Valgus High Tibial Osteotomy Research Articles

Clinical Outcomes and Long-term Survivorship After Osteochondral Autologous Transfer Combined With Valgus High Tibial Osteotomy: An Analysis After 19 Years With 56 Patients

Background: Osteochondral defects of the medial femoral condyle combined with varus malalignment in young and active patients are a debilitating condition, which can result in early osteoarthritis. Osteochondral autologous transfer (OAT) combined with valgus high tibial osteotomy (HTO) might therefore be a comprehensive solution to maintain long-term knee function. Purpose/Hypothesis: The purpose of this study was to report clinical results and survivorship after combined OAT and valgus HTO for symptomatic osteochondral defects of the medial femoral condyle in the setting of varus malalignment at a long-term follow-up. It was hypothesized that undergoing combined OAT and valgus HTO would produce favorable clinical results along with a low rate of conversion to arthroplasty. Study Design: Case series; Level of evidence, 4. Methods: All patients treated between 1998 and 2008 with combined valgus HTO and OAT for deep osteochondral defects of the medial femoral condyle and concomitant varus malalignment >2° without meniscal repair/transplantation, osteoarthritis, or ligamentous instability/reconstruction were included. The survival rates of this combined procedure were evaluated. Failure was defined as conversion to knee joint arthroplasty during the follow-up period. Patient-reported outcomes were collected pre- and postoperatively, including the Lysholm score, visual analog scale score, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score, and subjective level of satisfaction (scale 0-10). Results: Of 74 patients who were included for 10-year follow-up, 3 had died. A total of 15 patients were lost to follow-up, so 56 patients could be reevaluated, for a follow-up rate of nearly 80%. The mean age at surgery was 38.8 ± 9.9 years (range, 19.9-62.4 years), and the mean follow-up time was 18.9 ± 3.0 years (median, 18.8 years; range, 14.1-24.8 years). The survival rates were 87% at 10 years, 86% at 15 years, and 77% at 19 years after surgery. At final follow-up, the Lysholm score showed a mean increase of 39 points (95% CI, 25.4-50.0 points; P < .001) from 40 points to 79 points, representing a significant improvement. Overall, 96% of patients surpassed the minimal clinically important difference (MCID) for the Lysholm score. The visual analog scale score decreased by a mean of 4.8 points (range, 5-10 points) from 7.5 points to 2.7 points (P < .001), and 80% of patients surpassed the MCID. The mean Tegner Activity Scale score was 4.5 ± 1.6, and the mean KOOS subscale scores at final follow-up were as follows: Pain: 81 ± 21 (range, 19-100), Symptoms: 80 ± 22 (range, 21-100), Activities of Daily Living: 85 ± 21 (range, 18-100), Sports: 68 ± 32 (range, 0-100), and Quality of Life: 67 ± 28 (range, 0-100). Overall, 78% of the patients were satisfied with the results of the operation. Conclusion: The combination of OAT and valgus HTO presents a viable treatment option for patients affected by osteochondral defects of the medial femoral condyle and concurrent varus malalignment. A sustained and substantial improvement in clinical outcomes, significantly reduced pain severity, and a high rate of long-term survivorship can be anticipated in the long-term follow-up.

Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction in knees with Bony Frontal and/or Sagittal Deformities: Review of the Current Literature.

Simultaneous anterior cruciate ligament (ACL) reconstruction (ACLR) and valgus high tibial osteotomy (HTO) alleviates pain in 70% of individuals with ACL deficiency and varus femorotibial osteoarthritis, allows for sustainable stabilization of the knee at the 10-year follow-up and a return to sport (RTS) in 33%-80% of cases, but femorotibial osteoarthritis progression occurs in 39% of cases. The complication rate ranges from 0% to 23.5% (6.5% revision valgus HTO, 17.5% ACL graft failure, 7.7% venous thrombosis). Simultaneous ACLR and HTO leads to satisfactory results in patients with ACL deficiency and varus femorotibial osteoarthritis associated with a high posterior tibial slope (PTS) and appears to have a protective effect on further ruptures in the reconstructed ACL. The younger the patient and the more sporting demands he/she poses, the more we should be inclined to perform a combined intervention (ACLR and valgus HTO).

Management of medial femorotibial osteoarthritis: Epidemiology, and survival of unicompartmental knee arthroplasty versus valgus high tibial osteotomy in France. Study of 108,007 cases from the French National Hospitals Database

IntroductionUnicompartmental knee arthroplasty (UKA) and valgus high tibial osteotomy (HTO) are two options for isolated medial femorotibial osteoarthritis in genu varum. In the absence of registries for osteotomies and for arthroplasty in the knee, epidemiological data are hard to obtain in France. We therefore performed a retrospective study, with the aims of: 1) estimating UKA and HTO survival without revision by total knee arthroplasty (TKA), and 2) assessing risk factors for revision according to treatment group. HypothesisMedium-term survival is better with HTO than UKA in under-70-year-olds. Materials and methodAll elderly patients undergoing HTO or UKA in the French National Hospitals Database for the period 2011–2020 were included: i.e., 108,007 patients; 43,537 HTO (29,330 male, 14,207 female; mean age 49.7 years, 95% CI 49.6–49.8) and 64,470 UKA (31,181 male, 33,289 female; mean age 60.5 years, 95% CI 60.5–60.6). ResultsSurvival free of revision by TKA was 75.8% (95% CI=75.2–76.4) for UKA and 80.6% (95% CI=80.0–81.3) for HTO (p<0.00001). In UKA, revision risk factors comprised: low annual center volume (<17 UKAs per year) (HR=1.50; 95% CI=1.41–1.59), obesity (HR=1.25; 95% CI=1.18–1.32), and age <60years, with maximum risk for 50–59years (HR=2.41; 95% CI=1.83–3.16 in 50–59 year-olds). In HTO, revision risk factors comprised: obesity (HR=1.42; 95% CI=1.31–1.53), rheumatoid arthritis (HR=2.75; 95% CI=1.37–5.51), joint chondrocalcinosis (HR=2.01; 95% CI=1.18–3.39), and age >60years (HR=8.81; 95% CI=7.23–19.73 in 60–69-year-olds). Male gender was a protective factor against revision in both groups: UKA, HR=0.75 (95% CI=0.72–0.79); HTO, HR=0.73 (95% CI=0.69–0.77). The number of UKAs increased over the years, matching the increase in arthroplasty in France, with a decrease in HTOs until 2019. ConclusionHTO showed better medium-term survival than UKA in under-70-year-olds in France. Even so, indications decreased in favor of UKA, although the respective risk factors differ. These findings suggest that conservative surgery still has a role, depending on osteoarthritis stage. Level of evidenceIII; retrospective comparative study.

Long-Term Survival and Predictors of Failure of Opening Wedge High Tibial Osteotomy.

High tibial valgus osteotomy (HTO) is a widely accepted procedure indicated for varus knee with symptomatic osteoarthritis of the medial compartment. However, there is a lack of studies evaluating long term results of this procedure. The primary aim of this study was to evaluate the long-term survival of opening wedge high tibial osteotomy (HTO) for isolated osteoarthritis in the medial compartment of the knee. The secondary objective was to identify independent predictors of conversion to total knee arthroplasty (TKA). This is a long term retrospective study of 296 cases of open wedge HTOs performed at a single center (level of evidence IV) between January 2005 and August 2015. Opening wedge medial HTO was always performed after diagnostic arthroscopy. Eighty-three percent of the population (233 patients, 247 procedures) was followed up at a mean 11.6 years (6-17) by telephone interview, to evaluate the possible conversion to TKA. Mean age at the index operation was 42.8 years (range 15-70) and most patients were male (70%). Associated procedures (e.g., platelet rich plasma supplementation, microfractures, meniscectomy, etc.) were carried out at the time of the HTO in 80 (32%) cases. Survival of HTO and its association with age, sex, body mass index, smoking habit, preoperative severity of varus deformity, cartilage status at surgery, and associated procedures were evaluated. Kaplan-Meier and Cox regression analyses were performed. Thirty-three of the 247 HTOs (13.4%) were converted to knee replacement, with 86.6% of the original procedures surviving at a mean 12-year follow-up. Kaplan-Meier survival estimates at 17 years for HTO were 75.5% (95% confidence interval [CI] 66.7-84.3). There was significant difference (P < 0.001) in the 17-year survival rate between obese (55.5%; 95% CI 35.3-75.6) and non-obese (79.7%; 95% CI 70.1-89.2) patients. The determinants of conversion to knee arthroplasty detected at multivariate Cox regression analysis were body mass index, severity of cartilage degeneration in the medial compartment (Outerbridge grade), and age. The long-term survival of open wedge HTO for osteoarthritis in the medial compartment of the knee is satisfactory. The risk of conversion to TKA is significantly increased in obese patients. Advanced age and severity of pre-existing cartilage damage may also contribute to the risk of conversion to TKA.

The AMADEUS score is not a sufficient predictor for functional outcome after high tibial osteotomy

PurposeThe Area Measurement And Depth Underlying Structures (AMADEUS) classification system has been proposed as a valuable tool for magnetic resonance (MR)-based grading of preoperatively encountered chondral defects of the knee joint. However, the potential relationship of this novel score with clinical data was yet to determine. It was the primary intention of this study to assess the correlative relationship of the AMADEUS with patient reported outcome scores in patients undergoing medial open-wedge high tibial valgus osteotomy (HTO). Furthermore, the arthroscopic ICRS (International Cartilage Repair Society) grade evaluation was tested for correlation with the AMADEUS classification system.MethodsThis retrospective, monocentric study found a total of 70 individuals that were indicated for HTO due to degenerative chondral defects of the medial compartment between 2008 and 2019. A preoperative MR image as well as a pre-osteotomy diagnostic arthroscopy for ICRS grade evaluation was mandatory for all patients. The Knee Osteoarthritis Outcome Score (KOOS) including its five subscale scores (KOOS-ADL, KOOS-QOL, KOOS-Sports, KOOS-Pain, KOOS-Symptoms) was obtained preoperatively and at a mean follow-up of 41.2 ± 26.3 months. Preoperative chondral defects were evaluated using the AMADEUS classification system and the final AMADEUS scores were correlated with the pre- and postoperative KOOS subscale sores. Furthermore, arthroscopic ICRS defect severity was correlated with the AMADEUS classification system.ResultsThere was a statistically significant correlation between the AMADEUS BME (bone marrow edema) subscore and the KOOS Symptoms subscore at the preoperative visit (r = 0.25, p = 0.04). No statistically significant monotonic association between the AMADEUS total score and the AMADEUS grade with pre- and postoperative KOOS subscale scores were found. Intraoperatively obtained ICRS grade did reveal a moderate correlative relation with the AMADEUS total score and the AMADEUS grade (r = 0.28, p = 0.02).ConclusionsThe novel AMADEUS classification system largely lacks correlative capacity with patient reported outcome measures in patients undergoing HTO. The MR tomographic appearance of bone marrow edema is the only parameter predictive of the clinical outcome at the preoperative visit.

Custom-Made Devices Represent a Promising Tool to Increase Correction Accuracy of High Tibial Osteotomy: A Systematic Review of the Literature and Presentation of Pilot Cases with a New 3D-Printed System.

Background: The accuracy of the coronal alignment corrections using conventional high tibial osteotomy (HTO) falls short, and multiplanar deformities of the tibia require consideration of both the coronal and sagittal planes. Patient-specific instrumentations have been introduced to improve the control of the correction. Clear evidence about customized devices for HTO and their correction accuracy lacks. Methods: The databases PUBMED and EMBASE were systematically screened for human and cadaveric studies about the use of customized devices for high tibial osteotomy and their outcomes concerning correction accuracy. Furthermore, a 3D-printed customized system for valgus HTO with three pilot cases at one-year follow-up was presented. Results: 28 studies were included. The most commonly used custom-made devices for HTO were found to be cutting guides. Reported differences between the achieved and targeted correction of hip-knee-ankle angle and the posterior tibial slope were 3° or under. The three pilot cases that underwent personalized HTO with a new 3D-printed device presented satisfactory alignment and clinical outcomes at one-year follow-up. Conclusion: The available patient-specific devices described in the literature, including the one used in the preliminary cases of the current study, showed promising results in increasing the accuracy of correction in HTO procedure.

Can the MRI based AMADEUS score accurately assess pre-surgery chondral defect severity according to the ICRS arthroscopic classification system?

PurposeThe AMADEUS (Area Measurement And DEpth and Underlying Structures) scoring and grading system has been proposed for the MRI based evaluation of untreated focal chondral defects around the knee. The clinical practicability, its correlation with arthroscopically assessed grading systems (ICRS – International Cartilage Repair Society) and thereby its clinical value in terms of decision making and guiding prognosis was yet to determine.MethodsFrom 2008 to 2019 a total of 89 individuals were indicated for high tibial valgus osteotomy (HTO) due to tibial varus deformity and concomitant chondral defects of the medial compartment of the knee. All patients received a preoperative MRI (1.5 Tesla or 3.0 Tesla) and pre-osteotomy diagnostic arthroscopy. Chondral defects of the medial compartment were scored and graded with the MRI based AMADEUS by three independent raters and compared to arthroscopic defect grading by the ICRS system. Interrater and intrarater reliability as well as correlation analysis with the ICRS classification system were assessed.ResultsIntraclass correlation coefficients for the various subscores of the AMADEUS showed an overall good to excellent interrater agreement (min: 0.26, max: 0.80). Intrarater agreement turned out to be substantially inferior (min: 0.08, max: 0.53). Spearman correlation revealed an overall moderate correlative association of the AMADEUS subscores with the ICRS classification system, apart from the defect area subscore. Sensitivity of the AMADEUS to accurately identify defect severity according to the ICRS was 0.7 (0.69 for 3.0 Tesla MRI, 0.67 for 1.5 Tesla MRI). The mean AMADEUS grade was 2.60 ± 0.81 and the mean ICRS score 2.90 ± 0.63.ConclusionsOverall, the AMADEUS with all its subscores shows moderate correlation with the arthroscopic chondral grading system according to ICRS. This suggests that chondral defect grading by means of the MRI based AMADEUS is well capable of influencing and guiding treatment decisions. Interrater reliability shows overall good agreement.

UNLOADING REDUCES OSTEOARTHRITIS IN AN OVINE MODEL OF PARTIAL MEDIAL MENISCECTOMY

Purpose: Although osteoarthritis (OA), a leading cause of disability, has been associated with joint alignment, scientific translational evidence for this link is lacking. High tibial osteotomy (HTO) reduces unicompartmental overload, representing a causative therapy for symptomatic medial tibiofemoral varus knee OA. Here, we validate in a preclinical large animal model the effect of valgus HTO on the pattern of OA development induced by partial medial anterior meniscectomy (pMMx) in the osteochondral unit at two time points.

The 3-triangle method preserves the posterior tibial slope during high tibial valgus osteotomy: first preliminary data using a mathematical model

PurposeDespite much improved preoperative planning techniques accurate intraoperative assessment of the high tibial valgus osteotomy (HTO) remains challenging and often results in coronal over- and under-corrections as well as unintended changes of the posterior tibial slope. Noyes et al. reported a novel method for accurate intraoperative coronal and sagittal alignment correction based on a three-dimensional mathematical model. This is the first study examining preliminary data via the proposed Noyes approach for accurate intraoperative coronal and sagittal alignment correction during HTO.MethodsFrom 2016 to 2020 a total of 24 patients (27 knees) underwent HTO applying the proposed Noyes method (Noyes-Group). Radiographic data was analyzed retrospectively and matched to patients that underwent HTO using the conventional method, i.e., gradual medial opening using a bone spreader under fluoroscopic control (Conventional-Group). All operative procedures were performed by an experienced surgeon at a single orthopaedic university center.ResultsFrom the preoperative to the postoperative visit no statistically significant changes of the posterior tibial slope were noted in the Noyes-Group compared to a significant increase in the Conventional-Group (p = 0.01). Regarding the axial alignment no significant differences between both groups were observed pre- and postoperatively. The number of over- and under-corrections did not differ significantly between both groups. Linear regression analysis showed a significant correlation of the postoperative medial proximal tibial angle (MPTA) with the position of the weightbearing line on the tibial plateau.ConclusionThe 3-triangle method by Noyes seems to be a promising approach for preservation of the posterior tibial slope during HTO.

Accuracy of the correction achieved after a valgus high tibial osteotomy: Comparison of the Hernigou table and navigation

IntroductionThe outcome of a medial opening wedge valgus high tibial osteotomy indicated for the treatment of isolated medial tibiofemoral osteoarthritis depends mainly on the accuracy of the correction of the hip-knee-ankle angle (HKAA) and the mechanical medial proximal tibial angle (mMPTA). Most authors aim for a desired correction target between 2° and 4° of valgus. Several planning and surgical techniques have been described to achieve this target value that is specific to each surgeon. ObjectiveThe purpose of this study was to compare the accuracy of the correction achieved using either the Hernigou table (HT) planning method or a computer-assisted navigation system (CAS). It was hypothesized that no difference would be found between these 2 techniques. Materials and MethodsThis retrospective single-center study involved 43 knees: 21 in the HT group and 22 in the CAS group. Two surgeons (ME, JYJ), who were experts in 1 of the 2 planning methods performed these procedures, with a single surgeon assigned to each group. The correction was noted in the operative report and was considered to be the desired correction target. The surgical correction was calculated by comparing preoperative and immediate postoperative mMPTA measurements. The surgical accuracy, where a value close to 0 represented optimal accuracy, was defined as the absolute value of the difference between the correction target set by the surgeon and the surgical correction achieved. The median accuracy between the 2 groups was compared by a Mann-Whitney U test (significance level at 5%). The number of patients deviating from the target by>3° was analyzed with a Fisher exact test (significance level at 5%). Pre- and postoperative comparisons of the HKAA measurements could not be used because the measurement was not performed postoperatively for the CAS group. ResultsThe median surgical accuracy on the mMPTA was 1.4° (0–4.1) for the HT group versus 1.9° (0.2–6.7) for the CAS group (p=0.85). Sixteen procedures (76%) were performed with an accuracy of<3° in the HT group versus 15 in the CAS group (68%) (p=0.73). Discussion-ConclusionThe working hypothesis was confirmed: no differences were found between the HT and CAS groups regarding the surgical accuracy in achieving the corrections set in this series. We therefore demonstrated that HT was a highly accessible, simple and reliable technique for achieving the planned target. It can be used widely. Level of EvidenceIII; comparative retrospective series.

What does the "Cochrane Database of Systematic Reviews" Say with Regard to the Surgical Management of Knee Osteoarthritis?

Introduction: The Cochrane Library makes the outcomes of well-conducted controlled trials quickly accessible and is an essential resource for evidence-based medicine. Purpose: The purpose of this article is to review the data on the surgical treatment of knee osteoarthritis currently provided by the Cochrane database of systematic reviews (CDBSR). Results: The main results included the following: Joint lavage and arthroscopic debridement have no benefit for osteoarthritis; valgus high tibial osteotomy (HTO) reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee; in primary total knee arthroplasty (TKA) cemented fixation of the tibial components demonstrated less displacement compared with cementless fixation (with and without hydroxyapatite) after a follow‐up of two years; however, the cemented fixation presented a greater risk of future aseptic loosening than cementless fixation; clinically irrelevant differences have been found between retention and sacrifice of the posterior cruciate ligament (PCL) in primary TKA; moderate‐ to low‐quality evidence suggests that mobile-bearing prostheses can have similar effects on various parameters compared with fixed-bearing prostheses in PCL-retaining TKA. Conclusion: The CDBSR discourages joint lavage and arthroscopic debridement, demonstrates the utility of the valgus HTO in patients with medial compartmental osteoarthritis of the knee, and suggests that the various design types in primary TKA offer similar results.

Medial Opening Wedge Proximal Tibial Osteotomy: Lessons Learned from a Series of 175 Consecutive Cases.

High tibial osteotomy (HTO) is a surgical procedure aimed at inhibiting the progression of osteoarthritis of the knee joint. The aim of this study was to identify factors influencing the functional outcome after opening wedge valgus HTO. A total of 175 cases (155 patients) of varus-correcting high tibial open-wedge osteotomies using the Tomofix plate were reviewed retrospectively. Patients answered the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire and 4 survey follow-up questions. A total of 76 of the 155 patients studied (84 of the 175 knees) completed the KOOS questionnaire, on average 3.1 years (SD 1.8 years) after the surgery. The median scores (with median absolute deviations [MAD]) for the KOOS pain, symptoms, daily activities, sports, and quality of life sections were, respectively, 76.4 (MAD 12.5), 75.0 (MAD 14.3), 85.3 (MAD 11.8), 50.0 (MAD 25.0), and 59.4 (MAD 21.9). No cases of nonunion were observed throughout the length of the study. Identified predictors of worse outcomes were higher weight and body mass index, limited knee flexion, genu varum and tibial varus of small magnitude, active smoking status at the time of surgery, further surgery for plate removal, and some grades of chondropathy in the patellofemoral, medial tibial, and femoral compartments. Patient gender, joint obliquity and over- or undercorrection were not associated with any of the outcomes. This study shows good results following valgus HTO that are comparable to outcomes following total knee arthroplasty, reinforcing the option of HTO as a valid alternative for total knee arthroplasty.

Satisfactory clinical results and low failure rate of medial collagen meniscus implant (CMI) at a minimum 20\xa0years of follow-up

PurposeThe aim of the study was to evaluate the long-term clinical results, reoperations, surgical failure and complications at a minimum of 20 year of follow-up of the first 8 medial CMI scaffolds implanted by a single surgeon during a pilot European Prospective study.MethodsSeven (88%) out of 8 patients were contacted. The Cincinnati Score, VAS, and Lysholm score were collected. Moreover, magnetic resonance imaging (MRI) was performed on 4 patients at the last follow-up. Complications, reoperations and failures were also investigated.ResultsThe average follow-up was 21.5 ± 0.5 years. One patient underwent TKA after 13 years from CMI implantation; a second patient underwent valgus high tibial osteotomy 8 years after the index surgery and another patient underwent anterior cruciate ligament hardware removal at 21 years of follow-up. At the final follow-up, 3 patients were rated as “Excellent”, 1 as “Good” and 2 as “Fair” according to the Lysholm score. The Cincinnati score and the VAS were substantially stable over time. The MRI showed a mild osteoarthritis progression in 3 out of 4 patients according to the Yulish score, and the CMI signal was similar to the mid-term follow-up revealing 3 cases of myxoid degeneration and 1 case of normal signal with reduced scaffold size.ConclusionThe medial CMI is a safe procedure: satisfactory clinical results and a low failure rate could be expected even at a long-term follow-up. For this purpose, the correct indication as well as correcting axial malalignment and addressing knee instability at the time of the index surgery is mandatory. On the other hand, a mild osteoarthritis progression could be expected even after meniscus replacement.Level of evidenceIV.

ACL Reconstruction and High Tibial Valgus Osteotomy for Management of ACL Deficient Varus knee

Consolidated foremost cruciate tendon remaking and average opening wedge high tibial osteotomy can create solid re-visitation of donning action. This system permits patients to recapture a steady knee at right around 10-year follow-up, with a re-visitation of wearing exercises in about 80%. A critical decline in brandishing level is not out of the ordinary, and patient guiding is significant as the preinjury movement level in the objective patient segment is high. The point of this examination was to play out a precise audit of ACL remaking and high tibial valgus osteotomy in the administration of ACL insufficient with varus knee. This survey was finished utilizing standard approach sketched out in the Cochrane Handbook and detailed the discoveries as per the Preferred Reporting Items for Systematic Reviews and Meta-examinations (PRISMA) articulation rules. The writing search were performed utilizing the accompanying hunt terms: ACL reproduction with valgus osteotomy in administration of ACL inadequacy with varus knee. Watchwords: ACL recreation, and Varus knee. This precise survey included 6 examinations Only one investigation was and the others were single armed.We inferred that consolidated front cruciate tendon recreation and average opening wedge high tibial osteotomy is a feasible choice in youthful patients influenced by foremost shakiness, with great midterm results if a right sign, preoperative arranging, and careful method are applied. Also, The bone-patella ligament bone join has a more grounded obsession With the least re tear rate. This joined system gives palatable emotional, unbiased and radiological outcomes, improves the capacity and diminishes the agony.

Focal cartilage defects of the lateral compartment do influence the outcome after high tibial valgus osteotomy.

Introduction: High tibial medial open-wedge valgus osteotomy (HTO) is a well-established procedure for unicompartimental medial osteoarthritis of the young and active patient. However, the influence of cartilage defects of the lateral compartment on the total outcome remains obscure. Methods: From 2005 to 2012, a total of 63 patients underwent HTO for medial osteoarthritis of the knee at a single university orthopaedic center. Baseline data as well as intraoperative findings, including the grade and location of cartilage lesions, were evaluated retrospectively. Two groups were formed regarding the integrity of the lateral tibiofemoral compartment as measured by the Outerbridge score (group A: no lateral cartilage defects, group B: mild to moderate lateral cartilage defects). Functional outcome was assessed using the Knee and Osteoarthritis Outcome Score (KOOS), including its five subscores. Results: Comparing pre- and postoperative data, we identified an overall benefit of the HTO procedure as measured by the KOOS. Group A (no lateral cartilage defects) showed an increase in all five KOOS subscores (p = 0.00–0.01), whereas for group B (mild to moderate lateral cartilage defects), only two KOOS subscores revealed a significant increase (p = 0.03–0.04). There was also a statistically significant difference in the total KOOS score with higher values for group A at the postoperative visit. Cartilage defects with a higher Outerbridge score were associated with lower postoperative KOOS subscores. Discussion: Mild to moderate cartilage defects of the lateral compartment humble the total outcome after HTO procedure. Thus, indication for HTO should be made very carefully if any degree of lateral cartilage degeneration is present.

A new double level osteotomy procedure to restore a joint line and joint angles in severe varus osteoarthritis. - Double level osteotomy associated with tibial condylar valgus osteotomy (DLOTO)

High tibial valgus osteotomy (HTO) is a well-established surgical procedure to correct a varus malalignment and treat medial compartment osteoarthritis. Recently, double level osteotomy (DLO) was recommended for extensive varus knees as a single level osteotomy (SLO) approach may create an excessive joint line obliquity and eventually result in a new bony deformity. However, a severe varus knee in cases of advanced osteoarthritis involves not only a bony deformity (extra-articular deformity) but also a medial joint space narrowing with a widened lateral joint space (intra-articular deformity). A DLO alone cannot reduce this intra-articular deformity. However, tibial condylar valgus osteotomy (TCVO) can complement DLO as to reduce this intra-articular deformity. This technical note describes a novel modified DLO procedure associated with TCVO which can restore a normal alignment and a joint line and achieve joint preservation even in cases of extensive varus osteoarthritis.

Rotational Changes in the Tibia After High Tibial Valgus Osteotomy: A Comparative Study of Lateral Closing Versus Medial Opening Wedge Osteotomy

Background: After high tibial valgus osteotomy (HTO), rotational changes in the tibia may occur, which can affect the biomechanics of the patellofemoral joint and may lead to anterior knee pain. Purpose: To compare the rotational changes in the tibia between closing wedge HTO (CWHTO) and opening wedge HTO (OWHTO). Study Design: Cohort study; Level of evidence, 3. Methods: Among the patients who underwent HTO between May 2012 and August 2015, 53 (28 CWHTO and 25 OWHTO) who had computed tomography scans before and at 1 year after the HTO were included. The following parameters were compared between CWHTO and OWHTO: (1) tibial torsion angle, (2) knee rotation angle, and (3) tibial tuberosity–trochlear groove (TT-TG) distance. During the last follow-up, patients were asked to rate their anterior knee pain when climbing the stairs, using the visual analog scale. Results: The tibial torsion angle significantly decreased (internal rotation of the distal fragment) after CWHTO (mean ± SD, –2.1°± 4.1°; P = .019) and OWHTO (–1.8°± 3.3°; P = .029). The knee rotation angle significantly decreased (external rotation of the proximal fragment) after OWHTO (–1.8°± 3.4°; P = .039) but was not changed after CWHTO (0.1°± 3.1°; P = .859). The mean TT-TG distance significantly decreased after CWHTO (–3.1 ± 3.0 mm; P < .001) but increased after OWHTO (2.0 ± 4.3 mm; P = .012). At the final follow-up (minimum, 4 years), the visual analog scale pain score during stair climbing was significantly higher after OWHTO than after CWHTO (3.1 ± 1.4 vs 2.2 ± 1.3, P = .024). Conclusion: Internal rotation of the distal fragment occurred after both CWHTO and OWHTO. However, external rotation of the proximal fragment and increased TT-TG distance occurred after OWHTO. Because such rotational changes could affect anterior knee pain, further studies are warranted to investigate the definite relationship between tibial rotational changes and anterior knee pain after HTO.

The Ability to Achieve a Specific Target Angle on Weightbearing Radiographs After Valgus High Tibial Osteotomy for Medial Knee Arthritis Is Not Predictable

PurposeStanding radiographs are commonly used to plan angular correction in valgus tibial osteotomy for varus gonarthrosis. Most clinical studies have reported postoperative alignment as overall averages or means. The purpose of this study was to compare the preoperatively planned angle of correction measured on weight-bearing radiographs to the follow-up angle measured on weightbearing radiographs in individual patients 6 weeks after surgery and to analyze factors that could potentially affect achieving the planned degree of surgical correction. Our objective was to analyze factors potentially affecting the accuracy and ability to achieve the preoperatively planned correction angle (the target angle) in the individual patient.MethodsWe studied 35 tibial osteotomies (13 Coventry closing wedge osteotomies and 22 Maquet barrel vault osteotomies) performed for varus gonarthrosis between 1981 and 2019 to determine how accurately the target angle, based on preoperative standing weight-bearing radiographs, was achieved according to the postoperative radiographs in each individual. We reviewed 35 knees in 34 patients who had complete pre- and postoperative radiographs for review.ResultsOverall, only 14 of 35 (40%) of the patients were corrected to within ± 2° of the planned target angle. Valgus tibial osteotomy based on preoperative weightbearing radiographs is unpredictable in its ability to achieve the target angle on postoperative weightbearing radiographs when using either the Coventry or the Maquet surgical technique. The tendency was to undercorrect with either of the techniques. Larger (greater than 10°) preoperative varus alignment did not make it more difficult to achieve the target angle. Male or female sex and body mass index had no effect on the ability to achieve the target angle.ConclusionsValgus tibial osteotomy planning based on preoperative weightbearing is unpredictable in its ability to achieve the target angle on postoperative weightbearing radiographs. Overall, only 40% of our patients were corrected to within ± 2° of the planned target angle. The tendency was to undercorrect, with either the Coventry or the Maquet technique. Contrary to our hypothesis, larger preoperative varus alignment (greater than 10°) did not make it more difficult to achieve the target angle. The Coventry technique was as accurate as the Maquet technique.Level of EvidenceLevel IV.

Coronal Alignment Correction and Maintenance of Tibial Slope in Opening-Wedge Valgus High Tibial Osteotomy Using a 4-Reference Kirschner Wire Technique: A Cadaveric Study.

Background:Opening-wedge valgus high tibial osteotomy (OWHTO) is a common surgical procedure used to treat symptomatic varus femorotibial malalignment in adults. Several intraoperative methods are available to determine the correct correction alignment, but achieving the desired alignment correction is difficult.Purpose/Hypothesis:The aim of this study was to assess a 4-reference K-wire technique that is relatively easy to apply and can reliably assess actual alignment correction during surgery after determination of the desired corrective angle. We hypothesized that this technique would accurately determine the coronal correction and properly maintain the tibial slope intraoperatively during OWHTO.Study Design:Descriptive laboratory study.Methods:This study was conducted using 12 fresh-frozen cadavers; 12 randomly chosen knees were corrected 5° and 12 knees were corrected 10° by use of 2 coronal and 2 sagittal K-wires. The first and second coronal K-wires were drilled at 4 cm and 1 to 2 cm below the medial joint line toward the tibiofibular joint, respectively. The angles of these 2 coronal K-wires were measured before and after the gap was opened via a modified goniometer. The difference in the angle formed by these 2 coronal K-wires from before to after opening of the gap was the alignment correction angle. In addition, 2 sagittal K-wires were drilled parallel to each other before the gap opening above and below the osteotomy site. Ensuring that these 2 sagittal K-wires remained parallel after the gap opening confirmed that the tibial slope had been maintained. The paired t test was used to compare the desired alignment corrections and the different angles measured between the pre- and postoperative radiographic alignments.Results:The mean ± SD differences in angles between the pre- and postoperative alignments of the 5° and 10° corrections were 5.04° ± 0.68° and 10.03° ± 0.68°, respectively, indicating no statistically significant differences between pre- and postoperative alignment in both groups. As well, no significant difference was noted between the pre- and postoperative medial tibial slope (P = .54).Conclusion:The coronal alignment correction and maintenance of the tibial slope using the 4-reference K-wire technique was found to be highly accurate and reliable.Clinical Relevance:Achieving the correct angle in OWHTO is difficult, and the 4-reference K-wire technique provides an easier and more reliable way to obtain the correct angle. This technique can be used in most hospital settings, with no need for expensive equipment.

Patients have a wider stance following valgus high tibial osteotomy

Purpose: Valgus high tibial osteotomy (HTO) has been shown to be an effective treatment for patients with medial compartment osteoarthritis (OA) in a varus knee. However, the precise mechanisms by which this operation has its clinical effect are unclear. Previous studies have suggested that a wider stance gait can reduce medial compartment loading via a reduction in the external knee adduction moment (KAM); a measure which has been implicated in the progression of medial compartment OA. This study aimed to measure to what extent a valgus HTO is associated with a postoperative increase in static stance width. Methods: 32 patients, recruited as part of the Biomechanics and Bioengineering Centre Versus Arthritis HTO study, underwent valgus (medial opening wedge) HTO and had preoperative and postoperative radiographs taken, showing both lower limbs whilst weightbearing. The horizontal distance was measured from a fixed point on the right talus to the corresponding point on the left. This was then divided by the talus width to give a standardised “stance width” for each radiograph. The difference between the preoperative stance width and postoperative stance width was compared for each patient and a paired sample t-test performed. Results: Preoperatively, the mean stance was 4.00 talar-widths but postoperatively this increased to a mean of 5.41. This mean increase of 1.42 talar-widths was statistically significant (p=0.001) and represents a mean proportional increase in stance width of 35.5% following high tibial osteotomy. Of the 32 patients, 23 showed increased stance width post-operatively and 9 decreased with a range of -4.64 to 6.00 talar-widths. Conclusions: These findings show that frontal plane surgical realignment at the proximal tibia via a medial opening wedge HTO is associated with an increased stance width on postoperative radiographs. Both a wider stance gait and HTO have been shown to affect the progression of medial compartment OA so these results may explain part of the mechanism behind the efficacy of HTO. However, the range of changes in stance width within this patient group suggests a significant degree of variability in how patients adapt at a whole-limb and whole-body level following surgical realignment at the proximal tibia.