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

Meniscus Allograft Transplantation in Conjunction with Arthroscopic Biologic Knee Restoration Delays Arthroplasty in Patients Over 50 Years of Age

PURPOSE

The purpose of this study is to evaluate the utility of meniscus allografts in combination with other procedures to delay knee arthroplasty in patients older than 50 years of age previously advised joint arthroplasty.

METHODS

One hundred eight meniscus allograft transplants (MATs) using the arthroscopic three tunnel technique between 1997 and 2019 in patients over 50 years of age were retrospectively reviewed with two-year minimum follow-up period. Inclusion criteria were patients recommended knee arthroplasty with pain and preservation of some joint space by standing flexion x-rays. Exclusion criteria were lack of joint space, failure to comply with rehabilitation protocol or complete research questionnaires. International Knee Documentation Committee (IKDC) composite and isolated pain scale were evaluated longitudinally. Time from MAT to arthroplasty was measured with failure defined as allograft excision or revision, progression to arthroplasty, or same or increased pain.

RESULTS

Eighty-six of 108 (79.6%) patients met eligibility criteria. Over the follow-up mean 8.55 (range of 0.68 to 25.2) years, 42 of 87 (48.2%) grafts progressed to arthroplasty with mean time of 8.64 (median 8.05) years. Concomitant procedures did not have significant impact on survival; however, survival medians were higher among paste graft and chondroplasty and lower among osteotomy groups. At the time of reporting, 41 of 84 (48.8%) patients had intact meniscus transplants, demonstrating significant improvements (p<0.001) in pain and function as assessed by IKDC. These improvements were sustained ten years post-operatively, correlated to a mean of 65.8 years of age. At least 50% of patients achieved Minimal Clinically Important Difference (MCID) through 10 years post-operatively.

CONCLUSIONS

Meniscus allografts in combination with other arthroscopic interventions delay knee arthroplasty and improve knee symptoms of pain and function in a population of knee arthroplasty candidates over 50 years of age. Influences of concomitant procedures cannot be defined.

Total knee arthroplasty following lateral closing-wedge high tibial osteotomy versus primary total knee arthroplasty: a propensity score matching study

BACKGROUND

The disparity in patient-reported outcomes between total knee arthroplasty (TKA) following high tibial osteotomy (HTO) and primary TKA has yet to be fully comprehended. This study aims to compare the patient-reported outcomes, radiological parameters and complication rates between TKA following HTO and primary TKA.

METHODS

Sixty-five patients who underwent TKA following lateral closing-wedge HTO were compared to a matched group of primary TKA at postoperative 6-months and 1-year. Between-group confounders of age, gender, smoking status, Body Mass index, preoperative Numeric Rating Scale (NRS) pain in rest, Knee injury and Osteoarthritis Outcome Score-Physical function Shortform (KOOS-PS), EuroQol five-dimensional (EQ-5D) overall health score, and Oxford Knee Score (OKS) were balanced by propensity score matching. Patient-reported outcome measures were NRS pain in rest, KOOS-PS, EQ-5D overall health score, and OKS. Radiological parameters were femorotibial angle, medial proximal tibial angle, anatomical lateral distal femoral angle, posterior tibial slope, and patellar height assessed by Insall-Salvati ratio. The complication rates of TKA were compared between the two groups. The HTO survival time, the choice of staple removal before or during TKA in patients who underwent TKA following HTO patients, and the rate of patellar resurfacing were assessed. The p value < 0.0125 indicates statistical significance after Bonferroni correction.

RESULTS

After propensity score matching, no significant between-group differences in the patient-reported outcome measures, radiographical parameters and complication rates were found (p > 0.0125). In the TKA following HTO group, with an average HTO survival time of 8.7 years, staples were removed before TKA in 46 patients (71%) and during TKA in 19 patients, and 11 cases (17%) had patella resurfacing. In the primary TKA group, 15 cases (23%) had patella resurfacing.

CONCLUSION

The short-term assessment of TKA following HTO indicates outcomes similar to primary TKA. A previous HTO does not impact the early results of subsequent TKA, suggesting that the previous HTO has minimal influence on TKA outcomes.

LEVEL OF EVIDENCE

III, cohort study.

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.

Total Knee Arthroplasty Function at 25 Years Following Proximal Tibial Osteotomy: Paired Outcomes of Bilateral TKAs Following Unilateral Osteotomy

BACKGROUND

Proximal tibial osteotomy (PTO) is a well-established treatment for coronal deformity and focal cartilage defects. However, the utility of joint-preserving interventions must be weighed against potential effects on subsequent total knee arthroplasty (TKA). The purpose of this study was to determine the effect of PTO on subsequent TKA by comparing outcomes in patients with bilateral TKAs following unilateral PTO.

METHODS

Patients who underwent bilateral TKAs from 2000 to 2015 at a single institution and had previously undergone a unilateral valgus-producing PTO were reviewed. We evaluated 140 TKAs performed in 70 patients (24 female, 46 male) with a mean age at PTO of 50 ± 8 years. The patients underwent conversion to TKA at a mean of 14 ± 7 years following ipsilateral PTO and were followed for a mean of 25 ± 7 years (range, 6 to 40 years) following PTO. The Knee Society Score (KSS), Forgotten Joint Score-12 (FJS-12), subjective knee preference, and revision were compared between the PTO-TKA and contralateral TKA-only sides.

RESULTS

The PTO side demonstrated similar KSS Knee subscores (41 ± 16) compared with the contralateral side (39 ± 16, p = 0.67) immediately prior to arthroplasty. Patients had significant improvements in KSS (p < 0.001) after TKA, with clinically similar KSS values at 2 to 15 years of follow-up when knees were compared in a pairwise fashion (p = 0.10 to 0.83). Five PTO-TKA knees (7%) and 4 control TKA-only knees (6%) underwent revision at a mean of 5 years postoperatively (p = 0.76). The number of all-cause reoperations was approximately twice as high in PTO-TKA knees (13% compared with 6% in TKA-only knees, p = 0.24). At the time of final follow-up, PTO-TKA knees demonstrated similar FJS-12 scores (72 ± 26) compared with the contralateral knees (70 ± 28, p = 0.57). Nineteen percent of patients preferred the PTO-TKA knee, 19% preferred the contralateral TKA-only knee, and 62% stated that their knees were equivalent (p > 0.99). The final Tegner activity score was 2.5 ± 1.4.

CONCLUSIONS

Long-term clinical function of TKA following PTO was excellent, with patients demonstrating comparable subjective outcomes and equivalent knee preference compared with the contralateral TKA-only knees. Further, well-matched studies are needed to evaluate long-term revision and reoperation rates following PTO-TKA.

LEVEL OF EVIDENCE

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

Total Knee Arthroplasty Conversion after Open-wedge High Tibial Osteotomy

Background:

Open-wedge High Tibial Osteotomy (HTO) is an effective treatment for Osteoarthritis (OA) of the knee; however, postoperative changes due to HTO can make subsequent Total Knee Arthroplasty (TKA) technically difficult and can affect long-term survival.

Case Report:

Medio-lateral stability along with balanced flexion and extension gaps provides a good functional outcome.

A 71-year-old man underwent TKA conversion after open-wedge HTO 12 years earlier; the conversion was performed due to arthritic deterioration in the knee. Medial instability was noted because of poor ligament balancing. The residual medial instability was managed with a knee brace due to the unavailability of the constrained prosthesis. Management of persistent mediolateral instability persisting after soft tissue release and balancing ideally requires varus-valgus constraint.

Conclusion:

TKA conversion after open-wedge HTO requires a special technique and careful preparation before surgery.

[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.

Planning Results for High Tibial Osteotomies in Degenerative Varus Osteoarthritis Using Standing and Supine Whole Leg Radiographs

Objective

In this study, we hypothesized that standing and supine X‐rays lead to different preoperative planning results.

Methods

The present study included 168 pictures from 81 patients who were treated surgically with high tibial osteotomy (HTO) for varus deformity between January 2017 and February 2018. Each patient underwent whole leg X‐ray examinations in both standing and supine position. On both images, the following parameters were measured: degree of axis deviation (DAD), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), width of medial (MJS) and lateral joint space (LJS), and the correction angle (CA). The results were correlated with the patients’ age and body mass index (BMI). To analyze intra‐observer reliability, the same researcher, blinded to the previous measurements, remeasured all X‐rays from 10 patients 8 weeks after the initial measurements were carried out.

Results

While mLDFA (P = 0.075), mMPTA (P = 0.435), and MJS (P = 0.119) did not show any differences between the two modalities, LJS (P = 0.016) and DAD (P < 0.001) differed significantly, leading to different correction angles (P < 0.001). The mean difference of the CA was 1.7° ± 2.2° (range, −2.6° to−15.4°). In 14 legs (17%), the standing X‐ray led to a correction angle that was at least 3° larger than the calculation revealed in the supine X‐ray; in 4 legs (5%), it was at least 5° larger. Increased BMI (r = 0.191, P = 0.088) and older age (r = 0.057 , P = 0.605) did not show relevant correlation with DAD differences. However, more severe varus malalignment in the supine radiograph did correlate moderately with differences of correction angles between supine and weight‐bearing radiographs (r = 0.414, P < 0.001). The analysis of the intra‐rater reliability revealed mediocre to excellent intercorrelation coefficients between the measurements of the observer.

Conclusion

The use of supine and standing X‐ray images leads to different planning results when performing high tibial osteotomies for varus gonarthrosis. To avoid potential overcorrection, surgeons might consider increased lateral joint spaces on standing radiographs in osteoarthritic knees with varus deviation.

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.

Higher risk of revision in total knee arthroplasty after high tibial osteotomy: a systematic review and updated meta-analysis

Background

High tibial osteotomy is commonly performed in young patients with high activity demand. Several studies have reported outcome of HTO. The reported 10-year survival ranged from 79 to 97.6%. The reported 15-year survival ranged from 56 to 65.5%, resulting in the need for conversion to TKA. Primary TKA now provides satisfactory long-term outcome in terms of function and survival. Researches have been conducted to compare clinical outcome between primary TKA and TKA after HTO to see if TKA should be the prior treatment rather than HTO in some cases. But the results were inconsistent. This study aims to compare the risk of revision and other parameters between total knee arthroplasty after high tibial osteotomy and primary total knee arthroplasty.

Methods

Searches and screens of the relevant literature were conducted, after which data were extracted and pooled analysis was performed to compare the clinical outcomes between the two groups.

Results

A total of 14 studies with 144,692 cases were included. Pooled analysis showed significantly more revisions and complications, and more tibial component loosening and impingement in postoperative X-ray in the HTO-TKA group. Surgical complexity during conversion to total knee arthroplasty was summarised and listed in table.

Conclusion

High tibial osteotomy offers satisfactory pain relief and functional outcome in selected patients with high activity demand. However, the need for subsequent TKA should be noted, which might be a technically challenging procedure with significantly higher risk of revision comparing to primary TKA.

A meta-analysis of total knee arthroplasty following high tibial osteotomy versus primary total knee arthroplasty

BACKGROUND

This study was performed to compare the clinical and radiographic outcomes of total knee arthroplasty (TKA) following high tibial osteotomy (HTO) versus primary TKA.

METHODS

Relevant trials were identified via a search of Ovid, PubMed and the Cochrane Central Register of Controlled Trials from inception to 10 January 2019. A meta-analysis was performed to compare postoperative outcomes between revising HTO to TKA (RHTO) and primary TKA (PTKA) with respect to Knee Society Score (KSS), 10-year survival rate, operative time, flexion and extension angle, infection rate and radiographic results.

RESULTS

Sixteen of 340 studies involving 103,552 adult patients (RHTO group, n = 3955; PTKA group, n = 99,597) were eligible for inclusion in the meta-analysis. Compared with primary TKA, revising HTO to TKA required longer operative time and had a higher infection rate (P < 0.05). The PTKA group had better flexion angle than the RHTO group (P < 0.05). There were no significant differences between the two groups in the KSS, extension angle, radiographic results and 10-year survival rate (P > 0.05).

CONCLUSION

Patients who undergo conversion of HTO to TKA have similar 10-year survival rate, KSS, extension angle and radiographic results as patients who undergo primary TKA. However, conversion of HTO to TKA required longer operative time and had a higher infection rate than performing primary TKA. Moreover, conversion of HTO to TKA is associated with poorer flexion angle than primary TKA.

Survival of total knee arthroplasty after high tibial osteotomy versus primary total knee arthroplasty: A meta-analysis

BACKGROUND

Theoretical considerations suggest that total knee arthroplasty (TKA) is technically more challenging after high tibial osteotomy (HTO), resulting in inferior results compared to primary TKA. However, several studies on this issue have shown contradictory results. The purpose of this meta-analysis to compare survivorship and clinical outcomes between TKA with and without previous HTO.

METHODS

We reviewed studies that evaluated pain and function scores, range of motion (ROM), operation time, Insall-Salvati (IS) ratio, complications, and survival rates in patients treated with TKA with previous HTO or with primary TKA with short- to midterm (<10 years) or long-term (>10 years) follow-up.

RESULTS

Fifteen studies were included in the meta-analysis. There were no significant differences between TKA with and without previous HTO in pain score (95% CI: -0.27 to 0.29; P = .94), function score (95% CI: -0.08 to 0.24; P = .32), operation time (95% CI: -5.43 to 26.85; P = .19), IS ratio (95% CI: -0.03 to 0.08; P = .40), complication rates (TKA with previous HTO, 62/1717; primary TKA, 610/31386; OR 1.31, 95% CI: 0.97-1.77; P = .08), and short- to midterm survival rates (TKA with previous HTO, 1860/2009; primary TKA, 37848/38765; OR 0.55, 95% CI: 0.28-1.10; P = .09). Conversely, ROM (95% CI: -7.40 to -1.26; P = .006) and long-term survival rates (TKA with previous HTO, 1426/1523; primary TKA, 29810/31201; OR 0.71, 95% CI: 0.57-0.89; P = .003) were significantly different between the two groups. In addition, both groups had substantial proportions of knees exhibiting short- to midterm survivorship (92.6% by TKA with previous HTO and 97.6% by primary TKA) and long-term survivorship (93.6% by TKA with previous HTO and 95.5% by primary TKA).

CONCLUSIONS

This meta-analysis suggests that a previous HTO affected ROM or survival of TKA in the long-term even though both groups have equivalent clinical outcomes and complications. Thus, orthopedic surgeons should offer useful information regarding the advantages and disadvantages of both procedures to patients, and should provide advice on the generally higher risk of revision after TKA with previous HTO at long-term follow-up when counseling patients.

Primary cementless total knee arthroplasty with or without stem extension: a matched comparative study of ninety eight standard stems versus ninety eight long stems after more than ten years of follow-up

INTRODUCTION

Using a cementless fixation for total knee arthroplasty (TKA) is controversial. We hypothesized that cementless tibial base plate with a monoblock long stem (MLS) would provide secure tibial alignment and stable fixation when bone conditions were considered as poor for a cementless fixation. The purpose of this study was to compare the mean eight year survivorship of cementless standard keels (SK) vs cementless MLS.

MATERIAL METHODS

We report a matched series of 98 cases of SK and 98 cases of MLS in patients with poor bone conditions. The two cohorts were statistically compared. Revision for tibial loosening was used as the endpoint in the survivorship analysis.

RESULTS

We recorded two cases of tibial loosening and three cases of bipolar loosening in the SK group (0% MLS vs 5% SK). No tibial loosening occurred in the MLS group (statistically significant). No tibial periprosthetic or intra-operative fractures occurred in either group. The survivorship at eight years of follow-up was 95.6% in the SS cohort vs 100% in the MLS cohort using revision for tibial loosening as the endpoint.

DISCUSSION

This study was not randomized. Its strength was that it took into account the comparative midterm outcomes of a matched cohort of patients implanted with two types of cementless components in the same bone conditions. We did not record any tibial loosening in the MLS group. Using long stems has been criticized but we did not observe any adverse reactions and no intra-operative tibial fracture occurred.

CONCLUSION

MLS improves the alignment and fixation of cementless TKA. This is a safe solution when bone conditions are poor or modified by previous surgery.

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.

Subtubercle Osteotomy for Medial Compartment Osteoarthritis of the Knee Using Ilizarov Technique: Survival Analysis and Clinical Outcomes

BACKGROUND

High tibial osteotomy with acute correction and internal fixation can be used to correct malalignment and malorientation and reduce symptoms in patients with medial compartment osteoarthritis of the knee. To address the inadequacies of this technique, we performed a series of subtubercle tibial osteotomy (STO) procedures using circular ring fixation to correct knee varus malalignment and joint malorientation. The purpose of this study was to analyze the ability of this technique to delay subsequent knee arthroplasty and decrease symptoms.

METHODS

Sixty-one patients had a total of 72 STO procedures using the Ilizarov technique to correct a varus deformity of the proximal part of the tibia. Radiographic measurements were performed at the time of presentation and after osseous union and frame removal. Clinical and radiographic variables were compared from presentation to the time of the latest follow-up. We performed a survival analysis, and our primary outcome was the time to conversion to knee arthroplasty.

RESULTS

Radiographic measurements, including mechanical axis deviation, medial proximal tibial angle, and joint line congruence angle, significantly improved after deformity correction (p < 0.001 for all). In patients with a preoperative flexion contracture, the proximal posterior tibial angle significantly increased toward normal values (mean, 77.8° pretreatment versus 82.4° posttreatment; p = 0.007). Survival analysis demonstrated a rate of native knee-joint survival without conversion to arthroplasty of 94.2% (95% confidence interval [CI], 83% to 98%) at 5 years, 84.0% (95% CI, 69% to 92%) at 10 years, and 51.3% (95% CI, 28% to 71%) at 15 years. In addition, time-trade-off and Brief Pain Inventory outcomes significantly improved (p < 0.001). The complication rate was 8%.

CONCLUSIONS

STO procedures using the Ilizarov technique for symptomatic varus knee deformity, performed over the course of 18 years, resulted in high knee survival rates without arthroplasty and significant improvement in clinical status. The STO technique provides several advantages over acute correction with internal fixation through a conventional high tibial osteotomy, including maintenance of the patellofemoral relationship, no retained implants, and accurate coronal and sagittal plane corrections.

LEVEL OF EVIDENCE

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

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.

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.

Comparison of mid-term results between conversion total knee arthroplasties following closed wedge high tibial osteotomy and primary total knee arthroplasties: A matched pair study including patellar symptom and position

BACKGROUND

The purpose of this study was to compare mid-term clinical and radiographic results of conversion total knee arthroplasties (TKA) following a closed-wedge high tibial osteotomy (HTO) and primary TKAs.

METHODS

A total of 32 conversion TKAs (29 patients) were compared with a matched control group of patients who had undergone primary TKA. The clinical results were evaluated using the Knee Society Knee and Function score, the Western Ontario and McMaster Universities score, patella score, and range of motion (ROM). The radiographic results were evaluated using femorotibial angle, mechanical axis (MA), the method employed by the American Knee Society, joint line height (JLH), the amount of tibial bone resection, and the Insall-Salvati ratio. The clinical and radiographic results of conversion TKAs were compared with primary TKAs. The thickness of the polyethylene insert was also compared.

RESULTS

No significant differences were observed in the clinical scores or ROM between two groups. No significant differences were detected in femorotibial angle, MA, and position of the components between two groups. The amount of tibial bone resection and pre-operative JLH both were significantly lower in the conversion group than those in the control group, although postoperative JLH and pre and postoperative Insall-Salvati ratio did not differ between two groups. No significant difference in the thickness of the polyethylene insert was identified between two groups.

CONCLUSIONS

The previous closed-wedge HTO itself had no detrimental effect on the mid-term outcome of the subsequent TKA, including patellar symptom and position. No significant differences in the postoperative joint line and patella height were detected between the conversion and primary TKA groups.

Comparison of the impact of closing wedge versus opening wedge high tibial osteotomy on proximal tibial deformity and subsequent revision to total knee arthroplasty

PURPOSE

The purpose of this study was to assess the differences in proximal tibial deformity between closing wedge (CW) and opening wedge (OW) high tibial osteotomy (HTO) and their effects on the difficulty of total knee arthroplasty (TKA) conversion.

METHODS

Surgical simulations of CW-HTO and OW-HTO were performed on the same 3D computer-aided design knee models reconstructed from computed tomographic datasets of patients (median age 77 years; range 55-87 years; 40 knees) with medial osteoarthritis or osteonecrosis, and proximal tibial deformities were analysed. Subsequent TKA conversion was simulated in both CW and OW models, and the interference between the tibial implant and endosteal cortex was assessed.

RESULTS

The difference in the metaphyseal-diaphyseal angle in the CW-HTO and OW-HTO groups was 0.3° ± 0.2° (p < 0.001). The mechanical axis in the CW-HTO group was shifted laterally by 1.8 ± 1.1 mm relative to that in the OW-HTO group (p < 0.001) on the resection surface in TKA. Finally, the TKA tibial implant was substantially closer to the endosteal cortex in the CW-HTO group (mean 5.6 ± 1.6 mm) than to that in the OW-HTO group (mean 7.3 ± 1.6 mm) (p < 0.001).

CONCLUSION

The difference in the post-operative angular deformities of the proximal tibia between CW-HTO and OW-HTO was considered to be clinically irrelevant. The risk of interference between TKA tibial implant and endosteal bone was greater after CW-HTO than after OW-HTO. For clinical relevance, the difference between the two techniques has little influence on subsequent TKA difficulty regarding the proximal tibial deformity, although preoperative planning is obligatory, particularly after CW-HTO, to prevent interference with the tibial implant.

LEVEL OF EVIDENCE

II.

Similar outcome for total knee arthroplasty after previous high tibial osteotomy and for total knee arthroplasty as the first measure

Background and purpose - Patients having a total knee arthroplasty (TKA) after a previous high tibial osteotomy (HTO) constitute a minor group among those undergoing primary TKA for knee osteoarthritis (OA). There have been few reports on whether such patients differ pre- and postoperatively from those who undergo TKA as the first measure. We evaluated patient characteristics, knee-related pain, function, quality of life, and general health before and 1 year after TKA surgery in these 2 groups of patients. Patients and methods - We included 119 HTOs that were operated on for knee OA in the Skåne region, Sweden, in the period1998-2007 and that had been converted to a TKA during 2009-2013 (the C group). We also included 5,013 primary TKAs performed for knee OA in the same region, during the same period, and in patients of the same age range (42-82 years) (the P group). The patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EQ-VAS preoperatively and 1 year after the TKA surgery, when they were also asked about their satisfaction with the surgery. Case-mix variables available were Charnley category, American Society of Anesthesiologists (ASA) classification, sex, age, and body mass index (BMI). Results - Most of the HTOs were performed using open-wedge osteotomy with external fixation (81 of 119). Compared to the P group, the patients in the C group were more often men, were younger, and were healthier (according to the ASA classification). With respect to pre- and postoperative knee-related pain, function, quality of life, and general health, the 2 groups had similar mean values without any statistically significant differences. A similar proportion of patients in the 2 groups were satisfied with the surgery 1 year postoperatively (82% vs. 80%). Interpretation - Our findings indicate that HTO is a reasonable alternative for delaying TKA surgery in younger and/or physically active OA patients.

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.

Navigated TKA After Osteotomy Versus Primary Navigated TKA: A Matched-Pair Analysis

This article presents clinical and radiological outcome analysis of navigated total knee arthroplasty (TKA) following osteotomy compared with primary navigated TKA implantation. The study group (29 legs) received navigated TKA (Columbus with deep-dish, cruciate-retaining inlay, Aesculap AG, Tuttlingen, Germany) following distal femoral (6 legs) or high tibial (23 legs) osteotomy, and the control group (29 legs) received a primary navigated TKA. All patients were examined clinically and radiologically in a retrospective matched-pair analysis. Both groups showed comparable clinical scores (Oxford Knee Score, Tegner and Lysholm scores, and Knee Society Score). Radiological evaluations offered no relevant differences. The study group showed a significant mediolateral ligamentous instability (3 legs ≤5°, 1 leg 6°-9°, 25 legs ≥10° mediolateral deviation) compared with the control group (14 legs ≤5°, 9 legs 6°-9°, 6 legs >10°; P<.001). Significantly higher mediolateral ligamentous instability was seen in otherwise comparable clinical and radiological results in patients with navigated TKA implantation following osteotomy, compared with primary TKA. [Orthopedics; 2016. 39(3):S77-S82.].

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.

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 replacement following high tibial osteotomy versus total knee replacement without high tibial osteotomy: a systematic review and meta analysis

INTRODUCTION

Currently, there is no consensus as to whether total knee replacement(TKR) following high tibial osteotomy(HTO) provides similar postoperative outcomes as compared to TKR without previous HTO. Previous studies have provided limited evidence to small sample sizes and methodological inappropriateness.

METHODS

A systematic search process was conducted utilising PRISMA guidelines. Electronic, peer reviewed and published literatures were searched. Databases searched include Embase, Medline, Cochrane Library, PubMed and cross references. Methodological appropriateness was assessed with Papadokastakis system and Critical Appraisal Skills questionnaire. Data were analysed for both clinical and statistical homogeneity. Meta analytic pooling was subsequently performed.

RESULTS

11 studies including 2170 TKR procedures were analysed for systematic review. The study (TKR following previous HTO) and control (TKR without previous HTO) groups were adequately matched for age, sex ratio and follow-up. Meta analysis of six studies utilising KSS system and four studies utilising HSS system showed no significant (p > 0.05) difference between the two groups. Complications also showed no significant difference between the two groups. At an average follow-up of 7.2 years, with revision arthroplasty for any cause as the endpoint, survivorship for the study and control groups was 95 and 97 %, respectively. For revision arthroplasty with aseptic loosening as the end point, the survivorship was 98 % for both groups.

CONCLUSION

Systematic review and meta analysis suggested that TKR following HTO provides similar outcomes as compared to TKR without previous HTO. Therefore, a previous HTO does not negatively influence a future TKR, though the conversion process of HTO to TKR is technically challenging. Systematic review also identified paucity in prospective and long term studies.

Total knee arthroplasty after high tibial osteotomy: a comparison of opening and closing wedge osteotomy

PURPOSE

High tibial osteotomy (HTO) is frequently used to treat varus osteoarthritis in younger patients with the goal of delaying the need for total knee arthroplasty (TKA). While it has been reported that the results of TKA following HTO are worse than those in patients without prior knee surgery, the influence of osteotomy technique (medial opening-wedge versus lateral closing-wedge) has not been explored. The purpose of this study was to evaluate the influence of HTO technique on the performance and results of TKA.

METHODS

A total of 141 TKA's performed in 118 patients with prior HTO (24 opening wedge and 117 closing wedge) were reviewed at a mean follow-up of two years. Reviewed data included intra-operative factors (tourniquet time, the need for additional exposure, and intra-operative complications), clinical results (International Knee Score (IKS)) and radiographic assessment of limb alignment.

RESULTS

The average IKS knee and function scores improved from 54.0 and 60.3 to 87.0 and 79.5 (p <  0.0001). There was no significant difference in IKS scores based on osteotomy technique. There was a trend toward an increased need for tibial tubercle osteotomy in the closing wedge group. There was an increased need for extensive medial release in the opening wedge group and extensive lateral release in the closing wedge group. No differences in tourniquet time, complication rates, or hip-knee-ankle angle were noted between the two groups.

CONCLUSIONS

Radiographic limb alignment, patient-reported outcomes, and complication rates are equal in patients undergoing TKA after opening and closing wedge HTO.

High tibial osteotomy for the treatment of unicompartmental knee osteoarthritis: a review of the literature, indications, and technique

In the past decades, there has been varying support for high tibial osteotomy. This surgical procedure was originally popularized by Mark B. Coventry, MD in the 1960s, but fell out of favor with orthopedic surgeons as knee arthroplasty became more commonplace. In the past 10 years, osteotomy has been rediscovered as an important adjunct to cartilage repair procedures that rely on a normalized biomechanical environment. Furthermore, there has been an increase in the number of patients presenting with unicompartmental disease (eg, after prior meniscectomy) who are at an age and functional level that is not ideally suited for joint arthroplasty. High tibial osteotomy allows 70% to 85% of patients to delay arthroplasty for ≥ 5 to 10 years and 50% to 60% for ≥ 15 years. This article provides an overview of the indications, technique, complications, and outcomes of high tibial osteotomy, specifically the more commonly used opening wedge technique.