Changes in osseous correction after proximal tibial osteotomy: radiostereometry of closed- and open-wedge osteotomy in 33 patients

33 patients (22 men), median age 54 (40-68) years, with medial gonarthrosis grades 1-3, were treated by closed-wedge osteotomy (high tibial osteotomy = HTO, n 16) or open-wedge osteotomy by hemicallotasis (hemicallotasis osteotomy = HCO, n 19). 2 patients were operated on bilaterally. The patients were studied by RSA (radiostereometric analysis) for measuring 3-D changes in the correction achieved. In the HTO group the RSA measurements were obtained at the time of plaster removal, 1 month later and 1 year after surgery. In the HCO group, the RSA measurements were performed at the time of removal of the external fixator, 1 month later and 1 year after surgery. After removal of the fixation, HTO was associated with increased medial/lateral and distal translation of the proximal segment, compared to HCO. In addition, the tibial plateau rotated more around the longitudinal axis of the tibia after HTO.     

Changes in osseous correction after proximal tibial osteotomy: Radiostereometry of closed- and open-wedge osteotomy in 33 patients

33 patients (22 men), median age 54 (40-68) years, with medial gonarthrosis grades 1-3, were treated by closed-wedge osteotomy (high tibial osteotomy = HTO, n 16) or open-wedge osteotomy by hemicallota-sis (hemicallotasis osteotomy = HCO, n 19).

2 patients were operated on bilaterally. The patients were studied by RSA (radiostereometric analysis) for measuring 3-D changes in the correction achieved. In the HTO group the RSA measurements were obtained at the time of plaster removal, 1 month later and 1 year after surgery. In the HCO group, the RSA measurements were performed at the time of removal of the external fixator, 1 month later and 1 year after surgery.

After removal of the fixation, HTO was associated with increased medial/lateral and distal translation of the proximal segment, compared to HCO. In addition, the tibial plateau rotated more around the longitudinal axis of the tibia after HTO.     

A computer simulation study for preserving the tibial posterior slope in open-wedge high tibial osteotomy

European Journal of Orthopaedic Surgery & Traumatology - To measure the medial opening gap and examine a technique for preserving the tibial posterior slope (TPS) in open-wedge high tibial...     

开放胫骨高位楔形截骨术治疗膝关节内翻畸形

目的 评价双平面开放胫骨高位楔形截骨治疗成人膝关节内翻畸形的手术效果.方法 回顾性分析2001年6月至2008年7月存在膝关节内侧单间室退行性改变伴内翻畸形且进行双平面开放胫骨高位楔形截骨术治疗的12例患者的一般资料.术前膝内翻畸形5.0°～19.0°,平均11.5°;膝关节屈伸活动度大于90°;不伴有其他关节间室病变;1例伴有外侧副韧带及前交叉韧带断裂,行韧带重建手术后二期进行开放截骨矫形术.术前膝关节症状以内侧间室疼痛为主.手术前后测量患者关节活动度的大小,并对患者进行Lysholm评分.术后对患者进行主观满意度调查.结果 12例患者术后平均随访时间32.5个月.截骨处至术后12～16周均获得骨性愈合.矫正角度5.5°～18.0°,平均9.5°.在随访期间内X线检查下肢力线维持在术后水平,内外侧间室及髌股间室均未发现明显退变进展.手术总体效果优良率为83.3%,Lysholm评分、内翻角度变化在手术前后均有统计学显著性差异.结论 双平面开放胫骨高位楔形截骨术对中青年膝关节内翻畸形伴单间室退行性改变有良好的早、中期效果.     

胫骨高位截骨治疗膝关节骨性关节炎临床疗效分析

目的探讨闭合性与开放性胫骨高位楔形截骨术治疗膝关节单间室骨性关节炎的疗效。方法笔者自1998-03—2008-05采用闭合性胫骨高位楔形截骨(CWHTO)治疗膝关节骨性关节炎并内翻畸形90例(95膝),与自2007-08—2012-07采用开放性胫骨高位楔形截骨(OWHTO)治疗的膝关节内侧间室骨性关节炎并膝内翻27例(30膝)进行比较。采用膝关节HSS评分、VAS评分对术后疗效进行评价,下肢力线通过手术前后下肢全长X线片胫股角(FTA)、下肢负重线比率(WBL)评估。结果 OWHTO组获得平均60(36~96)个月随访。OWHTO组术后1周内屈曲可达90°,术后膝关节活动度、VAS评分、HHS评分、FTA及WBL均优于术前,差异均有统计学意义(P0.05)。CWHTO组获得平均144(80~204)个月随访。CWHTO组患者长腿管型石膏管型外固定4周后,去除石膏固定行免负重关节功能锻炼2周,骨折愈合后逐渐负重行关节功能锻炼。术后膝关节活动度、VAS评分、HSS评分、FTA、WBL均优于术前,差异均有统计学意义(P0.05)。所有患者无感染、截骨不愈合或延迟愈合发生,无腓总神经神经损伤、股四头肌力量及髌骨轨迹改变,无下肢短缩等发生,但行CWHTO截骨患者有下肢静脉血栓形成、有平台骨折发生。结论 2种截骨均能通过恢复下肢力线,达到缓解关节疼痛、改善关节功能,对于早期单间室骨性关节炎有较好疗效,开放楔形截骨更有优势。     

Limb alignment after open-wedge high tibial osteotomy and its effect on the clinical outcome

The purpose of this study was to evaluate the accuracy of alignment after open-wedge high tibial osteotomy and its effect on the clinical outcome. A prospective case series of 56 consecutive patients underwent open-wedge high tibial osteotomy fixed with a TomoFix plate fixator (Synthes, West Chester, Pennsylvania). The correction angle was radiologically determined preoperatively and at 6 months postoperatively. The patients were clinically and radiologically examined preoperatively and at 3, 6, and 36 months postoperatively. The mechanical axis of 50 knees was corrected from an average of 5.7° varus to 1.3° valgus. Forty-three patients had an acceptable correction with Mikulicz line crossing the tibial plateau between 50% to 70% of the tibial plateau width measured from the medial border. Undercorrection (<50%, group II) and over-correction (>70%, group III) were found in 4 and 3 patients, respectively. The mean Lysholm-Gillquist score at 36 months had improved in all groups, with a statistically lower value for group II. Open-wedge high tibial osteotomy results in significant improvement of symptoms and function in all patients in the short term, even with under- and overcorrection of the osteotomy. Undercorrection was associated with a significantly lower clinical outcome in comparison to the accurate correction and overcorrection. Ligamentous laxity or soft tissue slackness of the knee can influence the overall correction after high tibial osteotomy and must be considered in preoperative planning. Patients with a high body mass index had inferior clinical results after open-wedge high tibial osteotomy.     

The effect of plate position and size on tibial slope in high tibial osteotomy: a cadaveric study

Opening wedge high tibial osteotomies are performed for degenerative changes and varus. Opening wedge osteotomies can change proximal tibial slope in the sagittal plane, possibly imparting stability in the ACL-deficient knee. The aim of this study was to assess the effect of plate position and size on change in tibial slope. Eight cadaveric knees underwent opening wedge high tibial osteotomy with Puddu plates of each different size. Plates were placed anterior, central, and posterior for each size used. Lateral radiographs were obtained. Tibial slope was measured and compared with baseline slope. Tibial slope was affected by plate position (P < 0.05) and size (P < 0.001). Smaller, posterior plates had less effect on tibial slope. However, anterior and central plates increased tibial slope over all plate sizes (P < 0.05). This study found that tibial slope increases with opening wedge high tibial osteotomy. Larger corrections and anterior placement of the plate are associated with larger increases in slope.     

Comparative analysis of fixation configurations and their effect on outcome after medial open-wedge high tibial osteotomy

PurposeThe purposes of this study were to analyze and compare 1) the postoperative fixation configurations, and 2) radiological and clinical outcomes between the new conceptual fixation device (LCfit) and the conventional locking plates.MethodsRetrospective comparative analysis of 304 cases who underwent open-wedge high tibial osteotomy with four different locking plate systems including the LCfit system was conducted. In analyzing the fixation configuration of each locking plate system, the plate position, the gap between plate and bone, screw angle, and screw length were evaluated from postoperative CT scans. The clinical outcomes and radiological parameters of four patient groups corresponding to the four locking plate systems were also compared.ResultsIn the analysis of the fixation configurations, the LCfit system showed more posteromedial plate position, decreased gap between plate and bone, reduced screw angle, and longer screw length compared to the other three locking plates. However, there were no significant differences in clinical outcomes and radiological parameters such as hip-knee-ankle angle, weight-bearing line position, medial proximal tibial angle, and posterior slope between the four groups.ConclusionThe newly designed fixation system (LCfit) for open-wedge high tibial osteotomy showed fixation configurations that have theoretical mechanical advantages over conventional anatomical locking plates. However, there were no significant differences in clinical outcomes and radiological parameters between LCfit and the other locking plate systems.Level of evidenceLevel III, retrospective cohort study.     

Anterior opening wedge high tibial osteotomy: the effect of increasing posterior tibial slope on ligament strain

Background

Although a previous study showed that anterior opening wedge high tibial osteotomy (HTO) for sagittal plane correction induced no increased strain in the anterior cruciate ligament (ACL), we hypothesized that other ligamentous restraints of the knee may be subjected to increased strain.

Methods

We mounted 6 cadaveric knees at 15° flexion in a testing apparatus that provided compressive and anterior loading. We measured the strain in the ACL, posterior (PCL), medial (MCL) and lateral (LCL) ligaments for 6 randomized loading combinations and 3 conditions: intact, after anterior opening wedge HTO with a 5-mm plate and with a 10-mm plate.

Results

The mean ACL strain decreased from 0.84% (standard deviation [SD] 1.50%) at baseline to −6.28% (SD 5.40%) with a 5-mm anterior opening wedge osteotomy and to −6.77% (SD 4.79%) with a 10-mm osteotomy. Stepwise regressions yielded no significant effect of compression, anterior loading or osteotomy on PCL, MCL or LCL strain.

Conclusion

Increasing the posterior slope via HTO did not increase strain in the PCL, MCL or LCL.     

Impact of medial open-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee

BACKGROUNDMost populations worldwide, who are used to squatting and sitting cross-legged for their activities of daily living, largely comprise the lower socioeconomic strata, thus making them candidates for exclusion for total knee arthroplasty. Proximal/high tibial osteotomy (HTO) is a preferred strategy for clinically symptomatic osteoarthritis (OA) with genu varum due to painful medial compartment OA which is not amenable to conservative measures.AIMTo evaluate the outcomes of medial open-wedge HTO along with autologous bone grafting and buttress plate for the treatment of genu varum due to OA of the knee in a rural population of central India.METHODSA total of 65 knees in 56 patients with a mean age of 58.22 ± 5.63 years with genu varum due to intractable painful knee OA were treated with medial open-wedge HTO along with autologous bone grafting and buttress plate osteosynthesis from June 2015 to May 2018. The mean preoperative radiological angle of genu varum was 13.4°. Clinical outcomes were assessed by the range of movement, knee scores, pain scores, and functional scores. Radiographic studies were performed preoperatively and at regular intervals during the follow-up period.RESULTSAll patients reported pain relief immediately after the osteotomy and during the long-term analysis covering between one to three years. The genu varum angle was overcorrected to approximately four degrees in all patients. There was a loss of reduction by approximately three degrees in all patients at around six weeks postoperatively. Preoperative knee movements were restored in all patients. No major perioperative complications were noted during surgery and postoperative follow-up and the clinical scores were significantly improved during the final analysis which revealed good pain relief.CONCLUSIONMedial open-wedge HTO is a reliable, safe, practical, physiological, and feasible treatment for populations who are used to increased activity in their occupation and lifestyle and is associated with excellent short-term and long-term results for OA in genu varum knees.     

小切口开放胫骨高位截骨治疗膝内侧骨关节炎

目的:观察小切口开放楔形胫骨高位截骨术治疗膝内侧室骨关节炎的效果.方法:2000～2003年,对28例(40膝)膝内侧室骨关节炎患者采用小切口开放楔形胫骨高位截骨术治疗.手术采用胫骨结节外侧约5～6cm纵弧形切口和胫骨结节内侧2cm纵切口,骨膜下充分暴露胫骨结节至关节面间胫骨,根据术前测量的截骨角度在距关节面约2cm处开放楔形截骨,然后将胫骨远端于轻度内旋前移位与近端对合并用胫骨平台外侧支持钢板内固定.结果:随访12～55个月(平均30个月),通过X线片及膝关节功能评定,其优良率为90%.结论:小切口开放楔形胫骨高位截骨术治疗膝内侧室骨关节炎符合生物力学,可降低胫骨后倾角度减小、髌骨低位、胫骨骨量丢失等问题的发生率,延缓骨关节炎的发展,早中期疗效满意.     

改良内侧撑开楔形胫骨高位截骨矫正老年膝内翻的临床研究

目的探索高龄(>60岁)膝关节内侧骨关节炎并膝内翻畸形患者的手术技术及疗效。方法 2010年3月至2012年3月,采用改良内侧撑开楔形胫骨高位截骨矫正老年膝内翻畸形46例(52膝)。术前、后均拍患肢全长站立位X线片,测量髋(髋关节中心)-膝(膝关节中心)-踝(踝关节中心)形成的机械轴角度(HKA角),拍侧位X线片,测量胫骨平台后倾角,应用膝关节外科KOOS问卷评分标准对治疗后疗效评估。结果术后有32例(34膝)获随访,其余14例(18膝)因手术后不足3个月被排除在本组样本之外。32例随访时间为3～20个月,平均12.6个月。HKA角从术前(167.6°±3.7°)增加至术后平均(184.5°±1.2°)(P<0.05),胫骨平台后倾角术前平均(12.8°±1.3°),术后纠正到平均(9°±0.9°)(P<0.05);术后第2天带引流管直腿抬高、主动屈、伸膝关节锻炼;第3天,扶走步器负重行走;术后第7天生活已基本恢复自理;术后8～12周截骨端临床愈合。所有患者无一例感染、迟缓愈合、患肢无缺血及感觉障碍等并发症。疗效评估根据手术前、后的膝关节外科KOOS问卷评分结果,术前KOOS评分为(44.1±10.8)分,术后KOOS评分提高到(62.31±11.2)分,通过SPSS20统计学配对样本t检验确定其结果(P<0.05)有统计学差异。结论改良内侧撑开楔形胫骨高位截骨矫正老年膝内翻,是一种适合60岁以上患者的有效方法之一。不仅手术方法简便、组织损伤小、出血少、不易发生并发症,而且术后恢复快、住院时间短、不需要特殊昂贵的耗材,容易被广大患者接受,具有良好的社会效益和经济效益。     

Total knee arthroplasty after high tibial osteotomy: a medium-term review

A total of 50 consecutive knee arthroplasties in 42 patients who had undergone previous high tibial osteotomies have been reviewed with a minimum follow-up of 5 years and compared with 50 age-matched and sex-matched primary total knee arthroplasties. There were no significant preoperative differences between the 2 groups. Surgery in the osteotomy group took on average 23 minutes longer (P < .02), and there was a decrease of 80 flexion postoperatively but without an associated difference in knee scores. Patellar subluxation was also seen more frequently (P < .05). There was no difference in the revision rate at an average follow-up of > 6.2 years. Although there are significant technical difficulties and subtle clinical differences, the overall outcome remains good to excellent in most cases.     

Total knee replacement following high tibial osteotomy versus total knee replacement without high tibial osteotomy: a systematic review and meta analysis

Introduction

Currently, there is no consensus as to whether total knee replacement(TKR) following high tibial osteotomy(HTO) provides similar postoperative outcomes as compared to TKR without previous HTO. Previous studies have provided limited evidence to small sample sizes and methodological inappropriateness.

Methods

A systematic search process was conducted utilising PRISMA guidelines. Electronic, peer reviewed and published literatures were searched. Databases searched include Embase, Medline, Cochrane Library, PubMed and cross references. Methodological appropriateness was assessed with Papadokastakis system and Critical Appraisal Skills questionnaire. Data were analysed for both clinical and statistical homogeneity. Meta analytic pooling was subsequently performed.

Results

11 studies including 2170 TKR procedures were analysed for systematic review. The study (TKR following previous HTO) and control (TKR without previous HTO) groups were adequately matched for age, sex ratio and follow-up. Meta analysis of six studies utilising KSS system and four studies utilising HSS system showed no significant (p > 0.05) difference between the two groups. Complications also showed no significant difference between the two groups. At an average follow-up of 7.2 years, with revision arthroplasty for any cause as the endpoint, survivorship for the study and control groups was 95 and 97 %, respectively. For revision arthroplasty with aseptic loosening as the end point, the survivorship was 98 % for both groups.

Conclusion

Systematic review and meta analysis suggested that TKR following HTO provides similar outcomes as compared to TKR without previous HTO. Therefore, a previous HTO does not negatively influence a future TKR, though the conversion process of HTO to TKR is technically challenging. Systematic review also identified paucity in prospective and long term studies.     

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.

     

Results of high tibial osteotomy: review of the literature

The aim of this review is to evaluate long-term follow-up and survival analysis studies regarding high tibial osteotomies (HTO) for the treatment of medial knee arthritis. Despite the good number of studies available, comparison and pooling of the results are challenging because of the different evaluation systems and techniques used. However, in general, published studies on HTO report good long-term results with a correct patient selection and a precise surgical technique. Based on our findings, the ideal candidate for an HTO is a young patient (<60 years of age), with isolated medial osteoarthritis, with good range of motion and without ligamentous instability. Furthermore, the literature review shows that the outcomes gradually deteriorate with time. Nevertheless, some issues remain that need resolution; these include the choice between opening or closing wedge tibial osteotomy, the graft selection in opening wedge osteotomies, the type of fixation, the comparison with unicompartmental knee arthroplasty and whether HTO significantly affects a subsequent total joint replacement.