Factors influencing long-term results in high tibial osteotomy

Recorded here is a comprehensive review of the current literature on high tibial osteotomy with emphasis on postponing an inevitable total knee arthroplasty (TKA). Accompanying this review is a confirmatory, retrospective study of 35 patients with 39 high tibial osteotomies with an average follow-up study of 8.5 years (range, 3.8-15.1 years). Twenty-two of the patients (57%) had good results, seven (18%) fair, and ten (25%) poor at final follow-up examination. Nine of the 35 patients required TKA at an average of 4.7 years post-osteotomy. The percentage of good results diminished with time of follow-up study, starting at two years with 87% good results and ending at 15 years with only 57% of the patients remaining in that category. Patients lost an average of 8 degrees of flexion post-osteotomy, regardless of good, fair, or poor result. Patients with favorable results were usually younger than 60 years of age, and had less than 12 degrees of angular deformity, pure unicompartmental disease, ligamentous stability, and a preoperative range of motion are of at least 90 degrees.     

Roentgen stereophotogrammetry in high tibial osteotomy for gonarthrosis

Summary In three cases operated with high tibial osteotomy for medial gonarthrosis the exact method of roentgen stereophotogrammetry with tantalum balls as bone markers (Selvik 1974) was used to study angular and translational movements in three dimensions at the operation and during the healing period. Tibial osteotomy caused angular and translational movements even in planes where correction was not intended, and the stereo technique revealed that stability was not present when knee mobilisation started. Correlation between the stereo values and conventional radiographic measurements were best in the frontal plane (root mean square value of discrepancies 1.3°). Roentgen stereophotogrammetry gives superior information compared with the conventional radiographic technique, but it is concluded that the latter has sufficient accuracy for the clinical assessment of corrections in the frontal plane.     

Ten-year results of tibial osteotomy for medial gonarthrosis

Summary The results in relation to the correction achieved 1 year after surgery of a series of tibial osteotomies in 50 patients (52 knees) are presented with a total observation time of 10 years. Mean age at the time of osteotomy was 56 years. Overcorrected knees had a significantly better result after 10 years. Progress of gonarthrosis occured in 6/34 overcorrected knees compared with 3/4 in the normo- and undercorrected group. One out of 34 overcorrected knees recurred in varus. Five knees were revised by knee arthroplasty or reosteotomy, one of which was overcorrected.     

Medium- and long-term results of high tibial osteotomy for varus gonarthrosis in an agricultural population.

High tibial valgus osteotomy for varus gonarthrosis was performed in 63 consecutive patients in a homogenous agricultural population using two different surgical techniques. Patients were divided into two groups. A two-level Mittelmeier osteotomy was performed in group A patients, and a lateral closed wedge high tibial osteotomy using the AO/ASIF L-plate was performed in group B patients. Operations were performed by two different groups of surgeons. Patients were evaluated postoperatively for correction of knee axis, functional result, subjective impression, and complications. In group A patients, 80% of the operated knees were corrected to the mechanical axis and in group B patients, 82% of the knees were corrected to 6 degrees-10 degrees valgus of the anatomical axis. Ninety percent, 70%, and 54% of group A and 91%, 73%, and 57% of group B patients were rated as satisfactory results at 5, 9, and 12 years postoperatively, respectively; these differences were not statistically significant. One year postoperatively, 91% of group A and 96% of group B patients reported their symptoms had improved. However, patient satisfaction decreased at 5, 7, and 12 years postoperatively, with 91%, 89%, and 66% of group A and 96%, 93%, and 68%, respectively, of group B patients reporting their symptoms had improved; these differences were not statistically significant. Postoperatively, most patients returned to full agricultural activity. Total knee arthroplasty, which was later required in 12% of the knees, was not significantly jeopardized by the previous osteotomy.     

Medial and lateral gonarthrosis treated with high tibial osteotomy

Summary A prospective series comprising 52 knees in 48 patients suffering from medial or lateral unicompartmental gonarthrosis and treated by means of high tibial osteotomy shows, by comparing mechanical axis (MA) 0° corrected knees, how important is the overcorrection of the MA into valgus in medial osteoarthritis. The clinical results were significantly correlated to overcorrection, the results 2 years post-operatively being better than those obtained at a follow-up 1 year after the operation. Of the results, 82% were good within a limit of ± 3° after 2 years, while only 77% were correspondingly good 1 year postoperatively. In lateral gonarthrosis overcorrection was not as good, but there was a mean overcorrection of + 2°, and with respect to this overcorrection, the results were quite acceptable. The results were directly correlated to the opening up of the joint space affected (80%) and diminution or disappearance of subluxation, 1/3 being 0° preoperatively, 1/2 postoperatively in medial gonarthrosis. In lateral gonarthrosis, subluxation was increased, with 2/3 being 0° preoperatively, 1/3 being 0° postoperatively. The extension deficit in varus knees significantly diminished after valgus osteotomy; the change in valgus knees was also evident but not significant. The mean value of extension deficit was below 5° in all cases at the 2 years¹ follow-up examination. However, 95% of all patients showed good or fair results after a follow-up period of 2 years.     

Gait analysis in patients with gonarthrosis treated by high tibial osteotomy

The basic parameters of gait were studied in 14 patients with medial gonarthrosis before and eight to 12 months after high tibial osteotomy. In seven patients, the osteotomy was fixed with staples. The patient was placed in plaster immobilization for six weeks and weight bearing was allowed after ten weeks. In the other seven patients, the osteotomy was fixed with a T-plate, and immediate joint motion and weight bearing were allowed after six weeks. There was no difference in any parameter of gait among patients treated with the two techniques. For all patients, the mean maximal velocity preoperatively was 65% of that of normal people, with only a slight, nonsignificant increase at the follow-up examination. An additional indication of insufficient rehabilitation was the decrease in stride length at constant maximal velocity at the follow-up evaluation. Positive correlations were found between stride length and muscle torque in the thigh. Positive correlations were also found between a subjective score and maximal velocity. Simple tests of velocity, stride length, and stride frequency are recommended as an easy and decisive method of follow-up evaluation.     

Medical and lateral gonarthrosis treated with high tibial osteotomy. A prospective study

A prospective series comprising 52 knees in 48 patients suffering from medial or lateral unicompartmental gonarthrosis and treated by means of high tibial osteotomy shows, by comparing mechanical axis (MA) 0 degrees corrected knees, how important is the overcorrection of the MA into valgus in medial osteoarthritis. The clinical results were significantly correlated to overcorrection, the results 2 years postoperatively being better than those obtained at a follow-up 1 year after the operation. Of the results, 82% were good within a limit of +/- 3 degrees after 2 years, while only 77% were correspondingly good 1 year postoperatively. In lateral gonarthrosis overcorrection was not as good, but there was a mean overcorrection of +2 degrees, and with respect to this overcorrection, the results were quite acceptable. The results were directly correlated to the opening up of the joint space affected (80%) and diminution or disappearance of subluxation, 1/3 being 0 degrees preoperatively, 1/2 postoperatively in medial gonarthrosis. In lateral gonarthrosis, subluxation was increased, with 2/3 being 0 degrees preoperatively, 1/3 being 0 degrees postoperatively. The extension deficit in varus knees significantly diminished after valgus osteotomy; the change in valgus knees was also evident but not significant. The mean value of extension deficit was below 5 degrees in all cases at the 2 years' follow-up examination. However, 95% of all patients showed good or fair results after a follow-up period of 2 years.     

Prediction of long-term outcome of tibial osteotomy in medial gonarthrosis

To predict the long-term outcome after tibial osteotomy for medial gonarthrosis, multivariate statistical techniques were used and prognostic equations were defined. A comparison between different evaluation systems was also performed. Clinical and radiographic data from 81 patients followed up for more than 7 years were used. Twenty-eight preoperative variables were analysed in relation to the outcome at 7 years with the multivariate procedures discriminant analysis and cluster analysis. Among the variables, knee flexion and walking capacity were found to be the most dominant factors. Excluding the undercorrected osteotomies, preoperative walking capacity was now the dominating variable for prediction. Seven years postoperatively only small differences were found between the evaluation criteria of pain relief, London Hospital score, and HSS score. The discriminant functions for the highest ranked evaluation criteria are given in the text, as are dendrograms showing the patterns of interdependence between the evaluation criteria. Thus it was possible to transform clinical entities into factors suitable for determination and calculation of postoperative evaluation. The most commonly used evaluation systems had very similar discriminant functions showing good agreement.     

Prediction of long-term outcome of tibial osteotomy in medial gonarthrosis

Summary To predict the long-term outcome after tibial osteotomy for medial gonarthrosis, multivariate statistical techniques were used and prognostic equations were defined. A comparison between different evaluation systems was also performed. Clinical and radiographic data from 81 patients followed up for more than 7 years were used. Twenty-eight preoperative variables were analysed in relation to the outcome at 7 years with the multivariate procedures discriminant analysis and cluster analysis. Among the variables, knee flexion and walking capacity were found to be the most dominant factors. Excluding the undercorrected osteotomies, preoperative walking capacity was now the dominating variable for prediction. Seven years postoperatively only small differences were found between the evaluation criteria of pain relief, London Hospital score, and HSS score. The discriminant functions for the highest ranked evaluation criteria are given in the text, as are dendrograms showing the patterns of interdependence between the evaluation criteria. Thus it was possible to transform clinical entities into factors suitable for determination and calculation of postoperative evaluation. The most commonly used evaluation systems had very similar discriminant functions showing good agreement.

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Zusammenfassung Für die Vorhersage des Langzeitergebnisses einer proximalen Tibiaosteotomie bei medialer Gonarthrose wurden multivariante statistische Techniken benutzt and prognostische Zusammenhänge definiert. Außerdem wurde ein Vergleich zwischen verschiedenen Beurteilungssystemen vorgenommen. Klinische and röntgenologische Daten von 81 Patienten, die über mehr als 7 Jahre verfolgt wurden, sind dieser Untersuchung zugrunde gelegt wurden. 28 präoperative Variable wurden im Vergleich mit dem Ergebnis nach 7 Jahren mit der Diskriminanzanalyse untersucht. Unter den verschiede nen Variablen waren die Kniebeugung and die Gehstrecke die am meisten dominierenden Faktoren. Unter Ausschluß der unterkorrigierten Osteotomien war die präoperative Gehstrecke die wichtigste Variable für eine Vorhersage. 7 Jahre postoperativ wurden nur geringe Unterschiede gefunden zwischen den Beurteilungskriterien Schmerzlinderung, London Hospital Skala and HSS-Bewertungsskala. Die Diskriminanzfunktion fur die am höchsten bewerteten Beurteilungskriterien sind im Text erläutert, ebenso die Dendogramme, die das Muster der Wechselbeziehungen zwischen den Beurteilungskriterien zeigen. Dementsprechend war es möglich, klinische Begriffe in kalkulierbare Faktoren für die postoperative Beurteilung zu üiberführen.

     

Use of a low-profile thigh holder to facilitate high tibial osteotomy for varus gonarthrosis

In the performance of a proximal tibial osteotomy, the maintenance of proper leg positioning on a standard operating table can be cumbersome. A low-profile thigh holder commonly used for arthroscopic knee surgery effectively positions the limb and simplifies the performance of high tibial osteotomy.     

Boomerang proximal tibial osteotomy for the treatment of severe varus gonarthrosis

Purpose

The purpose of the study was to review the results of modified infratubercle displacement osteotomy in patients with severe varus gonarthrosis and to determine the factors influencing outcomes.

Methods

A total of 177 knees in 133 patients with severe varus gonarthrosis were treated with infratubercle boomerang-shaped osteotomy, stabilised with dual plates. The mean age of the patients was 63.8 years (range 43–80 years), and the mean follow-up period was 61.4 months (range 24 –139 months). The factors associated with clinical and survival outcomes were analysed including age, gender, body mass index (BMI), preoperative and post-operative femorotibial angle and femorotibial angle at one year after surgery.

Results

Using the Knee Society clinical rating system 149 knees or 84.2 % were rated as having good to excellent results and 21 knees or 15.8 % as having fair to poor results. Overall, the mean preoperative knee score of 33.6 points had improved significantly to 80.7 points at the final follow-up (p < 0.001). Using Kaplan-Meier survivorship analysis the five-year survival was 97.1 % with conversion to arthroplasty or second osteotomy as the end point and 89.2 % with a knee score of under 70 points as the end point. The anatomical femorotibial angle at one year after osteotomy had the most significant positive effect on the clinical (p < 0.001) and survival outcomes for all end points (p = 0.002 for conversion to arthroplasty or second osteotomy and p < 0.001 for knee score less than 70 points).

Conclusions

The boomerang osteotomy can create adequate valgus alignment in severe varus gonarthrosis. The one-year post-operative knee alignment of 11° valgus provided the most satisfactory results and that between six and 15° valgus the longest survival time.     

Short- and mid-term results after combined high tibial osteotomy

In a consecutive series, 103 knees were treated with combined osteotomy. From these 103 knees, 80 knees were studied. Mean follow-up was 54.15 months (range: 13-96 months). After the first osteotomy is made 2 cm distally to the joint line, a bone wedge is removed based laterally. Its tip ends at the center of the tibial head/half bone wedge. The distal part of the tibia is placed into the valgus position and the half bone wedge is placed into the gap opened medially. The result was excellent in 44%, good in 45%, and poor in 11% of the knees.     

Open wedge tibial osteotomy by callus distraction in gonarthrosis: Operative technique and early results in 36 patients

Proximal tibial osteotomy is indicated in cases of medial gonarthrosis with varus deformity in the active, younger patient. We report our experience of the hemicallotasis technique in 36 patients and the early clinical results after a median follow-up of 14 (11-16) months. The median patient age was 54 (33-64) years. The median hip-knee-ankle (HKA) angle was 172 (161-179)^o preoperatively, 184 (178-187) after completed correction and 183 (175-190)^o at follow-up. The median fixation time was 88 (61-146) days. Complications were minor. Superficial pin-site inflammation/infections occurred in one fifth of the pins. The HSS score increased from a median 71 preoperatively to 94 at follow-up, the Lysholm score from 56 to 91 and the Tegner activity score from 6 to 10. The Nottingham Health Profile showed significant improvements as regards pain and physical mobility.     

Mid-term results of total knee arthroplasty after high tibial osteotomy

Background The outcome of total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is still controversial. In order to determine if osteotomy has any effect on this outcome we performed a medium-term review of a cohort of patients with knee osteoarthritis. Materials and methods Thirty-two patients (38 knees), who were treated with a HTO before the TKA during the last 8 years, were compared with a matched group who underwent primary TKA. The knees were evaluated preoperatively and postoperatively according to the scoring systems of the Knee Society and Hospital for Special Surgery (HSS). The anteroposterior tibiofemoral alignment, the Insall–Salvati patellar position ratio, range-of-motion and the location of the lateral joint line, were also recorded. The patients were reviewed with a mean follow-up of 4.5 years after TKA. Results The preoperative and postoperative knee scores had no statistically significant differences between the two groups. So was the case with the intraoperative releases, blood loss, thromboembolic or neurologic complications and infection rates in either group. Access to perform the arthroplasty was reportedly more difficult and took an average of 25 min longer. A significant difference (p < 0.05) was detected in terms of impingement of the tibial stem on the lateral tibial cortex, patellar subluxation and patella baja between the two groups but this did not have any influence on the outcome of the prosthesis. Knee alignment and stability so as range of motion (ROM) measurements were also found with no statistical significance. Conclusion Although we did manage to detect statistically significant differences mainly in radiographic results between the two groups, this situation did not appear to influence the clinical outcome of the patients, however. The fact that most of the patients had good or excellent results at an average follow-up of 4.5 years suggests that HTO does not have a significant negative effect on later TKA.     

Function after tibial osteotomy for medial gonarthrosis below aged 50 years

Twenty-seven patients (28 knees), with a median age of 42 (27-50) years treated with a high tibial osteotomy for early medial gonarthrosis (Ahlb?ck's Stage I) were examined after 11 (7-18) years. Twenty-four were men; 18 knees had had previous meniscus and ligament lesions. At follow-up, 22 knees were satisfactory and 9 patients managed high-activity sports or heavy work. In 25/28 knees, the arthrotic process had not progressed radiographically.