The clinical outcomes and the ability to sit straight in the Japanese style following high tibial osteotomy combined with osteochondral autologous transfer for osteonecrosis of the medial femoral condyle

Autologous Osteochondral Grafts for Knee Osteochondral Diseases Result in Good Patient-Reported Outcomes in Patients Older Than 60 Years

Purpose

This study aims to examine the clinical autologous osteochondral grafts (AOG) outcomes for knee osteochondral diseases at operative ages >60 years, and to determine whether patients are able to sit straight in Japanese style after AOG.

Methods

All patients who underwent AOG for knee osteochondral diseases between November 2001 and April 2018 were retrospectively identified. The inclusion criteria were AOG only without osteotomy, operative ages between 60 and 79 years, >2 years of follow-up, and involved femorotibial angle between 169° and 179° (normal alignment). Patients who underwent osteotomy to improve knee alignment and patients with inflammatory diseases such as rheumatoid arthritis were excluded. The patients' knee symptoms and their clinical outcome were evaluated according to the criteria of the knee scoring system of the Japanese Orthopedic Association (JOA), International Knee Documentation Committee (IKDC) subjective score, and the ability of straight sitting in Japanese style.

Results

This study enrolled 57 cases and 60 knee joints during the study period. The follow-up ratio was 85.1%. Moreover, 14 men and 43 women and 29 right and 31 left knee joints were included in this study. The mean operative age and mean follow-up period were 67.8 years (range 60-76 years) and 81.1 months (range 24-167 months), respectively. In addition, the study involved 30 cases and 32 knee joints (60s group), and 27 cases and 28 knee joints (70s group). Moreover, 34 cases and 36 knee joints had osteonecrosis (ON group), and 23 cases and 24 knee joints had cartilage injury (CI group). The IKDC subjective and JOA scores in both the 60s and 70s groups showed significant differences: 2 years after AOG ＞at the follow-up period, ＞at the preoperative period. The scores in both the CI and ON groups showed similar significant differences. Furthermore, 8.3% and 53.5% of the patients could sit straight in Japanese style at the preoperative period and 2 years after AOG, respectively.

Conclusion

Even if the patient's operative age was >60 years, the AOG only for their knee osteochondral diseases had good clinical outcomes, including the ability to sit straight in Japanese style.

Level of Evidence

IV, Therapeutic case series Key words: autologous osteochondral grafts, aged patients, clinical outcome, knee joint, straight sitting in Japanese style.

Minimum 5-Year Outcomes of Osteochondral Autograft Transplantation with a Concomitant High Tibial Osteotomy for Spontaneous Osteonecrosis of the Knee with a Large Lesion

OBJECTIVE

The purpose of this study was to evaluate the mid-term clinical outcomes of osteochondral autograft transplantation (OAT) with concomitant high tibial osteotomy (HTO) in spontaneous osteonecrosis of the knee (SONK) with a large lesion.

DESIGN

A total of 48 knees of 48 consecutive patients with SONK (lesion size ≥4 cm², no age criteria) who underwent opening wedge HTO and concomitant OAT were retrospectively investigated, and those who were followed up postoperatively for at least 5 years were included in this case series study. Clinical outcomes were evaluated using knee and function scores of Knee Society Score, radiographic outcomes were evaluated using the anatomical femorotibial angle (FTA), and these outcomes were compared between patients aged ≥70 years and <70 years.

RESULTS

Of the 48 cases, a total of 43 cases were available for review at a minimum of 5 years, and 5 cases were excluded from the analysis. Overall, the mean knee score improved from preoperative 48.8 ± 13.3 to postoperative 87.9 ± 8.6 at 1 year (P < 0.05) and 85.0 ± 10.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean function score also improved from preoperative 60.1 ± 10.9 to postoperative 87.3 ± 12.2 at 1 year (P < 0.05) and 84.2 ± 12.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean standing FTA was corrected significantly from 181.1° ± 2.7° preoperatively to 169.7° ± 2.4° at 1 year (P < 0.05) and 169.4° ± 3.1° at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). There were no significant differences in clinical and radiographic outcomes between patients aged ≥70 years and <70 years. There were 4 cases of lateral hinge fracture around the osteotomy site and 1 case of delayed union. None of the patients underwent revision surgery during the follow-up period (survival rate of 100%).

CONCLUSIONS

Mid-term clinical outcomes of patients with SONK who underwent HTO and OAT with a relatively large lesion were good.

Midterm Outcomes of Autologous Osteochondral Graft Transplantation Only in the Femoral Condyle without Treating the Tibial Plateau with Subchondral Bone Exposed

OBJECTIVE

This study aimed to examine the midterm clinical outcomes of autologous osteochondral grafts (AOG) that were performed in the femoral condyle without treating the tibial plateau with subchondral bone exposed, and to compare these outcomes with those of AOG used in patients with osteoarthritis (lateral type or medial type) or osteonecrosis.

DESIGN

The study included 6 men and 16 women and 11 right knees and 11 left knees. The mean operative age was 56.0 years (range, 21-76 years), and the mean follow-up period was 98.4 months (range, 60-164 months). Six patients had lateral type osteoarthritis (OAL), 7 had medial type osteoarthritis (OAM), and 9 had osteonecrosis (ON). The patients' knee symptoms as their clinical outcome were evaluated using the knee scoring system of the Japanese Orthopedic Association (JOA), and the International Knee Documentation Committee (IKDC) subjective score.

RESULTS

The postoperative clinical outcomes of the OAL and ON group were significantly better than their preoperative clinical scores and remained the same until the final follow-up. However, the clinical outcomes of OAM improved 2 years after AOG, but eventually decreased thereafter. The number of worse cases in the OAM group was significantly larger than those in the OAL and ON groups.

CONCLUSION

In these procedures, the postoperative clinical outcomes of the OAL and ON groups were significantly better than their preoperative clinical scores and were maintained for about 8 years. However, the clinical outcomes of OAM improved until 2 years after AOG, but eventually decreased thereafter.

The Fate of Bone Marrow Lesions After Open Wedge High Tibial Osteotomy: A Comparison Between Knees With Primary Osteoarthritis and Subchondral Insufficiency Fractures

BACKGROUND

Subchondral insufficiency fracture of the knee (SIFK) is characterized by a subchondral lesion that may lead to end-stage osteoarthritis (OA). In patients who have SIFK in a precollapse state with varus malalignment, a joint-preserving technique such as open wedge high tibial osteotomy (OWHTO) should be considered.

PURPOSE

To evaluate the efficacy of OWHTO in primary OA and SIFK-dominant OA by clinical and radiological evaluations including magnetic resonance imaging (MRI).

STUDY DESIGN

Cohort study; Level of evidence 3.

METHODS

A total of 33 SIFK-dominant OA knees and 66 with primary OA that underwent biplanar OWHTO between March 2014 and February 2016 were included after 1:2 propensity score matching. The MRI Osteoarthritis Knee Score was used to assess bone marrow lesions (BMLs) preoperatively and at follow-up. The weightbearing line ratio, the hip-knee-ankle angle, and the joint line convergence angle were measured. The clinical outcomes assessed were range of motion, the American Knee Society Score, and the Western Ontario and McMaster University (WOMAC) score.

RESULTS

The mean follow-up period was 41.2 ± 12.6 months. The distribution of preoperative BML grade in the SIFK-dominant OA group was significantly higher in both the femur and tibia (P < .001 and <.001, respectively) than that in the primary OA group. However, the difference was not significant postoperatively (femur, P = .425; tibia, P = .462). In both groups, postoperative BMLs showed significant improvement compared with preoperative BMLs (primary OA [femur, P < .001; tibia, P = .001] and SIFK-dominant OA [femur, P < .001; tibia, P < .001]). The WOMAC pain score was higher in the SIFK-dominant OA group preoperatively (primary OA, 7.0 ± 3.73; SIFK-dominant OA, 9.17 ± 2.6; P = .032) even though it was not different at the final follow-up (primary OA, 2.11 ± 1.7; SIFK-dominant OA, 1.79 ± 1.32; P = .179).

CONCLUSION

OWHTO is an effective procedure not only for primary OA but also for SIFK-dominant OA. OWHTO can improve BMLs, which represent the main pathological feature of SIFK. Therefore, in patients who have SIFK with varus malalignment, OWHTO can be an attractive treatment option for preserving the joint and enhancing subchondral bone healing.