A critical appraisal of medial open wedge high tibial osteotomy for knee osteoarthritis

A medial open wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure to correct varus deformity related to Knee Osteoarthritis. It consistently provides relief in knee pain and improves knee function. This technique is recommended for active, middle and old aged individuals with an isolated medial compartment knee OA. The MOWHTO scores several advantages over lateral closed wedge osteotomy and hence is now a preferred choice of HTO.     

Upper tibial osteotomy for secondary osteoarthritis of the knee

Of 34 consecutive proximal tibial osteotomies for secondary degenerative arthritis in patients under 40 years of age, 33 were evaluated at least three years (mean 7.5 years) after operation. In all 73% were satisfactory, with four failures in 21 procedures in men and five failures in 12 procedures in women. The primary abnormalities were medial meniscectomy (11), medial and lateral meniscectomy (4), osteochondritis dissecans (3), osteochondritis dissecans with medial meniscectomy (4) and fracture (11). All four knees with both medial and lateral meniscectomy had unsatisfactory results despite obtaining anatomical alignment. Eight patients needed subsequent surgery; five of them had total knee replacement, four within four years of the osteotomy. Proximal tibial osteotomy in younger patients with secondary arthritis gives similar results to those for older patients with primary osteoarthritis. If it fails, this is generally within the first four years after the operation.     

High valgus tibial osteotomy for osteoarthritis of the knee

Summary We report a statistical analysis of the results of 65 tibial osteotomies for primary osteoarthritis of the knee followed up at 3 and 5 years. Preoperative walking ability and the severity of pain are the factors with which the long term prognosis can best be correlated. The preoperative range of motion and mild subluxation become important at 5 years, but these factors were not important at 3 years. Mild instability did not have any influence. The severity of the osteoarthritis in radiographs and the postoperative femoro-tibial angle did not have any important association with the result.The results are therefore best predicted by preoperative pain and activity. The degree of correction did not affect the result.

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Résumé Les auteurs présentent une analyse statistique des résultats à 3 et à 5 ans de l'ostéotomie tibiale pour arthrose sur genu varum, afin d'évaluer l'influence de certains facteurs pré et post-opératoires sur les résultats à distance. Ils ont trouvé que les capacités de marche et l'importance des douleurs étaient les principaux facteurs auxquels le pronostic à long terme pouvait être correlé. La gravité des lésions radiologiques et l'alignement fémorotibial post-opératoire n'influaient pas notablement sur le résultat final. La mobilité pré-opératoire et l'existence d'une subluxation modérée n'avaient d'influence que sur les résultats à 5 ans, mais non à 3 ans. Une instabilité légère semblait n'avoir aucun effet sur le résultat. On peut en conclure que ce sont l'importance de la douleur et le niveau d'activité qui constituent les meilleurs facteurs prédictifs du résultat de l'ostéotomie tibiale. Le valgus post-opératoire ne joue pas vraiment de rôle vis-à-vis du résultat final.

     

胫骨高位截骨治疗膝关节骨性关节炎

目的：总结外侧闭合楔形胫骨高位截骨术（high tibial osteotomy，HTO）治疗膝关节单间室骨性关节炎引起的关节疼痛临床应用结果。方法：应用外侧闭合楔形HTO治疗9例（男3例，女6例）伴内翻畸形的膝关节单间室骨性关节炎。年龄52～58岁，平均56岁。术中显露胫腓关节近侧，切开前侧关节囊，用骨锯或骨刀去除外侧楔形骨块，闭合截骨处缺损后用“U”形钉固定。结果：手术顺利，无手术并发症，经2-5、5年（平均3．5年）随访，按膝关节骨性关节炎疗效评定标准：优5例，良好3例，尚可1例。结论：外侧闲合楔形HTO是治疗膝关节单间室骨性关节炎引起关节疼痛的有效手术方法，但不适用于年龄过大的患者（〉60岁）。     

High tibial osteotomy for osteoarthritis of the knee: a changing concept.

High tibial osteotomy is most successful in patients with osteoarthritis with mild varus deformity which is not associated with subluxation of flexion contracture. Success in the valgus knee is limited. If tibial osteotomy is indicated, undercorrection is undesirable in the varus knee while overcorrection is undesirable in the valgus knee.     

Clinical effectiveness of high tibial osteotomy for osteoarthritis of the knee

An audit of high tibial osteotomy was done for 96 knees in 81 patients who had pain due to medial compartment osteoarthritis (OA) of the knee. The mean follow-up was 4.5 years. A modified preoperative and postoperative knee score was used to assess the knee pain and function for each patient. The standard 5-year follow-up results for this procedure, as described in the literature, is 85%. Our results were 71% satisfactory and good. This was because a large proportion of the Salisbury population was involved in farming and they wanted to carry on strenuous activities. Therefore they were not suitable candidates for total knee replacement. Since then we have changed our practice and are restricting this procedure to people who are less than 65 years old and we perform a pre-osteotomy arthroscopy as a matter of routine. It has been 2 years now since we have changed our practice. We will have to wait for at least 3 more years to evaluate our 5-year results in order to close the audit loop.     

膝关节骨关节炎合并膝内翻、胫骨高位截骨的治疗

目的　观察胫骨高位截骨治疗合并内翻畸形的膝关节骨关节炎 (OA)近、远期疗效 ,确定远期良好疗效的最佳下肢力线及术后各不同阶段的临床效果。方法　术前对所有手术患者进行临床X线检查的综合评估 ,测量全下肢立位力线 ,确定矫正截骨角度 ,采用胫骨高位楔形截骨术矫正下肢力线 ,术后 1年、2年、5～ 9年按同一评估标准进行追踪观察。资料应用 χ2检验分析。 结果　随访结果参考窦宝信标准进行综合评定 ,术后 1年组优良率 98.2 8% ,2年组优良率 96 .0 8% ,5～ 9年组优良率 78.12 % ,手术最佳下肢力线为 182°～ 185°。结论　全下肢立位力线测量准确性高 ,可重复性好 ,胫骨高位楔形截骨术矫正下肢力线治疗合并内翻畸形的膝关节OA ,矫正角度易于掌握 ,截骨部位愈合好 ,近、远期疗效高 ,是单侧股 -胫关节病变为主的膝关节OA患者首选的治疗方法。     

Inverted V-shaped high tibial osteotomy compared with closing-wedge high tibial osteotomy for osteoarthritis of the knee. Ten-year follow-up result

We compared the results ten years after an inverted V-shaped high tibial osteotomy with those of a historical series of conventional closing-wedge osteotomies. The closing-wedge series consisted of 56 knees in 51 patients with a mean follow-up of 11 years (10 to 15). The inverted V-shaped osteotomy was evaluated in 48 knees in 43 patients at a mean follow-up of 14 years (10 to 19). All the patients were scored using the Japanese Orthopaedic Association rating scale for osteoarthritis of the knee and radiological assessment. The pre-operative grade of osteoarthritis was similar in both groups. Post-operatively, the knee function score was graded as satisfactory in 63% (35) of the closing-wedge group but in 89% (43) of the inverted V-shaped osteotomy group. Post-operative radiological examination showed that delayed union and loss of correction occurred more often after a closing-wedge osteotomy than after an inverted V-shaped procedure. Our study suggests that the inverted V-shaped osteotomy may offer more dependable long-term results than traditional closing-wedge osteotomy.     

Long-term results of high tibial osteotomy for medial osteoarthritis of the knee

We reviewed retrospectively the results in patients who had undergone one hundred and four high tibial lateral osteotomies. The operations were all performed between 1985 and 1993. Each one of fifty men and forty nine women demonstrated a varus deformity of the knee with a coexistent medial osteoarthritis. Results were reviewed in 49 patients (62 knees) with an average follow-up of 10.2 years (range 6-14 years). Of the remaining 42 patients, 8 were lost to follow-up, 10 had died, and 24 were subsequently treated with total knee arthroplasty at an average 4.7 years after having had a high tibial osteotomy. Clinical results were evaluated using the Hospital for Special Surgery Score (HSS) and the Knee Society Score. Radiographs were systematically analysed to evaluate osteoarthritis and leg axis. Forty four (90 per cent) of the forty nine patients stated the results met their expectations and given the same circumstances, they would have the operation once again. In these patients the knee score results were excellent. The same patients had excellent HSS and Knee Society Scores. Five patients (10 per cent) had a poor result and twenty four patients were treated later by total knee arthroplasty because of pain. The following factors set these patients apart from those with more favorable results: previous arthroscopic debridement, obesity, lateral knee osteoarthritis, insufficient valgus correction, and an age of more than 55 years. High tibial valgus osteotomy provides good pain relief and improved function in carefully selected patients. Our results support this conclusion.     

Dome-shaped proximal tibial osteotomy using percutaneous drilling for osteoarthritis of the knee

We have improved a surgical technique for proximal tibial osteotomy that involves percutaneous drillings. We performed the modified dome-shaped proximal tibial osteotomy on 44 knees in 42 patients (8 men and 34 women) with an average age of 66 years (range 50-78 years) for osteoarthritis of the knee. The mean follow-up period was 39 months (range 24-63 months). The varus angle was 4 degrees +/- 3.6 degrees (mean +/- SD) preoperatively, and the valgus angle was 12 degrees +/- 3.3 degrees postoperatively. Pain relief was obtained in all cases postoperatively. Transient pin tract infection occurred in one case, but it resolved completely following local irrigation. Intercondylar fracture of the upper fragment with no displacement was noted in two patients. They were treated with AO cancellous screw fixation, and improvement of pain was obtained in both cases. Osteotomy drill guide instruments are useful for accurately performing dome-shaped osteotomy. Our proximal tibial dome osteotomy with an external fixator allowed early motion and accurately maintained the angle of correction.     

胫骨高位双平面截骨术治疗膝内侧间室骨关节炎

目的探讨胫骨高位双平面截骨术治疗膝内侧间室骨关节炎的近期疗效。方法采用胫骨高位双平面截骨术治疗37例膝内侧间室骨关节炎患者。测量手术前后膝关节站立负重位X线片胫股解剖角、髋—膝—踝角,记录手术前后膝关节损伤和骨关节炎KOOS评分、KSS评分和疼痛VAS评分。结果患者均顺利完成手术。术后未出现感染、骨筋膜室综合征、腓总神经损伤、下肢深静脉血栓等并发症,截骨处愈合良好,患者膝内翻畸形情况均得到矫正。37例均获得随访,时间6~30(18.6±7.0)个月。胫股解剖角、髋—膝—踝角、KOOS评分、KSS评分、VAS评分术后3个月较术前明显改善,差异均有统计学意义(P<0.001)。结论胫骨高位双平面截骨术治疗膝内侧间室骨关节炎能够纠正下肢异常力线,缓解或者消除膝关节疼痛症状,短期疗效满意。     

Quadriceps muscle function after high tibial osteotomy for osteoarthritis of the knee

In patients with osteoarthritis of the knees, quadriceps muscle dysfunction is an early and common clinical feature and an important determinant of disability. In the current study, changes in quadriceps muscle strength and voluntary quadriceps muscle activation after high tibial osteotomies for primary osteoarthritis of the knee in 19 patients were investigated. Quadriceps muscle function was assessed during different degrees of isometric maximum voluntary contraction using a specially built chair. One year after surgery all patients had reexamination of their surgically treated and contralateral knees. Voluntary activation and maximum voluntary contraction values of the followup assessment were significantly lower in the surgically treated knees compared with the preoperative assessment. In the contralateral knees, there were no differences between preoperative and followup measurements. High tibial osteotomy is an extraarticular operative therapeutic approach to treatment of osteoarthritis of the knee that does not lead to improvement of quadriceps muscle function. Because there is evidence that quadriceps sensorimotor dysfunction is important not only for the disability in osteoarthritis of the knee, but also for progression of the disease, knee function may be worsened by high tibial osteotomy in some patients.     

Three-dimensional knee motion before and after high tibial osteotomy for medial knee osteoarthritis

Background High tibial osteotomy (HTO) is an established surgical option for treating medial knee osteoarthritis. HTO moves the mechanical load on the knee joint from the medial compartment to the lateral compartment by changing the leg alignment, but the effects of the operation remain unclear. The purpose of this study was to evaluate the change in three-dimensional knee motion before and after HTO, focusing on lateral thrust and screw home movement, and to investigate the relationship between the change in knee motion and the clinical results. Methods A series of 19 patients with medial knee osteoarthritis who had undergone HTO were evaluated. We performed a clinical assessment, radiological evaluation, and motion analysis at 2.4 years postoperatively. The clinical assessment was performed using the Japanese Orthopaedic Association knee score. Results The score was significantly improved in all patients after operation. Motion analysis revealed that lateral thrust, which was observed in 18 of the 20 knees before operation, was reduced to 7 knees after operation. Regarding active terminal extension of the knee, three patterns of rotational movement were observed before operation: screw home movement (external rotation), reverse screw home movement (internal rotation), and no rotation. By contrast, after operation, only reverse screw home movement and no rotation were observed; the screw home movement disappeared in all patients. In the knees with reverse screw home movement after operation, the preoperative score was significantly lower than those in the knees with no rotation after operation. Conclusions Kinetically, HTO was useful for suppressing lateral thrust in medial knee osteoarthritis, although the rotational movement of the knee joint was unchanged.     

Proximal tibial osteotomy in the treatment of osteoarthritis of the knee

A long-term follow-up study is presented of 162 patients who were treated for knee arthrosis with proximal tibial osteotomy, 10 of whom had undergone a bilateral operation. The average follow-up time was 8 years. Pre-operatively, varus deformity was found in the knees of 117 patients; 45 of them had valgus knees. In 142 knees curved osteotomy was performed and wedge osteotomy in 30. At follow-up, 33% of the patients were found to have no pain. Significant long-term improvement was achieved, as registered at the time of follow-up, in 80% of the patients, whereas in 11% pain remained unchanged. Better results were recorded in women than in men (P less than 0.01). In the present study, slightly better results were obtained statistically using curved osteotomy (P less than 0.05). Postoperative plaster sleeve immobilisation for approximately 6 weeks (10 weeks at the most) gave the best results. Internal fixation seemed unnecessary.     

Proximal tibial osteotomy in the treatment of osteoarthritis of the knee

Summary A long-term follow-up study is presented of 162 patients who were treated for knee arthrosis with proximal tibial osteotomy,10 of whom had undergone a bilateral operation. The average follow-up time was 8 years. Pre-operatively, varus deformity was found in the knees of 117 patients; 45 of them had valgus knees. In 142 knees curved osteotomy was performed and wedge osteotomy in 30. At follow-up, 33% of the patients were found to have no pain. Significant longterm improvement was achieved, as registered at the time of follow-up, in 80% of the patients, whereas in 11% pain remained unchanged. Better results were recorded in women than in men (P<0.01). In the present study, slightly better results were obtained statistically using curved osteotomy (P<0.05). Postoperative plaster sleeve immobilisation for approximately 6 weeks (10 weeks at the most) gave the best results. Internal fixation seemed unnecessary.

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Zusammenfassung Es wird berichtet über eine Spätuntersuchung nach proximaler Tibiaosteotomie wegen Kniegelenkarthrose bei 162 Patienten, von denen 10 doppelseitig operiert wurden. Die durchschnittliche Beobachtungszeit betrug 8 Jahre. Präoperativ bestand bei 117 Patienten eine Varusfehlstellung und bei 45 Patienten eine Valgusfehlstellung des Kniegelenkes. An 142 Kniegelenken wurde eine bogenförmige Osteotomie und an 30 Kniegelenken eine Keilosteotomie ausgeführt. Bei der Nachuntersuchung waren bei 33% der Patienten die Kniegelenke schmerzfrei. Eine signifikante langfristige Beschwerdebesserung wurde bei 80% der Patienten verzeichnet, während bei 11% die Schmerzen unverändert waren. Bei Frauen waren die Ergebnisse besser als bei Männern (P < 0,01). Statistisch geringfügig bessere Ergebnisse wurden bei der bogenförmigen Osteotomie erzielt (P<0,05). Eine postoperative Immobilisation mit einer Gipshülse für etwa 6 Wochen, höchstens 10 Wochen, ergab die besten Ergebnisse. Eine Osteosynthese erscheint unnötig.

     

High tibial osteotomy combined with anterior displacement of the tibial tubercle for osteoarthritis of the knee

Summary Eighty-nine knees with medial tibiofemoral and patellofemoral osteoarthritis were treated by high tibial osteotomy between 1972 and 1978, and 71 were followed up for at least 5 years, the average being 6 years and 9 months. There was no significant loss of motion as recorded before and after operation. In most patients pain decreased or disappeared, and walking ability was regained. Evaluation using the Japanese rating system showed that there were Good and Fair results in 86% of the cases. The average tibio-femoral angle in the Good group was 169±5°. The angles in the Poor group varied over a wide range. There were serious complications such as nonunion, malunion and infection in a few cases. In Group 1 (30 knees) high tibial osteotomy alone was performed. In Group 2 (41 knees) there were associated osteoarthritic changes in the patellofemoral joint and a high tibial osteotomy was combined with anterior displacement of the tibial tubercle (ventralisation). In comparison, Group 2 had better results with regard to both clinical and radiological evaluation.Read at the 16th Congress of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie, London, England, 5th October, 1984     

Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee

From 1960 through 1979, a closing-wedge varus osteotomy of the proximal part of the tibia was performed in thirty-one knees (twenty-eight patients) for painful osteoarthritis of the lateral compartment of the knee that was associated with a valgus deformity. The patients were followed for two to seventeen years (average, 9.4 years). Twenty-four knees (77 per cent) had either no pain or only occasional mild pain at the last evaluation. Six knees had moderate pain and one, severe pain. Six knees required a subsequent total knee arthroplasty at an average of 9.8 years after the osteotomy. No patient had an infection or non-union. Osteotomy of the proximal part of the tibia is a reasonable method of treating unicompartmental degenerative arthritis in a knee with a valgus deformity. Although some patients with as much as 20 degrees of anatomical valgus deformity obtained a good result in this series, osteotomy in the supracondylar region of the femur is probably preferable if the valgus angulation exceeds 12 degrees or if the tilt of the tibial articular surface that will result from the surgery will exceed 10 degrees. Correction beyond the normal 5 to 7 degrees of valgus angulation to zero degree of anatomical tibiofemoral alignment is recommended to prevent recurrence of the valgus deformity and to decrease the load on the lateral tibiofemoral compartment.     

The effect of high tibial osteotomy on osteoarthritis of the knee

Summary High tibial osteotomies were performed on 136 osteoarthritic knees for correction of varus deformity. Before osteotomy all patients experienced moderate or severe pain, and the knees showed lateral thrust on weight-bearing. The patients were followed up for one to five years. Marked relief of pain was obtained in 112 knees, and the patients were satisfied with the result of operation in 122. These painless knees showed no lateral thrust, and in the majority the deformity had been adequately corrected, with post-operative femoro-tibial angles (standing) ranging from 165° to 174°. Four of 28 knees with femoro-tibial angles of 175° to 179°, when measured one year after operation, showed recurrence of varus deformity three years after osteotomy. Preoperative ranges of knee motion were well maintained after osteotomy even when arthrotomy had also been undertaken. Intra-articular assessment in two patients, several years after operation, showed that the most degenerated portions of the articular surface were completely covered by a fibrocartilagenous layer, with no bare bone.High tibial osteotomy is most effective in osteoarthritic knees with varus deformity, when correction is made to a femoro-tibial angle (standing) of 170° (10° valgus).

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Résumé Une ostéotomie de l'extrémité supérieure du tibia a été réalisée chez 125 malades (136 genoux) porteurs d'une arthrose sur genu varum. Avant l'intervention, tous les sujets se plaignaient de douleurs plus ou moins importantes et présentaient une augmentation de la déformation lors de l'appui.Le recul est de 1 à 5 ans. Une diminution notable des douleurs a été obtenue sur 112 genoux et 122 malades sont satisfaits de l'intervention. Les genoux stables et indolores ne présentent plus de bâillement externe et ont été en majorité corrigés de façon satisfaisante, avec un angle fémoro-tibial compris entre 165° et 174°. Sur les 28 genoux comportant un angle de 175° à 179° un an après l'opération, 4 ont donné lieu à une récidive du varus trois ans après l'ostéotomie. La mobilité pré-opératoire a été conservée, même dans les cas où une arthrotomie a été associée à l'ostéotomie. Un bilan intraarticulaire, effectué chez 2 malades, plusieurs années après l'ostéotomie, a montré que les parties les plus détruites de la surface articulaire étaient complétement recouvertes d'un tissu fibro-cartilagineux.L'ostéotomie tibiale est efficace dans l'arthrose sur genu varum, surtout si la correction réalise un angle fémoro-tibial de 170°, soit 10° de valgus.