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Wake JL, Chung B, Bottoni CR, Zhou L. Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature. J Knee Surg 2024; 37:693-701. [PMID: 35798349 DOI: 10.1055/s-0042-1750750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.
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Affiliation(s)
- Jeffrey L Wake
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Tripler AMC, Hawaii
| | - Brandon Chung
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Tripler AMC, Hawaii
| | - Craig R Bottoni
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Tripler AMC, Hawaii
| | - Liang Zhou
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Tripler AMC, Hawaii
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Ismailidis P, Schmid C, Werner J, Nüesch C, Mündermann A, Pagenstert G, Egloff C. Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome. Arch Orthop Trauma Surg 2023; 143:6147-6157. [PMID: 37278744 PMCID: PMC10491530 DOI: 10.1007/s00402-023-04923-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/21/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications. METHODS Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications. RESULTS The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal. CONCLUSION DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.
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Affiliation(s)
- Petros Ismailidis
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
| | - Corinna Schmid
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Julika Werner
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Department of Spine Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Department of Spine Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Geert Pagenstert
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Knee Institute Basel, Clarahof, Clinic of Orthopaedic Surgery, Clarahofweg 19a, 4058, Basel, Switzerland
| | - Christian Egloff
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
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Lee S, Brown JR, Bartolomei C, Turnbull T, Miles JW, Dornan GJ, Frank RM, Vidal AF. Effects of Lateral Opening-Wedge Distal Femoral Osteotomy on Meniscal Allograft Transplantation: A Biomechanical Evaluation. Orthop J Sports Med 2023; 11:23259671231156639. [PMID: 37347021 PMCID: PMC10280523 DOI: 10.1177/23259671231156639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/08/2022] [Indexed: 06/23/2023] Open
Abstract
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.
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Affiliation(s)
- Simon Lee
- Steadman Philippon Research Institute,
Vail, Colorado, USA
| | | | | | | | - Jon W. Miles
- Steadman Philippon Research Institute,
Vail, Colorado, USA
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Fujita K, Sawaguchi T, Goshima K, Shigemoto K, Iwai S. Influence of lateral hinge fractures on biplanar medial closing-wedge distal femoral osteotomy for valgus knee: a new classification of lateral hinge fracture. Arch Orthop Trauma Surg 2023; 143:1175-1183. [PMID: 34655322 DOI: 10.1007/s00402-021-04212-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose of this study was to examine the influence of lateral hinge fractures in medial closing-wedge distal femoral osteotomy (MCWDFO) on bone union. METHODS Twenty-one patients were followed-up for more than 1 year after MCWDFO. The incidence and type of hinge fracture, as well as the course of bone healing, were investigated. Slow healing was defined as bone union was not obtained until 3 months after surgery. RESULTS Hinge fractures were observed in 12 cases (57%). There were three types of hinge fractures. Type 1: the lateral cortex was completely cut through (4 cases), type 2: the osteotomy line was too proximal (6 cases), and type 3: the hinge point was significantly medial (2 cases). There was a significant difference in the mean correction angles between hinge fracture and no-fracture cases, with the mean angles being 13.8 ± 4.0° and 9.6 ± 3.1°, respectively. Sixty-seven percent (8/12) of cases with hinge fractures developed slow healing. Among the hinge fracture cases, when there was no displacement of the hinge fracture and good contact with the anterior flange, 40% (2/5) of cases developed slow healing. If there was displacement of the hinge or no contact of the anterior flange, 86% (6/7) of cases developed slow healing. In contrast, only 11% (1/9) of subjects who did not have a hinge fracture, developed slow healing. In 67% (6/9) of cases with slow healing, a correction loss of 2° or greater (average: 4.3 degrees valgus) was observed. There were no cases of non-union. Clinical outcomes at 1 year showed no significant difference between the groups with and without hinge fractures. CONCLUSIONS There is a very high risk of hinge fracture in patients undergoing MCWDFO. Hinge fractures often lead to slow healing and a loss of correction. We recommend the endpoint of the distal lateral cortex of the femur as the ideal hinge point for the prevention of hinge fractures. Bone union is obtained slowly in even all hinge fracture cases without revision surgery. Consequently, surgical results are not affected by the occurrence of hinge fracture at 1 year.
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Affiliation(s)
- Kenji Fujita
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1 Imaizumi Hokubu-machi, Toyama, 939-8511, Japan. .,Department of Orthopedic Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 920-8530, Japan.
| | - Takeshi Sawaguchi
- Department of Traumatology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, 960-1295, Japan.,Trauma Reconstruction Center, Shinyurigaoka General Hospital, 255 Furusawa Asao-ku, Kawasaki, Kanazawa, 215-0026, Japan
| | - Kenichi Goshima
- Department of Orthopedic Surgery, Kanazawa Munehiro Hospital, 24-30 Sakura-machi, Kanazawa, Ishikawa, 920-0923, Japan
| | - Kenji Shigemoto
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1 Imaizumi Hokubu-machi, Toyama, 939-8511, Japan
| | - Shintaro Iwai
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1 Imaizumi Hokubu-machi, Toyama, 939-8511, Japan
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Diaz CC, Lavoie-Gagne OZ, Knapik DM, Korrapati A, Chahla J, Forsythe B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med 2023; 51:798-811. [PMID: 35156408 DOI: 10.1177/03635465211051740] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Jorge Chahla
- Midwest Orthopaedics at Rush Chicago, Illinois, USA
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Nha KW, Han JH, Chae SW, Choi JY. Effect of Medial Closing Wedge Distal Femoral Varization Osteotomy on Coronal Ankle and Hindfoot Alignment. Foot Ankle Int 2023; 44:330-339. [PMID: 36825582 DOI: 10.1177/10711007231154208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND To date, only a few studies have reported postoperative changes in coronal ankle alignment after valgus knee correction through medial closing wedge distal femoral varization osteotomy (MCWDFO). This study aimed to measure the changes of MCWDFO on coronal ankle and hindfoot alignment. METHODS We retrospectively reviewed the radiographic findings of 27 consecutive patients (34 cases) with knee valgus malalignment who underwent MCWDFO for either lateral knee joint osteoarthritis (OA) or recurrent patellar subluxation/dislocation (RPD). Several radiographic parameters were measured and compared based on the reason for operation, followed by the status of preoperative hindfoot alignment (hindfoot alignment angle [HAA] > 4 degrees, varus; -4 degrees ≤HAA ≤ 4 degrees, neutral; HAA < -4 degrees, valgus) in each group. RESULTS Overall, pre- and postoperative hindfoot alignments were within the neutral alignment range and were not significantly changed after the operation (P > .05). Nineteen cases were for lateral knee OA and 15 were for RPD, respectively. In both groups, preoperative neutral hindfoot alignments accounted for the largest portion (52.6% in the lateral OA group; 80.0% in the RPD group). Postoperatively, regardless of the reason for operation, hindfoot alignments changed toward the neutral range in all subgroups (ie, no changes in the preoperative neutral group; increased in the valgus group; decreased in the varus group). CONCLUSION We recommend that surgeons leave the hindfoot untouched when they plan the MCWDFO to correct knee joint valgus malalignment concomitant with hindfoot valgus or varus deviation as the hindfoot malalignment appears to change toward the neutral range postoperatively. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Kyung Wook Nha
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jae Hwi Han
- Department of Orthopedic Surgery, Daegu Fatima Hospital
| | - Su Whi Chae
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
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Koiwa S, Tsunoda T, Madachi A, Murashima R. Single-Stage Total Knee Arthroplasty and Open-Wedge Distal Femoral Osteotomy for Osteoarthritis with Femoral Shortening and Extra-Articular Varus Deformity: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00067. [PMID: 36947647 DOI: 10.2106/jbjs.cc.22.00601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
CASE A 76-year-old female patient with a history of pyogenic arthritis of the right knee in childhood presented with severe osteoarthritis of the right knee with 24-mm femoral shortening and severe extra-articular femoral varus deformity. She received single-stage total knee arthroplasty (TKA) combined with a medial open-wedge distal femoral osteotomy and achieved good postoperative clinical and radiological results. CONCLUSION This case illustrated that extra-articular open-wedge distal femoral osteotomy and TKA performed simultaneously may be efficacious for severe extra-articular deformities with femoral shortening.
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Affiliation(s)
- Sora Koiwa
- Department of Orthopedics, Asama General Hospital, Saku City, Nagano, Japan
- Department of Orthopedics and Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Honkomagome, Bunkyo-ku, Tokyo, Japan
| | - Toshiharu Tsunoda
- Department of Orthopedics, Asama General Hospital, Saku City, Nagano, Japan
| | - Atsushi Madachi
- Department of Orthopedics, Asama General Hospital, Saku City, Nagano, Japan
| | - Ryutaro Murashima
- Department of Orthopedics, Asama General Hospital, Saku City, Nagano, Japan
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刘 云, 谢 雪, 罗 从. [Research progress of osteotomy around knee in the treatment of valgus knee osteoarthritis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:111-116. [PMID: 35038808 PMCID: PMC8844620 DOI: 10.7507/1002-1892.202108009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/01/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To review the research progress of surgical methods of osteotomy around the knee in the treatment of valgus knee osteoarthritis. METHODS The relevant literature on the surgical treatment of valgus knee osteoarthritis at home and abroad in recent years was reviewed, and the advantages, disadvantages, and effectiveness of different surgical methods of osteotomy around the knee were summarized. RESULTS For young and active patients with symptomatic valgus knee osteoarthritis, osteotomy around the knee is a safe and reliable treatment option. At present, the main surgical methods include medial closing wedge distal femoral osteotomy, lateral opening wedge distal femoral osteotomy, medial closing wedge high tibial osteotomy, and lateral opening wedge high tibial osteotomy. The indications, advantages, and disadvantages of different osteotomies are different, and the selection of appropriate surgical method is the key to achieve good effectiveness. CONCLUSION There are many osteotomies in the treatment of valgus knee osteoarthritis. In order to achieve good results, improve survival rate, and reduce postoperative complications, the most reasonable surgical strategy needs to be developed according to different situations.
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Affiliation(s)
- 云飞 刘
- 南京医科大学附属苏州科技城医院骨科(江苏苏州 215000)Department of Orthopedics, the Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou Jiangsu, 215000, P. R. China
| | - 雪涛 谢
- 南京医科大学附属苏州科技城医院骨科(江苏苏州 215000)Department of Orthopedics, the Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou Jiangsu, 215000, P. R. China
| | - 从风 罗
- 南京医科大学附属苏州科技城医院骨科(江苏苏州 215000)Department of Orthopedics, the Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou Jiangsu, 215000, P. R. China
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Osteotomies for lateral compartment knee osteoarthritis. J Clin Orthop Trauma 2021; 25:101726. [PMID: 34956830 PMCID: PMC8671116 DOI: 10.1016/j.jcot.2021.101726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Zheng L, Luo D, Li J, Ye H, Han Z, Feng R, Zhong Q, Jing J, Yao Y. Pathological changes and expression of lysine oxidases and matrix metalloproteinases -1, -2, and -3 in ligaments of patients with haemophilic arthritis. Haemophilia 2021; 28:145-150. [PMID: 34697874 DOI: 10.1111/hae.14443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/17/2021] [Accepted: 10/12/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Studying the pathological changes of ligaments in patients with haemophilic arthritis (HA) has important significance for guiding the release of ligaments during total knee arthroplasty (TKA) and exploring interventions to prevent ligament lesions. AIM This study was conducted to show the pathological changes and investigate the lysine oxidase (LOX) and matrix metalloproteinase (MMP)-1, -2, and -3 levels in the ligaments of patients with HA compared with those of patients with osteoarthritis (OA). METHODS Ligaments obtained during the TKA were stained with Masson trichrome, Verhoeff-Van Gieson and haematoxylin and eosin to show the basic pathological changes. Collagen I, elastin, LOXs and MMP-1, -2, and -3 expression levels were detected via western blot. LOX and MMP-1, -2, and -3 mRNA expression levels were analysed via quantitative real-time PCR. RESULTS Compared with OA ligaments, HA ligaments were constructed more loosely with wider gaps, more breaks, haemocytodeposition and local hypertrophy among the fibres. LOXs and MMP mRNA expression levels were upregulated in the HA tissues, which was consistent with the western blot results. Collagen I and elastin levels were also higher in patients with HA. CONCLUSIONS The metabolism of the ligaments in patients with HA is more complex than in those with OA, and the ligaments of patients with HA have stronger healing and destruction processes. This pathology is related to iron overload and imbalanced inflammatory factors due to repeated intra-articular bleeding.
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Affiliation(s)
- Liujie Zheng
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Dasheng Luo
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jiale Li
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Houlong Ye
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Zhiwei Han
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ru Feng
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Qigang Zhong
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Juehua Jing
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yunfeng Yao
- Department of Orthopaedic Surgery, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
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Patient-Specific Instrument Guided Double Chevron-Cut Distal Femur Osteotomy. J Pers Med 2021; 11:jpm11100959. [PMID: 34683100 PMCID: PMC8538705 DOI: 10.3390/jpm11100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Uboldi FM, Travi M, Tradati D, Maione A, Manunta AF, Berruto M. Medial closure supracondylar femoral osteotomy: an effective solution for long-term treatment of arthritic valgus knee? J Orthop Traumatol 2021; 22:35. [PMID: 34524550 PMCID: PMC8443729 DOI: 10.1186/s10195-021-00600-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Francesco Mattia Uboldi
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Università Degli Studi Di Milano, P.zza A. Ferrari 1, 20122, Milan, Italy. .,ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, U.O.C. Ortopedia e Traumatologia Pediatrica, P.zza A. Ferrari 1, 20122, Milan, Italy.
| | - Martino Travi
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Università Degli Studi Di Milano, P.zza A. Ferrari 1, 20122, Milan, Italy
| | - Daniele Tradati
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Università Degli Studi Di Milano, P.zza A. Ferrari 1, 20122, Milan, Italy
| | - Alessio Maione
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Università Degli Studi Di Milano, P.zza A. Ferrari 1, 20122, Milan, Italy
| | - Andrea Fabio Manunta
- Università Degli Studi Di Sassari, AOU Sassari, V.le San Pietro 43b, 07100, Sassari, Italy
| | - Massimo Berruto
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Università Degli Studi Di Milano, P.zza A. Ferrari 1, 20122, Milan, Italy
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Savov P, Hold M, Petri M, Horstmann H, von Falck C, Ettinger M. CT based PSI blocks for osteotomies around the knee provide accurate results when intraoperative imaging is used. J Exp Orthop 2021; 8:47. [PMID: 34176009 PMCID: PMC8236017 DOI: 10.1186/s40634-021-00357-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose Correction osteotomies around the knee are common methods for the treatment of varus or valgus malalignment of the lower extremity. In recent years, patient specific instrumentation (PSI) guides were introduced in order to enhance the accuracy of these procedures. The purpose of this study was to determine the accuracy of CT based PSI guides for correction osteotomies around the knee of low volume osteotomy surgeons and to evaluate if CT based PSI blocks deliver a high degree of accuracy without using intraoperative fluoroscopy. Methods Two study arms with CT based PSI cutting blocks for osteotomies around the knee were conducted. Part one: A retrospective analysis of 19 osteotomies was made in order to evaluate the accuracy in the hands of a low volume surgeon on long-leg radiographs. Part two: A cadaveric study with 8 knees was performed for the purpose of analyzing the accuracy without using intraoperative fluoroscopy on pre- and postoperative CT scans. Hip-Knee-Ankle angle (HKA), lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were analyzed. The mean absolute delta (∂) between the planned and postoperative parameters were calculated. The accuracy of both study arms were compared. Results Part one: The mean MPTA ∂, LDFA ∂ and HKA ∂ was 0.9°, 1.9° and 1.5°, respectively. Part two: The mean MPTA ∂ and LDFA ∂ was 3.5° and 2.2°, respectively. The mean ∂ of MPTA is significantly different between clinical patients with fluoroscopic control and cadaveric specimens without fluoroscopic control (P < 0.001). All surgeries were performed without complications such as a hinge fracture. Conclusion The clinical use of PSI guides for osteotomies around the knee in the hands of low volume surgeons is a safe procedure. The PSI guides deliver a reliable accuracy under fluoroscopic control whereas their non-use of intraoperative fluoroscopy leads to a lack of accuracy. The use of fluoroscopic control during PSI guided correction osteotomies is highly recommended. Level of evidence IV – Retrospective and experimental Study
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Affiliation(s)
- Peter Savov
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany.
| | - Mara Hold
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Maximilian Petri
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Hauke Horstmann
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Christian von Falck
- Institute for Radiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Max Ettinger
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
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Batty L, Getgood A. Combined Biplanar Medial Closing-Wedge Distal Femoral Osteotomy and Quadriceps Tendon Medial Patellofemoral Ligament Reconstruction. Arthrosc Tech 2021; 10:e1685-e1694. [PMID: 34354913 PMCID: PMC8322471 DOI: 10.1016/j.eats.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/09/2021] [Indexed: 02/03/2023] Open
Abstract
Lateral patellofemoral instability is multifactorial in etiology, with bony and soft-tissue factors contributing. Coronal plane alignment, in particular genu valgum, is important to consider when evaluating lateral patellofemoral instability. When genu valgum is present and thought to be a significant contributing factor, we typically address this with an extra-articular, biplanar, medial closing-wedge distal femoral osteotomy (DFO). This can be combined with a medial patellofemoral ligament reconstruction using a partial-thickness quadriceps tendon graft via the same incision. A medial closing-wedge DFO with locking plate fixation affords a highly stable construct suitable for early weight-bearing. The locking plate is less prominent as compared with a lateral opening-wedge DFO, and it does not irritate the iliotibial band or cause tightening of the illiopatellar expansion. The biplanar nature of the osteotomy prevents extension of the osteotomy into the proximal trochlear, helps to control rotation in both axial and sagittal plane after wedge removal, and increases the bony surface area for healing. The quadriceps tendon medial patellofemoral ligament reconstruction allows a graft that can be tailored in terms of length and diameter, does not require an anchor on the patellar, and can be performed through the same incision as for the DFO.
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Affiliation(s)
- Lachlan Batty
- St. Vincent’s Hospital, Epworth HealthCare, Western Health Melbourne, Victoria, Australia
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada,Address correspondence to Dr. Alan Getgood, M.Phil., M.D., F.R.C.S.(Tr.&Orth.), Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, N6A 3K7 Canada.
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Ten-year survival rate of 89% after distal femoral osteotomy surgery for lateral compartment osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 2021; 29:594-599. [PMID: 32285155 DOI: 10.1007/s00167-020-05988-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to assess the accuracy, safety, and survival of distal femoral osteotomy (DFO) surgery for lateral compartment OA of the knee. METHODS A retrospective cohort study was conducted at a single UK centre, using prospectively collected data over an 8-year period (2009-2017). All patients had pre-operative radiographic analysis and digital planning of their deformity correction in addition to post-operative analysis of the achieved correction and yearly face-to-face follow-up. Complications (defined as an undesirable medical or surgical event as a direct result of the operation), reoperations, and failure (defined as conversion to arthroplasty or revision) were recorded. RESULTS From a total of 83 patients, 81 patients undergoing 86 primary DFOs were included in this study, with a mean follow-up of 99 months (SD 27 months). The mean pre-operative percentage Mikulicz point was 78.7% (SD 19.1%) and post-operative 35.9% (SD 14.8%). The mean accuracy of correction (intended correction - achieved correction) was an 8.2% overcorrection (SD 13.7%). The complication rate was 4.7%. Using Kaplan-Meier analysis, the mean survival was 113 months (95% CI 106-120) with the probability of surviving 10 years 89%. CONCLUSION DFO for valgus alignment and lateral compartment arthritis is associated with low complications, long-term joint preservation, and the prevention of arthroplasty surgery. However, the accuracy of correction still requires improvement in intra-operative technique. LEVEL OF EVIDENCE IV.
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Puzzitiello RN, Liu JN, Garcia GH, Redondo ML, Forlenza EM, Agarwalla A, Yanke AB, Cole BJ. Return to Work After Distal Femoral Varus Osteotomy. Orthop J Sports Med 2020; 8:2325967120965966. [PMID: 33330734 PMCID: PMC7720305 DOI: 10.1177/2325967120965966] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/11/2020] [Indexed: 02/05/2023] Open
Abstract
Background Distal femoral varus osteotomy (DFVO) is a well-described procedure to address valgus deformity of the knee. There is a paucity of information available regarding patients' ability to return to work (RTW) after DFVO. Purpose To report the objective findings for RTW rates and times for patients receiving a DFVO for lateral compartment osteoarthritis secondary to valgus deformity of the knee. Study Design Cohort study; Level of evidence, 3. Methods This was a retrospective study of patients who received a lateral-wedge opening DFVO. Patients must have worked within 3 years before their operation to be included for analysis. Patients were contacted at a minimum of 2 years postoperatively for interview and questionnaire evaluation, including a subjective work questionnaire, visual analog scale (VAS) for pain, Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire. Results Overall, 32 patients were contacted at a mean follow-up of 7.1 ± 4.1 years (range, 2.2-13.3 years). The mean ± SD age at the time of surgery was 30.8 ± 8.8 years (range, 17.2-46.5 years), and 65.6% of patients were female. Eleven patients (34.4%) received a concomitant meniscal allograft transplant, and 12 (37.5%) received a cartilage grafting procedure. The average VAS pain score decreased significantly from 6.1 preoperatively to 3.2 postoperatively (P = .03). All patients were able to RTW, at a mean time of 6.0 ± 13.2 months postoperatively (range, 0-72 months). When stratified by work intensity, the average time to return was 13.8, 3.1, 2.7, and 2.9 months for high, moderate, light, and sedentary occupations, respectively. There was no significant difference between these RTW times (P = .16), although this analysis may have been limited by the small sample size. Four patients whose work was classified as heavy work (50%) and 3 whose work was classified as moderate work (18.8%) either switched jobs or kept the same job with lighter physical duties as a result of their procedures. Conclusion In a young and active population, DFVO for valgus deformity reliably afforded the ability to RTW within a relatively short time for patients with sedentary, light, and moderate occupational demands. However, patients with moderate- to high-intensity occupational demands may be unable to RTW at their preoperative level.
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Affiliation(s)
- Richard N Puzzitiello
- Department of Orthopedic Surgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Joseph N Liu
- Department of Orthopedic Surgery, Loma Linda Medical Center, Loma Linda, California, USA
| | | | - Michael L Redondo
- Department of Orthopedic Surgery, University of Illinois Medical Center, Chicago, Illinois, USA
| | - Enrico M Forlenza
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Avinesh Agarwalla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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Ekeland A, Nerhus TK, Dimmen S, Heir S. Better functional results of opening wedge HTO for varus knees with medial osteoarthritis than opening wedge LFO for valgus knees with lateral osteoarthritis. Bone Jt Open 2020; 1:346-354. [PMID: 33215123 PMCID: PMC7659673 DOI: 10.1302/2633-1462.17.bjo-2020-0081.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 11/05/2022] Open
Abstract
Aims To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee. Methods In all, 49 patients (52 knees) with a mean age of 47 years (31 to 64) underwent high tibial osteotomies (HTO), and 24 patients with a mean age of 48 years (31 to 62) low femoral osteotomies (LFO) with opening wedge technique due to medial, respectively lateral knee OA with malalignment. All osteotomies were stabilized with a Puddu plate and bone grafting performed in the same time period (2000 to 2008). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) pre-operatively and at six months, and at one, two, five, and ten years postoperatively. The knee OA was graded according to the Ahlbäck and Kellgren-Lawrence radiological scoring systems. Results The mean angular corrections were 8.0° (4° to 12°) for the HTO and 9.6° (4° to 20°) for the LFO. Both the pre-operative KOOS and the osteoarthritic gradings were similar for the two patient groups. The five subscores of KOOS increased significantly during the postoperative period (p < 0.001 to 0.029) levelling out after one year in both groups. The KOOS subscore symptoms was significantly higher for patients with HTO than those with LFO at all follow-up times, for sport and recreation in the period one to five years, and for pain and quality of life at two to five years (p < 0.001 to 0.009). Eight HTOs (15%) and five LFOs (21%) were converted to total knee arthroplasty after mean 6.7 years (2.0 to 9.8) and 5.4 years (4.0 to 8.0) respectively. The ten-year osteotomy survival rates were 88% for the HTO and 79% for the LFO (p = 0.745). Conclusion Patients with unicompartmental knee OA improved after a corrective opening wedge osteotomy, but four of the five subscores of KOOS were significantly higher for those with medial than those with lateral OA in most of the ten-year follow-up period. Cite this article: Bone Joint Open 2020;1-7:346–354.
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Affiliation(s)
| | | | | | - Stig Heir
- Martina Hansens Hospital, Sandvika, Norway
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Kim SC, Kim JS, Yoo HJ, Kim TW, Lee YS. Factors affecting the disparity between preoperative planning and postoperative correction status in distal femoral osteotomy. Knee 2020; 27:1608-1617. [PMID: 33010780 DOI: 10.1016/j.knee.2020.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/09/2020] [Accepted: 08/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purposes of this study were to evaluate whether the planning method using the contralateral limb status is reasonable and to determine the disparity between the preoperative planning and actual postoperative correction status by analyzing lateral cortical hinge fractures (LCHFs) in patients who underwent distal femoral osteotomy (DFO). METHODS From 2014 to 2018, 31 cases undergoing DFO were evaluated. The patients were divided into two groups according to two preoperative planning methods. The disparity between the preoperative planning and the postoperative weight-bearing line (WBL) ratio and clinical scores were compared. Analysis was performed to determine the causes of the disparity by evaluating the osteotomy configuration, including that of LCHFs. RESULTS The disparity was observed in the WBL ratio assessment (P < 0.01). In the comparison between two groups, no statistically significant differences were found in the change of WBL ratio (P = 0.78) and postoperative clinical scores. The length of the osteotomy gap was only related to the disparity (R2 = 0.22, P = 0.01), while no statistical significance was found for the regression equation of the displaced LCHF (P > 0.05). The length of the remaining bone between the osteotomy end and opposite cortex was significantly associated with the presence of LCHF (odds ratio, 3.904). CONCLUSIONS The planning method using a contralateral limb status showed similar results to the classical method, but the two methods produced disparity when the degree of correction was increased. LCHF was mostly related to the remaining bone in the medial closing-wedge DFO.
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Affiliation(s)
- Seong Chan Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Joo Sung Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Hyun Jin Yoo
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, South Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea.
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Mayfield CK, Bolia IK, Mayer EN, Heidari KS, Heckmann N, Pannell WC, Hill JR, McKnight B, Vangsness CT, Hatch GF, Weber AE. Factors Associated With Distal Femoral Osteotomy Survivorship: Data From the California Office of Statewide Health Planning and Development (OSHPD) Registry. Orthop J Sports Med 2020; 8:2325967120951554. [PMID: 33029543 PMCID: PMC7522844 DOI: 10.1177/2325967120951554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/22/2022] Open
Abstract
Background: Malalignment of the lower extremity can lead to early functional impairment and degenerative changes. Distal femoral osteotomy (DFO) can be performed with arthroscopic surgery to correct lower extremity malalignment while addressing intra-articular abnormalities or to help patients with knee osteoarthritis (OA) changes due to alignment deformities. Purpose: To examine survivorship after DFO and identify the predictors for failure. Study Design: Case series; Level of evidence, 4. Methods: Data from the California Office of Statewide Health Planning and Development, a statewide discharge database, were utilized to identify patients between the ages of 18 and 40 years who underwent DFO from 2000 to 2014. Patients with a history of lower extremity trauma, infectious arthritis, rheumatological disease, skeletal dysplasia, congenital deformities, malignancy, or concurrent arthroplasty were excluded. Failure was defined as conversion to total or unicompartmental knee arthroplasty, and the identified cohort was stratified based on whether they went on to fail. Age, sex, race, diagnoses, concurrent procedures, and comorbidities were recorded for each admission. Statistically significant differences between patients who required arthroplasty and those who did not were identified using the Student t test for continuous variables and a chi-square test for categorical variables. Kaplan-Meier survivorship curves were constructed to estimate 5- and 10-year survival rates. A Cox proportional hazards model was used to analyze the risk for conversion to arthroplasty. Results: A total of 420 procedures were included for analysis. Overall, 53 knees were converted to arthroplasty. The mean follow-up time was 4.8 years (range, 0.0-14.7 years). The 5-year survivorship was 90.2% (range, 85.7%-93.4%), and the 10-year survivorship was 73.2% (range, 64.7%-79.9%). The mean time to failure was 5.9 years (range, 0.4-13.9 years). Survivorship significantly decreased with increasing age (P = .004). Hypertension and a primary diagnosis of osteoarthrosis were significant risk factors for conversion to arthroplasty (odds ratio [OR], 3.12 [95% CI, 1.38-7.03]; P = .006, and OR, 2.42 [95% CI, 1.02-5.77]; P = .045, respectively), along with a primary diagnosis of traumatic arthropathy (OR, 10.19 [95% CI, 1.71-60.65]; P = .01) and a comorbid diagnosis of asthma (OR, 2.88 [95% CI, 1.23-6.78]; P = .02). Patients with Medicaid were less likely (OR, 0.11 [95% CI, 0.01-0.88]; P = .04) to undergo arthroplasty compared with patients with private insurance, while patients with workers’ compensation were 3.1 times more likely (OR, 3.08 [95% CI, 1.21-7.82]; P = .02). Conclusion: Older age was an independent risk factor for conversion to arthroplasty after DFO in patients ≥18 years but ≤60 years. Hypertension, asthma, and a diagnosis of osteoarthrosis or traumatic arthropathy at the time of surgery were predictors associated with failure, reinforcing the need for careful patient selection. The high survivorship rate of DFO in this analysis supports this procedure as a reasonable alternative to arthroplasty in younger patients with valgus deformities about the knee and symptomatic unicompartmental OA.
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Affiliation(s)
- Cory K Mayfield
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, California, USA
| | - Keemia Soraya Heidari
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Nathanael Heckmann
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, California, USA
| | - William C Pannell
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Jeffrey Ryan Hill
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Braden McKnight
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - C Thomas Vangsness
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - George F Hatch
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, California, USA
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Luceri F, Tamini J, Ferrua P, Ricci D, Batailler C, Lustig S, Servien E, Randelli PS, Peretti GM. Total knee arthroplasty after distal femoral osteotomy: a systematic review and current concepts. SICOT J 2020; 6:35. [PMID: 32880573 PMCID: PMC7469917 DOI: 10.1051/sicotj/2020033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/12/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Distal Femoral Osteotomy (DFO) is a common procedure for correcting lower limb valgus deformity and lateral compartment overload. Low 20-year survivorship rate was reported with a consequent need for total knee arthroplasty (TKA). This study aims to review literature and to analyse the influence of a previous distal femoral osteotomy on outcomes of patients undergoing TKA. METHODS A systematic literature review was performed in PubMed/Medline and Embase in May 2020. Papers were selected based on the following criteria: patient with a previous distal femoral osteotomy; total knee replacement; Pre- and Postoperative outcomes; surgical outcomes: clinical scores, range of motion, radiographic evaluation and revisions for any cause; case series, retrospective studies, observational studies, open-label studies, randomized clinical trials; systematic reviews and meta-analyses were included to extract primitive studies. RESULTS 306 articles were found, of which five papers were considered eligible for this review. In every study included, postoperative clinical outcomes (Knee Society Score or Hospital for Special Surgery score) statistically improved from the preoperative. Complications were not uncommon; implant survivorship at the available follow-up seems to be similar to primary TKA, although being too short to draw any conclusions. CONCLUSIONS Limited and highly heterogeneous evidence is currently available on the influence of DFO on outcomes after TKA. Knee replacement improves clinical middle-term outcomes in patients with previous distal femoral osteotomy. In this complex surgery, the use of technical tips and tricks could help surgeons to obtain an accurate knee balancing and better long-term results.
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Affiliation(s)
- Francesco Luceri
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy - FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, 103 Boulevard de la Croix Rousse, 69004 Lyon, France
| | - Jacopo Tamini
- Humanitas Clinical and Research Center - IRCCS, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Paolo Ferrua
- Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Damiano Ricci
- Humanitas Clinical and Research Center - IRCCS, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Cécile Batailler
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, 103 Boulevard de la Croix Rousse, 69004 Lyon, France
| | - Sébastien Lustig
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, 103 Boulevard de la Croix Rousse, 69004 Lyon, France - LBMC UMR T 9406, Laboratory of Chock Mechanics and Biomechanics, Claude Bernard Lyon 1 University, Lyon, France
| | - Elvire Servien
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, 103 Boulevard de la Croix Rousse, 69004 Lyon, France - LIBM, EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
| | - Pietro Simone Randelli
- U.O.C. 1a Divisione, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy - Laboratorio di Biomeccanica Applicata, Dipartimento di Scienze Biomediche per la Salute, University of Milan, Via Mangiagalli 31, 20133 Milan, Italy
| | - Giuseppe Maria Peretti
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy - Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Petersen W, Bierke S, Häner M. Kniegelenknahe Osteotomie bei unikompartimenteller Gonarthrose. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00378-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ogawa H, Matsumoto K, Akiyama H. Effects of lateral opening wedge and medial closing wedge distal femoral osteotomies on axial load stability. Knee 2020; 27:760-766. [PMID: 32563434 DOI: 10.1016/j.knee.2020.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/27/2020] [Accepted: 04/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The stability of the current distal femoral osteotomy is insufficient for early weight bearing and bone healing. The purpose of this study was to test the stability of medial closing wedge- (MCW-) and lateral opening wedge-distal femoral osteotomies (LOW-DFO), which have improved with the recent advances in technology. METHODS We used composite bone models with MCW-DFO, improved with biplanar osteotomy technique and a Tomofix™ MDF plate, or LOW-DFO improved with biplanar osteotomy technique, a Tomofix™ LDF plate, and a β-TCP bone substitute, BONISH® graft. A cyclic axial loading test was employed to evaluate the strain on a plate and hinge point. The breaking axial load was measured. RESULTS Tensile strain on the plate produced by cyclic axial loading was significantly lower for LOW-DFO (2.0 ± 0.8 MPa) than for MCW-DFO (3.9 ± 1.6 MPa, P < .05). Compressive strain on the hinge point produced by cyclic axial loading was lower for LOW-DFO (6.6 ± 2.9 MPa) than for MCW-DFO (7.7 ± 4.6 MPa,). The maximum breaking axial load was significantly higher for LOW-DFO (5511 ± 945 N) than for MCW-DFO (4303 ± 518 N, P < .05). CONCLUSIONS LOW-DFO improved with recent advanced technology was superior to MCW-DFO improved with advanced technology in both cyclic axial loading test and breaking axial load test. This suggests that LOW-DFO facilitates earlier weight bearing and bone healing than does MCW-DFO.
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Affiliation(s)
- Hiroyasu Ogawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan; Department of Advanced Joint Reconstructive Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazu Matsumoto
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan.
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Efficacy and Safety of Functional Medial Ligament Balancing With Stepwise Multiple Needle Puncturing in Varus Total Knee Arthroplasty. J Arthroplasty 2020; 35:380-387. [PMID: 31587980 DOI: 10.1016/j.arth.2019.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/13/2019] [Accepted: 09/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aims of this study were to (1) describe our functional stepwise multiple needle puncturing (MNP) technique as the final step in medial ligament balancing during total knee arthroplasty (TKA) and (2) evaluate whether this technique can provide sufficient medial release with safety. METHODS A total of 137 patients with 212 consecutive knees who underwent TKAs with or without functional stepwise MNP of superficial medial collateral ligament was recruited in this prospective cohort. Eighty-one patients with 129 knees who performed serial stress radiographs were enrolled in the final assessment. Superficial medial collateral ligament was punctured selectively (anteriorly or posteriorly or both) and sequentially depending on the site and degree of tightness. Mediolateral stability was assessed using serial stress radiographs and comparison was performed between the MNP and the non-MNP groups at postoperative 6 months and 1 year. Clinical outcomes were also evaluated between 2 groups. RESULTS Fifty-five TKAs required additional stepwise MNP (anterior needling 19, posterior needling 3, both anterior and posterior needling 33). Preoperative hip-knee-ankle angle and the difference in varus-valgus stress angle showed significant difference between the MNP and the non-MNP groups, respectively (P = .009, P = .037). However, there was no significant difference when comparing the varus-valgus stress angle between the MNP and the non-MNP groups during serial assessment. Clinical outcomes including range of motion also showed no significant differences between the 2 groups. CONCLUSION Functional medial ligament balancing with stepwise MNP can provide sufficient medial release with safety in TKA with varus aligned knee without clinical deterioration or complication such as instability. LEVEL OF EVIDENCE Level II, Prospective cohort study.
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Puzzitiello RN, Liu JN, Garcia GH, Redondo ML, Christian DR, Yanke AB, Cole BJ. Return to Sport and Outcomes After Concomitant Lateral Meniscal Allograft Transplant and Distal Femoral Varus Osteotomy. Arthroscopy 2020; 36:253-260. [PMID: 31864586 DOI: 10.1016/j.arthro.2019.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/06/2019] [Accepted: 07/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the time and rate of return to sport (RTS), as well as outcomes, in young and active patients receiving concomitant lateral meniscal allograft transplantation (MAT) and distal femoral varus osteotomy (DFVO) for lateral meniscal deficiency and valgus malalignment. METHODS This was a retrospective study of consecutive patients who underwent concomitant MAT and DFVO by a single surgeon. The exclusion criteria were any concomitant procedures other than cartilage restoration procedures for focal full-thickness cartilage defects of the lateral femoral condyle and less than 2 years of follow-up. At final follow-up, patients were asked to complete a subjective sports questionnaire, the Marx Activity Rating Scale, a visual analog scale (VAS), the Single Assessment Numeric Evaluation, and a satisfaction questionnaire. Changes in patient-reported outcome measures were assessed using nonparametric statistical testing. RESULTS A total of 21 patients met the inclusion criteria, of whom 17 were included for analysis at an average follow-up of 7.5 years (range, 2.2-13.3 years). The average age at the time of surgery was 23.3 years (range, 16.9-36.2 years), and 76.5% of patients were female patients. The average VAS score decreased from 5.7 preoperatively to 2.6 postoperatively (P = .02). Of the 15 patients who participated in sports within 3 years prior to their surgical procedure, 14 (82.4%) returned to 1 or more sports at an average of 16.9 months (range, 6-36 months); however, only 46.7% were able to return to their preinjury level of participation or higher. Furthermore, 88.2% of patients reported being satisfied with their sport-related outcomes. Direct rates of sport-specific return were as follows: weightlifting, 100%; skiing, 100%; running, 66.7%; and basketball, 50%. CONCLUSIONS In our study population, concomitant MAT and DFVO afforded a high rate of RTS at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores. These findings are essential to note when counseling patients receiving these procedures who wish to resume sports and physical activities so that they may expect an extensive recovery process before they can RTS. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Joseph N Liu
- Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Grant H Garcia
- Orthopedic Specialists of Seattle, Seattle, California, U.S.A
| | | | | | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Rush University Medical Center, Chicago, Illinois, U.S.A..
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Song JS, Hong KT, Kim NM, Jung JY, Park HS, Chun YS, Kim SJ. 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. Knee 2019; 26:1445-1450. [PMID: 31443940 DOI: 10.1016/j.knee.2019.07.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 07/03/2019] [Accepted: 07/30/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jun-Seob Song
- Department of Orthopaedic Surgery, Gangnam JS Hospital, Seoul, Republic of Korea
| | - Ki-Taek Hong
- Department of Orthopaedic Surgery, Gangnam JS Hospital, Seoul, Republic of Korea
| | - Na-Min Kim
- Department of Orthopaedic Surgery, Gangnam JS Hospital, Seoul, Republic of Korea
| | - Jae-Yub Jung
- Department of Orthopaedic Surgery, Gangnam JS Hospital, Seoul, Republic of Korea
| | - Han-Soo Park
- Department of Orthopaedic Surgery, Gangnam JS Hospital, Seoul, Republic of Korea
| | - You Seung Chun
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Jung Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Kim TW, Lee MC, Cho JH, Kim JS, Lee YS. The Ideal Location of the Lateral Hinge in Medial Closing Wedge Osteotomy of the Distal Femur: Analysis of Soft Tissue Coverage and Bone Density. Am J Sports Med 2019; 47:2945-2951. [PMID: 31465238 DOI: 10.1177/0363546519869325] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although an appropriate hinge position to prevent unstable lateral hinge fractures is well established in medial opening wedge high tibial osteotomy, the position during medial closing wedge distal femoral osteotomy has not been elucidated. PURPOSE/HYPOTHESIS The purpose was to evaluate the ideal hinge position that would prevent an unstable lateral hinge fracture during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density around the hinge area. The hypothesis was that the ideal hinge position could be clarified by analyzing soft tissue coverage and bone density around the lateral hinge area. STUDY DESIGN Controlled laboratory study. METHODS In 20 cadaveric knees (mean age, 70.3 ± 19.2 years), the femoral attachment of the gastrocnemius lateral head was quantitatively analyzed as a soft tissue stabilizer using digital photography and fluoroscopy. Then, medial closing wedge distal femoral osteotomy was performed, locating the lateral hinge either inside (group 1) or outside (group 2) the femoral attachment of the gastrocnemius lateral head, and the incidence of unstable lateral hinge fractures was compared between the 2 groups. Cortical bone density around the lateral hinge was measured using Hounsfield units on 30 computed tomography scans and reconstructed as a 3-dimensional mapping model. The transitional zone with low bone density was regarded as the safe hinge position with an increased capacity for bone deformation. RESULTS The upper and lower margins of the femoral attachment of the gastrocnemius lateral head were 9.1 ± 0.9 mm above and 8.0 ± 1.4 mm below the upper border of the lateral femoral condyle, respectively, and the femoral attachment of the gastrocnemius lateral head was widest in the anteroposterior dimension 0.4 ± 1.7 mm above the upper border of the lateral femoral condyle. The incidence of unstable lateral hinge fractures during osteotomy was significantly decreased in group 1 compared with group 2 (group 1: 0/10; group 2: 5/10; P = .01). An isolated transitional zone with low bone density was observed in all 30 knees and located 1.3 ± 0.8 mm above the upper border of the lateral femoral condyle. Bone density of the transitional zone with low bone density was significantly lower than surrounding femoral cortices (P < .001). CONCLUSION Only the upper border of the lateral femoral condyle can be recommended as an ideal hinge position to prevent unstable lateral hinge fractures during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density. CLINICAL RELEVANCE When the hinge is positioned at the upper border of the lateral femoral condyle during biplanar medial closing wedge distal femoral osteotomy, the risk of unstable hinge fractures can be minimized.
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Affiliation(s)
- Tae Woo Kim
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Ho Cho
- Department of Orthopaedic Surgery, Hallym University Medical Center, Chuncheon, Republic of Korea
| | - Jong Seop Kim
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Pietsch M, Hochegger M, Winkler M, Sandriesser S, Freude T, Augat P. Opening-wedge osteotomies of the distal femur: minor advantages for a biplanar compared to a uniplanar technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2375-2384. [PMID: 30547307 DOI: 10.1007/s00167-018-5332-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/07/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Valgus malalignment of the distal femur may be treated with corrective osteotomy. The purpose of this study was to compare the primary stability of a lateral opening-wedge osteotomy (LOWO) using a uniplanar compared to a biplanar technique. A study was carried out to test both surgeries, with both an intact medial cortex and with a deliberate attached cut of the medial cortex simulating a fracture. The primary hypothesis was that the biplanar technique provides higher axial and torsional stiffness. It was further hypothesized that the mechanical superiority of the biplanar technique would not be affected in the case of breakage of the far medial cortex. METHODS A LOWO was performed in ten synthetic femora (#3406 left large Femur, 4th Generation, Sawbones, Malmö, Sweden) using a lateral angle stable locking plate (NCB© Distal Femur Plate, Zimmer Biomet, Warsaw, USA). A uniplanar osteotomy was performed in five femora, and a biplanar osteotomy was performed in five femora. The femora were tested for axial and torsional loads using a servo-hydraulic testing machine (Instron 8874, Instron Structural Testing GmbH, High Wycombe, UK). RESULTS Axial stiffness decreased significantly (p = 0.001) in both groups (20% in the uniplanar group and 28 % in the biplanar group) by cutting the medial cortex. The type of osteotomy had no significant effect. A slightly lower but not statistically significant axial stiffness was seen in the biplanar group both for intact and broken medial cortices. Internal torsional stiffness dropped by more than 30% for the uniplanar group and almost 24% for the biplanar group when the cortex was cut (p < 0.001). No significant change concerning internal torsional stiffness was found between the two groups. External torsional stiffness decreased by 32% for the uniplanar group and 4% for the biplanar group after the cortical cut (p = 0.029). No significant change concerning external torsional stiffness was found between the groups, but the biplanar group showed a tendency towards higher values of external torsional stiffness. CONCLUSIONS The axial and torsional stiffness of the implant-bone construct were not significantly affected by the type of osteotomy performed. Biplanar osteotomy tended to increase external torsional stiffness. In cases of fracture of the medial cortex, biplanar osteotomy significantly reduced the external rotation at the osteotomy and showed a significantly increased external torsional stiffness.
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Affiliation(s)
- Martin Pietsch
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria.
| | - Markus Hochegger
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria
| | - Martin Winkler
- Institute of Biomechanics, Trauma Center Murnau, Prof.-Kuentscher-Straße 8, 82418, Murnau, Germany
| | - Sabrina Sandriesser
- Institute of Biomechanics, Trauma Center Murnau, Prof.-Kuentscher-Straße 8, 82418, Murnau, Germany
| | - Thomas Freude
- Department of Orthopaedic and Trauma Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Peter Augat
- Institute of Biomechanics, Paracelsus Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria
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Pilone C, Rosso F, Cottino U, Rossi R, Bonasia DE. Lateral Opening Wedge Distal Femoral Osteotomy for Lateral Compartment Arthrosis/Overload. Clin Sports Med 2019; 38:351-359. [PMID: 31079767 DOI: 10.1016/j.csm.2019.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Distal femoral osteotomy (DFO) is a valid option for the treatment of young and active patients with lateral compartment osteoarthritis/overload and valgus malalignment. DFOs can be performed with a closing wedge or opening wedge technique. Lateral opening wedge DFO is usually preferred for smaller corrections, whereas medial closing wedge for larger corrections and in patients with high risk of nonunion. This article describes the relevant aspects regarding lateral opening wedge DFO, including patient selection, preoperative planning, surgical technique, results, and complications.
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Affiliation(s)
- Carola Pilone
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, Torino 10128, Italy
| | - Federica Rosso
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, Torino 10128, Italy
| | - Umberto Cottino
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, Torino 10128, Italy
| | - Roberto Rossi
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, Torino 10128, Italy
| | - Davide Edoardo Bonasia
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, Torino 10128, Italy.
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Cha MS, Song SY, Jung KH, Seo YJ. Distal Femoral Medial Opening Wedge Osteotomy for Post-Traumatic, Distal Femoral Varus Deformity. Knee Surg Relat Res 2019; 31:61-66. [PMID: 30871294 PMCID: PMC6425889 DOI: 10.5792/ksrr.18.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022] Open
Abstract
Restoration of neutral mechanical alignment of the lower limb is an important factor in the treatment of unicompartmental arthrosis. Traditionally, medial opening wedge high tibial osteotomy has been widely performed to correct varus malalignment with unicompartmental arthrosis. However, an ideal indication for the high tibial osteotomy is the knee with metaphyseal tibial varus malalignment. The basic principle of corrective osteotomy is performing an osteotomy at the center of the deformity to prevent abnormal joint line obliquity. If pathologic distal femoral varus deformity is the cause of genu varum, the osteotomy should be performed in the distal femur. Reports of medial opening wedge distal femoral osteotomy (DFO) to correct varus malalignment are rare. We present a case of this very rare and challenging condition in a 47-year-old male, which was successfully treated by medial opening wedge DFO.
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Affiliation(s)
- Myoung-Soo Cha
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Si-Young Song
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Koo-Hyun Jung
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Young-Jin Seo
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
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Distal femoral varus osteotomy: results of the lateral open-wedge technique without bone grafting. INTERNATIONAL ORTHOPAEDICS 2018; 43:2315-2322. [PMID: 30426177 PMCID: PMC6787112 DOI: 10.1007/s00264-018-4216-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/29/2018] [Indexed: 11/09/2022]
Abstract
Background The lateral opening wedge distal femoral osteotomy (LOWDFO) to reconstruct knee alignment in patients with genu valgum originating in the distal femur has gained importance within the last years. Purpose To analyze clinical and radiographic outcome of patients treated with LOWDFO with respect to bone healing without grafting and patient age. Material and methods Twenty-two consecutive patients with genu valgum corrected with 23 LOWDFOs using a Tomofix-locking plate were retrospectively analyzed (mean age 23.7 years). Clinical evaluation was based on pre- and post-operative KOOS scores. A pre- and post-operative radiographic assessment, including MAD, mLDFA, LLD, bone healing, and patella parameters, was performed. Differences between subgroups (age, bone grafting) were analyzed. Results The restoration of MAD and mLDFA resulted in significantly improved post-operative KOOS5 scores in younger and older patients (p = 0.001). Bone healing without bone grafting was reliable in all patients. The leg length was significantly increased post-operatively (p = 0.001). The Blackburne-Peel ratio was significantly reduced to more normal values post-operatively (p < 0.001). Conclusion LOWDFO without bone grafting is a reliable procedure representing a promising treatment option particularly in young patients with genu valgum. Besides correction of the MAD, a significant leg length increase and additional patella stability can be expected.
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31
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Nha KW, Ha Y, Oh S, Nikumbha VP, Kwon SK, Shin WJ, Lee BH, Hong KB. Surgical Treatment With Closing-Wedge Distal Femoral Osteotomy for Recurrent Patellar Dislocation With Genu Valgum. Am J Sports Med 2018; 46:1632-1640. [PMID: 29688749 DOI: 10.1177/0363546518765479] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Closing-wedge distal femoral osteotomy (CWDFO)-combined with medial reefing and lateral release, if necessary- has been used to treat recurrent patellar dislocation (RPD) with genu valgum. PURPOSE To evaluate the clinical and radiologic outcomes of surgical treatment with CWDFO for treatment of RPD with genu valgum. STUDY DESIGN Case series; Level of evidence, 4. METHODS Fourteen consecutive patients (23 knees) with RPD and genu valgum were treated with CWDFO. Patients with a minimum 2-year follow-up period were eligible for this study. Patients with prior failed surgery were also eligible. Radiographic evaluation was performed with mechanical femorotibial and lateral distal femoral angle. The radiographic parameters presenting patellar positions and pathologic abnormalities associated with RPD were evaluated. Chondral lesion changes in second-look arthroscopic examination were examined, and clinical outcomes (eg, occurrence of redislocation, range of motion, and clinical scores) were assessed pre- and postoperatively at a minimum of 2 years. RESULTS At a mean follow-up of 30.7 months (range, 25-62 months), the mean mechanical femorotibial and mechanical lateral distal femoral angles changed significantly from valgus 5° (range, 2°-11°) to varus 3° (2°-11°; P < .001) and from 83° (range, 78°-86°) to 89° (84°-92°; P < .001), respectively. The mean patellar congruence angle improved from 40° lateral (range, 20°-53° lateral) to 4° medial (23° medial to 21° lateral; P < .001), as did the lateral patellofemoral angle from 26° (range, 8°-62°) to 9° (0°-15°; P < .001). Computed tomography scans showed that the mean distance of patellar lateral shift decreased from 13.5 mm (range, 4-22 mm) to 2.0 mm (-4 to 5 mm; P < .001). The mean tibial tubercle to trochlear groove distance significantly decreased from 20.4 to 13.5 mm ( P < .001), while the Caton-Deschamps ratio did not change significantly after surgery ( P = .984). Chondral lesions of the patella and trochlear groove significantly improved or were maintained. None of the patients experienced subluxation or redislocation after surgery. Patellar instability symptoms also improved, as validated by radiographic and other clinical outcomes. CONCLUSION CWDFO combined with medial reefing and lateral release successfully treated RPD with genu valgum for a minimum follow-up of 2 years, with improved patellar alignment and stability.
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Affiliation(s)
- Kyung Wook Nha
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Ilsanseo-gu, Goyang, Republic of Korea
| | - Yoonwon Ha
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Ilsanseo-gu, Goyang, Republic of Korea
| | - Seungmin Oh
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Ilsanseo-gu, Goyang, Republic of Korea
| | - Vivek P Nikumbha
- Department of Orthopedic Surgery, Mumbai Port Trust Hospital, Mumbai, India
| | - Sae Kwang Kwon
- Department of Orthopedic Surgery, Yonsei Sarang Hospital, Bucheon, Republic of Korea
| | - Woo-Jin Shin
- Department of Orthopedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical School, Seoul, Republic of Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical School, Seoul, Republic of Korea
| | - Keun Bae Hong
- Kang-Dong Sacred Heart Hospital, Hallym University Medical School, Seoul, Republic of Korea
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