Closing-Wedge and Opening-Wedge High Tibial Osteotomy as Successful Treatments of ‎Symptomatic Medial Osteoarthritis of the Knee: A Randomized Controlled Trial

Objectives

Closing-wedge high tibial osteotomy (CWHTO) and opening-wedge high tibial osteotomy (OWHTO) are commonly used osteotomy techniques for the symptomatic knee osteoarthritis treatment. However, there is no consensus on which method provides superior outcomes. In this study, we compared the clinical outcomes, radiologic outcomes, and postoperative complications of these techniques.

Methods

In a randomized controlled trial, 76 patients with medial compartment knee osteoarthritis and associated varus ‎malalignment were randomized into the CWHTO and OWHTO groups (n=38). The primary outcome measures were knee function evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and knee pain assessed by a visual analog scale. The secondary outcome measures were posterior tibial slope (PTS), tibial bone varus angle, and postoperative complications.

Results

Both techniques significantly improved the clinical and radiologic outcome measures. The mean improvement of total KOOS was not significantly different between the CWHTO and OPHTO groups (P=0.55). Moreover, the improvement in various KOOS subscales was not significantly different between the two groups. The mean improvement of Visual Analogue Scale (VAS) was not significantly different between the CWHTO and OWHTO groups (P=0.89). The mean PTS change was not significantly different between the two groups (P=0.34). The mean improvement of the varus angle was not significantly different between the two groups (P=0.28). The rate of postoperative complications was not remarkably different between the CWHTO and OWHTO groups.

Conclusion

Considering no observed superiority of each osteotomy technique over the other one, ‎two ‎techniques could be used interchangeably and based on the surgeon's‏ preference.

Less risk of conversion to total knee arthroplasty without significant clinical and survivorship difference for opening-wedge high tibial osteotomies in varus knee deformities at 10-year minimum follow-up compared to closing-wedge high tibial osteotomies

PURPOSE

The purpose of this study was to evaluate the clinical outcomes and survivorship at minimum 10-year follow-up of patients undergoing primary valgisation high tibial osteotomy (HTO) for medial osteoarthritis (OA), treated by Opening-Wedge HTO (OW-HTO) or Closing-Wedge HTO (CW-HTO).

METHODS

This was a retrospective cohort study of consecutive patients presenting to a single institution undergoing HTO for isolated medial compartment OA. Two hundred and twenty three HTOs for isolated medial tibio-femoral OA were performed between January 2002 and December 2010. Patients were eligible if they had minimum 10-year follow-up and received either a CW or OW-HTO. Fifteen (6.7%) patients died and twenty-five (11.2%) were lost to follow-up. One hundred and eighty three (82.1%) patients were included in the final analysis and divided into two groups: OW-HTO (96/183; 52.4%) and CW-HTO (87/183; 47.6%). Range of motion, KSS, KOOS scores, and conversion to TKA rate were analyzed between groups. Both groups were comparable regarding age, arthrosis stage, gender, ASA score and BMI at the time of HTO. Survival analysis was conducted with re-intervention for TKA as the end point.

RESULTS

At the time of HTO, mean age was 55 years ± 7.9 (27-73.9) with 72.7% of patients being male. The mean follow-up was 13.3 years ± 2.7 (10-19). Sixty-four (34.9%) patients underwent TKA at a mean delay of 9.3 years ± 3 (3-16). The conversion to TKA rate was significantly higher in the CW-HTO group versus the OW-HTO group: 42.5% (37/87) versus 28.1% (27/96) (p = 0.04). The survival at 15-year follow-up was 59.2% in the OW-HTO group versus 54.6% in the CW-HTO group (n.s.). At 13-year follow-up, KSS Function score was significantly better in the OW-HTO (90.9 versus 82.4; p = 0.007). No significant difference was observed between the two groups regarding the KOOS score, KSS Knee Score and complication rate.

CONCLUSION

At mean follow-up of 13 years, no significant clinical and survivorship difference was observed between the two groups. The conversion to TKA was significantly lower following OW-HTO. Minor correction was associated with risk of requiring subsequent TKA.

LEVEL OF EVIDENCE

Retrospective case series, IV.

Vascular injuries during closing-wedge high tibial osteotomy: A cadaveric angiographic study

INTRODUCTION

Closing-wedge high tibial osteotomy is a surgical option for patients with isolated medial compartment osteoarthritis and varus knee alignment. Vascular complications are rare, but incriminate the use of oscillating saw or osteotome. It is important to know the steps of this surgery that involve risk of vascular injury and what to do to decrease that risk.

HYPOTHESIS

Performing the distal osteotomy cut using an oscillating saw is a step with high risk of vascular injury. A protective device behind the tibia may decrease this risk.

MATERIALS AND METHODS

In this descriptive angiographic cadaver study, closing-wedge high tibial osteotomy was performed on 6 cadaveric knees in 90° knee flexion, and the distance between the surgical instrument and the popliteal artery was measured on fluoroscopy with artery opacification at the various steps of surgery.

RESULTS

Tibial osteotomy with oscillating saw involves high vascular risk: the mean distance between the saw-blade and the popliteal artery is 10.6mm in 90° knee flexion. Using a specific device placed behind the tibia protects the vascular structures.

DISCUSSION

High tibial osteotomy is indicated in medial compartment osteoarthritis of the knee and can be performed by closing or opening-wedge. Vascular injuries in closing-wedge osteotomy exist and it is recommended to perform this surgery at 90° knee flexion, although some studies report that this does not move the artery out of the way. A risk of vascular lesion should be kept in mind. The oscillation of the saw and the direction of the osteotomy should also be taken into consideration when performing a closing-wedge high tibial osteotomy in order to protect the popliteal artery.

STUDY DESIGN

Descriptive cadaver study. Level IV.

Complications of closing wedge high tibial osteotomies for unicompartmental osteoarthritis of the knee

We systematically reviewed the published literature on the complications of closing wedge high tibial osteotomy for the treatment of unicompartmental osteoarthritis of the knee. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled group clinical (CCTs) trials, case series in publications associated with closing wedge osteotomy of the tibia in patients with osteoarthritis of the knee and finally a Cochrane review. Many of these trials included comparative studies (opening wedge versus closing wedge) and there was heterogeneity in the studies that prevented pooling of the results.