Preliminary Evaluation of the Efficacy of Postoperative Early Weight-bearing Rehabilitation Protocol for Patients after Double-level Osteotomy

Consistent indications, targets and techniques for double-level osteotomy of the knee: a systematic review

PURPOSE

To systematically review and critically appraise the literature on double-level osteotomy (DLO) of the knee, and determine the indications, contraindications, targets and outcomes.

MATERIALS AND METHODS

A systematic literature search was performed on PubMed, Embase®, and Cochrane for studies that reported on DLO by any technique or approach, including indications, contraindications, and targets for DLO, as well as patient-reported outcome measures (pROMS) and radiographic angles.

RESULTS

Twelve eligible studies were found: 9 case series and 3 studies that compared DLO to high-tibial osteotomy (HTO). In all studies, DLO was performed by medial opening-wedge tibial osteotomy and lateral closing-wedge femoral osteotomy. Seven specified that DLO was performed if simple HTO would exceed thresholds of postoperative medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and/or predicted wedge size. The targets were 88°-95° for MPTA, 84°-89° for LDFA, and 0°-4° for hip-knee-ankle (HKA) angle. The 3 comparative studies reported lower MPTA after DLO (89.6°-92.5°) than after HTO (91.5°-98.3°). All 3 reported similar postoperative HKA after DLO (0.2°-4.4°) as HTO (0.4°-4.8°); only 2 compared postoperative LDFA, which was lower after DLO (85.4° and 84.9°) than HTO (88.7° and 88.8°). Two comparative studies reported postoperative overall KOOS which was slightly lower after DLO (351-403) than HTO (368-410); only 1 study reported separate items of the KOOS.

CONCLUSION

There was relative consistency between studies on the indications, targets and techniques for DLO. Furthermore, while the comparative studies reported similar preoperative MPTA, LDFA and HKA, the postoperative MPTA and LDFA were lower after DLO than after HTO, though both treatments achieved equivalent postoperative HKA.

LEVEL OF EVIDENCE

IV, systematic review.

Outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity. A systematic review

BACKGROUND

When correcting severe genu varus deformity, knee surgeons must choose between performing a single or double-level osteotomy. This systematic review aims to provide this equipoise with some clarity.

PATIENTS AND METHODS

We conducted this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Studies evaluating the effect of the double level osteotomy (DLO) or those comparing it to high tibial osteotomy (HTO) from all regions and written in any language were included.

RESULTS

Six studies were included in this systematic review. They were prepared and analysed using Review Manager V5.0 [Computer Program] (RevMan5). Performing DLO resulted in restoring patellar height, joint-line convergence angle (JLCA), and mMPTA to normal values. DLO was also more successful at avoiding joint line obliquity (JLO) in severe varus deformity when compared to HTO (P < 0.001). No significant difference was reported between the two cohorts regarding the mLPTA. DLO resulted in satisfactory short term KOOS and IKDC scores. The complication rate after DLO was 2.28%.

CONCLUSIONS

DLO showed a low complication rate and satisfactory short term KOOS and IKDAC scores. Randomised control trials with long term follow-up comparing the DLO and HTO are recommended.

Work intensity and quality of life can be restored following double-level osteotomy in varus knee osteoarthritis

PURPOSE

The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term.

METHODS

Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: -11.0 ± 3.0° (-6.0 to -17.0), age: 49.1 ± 9.5 (31-65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5-43) months).

RESULTS

The duration that the patients were unable to work was 12.2 ± 4.4 (6-20) weeks. The PCS improved from 32.1 ± 11.3 (14.5-53.3) preoperatively to 54.6 ± 8.5 (25.2-63.7) (p < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1-67.7) to 57.2 ± 3.1 (47.3-61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population (p < 0.001), whereas the preoperative MCS was similar between the two groups (n.s.). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0-5.0) to 4.0 (2.0-7.0) (p < 0.001).

CONCLUSION

Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO.

LEVEL OF EVIDENCE

Study type: therapeutic, IV.