A mid term comparison of open wedge high tibial osteotomy vs unicompartmental knee arthroplasty for medial compartment osteoarthritis of the knee

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.

The effect of high tibial osteotomy and unicompartmental knee arthroplasty on patellofemoral joint in young patients with medial knee arthrosis

INTRODUCTION

Osteoarthritis of the knee is a debilitating disease. In most cases, only the medial compartments are affected. High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are the two main procedures commonly used in the surgical treatment of unicompartmental knee osteoarthritis patients not responding to conservative treatment. The aim of our study was to compare UKA and biplanar medial open-wedge HTO in terms of patellofemoral changes and functional score in patients under 60 years of age with medial compartment arthrosis.

MATERIALS AND METHODS

A retrospective study. A total of 79 patients (37 HTO, 42 UKA) who received one of the two treatments in a single center were examined preoperatively and at a single postoperative follow-up. Posterior tibial slope, lateral patellofemoral angle (LPFA), Q-angle, patellar height, Cincinnati Rating System and Knee Injury and Osteoarthritis Outcome Score (KOOS) functional scores were evaluated in all patients preoperatively and at the 6-month follow-up examination.

RESULTS

Insall-Salvati ratio remained stable in the HTO group, while there was a minor decrease in the UKA group and the changes between the groups were not statistically significant. Caton-Deschamps ratio increased in the UKA group and decreased in the HTO group, and this change was statistically significant (p < 0.001). LPFA did not change in the UKA group in the postoperative period, while it increased in the HTO group (p < 0.001). Changes in Q angle and Cincinnati Rating System scores were statistically similar between the UKA and HTO groups (p = 0.827 and p = 0.340).

CONCLUSIONS

In our study, biplanar medial open-wedge HTO and UKA performed with appropriate surgical technique had no negative effect on patellofemoral joint. In patients under 60 years of age with medial compartment osteoarthritis of the knee, both surgical treatments can be performed with appropriate patient selection.

Comparison of Trends and Complications of Unicompartmental Knee Arthroplasty Versus Periarticular Knee Osteotomy Among ABOS Part II Oral Examination Candidates

Background

While unicompartmental knee arthroplasty (UKA) and osteotomy procedures are commonly used to treat knee osteoarthritis, the differences in complication profiles between procedures are still poorly understood.

Purpose/Hypothesis

The purpose of this study was to assess the trends and complication rates of UKA and periarticular knee osteotomy for knee osteoarthritis among newly trained surgeons by using the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List database. It was hypothesized that more adult reconstruction fellowship-trained surgeons would perform UKA, while more sports medicine fellowship-trained surgeons would perform osteotomy, and that both procedures would have low rates of complications.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The ABOS database was queried for patients who underwent UKA, high tibial osteotomy, and distal femoral osteotomy procedures in examination years 2011 to 2021. Patient characteristics, surgeon fellowship training history, surgeon-reported postoperative complications, and readmission and reoperation rates were recorded. Comparisons between the UKA and osteotomy groups were performed using independent t tests and chi-square tests.

Results

There were 2524 patients in the UKA group and 270 patients in the osteotomy group. The majority of newly trained surgeons performing UKA (70.5%) had fellowship training in adult reconstruction, while the majority of those performing osteotomy (57.8%) had fellowship training in sports medicine (P < .001). The incidence of UKA and osteotomy increased during the study period (18.8 UKAs and 1.8 osteotomies performed per 10,000 cases in 2011 vs 39.5 UKAs and 4.2 osteotomies performed per 10,000 cases in 2021). Rates were significantly higher for osteotomy compared with UKA regarding anesthetic complications (2.2% vs 0.6%; P = .015), surgical complications (23.7% vs 7.3%; P < .001), reoperation (5.2% vs 1.9%; P = .002), and infection (6.7% vs 1.4%; P < .001). There were no significant differences in rates of medical complication, readmission, deep vein thrombosis, pulmonary embolism, or stiffness/arthrofibrosis.

Conclusion

Among newly trained surgeons taking the ABOS Part II Oral Examination, the incidence of UKA and periarticular knee osteotomy increased over the past decade. Compared with UKA, complication rates were higher after osteotomy, with an overall surgical complication rate of 23.7%.

Effect of Medial Opening Wedge and External Rotational Humeral Osteotomies on Medial Elbow Compartment Pressure: An Ex Vivo Study

OBJECTIVE

 The aim of this study was to assess if the level of osteotomy (50 or 75% the length of the humerus), osteotomy angle (5, 10, or 20 degrees), direction of bone alteration (external rotational or medial opening wedge osteotomies), or orientation of osteotomy (perpendicular to the humeral long axis or perpendicular to the weight-bearing axis of the limb) affect pressure through the medial compartment of the elbow.

STUDY DESIGN

 Humeral osteotomies were performed at 50 and 75% the length of the humerus on 12 canine cadaver thoracic limbs and patient-specific three-dimensional (3D) printed plates applied to induce the desired alteration. Sensors were placed into the medial and lateral aspects of the elbow joint and the limb compressed to 90 N in a universal testing system.

RESULTS

 Increasing the angle of the induced change had a significant effect on the decreased load through the medial compartment. Performing the osteotomy at 75% of humeral length from proximal was significantly more effective at reducing the medial elbow load than performing it at 50%. Opening wedge osteotomies were more effective than external rotational osteotomies, but both were effective. Changing the direction of the osteotomy (comparing transverse to oblique) did not significantly affect the load reduction through the medial compartment.

CONCLUSION

 Performing an osteotomy at a more distal location along the humerus and increasing the angle of the induced change increased the effectiveness of load-shifting humeral osteotomies.

Diagnostic Performance of a Molecular Assay in Synovial Fluid Targeting Dominant Prosthetic Joint Infection Pathogens

Prosthetic joint infection (PJI) is one of the most serious complications of joint replacement surgery among orthopedic surgeries and occurs in 1 to 2% of primary surgeries. Additionally, the cause of PJIs is mostly bacteria from the Staphylococcus species, accounting for more than 98%, while fungi cause PJIs in only 1 to 2% of cases and can be difficult to manage. The current gold-standard microbiological method of culturing synovial fluid is time-consuming and produces false-negative and -positive results. This study aimed to identify a novel, accurate, and convenient molecular diagnostic method. The DreamDX primer-hydrolysis probe set was designed for the pan-bacterial and pan-fungal detection of DNA from pathogens that cause PJIs. The sensitivity and specificity of DreamDX primer-hydrolysis probes were 88.89% (95% CI, 56.50-99.43%) and 97.62% (95% CI, 87.68-99.88%), respectively, compared with the microbiological method of culturing synovial fluid, and receiver operating characteristic (ROC) area under the curve (AUC) was 0.9974 (*** p < 0.0001). It could be concluded that the DreamDX primer-hydrolysis probes have outstanding potential as a molecular diagnostic method for identifying the causative agents of PJIs, and that host inflammatory markers are useful as adjuvants in the diagnosis of PJIs.

Extra-articular Deformity Correction via Clamshell Osteotomy of the Tibia With Simultaneous Bilateral Total Knee Arthroplasty

Total knee arthroplasty (TKA) aims to alleviate severe pain and functional impairment in advanced knee arthritis. However, extra-articular deformities must be addressed preoperatively to ensure optimal implant positioning and soft tissue balancing. We present a case of a 58-year-old man with a history of a right tibial malunion and left femoral shaft fracture, who developed progressive bilateral knee osteoarthritis. He underwent simultaneous bilateral TKA with a right tibial clamshell osteotomy to correct a 17° varus deformity and left femoral hardware removal to accommodate a long stem implant. At one year follow-up, the patient had satisfactory functional outcomes with restoration of mechanical alignment and bony union at the osteotomy site. This case demonstrates the utility of the clamshell osteotomy in correcting tibial malunion to facilitate TKA with long stems, reducing the degree of intra-articular correction required.

The anteroposterior distance between the posterior edge of the medial tibial condyle and the posterior edge of the fibular head in the lateral view can be a reference in determining the axis perpendicular to the tibial anteroposterior axis

BACKGROUND

Obtaining an accurate tibial lateral view is important during high tibial osteotomy. This study investigated whether the posterior edge of the medial/lateral tibial condyle (PEMTC/PELTC) and the posterior edge of the fibular head (PEFH) in a lateral view could be a reference for determining the accurate tibial lateral view.

METHODS

A total of 75 lower limbs in 38 subjects were evaluated in this study. In order to target healthy knees, subjects undergoing primary total hip arthroplasty were selected. The MF/LF, comprising the anteroposterior distance between PEMTC/PELTC and PEFH, was measured on the lateral view of the tibial bone model based on the tibial anteroposterior (AP) axis (true lateral view: TLV). In addition, measurements were calculated in the model with a 10° external/internal rotation. Using these measurements, linear regression analysis was performed to predict the tibial rotation with MF/LF.

RESULTS

The mean MF/LF was 0.9/4.6 mm (P < 0.001). MF and LF increased with incremental tibial rotation. Regression formulas were derived from these results as follows: Tibial rotation = (1) -1.01 + 1.06 × MF (R2 = 0.87, P < 0.001), (2) -8.70 + 1.86 × LF (R2 = 0.51, P < 0.001). The mean tibial rotation angle when MF was 0 mm was -0.9°.

CONCLUSIONS

Based on formula (1) and actual measurements, the mean tibial rotation angle when MF is 0 mm is an internal rotation of about 1°. Therefore, a lateral view, in which PEMTC and PEFH are seen colinearly, can be the approximate TLV. The MF can be a suitable intraoperative reference in determining TLV.

Autologous Osteochondral Grafts for Knee Osteochondral Diseases Result in Good Patient-Reported Outcomes in Patients Older Than 60 Years

Purpose

This study aims to examine the clinical autologous osteochondral grafts (AOG) outcomes for knee osteochondral diseases at operative ages >60 years, and to determine whether patients are able to sit straight in Japanese style after AOG.

Methods

All patients who underwent AOG for knee osteochondral diseases between November 2001 and April 2018 were retrospectively identified. The inclusion criteria were AOG only without osteotomy, operative ages between 60 and 79 years, >2 years of follow-up, and involved femorotibial angle between 169° and 179° (normal alignment). Patients who underwent osteotomy to improve knee alignment and patients with inflammatory diseases such as rheumatoid arthritis were excluded. The patients' knee symptoms and their clinical outcome were evaluated according to the criteria of the knee scoring system of the Japanese Orthopedic Association (JOA), International Knee Documentation Committee (IKDC) subjective score, and the ability of straight sitting in Japanese style.

Results

This study enrolled 57 cases and 60 knee joints during the study period. The follow-up ratio was 85.1%. Moreover, 14 men and 43 women and 29 right and 31 left knee joints were included in this study. The mean operative age and mean follow-up period were 67.8 years (range 60-76 years) and 81.1 months (range 24-167 months), respectively. In addition, the study involved 30 cases and 32 knee joints (60s group), and 27 cases and 28 knee joints (70s group). Moreover, 34 cases and 36 knee joints had osteonecrosis (ON group), and 23 cases and 24 knee joints had cartilage injury (CI group). The IKDC subjective and JOA scores in both the 60s and 70s groups showed significant differences: 2 years after AOG ＞at the follow-up period, ＞at the preoperative period. The scores in both the CI and ON groups showed similar significant differences. Furthermore, 8.3% and 53.5% of the patients could sit straight in Japanese style at the preoperative period and 2 years after AOG, respectively.

Conclusion

Even if the patient's operative age was >60 years, the AOG only for their knee osteochondral diseases had good clinical outcomes, including the ability to sit straight in Japanese style.

Level of Evidence

IV, Therapeutic case series Key words: autologous osteochondral grafts, aged patients, clinical outcome, knee joint, straight sitting in Japanese style.

What is the difference in proprioception between single condylar arthroplasty and high tibial osteotomy? a comparative study on both knees of the same patient

OBJECTIVE

This study aims to investigate the efficacy and outcomes of different surgical procedures, namely unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO), for the treatment of bilateral medial compartment knee osteoarthritis in the same patient. The joint awareness and function of these two surgical methods were evaluated.

METHODS

A total of 15 patients with bilateral medial compartment knee osteoarthritis who underwent either UKA or HTO between 2012 and 2020 were included in the study. Patient data, including age, gender, body mass index and length of hospital stay, were collected. Pre- and post-operative measurements were conducted, including tibiofemoral angle, tibial plateau posterior inclination angle, proximal tibial medial angle, distance from mechanical axis to knee joint center, hip-knee-ankle angle, pre- and post-operative knee joint scores, knee joint range of motion, and FIS-12 scores at 3, 6, 12, and 24 months postoperatively. The latest follow-up was used for evaluating the outcomes of osteoarthritis treatment. Normality of continuous variables was assessed using the Shapiro-Wilk test. Between-group comparisons were performed using the paired sample t-test or Wilcoxon rank-sum test. Repeated measures analysis of variance was utilized to analyze FJS-12 measurements at different time points, and the correlation between FJS-12 and postoperative clinical results was examined using Pearson's correlation coefficient. Statistical significance was set at P < 0.05.

RESULTS

Significant differences were observed in FJS between the UKA and HTO groups at 3 and 6 months postoperatively, but no significant difference was found at 1 and 2 years postoperatively. FJS in the UKA group demonstrated a significant increase from 3 to 6 months postoperatively, but no significant difference was observed from 6 to 24 months postoperatively. In contrast, FJS in the HTO group showed a significant increase from 3 to 24 months postoperatively.

CONCLUSIONS

Patients who underwent UKA exhibited superior joint awareness compared to those who underwent HTO during the early postoperative period. Furthermore, the rate of joint awareness in UKA patients was faster than in HTO patients.

The gap height in open wedge high tibial osteotomy is not affected by the starting point of the osteotomy

INTRODUCTION

In open-wedge high-tibial-osteotomy (OWHTO), most surgeons use a preoperative planning software and realise that they should match the intraoperative alignment correction with the preoperative plan. We aimed to determine whether there is a difference in osteotomy gap height when starting the OWHTO either 3 or 4 cm distal to the joint line. This should help to clarify whether the osteotomy starting point must exactly match the preoperative planning.

METHODS

25 patients with constitutional varus alignment were planned for OWHTO. Long-leg-standing-radiographs and mediCAD-software were used. Osteotomy was planned to a neutral Hip-Knee-Ankle angle (HKA) of 0°. The osteotomy-starting-point was either 3 or 4 cm distal to the medial joint line. The following angles were compared: mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal femoral angle (mLDFA), joint line conversion angle (JCA), mechanical Tibio-Femoral angle (mTFA) or Hip Knee Ankle (HKA) angle.

RESULTS

25 Patients (18 males, 7 females) had a mean age of 62 ± 16.6 years and showed a varus-aligned leg-axis. The HKA was - 5.96 ± 3.02° with a mMPTA of 82.22 ± 1.14°. After osteotomy-planning to a HKA of 0°, the mMPTA was 88.94 ± 3.01°. With a mean wedge height of 8.08 mm when locating the osteotomy 3 cm and a mean wedge height of 8.05 mm when locating the osteotomy 4 cm distal to the joint-line, there was no statistically significant difference (p = 0.7).

CONCLUSION

When performing an OWHTO aiming towards the tip of the fibula, the osteotomy starting point does not need to exactly match the planned starting-location of the osteotomy. A starting-point 1 cm more distal or proximal than previously determined through the digital planning does not alter the size of the osteotomy gap needed to produce the desired amount of correction.

Unicompartmental knee arthroplasty is associated with lower pain levels but inferior range of motion, compared with high tibial osteotomy: a systematic overview of meta-analyses

Background

The purpose of this study was to overview the findings of reported meta-analyses on unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 (PRISMA 2020) guidelines were followed. Two independent reviewers conducted a literature search of PubMed, Embase, the Web of Science, and the Cochrane Database of Systematic Reviews for meta-analyses comparing UKA and HTO that were published prior to September 2021. Literature screening, data extraction, and article quality appraisal were performed according to the study protocol registered online at PROSPERO (CRD42021279152).

Results

A total of 10 meta-analyses were identified, and different studies reported different results. Five of the seven meta-analyses showed that the proportion of subjects with excellent or good functional results was higher for UKA than for HTO. All three meta-analyses showed that UKA was associated with lower pain levels, and all six of the studies that included an analysis of range of motion (ROM) reported that UKA was inferior to HTO. Four of the eight meta-analyses found that total complication rates were lower for UKA. Only 3 of the 10 meta-analyses found that UKA had lower revision rates. Moreover, in the subgroup analysis, the revision and complication rates of UKA were similar to those of opening-wedge HTO but much lower than those of closing-wedge HTO.

Conclusions

Compared to HTO, UKA was associated with lower pain levels but inferior postoperative ROM. The results were inconclusive regarding whether UKA yielded better knee function scores and lower revision or complication rates than HTO. Accurate identification of indications and appropriate patient selection are essential for treating individuals with OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03319-7.

Unicompartmental knee arthroplasty is superior to high tibial osteotomy for the treatment of medial unicompartmental osteoarthritis: A systematic review and meta-analysis

BACKGROUND

Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are widely used for the treatment of medial unicompartmental knee osteoarthritis (OA). However, the best approach remains controversial. This study aimed to present a systematic review and a meta-analysis to directly compare the clinical outcomes between HTO and UKA. We hypothesized that the clinical outcomes after UKA and HTO would be similar.

METHODS

Electronic databases (Web of Science, PubMed, Embase, CENTRAL, and Biosis Preview) were searched for related studies published before November 30, 2021. Retrospective and prospective studies that directly compared the postoperative outcomes between UKA and HTO were included. Odds ratio (ORs) and 95% confidence interval (CIs) for complications, revision to total knee arthroplasty (TKA), and weighted mean difference (MD) and 95% CIs in range of motion (ROM), pain, walking speed and function score were evaluated. Two reviewers independently assessed the quality of the studies. Subgroup and sensitivity analyses were performed to explore the heterogeneity.

RESULTS

Twenty-three retrospective and 6 prospective studies were included. A total of 3004 patients (3084 knees) were evaluated for comparison. Complications (OR, 4.88, 95% CI: 2.92-6.86) were significantly greater in the HTO group than in the UKA group. Postoperative function scores including Lysholm score (MD, -2.78, 95% CI: -5.37 to -0.18) and Hospital for Special Surgery (HSS) score (MD, -2.80, 95% CI: -5.39 to -0.20) were significantly lower in the HTO group than the UKA group. The postoperative ROM was similar between HTO and mobile-bearing UKA (MD, -3.78, 95% CI: -15.78 to 8.22). However, no significant differences were observed between the HTO and UKA group in terms of postoperative pain, walking speed, and revision to TKA.

CONCLUSIONS

UKA is superior to HTO in minimizing complications and enhancing postoperative function scores. Mobile-bearing UKA has a similar ROM compared with HTO. Both HTO and UKA provide satisfactory clinical outcomes in terms of walking speed, relieving pain, and revision to TKA. UKA appears to be more suitable for the elderly, and both mobile-bearing UKA and HTO are viable surgical options for younger active individuals.

High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Unicompartmental Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Purpose

High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are commonly performed procedures for the treatment of compartmental knee osteoarthritis; however, the optimal procedure remains controversial. We conducted this systematic review and meta-analysis to compare the functional outcomes and assess complications and revision rates between the two techniques.

Methods

We searched electronic databases for relevant studies comparing HTO versus UKA for unicompartmental knee osteoarthritis. Continuous data as visual analogue scale (VAS), range of motion, and free walking speed were pooled as mean differences (MDs). Dichotomous data as functional knee outcomes, complications, and revision were pooled as odds ratios (ORs), with 95% confidence interval (CI), using R software for windows.

Results

Twenty-five studies involving 8185 patients were included. Meta-analysis showed that HTO was associated with higher risk of complications (OR = 2.47, 95% CI [1.52, 4.04]), poorer functional results (excellent/good) (OR = 0.32, 95% CI [0.21, 0.49]), and greater range of motion (MD = 7.05, 95% CI [2.41, 11.68]) compared to UKA. No significant differences were found between the compared groups in terms of VAS (MD = 0.14, 95% CI [- 0.08, 0.36]), revision rates (OR = 1.30, 95% CI [0.65, 2.60]), and free walking speed (MD = - 0.05, 95% CI [- 0.11, 0.00]).

Conclusion

This study showed that UKA achieved fewer complications, better functional outcomes, and less range of motion compared to HTO. No significant differences were detected between HTO and UKA in terms of VAS and revision rate. Treatment options should be personalized to each patient considering factors such as their age, activities of daily living, their body mass index, and severity of osteoarthritis.

Level of evidence

II.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00620-9.

Comparison of joint awareness after medial unicompartmental knee arthroplasty and high tibial osteotomy: a retrospective multicenter study

INTRODUCTION

Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are established treatments for medial compartment osteoarthritis (OA) or osteonecrosis (ON) of the knee joint, and the predominance of either procedure is inconclusive. We compared the awareness of the knee after UKA and HTO using the Forgotten joint score-12 (FJS).

MATERIALS AND METHODS

This was a retrospective, multicenter study. Ninety-six knees of 90 patients who received UKA or HTO and were followed-up for at least 1 year were analyzed. Postoperative FJS was compared between the two groups and evaluated for the effect of patient-related factors and clinical outcomes. Multiple linear regression analysis was performed to predict FJS.

RESULTS

There was no significant difference in the FJS between the UKA and HTO groups (p = 0.24). FJS did not correlate with any of the patient-related factors. There was a correlation between the FJS and each item of the Knee Injury and Osteoarthritis Outcome Scores (KOOS) and Lysholm Knee Scoring Scale (LKS). In multiple linear regression analysis, lower BMI, the diagnosis of OA Kellgren-Lawrence (KL) grade ≥ 3, and ON were significant predictors of better FJS. In both groups, FJS was correlated with each item of the KOOS and LKS. Internal consistency in terms of Cronbach's alpha was excellent.

CONCLUSIONS

There was no significant difference in FJS between patients who underwent UKA and HTO. Lower BMI, the diagnosis of OA KL grade ≥ 3, and ON were significant predictors of better FJS.

A comparative study of 21,194 UKAs and 49,270 HTOs for the risk of unanticipated events in mid-age patients from the national claims data in South Korea

Background

Both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are well-established treatments for medial knee osteoarthritis (OA). However, over the past 20 years, results of comparisons of long-term survival rates and outcomes have remained controversial. Furthermore, in patients at the boundary age, from 50 to 70 years, considering age as a treatment indication, selecting a surgical method is difficult. Therefore, we aimed to investigate conversion rates to total knee arthroplasty (TKA) and perioperative adverse outcomes between the two surgical methods in mid-age patients.

Methods

We extracted data from the Korean National Health Insurance claims database. A total of 70,464 patients aged between 50 and 70 years, considered as mid-age patients were included in the final study population. We used a multivariable Cox proportional hazard regression model, adjusting for potential confounders such as age, sex, insurance type, region of residence, hospital type, comorbidities, and the Charlson comorbidity Index (CCI).

Results

Of the 70,464 patients, 21,194 were treated with UKA and 49,270 were treated with HTO. HTO showed a higher risk of revision than UKA at five, and 10 years and during the whole observation period. The incidence of deep vein thromboembolism, and surgical site infection was significantly higher in UKA than in HTO.

Conclusions

It is important to choose an appropriate surgical method considering that UKA has better results in terms of long-term survival rates but may have a higher incidence of various complications.

Role of joint distraction in osteoarthritis of the knee: Basic science, principles and outcomes

The burden of knee osteoarthritis (OA) is increasing worldwide. Advanced tibiofemoral joint OA in young patients is particularly a problem with inferior results seen with total knee arthroplasty in this patient population. Knee joint distraction (KJD) has been evaluated recently as a joint preserving procedure for young patients with advanced tibiofemoral osteoarthritis, to delay the need for a primary total knee arthroplasty (TKA). This will decrease the risk for revision TKA later in life. KJD temporarily unloads the knee joint and keeps the tibia and femur separated over a course of 6 weeks. Outcomes of KJD appear promising. Through this article, the authors hope to share from their collective experience as well as the available literature on the basic science, principles of surgery and outcomes of KJD.

Opening Wedge High Tibial Osteotomy with Combined Use of Patient-Specific 3D-Printed Plates and Taylor Spatial Frame for the Treatment of Knee Osteoarthritis

Background

High tibial osteotomy (HTO) is used to treat medial degeneration of the osteoarthritis (OA) knee. However, shortcomings still exist in the current procedure, like unprecise creation, inability to correct knee rotation, and internal fixed failure. Here, we reported a novel procedure: patient-specific 3D-printed plates for opening wedge high tibial osteotomy (OWHTO) combined with Taylor spatial frame (TSF). The detailed technique was described, and the clinical outcomes were evaluated.

Methods

We prospectively evaluate outcomes of patient-specific 3D-printed plates for OWHTO with use of TSF in 25 patients with knee OA and varus alignment. Postoperative efficacy was evaluated using the HSS knee score, pain visual simulation score (VAS), and knee joint motion (ROM), and lower limb alignment was evaluated by measuring femorotibial angle (FTA) and hip-knee-ankle (HKA). Results and Conclusion. All patients did not experience complications such as wound infection, nerve damage, or bone amputation. 25 patients were followed up for 6–18 months. The bony union at bone amputation was achieved in 3 months after surgery, and the pain symptoms were significantly alleviated or disappeared. The VAS score was significantly reduced in 6 months after surgery compared with preoperative; the HSSS score was significantly added in 6 months after surgery compared with preoperative. The ROM of knee joint increased significantly 6 months after operation compared with that before operation, and the difference was statically significant (P < 0.05). The FTA and HKA after operation were significantly superior to that before operation, and the difference was statically significant (P < 0.01).

Conclusions

Our study showed that patient-specific 3D-printed plates for HTO with the use of TSF have the advantages of small trauma, few complications, simple operation, and fast recovery in treating knee OA and varus alignment.

Risk of Revision and Adverse Outcomes Following Partial Knee Replacement and High Tibial Osteotomy for Unicompartmental Knee Osteoarthritis: A Nationwide Cohort Study

PURPOSE

To investigate comparative study for potential associations of adverse outcomes as well as survival rates after high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA).

METHODS

We reviewed the Korean National Health Insurance claims database from January 1, 2007 to May 31, 2019. A total of 90,705 patients aged 30-90 years who were newly treated for HTO or UKA were identified considering their eligibility. We performed four rounds of propensity score matching to reduce imbalance of baseline characteristics, especially disparities among different age groups. Multivariable logistic regression models were used to compare the risk of revision and various unwanted medical problems between HTO and UKA treatment groups after propensity score matching.

RESULTS

23,563 matched patients were assigned to each group on the basis of propensity score. HTO showed higher risk of revision than UKA at 5 years, 10 years and the whole observed period (hazard ratio: 1.21, 95% CI 1.10-1.34). Deep vein thromboembolism (0.27, 0.21-0.35), and surgical site infection (0.37, 0.30-0.44) were less likely for HTOs than UKAs. Postoperative admission to intensive care unit was significantly lower with HTO (odds ratio: 0.40, 0.29-0.54) while rehospitalization within 30 days (1.27, 1.16-1.38) and 90 days (1.24, 1.18-1.30) were higher than UKA.

CONCLUSION

When choosing the surgical method for unicompartmental knee OA, not only the survival rate, but also the risk of other adverse outcomes should be considered. In particular, attention should be paid to the risk of developing deep vein thromboembolism and surgical site infection.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00517-z.

Comparison of Long-Term Survival Analysis Between Open-Wedge High Tibial Osteotomy and Unicompartmental Knee Arthroplasty

BACKGROUND

To compare unicompartmental knee arthroplasty (UKA) and open-wedge high tibial osteotomy (OWHTO) in a long-term follow-up propensity score matching analysis.

METHODS

Patients who underwent UKA or OWHTO for unilateral medial unicompartmental osteoarthritis (OA) between 2004 and 2010 were included. The ROM, HSS score, KS score, WOMAC score, forgotten joint score, OA progression in patellofemoral and lateral compartments, and survivorship were compared within ten years of follow-up between 67 UKA and 67 OWHTO patients after propensity score matching for age, gender, body mass index, range of motion, and osteoarthritis (OA) grade.

RESULTS

At the last follow-up, there were no significant differences between the two groups in clinical outcomes, but the WOMAC score showed better results after UKA (13.1 in UKA vs 18.9 in OWHTO, P = .011). The OA progression also showed no significant difference between the two groups. After a 10-year follow-up, the survival rate was higher in UKA patients (96.2%) than in OWHTO patients (87.7%), with no statistical difference (P = .06).

CONCLUSION

UKA showed better clinical outcomes and OA progressions than OWHTO. The survival rate presented a superiority of 8.5% for the UKA group in the 10-year follow-up, without significant difference.

Abrasion arthroplasty promotes improvement of degenerated femoral trochlear cartilage after medial open wedge high tibial osteotomy

OBJECTIVES

Several studies have reported negative effects of open wedge high tibial osteotomy (OWHTO) on patellofemoral joints with cartilage degeneration and recommended performing other procedures. However, if chondral resurfacing surgery could promote improvement of cartilage degeneration in the patellofemoral joint, OWHTO would be an acceptable option. The purposes of this study were to arthroscopically evaluate the femoral trochlear articular cartilage after abrasion arthroplasty combined with OWHTO and to investigate the factors promoting improvement of that cartilage.

METHODS

The present study cohort comprised 18 knees of 18 patients with varus osteoarthritis of the knee who had (1) International Cartilage Repair Society (ICRS) grade 4 femoral trochlear chondral lesions at the time of OWHTO; (2) undergone abrasion arthroplasty of the femoral trochlear cartilage in combination with OWHTO; (3) undergone second-look arthroscopy; and (4) been followed up for more than 2 years. Cartilage status was arthroscopically graded at the time of OWHTO and second-look arthroscopy. Patients were allocated to two groups according to the status of the femoral trochlear cartilage at the time of second-look arthroscopy: the improved group comprised patients with an ICRS grade of less than 3, and the not improved group comprised those with an ICRS grade of 4. Clinical outcomes, expressed as Knee Injury and Osteoarthritis Outcome Score (symptoms, pain, activities of daily living, function in sports/recreation and quality of life) and selected radiographic variables were compared between the two groups.

RESULTS

There were 11 (61%) knees in the improved group and 7 (39%) in the not improved group. A comparison of radiographic variables between the two groups revealed that neither limb alignment nor patellar height affected cartilage changes. The two groups had similar results on the symptoms, pain, sports/recreation and activities of daily living subscales of the Knee Injury and Osteoarthritis Outcome Score. However, the quality of life subscale significantly differed between the two groups (p=0.025).

CONCLUSION

Degenerated femoral trochlear cartilage can improve after combined abrasion arthroplasty and OWHTO. A comparison of clinical outcomes between the improved and not improved groups revealed that neither radiographic variables nor clinical symptoms, including pain, affected cartilage changes at short-term follow-up.

LEVEL OF EVIDENCE

Case series, level V.

Outcome after treatment of osteoarthritis with open-wedge high-tibial osteotomy with a plate: 2-year results of a Japanese cohort study

PURPOSE

This prospective multicenter study evaluated patient reported outcomes (PROs) in individuals undergoing medial open-wedge high-tibial osteotomy (OWHTO) with plate stabilization compared to conservative care or no treatment.

METHODS

One hundred eighteen of 148 patients older than 40 years were elected for OWHTO with plate treatment. Thirty patients declined surgery and were followed as a conservative group. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 2 years. Secondary measures included Oxford knee score, Western Ontario and McMaster Universities osteoarthritis index, range of motion (ROM), joint space width (JSW), femorotibial angle (FTA), and weight-bearing line ratio (WBLR).

RESULTS

Patient enrollment and baseline characteristics were heterogeneously distributed and led to group characteristics that were not comparable. Therefore, the comparison of the KOOS between the groups showing no differences must be treated with caution. In the OWHTO plate group, all PROs and the ROM significantly improved between baseline and 2-year follow-up. JSW remained stable in the OWHTO group. The FTA and WBLR significantly changed from a mean of 179.3 (95% confidence interval (CI): 178.7, 179.9) to 169.8 (95% CI: 169.2, 170.5) and from 23.1 (95% CI: 20.7, 25.5) to 62.4 (95% CI 59.0, 65.8), respectively. Treatment failure with conversion to total knee arthroplasty occurred in 1% of the OWHTO group; and in the conservative group, 10% converted to HTO or knee arthroplasty.

CONCLUSIONS

OWHTO with plate leads to significant improvement of PROs and function 2 years after intervention and demonstrates reliable mechanical axis correction with subsequent shift of weight-bearing.

Opening wedge high tibial osteotomy allows better outcomes than unicompartmental knee arthroplasty in patients expecting to return to impact sports

PURPOSE

Prior studies have compared unicompartmental knee arthroplasty (UKA) with high tibial osteotomy (HTO) suggesting that both procedures had good functional outcomes. But none had established the superiority of one of the two procedures for patients with high expectation including return to impact sport. The aim of this study was to compare functional outcomes and ability to return to impact sport of active patients defined with a pre-arthritis University of California and Los Angeles activity (UCLA) score > 8, after UKA or HTO procedures.

METHODS

A retrospective review of patients with a pre-arthritis UCLA score > 8 operated between January 2014 and September 2017 has identified 91 patients with open-wedge HTO and 117 patients with UKA. A matching process based on age (± 3 years) and gender allowed to include 50 patients in each group for comparative analysis. Patient reported outcomes included Knee Osteoarthritis Outcomes Score (KOOS), UCLA Score, Knee Society Score (KSS) and time to return to sport or previous professional activities at 3, 6, 12 and 24 months following surgery.

RESULTS

Mean time to return to sport activities or previous professional activities were significantly lower for the HTO group than for UKA group [respectively, 4.9 ± 2.2 months for HTO group vs 5.8 ± 6.2 months for UKA group (p = 0.006) and 3 ± 3 months for HTO group vs 4 ± 3 months for UKA group (p = 0.006)]. At 24-month follow-up, UCLA score, KOOS Sports Sub-score and KSS activity score were significantly higher for HTO group than for UKA group (Δ: 2 CI 95% (1.3-2.5 points) p < 0.0001, (Δ: 10.9 CI 95% (2.9-18.9 points) p = 0.04 and Δ: 7.8 CI 95% (2.4-13.4 points) p = 0.006, respectively) and 31 patients (62%) were practicing impact sport in the HTO group versus 14 (28%) in the UKA group (odd-ratio 4.2 CI 95% (1.8-9.7) p < 0.0001).

CONCLUSION

HTO offers statistically significant quicker return to sport activities and previous professional activities with a higher rate of patients able to practice impact activity (62% for HTO vs 28% for UKA) and better sports related functional scores at two years after surgery compared to UKA.

LEVEL OF EVIDENCE

III retrospective case-control study.

Better outcomes and reduced failures for arthroplasty over osteotomy for advanced compartmental knee osteoarthritis in patients older than 50 years

BACKGROUND

Both compartmental knee arthroplasty (CKA) and open-wedge high tibial osteotomy (HTO) may be used to treat patients older than 50 years of age with advanced compartmental osteoarthritis (OA) secondary to leg axis deformities. A meta-analysis was conducted to clarify the role of open-wedge HTO versus CKA for patients older than 50 years with advanced compartmental knee OA. The present investigation aimed to analyse the clinical outcomes, implant failure and survivorship.

METHODS

This meta-analysis was performed in accordance with the PRISMA guidelines. In September 2020, the main online databases were accessed. All clinical trials comparing the outcomes of open-wedge HTO versus CKA for compartmental knee OA were considered. Data analysis was performed through the Review Manager Software 5.3 (the Nordic Cochrane Collaboration, Copenhagen). Implant survivorship was analysed with a Kaplan-Meier (KM) curve that was performed using the STATA/MP software (StataCorp, College Station, TX).

RESULTS

Data from 618 (HTO, 307; CKA, 311) patients were collected. Good baseline comparability among patient age, BMI and gender was detected. The Tegner Activity Scale was higher in the CKA group (P = 0.04), as were the Lysholm score (P = 0.001), the International Knee Documentation Committee (P = 0.0001) and the Knee injury and Osteoarthritis Outcome Score (P = 0.05). At a mean follow-up of 5 years, revisions were less in the CKA cohort (OR, 2.27; P = 0.004). The Kaplan-Meier curve evidenced longer implant survivorship in favour of the CKA group (P = 0.01).

CONCLUSION

In patients older than 50 years of age with compartmental knee OA secondary to frontal axis leg deformities, CKA performed better than open-wedge HTO.

Tranexamic Acid Is Beneficial to Patients Undergoing Open-Wedge High Tibial Osteotomy

The purpose of this study was to investigate the efficacy of tranexamic acid (TXA) in patients undergoing open-wedge high tibial osteotomy (OWHTO). Patients from August 2018 to May 2020 were retrospectively studied. Clinical data were obtained including gender, age, height, weight, body mass index (BMI), smoking, alcohol consumption, hypertension, diabetes, history of aspirin, prepostoperative hematocrit (Hct) and hemoglobin (Hb), thrombotic events, blood transfusion requirement, hospital length of stay, size of osteotomy gap, and wound complications such as wound hematoma and infection. 52 patients were enrolled in the tranexamic acid group (TA group), and 48 patients were enrolled in the nontranexamic acid group (NTA group); there were no significant differences between both groups in terms of gender, age, BMI, preoperative Hb, size of osteotomy gap, incidence of smoking, alcohol consumption, hypertension, diabetes, history of aspirin, thrombotic events, blood transfusion requirement, and wound hematoma and infection. The mean hospital length of stay was 9.4 ± 1.0 days in the TA group and 11.0 ± 1.2 days in the NTA group (P < 0.001), the blood loss was 296.0 ± 128.7 ml in the TA group and 383.3 ± 181.3 ml in the NTA group (P < 0.05), and the postoperative Hb level was 120.8 ± 15.0 g/l in the TA group and 109.5 ± 13.8 g/l in the NTA group (P < 0.001). In conclusion, the administration of TXA is beneficial to patients undergoing OWHTO via decreasing hospital length of stay, reducing blood loss, and maintaining higher postoperative Hb levels.

A protective hinge wire, intersecting the osteotomy plane, can reduce the occurrence of perioperative hinge fractures in medial opening wedge osteotomy

PURPOSE

A recent study reported that positioning a K-wire to intersect the cutting plane at the theoretical lateral hinge location increases the lateral hinge's resistance to fracture during the opening of opening wedge high tibial osteotomy (OWHTO). The purpose of this study was to evaluate the clinical relevance of the use of this K-wire and its benefits in terms of lateral hinge protection during OWHTO in daily practice.

METHODS

A retrospective comparative study identified 206 patients who underwent OWHTO from January 2014 to December 2017. Among these patients, 71 had an additional K-wire (HK + group), whereas 135 did not (HK- group). The subjects meeting the inclusion criteria were included in a matched pairing process, which identified 60 patients in the HK + group and 60 patients in the HK- group. Mean follow-up time was 2.3 ± 1.0 years (range 2-4.2). Radiographic outcomes were evaluated with intraoperative and postoperative fluoroscopic imaging and with CT imaging at 6 weeks post OWHTO surgery. The knee osteoarthritis outcomes score (KOOS) was used and time needed to return to work and any kind of sports was collected.

RESULTS

Thirty six patients (30%) were found to have a LHF. Among these patients, 26 (72%) did not have an additional K-wire positioned at their theoretical lateral hinge location (HK- group) during the procedure. LHF rate for patients without additional K-wire group (HK-) was 43.3%, whereas it was 16.7% for the patients with an additional K-wire (HK +) [Odd ratio 3.8 95% CI 1.6-8.3; p = 0.005]. The mean time to return to work, return to any kind of sports, and bone union was significantly shorter for HK + group (p < 0.05).

CONCLUSION

This study demonstrated that during OWHTO, positioning a K-wire intersecting the cutting plane at the theoretical lateral hinge location reduced the number of intraoperative lateral hinge fractures.

LEVEL OF EVIDENCE

III retrospective case-control study.

Therapeutic Effects Comparison and Revision Case Analysis of Unicompartmental Knee Arthroplasty and Open Wedge High Tibial Osteotomy in Treating Medial Knee Osteoarthritis in Patients Under 60 years: A 2-6-year Follow-up Study

Objective

To evaluate the therapeutic effects and revision cases of unicompartmental knee arthroplasty (UKA) and open wedge high tibial osteotomy (OWHTO) in treating medial knee osteoarthritis (MKOA) in patients under 60 years.

Methods

The present retrospective study included a total of 192 patients who were diagnosed with MKOA and treated by UKA or OWHTO in the Second Affiliated hospital of Xi'an Jiaotong University and Xi'an Honghui Hospital between December 2012 and December 2016. Among these patients, 83 were treated by UKA (17 men and 66 women, aged 53.7 ± 5.2 years) and 109 were treated by OWHTO (23 men and 86 women, aged 51.8 ± 6.9 years). Patients were followed up at 1, 3, 6, and 12 months for the first year postoperation, and every 6 months from the second year postoperation. Basic data, perioperative data, hospital for special surgery (HSS) score, visual analogue pain score (VAS), low‐impact recovery, and revision cases of the patients were evaluated.

Results

The average follow‐up periods of the UKA group and the OWHTO group were 39.3 ± 11.2 months and 40.2 ± 13.5 months, respectively. No significant difference was found in the basic data of the two groups (P ≥ 0.05). The operative time, incision length, and dominant blood loss of the UKA group was less than those of OWHTO group by 19.6%, 10.7%, and 35.1%, respectively, and the differences were significant (P < 0.05), while no significant difference was found in postoperative in‐bed time (P ≥ 0.05). The HSS scores of the UKA group at 1 and 3 months postoperation were higher than those of the OWHTO group by 5.1% and 3.9% (P < 0.05), while no differences were found from 6 months postoperation (P ≥ 0.05). The VAS score of the UKA group 1 month postoperation was lower than that of the OWHTO group by 12.2% (P < 0.05), while no differences were found from 3 months postoperation (P ≥ 0.05). One year after the operation, most patients in both groups could not achieve ideal recovery in low‐impact sports, and no significant differences were found (P < 0.05). The sport in which most patients could not achieve ideal recovery was mountain climbing. No revision cases occurred in the OWHTO group, while two revisions occurred in the UKA group.

Conclusion

Candidates for UKA should be chosen carefully and the current indications and contraindications raised by Goodfellow should be modified.

Treatment recommendations for chronic knee osteoarthritis

Primary osteoarthritis (OA) hinders an aging global population as one of the leading causes of years-lost-to-disability (YLD). OA in most patients is considered to be an overuse injury that results in degenerative inflammation of the joints with the associated formation of bony outgrowths. Due to the escalating nature of this chronic pain disease, treatment management for OA can initially begin with a more conservative approach. It can eventually lead to more invasive surgical procedures. At present, the standard of care remains initial conservative management with lifestyle changes, including weight loss with concurrent anti-inflammatory regimens. Injections are frequently used for the escalation of care, but a significant number of patients ultimately resort to total knee arthroplasty. This review will focus specifically on knee OA, providing a brief overview of risk factors and early management and in-depth exploration of the invasive interventions that can offer symptomatic relief and return of function.

Is iliac autogenous graft augmentation in medial open wedge high tibial osteotomies superior to no augmentation in terms of bone healing?

OBJECTIVES

This study aims to investigate if iliac autogenous graft augmentation in medial open wedge high tibial osteotomies (OWHTOs) is superior to no augmentation in terms of bone healing.

PATIENTS AND METHODS

Twenty-five patients (14 males, 11 females; mean age 40.9±4.0 years; range, 33 to 48 years) with medial compartmental osteoarthritis of knee joint who underwent high tibial osteotomy with medial open wedge between January 2016 and December 2018 were included in this retrospective study. Twelve of the operated knees were the right knee. Graft was used in 13 patients (52%). Data including age, gender, body mass index (BMI), direction, follow-up period, union, Lysholm and International Knee Documentation Committee (IKDC) scores, pre- and postoperative femoral tibial angles (FTAs) and posterior tibial slopes were evaluated.

RESULTS

The mean BMI was 26.4±1.9 (range, 22.0 to 30.0). Only 48% of the patients were smoking. The mean follow-up period was 28.6±5.3 months (range, 24 to 38 months). No statistically significant difference was found between the grafted and non-grafted groups in terms of age, BMI, follow-up time, gender, side and smoking status (p>0.05) There was no statistically significant difference between two groups in terms of pre- and postoperative Lysholm scores, pre- and postoperative IKDC scores, or pre- and postoperative FTA values (p>0.050).

CONCLUSION

Iliac autogenous graft augmentation in medial OWHTO has no effect on union but shortens the union time. Preoperative high varus degree adversely affects union. Therefore, routine use of iliac crest autograft is not recommended.

Radiographic changes and clinical outcomes after open and closed wedge high tibial osteotomy: a systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis is to examine changes in radiological variables and clinical outcomes between open and closed wedge high tibial osteotomy (OWHTO and CWHTO, respectively), which have ongoing controversial issues in numerous quantitative clinical studies.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched for suitable controlled trials between Jan 1, 1999, and Feb 2, 2018. The inclusion criteria included studies written in English, studies with a level of evidence of I-IV, and studies presenting comparisons between OWHTO and CWHTO. The main clinical and radiographic results were extracted and pooled using Stata 12.0.

RESULTS

After searching for and screening trials, 28 trials involving 2840 knees were eligible for the meta-analysis. After OWHTO or CWHTO, clinical scores, including the American Knee Society Score, Hospital for Special Surgery Knee Score, Lysholm score, and Visual Analog Scale pain score, improved (p < 0.05), but the range of motion was unchanged (p > 0.05). The anatomical femorotibial angle (SMD 0.04, 95% CI - 0.66 to 0.74) and hip-knee-ankle angle (SMD 0.11, 95% CI - 0.11 to 0.33) data suggested that the OWHTO and CWHTO groups were similar in function of correction. Posterior tibial slope increased (SMD - 0.71, 95% CI - 1.04 to - 0.37) after OWHTO but decreased (SMD 0.72, 95% CI 0.35 to 1.08) after CWHTO. OWHTO decreased patellar height (p < 0.05), while patellar height did not change significantly after CWHTO (p > 0.05).

CONCLUSION

This meta-analysis indicates that compared with CWHTO, OWHTO increases the posterior slope, decreases the patellar height, and provides a similar accuracy of correction; however, CWHTO leads to a decreased posterior slope and an unchanged patellar height. Therefore, programs should be personalized and customized for the specific situation of each patient.

High Tibial Osteotomy: Review of Techniques and Biomechanics

High tibial osteotomy becomes increasingly important in the treatment of cartilage damage or osteoarthritis of the medial compartment with concurrent varus deformity. HTO produces a postoperative valgus limb alignment with shifting the load-bearing axis of the lower limb laterally. However, maximizing procedural success and postoperative knee function still possess many difficulties. The key to improve the postoperative satisfaction and long-term survival is the understanding of the vital biomechanics of HTO in essence. This review article discussed the alignment principles, surgical technique, and fixation plate of HTO as well as the postoperative gait, musculoskeletal dynamics, and contact mechanics of the knee joint. We aimed to highlight the recent findings and progresses on the biomechanics of HTO. The biomechanical studies on HTO are still insufficient in the areas of gait analysis, joint kinematics, and joint contact mechanics. Combining musculoskeletal dynamics modelling and finite element analysis will help comprehensively understand in vivo patient-specific biomechanics after HTO.

Long-term survival is similar between closed-wedge high tibial osteotomy and unicompartmental knee arthroplasty in patients with similar demographics

PURPOSE

Long-term clinical and radiographic results and survival rates were compared between closed-wedge high tibial osteotomy (HTOs) and fixed-bearing unicompartmental knee arthroplasty (UKA) in patients with similar demographics.

METHODS

Sixty HTOs and 50 UKAs completed between 1992 and 1998 were retrospectively reviewed. There were no significant differences in pre-operative demographics. The mean follow-up period was 10.7 ± 5.7 years for HTO and 12.0 ± 7.1 years for UKA (n.s.). The Knee Society knee and function scores, WOMAC, and range of motion (ROM) were investigated. The mechanical axis and femorotibial angle were evaluated. Kaplan-Meier survival analysis was performed (failure: revision to TKA) and the failure modes were investigated.

RESULTS

Most of the clinical and radiographic results were not different at the last follow-up, except ROM; ROM was 135.3° ± 12.3° in HTO and 126.8° ± 13.3° in UKA (p = 0.005). The 5-, 10-, 15-, and 20-year survival rates were 100%, 91.0%, 63.4%, and 48.3% for closed-wedge HTO, respectively, and 90.5%, 87.1%, 70.8%, and 66.4% for UKA (n.s.). The survival rate was higher than that for UKA until 12 years post-operatively but was higher in UKAs thereafter, following a remarkable decrease in HTO. The most common failure mode was degenerative osteoarthritic progression of medial compartment in HTO and femoral component loosening in UKA.

CONCLUSIONS

Long-term survival did not differ significantly between closed-wedge HTO and fixed-bearing UKA in patients with similar pre-operative demographics and knee conditions. The difference in post-operative ROM and failure mode should be considered when selecting a procedure.

LEVEL OF EVIDENCE

III.

Predictive factors for satisfaction after contemporary unicompartmental knee arthroplasty and high tibial osteotomy in isolated medial femorotibial osteoarthritis

INTRODUCTION

Both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are viable treatment options for early osteoarthritis (OA). Although a substantial proportion of the patient selection criteria for HTO and UKA are now shared, the factors related to satisfaction following each procedure remain unclear.

HYPOTHESIS

We hypothesized that patient factors associated with satisfaction following contemporary HTO and UKA would be different.

MATERIAL AND METHODS

We retrospectively reviewed the records of consecutively enrolled medial opening-wedge HTOs (n=123) and Oxford mobile-bearing UKAs (n=118) with satisfactory postoperative alignment. Preoperative demographics, physical activity levels, varus deformity status, and degree of OA were recorded. Postoperative radiographs, frequency of combined procedures and patient-reported outcomes (PROs) including pain, Western Ontario and McMaster Universities Osteoarthritis Index score, and patient satisfaction were assessed.

RESULTS

Severe OA (p<0.01) was associated with an increased risk of dissatisfaction following HTO, whereas young age (p<0.01) and severe varus deformity (p=0.045) were related to dissatisfaction after UKA. In addition, patient satisfaction following UKA was higher than that following HTO in individuals with highly physically demanding activity. All UKA PROs were superior to those of the HTO group, except pain level.

CONCLUSION

Despite the shared patient selection criteria for contemporary HTO and UKA, severe OA was associated with dissatisfaction following HTO, whereas young age and varus deformity were associated with dissatisfaction following UKA. Age, varus deformity and OA severity should be considered when deciding whether to perform HTO or UKA.

TYPE OF STUDY AND LEVEL OF PROOF

Retrospective cohort study, Level III.

The clinical outcomes and the ability to sit straight in the Japanese style following high tibial osteotomy combined with osteochondral autologous transfer for osteonecrosis of the medial femoral condyle

BACKGROUND

There have been some reports of high tibial osteotomy combined with osteochondral autograft transfer for osteonecrosis of the medial femoral condyle of the knee. However, few of them have focused on the deep knee flexion needed to sit straight in the Japanese style.

PURPOSE

To evaluate the clinical outcomes and the knee flexion of HTO combined with OAT for osteonecrosis of the medial femoral condyle of the knee, especially the ability to sit straight in the Japanese style.

METHODS

Between 1998 and 2012, valgus HTO combined with OAT was performed in 23 patients for stage IV osteonecrosis according to Koshino's radiological classification of the medial femoral condyle. The follow-up period was more than 2 years in all cases. The mean age at the time of the surgery was 65.8 years, and the mean follow-up period was 72.2 months. The function of the knee and the ability to sitting straight in the Japanese style were examined. Twenty-one knees were examined with second-look arthroscopy to assess the recipient and donor sites.

RESULTS

The JOA scale and IKDC subjective scores were significantly improved. Twelve patients were able to sit straight in the Japanese style after the surgery, compared to 3 patients who were able to do so before surgery. On second-look arthroscopy of 21 knees, the average ICRS score was 10.5 points. No patient needed additional surgery except for removal of the implants.

CONCLUSION

Valgus HTO combined with OAT is one treatment option for osteonecrosis of the medial femoral condyle with osteoarthritis. In the present study, many of the patients regained good knee function, and 50% of the patients were able to sit straight in the Japanese style after surgery, which is a higher rate than after total knee arthroplasty and unilateral knee arthroplasty.

Function scores of different surgeries in the treatment of knee osteoarthritis: A PRISMA-compliant systematic review and network-meta analysis

BACKGROUND

Osteoarthritis (OA) is the third most common diagnosis made by general practitioners in older patients. The aim of this study was to compare the function scores of different surgeries in the treatment of knee osteoarthritis (KOA).

METHODS

Cohort studies about different surgical treatments for KOA were included with a comprehensive search in PubMed, Cochrane Library, and Embase. The standard mean difference (SMD) value was evaluated and the surface under the cumulative ranking (SUCRA) curve was drawn with a combination of direct and indirect evidence. A total of 265 eligible patients were enrolled and served as the nonoperative treatment group, osteotomy group, unicompartmental knee arthroplasty (UKA) group, total knee arthroplasty (TKA) group, and arthroscopic surgery group. Before surgery, 6 months after surgery, 1 year after surgery and 5 years after surgery, the hospital for special surgery (HSS) knee score, Lysholm score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and American knee society score (KSS) were recorded.

RESULTS

A total of 9 cohort studies including 954 patients with KOA were finally enrolled into the study. The network-meta analysis revealed that osteotomy and UKA treatments showed a better efficacy on improving the function score. Our cohort study further confirmed that, a higher HSS knee score after 1 year and higher Lysholm score after 6 months and 1 year were observed in the osteotomy and UKA groups, while better HSS knee score and KSS after 6 months and 1 year were showed in the osteotomy and TKA groups. In the TKA group, Lysholm score and KSS were higher and WOMAC score was lower after 5 years than other groups. WOMAC score was lowest in the UKA group after 6 months, 1 year and 5 years of surgery.

CONCLUSION

These results provide evidence that function scores of patients with KOA were improved by osteotomy, UKA, TKA, and arthroscopic surgery. And osteotomy and UKA showed better short-term efficacy, while TKA appeared better long-term efficacy.

Unicompartmental Knee Arthroplasty vs High Tibial Osteotomy for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUND

Prior studies have compared unicompartmental knee arthroplasty (UKA) with high tibial osteotomy (HTO) suggesting that both procedures had good clinical outcomes. However, which treatment is more beneficial for unicompartmental knee osteoarthritis is still a controversy. The purpose of our study is to obtain postoperative outcomes of revision rate, complications, function results, range of motion (ROM), and pain between the 2 procedures.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed and study protocol was published online at PROSPERO under registration number CRD42016049316. We searched the databases MEDLINE, EMBASE, Cochrane Library, and Web of Science up to May 2017. Articles that directly compared postoperative outcomes of UKA to HTO were included.

RESULTS

A total of 10 comparative studies were included in our meta-analysis. UKA patients showed less revision rate, less complications, and less postoperative pain than HTO patients; however, HTO patients obtained more ROM. No significant difference was observed between the group accruing to the knee function scores and excellent/good surgical results.

CONCLUSION

UKA offers a safe and efficient alternative to osteoarthritis reduced postoperative pain, less postoperative complication, and revision. The 2 surgical techniques showed satisfactory function results for the patients; however, the HTO group achieved superior ROM compared to the UKA group. HTO may be suitable for patients with high activity requirements. Treatment options should be carefully considered for each patient in accordance with their age, body mass index, grade of osteoarthritis, and patients' activity levels.

High Tibial Osteotomy versus Unicompartmental Knee Arthroplasty for Medial Compartment Arthrosis with Kissing Lesions in Relatively Young Patients

Purpose

The purpose of this study is to compare the clinical and radiographic outcomes of high tibial osteotomy (HTO) and unicompartmental arthroplasty (UKA) in advanced medial compartment arthritis accompanied by kissing lesions in relatively young patients.

Materials and Methods

Forty-five patients were divided into the HTO (n=23) and UKA (n=22) groups. Clinically, we evaluated the Lysholm knee scoring scale, visual analogue scale, Hospital for Special Surgery, and Western Ontario and McMaster Universities Osteoarthritis index scores preoperatively, 6 and 12 months postoperatively, and at the final follow-up. Radiographically, we measured the femoral-tibial angle and mechanical axis deviation preoperatively and at the final follow-up.

Results

All clinical outcomes gradually improved in both groups from the postoperative period to the final follow-up. At the final follow-up, all clinical outcomes were slightly better in the UKA group than in the HTO group; however, differences were not statistically significant.

Conclusions

HTO is comparable to UKA in terms of clinical outcomes. Thus, the results of this study suggest that HTO might be a good alternative treatment to UKA for medial unicompartmental arthritis accompanied by kissing lesions in relatively young patients.

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.

Revision total knee arthroplasty for failed high tibial osteotomy and unicompartmental knee arthroplasty have similar patient-reported outcome measures in a two-year follow-up study

Aims

Little is known about the relative outcomes of revision of unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) to total knee arthroplasty (TKA). The aim of this study is to compare the outcomes of revision surgery for the two procedures in terms of complications, re-revision and patient-reported outcome measures (PROMs) at a minimum of two years follow-up.

Patients and Methods

This study was a retrospective review of data from an institutional arthroplasty registry for cases performed between 2001 and 2014. A total of 292 patients were identified, of which 217 had a revision of HTO to TKA, and 75 had revision of UKA to TKA. While mean follow-up was longer for the HTO group compared with the UKA group, patient demographics (age, body mass index and Charlson co-morbidity index) and PROMs (Short Form-36, Oxford Knee Score, Knee Society Score, both objective and functional) were similar in the two groups prior to revision surgery. Outcomes included the rate of complications and re-operation, PROMS and patient-reported satisfaction at six months and two years post-operatively. We also compared the duration of surgery and the need for revision implants in the two groups.

Results

At two-year follow-up, both groups of patients had made significant improvement in terms of PROMs compared with pre-operative scores. PROMs and satisfaction rates were similar in the two groups. Complications requiring re-operation were significantly more frequent in the HTO group whilst more revision implants were used in the UKA group, resulting in a longer operative duration.

Conclusion

Revision of HTO and UKA achieve similar post-operative PROMs and satisfaction. Revision of UKA more frequently requires revision components with increased operation duration but fewer complications requiring re-operation compared with revision of HTO. Cite this article: Bone Joint J 2017;99-B:1329–34.

Robotic device-assisted knee extension training during the early postoperative period after opening wedge high tibial osteotomy: a case report

BACKGROUND

Maintenance or restoration of a good range of motion of the knee is one of the most important outcomes following knee surgery. According to previous studies, opening wedge high tibial osteotomy enables better recovery of range of motion in knee flexion than that achievable after total knee arthroplasty or unicompartmental knee arthroplasty. However, few reports provide a detailed description of the postoperative recovery of knee extension range of motion after opening wedge high tibial osteotomy. We describe our experience with a knee extension training program using a single-joint hybrid assistive limb device (HAL-SJ; Cyberdyne Inc., Tsukuba, Japan) during the acute recovery phase after opening wedge high tibial osteotomy. The HAL-SJ is a wearable robotic device that facilitates voluntary control of knee joint motion.

CASE PRESENTATION

A 67-year-old Japanese woman who underwent opening wedge high tibial osteotomy for spontaneous osteonecrosis of the left medial femoral condyle received HAL-SJ-based knee extension training postoperatively. Our experience with this patient revealed that knee extension training with the HAL-SJ during the acute phase following opening wedge high tibial osteotomy is feasible. Furthermore, the patient's knee extension range of motion improved to values similar to those seen during the preoperative stage, and her flexion range of motion was improved at 3 months after the surgery.

CONCLUSIONS

HAL-SJ-based knee extension training could be used as a novel post-opening wedge high tibial osteotomy rehabilitation modality. Further exploration of individualized optimal settings of the HAL-SJ is required to improve its safety and efficacy.

Survivorship of medial opening wedge high tibial osteotomy in the elderly: two to ten years of follow up

BACKGROUND AND PURPOSE

Medial opening wedge high tibial osteotomy (MOWHTO) is a well-accepted procedure, which has been widely used for pain relief and varus deformity correction in the osteoarthritic (OA) knee, especially in the young patient. However, in the elderly patient, the efficacy of this procedure is still unknown. Therefore, this study aims to evaluate the survivorship of MOWHTO in elderly patients as the primary outcome. The secondary outcome is to evaluate the loss of correction angle that is the common complication after MOWTHO.

MATERIALS AND METHOD

A retrospective study of 50 elderly patients (≥ 60 years) was conducted to track survivorship of MOWHTO. All patients were diagnosed with varus OA knee and underwent MOWHTO at our institute. The patients who had previous knee surgery or incomplete data were excluded. Medical records and radiographs of eligible patients were reviewed for recruiting the data. Survivorship of MOWHTO was analyzed using Kaplan-Meier curves. The starting point was the time of operation and the end point was the time of subsequent TKA. The loss of correction angle was defined as the change of medial proximal tibial angle (MPTA) between three months and one year post-operatively.

RESULTS

The mean age of patients was 66 ± 5.0 years. The majority of patients were female (74%). The mean correction angle was 10.6 ± 3.6 degrees. The union rate of osteotomy site was 100%. In survival analysis, the median follow-up time was 6.0 ± 3.0 years. Two patients required subsequent conversions to TKA. The survivorship of MOWHTO at four years was 95.5% (95%CI, 96.0 to 98.0). For radiographic assessment, the loss of correction angle was 1.0 ± 0.5 degrees at one year post-operatively.

CONCLUSION

This study proved that MOWHTO in patient ≥60 years had good mid-term survivorship with acceptable complications. This procedure can be the alternative option for the treatment of varus OA knee in the elderly.

Unicompartmental knee arthroplasty, is it superior to high tibial osteotomy in treating unicompartmental osteoarthritis? A meta-analysis and systemic review

BACKGROUND

Debate remains whether high tibial osteotomy (HTO) or unicompartmental knee arthroplasty (UKA) is more beneficial for the treatment of unicompartmental knee osteoarthritis. The purpose of this study was to compare the functional results, knee scores, activity levels, and complications between the two procedures.

METHODS

We performed a systematic review of published literature from August 1982 through January 2017. Fifteen papers reporting three prospective randomized trials were subjected to a meta-analysis.

RESULTS

No significant difference between the two groups was noted with respect to free walking (velocity), knee score, deterioration of the contralateral or patellofemoral knee, or revision rate and total knee arthroplasty. However, UKA produced better outcomes compared to HTO in terms of the functional results, pain assessment, and complications, although patients who underwent HTO tended to have slightly better range of motion.

CONCLUSIONS

Valgus HTO provides better physical activity for younger patients whereas UKA is more suitable for older patients due to shorter rehabilitation time and faster functional recovery. Although UKA patients tended to have improved overall long-term outcomes, which may be due to accurate indications and patient selection, both treatment options yielded pleasing results. Therefore, we are unable to conclude that either method is superior.

Tibial condylar valgus osteotomy (TCVO) for osteoarthritis of the knee: 5-year clinical and radiological results

PURPOSE

Tibial condylar valgus osteotomy (TCVO) is a type of opening-wedge high tibial osteotomy for advanced medial knee osteoarthritis (OA) with subluxated lateral joint. We report the concept, the current surgical technique with a locking plate, and the short-term clinical and radiological results of this procedure.

METHODS

11 knees with medial OA and a widened lateral joint were treated by TCVO (KL stage III: 6, IV: 5). In this procedure, by the L-shaped osteotomy from the medial side of the proximal tibia to the intercondylar eminence and the valgus correction, lateralization of the mechanical axis and reduction of the subluxated lateral joint are obtained with early postoperative weight-bearing. Before, 6 months, 1, and 5 years after the operation, a visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), alignment of the lower extremity, and congruency and stability of the femorotibial joint were investigated.

RESULTS

The VAS improved from an average of 73 mm to 13 mm, and the total WOMAC score from 52 to 14 before to 5 years after the operation, respectively. The mechanical axis changed from 1 to 60%, and the FTA changed from 186° to 171°. The joint line convergence angle (JLCA) changed from 6° to 1°, and the angle difference of JLCA between varus and valgus stress improved from 8° to 4° after the procedure.

CONCLUSION

Improvements in pain and activities of daily living were observed by TCVO along with valgus correction of the lower extremity and stabilization of the femorotibial joint.

Computer-Assisted Navigation in High Tibial Osteotomy

Computer-assisted navigation is used to improve the accuracy and precision of correction angles during high tibial osteotomy. Most studies have reported that this technique reduces the outliers of coronal alignment and unintended changes in the tibial posterior slope angle. However, more sophisticated studies are necessary to determine whether the technique will improve the clinical results and long-term survival rates. Knowledge of the navigation technology, surgical techniques and potential pitfalls, the clinical results of previous studies, and understanding of the advantages and limitations of the computer-assisted navigation are crucial to successful application of this new technique in high tibial osteotomy. Herein, we review the evidence concerning this technique from previous studies.

Complication rate following high tibial open-wedge osteotomy with spacer plates for incipient osteoarthritis of the knee with varus malalignment

PURPOSE

Medial open-wedge high tibial osteotomy (HTO) with spacer plates is recommended to correct varus malalignment of the knee with symptomatic overload of the medial compartment.

METHODS

Fifty-five knees in 50 patients were assessed. Intra- and post-operative complications were recorded, and Tegner, Lysholm and IKDC scores were used to evaluate functional results. Radiological parameters consisted of medial proximal tibial angle (aMPTA), femorotibial angle (aFTA), posterior proximal tibial angle, lateral distal femur angle, mechanical axis deviation (MAD) and osteoarthritis score (Jäger and Wirth).

RESULTS

Duration of follow-up was 5.0 ± 1.4 years. Overall and implant-related complication rates were 27.3 and 10.9 %, respectively. No statistical association could be detected between overall and implant-related complication rates and age, gender, wedge size, angle of correction or body mass index. Mean improvement in Lysholm score was 26.8. Overall IKDC scores at follow-up were A25, B26, C2 and D2. Post-operative correction of MPTA and FTA averaged to 89.6° and 173° and to 89° and 173.5° at follow-up, respectively. Initial MAD of 21.8 mm was corrected to 11.8 mm at follow-up. Osteoarthritis score increased from 1.4 ± 0.9 to 1.9 ± 0.9 points.

CONCLUSIONS

HTO with spacer plates improves knee function and is an effective procedure in selected patients. Overall and implant-related complication rates should be considered and seem to be lower with a smaller angle of correction corresponding to incipient osteoarthritis and less varus deformity.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.