Varus osteotomy of the distal part of the femur. A survivorship analysis

Surgical Technique and Preliminary Outcomes of Double-Level Osteotomy for Valgus Deformity

Background

Data are limited regarding the surgical technique or outcomes of double-level osteotomy (DLO) combining medial closing-wedge distal femoral osteotomy and medial closing-wedge high tibial osteotomy in patients with moderate-to-severe valgus deformity.

Purpose/Hypothesis

To describe the surgical technique and assess the short-term outcomes and surgical accuracy of DLO in patients with a moderate or severe valgus deformity. It was hypothesized that this technique would result in good clinical outcomes with precise deformity correction.

Study Design

Case series; Level of evidence, 4.

Methods

Eight patients (mean age, 44.2 ± 10.9 years) with a moderate or severe valgus knee treated with DLO (9 knees; mechanical tibiofemoral angle [mTFA], 10.3°± 3.5°) were included. The mean follow-up was 25.1 ± 11.1 months. Preoperative to postoperative changes in radiographic parameters (mTFA, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, joint line convergence angle) and clinical scores (Hospital for Special Surgery score, Oxford Knee Score, Lysholm score) were assessed. Surgical accuracy was calculated by subtracting the achieved postoperative correction from the preoperatively planned targeted correction.

Results

The mTFA changed significantly from 10.3°± 3.5° preoperatively to -1.8°± 3.4° postoperatively (P < .001); the mechanical lateral distal femoral angle and mechanical medial proximal tibial angle changed significantly by 5.1°± 2.7° and 5.9°± 2.2°, respectively (P < .001 for both); and the posterior distal femoral angle decreased significantly from 85.9°± 3.1° to 84.2°± 2.4° (P < .01). There was no significant difference between pre- and postoperative joint line convergence angles (3.3°± 2.3° to 2.6°± 2.1°). The accuracy of the correction was high: the mTFA achieved postoperatively differed from the mTFA planned preoperatively by a mean of 2.7°± 1.9° (range, 0.6°-6.6°). Significant pre- to postoperative improvement was seen for all outcome scores (Hospital for Special Surgery, from 67 ± 11 to 93 ± 4; Oxford Knee Score, from 29 ± 7 to 43 ± 3; Lysholm, from 41 ± 24 to 89 ± 8; P < .001 for all).

Conclusion

High surgical accuracy was achieved, and patients who underwent varus DLO for valgus knees showed improved knee function at short-term follow-up. Varus DLO can be a surgical option to restore the optimal alignment and joint line obliquity in patients with moderate or severe valgus malalignment.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies

PURPOSE

This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO).

METHODS

A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests.

RESULTS

An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees.

CONCLUSION

In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered.

LEVEL OF EVIDENCE

Level Ⅳ, retrospective case-control study.

Effect of Varus-Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area at Varying Degrees of Knee Flexion

Background

In patients with valgus alignment and degenerative changes in the lateral compartment, both distal femoral osteotomy (DFO) and high tibial osteotomy (HTO) can be used to unload the lateral compartment. Prior studies have shown that in valgus knees, the tibial wear is posterior and DFO exerts the greatest effect in extension; however, its effect is decreased as flexion angle rises.

Hypothesis

Medial closing-wedge (MCW) HTO would significantly decrease contact area, mean contact pressure (MCP), and peak contact pressure (PCP) in the lateral knee compartment through knee flexion to a greater extent compared with lateral opening-wedge (LOW) DFO.

Study Design

Controlled laboratory study.

Methods

MCWHTO and LOWDFO were performed, correcting a mean of 8° of valgus alignment, in 10 cadaveric knees using plate fixation. Tibiofemoral contact pressure of the medial and lateral compartments was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors and load applied through an Instron device. PCP, MCP, and contact area were measured for each condition.

Results

The lateral MCP was significantly decreased in the HTO state compared with the native state in 30° (P = .015), 60° (P = .0199), and 90° (P < .0001) of flexion. The lateral MCP was also significantly decreased in the HTO state when compared with the DFO state in 60° (P = .0093) and 90° of flexion (P < .0001). After DFO, the lateral MCP returned to that of the native state in 60° (P > .999) and 90° (P > .999) of flexion. The lateral PCP decreased for all test states in all degrees of flexion; the HTO state was significantly decreased when compared with the native state in 60° (P < .0001) and 90° (P < .0001).

Conclusion

With varus corrections of 8°, MCWHTO was more effective at unloading the lateral compartment than LOWDFO. This effect was significant as the knee flexion angle increased. This study should be considered as one aspect of the surgical decision-making process.

Clinical Relevance

In patients with mild to moderate valgus deformity without hypoplastic lateral femoral condyle and without significant joint line obliquity, MCWHTO may improve offloading of the lateral compartment in flexion.

In closed wedge distal femur osteotomies for correction of valgus malalignment overcorrection of mLDFA should be avoided

PURPOSE

The purpose of the study was to investigate the influence of the mLDFA (mechanical lateral distal femur angle) as a parameter in varus realignment osteotomies for valgus deformities of the knee. We hypothesized that joint line obliquity with mLDFA > 90° after distal femur osteotomy (DFO) is associated with inferior clinical outcome.

METHODS

In a retrospective study, a total of 52 patients with isolated femoral valgus deformities were included in the study. The mean postoperative follow-up was 70.5 (SD 33.3) months (standard deviation SD±33.3). In all patients, a distal femur osteotomy was performed. A clinical examination and survey of questionnaires was conducted with the HSS (Hospital for Special Surgery), LG (Lysholm-Gilquist), and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Several radiological parameters were assessed on long-standing x-rays: mechanical tibio-femoral angle (mTFA), mLDFA, mechanical medial proximal tibia angle (mMPTA), joint-line convergence angle (JLCA). The t test was used for normally distributed data. The Mann-Whitney U test was performed in non-normally distributed data.

RESULTS

The mLDFA was 84.9° (SD±2.3) preop and changed to 91.9° (SD±3, 22.9) postop. The mTFA (mechanical tibio-femoral angle) was 5.2° (SD±2.9°) preop and - 1.8° (SD±2.9) postop demonstrating a difference of 6.7°. For analysis, the data was divided into two groups based on postop mLDFA. Group 1: mLDFA ≤ 90°; Group 2: > 90°. Postoperatively, a mean mLDFA of 88.6° (SD±1.4°) was measured in group 1 and 93.9° (SD±2.1) in group 2. The change in mLDFA was 4.7° (SD±1.6) in group 1 and 8.4° (SD±2.8) in group 2. Preoperatively, the mTFA was 4.8° (SD±1.9) in group 1 and 5.5° (SD±3.3) in group 2. Postoperatively, the mTFA decreased in group 1 by 4.8° (SD±2.3) to - 0.1° (SD±2.1). In group 2, the mTFA decreased by 8.2° (SD±3.8) to - 2.8° (SD±2.9). Regarding the HSS, group 1 showed a 10.4 points better score than group 2 (p<0.01). Also, regarding the Lysholm, a significant difference of 16.9 points was found (p<0.01).

CONCLUSION

Correction of valgus knees using closed wedge DFO leads to good clinical results. A postoperative mLDFA of 85-90° results in superior clinical outcome compared to mLDFA > 90°. Joint-line obliquity should be avoided using double level osteotomy, if needed.

LEVEL OF EVIDENCE

III.

Effects of Lateral Opening-Wedge Distal Femoral Osteotomy on Meniscal Allograft Transplantation: A Biomechanical Evaluation

Background

Lateral meniscal deficiency with valgus malalignment increases the rate of lateral compartment osteoarthritis. Lateral meniscal allograft transplantation (LMAT) with a concomitant varus-producing opening-wedge distal femoral osteotomy (DFO) is an option yet to be evaluated biomechanically.

Purpose/Hypothesis

The purpose of this study was to clarify the biomechanical effects of the realignment procedure in the setting of LMAT. We hypothesized that (1) given the dependence of the lateral compartment on the lateral meniscus, a DFO and increasing degrees of varus would be insufficient to restore lateral compartment pressures to normal from a lateral meniscus-deficient state, and that (2) LMAT would restore lateral compartment pressures to the intact state while DFO would decrease lateral compartment pressures for any given state of the meniscus.

Study Design

Controlled laboratory study.

Methods

Ten cadaveric knees underwent opening-wedge varus-producing DFO secured by an external fixator. Anatomic alignment was standardized to 6° of mechanical valgus, and each joint was tested in full extension. Submeniscal placement of thin film pressure sensors allowed for the recording of contact pressure, peak contact pressure, and contact area. The specimens were loaded on a biaxial dynamic testing machine with loading angles between 9° valgus and 6° varus of mechanical alignment. Conditions tested included intact meniscus, meniscal deficiency, and meniscal transplantation.

Results

Isolated varus-producing DFO to 6° in the meniscus-deficient state failed to restore joint pressures and contact areas to the intact state, with significant changes in mean contact pressure (175%), mean peak contact pressure (135%), and contact area (-41%) (all P < .05 vs intact), while LMAT restored all outcome measures (all P > .05 compared with intact). After LMAT, every additional 1° of DFO correction contributed to a decrease in the mean contact pressure, peak pressure, and contact area of 5.6% (-0.0479 N/mm²), 5.9% (-0.154 N/mm²), and 1.4% (-6.99 mm²) for the lateral compartment and 7.3% (+0.034 N/mm²), 12.6% (+0.160 N/mm²), and 4.3% (+20.53 mm²) for the medial compartment, respectively.

Conclusion

Isolated DFO was inadequate to restore load distribution in meniscus-deficient knees, while concomitant LMAT restored near normal forces and improved the lateral compartment biomechanical profile.

Clinical Relevance

Our findings support the concomitant use of LMAT and varus-producing DFO in the setting of lateral meniscal deficiency with valgus malalignment. This study provides tools for the orthopaedic surgeon to individualize the correction for each patient.

Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques

BACKGROUND

Valgus knee deformity increases the risk for lateral articular chondral damage, contributing to earlier onset and accelerated progression of osteoarthritis. Distal femoral osteotomy (DFO) unloads the lateral joint compartment and can be performed using closing wedge (CW) or opening wedge (OW) techniques.

PURPOSE

To perform a systematic review and meta-analysis for patients with valgus knee deformity undergoing DFO to determine differences in patient-reported outcome measures (PROMs), complications, and survival rates, comparing CW versus OW DFO.

STUDY DESIGN

Systematic review, Level of evidence, 4.

METHODS

A literature review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines utilizing PubMed, Cochrane Database, Ovid/MEDLINE, and Scopus. Inclusion criteria consisted of studies reporting outcomes in patients undergoing CW or OW DFO for the treatment of valgus knee deformities with symptomatic lateral compartment pathology with a minimum 2-year follow-up. PROMs and complications were analyzed using random-effects modeling to identify differences in outcomes as a function of surgical technique. Long-term survival data, defined as conversion to total knee arthroplasty, were analyzed using a multiple metaregression model as a function of individual study follow-up time points and surgical technique.

RESULTS

In total, we included 23 retrospective studies (n = 619 knees), of which 10 studies (n = 271 knees) reported outcomes after CW DFO and 13 studies (n = 348 knees) reported on OW DFO outcomes. Good to excellent clinical outcomes were reported in PROMs when compared with preoperative values with both techniques, while no significant differences between techniques were appreciated on functional Knee Society Scores and Tegner scores. No significant differences were appreciated in the incidence of complications reported in patients undergoing CW (20%) versus OW (33%) DFO (P = .432). Pain requiring hardware removal was the most commonly reported complication in both groups. The survival rate for CW DFO was 81.5% (mean follow-up, 8.8 ± 4.3 years) compared with 90.5% for OW DFO (mean follow-up, 4.5 ± 1.5 years). Multiple metaregression demonstrated that patient follow-up (P < .001) was significantly associated with knee survival, while surgical technique (P = .810) was not a predictor of clinical failure.

CONCLUSIONS

Both CW and OW DFO techniques were associated with good to excellent clinical outcomes with no significant differences in PROMs based on technique. Pain requiring hardware removal was the most common complication in both techniques, while long-term survivability was found to be a function of follow-up and not surgical technique. Technique selection should be based on shared patient-physician decision making with an emphasis on surgeon preference and technique familiarity.

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy

PURPOSE

Closing wedge distal femoral osteotomies (CWDFO) are attractive treatment options for unicompartmental knee osteoarthritis with coronal plane deformity. However, it has been traditionally associated with high rates of hinge fracture that can adversely impact recovery and patient outcomes. Appropriate siting of hinge point can be an effective method of reducing the incidence of hinge fractures. This study aims to illustrate a case series of CWDFO with low rates of hinge fracture utilising our preferred hinge point site.

METHODS

A retrospective study of a cohort of 39 CWDFO was performed between May 2019 and May 2022. Both medial and lateral CWDFO were included. The hinge point in all cases was placed at the level of the inferior margin of the metaphyseal flare, and inferior to the gastrocnemius origin, with a hinge thickness of 10 mm. Post-operative radiographs were obtained at 2, 4 and 8 weeks after surgery to assess for hinge fracture and union.

RESULTS

Thirty-nine cases of CWDFO were performed, consisting of eighteen cases of valgus malalignment that underwent medial CWDFO and twenty-one cases of varus malalignment that underwent lateral CWDFO. At surgery, the mean age was 47.6 (± 13.9) years and mean BMI was 29.4 (± 4.9). There were 23 men and 16 women. Three cases of hinge fractures occurred intraoperatively, translating into a hinge fracture rate of 7.69%. However, union was achieved in all three cases and all patients in this case series were able to progress to weight bear as tolerated at 2 months post-osteotomy.

CONCLUSION

Distal placement of the hinge at the level of the inferior metaphyseal flare margin with the use of a hinge wire can greatly reduce the rates of hinge fracture in CWDFO.

LEVEL OF EVIDENCE

Level III.

Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system

INTRODUCTION

To compare bone union after medial closing wedge distal femoral osteotomy (MCWDFO) with that after lateral closing wedge distal femoral osteotomy (LCWDFO) using a novel scoring system.

MATERIALS AND METHODS

The data of 30 patients who received biplanar MCWDFO for valgus knees (MCWDFO group) were retrospectively examined and compared to that of 22 patients (25 knees) who underwent biplanar LCWDFO via a double-level osteotomy (DLO) for varus knees (LCWDFO group). The progression of bone union of the transverse osteotomy plane in the femur was assessed using a newly developed scoring system using radiographs taken immediately after surgery and 3 and 6 months postoperatively. The scoring system is based on a scale of zero to six points with higher scores indicating better bone union. The incidence of hinge fractures was assessed using CT images, and the rates of reoperation were evaluated using medical record data.

RESULTS

The mean bone union score was significantly lower in the MCWDFO group than in the LCWDFO group 3 months (2.1 ± 1.9 vs. 3.7 ± 1.7, P < 0.01) and 6 months (3.8 ± 2.1 vs 4.9 ± 1.5, P < 0.05) postoperatively. The incidence ratio of hinge fractures was significantly higher in the MCWDFO group than in the LCWDFO group (70.0% vs. 32.0%, P < 0.01). Two patients in the MCWDFO group underwent reoperation for delayed bone union or non-union.

CONCLUSION

Bone union progression was slower and hinge fractures were more frequently observed after MCWDFO than after LCWDFO via DLO. MCWDFO is technically challenging, and patients must be monitored closely during and after surgery.

Long Term Outcomes of Computer-Navigated Lateral Opening Wedge Distal Femoral Osteotomy for Lateral Compartment Knee Arthrosis

Objective  The primary aim of the present study was to evaluate the long-term outcomes including survivorship of computer navigated distal femoral lateral opening wedge osteotomy (DFLOWO). The secondary aim was to identify the potential factors that may influence its survivorship. Methods  A retrospective analysis of prospectively collected data for patients with lateral compartment arthritis who underwent navigated DFLOWO from December 2006 to November 2012 was performed. The International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores were analyzed for outcome measures. Conversion to arthroplasty during the follow-up was the end point. Results  A total of 19 DFLOWOs were performed in 17 patients with a mean age of 46.6 ± 6.5 years formed the study cohort. The coronal alignment was corrected from a mean of 7.1° (2-11°) valgus to a mean of 2.1° (0.5°-3°) varus. The IKDC scores improved from mean of 39 preoperatively to 53 at the mean long-term follow-up of 9.1 years. The mean KOOS scores at the long-term follow-up were pain 71, symptoms 56, activities of daily living 82, sports and recreation 59, quality of life 43. Survivorship of the DFLOWO was 78.9% at a follow-up of 9.1 years. Presence of ≥ grade 2 according to the International Cartilage Repair Society (ICRS) cartilage degeneration in the medial compartment of the knee and >7° preoperative valgus deformity were strongly correlated with conversion to total knee arthroplasty (TKA) at the long-term follow-up ( r  = 0.66). Conclusions  Computer navigated DFLOWO has satisfactory clinical outcomes and 79% survivorship in long-term follow-up. Presence of more than ICRS ≥ grade 2 degenerative changes in the medial compartment of knee with > 7° preoperative valgus deformity negatively affects the survivorship of DFLOWO in the long-term follow-up.

Biomechanical analysis of the role of hinge support fixators on hinge stability in medial closing wedge distal femoral osteotomy

BACKGROUND

This study aimed to examine the hinge-stabilizing biomechanical effects of hinge support fixators, applied for lateral hinge fractures sustained following distal femoral osteotomy.

METHODS

Medial closing wedge distal femoral osteotomy was performed using a locking plate on 10 cadaveric limbs. The limbs were divided into two groups: the non-fracture group and the lateral hinge fracture group. A cyclic axial load of 400 N was applied to the knee to keep it extended and flexed at 45°. The hinge-stabilizing effects of adding a screw or a short support plate to the lateral fracture site were examined by measuring the translation and rotational angles of the anterodistal and posterodistal hinge positions as well as the surface strains of the medial locking plate.

FINDINGS

Translation and rotation in the fracture group were significantly more pronounced than in the non-fracture group, at the anterodistal and posterodistal positions. Translations at both positions were significantly reduced, by adding the support plate, during both extension and 45-degree flexion in the fracture group. The rotation at the posterodistal position upon extension and the anterodistal position upon 45-degree flexion was significantly reduced by the support plate. The surface strain of the medial plate in the fracture group was significantly reduced by the support plate upon both extension and 45-degree flexion.

INTERPRETATION

Lateral hinge fractures caused abnormal hinge movements, which were significantly reduced by the short support plate. A short support plate could be used if a hinge fracture occurs during distal femoral osteotomy, to improve lateral hinge stability.

Osteotomies for lateral compartment knee osteoarthritis

Lateral compartment osteoarthritis (LCOA) is often associated with valgus deformity of the knee. The concept of correcting the alignment by performing distal femoral varus osteotomy (DFVO) to unload the lateral compartment is well accepted and it is viewed as the preferred option for young active patients due to dissatisfaction from arthroplasty under 55 years of age or if they wish to remain active. Beyond this there is no consensus on patient selection, preoperative assessment, techniques to achieve correction, end point of correction, return to work or sports post-surgery, and survivorship of osteotomy with conversion to a total knee replacement as the end point due to heterogenous, retrospective studies. Here, we review relevant literature to help patient selection, preoperative work up, techniques, and outcomes.

Genu Valgum Correction and Biplanar Osteotomies

Valgus malalignment is an important risk factor in recurrent patella instability. This article explores the role of corrective osteotomy and discusses the various described methods both on the femoral and tibial sides of the joint. A detailed operative technique of medial closing wedge distal femoral osteotomy is included.

Patient-Specific Instrument Guided Double Chevron-Cut Distal Femur Osteotomy

The risk of non-union and prolonged periods of protected weight-bearing still remain unsolved issues after distal femur osteotomy (DFO). To improve the stability, we developed the double chevron-cut technique, which is a modified medial closing-wedge DFO guided by a patient-specific instrument. The purpose of this study was to investigate the feasibility and outcome of this operative approach. Twenty-five knees in twenty-three consecutive patients with genu valgum and lateral compartment osteoarthritis that received double chevron-cut DFO were included. The target of correction was 50% on the weight-bearing line (WBL) ratio. Patient-reported outcomes included the Oxford Knee Score (OKS) and the 2011 Knee Society Score (KSS). The mean of the WBL ratio was corrected from 78.7% ± 12.0% to 48.7% ± 2.9% postoperatively. The mean time to full weight bearing was 3.7 ± 1.4 weeks. Union of the osteotomy was achieved at 11.3 ± 2.8 weeks. At a mean follow-up of 17 months, the OKS improved from a mean of 27.6 ± 11.7 to 39.1 ± 7.5 (p = 0.03), and the KSS from a mean of 92.1 ± 13.0 to 143.9 ± 10.2 (p < 0.001). Three patients developed complications, including one case of peri-implant fracture, one of loss of fixation, and one of non-union. The double chevron-cut DFO followed by immediate weight-bearing as tolerated is effective in treating genu valgum deformity and associated lateral compartment osteoarthritis.

Medial closure supracondylar femoral osteotomy: an effective solution for long-term treatment of arthritic valgus knee?

Purpose

The aim of this work was to retrospectively analyze the clinical, subjective, and radiological results of medial closing-wedge distal femur osteotomy (MCW-DFO) for the treatment of osteoarthritis (OA) in valgus knee at medium- to long-term follow-up.

Materials and methods

A total of 57 patients (62 knees) treated with MCW-DFO between 1984 and 2018 were included in the study. Patient age at the time of the surgery ranged between 28 and 61 years (average: 48 years). All patients with a minimum follow-up of 4 years were contacted to request for them to undergo clinical, subjective, and radiological evaluation. Preoperative hip–knee–ankle (HKA) angle (i.e., preoperative valgus malalignment) was 8.6° ± 2°. Patients were evaluated using the following scales: the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Knee Society Score (KSS), the International Knee Documentation Committee (IKDC), the Visual Analog Scale (VAS), and the Numeric Rating Scale 11 (NRS-11).

Results

Mean follow-up was 11.6 ± 4.9 years, and a total of 17 patients (20 knees) were available for the last examination. At maximum follow-up, 4 patients underwent conversion to a total knee replacement (20%); their survival rate was 100% at 10 years and 66.7% at 15 years, as estimated using the Kaplan–Meier curve. The subjective Knee Society Score improved on average from 37.7 ± 10 to 63.9 ± 15.4. The objective Knee Society Score improved on average from 42.2 ± 11.7 to 75 ± 22.5. The pain detected through the VAS and NRS-11 scales improved from 56.7 ± 12.9 to 42 ± 17.1 and from 5.8 ± 1.1 to 4.4 ± 1.7, respectively. Thirteen patients (70%) required hardware removal at an average time of 19 ± 4 months due to a local nuisance.

Conclusions

MCW-DFO can improve symptoms in patients with osteoarthritis in a valgus knee at medium- to long-term follow-up, reducing the progression of osteoarthritis in properly selected patients.

Medial closing-wedge distal femoral varus osteotomy: Symptoms and functional impact in cases of associated patellofemoral osteoarthritis. A two-year follow-up prospective pilot study

PURPOSE

To date, indications for distal femoral varus osteotomy (FVO) in cases of associated patellofemoral osteoarthritis (PFO) have yet to be clarified. The purpose of this prospective study is to assess the short-term symptoms, functional and radiological impact of a medial closing-wedge femoral varus osteotomy on the patellofemoral joint in patients with valgus deformities who are afflicted with lateral tibiofemoral osteoarthritis (LTFO) associated with PFO.

METHODS

Fourteen patients (15 knees) received a medial closing-wedge femoral varus osteotomy. The functional impact of an FVO on the patellofemoral joint was assessed based on the KOOS-PF (Knee Injury and Osteoarthritis Outcome Score-Patellofemoral Subscale), the Kujala score and the patellofemoral symptoms. Realignment of the patella was measured by the Merchant's patellofemoral congruence angle. The pre- and post-operative symptoms and functional scores were compiled prospectively and compared two years after the surgery.

RESULTS

The Kujala patellofemoral functional scores and the KOOS-PF showed considerable improvement with a differential of +37.5 points ± 20.4 and +42.7 points ± 19.3 (p < .01) respectively. The average Merchant's congruence angle went from 8.8° laterally to 3.6° medially, resulting in medialization of the patella, with a significant difference (p < .01). Based on the specific clinical analysis of the patellar joint, preoperative J-sign was identified in 26.7% of patients (n = 4) and was not found during postoperative examination (p = .1). Preoperative apprehension test was identified in 33.3% of patients (n = 5) against 13.3% (n = 2) after surgery (p = .39). Preoperative pain extension test was identified in 40% of patients (n = 6) against 20% during postoperative clinical analysis (p = .43).

DISCUSSION

Although the threshold of significance for patellofemoral symptoms was not reached, the medial closing-wedge femoral varus osteotomy induces a significant medialization of the patella (Merchant's congruence angle) and improves short-term functional results even with co-existing patellofemoral osteoarthritis. Due to the lack of specificity of the patellofemoral scores, patellofemoral osteoarthritis improvement is difficult to determine on its own, but does not represent a contraindication to FVO.

LEVEL OF EVIDENCE

III. Prospective clinical study.

Cartilage regeneration in osteoarthritic knees treated with distal femoral osteotomy and intra-lesional implantation of allogenic human umbilical cord blood-derived mesenchymal stem cells: A report of two cases

BACKGROUND

To treat lateral compartment osteoarthritis caused by a valgus deformity, partial or total knee joint arthroplasty is recommended. However, for young patients, joint preservation surgery such as distal femoral osteotomy (DFO) can be an alternative treatment option. Combined cartilage defects of lateral compartment osteoarthritis can be restored by human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs). This case report presents the results of DFO and hUCB-MSC implantation for treating two patients with valgus deformity who had lateral compartment osteoarthritis.

CASE PRESENTATION

Two middle-aged patients with lateral compartment osteoarthritis and valgus deformity were treated using DFO and hUCB-MSC implantation. They recovered sufficiently to perform moderate exercise one year after surgery. The International Knee Documentation Committee, visual analog scale, and Western Ontario and McMaster Universities Osteoarthritis Index scores showed continuous improvement after surgery. Cartilage regeneration of International Cartilage Repair Society Grade 1, which was similar to normal, was observed in both patients through second-look arthroscopy. With time, the modified two-dimensional magnetic resonance observation of cartilage repair tissue scores also increased in both cases.

CONCLUSION

This is the first case report detailing the results of treating lateral compartment osteoarthritis using hUCB-MSCs and DFO. In conclusion, this can be considered a new treatment option for such cases.

Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology

Background

There is a paucity of literature describing distal femoral osteotomies (DFO) in regards to complications and outcomes with previously studied cohorts containing primarily older, arthritic subjects. There has been no study to date focusing on younger, pre-arthritic patients.

Methods

All service members indicated for distal femoral osteotomy for coronal plane malalignment were isolated from military treatment centers between 2007 and 2013. Demographic and surgical variables were extracted, and perioperative complications, clinical course, and return to military function were extracted using clinical notes and radiographs.

Results

A total of 22 knees in 19 patients were identified at an average 3.2 year follow-up, with the exclusion of 16 individuals. Statistical analysis revealed worse outcomes associated with smoking, over correction, breach of the medial cortex, and prior surgeries. Overall 58% of patients left the military as the result of knee dysfunction despite an average improvement in visual analog scores (VAS) from 4.0 to 1.9 (p = 0.004).

Conclusions

While offloading the lateral compartment improves symptoms at short to midterm follow-up preventing progression to arthroplasty, young active duty military members have suboptimal return to duty rates.

Medial Closing Wedge Distal Femoral Osteotomy

The main indication for performing a distal femoral osteotomy is valgus malalignment of the knee joint. The ideal candidates are young and active individuals with isolated lateral compartment arthritis. The goal of the procedure is to create a neutral mechanical axis of the limb to relieve pain and preserve the knee joint. The amount of correction is calculated from a preoperative, high-quality, weight-bearing radiograph from the hip to ankle. This technically challenging operation is a viable option for patients with valgus malalignment because early survivorship is strong and patient-reported outcome scores are significantly improved.

Correction of distal femoral valgus deformities with fixator-assisted plating: How accurate is the correction?

Objective

The aim of this study was to evaluate the results of fixator assisted correction of the distal femoral valgus deformities and the precision of the correction.

Methods

Seventeen extremities of 13 patients (7 women and 6 men; mean age: 16 ± 5.4 years) who had fixator assisted plating of the distal femur for genu valgum deformity were evaluated. Mechanical axis deviation (MAD) and mechanical lateral distal femoral angles (mLDFA) were measured pre-operatively and post-operatively. mLDFA was graded as perfect if it is between 85° and 90°(85° ≤ x ≤ 90°); overcorrection if it is between 91° and 95° (91° ≤ x ≤ 95°) and undercorrection if it is between 80° and 85° (80° ≤ x < 85°). Measurements beyond those limits were graded as a poor result. The position of the mechanical axis line with respect to center of the knee was graded from zone 1 to zone 4 pre-operatively and post-operatively.

Results

The mean follow-up period was 12.8 ± 3.7 months. The pre-operative and post-operative mLDFA was 70.5°±9.4° (range, 57°–82°) and 87.7° ± 3.5° (range, 80°–94°), respectively (p < 0.001). Based on post-operative standing radiographs, the correction was graded perfect in 12 femurs. The correction in three femurs were graded as overcorrection and graded as undercorrection in two femurs. Sagittal plane correction was also achieved in two femurs. Peroneal nerve decompression was done in three patients (5 extremities) with valgus deformity over 30°. The mechanical axes in all lower extremities were passing through zone 2 or more, pre-operatively, whereas the mechanical axes were in zone 2 or more in five extremities post-operatively.

Conclusion

Fixator assisted plating is an effective treatment modality in patients with distal femoral valgus deformity. Although the technique enables to obtain significant correction in coronal plane it has the disadvantages of over- and undercorrection. Thus, we advise intraoperative confirmation of the correction under fluoroscopic control.

Level of Evidence: Level IV Therapeutic Study.

Successful Return to Sport Following Distal Femoral Varus Osteotomy

OBJECTIVE

Distal femoral varus osteotomy (DFVO) is an effective treatment for unloading valgus knee malalignment; however, there is limited evidence on the ability for patients to return to athletics following this procedure. The purpose of this study is to report the functional outcomes and rate of return to sport for athletes that underwent DFVO.

DESIGN

A consecutive series of athletes that had undergone DFVO were retrospectively reviewed. Radiographs were assessed to determine preoperative and postoperative alignment. Institutional registries were used to collect preoperative and postoperative Marx Activity Scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form scores, and return to sport.

RESULTS

Thirteen patients (8 males, 5 females) with a mean age of 24 years (range 17-35 years) and a mean follow-up of 43 months (range 24-74 months) were included in the study. Six patients underwent medial closing wedge DFVO versus 7 patients who underwent lateral opening wedge DFVO. Nine of 13 had concomitant chondral, meniscal, or ligamentous procedures performed. The mean alignment correction was 8° (range 5°-13°). All patients were able to successfully return to sport at a mean of 11 months (range 9-13 months). Furthermore, all 13 patients demonstrated an improvement in both Marx Activity Scale (4-11; P < 0.01) and IKDC scores (53-89; P < 0.01) after surgery.

CONCLUSIONS

Correction of valgus knee malalignment through DFVO-either medial closing wedge or lateral opening wedge-can reliably result in improvement in function and return to sport. Concomitant chondral, meniscal, and ligamentous pathology should be addressed.

Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee

Distal femoral varus osteotomy is a well-described treatment option for patients with valgus malalignment associated with a variety of underlying conditions. This procedure may be the definitive treatment option in active patients with isolated lateral compartment osteoarthritis or posttraumatic arthritis. It may be a useful concomitant procedure in young patients with lateral meniscus deficiency, focal chondral defects, chronic medial collateral ligament insufficiency, and/or patellofemoral instability. Distal femoral varus osteotomy can be performed with medial closing wedge or lateral opening wedge techniques. Variable outcomes and complication rates have been reported. A framework for the use of distal femoral varus osteotomy can aid the orthopaedic surgeon in the evaluation and treatment of patients with symptomatic valgus malalignment.

Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy

Purpose

The purpose of this review is to compare the clinical and radiological outcomes between open and closed wedge distal femoral varus osteotomy (DFO).

Methods

A literature search of online databases (MEDLINE, EMBASE, and Cochrane Library database) was made in addition to manual search of major orthopedic journals. Data were searched from the time period of January 1990 to October 2016. A modified Coleman Methodology Score system was used to assess the methodologic quality of the included studies. A total of 20 studies were included in the review. All studies were level IV evidence.

Results

Comparative analysis of open and closed wedge DFO did not demonstrate clinical and radiological differences. The survival rates were also similar. Five studies (56%) on open wedge DFO mentioned the need for either bone grafting or substitute for osteotomy gap filling and reported higher incidences of reoperation for plate removal than the closed wedge DFO studies.

Conclusions

The present systematic review showed similar performance between open and closed wedge DFO. Outcomes including survival rates were not statistically significantly different. However, additional bone grafting or substitutes were often needed to prevent delayed union or nonunion for open wedge techniques. Additional operations for plate removal were commonly required due to plate irritation in both techniques.

High Rates of Return to Sports Activities and Work After Osteotomies Around the Knee: A Systematic Review and Meta-Analysis

BACKGROUND

Knee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce.

OBJECTIVES

Our aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW.

METHODS

We systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled.

RESULTS

We included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders.

CONCLUSION

Eight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload.

Failure of high tibial varus osteotomy for lateral tibio-femoral osteoarthritis with<10° of valgus: Outcomes in 19 patients

BACKGROUND

Osteotomy is a rational approach to slowing knee osteoarthritis progression by modifying loads, thereby avoiding joint replacement in younger individuals. Varus femoral osteotomy is recommended only in patients with more than 10° of valgus. The objective here was to assess outcomes of tibial varus osteotomy in patients with lateral compartment tibio-femoral osteoarthritis and less than 10° of valgus. The hypothesis was that high tibial varus osteotomy produces satisfactory and long-lasting improvements.

MATERIAL AND METHODS

A single-centre retrospective study was conducted in 19 consecutive patients managed by high tibial varus osteotomy between January 2005 and May 2012. Mean age was 54.5years. The clinical IKS knee and function scores and radiological parameters were determined pre-operatively then after 6 and 12months and at last follow-up. The primary outcome measure was the global IKS score. Failure was defined as a global IKS score <140 or total knee arthroplasty (TKA). Secondary outcome measures were a post-operative hip-knee-ankle (HKA) angle between 180° and 183° and less than 10° of joint line obliquity. The hypothesis was that high tibial varus osteotomy produced satisfactory and long-lasting improvements in lateral compartment tibio-femoral osteoarthritis.

RESULTS

After the mean follow-up of 4.3years (range, 2-9years), 10/19 patients had a global IKS score <140. Among them, 7 underwent TKA after a mean of 5.0±2.7years. Varus tibial osteotomy was followed by significant improvements in the IKS knee and function scores from baseline to last follow-up (P<0.05). A global IKS<140 predicted TKA. Mean HKA angle values were 186.3±2.9° pre-operatively and 181.3°± 3.9°at last follow-up (P<0.05); the HKA angle was within the 180°-183° range in 8 (42.1%) patients. Mean post-operative joint line obliquity was 7.8±3.0°. An HKA angle outside the 180-183° range and joint line obliquity >10° were associated with poor outcomes.

DISCUSSION

High tibial varus osteotomy produces unsatisfactory medium-term outcomes, with an overall failure rate of 52%. At present, high tibial varus osteotomy has no role in the management of lateral compartment tibio-femoral osteoarthritis with <10° of valgus.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Geometry of the Valgus Knee: Contradicting the Dogma of a Femoral-Based Deformity

BACKGROUND

Realignment osteotomies of valgus knee deformities are usually performed at the distal femur, as valgus alignment is considered to be a femoral-based deformity. This dogma, however, has not been proven in a large patient population. Valgus malalignment may also be caused by a tibial deformity or a combined tibial and femoral deformity.

PURPOSE

The purposes of this study were (1) to analyze the coronal geometry of patients with valgus malalignment and identify the location of the underlying deformity and (2) to investigate the proportion of cases that require realignment osteotomy at the tibia, the femur, or both locations to avoid an oblique joint line.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The analysis included 420 standing full-leg radiographs of patients with valgus malalignment (mechanical femorotibial angle [mFTA], ≥4°). A systematic analysis of the coronal leg geometry was performed including the mFTA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and joint-line convergence angle (JLCA). The localization of the deformity was determined according to the malalignment test described by Paley, and patients were assigned to 1 of 4 groups: femoral-based valgus deformity, tibial-based valgus deformity, femoral- and tibial-based valgus deformity, or intra-articular/ligamentary-based valgus deformity. Subsequently, the ideal osteotomy site was identified with the goal of a postoperative change of the joint line of two different maximum values, ±2° and ±4°, from its physiological varus position of 3°.

RESULTS

Measurements of the coronal alignment revealed a mean (±SD) mFTA of 7.4° ± 4.3° (range, 4°-28.2°). The mean mLDFA and mean mMPTA were 84.8° ± 2.4° and 90.9° ± 2.6°, respectively. The mean JLCA was 1.2° ± 3.1°. The majority (41.0%) of valgus deformities were tibial based, 23.6% were femoral based, 26.9% were femoral and tibial based, and 8.6% were intra-articular/ligamentary based. To achieve a straight-leg axis and an anatomic postoperative joint line with a tolerance of ±4°, the ideal site of a corrective osteotomy was tibial in 55.2% of cases and femoral in 19.5% of cases. A double-level osteotomy would be necessary in 25.2% of cases. With a tolerance of ±2°, the ideal osteotomy site was the proximal tibia in 41.0% of cases and the distal femur in 13.6% of cases; a double-level osteotomy would be necessary in 45.5% of cases.

CONCLUSION

In contrast to the widespread belief that valgus malalignment is usually caused by a femoral deformity, this study found that valgus malalignment was attributable to tibial deformity in the majority of patients. In addition, a combined femoral- and tibial-based deformity was more common than an isolated femoral-based deformity. As a clinical consequence, varus osteotomies to treat lateral compartment osteoarthritis must be performed at the tibial site or as a double-level osteotomy in a relevant number of patients to avoid an oblique joint line.

Distal femoral varus osteotomy for unloading valgus knee malalignment: a biomechanical analysis

PURPOSE

To investigate the biomechanical properties of the load shifting following opening-wedge distal femoral varus osteotomies (DFVOs) and determine the osteotomy correction needed to unload the lateral compartment.

METHODS

Five human cadaveric knees were tested with a load of 500 N of axial compression. Medial and lateral tibiofemoral compartment contact area and pressure were assessed utilizing a modified F-scan pressure-sensitive sensor. The knees were tested in their baseline anatomic alignment, 10° valgus malalignment and following corrective DFVOs of 5°, 10° and 15°. The load shifting effect of the various DFVO correction angles was analysed using a one-way ANOVA to determine the correction angle necessary to unload the lateral compartment.

RESULTS

Gradually shifting the loading vector medially with increasing DFVO angles resulted in a decrease in the mean contact area and mean contact pressures in the lateral compartment with progressive increases in the medial compartment. The largest reduction in lateral compartment pressure and contact area was seen with the 15° osteotomy with a 25 % decrease in mean contact pressure and 20 % decrease in mean maximum contact pressure and mean contact area when compared to the 10° valgus-malaligned knee. For the 10° valgus knee, a 15° correction resulted in near-normal contact pressures and areas compared with the knee in normal anatomic alignment.

CONCLUSION

Progressive unloading of the lateral tibiofemoral compartment occurred with increasing DFVO correction angles. Clinically, when performing a DFVO for valgus malalignment, surgeons should consider overcorrecting the osteotomy by 5° to restore near-normal contact pressures and contact areas in the lateral compartment rather than the traditional teaching of correcting to neutral alignment.

Role of computer-assisted surgery in osteotomies around the knee

PURPOSE

The goal of this article is to present our experience on navigation for osteotomies around the knee and especially osteotomies for coronal deformities. The first computer-assisted osteotomy was performed in March 2001 and since that time more than 1000 osteotomies have been performed in our department.

METHODS

All the osteotomies were performed with the Orthopilot^® device (B-Braun-Aesculap, Tuttlingen, Germany). The main indication was for genu varum deformities but several cases were operated for genu valgum. The surgical procedure as well as the indications and the rationale for each osteotomy (high tibial osteotomy-HTO, double-level osteotomy-DLO, femoral osteotomy-FO) are addressed in the article.

RESULTS

The results are focused on several papers published by the authors since more than 10 years. Regarding HTO for genu varum, the preoperative goal (HKA angle: 184° ± 2°) was reached in 96 % of cases and the difference was statistically significant compared to the non-navigated series (71 %: p < 0.05). Regarding DLO for genu varum, the preoperative goal was reached in 92.7 % for the HKA angle and in 88.1 % for the medial proximal tibial mechanical angle (MPTMA). Regarding genu valgum deformity, the preoperative goal was achieved in 86.2 % of cases for the HKA angle and 100 % of cases for the MPTMA.

CONCLUSION

According to these results, one can say that, regardless the type of osteotomy, the procedure is reliable, reproducible and accurate. Since 15 years, all the osteotomies around the knee are navigated in our department. Provided that one uses a reproducible radiograph protocol, navigation allows to perform double-level osteotomies, both for genu varum and genu valgum, with optimal accuracy in order to avoid oblique joint line, which will be difficult to revise to TKA.

LEVEL OF EVIDENCE

IV.

Knee osteoarthritis: a review of management options

Osteoarthritis of the knee is a complex peripheral joint disorder with multiple risk factors. The molecular basis of osteoarthritis has been generally accepted; however, the exact pathogenesis is still not known. Management of patients with osteoarthritis involves a comprehensive history, thorough physical examination and appropriate radiological investigation. The relative slow progress in the disease allows a stepwise algorithmic approach in treatment. Non-surgical treatment involves patient education, lifestyle modification and the use of orthotic devises. These can be achieved in the community. Surgical options include joint sparing procedures such as arthroscopyando osteotomy or joint-replacing procedures. Joint-replacing procedures can be isolated to a single compartment such as patellofemoral arthroplasty or unicompartmental knee replacement or total knee arthroplasty. The key to a successful long-term outcome is optimal patient selection, preoperative counselling and good surgical technique.

Opening- and Closing-Wedge Distal Femoral Osteotomy: A Systematic Review of Outcomes for Isolated Lateral Compartment Osteoarthritis

Background:

Lateral compartment osteoarthritis of the knee can be a challenging pathology in the younger, active population due to limited treatment options and high patient expectations. Distal femoral osteotomy (DFO) has been reported to be a potential treatment option.

Purpose:

To perform a systematic review on the survival, outcomes, and complications of DFO for treatment of genu valgum with concomitant lateral compartment osteoarthritis of the knee.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, PubMed, and MEDLINE from 1980 to present. Inclusion criteria were as follows: outcomes of opening- and closing-wedge DFOs performed for treatment of genu valgum with concomitant lateral compartment osteoarthritis of the knee, English language, minimum 2-year follow-up, and human studies. Data abstracted from the selected studies included type of osteotomy (opening vs closing), survival rate, patient-reported and radiographic outcomes, and complications.

Results:

Fourteen studies met the inclusion criteria and were considered for the review. A total of 9 closing-wedge and 5 opening-wedge DFO studies were included. All were retrospective studies and reported good to excellent patient-reported outcomes after DFO. Survival decreased with increasing time from surgery, with 1 study reporting a 100% survival rate at 6.5 years, compared with 21.5% at 20 years in another study. A low rate of complications was reported throughout the review.

Conclusion:

Highly heterogeneous literature exists for both opening- and closing-wedge DFOs for the treatment of isolated lateral compartment osteoarthritis with valgus malalignment. A mean survival rate of 80% at 10-year follow-up was reported, supporting that this procedure can be a viable treatment option to delay or reduce the need for joint arthroplasty. A low complication rate was observed, with symptomatic hardware being the most prevalent postoperative complication.

Good functional results of distal femoral opening-wedge osteotomy of knees with lateral osteoarthritis

PURPOSE

To evaluate the time-dependent functional outcome of patients with lateral knee osteoarthritis with increased valgus treated with lateral opening-wedge osteotomy to shift the load from the lateral to the medial compartment of the knee.

METHODS

Twenty-four consecutive patients with lateral knee osteoarthritis were treated with distal femoral opening-wedge varus osteotomy stabilized with the Puddu plate and bone transplantation. The mean age of the patients was 48 years (CI 40.3-55.7, range 31-62). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at 3 and 6 months, 1, 2, 5 and 10 years post-operatively. The knee osteoarthritis was graded according to the Kellgren-Lawrence radiological scoring system. The mean follow-up time was 7.9 years (CI 6.8-9.0, range 4.0-10.2).

RESULTS

The mean angular correction measured on pre- and post-operative radiographs was 9.6° (CI 7.7°-11.5°, range 4°-20°). All osteotomies healed. KOOS increased significantly during the first year by 28-122 % beyond the preoperative values for all the five subscores. This improvement remained at 10-year follow-up for those with surviving osteotomy. Six knees were converted to total knee arthroplasty (TKA) mean 6.4 years (CI 3.3-9.6, range 4.0-11.8) post-operatively. The osteotomy survival rate at 5 years was 88 % and at 10 years 74 %. The preoperative osteoarthritic grade did not increase significantly during the follow-up period, but was significantly correlated (r = -0.49), P = 0.019 to the KOOS subscore symptoms at the 2-year follow-up.

CONCLUSION

Distal femoral opening-wedge osteotomy for lateral knee osteoarthritis resulted in good functional recovery after 1 year and favourable midterm results. It may be a good treatment option for middle-aged patients with valgus knees and lateral osteoarthritis in order to prevent or postpone TKA.

LEVEL OF EVIDENCE

IV.

The effect of lateral opening wedge distal femoral osteotomy on leg length

PURPOSE

Varisation distal femoral osteotomy is a well-described treatment for lateral compartment arthrosis in the young, active patient. This treatment may potentially alter the length of the lower limb . The objective of this study was to quantify the change in leg length following lateral opening wedge distal femoral osteotomy using a blade plate.

METHODS

Between 1998 and 2011, 29 lateral opening wedge distal femoral osteotomies were performed for symptomatic genu valgum with signs of lateral compartment arthrosis or patello-femoral symptoms. The mean age was 44.4 years (±11.3). Average follow-up was 80.2 months (±50.6).

RESULTS

The mean osteotomy opening was 8.3° (±2.3). The femoro-tibial mechanical axis (mFTA) was improved significantly, from 187.8° (±3.5) to 180.4° (±2.6) post-operatively (p < 0.001). The pre-operative leg length discrepancy was -0.7 cm, compared to -0.6 cm post-operatively, which was not significant (n.s.). There were five revisions to arthroplasty for disease progression at meantime of 166.6 months post-operatively. The probability of survival at 60 months was 91.4% (95% CI 74.9-100%) with end-point of revision to total knee arthroplasty and 87.6% (95% CI 74.1-100%) of revision for complications.

CONCLUSIONS

Lateral opening wedge distal femoral osteotomy, performed for symptomatic genu valgum, has no effect on leg length. This technique allows good correction of the axis of the lower limb; however, the complication rate is not insignificant (14%). Complications occurred mainly in post-traumatic cases and may be avoidable with attention to technique and optimum rehabilitation. The procedure should be reserved for young, active patients with significant symptoms.

LEVEL OF EVIDENCE

IV.

DISTAL FEMORAL VARUSING FOR OSTEOARTHRITIS OF VALGUS KNEE: A LONG-TERM FOLLOW-UP

Objective: Assess the long-term results of distal femoral varusing osteotomy and try to establish predictive criteria that could help on selecting patients to be submitted to this technique. Methods: Fifteen patients with lateral compartment osteoarthritis and valgus deformity of the knee were submitted to distal femoral “V” varusing osteotomy fixated with lateral plate, pursuing knee alignment at 0° on the anatomical axis. The mean follow-up period was 81.4 months, ranging from 43 to 132 months. The Knee Society Rating System protocol was employed. Additional assessed variables were the following: patient age, follow-up time, and postoperative anatomical angle. Results: 11 results were regarded as excellent or good (73%) and four as fair or poor (27%). Conclusion: Distal femoral “V” varusing osteotomy constitutes a good treatment alternative for patients with lateral compartment osteoarthritis and valgus knee. The following variables have not been confirmed: patient age at the time of surgery, follow-up time, and postoperative anatomical angle as predictive factors for the results.

The Meniscus-Deficient Knee: Biomechanics, Evaluation, and Treatment Options

Meniscal tears are the most common knee injury, and partial meniscectomies are the most common orthopaedic surgical procedure. The injured meniscus has an impaired ability to distribute load and resist tibial translation. Partial or complete loss of the meniscus promotes early development of chondromalacia and osteoarthritis. The primary goal of treatment for meniscus-deficient knees is to provide symptomatic relief, ideally to delay advanced joint space narrowing, and ultimately, joint replacement. Surgical treatments, including meniscal allograft transplantation (MAT), high tibial osteotomy (HTO), and distal femoral osteotomy (DFO), are options that attempt to decrease the loads on the articular cartilage of the meniscus-deficient compartment by replacing meniscal tissue or altering joint alignment. Clinical and biomechanical studies have reported promising outcomes for MAT, HTO, and DFO in the postmeniscectomized knee. These procedures can be performed alone or in conjunction with ligament reconstruction or chondral procedures (reparative, restorative, or reconstructive) to optimize stability and longevity of the knee. Complications can include fracture, nonunion, patella baja, compartment syndrome, infection, and deep venous thrombosis. MAT, HTO, and DFO are effective options for young patients suffering from pain and functional limitations secondary to meniscal deficiency.

Supracondylar femur osteotomies around the knee: patient selection, planning, operative techniques, stability of fixation, and bone healing

BACKGROUND

Similar to the re-appreciation of high tibial osteotomy (HTO), supracondylar distal femur varus osteotomy (SCO) for lateral compartment osteoarthritis (OA) of the knee has gained renewed interest as new knowledge has become available on the influence of malalignment on the development, progression and symptoms of OA. Furthermore, the less than optimal results of knee replacements (TKR) in younger patients have also led to renewed interest in joint-preserving treatment options.

PURPOSE

Varus SCO has not had the same success or widespread use as valgus HTO. The goal in SCO is similar to HTO, to shift the load from the diseased to the healthy compartment, in order to reduce pain, improve function and delay placement of a TKR. Valgus OA however occurs much less frequently than varus OA and varus SCO is considered a technically more demanding procedure. In the past the surgical techniques for SCO were mainly dependent on difficult-to-use implants making the procedure more complex. Complication rates related to the failure of fixation up to 16% have been reported.

DISUSSION

The new biplane osteotomy technique fixated with a locking compression plate is very stable; bone healing potential is optimal using this technique and takes 6-8 weeks. Full weight bearing before full bone healing is possible without loss of correction.

CONCLUSION

In this article, patient selection, planning, surgical techniques, stability of fixation, and bone healing are discussed. Varus supracondylar osteotomy is a viable treatment option for a well-defined patient group suffering from valgus malalignment and lateral compartment osteoarthritis, and in addition may be considered in ligamentous imbalance and lateral patellofemoral maltracking.

Varization open-wedge osteotomy of the distal femur: comparison between locking plate and angle blade plate constructs

PURPOSE

Biomechanical properties of locking plate and angle blade plate constructs in opening-wedge distal femur osteotomy were compared, with special attention to the impact of opposite cortex breakage and buttressing.

METHODS

Forty-eight synthetic femora underwent a lateral opening-wedge distal femur osteotomy, which was fixed either with a locking plate or with an angle blade plate. Two main groups were constituted based on the integrity of the opposite medial cortex-intact medial cortex and fractured medial cortex (FMC). Axial compression and torsion tests were performed comparing stiffness of all bone-implant constructs. In the group FMC, a special subgroup has been tested taking into consideration the effect of placing an additional 6.5-mm cancellous screw buttressing the medial cortex. Statistical level of significance was fixed in 0.05 using a confidence interval of 95 %.

RESULTS

Intact medial cortex significantly increased the stiffness for both implants tested in this study. In the FMC group, angle blade plate constructs reached higher stiffness mean values for both torsion and axial compression. The insertion of a buttressing screw on the medial cortex increased the stiffness of all tested bone-plate constructs. This additional screw favoured mostly locking plate constructs implementing their stiffness to torsion to mean values comparable to those reached by angle blade plate constructs.

CONCLUSIONS

Angle blade plate constructs reached higher stiffness mean values than locking plates for both axial compression and torsion loads. The addition of a buttressing screw on the opposite cortex increased the stability of all bone-implant constructs to levels similar to those showed with an intact medial cortex. The present study findings support the clinical use of angle blade plates, alone or associated with a medial buttressing screw, as an alternative fixation method for supracondylar open-wedge osteotomies of the femur.

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years

BACKGROUND

Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship.

QUESTIONS/PURPOSES

(1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy?

METHODS

Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2 years (mean, 5 years; SD, 2; range, 2-12 years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution's osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded.

RESULTS

Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of ± 3° from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5 years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group.

CONCLUSIONS

Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of ± 3° from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Osteotomy for treating knee osteoarthritis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Distal femoral osteotomy

Osteotomies around the knee are well-recognized treatments for unloading the affected compartment in cases of lower limb malalignment. There are few papers in the literature describing the outcomes of distal femoral osteotomy (DFO), as compared with the studies reporting on high tibial osteotomy (HTO), probably because valgus malalignment is less common than the varus one. There is still debate as to what the correct indication is and which surgical techniques lead to the best outcomes in performing a DFO. Besides, it is still controversial whether patellofemoral arthritis should be considered as a contraindication to performing a DFO, as well as in HTO. In this article, we will summarize the indications for DFO, the surgical techniques reported in the literature, and their outcomes.

Computer-assisted osteotomy for valgus knees: medium-term results of 29 cases

INTRODUCTION

Computer-assisted surgery has been shown to be beneficial for correcting misaligned lower limbs. The purpose of this study was to analyze the medium-term results of computer-assisted osteotomy for 29 valgus knees. The hypothesis was that computer navigation would allow a valgus deformity to be corrected with similar precision as varus deformity.

MATERIAL AND METHODS

The series consisted of 27 patients (29 knees); there were 7 men and 20 women with ages ranging from 15 to 63 years (mean: 42.4±14.3 years). Twenty-four varus osteotomies of the femur (14 medial closing and 10 lateral opening) and five double osteotomies (proximal tibia and distal femur) were performed. The pre-operative functional status was evaluated with the Lysholm-Tegner score. The mean score was 64±20.5 points (range: 18-100). According to Ahlbäck's modified classification for knee osteoarthritis, 12 patients were at stage 1, nine were at stage 2, five at stage 3 and one at stage 4. Two of the knees had no radiological signs of osteoarthritis but had a particularly unsightly deformity; one of these was secondary to high tibial valgus osteotomy. The mean pre-operative hip-knee-angle (HKA) angle was 189.3±3.9°; the mean mechanical medial distal femoral angle (mMDFA) was 97.2±2.6° and mechanical medial proximal tibial angle (mMPTA) was 90.1±2.8°. The goal was to achieve an HKA angle of 179±2° and mMPTA of 90±2° to avoid an oblique joint line. Functional outcomes were evaluated with the Lysholm-Tegner, KOOS and IKS scores.

RESULTS

No complications other than a transient paralysis of the common fibular nerve were observed. Twenty-three patients (25 knees) were reviewed at a mean follow-up of 50.9±38.8 months (range: 6-144). The mean Lysholm-Tegner score was 92.9±4 points (86-100), the mean KOOS was 89.7±9.3 (range: 68-100), the mean IKS "knee" score was 88.7±11.4 points (range: 60-100) and the "function" score was 90.6±13.3 points (range: 55-100). Twenty-two patients were satisfied or very satisfied. The mean HKA angle was 180.1±1.9°, the mean mMDFA 90.7±2.5° and the mean mMPTA 89.1±1.9°. The pre-operative goal was achieved in 86.2% of cases (25/29) for the HKA angle and 100% of cases of the mMPTA angle. At the follow-up, none of the knees had been revised with a prosthesis.

CONCLUSION

Computer-assisted osteotomy for cases of osteoarthritis secondary to valgus knee leads to excellent medium-term results. Navigation provides reliable and accurate deformity correction.

LEVEL OF EVIDENCE

IV. Retrospective study.

Physical activity after distal femur osteotomy for the treatment of lateral compartment knee osteoarthritis

PURPOSE

Distal femoral osteotomy (DFO) is the preferential treatment for the symptomatic osteoarthritis of the lateral compartment of the knee in young active patients. The objective of this study is to evaluate the physical activity and functional outcome of a group of patients presenting with lateral compartment osteoarthritis of the knee prior to and after a DFO for correction of genum valgum.

METHODS

Twenty-six patients who had been submitted to complete V-shaped distal femoral osteotomy were evaluated after a mean follow-up period of 48 months by interview and questionnaire. Functional and physical activities were scored according to published rating systems.

RESULTS

Twenty-two (84.6 %) patients were very satisfied or satisfied (mean satisfaction 2) with the outcome of surgery and 88.5 % of the patients had normal work duties after surgery without limitation or decline in performance. The preoperative median level for physical activity according to the Tegner activity level was 3(2-7), while the median postoperative level was 3 (1-7) (n.s.) 57.7 % had resumed physical activities at preoperative levels: some patients had increased the number and type of exercises. According to Lysholm score, the mean preoperative score for physical performance was 53.1 ± 16.2 while the mean postoperative score had increased to 77.3 ± 16.7 (p < 0.05).

CONCLUSION

Based on this study, distal femoral osteotomy allowed the resumption of physical activities for individuals with symptomatic osteoarthritis of the lateral compartment of the knee, resulting in improvements in clinical conditions and, consequently, in their daily working and recreational activities.

Surgical options for articular defects of the knee

Cartilage and osteochondral defects of the knee can in most cases be treated with total knee replacement in the elderly population. However, these lesions pose a difficult treatment problem in the younger patient. A number of surgical options are available today to address this increasingly common condition and each has its own indications and limitations. This article reviews debridement and microfracture, fixation, metallic spacing devices, autologous chondrocyte implantation, osteochondral autograft transplantation, fresh cadaveric allografts and osteotomies. In addition, possible future developments are discussed.

Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee

INTRODUCTION

Osteotomy aims to reduce pain and the rate of progression of arthritis by correcting deformity and offloading the affected compartment. This study reports the results of a case series of opening wedge distal femoral varus osteotomies for valgus lateral osteoarthritis of the knee.

PATIENTS AND METHODS

Eighteen patients underwent osteotomy surgery (21 knees) with the aim of correcting the mechanical axis to 48-50% from medial to lateral.

RESULTS

The mean follow-up for the study population was 4.5 years (range 1.6 to 9.2 years). Four patients underwent conversion to arthroplasty at a mean time of 3.3 years postosteotomy. Kaplan-Meier analysis demonstrates a cumulative survival of 79% at 5 years. In the remaining 17 osteotomies, all patients reported that outcome measures improved from baseline. However, only the IKDC and pain subdomain of KOOS showed a statistically significant and clinically relevant difference. Re-operation for non-arthroplasty related surgery was common. In part this was due to symptoms related to prominence of metalwork (10). Other reasons included non-union (1), loss of correction (2), infection (1), and persistent symptoms (2).

CONCLUSION

Cumulative survival of opening wedge DFVO is comparable with that reported in closing wedge series. Clinically relevant differences in the IKDC and KOOS pain scores suggest that opening wedge DFVO is a useful option in the management of valgus gonarthrosis. However, DFVO is a technically demanding procedure and re-operation, particularly for removal of metalwork, is common.

Lateral compartment osteoarthritis of the knee

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Cite this article: Bone Joint J 2013;95-B:436–44.

Opening wedge distal femoral varus osteotomy using the Puddu plate and calcium phosphate bone cement

PURPOSE

The goal of this study was to document the outcome at midterm follow-up of 19 patients treated for lateral osteoarthritis of the knee between 1999 and 2007. It was our hypothesis that the results and complication rate would be comparable to or better than those reported in the literature for closing wedge or alternative open wedge techniques.

METHODS

All patients underwent an open wedge distal femoral varisation osteotomy using the Puddu plate system combined with calcium phosphate injection into the defect. Knee Society Knee Score and Kellgren-Lawrence osteoarthritis score were assessed preoperatively and at final follow-up.

RESULTS

The average knee score improved significantly from 43 ± 8 preoperatively to 78 ± 23 at final follow-up. The Kellgren-Lawrence osteoarthritis score remained unchanged. Kaplan-Meier analysis using revision surgery or conversion to TKA as an endpoint demonstrated an 82% successful survivorship at 7 years of follow-up.

CONCLUSION

Based upon these results, we believe that a distal femoral varisation osteotomy using the Puddu plate and injectable bone cement is an equivalent treatment option compared to closing wedge techniques and leading to good results at midterm follow-up in patients with lateral gonarthrosis and valgus alignment.

LEVEL OF EVIDENCE

IV.

The results of corrective osteotomy for valgus arthritic knees

PURPOSE

To evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity.

METHODS

The data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications.

RESULTS

A total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence.

CONCLUSION

The role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates.

LEVEL OF EVIDENCE

IV.