA, respectively, using four electronic databases (EMBASE, CINAHL Plus, PubMed, and Scopus) were conducted. We identified a total of 209 reports that encompassed nine potential host factors affecting aseptic loosening. Inclusion criteria for consideration of scientific clinical reports were that 20 or more patients were involved, with more than 1-year followup, with at least three studies pertaining to each factor, and at least six of the Methodological Index for Non-randomized Studies criteria met, and with raw data for odds ratio (OR) calculations. Twenty-one studies (16 THA studies with 45,779 hips and five TKA studies with 288 knees, respectively) were used to calculate weighted OR and CIs (using the random effects theory) and study heterogeneity for four different host factors in THAs (male sex, high activity level, obesity defined as BMI≥30 kg/m2, and current or former tobacco use) and one factor in TKA (BMI≥30 kg/m2), which were placed in a forest plot.

RESULTS

For THA, male sex (OR, 1.39; 95% CI, 1.22-1.58; p=0.001) and high activity level (University of California Los Angeles [UCLA] activity score≥8 points; OR, 4.24; 95% CI, 2.46-7.31; p=0.001) were associated with aseptic loosening. However, obesity (OR, 1.01; 95% CI, 0.73-1.40; p=0.96), and tobacco use (OR, 1.96; 95% CI, 0.43-8.97; p=0.39) were not associated with an increased risk of aseptic loosening after THA with the numbers available. For TKA, we found no host factors associated with loosening. In particular, obesity (BMI≥30 kg/m2) was not associated with aseptic loosening with the numbers available (OR, 2.28; 95% CI, 0.60-8.62; p=0.22).

CONCLUSIONS

Patients undergoing a lower-extremity total joint arthroplasty who engage in impact sports should be counseled regarding their potential increased risk of aseptic loosening; however, given the weak evidence available, we believe that higher-level studies are necessary to clearly define the risk factors, particularly with newer-generation constructs.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Computer-assisted total knee replacement after medial opening wedge high tibial osteotomy: medium-term results in a series of ninety cases

PURPOSE

The aim of this study was to evaluate the medium-term results of total knee replacements (TKRs) after medial opening wedge valgising tibial osteotomy to those of primary TKR (TKR1). The hypothesis being that there would be no difference in results between these groups.

METHODS

Series 1 was made up of 45 TKRs after medial opening wedge high tibial osteotomy (MHTO)-30 men and ten women at an average age of 69 ± seven years (54-82). This was compared to a second series of TKR1s-30 men and ten women at an average age of 69 ± seven years (55-78). The average IKS scores were 91 ± 22.5 points (42-129) and 86 ± 18 points (38-116) in the two groups respectively. The average pre-operative HKA angle was 179 ± 5° (169-193°) in group 1, and 173 ± 7.5° (161-193°) in group 2. Tibial mechanical axes were 90.5 ± 4° (of which 24 knees had a valgus angle) and 85.05 ± 3.5° (79-93°) in the two groups respectively.

RESULTS

All patients were reviewed at an average follow-up of 47 ± 24.5 months for series 1 and 185 ± 8.5 months for series 2. The average IKS score was 184 ± 6 for series 1 (172-200) and 185 ± 8.5 (163-200) for series 2 (p = 0.872). Thirty-seven patients in series 1 and 38 patients in series 2 were either extremely satisfied or satisfied with the intervention. The average post-operative HKA angle was 180.5 ± 2.5° and 181 ± 2° (p = 0.122) and the average tibial mechanical axis was 89 ± 1.5° against 90 ± 1° (p = 0.001). The results of the 24 knees with a valgus tibial mechanical axis were statistically no different.

CONCLUSIONS

TKRs post medial opening wedge high tibial osteotomy have identical results to primary TKRs even in knees with a valgus tibial mechanical axis.

The outcome at ten years of lateral closing-wedge high tibial osteotomy: determinants of survival and functional outcome

The aim of this study was to examine the functional outcome at ten years following lateral closing wedge high tibial osteotomy for medial compartment osteoarthritis of the knee and to define pre-operative predictors of survival and determinants of functional outcome. 164 consecutive patients underwent high tibial osteotomy between 2000 and 2002. A total of 100 patients (100 knees) met the inclusion criteria and 95 were available for review at ten years. Data were collected prospectively and included patient demographics, surgical details, long leg alignment radiographs, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five years. Overall Kaplan-Meier survival was 87% (95% confidence interval (CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years, respectively. When compared with unrevised patients, those who had been revised had significantly lower mean pre-operative WOMAC Scores (47 (21 to 85) vs 65 (32 to 99), p < 0.001), higher mean age (54 yrs (42 to 61) vs 49 yrs (26 to 66), p = 0.006) and a higher mean BMI (30.2; 25 to 39 vs 27.9; 21 to 36, p = 0.005). Each were found to be risk factors for revision, with hazard ratios of 10.7 (95% CI 4 to 28.6; pre-operative WOMAC < 45), 6.5 (95% CI 2.4 to 17.7; age > 55) and 3.0 (95%CI 1.2 to 7.6; BMI > 30). Survival of patients with pre-operative WOMAC > 45, age < 55 and BMI < 30 was 97% at five and ten years. WOMAC and KSS in surviving patients improved significantly between pre-operative (mean 61; 32 to 99) and five (mean 88; 35 to 100, p = 0.001) and ten years (mean 84; 38 to 100, p = 0.001). Older patients had better functional outcomes overall, despite their higher revision rate. This study has shown that improved survival is associated with age < 55 years, pre-operative WOMAC scores > 45 and, a BMI < 30. In patients over 55 years of age with adequate pre-operative functional scores, survival can be good and functional outcomes can be significantly better than their younger counterparts. We recommend the routine use of pre-operative functional outcome scores to guide decision-making when considering suitability for high tibial osteotomy.

Osteotomy for treating knee osteoarthritis

BACKGROUND

Patients with unicompartmental osteoarthritis of the knee can be treated with an osteotomy. The goal of an osteotomy is to unload the diseased compartment of the knee. This is the second update of the original review published in The Cochrane Library, Issue 1, 2005.

OBJECTIVES

To assess the benefits and harms of an osteotomy for treating patients with knee osteoarthritis, including the following main outcomes scores: treatment failure, pain and function scores, health-related quality of life, serious adverse events, mortality and reoperation rate.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE (Current Contents, HealthSTAR) were searched until November 2013 for this second update.

SELECTION CRITERIA

Randomised and controlled clinical trials comparing an osteotomy with other treatments for patients with unicompartmental osteoarthritis of the knee.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias using the domains recommended in the 'Risk of bias' tool of The Cochrane Collaboration. The quality of the results was analysed by performing overall grading of evidence by outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

Eight new studies were included in this update, for a total of 21 included studies involving 1065 people.In four studies, the randomised sequence was adequately generated and clearly described. In eight studies, allocation concealment was adequately generated and described. In four studies, the blinding procedures were sufficient. In six studies, incomplete outcome data were not adequately addressed. Furthermore, in 11 studies, the selective outcome reporting item was unclear because no study protocol was provided.Follow-up of studies comparing different osteotomy techniques was too short to measure treatment failure, which implicates revision to a knee arthroplasty.Four studies evaluated a closing wedge high tibial osteotomy (CW-HTO) with another high tibial osteotomy (aHTO). Based on these studies, the CW-HTO group had 1.8% (95% confidence interval (CI) -7.7% to 4.2%; low-quality evidence) more pain compared with the aHTO group; this finding was not statistically significant. Pooled function in the CW-HTO group was 0.5% (95% CI -3.8% to 2.8%; low-quality evidence) higher compared with the aHTO group; this finding was not statistically significant. No data on health-related quality of life and mortality were presented.Serious adverse events were reported in only four studies and were not significantly different (low-quality evidence) between groups. The reoperation rate were scored as early hardware removal because of pain and pin track infection due to the external fixator. Risk of reoperation was 2.6 (95% CI 1.5 to 4.5; low-quality evidence) times higher in the aHTO group compared with the CW-HTO group, and this finding was statistically significant.The quality of evidence for most outcomes comparing different osteotomy techniques was downgraded to low because of the numbers of available studies, the numbers of participants and limitations in design.Two studies compared high tibial osteotomy versus unicompartmental knee replacement. Treatment failure and pain and function scores were not different between groups after a mean follow-up of 7.5 years. The osteotomy group reported more adverse events when compared with the unicompartmental knee replacement group, but the difference was not statistically significant. No data on health-related quality of life and mortality were presented.No study compared an osteotomy versus conservative treatment.Ten included studies compared differences in perioperative or postoperative conditions after high tibial osteotomy. In most of these studies, no statistically significant differences in outcomes were noted between groups.

AUTHORS' CONCLUSIONS

The conclusion of this update did not change: Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee. However, this conclusion is based on within-group comparisons, not on non-operative controls. No evidence suggests differences between different osteotomy techniques. No evidence shows whether an osteotomy is more effective than alternative surgical treatment such as unicompartmental knee replacement or non-operative treatment. So far, the results of this updated review do not justify a conclusion on benefit of specific high tibial osteotomy technique for knee osteoarthritis.

Early experience with the Vanguard complete total knee system: 2-7 years of follow-up and risk factors for revision

A cross-sectional study in two hospitals was performed on 807 patients with a primary Vanguard (Biomet) total knee Arthroplasty (TKA). The research questions addressed were (1) what are the two- and six year survival rates of the Vanguard, (2) what are the clinical outcome scores, (3) what are the findings at revision and (4) what are predictors for revision? The mean age at time of surgery was 67.0 (SD 10.0). The mean follow-up was 3.6 years (95% CI 3.56-3.73). At two years the survival was 97.2% for all-reasons (767 patients remaining) and 99%, for prosthesis-related-reasons (777 remaining). At six years this was 96.5% (40 remaining) and 98.6% (41 remaining). The mean clinical results (84% response on KOOS, Oxford and NRS) were good. A previous osteotomy was a risk factor for revision (hazard ratio 5.1, P=0.001). This early experience with the Vanguard shows a good survival with no adverse outcomes related to the implant and therefore further use of the implant is justified.

Total knee arthroplasty after high tibial osteotomy: no differences between medial and lateral osteotomy approaches

BACKGROUND

High tibial osteotomy (HTO) has long been accepted as an effective treatment for unicompartmental osteoarthritis of the knee in young, active adults. For varus knees, the two most commonly performed valgus-producing HTOs are the lateral closing wedge and the medial opening wedge. Regardless of technique, some HTOs fail and are converted to TKA. To our knowledge, no studies have directly compared TKAs done after lateral closing-wedge osteotomies to those done after medial opening-wedge osteotomies.

QUESTIONS/PURPOSES

We compared pain- and function-related outcomes and survivorship of TKAs in patients who previously underwent medial opening-wedge and lateral closing-wedge HTOs.

METHODS

We reviewed our institutional database to identify all patients having undergone a HTO with subsequent conversion to TKA and identified 188 lateral closing-wedge HTOs and 77 medial opening-wedge HTOs. Mean followup was 88 months (range, 3-264 months) for the lateral closing-wedge HTO cohort and 59 months (range, 3-180 months) for the medial opening-wedge cohort. SF-12, WOMAC, and Knee Society Scores, as well as survivorship at 5 years, were compared between the two groups. Statistical analysis was completed using the independent-samples t-test.

RESULTS

No differences were found between groups in postoperative SF-12 scores (p = 0.77 for the mental component summary score and p = 0.21 for the physical component summary score), WOMAC scores (p = 0.67), or Knee Society Scores (p = 0.80). No difference was found in survivorship between groups at 5 years.

CONCLUSIONS

Our results suggest there is no difference in functional outcomes or survivorship of TKA in patients having previously undergone medial opening-wedge and lateral closing-wedge HTOs.

Total knee arthroplasty after high tibial osteotomy: a registry-based case-control study of 1,036 knees

INTRODUCTION

Total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is a technically demanding procedure, and concerns have been raised that previous HTO might compromise the outcome of TKA. The aims of the study were to assess the survivorship of TKA after HTO and to determine whether the survivorship is similar to that of primary TKA without previous HTO.

MATERIALS AND METHODS

Using the Finnish Arthroplasty Register and the National Hospital Discharge Register, we extracted the data of 1,036 patients [mean age 64.3 years; followup 6.7 years (0-22)] who had undergone TKA after a previous HTO between 1987 and 2008. From this cohort, we calculated the Kaplan-Meier survivorship and compared the survivorship of these cases to that of 4,143 age- and gender-matched patients who had undergone primary TKAs without previous HTO.

RESULTS

In the TKA after HTO group, we found Kaplan-Meier survivorship to be 95.3% at 5 years, 91.8% at 10 years, and 88.4% at 15 years. Those survivorship values were lower than those of patients who had TKA without previous HTO (97.2, 94.5, and 90.6%, respectively) (hazard ratio 1.40; 95% confidence interval 1.09-1.81; p = 0.010).

CONCLUSIONS

Previous studies have described technical difficulties during the TKA procedure after HTO, but they have found no adverse effects on the outcome. Our study supports previous research, and despite the slightly higher revision rate, TKA after HTO provides satisfactory results when compared to routine primary TKAs.

Complex cartilage cases in the athletic patient: advances in malalignment, instability, articular defects, and meniscal insufficiency

For sports medicine specialists, patients presenting with multiple coexisting knee pathologies can be some of the most difficult to treat patients, especially those with cartilage pathology. In particular, articular cartilage lesions are often incidental findings, and the decision to treat patients must be based on the lesions' confirmed contribution to patient symptomatology. The combination of malalignment, ligamentous instability, and chondral/meniscal damage in patients is challenging to treat because of the difficulty in determining both the relative contribution of each of the pathologies to patient clinical condition and the timing of performing specific corrective procedures. Corrective operations performed in isolation to treat each of the pathologies have historically produced reasonable results in patients; however, combined procedures for treatment of combined pathologies may prove essential for the success of any single procedure. This review describes the clinical evaluation of patients with multiple coexisting knee pathologies and highlights current evidence-based treatment strategies for the management of these combined disorders.

High tibial osteotomy

High tibial osteotomy (HTO) is a widely performed procedure to treat medial knee arthrosis. In general, published studies on HTO report good long-term results with a correct patient selection and a precise surgical technique. The ideal candidate for an HTO is a middle aged patient (60 to 65 years of age), with isolated medial osteoarthritis, with good range of motion and without ligamentous instability. Some issues that need resolution remain; these include the choice between opening and closing wedge tibial osteotomy, the graft selection in opening wedge osteotomies, the type of fixation, the comparison with unicompartmental knee arthroplasty and whether HTO significantly affects a subsequent total joint replacement. Precise indication, preoperative planning, and operative technique selection are essential to achieve good results.

The role of high tibial osteotomy in the varus knee

High tibial osteotomy (HTO) is a widely performed procedure, and good results can be achieved with appropriate patient selection and precise surgical technique. Clinical indications include varus alignment of the knee associated with medial compartment arthrosis, knee instability, medial compartment overload following meniscectomy, and osteochondral defects requiring resurfacing procedures. Coronal alignment (ie, varus, valgus) and sagittal alignment (ie, tibial slope) should be thoroughly evaluated in all cases. Many techniques have been described for HTO, whether alone or in combination with other procedures (eg, anterior cruciate ligament reconstruction, meniscal transplant, cartilage resurfacing). Little direct evidence exists regarding the effectiveness of HTO alone or in combination with other procedures because of the lack of randomized controlled studies. However, it is commonly accepted that correct alignment is essential in achieving durable results.

TKA following high tibial osteotomy versus primary TKA--a matched pair analysis

Background

High tibial osteotomy (HTO) is a well established technique for the treatment of medial osteoarthritis of the knee with varus malalignment. Results of total knee arthroplasty (TKA) after previous HTO are still discussed controversially. The aim of this study was to elucidate the clinical and radiological results as well as perioperative data of prior HTO on TKA.

Methods

Forty-one TKA after HTO were compared to 41 primary TKA at minimum of six years follow-up. Patients were matched according to age, gender, follow-up, etiology, and prosthetic design. Surgical data and complications were evaluated. Clinical outcome was assessed using a number of clinical scores and the visual analogue scale (VAS) for pain. X-rays were evaluated by the method of the American Knee Society. The patellar position was measured by the Insall-Salvati ratio.

Results

There was no significant difference in mean operation time (p = 0.47) and complication rate (p = 0.08). The Knee Score of the KSS (p = 0.0007) and the ROM (p = 0.006 for extension and p = 0.004 for flexion, respectively) were significantly better in the control group. Mid-term results of the VAS, WOMAC, Lequesne, UCLA, Feller's Patellar Score and SF-36 showed no significant difference. Femoral and tibial component alignment were similar in both groups. One tibial component showed suspect radiolucencies in the HTO group. The Insall-Salvati ratio showed three patients with patella alta and one patient with patella baja in the HTO group. At latest follow-up all implants were still in place.

Conclusions

Evaluating the clinical and radiological outcome, significant differences were only detected for range of motion and the Knee Score of the KSS. The present study suggests that the results of TKA with and without prior HTO are mainly identical. Although patients with a previous HTO had more complications, no statistically significant differences were noted with this group size.

High tibial osteotomy versus unicompartmental knee arthroplasty for medial compartment arthrosis of the knee: a review of the literature

This review examined the literature regarding high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA), focusing on indications, survivorship and functional outcomes of the two procedures, as well as revision to total knee arthroplasty (TKA) after failed HTO or UKA. HTO and UKA share the same indications in selected cases of medial unicompartmental knee arthrosis. These indications include patients who are: 1) 55 to 65 years old; 2) moderately active; 3) non-obese; 4) have mild varus malalignment; 5) no joint instability; 6) good range of motion; and 7) moderate unicompartmental arthrosis. Few studies are available in the literature comparing the outcomes of HTO and UKA. Those few studies show slightly better results for UKA in terms of survivorship and functional outcome. Nevertheless, the differences are not remarkable, the study methods are not homogeneous and most of the papers report on closing wedge HTOs. For these reasons, no definitive conclusions can be drawn. TKA represents the revision option for both treatments and yields satisfactory functional outcomes and survivorship. Whether revision HTO and UKA-to-TKA perform any worse than primary TKA is still controversial. With the correct indications, both treatments produce durable and predictable outcomes in the treatment of medial unicompartmental arthrosis of the knee. There is no evidence of superior results of one treatment over the other.