Clinical Outcomes of Revision Total Knee Arthroplasty after High Tibial Osteotomy and Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis

Survival rate and use of revision components in total knee arthroplasty following unicompartmental knee arthroplasty or proximal tibial osteotomy: an analysis of 11,983 procedures from the Dutch Arthroplasty Register

BACKGROUND AND PURPOSE

 Unicompartmental osteoarthritis of the knee can be treated with high tibial osteotomy (HTO) or unicompartmental knee arthroplasty (UKA). This study aimed to investigate the use of revision components in total knee arthroplasty (TKA) after HTO or UKA and to investigate the revision-free survival of the 2 groups of TKA at different time points, including reasons for revision.

METHODS

 TKAs after HTO and revision TKAs after failed UKA in the years 2007-2022 were selected from the Dutch Arthroplasty Register. For complexity, the usage of revision components was analyzed. Kaplan-Meier survival analysis was used to estimate survival rate. Multivariable Cox proportional hazards regression analyses were used to estimate the risk of revision, considering potential confounders. Indications of revision were evaluated.

RESULTS

 11,983 procedures were analyzed (9,835 HTO-TKA and 2,148 UKA-TKA). In the HTO-TKA group, 3% had revision components in the TKA compared with 22% in the UKA-TKA group (P < 0.001). After 12 years' follow-up the revision-free survival was 90.4% (95% confidence interval [CI] 89.6-91.2) for HTO-TKA and 81.7% (CI 79.3-84.1) for UKA-TKA. The multivariable Cox regression analysis showed that UKA-TKA was a significant risk factor for a revision of the TKA (hazard ratio 2.3, CI 1.8-2.6), compared with HTO-TKA. In both groups the most frequent reason for revision was instability, followed by patellar pain and loosening of the tibial component.

CONCLUSION

 TKAs after UKAs had higher use of revision components and a lower survival rate compared with TKAs following an HTO. The choice of surgical treatment should be considered for the young and active patient with unicompartmental knee osteoarthritis.

Quality Performance Management in the Tuscany Procurement and Transplant System: A Reporting and Monitoring Approach

OBJECTIVES

The Tuscany Region has an annual number of donors of about 100 donors per million population, whereas transplant activity is about 80 per million population. We aimed to describe the reporting and monitoring approach for assessment of quality performance implemented since 2022 by the Tuscany Procurement and Transplant Center and the effects of this reporting and monitoring approach on donation and transplant activity in 2024. The goal of this approach was to maintain donation activity and increase transplant activity.

MATERIALS AND METHODS

For the Tuscany reporting approach, the Tuscany Procurement and Transplant Center measures indicators, which are transmitted monthly to hospital management staff, transplant coordinators, and transplant centers. Data sources are donor electronic files.

RESULTS

From January to November 2024, 352 donors were assessed (utilization rate 92%). Donation activity in the Tuscany Region was comparable in 2024 versus in 2023 (101.2 vs 103 per million population). Controlled donations after circulatory death increased (+13). The number of actual donors and utilization rate of organs showed an increase compared with 2023. In 2024, 336 transplants were performed by Tuscany transplant centers, 74 transplants more than in 2023. Transplant activity was therefore 91.3 per million population versus 80 per million population in the Tuscany Region in 2023.

CONCLUSIONS

The reporting and monitoring approach led to the maintenance of a high donation activity (about 100 donors per million population) and an increase in transplant activity in Tuscany. This approach was shown to be effective and efficacious for the solid-organ donation and transplant system in Tuscany.

Medial open wedge high tibial osteotomy is a viable option in young patients with advanced arthritis in a long-term follow-up

PURPOSE

This study aimed to evaluate the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) as a treatment option for advanced medial compartment knee osteoarthritis (OA) Kellgren-Lawrence (K-L) III and IV.

METHODS

Patients with severe medial compartment arthritis, who underwent MOWHTO with locking plate between 2003 and 2015, were retrospectively reviewed. A locking plate for the osteotomy was utilized. Preoperative and postoperative patients' evaluation was performed using the International Knee Documentation Committee Score (IKDC), the Oxford Knee Score (OKS), the Knee Injury Osteoarthritis Outcome Score (KOOS) and the Short Form-12 Score (SF-12). Standardized standing whole-limb X-rays were taken to evaluate the mechanical tibiofemoral angle (mTFA) and proximal medial tibial angle (PMTA), and the severity of OA.

RESULTS

A total of 32 patients, 35 knees (27 males, five females) of which 21 were classified as K-L Grade III and 14 as K-L Grade IV, and mean age 47.1 ± 9.17 years old, who were followed for 13.6 years (range 7-20 years), were included in the study. During the follow-up period, three knees required conversion to total knee replacement (91.5% survival rate). All clinical outcome scores (KOOS, OKS, IKDC and SF-12) showed a significant improvement compared to preoperative status (p < 0.05). Preoperative mTFA and PMTA were significantly corrected immediately after surgery and retained this improvement at the last follow-up.

CONCLUSION

MOWHTO with a locking plate is an effective method to treat severe medial compartments. Clinical and radiological results are satisfactory and the survival rate is 91.5%, at a mean follow-up of 13.6 years after the procedure.

LEVEL OF EVIDENCE

Level IV.

How to manage and avoid revision after unicompartmental knee arthroplasty?

The article by Zhao et al presents a retrospective case series on the reasons for initial revision after unicompartmental knee arthroplasty (UKA). Clarifying the reasons that may cause UKA revision can further reduce the rate of revision UKA, focusing on gasket dislocation, osteophytes, intra-articular loose bodies, and tibial prosthesis loosening. This article provides valuable insights, not only by detailing the revision status of 13 patients who underwent revision after initial UKA but also by providing a comprehensive analysis of the incidence of revision after initial UKA. By reviewing and analyzing the causes, they established references for the early detection of risk factors for revision in clinical practice and for formulating surgical strategies and rehabilitation programmes. This commentary emphasizes the need for a meticulous understanding and an analysis of the revision rate following initial UKA and related management strategies. The implant rates, regional variation, and benefits of uncemented Oxford UKA have been explored, particularly in terms of bone preservation, appropriate surgical techniques, and weight management to control complications and improve patient prognosis.

Clinical and functional outcomes of TKA after HTO or UKA: a New Zealand Joint Registry Study

INTRODUCTION

Surgical options for patients with unicompartmental knee osteoarthritis include high tibial osteotomy (HTO) or unicompartmental knee arthroplasty (UKA). When managing younger patients with a higher chance of further surgery, the outcome of any subsequent conversion to total knee arthroplasty (TKA) also needs to be considered. The aim of this study was to compare implant survivorship and patient-reported outcomes for patients undergoing TKA after previous HTO or UKA, with comparisons for age, gender and comorbidities.

METHODS

Revision risk and 6-month Oxford Knee Scores (OKS) from the New Zealand Joint Registry were compared for patients who underwent TKA after HTO (HTO-TKA; n = 1556) or UKA (UKA-TKA; n = 965) between 1999 and 2019, with a comparison group of primary TKA (n = 110,948). Mean follow-up was 8.2 years.

RESULTS

Adjusted revision risk was similar for HTO-TKA and UKA-TKA groups (hazard ratio (HR) 1.04, p = 0.84); and risk for both groups were higher than primary TKA (HTO-TKA HR 1.45, p = 0.002; UKA-TKA HR 1.51, p = 0.01). Overall adjusted mean OKS at 6 months for HTO-TKA (36.2) was similar to primary TKA (36.8, p = 0.23); and both were higher than UKA-TKA (34.2, p < 0.001). For the youngest patient group (< 55 years), revision rates of UKA-TKA were two-fold higher than HTO-TKA (2.8 vs. 1.3 per 100 component yrs, p < 0.03). HTO-TKA had better OKS (37.5 vs. 34.1, p < 0.0001) for males. Mean OKS for UKA-TKA was lower than HTO-TKA for patients with ASA 1-2 (35.6 vs. 37.5, p < 0.01).

CONCLUSION

The findings from this study suggest that revision rate following TKA after HTO and UKA are similar. However, TKA after HTO have superior functional outcomes compared with TKA after UKA and are comparable to functional outcomes post primary TKA. The results support the use of HTO for young, male and less co-morbid patients.

Trends and outcomes in the surgical management of young adults with knee osteoarthritis using high tibial osteotomy and unicompartmental knee arthroplasty

INTRODUCTION

A significant portion of knee osteoarthritis is diagnosed in patients under the age of 55, where greater activity demands make total knee arthroplasty less desirable. High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are useful alternatives, but there is little understanding of which procedure is advantageous. Hence, this study examines the utilization, complication, and reoperation rates among the HTO vs. UKA in young patients with primary osteoarthritis.

METHODS

A retrospective review of the National Surgical Quality Improvement Program was performed to identify 2318 patients < 55 years of age who received either a HTO or UKA for primary osteoarthritis between 2011 and 2021. Bivariate analyses compared preoperative and intraoperative characteristics among each procedure. Then, multivariate analyses examined if either procedure was associated with worse 30-day postoperative complications or need for reoperation, independent of the statistically significant pre- and intraoperative disparities.

RESULTS

UKAs were performed 14.2 times more commonly than HTOs, and the patients selected for HTO were more likely to be younger, have a lower BMI, have the healthiest ASA Class score, and less likely to have hypertension requiring medication (p < 0.001). HTOs took 17.5% longer to perform and had a longer average length of stay (p < 0.001), while UKAs were more likely to be performed out-patient (p < 0.001). HTOs also had higher rates of serious complications (p = 0.02), overall complications (p = 0.004), and need for reoperation (p = 0.004). Multivariate modelling demonstrated that procedure type was not a predictor of serious complications, but the use of HTO was significantly associated with any complications (odds ratio = 3.63, p = 0.001) and need for reoperation (3.21, p = 0.029).

CONCLUSION

Although healthier patients were selected for HTOs, UKAs were found to have a lower risk of complications and immediate reoperation. Additionally, UKAs had the advantage of lower operative burden, shorter length of stay, and a higher efficacy in outpatient settings.

Surgical strategy and complication management of osteotomy around the painful degenerative varus knee: ESSKA Formal Consensus Part II

PURPOSE

The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy.

METHODS

Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released.

RESULTS

The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months.

CONCLUSION

Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research.

LEVEL OF EVIDENCE

Level II, consensus.

Age-stratified analysis of HTO and UKA clinical effects in cross-indicated anterior medial osteoarthritis

PURPOSE

To compare clinical outcomes of high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) for anterior medial osteoarthritis (AMOA) as well as offer surgical recommendations through age stratification.

METHODS

Between May 2019 and May 2021, 68 cross-indicated AMOA patients were analyzed. The patients were divided into HTO and UKA groups and further into two age groups of 55-60 and 60-65 years. Additionally, general data, visual analog scale (VAS) score, and Hospital for Special Surgery knee score (HSS) were analyzed.

RESULTS

All the patients were followed up for 18 months. Knee joint HSS significantly improved, and VAS score decreased in both groups (P < 0.05). In the 55-60 age group, HTO showed superior knee HSS at 1 and 3 months (P < 0.05), with no significant difference at 6, 12, and 18 months. HTO had a significantly lower VAS score at one month, and the VAS scores of the two groups decreased gradually with no significant difference. In the 60-65 age group, the UKA group showed superior knee joint HSS at one month, with no significant difference at 3, 6, 12, and 18 months. The UKA group had a significantly lower VAS score at one month, and both groups' VAS scores decreased gradually with no significant difference.

CONCLUSION

Both methods yield satisfactory results for AMOA cross-indications, improving knee joint function. The observed recovery trends have implications for personalized surgical recommendations, guiding interventions based on age-specific considerations for optimal outcomes in anterior medial osteoarthritis cases.

How Useful Is Preoperative Aspiration before Revision of Unicompartmental Knee Prostheses Because of Osteoarthritis in the Other Compartments?

AIM

Periprosthetic joint infections (PJIs) of unicompartmental knee arthroplasties (UKAs) can lead to secondary osteoarthritis of the other compartments. The objective of this study was to identify the frequency of PJIs in cases of UKA with progressed secondary osteoarthritis and the result of septic one-stage revision in these cases to verify the value of preoperative aspiration in cases of secondary osteoarthritis of UKA.

METHODS

We retrospectively reviewed 97 patients with a unicompartmental arthroplasty who underwent revision surgery to a total knee arthroplasty (TKA) between January 2013 and March 2021 because of subsequent osteoarthritis. Preoperative aspiration and sample collection during the revision surgery were employed to identify potential periprosthetic joint infections (PJIs). The post-revision period was monitored for septic complications over an average duration of 55.7 ± 25.2 months (24-113).

RESULTS

PJIs were identified in 5.2% of cases through preoperative aspiration. In all instances of PJIs, a one-stage septic revision was performed, and notably, none of these cases experienced septic complications during the follow-up period.

CONCLUSIONS

Preoperative aspiration is essential in order to exclude the presence of a PJI before performing revision surgery of UKA due to secondary osteoarthritis.

What Influences Patients Readiness for Discharge: The Case of Total Knee Arthroplasty: A Cross-Sectional Study

Background

Evidence has suggested that most clinical staff use clinical laboratory indicators to determine discharge times, while paying little attention to patients' feelings and needs. Additional research findings have suggested a relationship between patients' self-reported readiness for hospital discharge and postdischarge complication rates, readmission rates, mortality, as well as quality of life. RHD is strongly associated with patient health outcomes. Identifying relevant influencing factors can provide guidance for early individualized interventions by healthcare professionals.

Design

A cross-sectional study.

Methods

During 2022, a total of 320 post-TKA patients were selected for this study. The patients were divided into the low-RHD group (<7 points) and the high-RHD group (≥7 points) according to the mean score of the Readiness for Hospital Discharge Scale (RHDS). Established scales were used to collect patients' information and to adopt univariate and binary logistic regression analysis to screen for independent factors.

Results

In this study, the RHDS score of patients after TKA is 91.90 ± 7.05, of which 12.8% are in the low-RHD group (mean score <7). The binary logistic regression results reveal that age, educational level, postactivity pain, self-efficacy, and family care have to be considered risk factors generating low-RHD in TKA patients.

Conclusions

The present study suggests that over 1/8 TKA patients are not ready at the time of discharge. Physicians and nurses can improve patients' RHD by reducing postactivity pain and improving self-efficacy during their rehabilitation period. Relevance to Clinical Practice. The results of this study can help physicians and nurses early identify high-risk patients with low RHD and provide them with individualized interventions. In addition to this, it is important that nurses use RHDS to assess the readiness of TKA patients before they are discharged from the hospital.

High survivorship and low complication rate in a single-centre series of 651 medial opening wedge high tibial osteotomy cases with a mean follow-up of 13 years

PURPOSE

This study aimed to report the early to midterm results of medial opening wedge high tibial osteotomy (MOWHTO) from the largest single-centre osteotomy database. The primary outcomes were reporting the radiological corrections and the functional outcomes represented by multiple patient-reported outcome measures (PROMs). The secondary outcomes were to report the complications, revisions and survivorship up to 10 years postoperatively.

METHODS

A prospectively maintained single-centre database of 1138 knee osteotomies was retrospectively reviewed. Patients who underwent MOWHTO and met the inclusion criteria were included. Those inclusion criteria were moderate to severe knee pain that failed conservative management; varus knee malalignment; and isolated medial osteoarthritis of the knee. A total of 651 cases, with a mean age of 46.7 ± 9 years and a mean body mass index of 29.6 ± 5.2 kg/m2 , were included. This comprised 71% males (n = 462) and 29% females (n = 189). The mean follow-up was 158.1 ± 45.4 months. Multiple PROMs were recorded preoperatively and serially postoperatively. This included the Knee injury and Osteoarthritis Outcome Scores, the Oxford Knee Score, the Oxford Knee Score-Activity and Participation Questionnaire, the Western Ontario and McMaster University Scores, the Visual Analogue Scale for health and pain, and the EQ-5D, which is a standardised measure of health-related quality of life. All lower limb alignment measurements were recorded pre- and postoperatively. The rates of osteotomy revision, conversion to arthroplasty, complications, and 5- and 10-year survivorship were recorded.

RESULTS

A total of 651 cases were followed up to a mean of 158.1 ± 45.4 months. The mean planned correction angle was 7.6° ± 2.9°. The mean planned opening wedge distance was 8.1 ± 3.1 mm. The mean intraoperative anterior and posterior osteotomy gaps opening were 7.7 ± 3.4 and 8.9 ± 3.8 mm, respectively. Postoperatively, the mean mechanical tibiofemoral angle improved from -5.7° ± 2.9° varus to 1.3° ± 2.5° valgus, the mean medial proximal tibial angle improved from preoperative 85.5° ± 2.3° to postoperative 91.6° ± 2.7° and the mean Mikulicz point improved from 21.7 ± 12.6% to 54.8 ± 11% (all p values < 0.001). All PROMs significantly improved at 24 months follow-up (all p values < 0.001). The rate of osteotomy revision was 1.1% at a mean of 2 ± 2.5 years postoperatively. The overall rate of arthroplasty conversion was 9.1%. This comprised 5.8% total knee arthroplasty conversion at a mean of 6.9 ± 3.5 years postoperatively and 3.2% unicompartmental knee arthroplasty conversion at a mean of 5.7 ± 2.5 years postoperatively. An overall 10.3% complication rate was recorded. The 5 and 10-year survivorship was 97.2% and 91.9%, respectively.

CONCLUSION

MOWHTO is a radiologically and clinically rewarding procedure with a high survival rate at 5 and 10 years and a low complication rate in experienced hands. MOWHTO should be considered in patients presenting with medial unicompartmental knee pain with an evidence of overload and a varus mechanical coronal plane axis.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Osteotomy for treating knee osteoarthritis from 2012 to 2023: Bibliometric analysis and global trends

BACKGROUND

Numerous surgical interventions are available for the treatment of knee osteoarthritis (KOA). In recent years, knee-preserving surgery, specifically osteotomy, has gained significant attention from patients, particularly those who are young and physically active, as it not only effectively alleviates pain but also preserves bone integrity, thereby allowing for potential future joint replacement. This study aims to comprehensively analyze the global application trends of osteotomy for KOA and identify the current research hotspots.

METHODS

We conducted a literature search encompassing English-language studies on osteotomy for KOA published from 2012 to 2023 in the Web of Science Core Collection (WoSCC) database. Bibliometric analysis tools, including VOSviewer, CiteSpace, and R Studio, were employed to analyze global trends and research hotspots.

RESULTS

We analyzed 1520 eligible publications, comprising 1350 articles and 170 reviews. The number of articles on osteotomy for KOA has exhibited a consistent upward trend over the past decade. The top 3 contributing countries (South Korea, United States, and China) accounted for 45.98% of all published articles. U.S. scholars exhibited high productivity, prominence, and academic impact in this field. Seoul National University published the most papers on the relationship between osteotomy and KOA, while Sungkyunkwan University had the highest average citation rate. Among authors, Yong Seuk Lee from Korea and Steffen Schroeter from Germany had the highest number of publications and average citation values, respectively. Research interests were clustered into 5 categories: "High tibial osteotomy," "Biomechanics of osteotomy," "Osteotomy combined with cartilage repair techniques," "Postoperative prognosis and outcomes," and "Improvement of surgical techniques."

CONCLUSION

Recent years have witnessed notable rapid progress in the research on osteotomy for KOA. The field is poised for continued growth in terms of academic literature. The United States has emerged as a global leader in knee osteotomy research, while Korea demonstrates considerable potential in this domain. Future research hotspots may encompass high tibial osteotomies, osteotomies combined with cartilage repair techniques, and advancements in surgical techniques for KOA.

Etiology of Total Knee Arthroplasty Revisions: A Two-Decade Institutional Perspective

Total knee arthroplasty (TKA) implant survival time is determined by various patient and implant-related factors and varies significantly in recent worldwide reports. In our study, we have included 247 TKA revisions in 203 patients performed in our hospital over the last 20 years. Multiple etiologies of revisions were identified and classified into 10 categories. Time to failure was analyzed with regard to etiology, patient demographics, and other relevant data. The overall average time to revision was 44.08 months (95% confidence interval (CI) between 33.34 and 49.82 months). Age at primary implant was negatively correlated with time to revision (hazard ratio (HR) = 1.0521 and 95% CI of HR = 1.0359 to 1.0685) and female patients showed a 1.59 times higher risk of implant failure than males. Periprosthetic joint infection was the cause of 46.56% (n=115) of revisions (out of which 12.55% (n=31) were early infections, diagnosed within the first three months), while aseptic loosening was found in 31.98% (n=79) of cases. Infection correlated with a shorter time to revision compared to aseptic loosening (p<0.05). These findings emphasize the need to intensify efforts to deliver the best patient care, select the best antibiotic regimen, and improve surgical techniques to decrease the incidence of infectious complications.

Unicompartmental Knee Arthroplasty Provides Superior Clinical and Radiological Outcomes Compared to High Tibial Osteotomy at a Follow-Up of 5-8 Years

BACKGROUND

Knee Osteoarthritis (OA) is a debilitating disease. Initially, the medial compartments are affected in most cases. For this pathology, joint preservation is preferable. Two surgical procedures aim to meet this goal: high-tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA). The aim was to compare clinical and radiological outcomes of HTO versus UKA in patients with unicompartmental, medial OA.

METHOD

Retrospective case series. A total of 86 (61 UKA, 25 HTO) patients that received either treatment at a single, specialized center were assessed pre-operatively and at a single follow-up examination at 77.13 months (±8.170). The Knee Society Score (KSS), range of motion (ROM), SF36 questionnaire and the Tegner score were used. The Kellgren-Lawrence score was assessed pre- and post-surgically. Survivorship with the endpoint "revision" was assessed.

RESULTS

The UKA group showed significantly better improvements in KSS scores for pain (p < 0.006) and function (p < 0.001). OA progression (p < 0.02) and survivorship (p < 0.018) differed, significantly favoring UKA. ROM, SF36 and Tegner score did not differ significantly.

CONCLUSIONS

The presented mid-to long-term data suggest that UKA provides superior results in selected outcomes. Nevertheless, significant differences in the demographics of treatments indicate the challenge of comparing these two treatments.