Closing Wedge High Tibial Osteotomy Research Articles

Male Sex Is an Associated Factor for Delayed Bone Union Following Hybrid Closed-Wedge High Tibial Osteotomy

Background and Objectives: Although hybrid closed-wedge high tibial osteotomy (HTO) is an effective procedure for varus knee osteoarthritis, delayed bone union is a frequent occurrence. The rate of bone union and its associated factors remain unclear. This study aimed to investigate the detailed process of bone union in hybrid closed-wedge HTO using computed tomography (CT) and to examine factors associated with delayed bone union. Materials and Methods: We retrospectively reviewed 53 consecutive patients who underwent hybrid closed-wedge HTO. Cases with no bone union at any of five sites (anterior flange, posterior, lateral, hinge, and medial) on coronal and sagittal computed tomography at 3 months postoperatively were defined as delayed bone union. Regression analysis was performed with delayed bone union as the dependent variable and sex, age, height, body weight, body mass index, correction distance, smoking, and diabetes mellitus as independent variables. Results: Among 50 analyzed knees (mean age, 61.4 ± 7.8 years), 17 (34.0%) had delayed bone union at 3 months postoperatively and one knee had screw breakage. Sex was the only significant factor associated with delayed bone union (male: β = 2.1, p < 0.004). Conclusions: Delayed bone union (absence at 3 months after hybrid closed-wedge high tibial osteotomy) occurred in 34% of patients, and male sex was associated with delayed bone union.

Anterior Slope–Modifying Osteotomies Alter the Length Change Behavior of the Superficial Medial Collateral Ligament: A Biomechanical Study

Background: Increased tibial slope has been shown to lead to higher rates of anterior cruciate ligament graft failure. A slope-decreasing osteotomy can reduce in situ anterior cruciate ligament force and may mitigate this risk. However, how this procedure may affect the length change behavior of the medial ligamentous structures is unknown. Purpose/Hypothesis: The purpose of this study was to examine the effect of anterior slope–modifying osteotomies on the medial ligamentous structures. It was hypothesized that (1) decreasing the tibial slope would lead to shortening of the superficial medial collateral ligament (sMCL), (2) while the fibers of the posterior oblique ligament (POL) would be unaffected. Study Design: Descriptive laboratory study. Methods: Eight fresh-frozen cadaveric knee specimens underwent anatomic dissection to precisely identify the medial ligamentous structures. The knees were mounted in a custom-made kinematics rig with the quadriceps muscle and iliotibial tract loaded. An anterior slope–modifying osteotomy was performed and fixed using an external fixator, which allowed modification of the wedge height between −15 and +10 mm in 5-mm increments. Threads were mounted between pins positioned at the anterior, middle, and posterior parts of the tibial and femoral attachments of the sMCL and POL. For different tibial slope modifications, length changes between the tibiofemoral pin combinations were recorded using a rotary encoder as the knee was flexed between 0° and 120°. Results: All sMCL fiber regions shortened with slope reduction (P < .001) and lengthened with slope increase (P < .001), with the anterior sMCL fibers more affected than the posterior sMCL fibers. A 15-mm anterior closing-wedge high tibial osteotomy (ACWHTO) resulted in a 6.9% ± 3.0% decrease in the length of the anterior sMCL fibers compared with a 3.6% ± 2.3% decrease for the posterior sMCL fibers. A 10-mm anterior opening-wedge high tibial osteotomy (AOWHTO) increased anterior sMCL fiber length by 5.9% ± 2.3% and posterior sMCL fiber length by 1.6% ± 1.0%. The POL fibers were not significantly affected by a slope-modifying osteotomy. Conclusion: Tibial slope–modifying osteotomies changed the length change pattern of the sMCL such that an AOWHTO increased whereas an ACWHTO decreased the sMCL strain. This effect was most pronounced for the anterior fibers of the sMCL. The length change pattern of the POL remained unaffected by slope-modifying osteotomy. Clinical Relevance: Surgeons should be aware that anterior tibial slope–modifying osteotomies affect the biomechanics of the sMCL. After an extensive ACWHTO, patients may develop a medial or anteromedial instability, while an AOWHTO may overconstrain the medial compartment.

Lateral closing wedge high-tibial osteotomy is a long-lasting option for patients under the age of 55 with medial compartment osteoarthritis.

Assess the survival of the closing wedge high tibial osteotomy (CWHTO) with failure defined as progression to total knee arthroplasty (TKA) and perioperative complications. Patients undergoing CWHTO in a single centre were included in this study. The patient's demographics, operative data and patient-reported outcome measures were collected from the medical records. The outcomes assessed were progression to TKA, complications and patient-reported outcome measures. The Australian joint registry was used to assess which patients progressed to TKA. A binary logistics regression is used to determine if any of the collected factors increase the likelihood of conversion to arthroplasty. Survival analysis is conducted using a Kaplan-Meier survivorship analysis with failure defined as progression to TKA. Three hundred and fifty-four (244 males and 110 females) patients were included in the study. The average age of the group was 51 years with an average follow-up of 18 years. Patients under the age of 55 had a lower rate of progression to TKA. At 15 years, the rate of progression to TKA was 64% and 85% for those under the age of 55 and over 55, respectively. The complication rate was 6% without any peroneal nerve palsies. CWHTO is a good surgical option particularly when indicated in patients under the age of 55. Additionally, this technique results in a low overall complication rate with an absence of the often-feared complication of peroneal nerve palsy. Level III, Retrospective study.

Influence of Increased Joint Line Obliquity on Survivorship After Lateral Closing-Wedge High Tibial Osteotomy

Background: Although high tibial osteotomy (HTO) has emerged as a powerful intervention for treating symptomatic medial osteoarthritis and varus malalignment, it can result in an increase in knee joint line obliquity (KJLO) in the frontal plane. Limited current evidence hinders understanding of the effect of increased KJLO on HTO survivorship. Purpose: To investigate the influence of KJLO and other potential risk factors on the survivorship of lateral closing-wedge HTO. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with symptomatic medial knee osteoarthritis and varus malalignment treated with lateral closing-wedge HTO at a single hospital were screened with a minimum follow-up of 5 years. HTO survival rate was assessed using Kaplan-Meier survival analysis. The influence of postoperative increased KJLO (medial proximal tibial angle ≥95°), age (≥55 years), sex (female), preoperative malalignment (hip-knee-ankle angle ≥10° of varus), postoperative untargeted alignment (hip-knee-ankle angle <2° or >6° of valgus), and preoperative osteoarthritis severity (Kellgren-Lawrence grade ≥3) on survivorship of HTO was evaluated using Cox regression analysis. A failure of HTO was defined as a conversion to total knee arthroplasty (TKA). Results: A total of 410 patients (463 knees) were included, with a mean follow-up of 13.0 years (range, 5.0-18.1 years) and a mean survival time of 11.2 years (range, 1.2-18.1 years) for patients who reached the endpoint of TKA. HTO survival rates at 5, 10, and 15 years postoperatively were 91%, 78%, and 60%, respectively. Multivariate Cox regression analysis showed no significant difference in survivorship between patients with increased KJLO and those with acceptable KJLO (178 vs 285 knees; hazard ratio [HR], 0.8; 95% CI, 0.6-1.1; P = .148), with no significant between-group difference observed in the mean follow-up length (12.9 ± 3.0 years vs 13.1 ± 3.3 years; P = .105). Female sex (HR, 2.0; P < .001) and postoperative untargeted alignment (HR, 1.6; P = .003) were risk factors for a conversion to TKA. Conclusion: Increased postoperative KJLO (medial proximal tibial angle ≥95°) had no significant influence on the survivorship of lateral closing-wedge HTO. Men demonstrated superior survival outcomes compared with women, and it was important to achieve a targeted postoperative alignment (HKA 2°-6° of valgus) to ensure favorable HTO survivorship.

Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures.

Angular deformities of the tibia and femur lead to mechanical axis deviation (MAD) of the lower limb and malorientation of the joints adjacent to the deformity. The current study analyses the outcomes of using a medial closing wedge high tibial osteotomy (MCWHTO) for the management of genu valgum with high medial proximal tibial angle (MPTA), and combined MCWHTO with lateral opening-wedge distal femoral osteotomy (LOWDFO) in the setting of concomitant genu varum with low lateral distal femoral angle (LDFA). There were 18 high tibial osteotomy (HTO)-only and 13 combined HTO + distal femoral osteotomy (DFO) procedures performed. The primary radiographic outcome variables included postoperative MPTA and MAD (in mm). The accuracy of MAD correction was expressed as a percentage. The postoperative posterior proximal tibial angle (PPTA) and limb length discrepancy (LLD) were also measured as secondary radiographic outcome variables. The clinical outcome variables included intraoperative surgical complications (e.g., hinge fracture), all-causes for revision, union rate, time to union, and postoperative knee range of motion. Functional outcomes used included the LDSRS, PROMIS, and EuroQOL scores. The mean preoperative MPTA was 92.9° (SD = 1.81, range: 88-96). After surgical correction, the mean MPTA was 86.0° (SD = 1.80, range: 83-90) (p < 0.0001). The mean preoperative MAD was 32.5 mm (SD = 20.16, range: 10-77) lateral to the centre of the knee joint. The mean postoperative MAD was 2.44 mm medial to the centre of the joint (SD = 7.13, range: 13 medial - 15 lateral) (p < 0.0001). The mean change in MAD achieved through surgical correction was 38.16 mm (SD = 17.94, range: 13-77). The accuracy of MAD correction was 96.1% (SD = 0.06%, range: 81.25-100%). The time to unassisted WB was a mean of 75 days (SD = 44.5, range: 44-242).There was a single stable hinge fracture and one case of chronic regional pain syndrome diagnosed. There were no cases of non-union and no indications for revision surgery in any case. Medial closing wedge high tibial osteotomy is an effective surgical procedure for the management of genu valgum deformity. The MPTA, LDFA, and MAD can be accurately corrected without significantly altering PPTA or limb length. It may be combined with open lateral distal femoral osteotomy for cases with femoral and tibial contributions to deformity without significantly impacting clinical outcomes. Functional outcomes, specifically relating to self-image are significantly improved after the MCWHTO has been performed. Sheridan GA, Page BJ, Greenstein MD, et al. Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures. Strategies Trauma Limb Reconstr 2024;19(2):82-86.

Knee valgus deformity: indications and outcomes for a high tibial medial closing-wedge osteotomy

IntroductionTraditionally, knee valgus deformities have been corrected through distal femur osteotomies. The advances in preoperative planning allow surgeons to understand the leading site of deformity better and, therefore, propose corrections at the appropriate anatomical location. ObjectivesThe purpose of this evaluation is to present a case of a knee valgus deformity where most of the deformity resulted from the joint and the proximal tibia. A medial closing wedge tibial osteotomy corrected the proximal tibia deformity, while a fresh osteochondral allograft aimed to improve the surface of the lateral compartment of the knee, optimizing the joint lateral convergence angle. In addition, indications, outcomes and a scoping review of the literature for closing wedge high tibial osteotomy for knee valgus deformity is reviewed. MethodsA clinical case report example of a patient with knee valgus deformity requiring closing wedge high tibial osteotomy is presented. Detailed discussion of preoperative templating, planning and surgical completion is reviewed. A systematic review of previous studies and outcomes after closing wedge high tibial osteotomy was undertaken and summarized. ResultsThe case presented demonstrates an example of a valgus knee deformity with alignment correction vis a proximal tibial ostetomy. A review of and summary of previous case reports and outcomes studies for similar pathology demonstrates a high degree of success for this surgical approach. ConclusionsClosing wedge high tibial osteotomy is a viable treatment option for knee valgus deformity with an abnormal mechanical medial proximal tibial angle (mMPTA). A thorough evaluation of joint orientation angles is necessary to appropriately address limb deformity at the specific locations(s) of significant anatomic abnormality.

Poster 261: The Influence of Slope Reducing Osteotomy on Patella Height in Patients Undergoing Revision ACL Reconstruction: An Evaluation of a Tibial Tubercle-Sparing Anterior Closing-Wedge Osteotomy Technique

Objectives: The purpose of this study was to evaluate the effect of tibial tubercle-sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstructions (ACLR). Methods: Patients who underwent arthroscopic revision ACLR combined with retro-tibial tubercle anterior closing wedge high tibial osteotomy (ACW-HTO) from 01/01/2016 to 31/03/2021 were assessed for eligibility. Patellar height was measured on full weightbearing lateral x-rays according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal x-rays using the Femoral Patellar Height Index (FPHI). The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral x-rays. The delta (post-operative - preoperative) and the ratio (pre-operative / post-operative) of the three patellar height indices and PTS were calculated. Preoperative to postoperative patellar height were compared using independent t tests for each index. It was also investigated whether patients changed patellar height category (baja, norma, or alta). Results: Among 475 revision ACLR, 47 tibial tubercle-sparing ACW-HTOs were performed. No significant difference in patellar height was found between pre- and postoperative x-rays regardless of the index (ISI P = .1729, CDI P = .4034, FPHI P = .5130). Despite the lack of a statistically significant difference, 15 patients (31.9%) exhibited a post-operative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down a category) and 18 (38.3%) patients changed category according to the CDI (10 moved up a category, 8 moved down a category). Conclusions: Although a statistically significant difference between pre- and postoperative patella height was not observed, changes in patellar height category were common after tibial tubercle-sparing anterior closing-wedge high tibial osteotomy, in patients undergoing revision ACL reconstruction. The clinical impact of these changes is unknown and further study is needed to investigate whether they may result in patellofemoral symptoms.

Minimally Invasive Anterior Closing–wedge Osteotomy for Posterior Tibial Slope Correction: A Pilot Study

Introduction: The purpose of this study was to investigate the feasibility of performing a new minimally invasive technique for anterior closing–wedge high tibial osteotomy. Our hypothesis was that we would be able to successfully perform the minimally invasive osteotomy with consistent correction of the posterior tibial slope. Materials and Methods: Five lower limbs from cadaveric unidentified donors were obtained. Fluoroscopic imaging of the knee was obtained to determine the baseline tibial slope. A standard anterior closing–wedge osteotomy was planned to obtain the desired correction. The anterior bony segment was resected from the proximal tibia utilizing the Shannon burr under fluoroscopic guidance through a 2 cm medial incision. Fixation was completed with 2 staples positioned medial and lateral to the tibial tubercle. Results: The average posterior tibial slope of the 5 specimens was 8 degrees (SD: 2.3, range: 6 to 12). The average final posterior tibial was 1.8 degrees (SD: 2.1, range: −1 to 5). The average slope correction was 6.2 degrees (SD: 0.7, range: 5 to 7). Posterior tibial cortical fracture did not occur in any of the cases. Conclusions: Our novel minimally invasive anterior closing–wedge high tibial osteotomy technique resulted in a reproducible correction of posterior tibial slope in a cadaveric model. This is the first study to describe a minimally invasive technique for anterior closing–wedge high tibial osteotomy. Larger cadaveric studies including multiple surgeons across institutions are warranted to validate the described technique between providers. Level of Evidence: Level IV—Controlled laboratory study

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

Data are limited regarding the surgical technique or outcomes of double-level osteotomy (DLO) combining medial closing-wedge distal femoral osteotomy and medial closing-wedge high tibial osteotomy in patients with moderate-to-severe valgus deformity. To describe the surgical technique and assess the short-term outcomes and surgical accuracy of DLO in patients with a moderate or severe valgus deformity. It was hypothesized that this technique would result in good clinical outcomes with precise deformity correction. Case series; Level of evidence, 4. Eight patients (mean age, 44.2 ± 10.9 years) with a moderate or severe valgus knee treated with DLO (9 knees; mechanical tibiofemoral angle [mTFA], 10.3°± 3.5°) were included. The mean follow-up was 25.1 ± 11.1 months. Preoperative to postoperative changes in radiographic parameters (mTFA, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, joint line convergence angle) and clinical scores (Hospital for Special Surgery score, Oxford Knee Score, Lysholm score) were assessed. Surgical accuracy was calculated by subtracting the achieved postoperative correction from the preoperatively planned targeted correction. The mTFA changed significantly from 10.3°± 3.5° preoperatively to -1.8°± 3.4° postoperatively (P < .001); the mechanical lateral distal femoral angle and mechanical medial proximal tibial angle changed significantly by 5.1°± 2.7° and 5.9°± 2.2°, respectively (P < .001 for both); and the posterior distal femoral angle decreased significantly from 85.9°± 3.1° to 84.2°± 2.4° (P < .01). There was no significant difference between pre- and postoperative joint line convergence angles (3.3°± 2.3° to 2.6°± 2.1°). The accuracy of the correction was high: the mTFA achieved postoperatively differed from the mTFA planned preoperatively by a mean of 2.7°± 1.9° (range, 0.6°-6.6°). Significant pre- to postoperative improvement was seen for all outcome scores (Hospital for Special Surgery, from 67 ± 11 to 93 ± 4; Oxford Knee Score, from 29 ± 7 to 43 ± 3; Lysholm, from 41 ± 24 to 89 ± 8; P < .001 for all). High surgical accuracy was achieved, and patients who underwent varus DLO for valgus knees showed improved knee function at short-term follow-up. Varus DLO can be a surgical option to restore the optimal alignment and joint line obliquity in patients with moderate or severe valgus malalignment.

Difference in Correction Power between Hybrid Lateral Closed-Wedge High Tibial Osteotomy and Medial Open-Wedge High Tibial Osteotomy was Associated with Severity of Varus Deformity and Different Hinge Distance from Center of Deformity.

Hybrid lateral closed-wedge high tibial osteotomy (HBHTO) carries certain advantages over medial open-wedge high tibial osteotomy (OWHTO). We investigated the potential difference in the required correction angle between HBHTO and OWHTO to achieve an equal amount of whole lower-extremity alignment correction, retrospectively analyzing the preoperative plain radiographic images of 100 patients. The medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle axis (HKA), length of the tibia, width of the tibial plateau, length of the lower limb (leg length), and location of the center of deformity (CD) were measured. Differences in the required correction angle at the hinge point between the two techniques (CAD) were compared, and correlation analysis was performed to reveal the influential factors. The mean difference in CAD between HBHTO and OWHTO was 0.78 ± 0.22 (0.4~1.5)°, and mean WBL position change per correction angle was 3.9 ± 0.3 (3.0~4.6)% in HBHTO and 4.1 ± 0.3 (3.1~4.7)% in OWHTO. Correlation analysis revealed a strong positive correlation between CAD and HKA. mLDFA, JLCA, MPTA, leg length, OWCD, HBCD, and HCD were also significantly correlated with CAD. HBHTO required a 5.6% larger correction angle at the hinge point to achieve the same amount of alignment correction as OWHTO.

Total knee arthroplasty following lateral closing-wedge high tibial osteotomy versus primary total knee arthroplasty: a propensity score matching study

BackgroundThe disparity in patient-reported outcomes between total knee arthroplasty (TKA) following high tibial osteotomy (HTO) and primary TKA has yet to be fully comprehended. This study aims to compare the patient-reported outcomes, radiological parameters and complication rates between TKA following HTO and primary TKA.MethodsSixty-five patients who underwent TKA following lateral closing-wedge HTO were compared to a matched group of primary TKA at postoperative 6-months and 1-year. Between-group confounders of age, gender, smoking status, Body Mass index, preoperative Numeric Rating Scale (NRS) pain in rest, Knee injury and Osteoarthritis Outcome Score-Physical function Shortform (KOOS-PS), EuroQol five-dimensional (EQ-5D) overall health score, and Oxford Knee Score (OKS) were balanced by propensity score matching. Patient-reported outcome measures were NRS pain in rest, KOOS-PS, EQ-5D overall health score, and OKS. Radiological parameters were femorotibial angle, medial proximal tibial angle, anatomical lateral distal femoral angle, posterior tibial slope, and patellar height assessed by Insall-Salvati ratio. The complication rates of TKA were compared between the two groups. The HTO survival time, the choice of staple removal before or during TKA in patients who underwent TKA following HTO patients, and the rate of patellar resurfacing were assessed. The p value < 0.0125 indicates statistical significance after Bonferroni correction.ResultsAfter propensity score matching, no significant between-group differences in the patient-reported outcome measures, radiographical parameters and complication rates were found (p > 0.0125). In the TKA following HTO group, with an average HTO survival time of 8.7 years, staples were removed before TKA in 46 patients (71%) and during TKA in 19 patients, and 11 cases (17%) had patella resurfacing. In the primary TKA group, 15 cases (23%) had patella resurfacing.ConclusionThe short-term assessment of TKA following HTO indicates outcomes similar to primary TKA. A previous HTO does not impact the early results of subsequent TKA, suggesting that the previous HTO has minimal influence on TKA outcomes.Level of evidenceIII, cohort study.

Hybrid Closed Wedge High Tibial Osteotomy Maintains the Leg Length After Surgery Compared With Open Wedge High Tibial Osteotomy.

This study aimed to assess the changes in leg length following open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge high tibial osteotomy (h-CWHTO) and whether the change in leg length was associated with preoperative radiographic factors and the change in planned opening or closing width. We retrospectively evaluated the data of patients who underwent OWHTO (n=57) and h-CWHTO (n=31) between 2016 and 2019. Standing full-length anteroposterior radiographs were obtained preoperatively and one year postoperatively. Changes in the lower leg and tibial length were measured using radiography, and the planned opening or closing width was decided via operative planning. Flexion contracture was examined preoperatively and one year postoperatively using a goniometer, and the correlation factors and changes in leg length were analyzed using Spearman's rank correlation. In the OWHTO group, the lower leg was significantly longer by a mean of 6.0±8.7 mm compared to that preoperatively (p<0.01); however, no significant difference was observed in the h-CWHTO group (mean, -0.56±11.6 mm) (p=0.788). In the OWHTO group, flexion contracture did not improve after surgery, however, in the h-CWHTO group, flexion contracture significantly improved from -7.1±7.0 degrees to -4.7±6.2 degrees postoperatively (p<0.01). No radiographic factors or bone opening or closing width were associated with changes in leg length in both groups. OWHTO led to a significant elongation of the lower leg while leg length was maintained post-h-CWHTO. However, the changes in leg length following both OWHTO and h-CWHTO were not predictable from preoperative radiographic factors or changes in bone width.

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

In patients with valgus alignment and degenerative changes in the lateral compartment, both distal femoral osteotomy (DFO) and high tibial osteotomy (HTO) can be used to unload the lateral compartment. Prior studies have shown that in valgus knees, the tibial wear is posterior and DFO exerts the greatest effect in extension; however, its effect is decreased as flexion angle rises. Medial closing-wedge (MCW) HTO would significantly decrease contact area, mean contact pressure (MCP), and peak contact pressure (PCP) in the lateral knee compartment through knee flexion to a greater extent compared with lateral opening-wedge (LOW) DFO. Controlled laboratory study. MCWHTO and LOWDFO were performed, correcting a mean of 8° of valgus alignment, in 10 cadaveric knees using plate fixation. Tibiofemoral contact pressure of the medial and lateral compartments was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors and load applied through an Instron device. PCP, MCP, and contact area were measured for each condition. The lateral MCP was significantly decreased in the HTO state compared with the native state in 30° (P = .015), 60° (P = .0199), and 90° (P < .0001) of flexion. The lateral MCP was also significantly decreased in the HTO state when compared with the DFO state in 60° (P = .0093) and 90° of flexion (P < .0001). After DFO, the lateral MCP returned to that of the native state in 60° (P > .999) and 90° (P > .999) of flexion. The lateral PCP decreased for all test states in all degrees of flexion; the HTO state was significantly decreased when compared with the native state in 60° (P < .0001) and 90° (P < .0001). With varus corrections of 8°, MCWHTO was more effective at unloading the lateral compartment than LOWDFO. This effect was significant as the knee flexion angle increased. This study should be considered as one aspect of the surgical decision-making process. In patients with mild to moderate valgus deformity without hypoplastic lateral femoral condyle and without significant joint line obliquity, MCWHTO may improve offloading of the lateral compartment in flexion.

Varus osteotomy as a salvage procedure for young patients with symptomatic patellofemoral arthritis and valgus malalignment at short- to mid-term follow-up: a case series

PurposeThe purpose of the study was to report the clinical, functional and radiological outcome following varus osteotomy as a salvage procedure in young to middle-aged patients with patellofemoral arthritis (PFA) and associated valgus malalignment. It was hypothesized that a significant improvement in knee function and reduction in pain would be achieved. Moreover, no conversion to patellofemoral joint arthroplasty could be observed.Material and methodsPatients (< 50 years of age) that underwent varus osteotomy between 08/2012 and 01/2020 for the treatment of symptomatic PFA and associated valgus malalignment were consecutively included (minimum follow-up: 24 months). Patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form [IKDC]), Visual Analog Scale [VAS] for pain, Tegner Activity Scale [TAS], and satisfaction with the postoperative results (1–10-scale, 10 = highest satisfaction) and weight-bearing whole-leg anteroposterior radiographs were conducted pre- and postoperatively. The change in PROM and femorotibial angle (FTA) were tested for statistical significance.ResultsIn total, 12 patients (14 knees) were included (66.7% female; mean age: 33.8 ± SD 6.6 years). In ten cases, lateral opening-wedge distal femoral osteotomies (DFO) were performed, of which three cases included a concomitant femoral derotation. Three medial closing-wedge DFO and one medial closing-wedge high tibial osteotomy were performed. At follow-up (55.3 ± 29.3 months), a significant improvement in knee function (IKDC: 56.4 ± 14.4 to 69.1 ± 11.2, p = 0.015) and reduction in pain (VAS for pain: 3.5 [interquartile range 2.3–5.8] to 0.5 [0–2.0], p = 0.018) were observed. Patients were able to reach their preoperative sporting activity level (TAS: 3.0 [3.0–4.0] to 3.5 [3.0–4.0], p = 0.854) and were highly satisfied with the postoperative result (9.0 [6.5–10]). Additionally, a significant correction of valgus malalignment was observed (5.0° ± 2.9° valgus to 0.7° ± 3.2° varus, p < 0.001). Regarding complications, two re-osteosyntheses were performed due to loss of correction and delayed union. No conversion to patellofemoral arthroplasty occurred.ConclusionIn patients with symptomatic PFA and associated valgus malalignment, varus osteotomy as a salvage procedure achieved a significant improvement in knee function and reduction in pain. No conversion to patellofemoral joint arthroplasty occurred at short- to mid-term follow-up.Level of evidenceRetrospective case series, Level IV.

The Influence of Tibial Tubercle–Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction

Background: A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. Purpose: To evaluate the effect of tibial tubercle–sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent arthroscopic revision ACLR combined with retro–tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative – preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. Results: Among 475 revision ACLRs, 47 tibial tubercle–sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative – postoperative) (ISI: 1.0 ± 0.2 – 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 – 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 – 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). Conclusion: Changes in patellar height ratio are common after tibial tubercle–sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.

[Translated article] Closing wedge high tibial osteotomy: An old-fashioned technique? Survival, clinical and radiological outcomes of a case series analysis

IntroductionClosing wedge high tibial osteotomy (CW-HTO) is a surgical option for active patients with medial knee pain and mild–moderate osteoarthritis with varus limb deformity. Despite its good reported results, this technique has been losing popularity. The aim of this study was to analyse the survival rate, clinical functional outcomes and radiological results of CW-HTO. MethodsIt is a retrospective case series study. Seventy patients with primary knee osteoarthritis, operated on between 2010 and 2020 in a single Spanish tertiary hospital using the CW-HTO technique and with a minimum follow-up of 2 years were analysed. ResultsSurvival rate was 87.6% and 75.5% after a follow-up of 5 and 10 years respectively. Functional outcomes were good-to-excellent (KSS 77.7/100 and OKS 35.6/48) and good pain control (VAS 3.9/10) and high satisfaction (7.2/10) were achieved. Limb varus malalignment was significantly corrected (mean postoperative HKA angle 177.6° and MPTA 90.7°). However, 30% of patients presented hypocorrection, which was associated with inferior survival, functionality and satisfaction. ConclusionCW-HTO technique can be useful for patients with knee osteoarthritis and varus limb. It allows to correct varus malalignment while achieving good-to-excellent functional outcomes, good pain control, high patient satisfaction and acceptable medium-long term survival rate. However, it is associated with a non-negligible risk of hypocorrection or medial hinge disruption.

20-Year Outcomes of High Tibial Osteotomy: Determinants of Survival and Functional Outcome

Background: High tibial osteotomy (HTO) is a successful joint-preserving procedure for the treatment of medial compartment osteoarthritis. Long-term survivorship of HTO ranges from 40% to 85%. There are consistent factors that predict failure. Purpose: To determine the 20-year survival of HTO and identify predictors of failure. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 consecutive patients with medial bone-on-bone arthritis were prospectively studied to provide long-term patient-reported outcome measures after lateral closing-wedge HTO and determine the time to failure. Failure was defined as conversion to arthroplasty (total knee arthroplasty or unicompartmental knee arthroplasty) or revision HTO. Results: At 20 years, HTO survival was determined in 95 patients, and 5 were lost to follow-up. The overall survivorship of HTO at 20 years was 44%. The significant factors that were associated with better survivorship were age <55 years, body mass index <30, and Western Ontario and McMaster Universities Osteoarthritis Index pain score >45. These factors were used to define the favorable candidates. In the favorable candidates, survivorship was 100% at 5 years, after which there was a gradual decline to 62% survival at 20 years. Of those with HTO survival, 32 of 33 (97%) reported satisfaction with surgery, with a mean Knee injury and Osteoarthritis Outcome Score Pain score of 91 and Activities of Daily Living score of 97. Conclusion: HTO is a successful surgical option to treat medial compartment osteoarthritis and prevent the need for arthroplasty in young patients. The most suitable candidates for HTO are aged <55 years, are not obese, and have not progressed to severe symptomatic disability.

Economic evaluation of high tibial osteotomy: Closing wedge is more cost-effective than open wedge technique when analysing the KOOS-12 improvement.

The purpose of this study was to compare the cost-effectiveness of two techniques for performing a knee valgus osteotomy: opening wedge high tibial osteotomy (OW-HTO) vs closing wedge high tibial osteotomy (CW-HTO). In this economic evaluation study, a cost-effectiveness analysis from the perspective of the Spanish public healthcare system was performed, comparing OW-HTO with CW-HTO. All patients with medial knee osteoarthritis who underwent one of these procedures between 2018 and 2020 in our institution were included. The cost analysis included operating room, implant, graft and hospital admission costs. Functional outcomes (KOOS-12, Tegner activity scale, pain and satisfaction) and radiological outcomes (hip-knee-ankle angle, medial proximal tibial angle, tibial slope and patellar height) were analysed. The cost-effectiveness ratio was obtained by calculating the cost of improving the minimal clinically important difference (MCID) of KOOS-12 for each procedure. All costs are expressed in 2020 euros. Fifty-one patients met the inclusion criteria (27 OW-HTO and 24 CW-HTO). Good to excellent functional outcomes, significant pain reduction (>6 points) and high patient satisfaction (>9/10) were observed in both groups. Both techniques yielded excellent radiological outcomes. N.s. differences in functional or radiological outcomes improvements between both procedures were found. However, the OW-HTO group presented a higher total cost than the CW-HTO group (4612.1 ± 765.6€ vs. 1827.1 ± 701.9€; p < 0.001). The cost-effectiveness ratio was 818.1 ± 46.8 €/MCID for the CW-HTO procedure and 2414.3 ± 115.2 €/MCID for the OW-HTO procedure (p = 0.025). The CW-HTO procedure presented a cost-effectiveness ratio almost three times lower than the OW-HTO procedure. Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis. Level III; economic study.

Surgical accuracy of coronal and sagittal alignment in conventional closed-wedge high tibial osteotomy after computer-assisted surgery experience

BackgroundAlthough intraoperative navigation can improve the surgeon’s proficiency, no studies have analyzed postoperative outcomes of high tibial osteotomy (HTO) after computer-assisted surgery (CAS) experience. The present study compared the clinical and radiographic results between conventional and CAS closed-wedge (CW) HTOs after CAS experience.MethodsEach of the 50 conventional and CAS CW HTOs performed by single surgeon between 2015 and 2017 were included. The surgeon had experience of 140 cases of CAS CW HTOs before the study period. The groups were not different in terms of demographics. Clinically, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were investigated. Radiographically, the mechanical axis (MA), change in posterior tibial slope angle (PTS), and parallel angle were evaluated. The proportions of inlier groups for the postoperative MA (within valgus 2° ± 3°), change in the PTS (within ± 3°), and parallel angle (< 3°) were compared.ResultsThere were no significant differences in postoperative clinical results between the conventional and CAS groups. The MA was appropriately corrected in both groups (2.4° versus 2.9°, p = 0.317). The amount of change in PTS was significantly greater in the conventional group (−2.2° versus −0.8°, p = 0.018). The parallel angle was 5.3° in the conventional groups and 3.1° in the CAS group (p = 0.003). The proportion of inlier group was not significantly different in the postoperative MA (72% versus 78%) and change in the PTS (52% versus 66%). The proportion of inlier for the parallel angle was significantly lower in the conventional group (36% versus 60%, p = 0.027).ConclusionsThe surgical proficiency after CAS experience could cover the advantages of an intraoperative navigation in coronal adjustment, not in the sagittal adjustments in CW HTOs. A larger cohort with multiple surgeons in multiple centers would be required to identify the general trend.Study designLevel of evidence III.

Outcomes of Slope-Reducing Proximal Tibial Osteotomy Combined With a Third Anterior Cruciate Ligament Reconstruction Procedure With a Focus on Return to Impact Sports

Background: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR). Purpose/Hypothesis: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure. Study Design: Case series; Level of evidence, 4. Methods: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded. Results: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively (P < .0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively (P < .001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores (P < .001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was −4.03 ± 0.18 mm and −3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Conclusion: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports.