Return to Work and Sport After Proximal Tibial Osteotomy and the Effects of Opening Versus Closing Wedge Techniques on Adverse Outcomes: A Systematic Review and Meta-analysis

Return to Duty in Military Servicemembers After High Tibial Osteotomy Not Associated With Preoperative Radiographic Parameters : A Retrospective Analysis

Background

Evidence on return to sports/work after high tibial osteotomy (HTO) is limited, especially in a young, high-demand population.

Purpose

To (1) identify whether preoperative knee pathology or intraoperative correction was associated with successful return to duty (RTD) and (2) assess whether postoperative complications and reoperation were associated with failure to RTD.

Study Design

Case series; Level of Evidence, 4.

Methods

We performed a retrospective cohort study of a consecutive series of patients in the Military Health System aged 18 to 55 years with medial compartment osteoarthritis who underwent HTO between 2003 and 2018. Concomitant meniscal and cartilage procedures were included, while cases with concomitant ligamentous procedures were excluded. The inclusion criteria were as follows: active-duty military status, minimum 2-year follow-up, preoperative knee radiographs, and pre- and postoperative long-leg alignment radiographs. Preoperative Kellgren-Lawrence grades and pre- and postoperative hip-knee-ankle angles were measured. The primary outcome was RTD. Failure was defined as knee-related medical separation from the military or conversion to total knee arthroplasty. The secondary outcome was reoperation.

Results

A total of 55 HTOs were performed in 50 patients who met the inclusion criteria, with a mean age of 39 years old (range, 22.8-55 years). The mean follow-up was 5 years (range, 2.1-10.7 years). Ten knees (18.2%) failed HTO (1 conversion to total knee arthroplasty, 9 medical separations), 15 additional knees (27.3%) had permanent activity restrictions, and 30 knees (54.5%) returned to duty without restrictions. Reoperation occurred in 36.4% of knees and was associated with medical separation (P = .039). Younger age was associated with medical separation (P = .003) and permanent restrictions (P = .006). Patients with a postoperative varus deformity of >5° were more likely to undergo medical separation (P = .023).

Conclusion

In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. Residual varus deformity or reoperation was associated with lower RTD rates. No association was identified between RTD and preoperative osteoarthritis grading or deformity.

Better clinical outcomes and return to sport rates with additional medial meniscus root tear repair in high tibial osteotomy for medial compartmental knee osteoarthritis

PURPOSE

This retrospective study aimed to investigate whether the repair of medial meniscus posterior root tears (MMPRTs) is effective for improving clinical outcomes and return to sports rates in young patients (50 years old or younger) with medial compartment knee osteoarthritis (KOA) and MMPRTs.

METHODS

Between 2016 and 2019, 153 patients with KOA and MMPRTs who underwent open-wedge high tibial osteotomy (OWHTO) were retrospectively included. The patients were divided into OWHTO combined with MMPRT repair (n = 73) and isolated OWHTO (n = 80) groups. Lysholm scores, Hospital for Special Surgery (HHS) scores, Tegner scores, flexion contracture, range of knee flexion, return to sports rates and postoperative complications were compared. Radiological outcomes, including hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA) and Kellgren-Lawrence (K-L) grade, were compared between the two groups.

RESULTS

After a mean follow-up of 30.1 ± 3.0 months, the OWHTO + Repair group observed better clinical outcomes compared with the OWHTO group (Lysholm score: 86.7 ± 7.4 vs. 81.6 ± 6.9, p = 0.023. HHS score: 85.4 ± 8.20 vs. 80.5 ± 7.1, p = 0.039). The OWHTO + Repair group had higher Tegner scores and return to sports rates than the OWHTO group (Tegner score: 6 vs. 5, p = 0.020; return to sports rates: 38% vs. 15%, p = 0.001). No fracture or major complications occurred. Radiological outcomes showed no significant differences between the two groups (HKA: 181.1 ± 2.7 vs. 180.1 ± 1.5 n.s; MPTA: 90.1 ± 1.8 vs. 89.2 ± 1.4, n.s; JLCA:1.9 ± 0.7 vs. 2.1 ± 0.7, n.s).

CONCLUSIONS

Additional MMPRT repair during OWHTO was associated with better clinical outcomes and higher rates of return to sports in young patients with medial compartment KOA and MMPRTs.

LEVEL OF EVIDENCE

Level III.

Medial opening wedge high tibial osteotomy for the treatment of medial unicompartmental knee osteoarthritis: A state-of-the-art review

Medial unicompartmental knee osteoarthritis is a common condition that is frequently associated with significant pain and dysfunction. Medial opening wedge high tibial osteotomy (MOWHTO) offers a unique opportunity to preserve the knee joint and potentially alter the course of the degenerative process. Recent advances in this field of surgery have enabled surgeons to perform a MOWHTO in a safe, reliable and reproducible manner. This state-of-the-art review highlights the most important advances in the field of MOWHTO. Key concepts related to patient selection, pre-operative planning, surgical accuracy and patient outcome are considered. The importance of an individualized approach is emphasized and its influence on the future direction of the procedure is discussed.

Comparison of Early Complication Rates After High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Knee Osteoarthritis

Background

Although both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) can be utilized to treat unicompartmental osteoarthritis (OA) in select patients, the early complication rates between the 2 procedures are not well understood. Understanding of the complication profiles for both procedures would help clinicians counsel patients with unicompartmental knee OA who may be eligible for either treatment option.

Purpose

To compare the 30-day complication rates after HTO versus UKA for the treatment of knee OA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Study Design

Cohort study; Level of evidence, 3.

Methods

NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing HTO and UKA for knee OA. Patients >60 years of age were excluded. Patient demographics, preoperative comorbidities, and intraoperative data were collected. Postoperative 30-day complications, including venous thromboembolism (VTE), urinary tract infection (UTI), transfusion, surgical-site infection (SSI), and reoperations were recorded. Complication rates between treatment groups were compared using a multivariate logistic regression model adjusted for sex, age, body mass index, steroid use, respiratory status (smoking/dyspnea/chronic obstructive pulmonary disease), diabetes, and hypertension.

Results

A total of 156 patients treated with HTO and 4755 patients treated with UKA for knee OA were identified. Mean patient ages were 46 years for the HTO group and 53.4 years for the UKA group. Operative time was significantly longer in the HTO group versus the UKA group (112 minutes vs 90 minutes; P < .001). Multivariate analyses found no significant differences in VTE (1.3% vs 0.6%), UTI (0.6% vs 0.3%), transfusion (0.6% vs 0.2%), deep SSI (0.6% vs 0.1%), and reoperation (1.3% vs 1%) rates between HTO and UKA groups. The HTO group had a higher rate of superficial SSI compared with the UKA group (2.6% vs 0.6%; P = .006) (adjusted odds ratio, 4.2; 95% CI, 1.4-12.5; P = .01).

Conclusion

There were no differences in 30-day VTE, UTI, transfusion, deep SSI, and reoperation rates for HTO versus UKA in the treatment of knee OA. HTO was associated with a higher rate of superficial SSI compared with UKA. These findings serve to guide clinicians in counseling patients regarding the early risks after HTO and UKA.

Assessment of return to sport and functional outcomes following distal femoral, double level and high tibial osteotomies for active patients with symptomatic varus malalignment

PURPOSE

This study indicated the outcomes of three surgical techniques for the treatment of symptomatic unicompartmental knee osteoarthritis (UKOA) with varus malalignment in younger, active patients: distal femoral osteotomy (DFO), double-level osteotomy (DLO) and high tibial osteotomy (HTO). The outcomes measured included the return to sport, sport activity and functional scores.

METHODS

A total of 103 patients (19 DFO, 43 DLO, 41 HTO) were enrolled in the study and were divided into three groups based on their oriented deformity, each undergoing one of the three surgical techniques. All patients underwent pre- and post-operative evaluations including X-rays, physical exams and functional assessments.

RESULTS

All three surgical techniques were effective in treating UKOA with constitutional malalignment. The average time to return to sport was similar among the three groups (DFO: 6.4 ± 0.3 [5.8-7] months, DLO: 4.9 ± 0.2 [4.5-5.3] months, HTO: 5.6 ± 0.2 [5.2-6] months). The sport activity and functional scores improved significantly for all three groups, with no significant differences observed among the groups.

CONCLUSION

Various knee osteotomy procedures, DFO, DLO, and HTO, result in high RTS rates and quick RTS times with satisfactory functional scores. Despite pre- to post-operative improvements in sport activities following DFO and DLO, pre-symptom levels were not reached following all evaluated procedures.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

Risk Factors Affecting Return to Sports and Patient-Reported Outcomes After Opening-Wedge High Tibial Osteotomy in Active Patients

Background:

Although opening-wedge high tibial osteotomy (OWHTO) is favored for active patients who expect to return to sports, there is still a lack of robust evidence for factors affecting their recovery.

Purpose:

To identify (1) risk factors leading to a decreased level of return to preoperative sports after OWHTO and (2) patient characteristics and intraoperative factors influencing patient-reported outcomes after return to sports.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Included were 69 patients who underwent OWHTO and who expected to return to their preoperative level of sports, measured as a Tegner activity level ≥2. All included patients had a minimum of 1 year of follow-up data. Logistic regression analyses were performed to assess the effect of independent variables on the level of return to preoperative sports after surgery; the independent variables were age, sex, body mass index, preoperative Tegner score, preoperative Kellgren-Lawrence grade, preoperative percentage of mechanical axis (%MA), opening gap width, concomitant meniscal treatment, postoperative %MA, postoperative medial proximal tibial angle (MPTA), and postoperative posterior tibial slope. Univariate and multiple regression analyses were performed to assess for influencing factors on postoperative International Knee Documentation Committee (IKDC) subjective scores in patients who were able to return to sports.

Results:

Of the 69 patients, 51 (73.9%) returned to sports after OWHTO. High preoperative Tegner scores were statistically associated with a decrease in return to sports (odds ratio, 1.494; P = .033). Multiple regression analysis (n = 46 patients) identified that a higher postoperative MPTA was associated with a decreased IKDC subjective score after return to sports (r = –0.345; P = .019).

Conclusion:

Higher postoperative MPTA was associated with the worsening of patient-reported outcomes among those patients who did return to their preoperative sports after OWHTO. Also, participation in high-activity sports was confirmed to be a significant risk factor for a decreased rate of return to preoperative sports. These findings can support preoperative planning and intraoperative decision making, particularly for active patients.

Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies

PURPOSE

To evaluate the accuracy and precision of postoperative coronal plane alignment using 3D-printed patient-specific instrumentation (PSI) in the setting of proximal tibial or distal femoral osteotomies.

METHODS

A systematic review evaluating the accuracy of 3D-printed PSI for coronal plane alignment correcting knee osteotomies was performed. The primary outcomes were accuracy of coronal plane limb alignment correction and number of correction outliers. Secondary variables were duration of surgery, number of intraoperative fluoroscopic images, complications, cost, and clinical outcomes (as applicable).

RESULTS

Ninety-three studies were identified, and 14 were included in the final analysis. Overall, mean postoperative deviation from target correction ranged from 0.3° to 1° for all studies using hip-knee angle measurements and 2.3% to 4.9% for all studies using weight-bearing line measurements. The incidence of correction outliers was assessed in 8 total studies and ranged from 0 to 25% (total n = 10 knees) of patients corrected with 3D-printed PSI. Osteotomies performed with 3D-printed cutting guides or wedges demonstrated significantly shorter operative times (P < .05) and fewer intraoperative fluoroscopic images (P < .05) than control groups in four case control studies.

CONCLUSION

Patients undergoing distal femoral osteotomy or proximal tibial osteotomy procedures with 3D-printed patient-specific cutting guides and wedges had highly accurate coronal plane alignment with a low rate of outliers. Patients treated with 3D printed PSI also demonstrated significantly shorter operative times and decreased intraoperative fluoroscopy when compared to conventional techniques.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

Extreme Hinge Axis Positions Are Necessary to Achieve Posterior Tibial Slope Reduction With Small Coronal-Plane Corrections in Medial Opening Wedge High Tibial Osteotomy

Background:

Both coronal- and sagittal-plane knee malalignment can increase the risk of ligamentous injuries and the progression of degenerative joint disease. High tibial osteotomy can achieve multiplanar correction, but determining the precise hinge axis position for osteotomy is technically challenging.

Purpose:

To create computed tomography (CT)–based patient-specific models to identify the ideal hinge axis position angle and the amount of maximum opening in medial opening wedge high tibial osteotomy (MOWHTO) required to achieve the desired multiplanar correction.

Study Design:

Descriptive laboratory study.

Methods:

A total of 10 patients with lower extremity CT scans were included. Baseline measurements including the mechanical tibiofemoral angle (mTFA) and the posterior tibial slope (PTS) were calculated. Virtual osteotomy was performed to achieve (1) a specified degree of PTS correction and (2) a planned degree of mTFA correction. The mean hinge axis position angle for MOWHTO to maintain an anatomic PTS (no slope correction) was 102.6° ± 8.3° relative to the posterior condylar axis (PCA). Using this as the baseline correction, the resultant hinge axis position and maximum opening were then calculated for each subsequent osteotomy procedure.

Results:

For 5.0° of mTFA correction, the hinge axis position was decreased by 6.8°, and the maximum opening was increased by 0.49 mm for every 1° of PTS correction. For 10.0° of mTFA correction, the hinge axis position was decreased by 5.2°, and the maximum opening was increased by 0.37 mm for every 1° of PTS correction. There was a significant difference in the trend-line slopes for hinge axis position versus PTS correction (P = .013) and a significant difference in the trend-line intercepts for maximum opening versus PTS correction (P < .0001).

Conclusion:

The mean hinge axis position for slope-neutral osteotomy was 102.6° ± 8.3° relative to the PCA. For smaller corrections in the coronal plane, more extreme hinge axis positions were necessary to achieve higher magnitudes of PTS reduction.

Clinical Relevance:

Extreme hinge axis positions are technically challenging and can lead to unstable osteotomy. Patient-specific instrumentation may allow for precise correction to be more readily achieved.

Return to sport following distal femur osteotomy: a systematic review

INTRODUCTION

Distal femur osteotomies (DFOs) are well-accepted procedures in treating unicompartmental knee osteoarthritis associated with valgus malalignment. This study aims to investigate the Return to sport (RTS) after DFO.

MATERIALS AND METHODS

We conducted a systematic review of the literature according to the PRISMA guidelines, including all articles published in English, with no time limit, excluding double-level knee osteotomies.

RESULTS

Five articles were included for an overall cohort of 76 patients. The mean follow-up was 45.53 months. The mean age of the patients at the time of surgery was 33.87 years, and the mean malalignment was 5.59° in valgus. In 70 cases, patients received a lateral DFO, while in 6 cases, a medial closing-wedge DFO. An RTS of 86.1% was observed after DFO and a mean time to RTS of 12.3 months. 76.8% of patients recovered to a level equal to or higher than that practiced before the onset of symptoms. No statistically significant differences were observed in the RTS rate between those who performed lateral or medial DFO.

CONCLUSIONS

RTS after DFO is ubiquitous and occurs around one year after surgery. In most cases, patients report improved performance compared to what they experienced before the onset of symptoms. Unfortunately, while athletes often have RTS at a similar or better level, other patients often see a return to lower impact sports.

High Tibial Osteotomies for the Treatment of Osteoarthritis of the Knee

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A high tibial osteotomy (HTO) is a joint-preserving procedure that can be used to treat symptomatic unicompartmental cartilage disorders in the presence of limb malalignment.

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Appropriate patient selection and careful preoperative planning are vital for optimizing outcomes.

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Based on past literature, correction of varus malalignment to 3° to 8° of valgus appears to lead to favorable results. Recently, there has been growing awareness that it is important to consider soft-tissue laxity during preoperative planning.

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Although there has been a recent trend toward performing opening-wedge rather than closing-wedge or dome HTOs for unicompartmental osteoarthritis, current data suggest that all 3 are acceptable techniques with varying complication profiles.

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Based on current evidence, an HTO provides pain relief, functional improvement, and a high rate of return to sport, with reported survivorship ranging from 74.7% to 97.6% and 66.0% to 90.4% at 10 and 15 years, respectively.

Differences in the Demographics and Preferred Management of Knee Cartilage Injuries in Soccer Players Across FIFA Centers of Excellence

OBJECTIVE

We sought to report on the demographics and epidemiology of knee cartilage injuries and preferred management in soccer players, across FIFA Medical Centers of Excellence (FMCE).

DESIGN

A descriptive questionnaire focusing on characteristics of knee cartilage injuries and their management in soccer players during the 10-year period prior to the distribution of the questionnaire was sent to all FMCE around the world in September 2019 via an online platform. Voluntary responses from centers were processed and analyzed. Descriptive characteristics were reported using median and interquartile ranges (IQR) for continuous variables and frequencies and percentages (%) for discrete variables.

RESULTS

A total of 15 centers from 5 continents responded to the questionnaire and reported on a total of 4526 soccer players. Among centers, the median age was 27 years (IQR: 23-38), the median rate of male players was 75% (IQR: 68-90), and the median rate of professional players was 10% (IQR: 5-23). The most common reported etiology for cartilage injury was traumatic (median 40%, IQR: 13-73). The most common nonoperative treatment utilized was physical therapy (median 90%, IQR: 51%-100%) and the most common operative treatment utilized was bone marrow stimulation/micro-fracture (median 40%, IQR: 19-54%). The utilization of other cartilage restoration procedures varied across centers.

CONCLUSIONS

Our findings highlight different tendencies in the management of these injuries across FMCE and emphasize the need for collaborative efforts focusing on establishing consensus guidelines for the optimal management of these challenging injuries in soccer players.

Role of high tibial osteotomy in medial compartment osteoarthritis of the knee: Indications, surgical technique and outcomes

Knee osteoarthritis (OA) is the most common joint disorder worldwide. In particular, primary knee OA often presents with a varus malalignment. This increases the loads going through the medial compartment resulting in cartilage degeneration and symptomatic arthritis. High tibial osteotomy (HTO) is the workhorse surgical procedure for treating medial knee OA. When performed precisely in the hands of an experienced surgeon, HTO can delay or avoid knee arthroplasty. Of note, outcomes of knee arthroplasty are at best unpredictable in patients of younger age. Hence, there is a growing need for joint preservation procedures for younger patients presenting with knee OA, of which HTO is one. Through this article, the authors of whom all are joint preservation surgeons with a special interest in osteotomy hope to share from their experience as well as the available literature on the indications, perioperative planning, surgical technique, outcomes as well as pearls and pitfalls of HTO.

Return to sports activity after opening wedge high tibial osteotomy in patients aged 70 years and older

BACKGROUND

The purpose of this study was to evaluate return to sports (RTS) after opening wedge high tibial osteotomy (OWHTO) in elderly patients and associated factors affecting RTS.

METHODS

Seventy-four patients (mean age 68 years) who underwent OWHTO were enrolled. Clinical outcomes were evaluated using the Knee Society Score (KSS). Patients were asked regarding types of sports activities and their levels of participation within preoperative 1 year and postoperative 1 year. Levels of participation in sports and recreational activities were examined using the Tegner activity scale. The outcomes were compared between two age groups (≥ 70 years vs. < 70 years).

RESULTS

Of the 74 patients overall, 59 participated in at least one sport preoperatively, and 55 returned to sports postoperatively (RTS 93%). The KSS knee score and function score were significantly improved after surgery in both age groups (P < 0.05), but no significant differences were found between the age groups. The Tegner activity scales for ≥ 70 years and < 70 years were 2.9 ± 1.1 and 4.0 ± 1.9 preoperatively (P < 0.01) and 2.7 ± 1.2 and 3.3 ± 1.4 postoperatively (P = 0.16), respectively. RTS was reported by 24 of 25 (96.0%) in the age < 70 years group and 31 of 34 (91.2%) in the age ≥ 70 years group. Majority of age ≥ 70 years participated in low-impact sports preoperatively and returned to the same impact level postoperatively.

CONCLUSIONS

The rate of RTS after OWHTO was high in patients aged 70 years and older with low-impact level. OWHTO is a preferred surgical option for elderly patients who desire RTS.

Return to Work and Sport After Distal Femoral Osteotomy: A Systematic Review

CONTEXT

Distal femoral osteotomy (DFO) is a joint preservation procedure that corrects genu valgum deformities and patellofemoral maltracking, thereby restoring kinematics and unloading contact pressures in the lateral tibiofemoral and patellofemoral compartments.

OBJECTIVE

To evaluate the rates of return to work (RTW) and return to sport (RTS) after DFO for valgus malalignment and lateral compartment osteoarthritis through a systematic review of the literature.

DATA SOURCES

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on the PubMed, Cochrane, and Embase databases.

STUDY SELECTION

The search terms femoral osteotomy AND (sports OR work) were used. Studies in which patients underwent concomitant total knee arthroplasty were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4 (systematic review of level 4 studies).

DATA EXTRACTION

Data included the number of patients, age, gender, laterality of operation, time to follow-up, rate of RTW and RTS, time to RTS, activity level on return, and activity level scores (Tegner, Marx, Lysholm, and the International Knee Documentation Committee). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Seven articles with 194 patients were included. The average age ranged from 19 to 49 years with a mean postoperative follow-up range of 36 to 90 months. RTW data were available for 125 patients, of whom 42.1% to 91.3% returned by final follow-up. Data on RTS were available for 149 patients, of whom 70% to 100% returned at a range of 8.3 to 16.9 months postoperatively, and 41.6% to 100% returned to the same or greater level of sports activity. The Tegner and Marx activity level scores ranged from 3 to 4 and from 5 to 11, respectively, at final follow-up.

CONCLUSION

Patients treated with DFO reported high rates of RTW and RTS, with most patients being able to return to recreational sport after surgery.

Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis

Osteoarthritis causes joint pain and functional disorder, of which knee osteoarthritis is the most common. Nowadays, clinically effective treatments mainly include conservative treatment, arthroplasty, and osteotomy. However, conservative treatment only offers symptomatic relief and arthroplasty is limited to the patients with a moderate to severe degree of osteoarthritis. For relatively young patients who require greater knee preservation, a surgical treatment with low operation trauma and revision rate is needed. Osteotomy around the knee, based on the notion of “knee preservation,” has been chosen as an alternative surgical treatment. Cutting and realigning the bones corrects the mechanical line of lower limb force bearing. As such, osteotomy around the knee retains normal anatomical structure and obtains good functional recovery of the knee joint. The techniques of osteotomy around the knee includes anti‐varus deformity and anti‐valgus deformity osteotomy, aiming to reallocate the force bearing in the compartment of the knee joint. By choosing the surgical section of the lower limbs, the osteotomy around the knee can achieve the correction of mechanical axis, such as the high tibial osteotomy (HTO), proximal fibular osteotomy (PFO), and distal femur osteotomy (DFO). Numerous modified techniques have been developed to meet the demands of patients based on traditional methods. These modified osteotomy have their own advantages and indications. This paper aims to guide clinical treatment by reviewing different types of osteotomies, and their effects, that have been studied and applied widely in clinical practices.

Good clinical outcomes and return to sports after hybrid closed-wedge high tibial osteotomy

PURPOSE

This study aimed to investigate preoperative sports participation and postoperative clinical outcomes including a return to sports (RTS) after hybrid closed-wedge high tibial osteotomy (CWHTO) for medial compartment osteoarthritis of the knee. Characteristic of Hybrid CWHTO was defined as extra-articular lateral closed and medial open wedge osteotomy.

METHODS

The patients who underwent hybrid CWHTO from January 2016 to December 2018 were retrospectively reviewed and divided them into sports and non-sports groups. The preoperative demographic and radiographic characteristics were compared in both groups. And the clinical outcomes including the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS), Lysholm score, University of California at Los Angeles (UCLA) activity score, and RTS in the sports group were also investigated. Statistical analysis was performed for comparisons among the preoperative factors between the two groups. Influence of sports impact and bone union of fibular osteotomy was also statistically investigated for RTS.

RESULTS

Of the 161 knees (129 patients; 46 males, 83 females), 20 knees (16 patients; 13 males, 3 females; 12.3%) belonged to sports group. Although there were no significant differences regarding the age and radiographic parameters, there were significant differences in the body mass index and proportion of males between both groups. The JOA, VAS, Lysholm, and UCLA activity scores significantly improved after surgery. RTS was 80% at a mean duration of 7.2 ± 3.1 months. RTS in the high-impact sports group was significantly lower than that in the low-impact sports group (high-impact 60% vs. low-impact 100%, p = 0.043). There was no significant difference in RTS regarding bone union after fibular osteotomy.

CONCLUSION

The clinical outcomes including RTS were satisfactory in patients with hybrid CWHTO.

LEVEL OF EVIDENCE

IV.

Posterior Root Repair of Medial Meniscus Combined With Valgus Opening Wedge Tibial Osteotomy

The medial meniscal root tear, a particular meniscal injury at the level of its posterior bone insertion, leads to a loss of impact absorption and load distribution capacity, similar to total meniscectomy. Therefore, its repair is fundamental for knee joint longevity. This type of injury often occurs in middle-aged patients with lower limbs varus malalignment, which results in mechanical overloading of the medial compartment and induces premature cartilage wear out. The success of meniscal root repair, with meniscal bone reinsertion, depends on the correction and realignment of varus deformities greater than 5° for physiological levels. In this situation, corrective tibial osteotomy combined with meniscal repair is indicated. Our goal is to describe the step-by-step technique of the valgus opening wedge tibial osteotomy combined with the arthroscopic reinsertion of the posterior meniscal root in tibia during the treatment of a patient with varus deformity and medial meniscus root tear.

Factors Influencing Clinical and MRI Outcomes of Mesenchymal Stem Cell Implantation With Concomitant High Tibial Osteotomy for Varus Knee Osteoarthritis

Background

Cartilage repair procedures using mesenchymal stem cells (MSCs) can provide superior cartilage regeneration in the medial compartment of the knee joint when high tibial osteotomy (HTO) is performed for varus knee osteoarthritis (OA). However, few studies have reported the factors influencing the outcomes of MSC implantation with concomitant HTO.

Purpose

To investigate the outcomes of MSC implantation with concomitant HTO and to identify the prognostic factors that are associated with the outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 71 patients (75 knees) were retrospectively evaluated after MSC implantation with concomitant HTO. Clinical and radiological outcomes were evaluated, and magnetic resonance imaging (MRI) was used to assess cartilage regeneration. Statistical analyses were performed to determine the effect of different factors on clinical, radiographic, and MRI outcomes.

Results

Clinical and radiographic outcomes improved significantly from preoperatively to final follow-up (P < .001 for all), and overall cartilage regeneration was encouraging. Significant correlations were found between clinical and MRI outcomes. However, radiographic outcomes were not significantly correlated with clinical or MRI outcomes. Patient age and number of MSCs showed significant correlations with clinical and MRI outcomes. On multivariate analyses, patient age and number of MSCs showed high prognostic significance with poor clinical outcomes.

Conclusion

MSC implantation with concomitant HTO provided feasible cartilage regeneration and satisfactory clinical outcomes for patients with varus knee OA. Patient age and number of MSCs were important factors that influenced the clinical and MRI outcomes of MSC implantation with concomitant HTO for varus knee OA.