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Pullen WM, Slone H, Abrams G, Sherman SL. High Tibial Osteotomy in Knee Reconstruction and Joint Preservation. J Am Acad Orthop Surg 2024; 32:577-586. [PMID: 38175969 DOI: 10.5435/jaaos-d-23-00323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/08/2023] [Indexed: 01/06/2024] Open
Abstract
High tibial osteotomy is a dynamic operation, used as an effective procedure in both joint preservation and knee stability. Applications and indications are expanding, with good results in the treatment of malalignment associated with arthrosis, knee instability, meniscus deficiency or transplants, and/or cartilage restoration. Appropriate patient selection and preoperative planning are critical to achieving good outcomes after surgery. Coronal and sagittal plane corrections made through the proximal tibia can effectively alter joint mechanics creating a more favorable environment for cartilage, meniscus, and ligamentous structures about the knee. Advancing techniques and technologies have allowed for more precise planning and execution of osteotomies.
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Affiliation(s)
- W Michael Pullen
- From the Department of Orthopaedic Surgery, Medical University of South Carolina (Pullen, and Slone), and the Department of Orthopaedic Surgery, Stanford University (Abrams, and Sherman)
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Şahbat Y, Chou TFA, An JS, Gülağacı F, Ollivier M. CPAK classification detect the real knee joint apex position in less than half of the knees. Knee Surg Sports Traumatol Arthrosc 2024; 32:1548-1556. [PMID: 38613184 DOI: 10.1002/ksa.12175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE Accurate assessment of the knee joint line is essential for surgeries involving the knee. The knee joint line obliquity (KJLO) is a radiological measurement that evaluates the position of the knee joint relative to the ground and is frequently used in preoperative planning and clinical follow-up. On the other hand, coronal plane alignment of the knee (CPAK) classifications assesses the joint line as the summation of the medial proximal tibial angle (MPTA) and mechanical lateral distal femoral angle (mLDFA). The purpose of this study is to determine the concordance of these two measurement techniques. METHODS This cross-sectional study evaluated the long-leg standing radiographs (LSRs) of 164 healthy knees. The extremity KJLO and CPAK classification JLO were measured twice by two observers at 8-week intervals. The knee joint line apex positions (proximal, neutral and distal) of the two measurement techniques are compared (concordance or discordant). The intraobserver and interobserver reliability were examined using the intraclass correlation coefficient (ICC). Possible causes of the discordant were evaluated with univariate and multivariate logistic regression analysis. RESULTS CPAK classification detected the KJLO apex position in 70 extremities (42.7%) only. Subgroups CPAK JLO detected 13.6% of the proximal apex, 20.4% of the neutral, and 90.7% of the distal apex (p < 0.01). Upon multivariate logistic regression analysis, the variable KJLO apex position (proximal, neutral vs. distal, odds ratio (OR) = 10.291, 95% confidence interval [CI] = 2.225-25.656, and (p < 0.01) was determined as a risk factor for discordant. CONCLUSION The CPAK JLO measurement technique can be misleading in defining the KJLO apex position and the concordance between them is less than 50%. It has a high tendency to misleadingly predict proximal and neutral apex positions, which can potentially have negative implications for assessing the joint line. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Yavuz Şahbat
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Erzurum Regional Training and Research Hospital, Department of Orthopaedics and Traumatology, Erzurum, Turkey
| | - Te-Feng Arthur Chou
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Orthopaedic Surgery, Medstar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Jae-Sung An
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Fırat Gülağacı
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Matthieu Ollivier
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
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Takagawa S, Yukizawa Y, Hirotomi K, Hiagashihra S, Inaba Y, Kobayashi N. Comparison of the indications for high tibial osteotomy and double-level osteotomy for the correction of diverse lower-leg deformities in an Asian population with medial compartment osteoarthritis: a retrospective observational study. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06218-0. [PMID: 38758493 DOI: 10.1007/s00264-024-06218-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Double-level osteotomy (DLO) for knee osteoarthritis is becoming increasingly popular to achieve superior anatomical correction. This study aimed to compare the indication for open-wedge high tibial osteotomy (OWHTO) and DLO and to investigate preoperative bone morphology. METHODS Data of 166 knees treated with osteotomy were evaluated. The weight-bearing line ratio, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured. Bone deformity assessment and osteotomy simulation were conducted. Normal values of mLDFA and mMPTA were defined as 85-90°. Bone deformity was classified into four patterns: femoral, tibial, both, and no deformity. Simulation was performed to achieve a postoperative weight-bearing line ratio of 62%. Distal femoral osteotomy (DFO) or OWHTO was performed to achieve an mLDFA of 85° or mMPTA of up to 95°. If the postoperative parameter remained outside the correctable limit, DLO was performed. Cases were classified according to the corrective surgery performed, and those that could not be corrected after DLO were classified into the uncorrectable group. RESULTS Femoral, tibial, both, and no deformities were observed in 14.2%, 37.8%, 10.7%, and 33.9% of cases, respectively. No cases were classified into the DFO group; however, 53.6%, 38.1%, and 8.3% were classified into the OWHTO, DLO, and uncorrectable groups, respectively. CONCLUSION Bone deformity differed among cases, and only one-third had tibial deformity. OWHTO and DLO were indicated in approximately 50% and 40% of cases, respectively. Our study results reinforce the importance of evaluating leg morphology before surgical planning to achieve acceptable alignment.
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Affiliation(s)
- Shu Takagawa
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Yohei Yukizawa
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Kunihito Hirotomi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Shota Hiagashihra
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
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Ehlinger M, Micicoi G, Mekki T, Favreau H, Ollivier M. Comments on: "Lateral knee laxity increases the risk of excessive joint line obliquity after medial opening-wedge high tibial osteotomy" by BA Matache, PO Jean, S Pelet, AM Roger, J Dartus, E Belzile published in Orthop Traumatol Surg Res 2023: doi.10.1016/j.otsr.2023.103717. Orthop Traumatol Surg Res 2024; 110:103862. [PMID: 38458317 DOI: 10.1016/j.otsr.2024.103862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/23/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Matthieu Ehlinger
- Orthopedic and Trauma Surgery of the Lower Limb, Sports Traumatology, The Locomax center, Hautepierre II Hospital - Strasbourg University Hospitals, 1, avenue Molière, 67098 Strasbourg Cedex, France.
| | - Grégoire Micicoi
- Institute universitaire locomoteur et du sport, CHU de Nice, Hospital Pasteur, voie Romaine, Nice, France
| | - Tamir Mekki
- Orthopedic and Trauma Surgery of the Lower Limb, Sports Traumatology, The Locomax center, Hautepierre II Hospital - Strasbourg University Hospitals, 1, avenue Molière, 67098 Strasbourg Cedex, France
| | - Henri Favreau
- Orthopedic and Trauma Surgery of the Lower Limb, Sports Traumatology, The Locomax center, Hautepierre II Hospital - Strasbourg University Hospitals, 1, avenue Molière, 67098 Strasbourg Cedex, France
| | - Matthieu Ollivier
- Institut du mouvement et de l'appareil locomoteur, AP-HM, CHU de Marseille, boulevard Sainte-Marguerite, Marseille, France
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Kim TW, D'Lima DD, Moon NH, Shin WC, Suh KT, Yun MS, Lee SM. Effect of Meniscal Tear Patterns and Preoperative Cartilage Status on Joint Space Width After Medial Opening-Wedge High Tibial Osteotomy. Am J Sports Med 2024; 52:1535-1542. [PMID: 38623875 DOI: 10.1177/03635465241239327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND Medial opening-wedge high tibial osteotomy (MOWHTO) is performed to treat young adults with medial compartment knee osteoarthritis associated with varus deformity. However, factors influencing joint space width (JSW) vary according to the type of medial meniscal tear and have not yet been completely elucidated. PURPOSE To examine changes in JSW according to the type of medial meniscal tear after MOWHTO and analyze the influencing factors. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This study was conducted on 134 patients who underwent MOWHTO for medial osteoarthritis and were followed up for >2 years. The patients were classified into 3 groups based on medial meniscal status: intact, nonroot tear, and root tear. The authors then measured the JSW preoperatively and at 3 months, 6 months, 1 year, and >2 years postoperatively; analyzed whether the change in JSW varied according to meniscal status; and determined the association of these changes with the preoperative cartilage grade of the medial femoral condyle (MFC) and medial tibial plateau (MTP). International Knee Documentation Committee (IKDC) scores were used to evaluate clinical function. RESULTS Of the 134 patients, the medial meniscus was intact in 29 patients, a nonroot tear was observed in 58 patients, and a root tear was observed in 47 patients. Postoperatively, JSW increased for all groups, but the timing of the increase varied between the groups (P < .001). JSW increased the most 6 months postoperatively in the intact group and 3 months postoperatively in the nonroot tear and root tear groups (P < .001). Additionally, the increase in JSW was the greatest in the root tear group. Preoperatively, MFC and MTP cartilage status differed among the groups; MTP status did not affect the JSW, but MFC status did (P < .001). The IKDC score increased from the preoperative to postoperative time point in all groups, but there was no significant difference between groups. CONCLUSION The authors observed that the amount and timing of increase in JSW were dependent on the pattern of medial meniscal tear observed when MOWHTO was performed. In addition, the cartilage grade of MFC before surgery was associated with changes in JSW. The IKDC score was not significantly different between groups. However, a longer follow-up period is needed to analyze the correlation with the meniscal tear pattern and JSW.
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Affiliation(s)
- Tae Woo Kim
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Republic of Korea
- Department of Orthopedic Surgery, Gupo Sungshim Hospital, Busan, Republic of Korea
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Department of Molecular Medicine, Scripps Research, La Jolla, California, USA
| | - Nam Hoon Moon
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Department of Molecular Medicine, Scripps Research, La Jolla, California, USA
- Department of Orthopedic Surgery, Pusan National University Hospital, Busan, Republic of Korea
- Pusan National University, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Republic of Korea
- Pusan National University, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Kuen Tak Suh
- Pusan National University, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Orthopedic Surgery, Sehung Hospital, Busan, Republic of Korea
| | - Mi Sook Yun
- Division of Biostatistics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sang-Min Lee
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Republic of Korea
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, Department of Molecular Medicine, Scripps Research, La Jolla, California, USA
- Pusan National University, Pusan National University School of Medicine, Yangsan, Republic of Korea
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An JS, Jacquet C, Loddo G, Mabrouk A, Koga H, Argenson JN, Ollivier M. Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies. Knee Surg Sports Traumatol Arthrosc 2024; 32:1087-1095. [PMID: 38506121 DOI: 10.1002/ksa.12141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO). METHODS A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests. RESULTS An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees. CONCLUSION In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered. LEVEL OF EVIDENCE Level Ⅳ, retrospective case-control study.
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Affiliation(s)
- Jae-Sung An
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Christophe Jacquet
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
| | - Glauco Loddo
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
| | - Ahmed Mabrouk
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Orthopedic Surgery Department, Leeds Teaching Hospitals, Leeds, UK
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jean-Noël Argenson
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
| | - Matthieu Ollivier
- Orthopedic Surgery Department, Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
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Jun JB, Lee SS, Oh J, Lee DH. Knee Joint Line Obliquity With Adaptational Hip and Ankle Joint Orientation After Medial Open Wedge High Tibial Osteotomy. Am J Sports Med 2024; 52:1265-1273. [PMID: 38456270 DOI: 10.1177/03635465241230068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Time-dependent postoperative changes in knee joint line obliquity (KJLO) and subsequent adaptational changes in the hip and ankle joints have not been fully proven after medial open wedge high tibial osteotomy (MOWHTO). PURPOSE To investigate the serial postoperative changes in KJLO and subsequent adaptational changes in the hip and ankle joints over time after MOWHTO. STUDY DESIGN Case series, Level of evidence, 4. METHODS A total of 92 patients who underwent MOWHTO between April 2015 and December 2020 were evaluated. Radiographic parameters, including KJLO, ankle joint line obliquity (ALO), hip abduction angle (HAA), joint line convergence angle, weightbearing line ratio, and hip-knee-ankle angle, were analyzed in time sequence (preoperatively and 3, 6, 12, and 24 months postoperatively). Repeated-measures analysis of variance and post hoc analysis were used to demonstrate alterations and the statistical significance of KJLO and other related radiographic parameters over time. RESULTS The mean KJLO values were -1.9°, -2.1°, -2.7°, and -3.2° at 3, 6, 12, and 24 months postoperatively, respectively, indicating that there was consistent increase in valgus tilting of KJLO from 6 to 24 months (P < .001 for both 6-12 months and 12-24 months). ALO and HAA showed significant changes from 6 to 12 months (ALO, P < .001; HAA, P = .002), but not between 12 and 24 months (ALO: -3.0°, -2.7°, -1.9°, and -1.6°; HAA: -0.8°, -0.9°, -1.5°, and -1.8° at 3, 6, 12, and 24 months, respectively). The mean joint line convergence angle, weightbearing line ratio, and hip-knee-ankle angle did not change significantly from 3 months to 24 months postoperatively. CONCLUSION There was a consistent increase in valgus tilting of the postoperative KJLO from 6 to 24 months after MOWHTO. The adaptive ALO and HAA significantly changed between 6 and 12 months and were maintained until 24 months after MOWHTO. It is necessary to consider the adaptive change when hip or ankle surgery is planned within this period.
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Affiliation(s)
- June-Bum Jun
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Republic of Korea
| | - Juyong Oh
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Horita K, Okimura S, Hamaoka K, Ikeda Y, Okada Y, Kamiya T, Suzuki T, Teramoto A. Relationship between increased knee joint line obliquity after medial open-wedge high tibial osteotomy and patient-reported outcome measures. Arch Orthop Trauma Surg 2024; 144:1751-1762. [PMID: 38492062 DOI: 10.1007/s00402-024-05203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 01/12/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION This study evaluated the correlation between postoperative knee joint line obliquity after medial open-wedge high tibial osteotomy and patient-reported outcome measures excluding excessively overcorrected knees. This study further identified preoperative radiological factors related to the increased postoperative knee joint line obliquity. MATERIALS AND METHODS We retrospectively evaluated patients who underwent medial open-wedge high tibial osteotomy between March 2013 and March 2021. Postoperative excessively overcorrected knees with hip-knee-ankle angle > 7° were excluded. We investigated radiological parameters and patient-reported outcome measures preoperatively and at the last follow-up. The following radiologic parameters were measured: hip-knee-ankle angle, weight-bearing line ratio, mechanical medial proximal tibial angle, mechanical lateral distal femoral angle, lateral distal tibial angle, joint line convergent angle, knee joint line obliquity, ankle joint line obliquity, hip abduction angle, tibial posterior slope, Carton-Deschamps index, and patella tilting angle. Clinical outcomes were evaluated using Japanese knee outcome measures. This assessment criterion is based on the Western Ontario McMaster Universities Arthritis Index and MOS Short Form 36. Multiple regression analysis was performed to evaluate the association between postoperative knee joint line obliquity and patient-reported outcome measures or preoperative radiological factors (P < .05). RESULTS A total of 52 knees were included. The mean age at the time of the surgery was 61.6 ± 9.0 years and the mean follow-up period was 30.6 ± 10.1 months. Increased postoperative knee joint line obliquity was associated with lower Japanese knee outcome measures. The preoperative hip-knee-ankle angle was significantly associated with postoperative knee joint line obliquity. CONCLUSIONS Increased knee joint line obliquity after medial open-wedge high tibial osteotomy is associated with inferior clinical outcomes. Care should be given to the center of the rotational angulation in around-knee osteotomy to avoid postoperative increased knee joint line obliquity. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Kazushi Horita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Shinichiro Okimura
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Kodai Hamaoka
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Yasutoshi Ikeda
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Yohei Okada
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
| | | | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South1 West16, Chuo-ku, Sapporo, 060-8543, Japan
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Kayaalp ME, Apseloff NA, Lott A, Kaarre J, Hughes JD, Ollivier M, Musahl V. Around-the-knee osteotomies part 1: definitions, rationale and planning-state of the art. J ISAKOS 2024:S2059-7754(24)00045-2. [PMID: 38460600 DOI: 10.1016/j.jisako.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
Knee osteotomies are essential orthopedic procedures with the ability to preserve the joint and correct ligament instabilities. Literature supports the correlation between lower limb malalignment and outcomes after knee ligament reconstruction and cartilage procedures. Concepts such as joint line obliquity, posterior tibial slope angle, and intra-articular deformity correction are integral components of both preoperative planning and postoperative evaluations. The concept of preserving and/or restoring joint line congruence during simultaneous correction of varus or valgus deformity can be achieved through several different approaches. With advancements in osteotomy research and surgical planning technology, the surgical decision-making has increased in complexity. Based upon a patient's specific deformity, decisions need to be made whether to perform a single-level (proximal tibia or distal femur) versus double-level (both proximal tibia and distal femur) osteotomy, and whether to correct deformity in a single plane (coronal or sagittal) or perform a biplanar osteotomy, correcting two of the malalignments in either coronal, sagittal, or axial planes. Osteotomy procedures prioritize safety, reproducibility, precision, and meticulous planning. Equally important is the proactive management of possible complications and the implementation of preventive strategies for complications such as hinge fractures and unintentional changes to alignment in other planes. This review navigates the intricate landscape of lower limb alignment, commencing with foundational definitions and rationale for performing osteotomies, progressing through the planning phase, and addressing the critical aspect of complication prevention, all while looking ahead to anticipate future advancements in this field. However, rotational osteotomies and tibial tubercle osteotomies in isolation or as an adjunct procedure are beyond the scope of this review.
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Affiliation(s)
- M Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, 34865, Turkiye
| | - Nicholas A Apseloff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 41345, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, 41345, Sweden
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Matthieu Ollivier
- Aix Marseille Univ, CNRS, ISM, Inst Movement Sci, Marseille, 13009, France
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA.
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Ferreira A, Jacquet C, Guy S, Khakha R, Kley K, Argenson JN, Ollivier M. Distal femoral osteotomy planning: Reversed Miniaci's method is more accurate than Dugdale and Paley methods. Orthop Traumatol Surg Res 2024; 110:103697. [PMID: 37783427 DOI: 10.1016/j.otsr.2023.103697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023]
Abstract
PURPOSES The purpose of this study was to validate the reversed Miniaci method for distal femoral osteotomies and to compare the accuracy with Dugdale and Paley methods. METHODS Between January 2019 and October 2021, 59 DFO were performed in a single center. Following application of the eligibility and exclusion criteria, radiographic measurements and analysis was performed for 24 patients by two independent observers, then repeated after one month. Medical planning software: PeekMed v2.3.7.6® was used. For all patients the following measurements were performed: Hip-Knee-Ankle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), joint line obliquity (JLO), width of the proximal tibia and the weight-bearing line (WBL). Each image was then analysed using the following planning methods for realignment surgery: Reversed Miniaci, Dugdale and Paley. Measurements were recorded post deformity correction. Difference between target and post-correction WBL was evaluated. This difference was adjusted by the objective in order to limit biases related to the different objectives according to the method. RESULTS Eighteen patients were managed for a varus osteotomy and 6 for a valgus osteotomy. Preoperative data was, HKA at 176.7±6.3, mLDFA at 90.6±5.4, MPTA 88.9±1.1, a WBL for valgus 80.9%±9.1 and for varus deformity 23.5%±11.7. Inter- and intra-rater reliability was>0.8 for every method. After normalizing reported precision on the amount of correction expected, reversed Miniaci method was the most accurate with a mean deviation from the target of 3%, compared to the Dugdale's method with 9% (p<0.001) and to Paley's method with 8.6% (p<0.001). CONCLUSION The reversed Miniaci method is effective and reliable for planning distal femoral osteotomies. Compared to other planning methods, it is the most accurate approach for achieving a correction goal. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- Alexandre Ferreira
- Department of Orthopedics and Traumatology, Caen University Hospital, avenue Côte de Nacre, 14000 Caen, France.
| | - Christophe Jacquet
- Department of Orthopedics and Traumatology, Institute of movement and locomotion, Sainte-Marguerite Hospital, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France
| | - Sylvain Guy
- Department of Orthopedics and Traumatology, Institute of movement and locomotion, Sainte-Marguerite Hospital, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France
| | - Raghbir Khakha
- Harley Street Specialist Hospital, London, United Kingdom
| | - Kristian Kley
- Harley Street Specialist Hospital, London, United Kingdom; Orthoprofis Hannover Luisenstraße 10/11, 30539 Hannover, Germany
| | - Jean-Noël Argenson
- Department of Orthopedics and Traumatology, Institute of movement and locomotion, Sainte-Marguerite Hospital, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France; Aix Marseille Unit, Department of Orthopedics and Traumatology, Institute for Locomotion, CNRS, ISM, Sainte-Marguerite Hospital, AP-HM, Marseille, France
| | - Matthieu Ollivier
- Department of Orthopedics and Traumatology, Institute of movement and locomotion, Sainte-Marguerite Hospital, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France; Aix Marseille Unit, Department of Orthopedics and Traumatology, Institute for Locomotion, CNRS, ISM, Sainte-Marguerite Hospital, AP-HM, Marseille, France
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Jie K, Liang J, Xu J, Zou Y, Li B, Tan Y, Zhang H, Zhu Y. Changes in clinical outcomes and alignment of the ipsilateral knee and ankle after supramalleolar osteotomy in patients with varus osteoarthritis of the ankle: a short-term follow-up study. Arch Orthop Trauma Surg 2024; 144:161-170. [PMID: 37789151 DOI: 10.1007/s00402-023-05079-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 09/17/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE The purpose of this study was to investigate the changes in clinical outcomes and alignment of the ipsilateral knee and ankle in patients with varus ankle osteoarthritis after supramalleolar osteotomy (SMO). METHODS We retrospectively reviewed 23 patients (24 ankles) with Takakura II, IIIa and IIIb ankle osteoarthritis treated with SMO between May 2017 and March 2022. The radiologic parameters of ankles contained medial distal tibial angle (TAS), tibiotalar angle (TT), tibial lateral surface (TLS), tibial plafond inclination (TPI) and talar inclination (TI). The radiologic parameters of knees contained medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), the knee joint line orientation relative to ground (G-KJLO) and WBL. Hip-knee-ankle angle (HKA) was also collected. The Takakura system was used for evaluating the ankle osteoarthritis and the Kellgren-Lawrence (KL) system was used for evaluating the knee osteoarthritis. Clinical evaluation of the ankle joints contained American Orthopedic Foot and Ankle Society (AOFAS), range of motion (ROM) and visual analogue scale (VAS). Clinical evaluation of the knee joints contained Japanese Orthopaedic Association Scores (JOA), ROM, VAS. RESULTS The mean follow-up times were 20.3 ± 7.3 months (range 12-38). According to the radiologic evaluation, the TAS increased from preoperative 84.7° ± 2.0° to 91.2° ± 1.8° at the last follow-up (P < 0.001). The TPI and TI decreased from 4.4° ± 4.2° and 11.0° ± 5.2° to 0.1° ± 4.7° and 4.1° ± 4.8° (P < 0.001 for both). The TT angel improved from 9.5° ± 4.1° to 4.9° ± 3.3° (P < 0.001). No significant differences were found regarding MPTA, JLCA, G-KJLO, knee WBL and HKA (P > 0.05 for all). The Takakura stage improved after SMO (P < 0.001) whilst the KL stage maintains the similar lever (P > 0.05). According to the clinical evaluation, the AOFAS significantly increased from 67.5 ± 10.6 to 88.5 ± 9.3 and the VAS of the ankle decreased from 4.7 ± 1.6 to 1.2 ± 1.1, whilst there were no changes on VAS and even the JOA and knee ROM after SMO (P > 0.05 for all). CONCLUSIONS SMO can alleviate the symptoms of varus ankle osteoarthritis and delay the time for ankle replacement or arthrodesis by redistributing the abnormal stress of the ankle and restoring the congruence of the tibiotalar joint. In addition, it did not induce the clinical symptoms of knee without compromising lower limb alignment or knee joint line orientation in the short term. LEVEL OF EVIDENCE Level IV case series.
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Affiliation(s)
- Ke Jie
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Jinjie Liang
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Jingcheng Xu
- Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Yunxuan Zou
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Biyi Li
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Yanqing Tan
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Hongning Zhang
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China
| | - Yongzhan Zhu
- Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Foshan, 528000, Guangdong, China.
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12
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Cho JH, Nam HS, Park SY, Ho JPY, Lee YS. Constitutional and postoperative joint line obliquity can predict serial alignment change after opening-wedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification. Knee Surg Sports Traumatol Arthrosc 2023; 31:5652-5662. [PMID: 37875585 DOI: 10.1007/s00167-023-07611-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE The purposes of this study were (1) to clarify the distribution of the Coronal Plane Alignment of the Knee (CPAK) phenotype in patients who underwent medial opening-wedge high tibial osteotomy (OWHTO) and (2) to identify the predictive factors for postoperative serial alignment changes after OWHTO by analyzing constitutional phenotypes. METHODS Patients who underwent OWHTO between March 2014 and December 2019 were retrospectively evaluated. Those who completed a minimum follow-up of 3 years were divided into three groups based on the direction of alignment changes from postoperative 3 months to the final follow-up: Group 1 (varus direction) when the weight-bearing line ratio (WBLR) change was less than - 4%, Group 2 (maintained) when the WBLR change was between - 4% and 4%, and Group 3 (valgus direction) when the WBLR change was greater than 4%. The following parameters were assessed serially and compared between the groups: (1) radiologic parameters of coronal limb alignment such as joint line obliquity (JLO), (2) CPAK phenotypes, and (3) clinical outcomes. RESULTS In total, 163 knees were included, and the average duration of follow-up was 4.8 ± 1.6 years. More apex distal JLO was observed in the order of Group 1, 2, and 3 at all times (all p < 0.05). The most common CPAK type was type (I + II) (constitutional: apex distal JLO) + type (V + VI) (postoperative 3 months: neutral JLO) in Group 1 (29.4%; p = 0.000); otherwise, the most common CPAK type was type (IV + V) (constitutional: neutral JLO) + type (VIII + IX) (postoperative 3 months: apex proximal JLO) in Group 3 (11.7%; p = 0.000). Clinical outcomes did not differ between the groups. CONCLUSION Constitutional and postoperative JLO were predictive factors of postoperative alignment changes after OWHTO. Constitutional apex distal and postoperative neutral JLO had a tendency for varus alignment progression, whereas constitutional neutral and postoperative apex proximal JLO had a tendency for valgus alignment progression. LEVEL OF EVIDENCE Retrospective cohort study; Level III.
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Affiliation(s)
- Joon Hee Cho
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 463-707, South Korea
| | - Hee Seung Nam
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 463-707, South Korea
| | - Seong Yun Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 463-707, South Korea
| | - Jade Pei Yuik Ho
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 463-707, South Korea
| | - Yong Seuk Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 463-707, South Korea.
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Kim SG, Jun JB, Bae IW, Lee DH. Changes in ankle and hip joints following medial opening-wedge high tibial osteotomy affect knee joint line obliquity. Knee Surg Sports Traumatol Arthrosc 2023; 31:5420-5427. [PMID: 37778016 DOI: 10.1007/s00167-023-07581-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE This study aimed to measure the change in knee joint line obliquity (KJLO) and the changes in radiologic parameters of the ankle and hip joints after medial opening-wedge high tibial osteotomy (MOWHTO), and to evaluate the correlation and causal relationship between these parameters. METHODS This study evaluated 109 patients who underwent MOWHTO between April 2015 and December 2021. Radiologic parameters, including KJLO, medial proximal tibial angle (MPTA), ankle joint line obliquity (AJLO), and hip abduction angle (HAA), were analysed before and 1 year after MOWHTO. Multiple linear regression analysis was used to identify independent variables that significantly affected the change in KJLO after MOWHTO. Receiver operating characteristic (ROC) analysis was used to evaluate the cutoff value for a change in KJLO that exceeded 5° postoperatively, and the predicting values of radiologic parameters. RESULTS Multiple linear regression analysis showed that changes in MPTA, AJLO, and HAA (β = 0.440, P < 0.001; β = - 0.310, P < 0.001; β = 0.164, P = 0.035, respectively) were predictors of the change in KJLO after MOWHTO. ROC analysis showed that the threshold value for a change in KJLO which exceeded 5° postoperatively was 4.6° (66.7% sensitivity, 63.8% specificity, P = 0.025). Moreover, ROC curves for predicting a change in KJLO of > 4.6° showed that the AUC was significantly higher for the change in MPTA than that of the other two parameters (P = 0.011 for AJLO and P < 0.001 for HAA). CONCLUSION MOWHTO increases the KJLO by valgization of the proximal tibia and causes hip adduction and ankle valgization. The postoperative ankle valgization after MOWHTO could reduce the increase in KJLO, counteracting the effects of proximal tibial valgization and hip adduction. Therefore, the effects of the hip and ankle joints should be considered to achieve an optimal KJLO and satisfactory clinical outcomes after MOWHTO. LEVEL OF STUDY Cohort study, IV.
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Affiliation(s)
- Sang-Gyun Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, South Korea
| | - June-Bum Jun
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Il Wook Bae
- Department of Orthopaedic Surgery, National Medical Center, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Xie T, Huizinga MR, van den Akker-Scheek I, van der Veen HC, Brouwer RW. Joint line obliquity after lateral closing-wedge high tibial osteotomy does not adversely affect clinical and radiological outcome: a 5-year follow-up study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4851-4860. [PMID: 37561185 PMCID: PMC10598188 DOI: 10.1007/s00167-023-07532-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/27/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE To analyze the association between change in knee joint line obliquity (KJLO) and patient-reported outcome, radiological progression of osteoarthritis, and surgical survival after lateral closing-wedge high tibial osteotomy (HTO). METHODS A cohort of 180 patients treated in one single hospital with lateral closing-wedge HTO was examined. KJLO was defined by the medial proximal tibial angle (MPTA). To assess the association between KJLO and patient-reported outcome, radiological progression of osteoarthritis, and surgical survival, patient groups were defined: I, postoperative MPTA < 95.0°; II, postoperative MPTA ≥ 95.0°; A, MPTA change < 8.0°; B, MPTA change ≥ 8.0°. Propensity score matching was used for between-groups (I and II, A and B) covariates matching, including age, gender, preoperative lower limb alignment, preoperative medial joint space width (mJSW), preoperative Western Ontario and McMaster Universities osteoarthritis Index (WOMAC) score, wedge size, and postoperative follow-up time. Patient-reported outcome was assessed by the WOMAC questionnaire, radiological progression of osteoarthritis by mJSW and Kellgren-Lawrence (KL) grade progression (≥ 1) preoperatively and at follow-ups (> 2 years). Failure was defined as revision HTO or conversion to knee arthroplasty. RESULTS After propensity score matching, groups I and II contained 58 pairs of patients and groups A and B contained 50 pairs. There were no significant differences in postoperative WOMAC score or surgical failure rate between groups I and II or between groups A and B (p > 0.05). However, the postoperative mJSW was significantly lower in group I than group II (3.2 ± 1.6 mm vs 3.9 ± 1.8 mm; p = 0.018) and in group A than group B (3.0 ± 1.7 mm vs 3.7 ± 1.5 mm; p = 0.040). KL grade progression rate was significantly higher in group I than group II (53.4% vs 29.3%; p = 0.008) and in group A than group B (56.0% vs 28.0%; p = 0.005). CONCLUSION Increased KJLO (postoperative MPTA ≥ 95.0°) or MPTA change ≥ 8.0° after lateral closing-wedge HTO does not adversely affect patient-reported outcome, radiological progression of osteoarthritis, or surgical survival at an average 5-year follow-up. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Tianshun Xie
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Maarten R Huizinga
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Hugo C van der Veen
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Reinoud W Brouwer
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
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Ollivier M, An JS, Kley K, Khakha R, Fernandes LR, Micicoi G. A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus. Knee Surg Sports Traumatol Arthrosc 2023; 31:4927-4934. [PMID: 37597039 DOI: 10.1007/s00167-023-07518-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/18/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE The recent ESSKA consensus recommendations defined indications and outlined parameters for osteotomies around a degenerative varus knee. The consensus collated these guidelines based on the published literature available to answer commonly asked questions including the importance of identifying the site and degree of the lower limb deformity. In the consensus, the authors suggest that a knee joint line obliquity (JLO) greater than 5° or a planned medial proximal tibial angle (MPTA) > 94° preferentially indicates a double level osteotomy (DLO) compared to an isolated opening wedge high tibial osteotomy (OWHTO). This study aimed to analyze the corrections performed on a cohort of isolated opening wedge high tibial osteotomies (OWHTOs) prior to the recent ESSKA recommendations, with a focus on the impact of knee joint line obliquity (JLO) and medial proximal tibial angle (MPTA) on the choice of osteotomy procedure. METHODS This monocentric, retrospective study included 129 patients undergoing medial OWHTO for symptomatic isolated medial knee osteoarthritis (Ahlbäck grade I or II) and a global varus malalignment (hip-knee-ankle angle ≤ 177°). An automated software trained to automatically detect lower limb deformity was implemented using patients preoperative long leg alignment X-rays to identify suitability for an isolated HTO in knee varus deformity. Based on the ESSKA recommendations, the site of the osteotomy was identified as well as the degree of correction required. The ESSKA consensus considers avoiding an isolated high tibial osteotomy if the planned resultant knee joint line orientation exceeds 5 ̊ or MPTA exceeds 94°. A preoperative abnormal MPTA was defined by a value lower than 85° and a preoperative abnormal LDFA by a value greater than 90°. The cases of DLO or DFO suggested by the software and the number of extra-tibial anomalies were collected. Multiple linear regression models were developed to establish a relationship between preoperative values and the risk of being outside of ESSKA recommendations postoperatively. RESULTS Based on ESSKA recommendations and on threshold values considered abnormal, the software suggested a DLO in 17.8% (n = 23/129) of cases, a distal femoral osteotomy in 27.9% (n = 36/129) of cases and advised against an osteotomy procedure in 24% (n = 31/129) of cases. The software detected a femoral anomaly in 34.9% (n = 45/129) of cases and an JLCA > 6° in 9.3% (n = 12/129). Postoperatively, the MPTA exceeds 94° in 41.1% (n = 53/129) and the JLO exceeds 5° in 29.4% (n = 38/129). On multivariate analysis, a high preoperative MPTA was associated with higher risk of postoperative MPTA > 94° (R2 = 0.36; p < 0.001). Similarly, the probability of the software advising a DLO or DFO was associated with the presence of an "normal" preoperative MPTA (R2 = 0.42; p < 0.001) or an abnormal preoperative LDFA (R2 = 0.48; p < 0.001) or a planned JLO > 5° (R2 = 0.27; p < 0.001). CONCLUSIONS Analysis of patients who underwent an isolated OWHTO prior to the ESSKA guidelines, demonstrated a significant rate of post-operative tibial overcorrection and a resultant increased JLO. Pre-operative planning that considers the ESSKA guidelines, allows for better identification of those patients requiring a DFO or DLO and avoidance of resultant post-operative deformities. LEVEL OF EVIDENCE IV, case-series.
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Affiliation(s)
- Matthieu Ollivier
- APHM, CNRS, ISM, Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, Aix Marseille University, Sainte-Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.
| | - Jae-Sung An
- APHM, CNRS, ISM, Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, Aix Marseille University, Sainte-Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Kristian Kley
- Orthoprofis Hannover Luisenstraße, 10/11, 30539, Hannover, Germany
| | - Raghbir Khakha
- Guys and St. Thomas' Hospitals, Great Maze Pond, London, SE1 9RT, England
| | - Levi Reina Fernandes
- Department of Orthopedics and Traumatology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Grégoire Micicoi
- Institute for Locomotion and Sports, iULS-University, Pasteur 2 Hospital, University Côte d'Azur, UR2CA, Nice, France
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Machado A, Micicoi L, Ernat J, Schippers P, Bernard de Dompsure R, Bronsard N, Gonzalez JF, Micicoi G. Normo-or slightly overcorrection show better results after medial closing wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2023; 31:4276-4284. [PMID: 37326635 DOI: 10.1007/s00167-023-07465-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/20/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE The objectives of this study were to evaluate functional results, revision-free survival, and the influence of postoperative alignment on outcomes after MCWHTO. METHODS This retrospective study included 27 MCWHTO operated on from 2009 to 2021. Radiographic measurements were performed pre- and postoperatively. The HKA (Hip-Knee-Ankle angle), MPTA (Medial Proximal Tibial angle), LDFA (Lateral Distal Femoral Angle), JLO (Joint Line Obliquity), and JLCA (Joint Line Convergence Angle) were evaluated. The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee Score, and the Subjective Knee Value (SKV) as well as revision-free survival were evaluated. Postoperative alignment and its influence on clinical outcomes were also analysed. RESULTS The mean follow-up was 61.9 months ± 31.4 (13-124). The HKA, MPTA, and JLCA angles were decreased post-operatively (respectively, Δ = 5.9° ± 2.6, p < 0.001; Δ = 6.1° ± 3.2, p < 0.001 and Δ = 2.5° ± 1.9, p < 0.001). LDFA and JLO were unchanged, post-operatively (respectively, Δ = 0.1° ± 2.2, p = 0.93 and Δ = 1.2° ± 3.3, p = 0.23). Postoperative HKA correlated with knee IKS (R = - 0.15, p = 0.04) and function IKS (R = - 0.44, p = 0.03). Postoperative LDFA correlated with knee IKS(R = 0.8, p < 0.01). Patients with postoperative HKA ≤ 180° had better KOOS (Δ = 12.3, p = 0.04) and IKS function (Δ = 28.1, p < 0.01) than those with HKA > 180°. CONCLUSION Functional results and revision-free survival after MCWHTO are satisfactory when the deformity is located in the proximal tibia. The joint line obliquity is not significantly altered with small tibial correction and, obtaining an overall neutral or slightly varus alignment under the conditions of this study allowed an improvement in the postoperative clinical scores. The literature is still inconclusive on the ideal alignment for valgus deformities and larger series are needed to draw definitive conclusions. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Axel Machado
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Lolita Micicoi
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Justin Ernat
- University of Utah Health, Salt Lake City, Utah, USA
| | - Philipp Schippers
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Régis Bernard de Dompsure
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Nicolas Bronsard
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Jean-François Gonzalez
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Grégoire Micicoi
- University Institute of Locomotor and Sports (iULS), Pasteur II Hospital, 30, voie Romaine, 06000, Nice, France.
- Unité de Recherche Clinique Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France.
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Xie T, Brouwer RW, van den Akker-Scheek I, van der Veen HC. Clinical relevance of joint line obliquity after high tibial osteotomy for medial knee osteoarthritis remains controversial: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:4355-4367. [PMID: 37340220 PMCID: PMC10471655 DOI: 10.1007/s00167-023-07486-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE To systematically review the literature on the association between knee joint line obliquity (KJLO) and clinical outcome after high tibial osteotomy (HTO) for medial knee osteoarthritis and summarize the KJLO cut-off value used when studying this association. METHODS A systematic search was conducted in three databases (PubMed, Embase, and Web of Science) on September 2022, updated on February 2023. Eligible studies describing postoperative KJLO in relation to clinical outcome after HTO for medial knee osteoarthritis were included. Nonpatient studies and conference abstracts without full-text were excluded. Two independent reviewers assessed title, abstract and full-text based on the inclusion and exclusion criteria. The modified Downs and Black checklist was used to assess the methodological quality of each included study. RESULTS Of the seventeen studies included, three had good methodological quality, thirteen fair quality, and one had poor quality. Conflicting findings were shown on the associations between postoperative KJLO and patient-reported outcome, medial knee cartilage regeneration, and 10-year surgical survival in sixteen studies. Three good-quality studies found no significant differences in lateral knee cartilage degeneration between postoperative medial proximal tibial angle > 95° and < 95°. Joint line orientation angles by the tibial plateau of 4° and 6°, joint line orientation angle by the middle knee joint space of 5°, medial proximal tibial angles of 95° and 98°, and Mikulicz joint line angle of 94° were KJLO cut-off values used in the included studies. CONCLUSION Based on current evidence, the actual association between postoperative KJLO and clinical consequences after HTO for medial knee osteoarthritis cannot be ascertained. The clinical relevance of KJLO after HTO remains controversial. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Tianshun Xie
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Reinoud W Brouwer
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Hugo C van der Veen
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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Xie T, van der Veen HC, van den Akker-Scheek I, Brouwer RW. Assessment of joint line obliquity and its related frontal deformity using long-standing radiographs. J Orthop 2023; 40:57-64. [PMID: 37188146 PMCID: PMC10172862 DOI: 10.1016/j.jor.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/13/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
Purpose To investigate how radiographic techniques and osteoarthritis grade influence measurements of knee joint line obliquity (KJLO) and KJLO-related frontal deformity, and to propose preferable KJLO measurement methods. Methods Forty patients with symptomatic medial knee osteoarthritis indicated for high tibial osteotomy were assessed. Measurements were compared between single-leg and double-leg standing radiographs for KJLO measurement methods including joint line orientation angle by femoral condyles (JLOAF), joint line orientation angle by middle knee joint space (JLOAM), joint line orientation angle by tibial plateau (JLOAT), Mikulicz joint line angle (MJLA) and medial proximal tibial angle (MPTA), as well as KJLO-related frontal deformity parameters including joint line convergence angle (JLCA), knee ankle joint angle (KAJA) and hip-knee-ankle angle (HKA). Influences of bipedal distance in double-leg standing and osteoarthritis grade on the above measurements were analysed. Measurement reliability was evaluated by intraclass correlation coefficient. Results From single-leg to double-leg standing radiographs MPTA and KAJA did not change significantly, whereas the other measurements showed significant changes: JLOAF, JLOAM and JLOAT decreased 0.88°, 1.24° and 1.77°, MJLA and JLCA decreased 0.63° and 0.85°, and HKA increased 1.11° (p < 0.05). Bipedal distance in double-leg standing radiographs moderately correlated with JLOAF, JLOAM and JLOAT (rp = -0.555, -0.574 and -0.549). Osteoarthritis grade moderately correlated with JLCA in single-leg and double-leg standing radiographs (rs = 0.518 and 0.471). All measurements had at least good reliability. Conclusion In long-standing radiographs, measurements of JLOAF, JLOAM, JLOAT, MJLA, JLCA and HKA are all influenced by single-leg/double-leg standing; JLOAF, JLOAM and JLOAT are also affected by bipedal distance in double-leg standing; and JLCA is affected by osteoarthritis grade. Knee joint obliquity as assessed by MPTA measurement is independent of single-leg/double-leg standing, bipedal distance or osteoarthritis grade, and has excellent measurement reliability. We therefore propose MPTA as the preferable KJLO measurement method for clinical practice and future research. Level of evidence III, cross-sectional study.
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Affiliation(s)
- Tianshun Xie
- Department of Orthopaedic Surgery, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Hugo C. van der Veen
- Department of Orthopaedic Surgery, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopaedic Surgery, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Reinoud W. Brouwer
- Department of Orthopaedic Surgery, Martini Hospital, P.O. Box 30.0331, 9700 RM, Groningen, the Netherlands
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Choe JS, Bin SII, Kim JM, Lee BS, Song JH, Cho HK, Kee TH. Association of Medial Meniscal Volume With Decreased Joint Space Width After Medial Opening-Wedge High Tibial Osteotomy. Orthop J Sports Med 2023; 11:23259671231166920. [PMID: 37223072 PMCID: PMC10201151 DOI: 10.1177/23259671231166920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/24/2023] [Indexed: 05/25/2023] Open
Abstract
Background Medial opening-wedge high tibial osteotomy (MOWHTO) reduces contact stress by altering the weightbearing axis from the medial to the lateral compartment, relieves knee pain, and slows the progression of osteoarthritis. Purpose/Hypothesis To evaluate whether the volume of the medial meniscus affects outcomes after MOWHTO. It was hypothesized that reduced medial meniscal volume would be associated with worse midterm clinical and radiographic outcomes. Study Design Cohort study; Level of evidence, 3. Methods Included were 59 patients who underwent MOWHTO and had ≥4 years of follow-up data. The mean follow-up period was 66.5 ± 15.1 months (range, 48-110 months). The cohort was classified into 3 groups according to the status of the medial meniscus on arthroscopic examination before osteotomy: no meniscal tear, degenerative tear leading to partial meniscectomy, and degenerative tear leading to subtotal meniscectomy. The Hospital for Special Surgery score and Knee Society objective and functional scores were compared among the groups at 2 time points (preoperative and latest follow-up), and the medial joint space width (JSW) was compared among the groups at 3 time points (preoperative, 1 year postoperative, and latest follow-up). Results Overall, 9 patients had no meniscal tear, 20 patients underwent partial meniscectomy, and 30 patients underwent subtotal meniscectomy. The clinical scores improved significantly from preoperatively to the latest follow-up (P ≤ .001 for all), with no significant difference among the groups. Post hoc analysis indicated that at the latest follow-up, JSW was significantly lower in the subtotal meniscectomy group compared with the no-tear group on both 45° of flexion posterior-anterior (2.5 ± 1.3 vs 3.9 ± 1.8 mm; P = .004) and anterior-posterior (3.4 ± 1.1 vs 4.5 ± 0.9 mm; P = .011) radiographs. Conclusion Subtotal meniscectomy of the medial meniscus performed during arthroscopic examination with MOWHTO was associated with decreased JSW at midterm follow-up. Efforts should be made to preserve the medial meniscus as much as possible during MOWHTO.
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Affiliation(s)
- Jung-Su Choe
- Department of Orthopedic Surgery, Cheju
Halla General Hospital, Jeju, Republic of Korea
| | - Seong-II Bin
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
| | - Jong-Min Kim
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
| | - Ju-Ho Song
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
| | - Hyung-Kwon Cho
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
| | - Tae-Hong Kee
- Department of Orthopedic Surgery, Asan
Medical Center, University of Ulsan College of Medicine, Seoul, Republic of
Korea
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Koh DTS, Soong J, Yeo W, Tan MWP, Teo SJ, Wilson A, Lee KH. Large Versus Small Opening Wedge High Tibial Osteotomies Performed With a Protective Wire Over the Lateral Hinge: Incidence of Lateral Hinge Fracture and Early Clinical Outcomes. Am J Sports Med 2023; 51:672-677. [PMID: 36856282 DOI: 10.1177/03635465221148496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND The incidence of lateral hinge fractures (LHFs) during medial opening wedge high tibial osteotomy (MOW-HTO) is unacceptably high, especially with distractions >10 mm. LHFs result in malunion, loss of correction, and recurrence of symptoms adversely affecting clinical outcomes. PURPOSE (1) To investigate the incidence of LHF when a protective guide wire is utilized during MOW-HTO in small and large corrections and (2) to study the effect of correction size on early clinical outcomes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis was performed of 96 knees that underwent MOW-HTO between 2019 and 2020. A protective wire applied intraoperatively across the lateral hinge point before opening wedge distraction was performed for all patients. Patients were divided into 2 groups based on opening wedge sizes: group A (opening distraction <10 mm) and group B (opening distraction ≥10 mm). LHF and wound complications were recorded. Prospective Knee Score and Function Score (Knee Society), Oxford Knee Score, and Physical and Mental Component Summaries of the 36-Item Short Form Health Survey questionnaire were recorded preoperatively and at 6 months and 2 years after surgery. RESULTS Incidence of LHF was low in group A (n = 2; 6.1%) and group B (n = 3; 9.1%). A single case of intraoperative LHF was noted in each group, with each case resulting in a type 1 fracture. The incidence of postoperative fractures was comparable between groups (groups A vs B, n = 1 vs 2). At 6 months, clinical outcomes in group A were superior to those of group B (Knee Score, 85.7 ± 14.7 vs 73.1 ± 20.3, P = 0.028; Function Score, 73.5 ± 16.5 vs 63.1 ± 19.5, P = 0.047; Oxford Knee Score, 20.2 ± 4.7 vs 25.6 ± 8.5, P = 0.008; Physical Component Summary, 46.8 ± 8.1 vs 40.2 ± 10.9, P = 0.018). However, clinical outcomes were comparable at 2 years (P > .05). CONCLUSION A protective wire was associated with a low incidence of LHF, even in larger MOW-HTO corrections. Large corrections had poorer clinical outcomes as compared with small corrections at 6 months. However, clinical outcomes between groups were comparable at 2 years.
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Affiliation(s)
| | - Junwei Soong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - William Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Shao Jin Teo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Adrian Wilson
- London Osteotomy Centre, Harley Street Specialist Hospital, London, UK.,Department of Sports and Exercise, University of Winchester, Winchester, UK
| | - Kong Hwee Lee
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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21
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Abs A, Micicoi G, Khakha R, Escudier JC, Jacquet C, Ollivier M. Clinical and Radiological Outcomes of Double-Level Osteotomy Versus Open-Wedge High Tibial Osteotomy for Bifocal Varus Deformity. Orthop J Sports Med 2023; 11:23259671221148458. [PMID: 36814769 PMCID: PMC9940185 DOI: 10.1177/23259671221148458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Background In bifocal varus deformity, double-level osteotomy (DLO) is advocated to treat lower limb alignment to prevent an adverse increase in joint line obliquity. Purpose/Hypothesis The purpose of this study was to compare the clinical and radiological results after DLO and open-wedge high tibial osteotomy (OWHTO) in patients with combined varus deformity. It was hypothesized that DLO would improve clinical results without increasing the complication rate compared with OWHTO. Study Design Cohort study; Level of evidence, 3. Methods Inclusion criteria were medial tibiofemoral compartment pain, varus knee deformity with an abnormal medial proximal tibial angle <84° and a lateral distal femoral angle >90°, a functional anterior cruciate ligament, failure of nonoperative treatment, and a minimum 2-year follow-up with all clinical and radiological data. The rate of return to work or sports; the Knee injury and Osteoarthritis Outcome Score (KOOS); the University of California, Los Angeles (UCLA) activity score; and patient satisfaction were assessed at a minimum of 2 years of follow-up. Statistical comparison of the 2 groups was made using the chi-square or Student t test. Results A total of 69 consecutive patients were analyzed, of whom 38 underwent OWHTO and 31 underwent DLO surgery. A significant between-group difference was found for all radiological parameters; in particular, there was less joint line obliquity after DLO compared with OWHTO (1.7° vs 5.6°; P < .001). DLO provided better outcomes compared with OWHTO regarding the UCLA score (4.3 vs 6.7; P < .001) and patient satisfaction (2.6 vs 3.9; P < .001), but no significant difference in KOOS or return to work or sports was observed. The OWHTO group had more hinge fractures than the DLO group (34.2% vs 12.9%; P < .001). Conclusion For combined tibial and femoral varus deformity, DLO produced more physiologic joint line obliquity with slightly improved UCLA and patient satisfaction scores. A greater incidence of hinge fracture was observed after isolated OWHTO compared with DLO due to a larger tibial correction; however, this had little effect on clinical results at the 2-year follow-up.
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Affiliation(s)
- Alice Abs
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France.,APHM, CNRS, ISM, Aix-Marseille University, Marseille, France
| | - Grégoire Micicoi
- IULS–University Institute for Locomotion and Sports, Pasteur 2 Hospital, Unité de Recherche Clinique Côte d’Azur (UR2CA), Hôpital Pasteur II, Nice, France
| | - Raghbir Khakha
- Guys and St. Thomas’ Hospitals, Great Maze Pond, London, UK
| | - Jean-Charles Escudier
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France.,APHM, CNRS, ISM, Aix-Marseille University, Marseille, France
| | - Christophe Jacquet
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France.,APHM, CNRS, ISM, Aix-Marseille University, Marseille, France
| | - Matthieu Ollivier
- Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France.,APHM, CNRS, ISM, Aix-Marseille University, Marseille, France.,Matthieu Ollivier, MD, PhD, Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274 Marseille, France () (Instagram: @pr.matt.ollivier)
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22
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Current clinical practice of knee osteotomy in the Netherlands. Knee 2023; 41:292-301. [PMID: 36801495 DOI: 10.1016/j.knee.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/16/2022] [Accepted: 01/26/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Realignment osteotomies is gaining popularity amongst Dutch orthopaedic surgeons. Exact numbers and used standards in clinical practice concerning osteotomies are unknown due to the absence of a national registry. The aim of this study was to investigate the national statistics of performed osteotomies, utilized clinical workups, surgical techniques, and post-operative rehabilitation standards in the Netherlands. METHOD Dutch orthopaedic surgeons, all members of the Dutch Knee Society, received a web-based survey between January and March 2021. This electronic survey contained 36 questions, subdivided into: general surgeon-related information, number of performed osteotomies, inclusion of patients, clinical workup, surgical techniques, and post-operative management. RESULTS 86 orthopaedic surgeons filled in the questionnaire, of whom 60 perform realignment osteotomies around the knee. All the 60 responders (100%) perform high tibial osteotomies and 63.3% additionally perform distal femoral osteotomies, while 30% perform double level osteotomies. Discrepancies in surgical standards were reported regarding to inclusion criteria, clinical workup, surgical techniques, and post-operative strategies. CONCLUSIONS In conclusion, this study got more insight in knee osteotomy clinical practices as applied by Dutch orthopaedic surgeons. However, there are still important discrepancies which pleads for more standardization based on available evidence. A (inter)national knee osteotomy registry, and even more so, a (inter)national registry for joint preserving surgeries could be helpful to achieve more standardization and treatment insights. Such a registry could improve all aspects of osteotomies and its combinations with other joint-preserving interventions towards evidence for personalised treatments.
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23
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Rupp MC, Lindner F, Winkler PW, Muench LN, Mehl J, Imhoff AB, Siebenlist S, Feucht MJ. Clinical Effect of Isolated Lateral Closing Wedge Distal Femoral Osteotomy Compared to Medial Opening Wedge High Tibial Osteotomy for the Correction of Varus Malalignment: A Propensity Score-Matched Analysis. Am J Sports Med 2023; 51:437-445. [PMID: 36629434 PMCID: PMC9909033 DOI: 10.1177/03635465221142615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recent evidence questions the role of medial opening wedge high tibial osteotomy (mowHTO) in the correction of femoral-based varus malalignment because of the potential creation of an oblique knee joint line. However, the clinical effectiveness of alternatively performing an isolated lateral closing wedge distal femoral osteotomy (lcwDFO), in which the mechanical unloading effect in knee flexion may be limited, is yet to be confirmed. PURPOSE/HYPOTHESIS The purpose of this article was to compare clinical outcomes between patients undergoing varus correction via isolated lcwDFO or mowHTO, performed according to the location of the deformity, in a cohort matched for confounding variables. It was hypothesized that results from undergoing isolated lcwDFO for symptomatic varus malalignment would not significantly differ from the results after mowHTO. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Consecutive patients who underwent isolated mowHTO or lcwDFO according to a tibial- or femoral-based symptomatic varus deformity between January 2010 and October 2019 were enrolled. Confounding factors, including age at surgery, sex, body mass index, preoperative femorotibial axis, and postoperative follow-up, were matched using propensity score matching. The International Knee Documentation Committee (IKDC) Subjective Knee Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RESULTS Of 535 knees assessed for eligibility, 50 knees (n = 50 patients, n = 25 per group) were selected by propensity score matching. Compared with preoperatively, both the mowHTO group (IKDC, 55.1 ± 16.5 vs 71.3 ± 14.7, P = .002; WOMAC, 22.0 ± 18.0 vs 9.6 ± 10.8, P < .001; Lysholm, 55.2 ± 23.1 vs 80.7 ± 16, P < .001; VAS, 4.1 ± 2.4 vs 1.6 ± 1.8, P < .001) and the lcwDFO group (IKDC, 49.4 ± 14.6 vs 66 ± 20.1, P = .003; WOMAC, 25.2 ± 17.0 vs 12.9 ± 17.6, P = .003; Lysholm, 46.5 ± 15.6 vs 65.4 ± 28.7, P = .011; VAS, 4.5 ± 2.2 vs 2.6 ± 2.5, P = .001) had significantly improved at follow-up (80 ± 20 vs 81 ± 43 months). There were no significant differences between the groups at baseline, at final follow-up, or in the amount of clinical improvement in any of the outcome parameters (P > .05; respectively). CONCLUSION Performing both mowHTO or lcwDFO yields significant improvement in clinical outcomes if performed at the location of the deformity of varus malalignment. These findings confirm the clinical effectiveness of performing an isolated lcwDFO in femoral-based varus malalignment, which is comparable with that of mowHTO in the correction of varus malalignment.
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Affiliation(s)
- Marco-Christopher Rupp
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany,Marco-Christopher Rupp, MD, Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, Munich, 81675, Germany ()
| | - Felix Lindner
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany,Marco-Christopher Rupp, MD, Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, Munich, 81675, Germany ()
| | - Philipp W. Winkler
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lukas N. Muench
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Julian Mehl
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas B. Imhoff
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sebastian Siebenlist
- Department of Orthopaedic Sports Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias J. Feucht
- Orthopaedic Clinic Paulinenhilfe, Diakonie-Hospital, Stuttgart, Germany,Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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24
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Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral-based symptomatic varus malalignment: an analysis at a mean 6-year follow-up. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-022-07303-w. [PMID: 36592216 DOI: 10.1007/s00167-022-07303-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/18/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE To evaluate return to sport (RTS), work (RTW) and clinical outcomes following lateral closing wedge distal femoral osteotomy (LCW-DFO) for symptomatic femoral varus malalignment. METHODS Consecutive patients who underwent LCW-DFO for symptomatic varus malalignment between 12/2007 and 03/2018 were included. The International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analogue scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were assessed by questionnaire. RESULTS Thirty-two patients (mean age: 45.9 ± 12.3 years), who underwent LCW-DFO for femoral-based varus malalignment (6.4 ± 3.0°), were included at a mean follow-up of 72.7 ± 39.1 months. The patient collective significantly improved in IKDC (51.8 ± 12.3 to 61.8 ± 21.5, p = 0.010; 95% CI = 3-21), WOMAC (26.7 ± 17.6 to 12.5 ± 13.5; p < 0.001; 95% CI = 21-6) and Lysholm (46.5 ± 19.4 to 67.9 ± 22.8 points (p < 0.01; 95% CI = 9-31)) scores at final follow-up. The VAS for pain reduced significantly postoperatively (4.8 ± 2.3 points to 2.6 ± 2.3 points (p = 0.002; 95% CI = 0-3)). Following LCW-DFO, 96% of patients returned to sports at a mean of 5.3 ± 2.9 months. Yet, a shift to lower impact sports compared to one year preoperatively was observed, with patients participating in a significantly lower number of high-impact disciplines (p = 0.024) and fewer hours in high-impact sports (p = 0.034). Twenty-three out of 24 patients returned to work at a mean 11.4 ± 10.9 weeks, with 18 patients reporting a similar or superior working ability. CONCLUSION Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to RTS and RTW along with a significant functional improvement at mid-term follow-up. However, patients' expectations have to be adequately managed regarding a limited probability to return to high-impact sports and work after surgery. LEVEL OF EVIDENCE Retrospective case series; Level IV.
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Caubère A, Barbier O, Kley K, Hanak L, Jacquet C, Ollivier M. Double level osteotomy for genu varum: Is a return to sport possible? Orthop Traumatol Surg Res 2022; 109:103397. [PMID: 36087834 DOI: 10.1016/j.otsr.2022.103397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A double level osteotomy (DLO) may be indicated in patients with genu varum when the deformity involves both the tibia and femur. These patients, who are often young and active, have a high functional demand and hope for a rapid return to sport. The purpose of our study was to assess return to sport and functional outcomes following DLO for symptomatic genu varum. MATERIALS AND METHODS A total of 40 patients (mean age 45.5±2 years) who underwent a DLO between 2018 and 2020, performed in 2 different hospitals, were reviewed after a minimum follow-up of 1-year. The mean initial varus was 11±2°. The type of sport and frequency of participation (UCLA activity score) as well as time to return to sport and level of activity recovered were defined as the primary endpoints. Functional scores were also assessed with the knee injury and osteoarthritis outcome score (KOOS). RESULTS At the last follow-up, 87.5% (n=35) of patients reported that they had returned to sport. The mean time to return to sport was 6±1 months with a significant difference (p<0.001) between the pre- and postoperative UCLA activity scores. There was a strong correlation between the presence of a joint line obliquity >3° and decreased functional outcomes (p<0.0001). The overall KOOS score improved (p<0.001) by a mean of 38.6 points after the correction. The 8 lateral cortical fractures (Takeuchi type I and II) and the 2 medial cortical fractures (Nakayama type 1) that were found had no impact on functional outcomes (p>0.05). CONCLUSION Our findings demonstrated that DLO provided rapid return to sport, thus making it possible to meet the functional demands and expectations of patients. LEVEL OF EVIDENCE IV; Retrospective study.
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Affiliation(s)
- Alexandre Caubère
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte-Anne, 2, boulevard Sainte-Anne, BP 600, 83800 Toulon, France.
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte-Anne, 2, boulevard Sainte-Anne, BP 600, 83800 Toulon, France
| | - Kristian Kley
- Harley Street Specialist Hospital, 18-22, Queen Anne Street, London, W1G8HU, United Kingdom
| | | | - Christophe Jacquet
- Service de Chirurgie Orthopédique et Traumatologie, Université Aix-Marseille, APHM, CNRS, ISM, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Marseille, France; Service de Chirurgie Orthopédique et Traumatologie, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France
| | - Matthieu Ollivier
- Service de Chirurgie Orthopédique et Traumatologie, Université Aix-Marseille, APHM, CNRS, ISM, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Marseille, France; Service de Chirurgie Orthopédique et Traumatologie, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France
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Lee NK, Kim TW, Lee S, Choi YS, Kang SB, Chang CB. Effect of distance between the feet on knee joint line orientation after total knee arthroplasty in standing full-limb radiographs. Knee Surg Sports Traumatol Arthrosc 2022; 30:3032-3040. [PMID: 34269849 DOI: 10.1007/s00167-021-06662-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Although knee joint line orientation (KJLO) after total knee arthroplasty (TKA) has been emphasized as an important factor that can affect postoperative knee kinematics, the effect of foot position on KJLO has not been fully understood. This study aimed to (1) identify the anatomical and positional factors that determine KJLO after TKA, and (2) determine the effect of foot position on KJLO after TKA. The hypothesis of this study was that the post-TKA KJLO would change depending on the distance between the feet, as well as the coronal implant positions. METHODS A total of 92 radiographs from 46 patients who underwent TKA were retrospectively reviewed. Two postoperative standing full-limb anteroposterior radiographs taken with the feet in different positions (with both feet in contact with each other or shoulder width apart) from each patient were evaluated. The correlation between KJLO after TKA and possible anatomical and positional factors, including leg length, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), ankle joint line orientation (AJLO), mechanical tibiofemoral angle (mTFA), and distance between the feet, were analyzed, and the KJLO equation was computed using multiple linear regression. KJLO was also compared among different combinations of valgus or varus alignment of the femoral and tibial components. RESULTS LDFA, MPTA, AJLO, and distance between the feet were identified as determinants of KJLO after TKA, and the distance between the feet was strongly correlated with KJLO. Based on the KJLO equation (KJLO [°] = 107.548 - 0.441 × LDFA [°] - 0.832 × MPTA [°] + 0.093 × AJLO [°] + 0.037 × ITD [mm]), KJLO changes by 3.7° per 100 mm of distance between the feet. The KJLO of patients with valgus femoral and varus tibial components was more parallel to the ground than those with other combinations. CONCLUSION KJLO after TKA was strongly affected by the distance between the feet when taking full-limb radiography, and the KJLO changed by 3.7° per 100 mm of distance between the feet. To assess the KJLO after TKA reproducibly, standardization of the distance between the feet is necessary. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Na-Kyoung Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Tae Woo Kim
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea.
| | - Sanghoon Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Yun Seong Choi
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea.,Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Chong Bum Chang
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea.,Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Jeong HW, Kim JS, Nam HS, Noh GS, Lee YS. Assessment of Anatomic Restoration and Clinical Outcomes Between Medial and Lateral Meniscal Allograft Transplantation. Orthop J Sports Med 2022; 10:23259671221113280. [PMID: 36105654 PMCID: PMC9465589 DOI: 10.1177/23259671221113280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Proper anatomic restoration is an important consideration for meniscal
allograft transplantation (MAT), even with the different anatomica
characteristics between the medial meniscus and lateral meniscus. Purpose/Hypothesis: The purpose of this study was to assess the accuracy of anatomic restoration
in medial and lateral MAT (MMAT and LMAT) procedures and to compare their
outcomes. We hypothesized that (1) the anatomic differences between the
medial and lateral menisci will mean a less accurate anatomic restoration
for MMAT and (2) clinical outcomes after MMAT will be inferior compared with
LMAT. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively evaluated 20 patients who underwent MMAT using the bone
plug technique and 21 patients who underwent LMAT using the keyhole
technique at a single institution from July 2014 to June 2019. Demographic
data, previous surgeries, and concomitant procedures were recorded, as were
lower limb alignment and osteoarthritis grade on radiographs. Using
preoperative and follow-up magnetic resonance imaging, the meniscal
position, rotation, extrusion, and intrameniscal signal intensity were
evaluated. Clinical outcomes were evaluated using the International Knee
Documentation Committee and Lysholm scores. Results: The mean follow-up was 41.15 ± 18.86 and 45.43 ± 21.32 months for the MMAT
and LMAT patients, respectively. Concomitant procedures were performed in
90% of MMATs and 15% of LMATs. There was no significant difference between
the native and postoperative root positions after LMAT; however, for MMAT,
the position of the anterior root was located significantly posteriorly
(P = .002) and medially (P = .007)
compared with preoperatively. In addition, the allograft medial meniscus was
restored in a more internally rotated position (P = .029).
MMATs also exhibited significantly increased meniscal extrusion compared
with LMATs (posterior horn, P < .001; midbody,
P = .027; anterior horn, P = .006).
However, there was no significant difference between the 2 groups at final
follow-up in intrameniscal signal intensity or clinical scores. Conclusion: LMAT showed higher accuracy than MMAT in restoring meniscal position and
rotation, and there was less meniscal extrusion. However, clinical scores
improved after both LMAT and MMAT compared with preoperative values, and
midterm clinical outcomes were similar. The small anatomical errors seen in
the MMAT technique were not clinically relevant at midterm follow-up.
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Affiliation(s)
- Ho Won Jeong
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Joo Sung Kim
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Hee Seung Nam
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Gwon Seok Noh
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
- Yong Seuk Lee, MD, PhD, Department of Orthopaedic Surgery, Seoul
National University College of Medicine, Bundang Hospital, 82, Gumi-ro
173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea (
,
)
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Lee SS, Kim JH, Kim S, Jung EY, Ryu DJ, Lee DK, Wang JH. Avoiding Overcorrection to Increase Patient Satisfaction After Open Wedge High Tibial Osteotomy. Am J Sports Med 2022; 50:2453-2461. [PMID: 35722821 DOI: 10.1177/03635465221102144] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Achieving the postoperative mechanical axis passing through 62.5% of the tibial plateau is considered successful osteotomy surgery. Despite precise preoperative planning and surgical techniques, some procedures result in under- or overcorrection. Few studies have investigated the relationship between clinical outcomes and unintentional under- or overcorrection after open wedge high tibial osteotomy (OWHTO) using whole-leg standing radiographs. PURPOSE To investigate the relationship between postoperative alignment using whole-leg standing radiographs and clinical outcomes after OWHTO. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 89 knees (72 patients) that underwent OWHTO between October 2013 and September 2018 were included. Patients with postoperative weightbearing line (WBL) ratios within 57% to 67% were classified as appropriate correction (group A; 45 cases), whereas ratios <57% and >67% were classified as undercorrection (group U; 20 cases) and overcorrection (group O; 24 cases), respectively. The following patient-reported outcomes (PROs) were investigated: International Knee Documentation Committee (IKDC) subjective score, Kujala score, and Knee injury and Osteoarthritis Outcome Score (KOOS). The correlation between postoperative WBL and PROs was analyzed. PROs were compared among the 3 groups. RESULTS Regarding the correlation between postoperative WBL ratio and PROs, a larger postoperative WBL ratio was significantly correlated with a poor IKDC subjective score (P = .002), Kujala score (P = .009), and KOOS. Group O showed inferior postoperative PRO scores when compared with group A or U, whereas group U showed a similar result to group A (mean IKDC subjective scores: group U, 62.0; group A, 61.2; group O, 47.6; P = .004). CONCLUSION Overcorrection after OWHTO surgery correlated with inferior PROs; therefore, overcorrected alignment should be avoided for patient satisfaction. Knees with an undercorrected alignment showed clinical results similar to those with appropriate correction.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Korea
| | - Joo Hwan Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eui Yub Jung
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea
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Rupp MC, Mehl J, Feucht MJ, Imhoff AB. Biomechanical Rationale of Correction Osteotomy and Overcorrection. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim JS, Lim JK, Choi HG, Jeong HW, Park SB, Shim SJ, Lee YS. Excessively Increased Joint-Line Obliquity After Medial Opening-Wedge High Tibial Osteotomy Is Associated With Inferior Radiologic and Clinical Outcomes: What Is Permissible Joint-Line Obliquity. Arthroscopy 2022; 38:1904-1915. [PMID: 34785297 DOI: 10.1016/j.arthro.2021.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to evaluate the permissible joint-line obliquity (JLO) based on radiologic and clinical outcomes with midterm follow-up after medial open-wedge high tibial osteotomy (MOWHTO). METHODS Patients who had undergone MOWHTO from March 2014 to May 2016 were retrospectively evaluated. They were divided into 4 groups based on JLO as represented by postoperative medial proximal tibial angle (MPTA). Radiologic parameters including MPTA, joint-line orientation angle (JLOA), joint-line convergence angle (JLCA), posterior tibial slope, weightbearing line ratio (WBLR), and coronal translation were analyzed. Clinical outcomes were evaluated with American Knee Society Score (AKSS), Western Ontario and McMaster University Index, and short-form 36 health survey (SF-36). The changes between preoperation and final follow-up in JLOA and MPTA were defined as ΔJLOA and ΔMPTA. RESULTS A total of 135 knees were finally included (MPTA ≤90.32° as group I; 90.33° to 92.62° as group II; 92.74° to 95.22° as group III; and ≥95.23° as group IV). The last follow-up MPTA, JLOA, and JLCA values were different between the groups (P < .001, P < .001, and P = .015, respectively). WBLR and JLOA positively correlated with MPTA; however, WBLR showed an abrupt increase at MPTA >96.5°, and the JLOA distribution tended to be greater than the regression line at MPTA >96°. Moreover, ΔJLOA was not as large as ΔMPTA. The percentage of patients attaining a minimal clinically important difference was significantly lower in the AKSS-functional score and SF-36 physical component summary in group IV (P = .008 and 0.021, respectively). CONCLUSION The JLOA did not change as much as the MPTA, but an MPTA >95.2° abruptly increased the JLOA and valgus overcorrection after MOWHTO. Poor clinical outcomes were more evident in excessive MPTA (>95.2°) than in mildly undercorrected or properly corrected MPTA (<95.2°). LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Joo Sung Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Kyu Lim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Han Gyeol Choi
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ho Won Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sung Bae Park
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung Jae Shim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Editorial Commentary: Avoid Creating an Oblique Joint Line After an Opening Medial Wedge High Tibial Osteotomy. Arthroscopy 2022; 38:1916-1918. [PMID: 35660185 DOI: 10.1016/j.arthro.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 02/02/2023]
Abstract
A medial opening wedge high tibial osteotomy is a cost-effective procedure for younger patients with symptomatic medial compartment knee arthritis. A high rate of success can be expected, but excessive postoperative joint line obliquity is associated with inferior clinical outcomes. If preoperative planning predicts that the postoperative medial proximal tibial angle, the medial angle between the tibial anatomical axis and the joint line of the proximal tibia, will exceed 95°, a surgeon should consider performing a double-level osteotomy (combined proximal tibial and distal femoral osteotomies).
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Rupp MC, Muench LN, Ehmann YJ, Themessl A, Winkler PW, Mehl J, Imhoff AB, Feucht MJ. Improved Clinical Outcome and High Rate of Return to Low-Impact Sport and Work After Knee Double Level Osteotomy for Bifocal Varus Malalignment. Arthroscopy 2022; 38:1944-1953. [PMID: 34920011 DOI: 10.1016/j.arthro.2021.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate return to sport (RTS) and work (RTW), as well as clinical outcomes following double level osteotomy (DLO) via combined medial open wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy for bifocal symptomatic varus malalignment, and to compare these outcome parameters between patients undergoing a single surgery and those undergoing a two-stage procedure. METHODS Consecutive patients who underwent DLO for symptomatic varus malalignment between 12/2007 and 03/2018 were enrolled. Patients converted to arthroplasty (n = 3) during follow-up were excluded. Outcome measures included the International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain, which were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were evaluated by questionnaire. Outcome measures were compared between DLO performed in a single- versus a two-stage surgery. RESULTS Thirty-two patients (mean age: 44.2 ± 12.6 years), who underwent DLO for varus malalignment (10.1° ± 2.9°) were included at a mean follow-up of 56.9 ± 35.3 months (range: 24-148). Compared to preoperatively, these patients significantly improved in IKDC (50.4 ± 13.9 to 66.1 ± 15.4; P < .001), WOMAC (29.7 ± 19.2 to 11.8 ± 13.5; P < .001) and Lysholm (53.6 ± 23.6 to 73.1 ± 23.6; P = .002) scores at final follow-up. For the WOMAC score, 78% of the patients included reached the minimally important clinical difference, along with a significant reduction of the VAS for pain (5.0 ± 3.0 to 2.5 ± 2.4; P < .001). Postoperatively, 96% of patients returned to sport after 7.7 ± 4.8 months, but at a lower frequency (P = .010) and to fewer disciplines (P = .005) with a shift to low-impact sports. 90% of the patients returned to work at a mean 5.9 ± 9.4 months, with 79% reporting a similar or superior working ability. Patients undergoing a two-stage procedure recovered to full physical working ability at a significantly longer duration, as compared to a single-stage procedure (9.8 ± 3.8 vs 9.0 ± 13.1 months; P = .047). CONCLUSION The majority of patients undergoing DLO for symptomatic varus malalignment, who were not converted to arthroplasty, experienced clinically significant functional improvement at mid-term follow-up. Return to sport and work rates in these patients were high; however, a shift to lower-impact sports disciplines was observed. Similar clinical outcomes can be expected when performing DLO in a single surgery or a two-stage procedure. LEVEL OF EVIDENCE Retrospective case series; Level IV.
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Affiliation(s)
- Marco-Christopher Rupp
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine
| | - Lukas N Muench
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine
| | - Yannick J Ehmann
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine
| | - Alexander Themessl
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine; Alps Surgery Institute, Annecy, France
| | - Philipp W Winkler
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine
| | - Julian Mehl
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany, School of Medicine.
| | - Matthias J Feucht
- Orthopaedic Clinic Paulinenhilfe, Diakonie-Hospital, Stuttgart, Germany; Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Tripon M, Sautet P, Argenson JN, Jacquet C, Martz P, Ollivier M. Is the lateral tibial spine a reliable landmark for planning tibial or femoral valgus osteotomies? Orthop Traumatol Surg Res 2022; 108:103253. [PMID: 35183756 DOI: 10.1016/j.otsr.2022.103253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A valgus osteotomy around the knee is a conservative procedure performed to unload the medial tibiofemoral compartment. However, the optimal postoperative alignment target remains controversial. Many studies have applied a "Fujisawa point" at 62.5%. The results of recent studies suggest decreasing the range of the mechanical axis target correction to 50-55%. The primary purpose of this study was to define the mean position of the lateral tibial spine in healthy patients from a reproducible 3-dimensional (3D) analysis. The study hypothesis was that the apex of the lateral tibial spine was a reliable and reproducible landmark for planning valgus osteotomies and preventing overcorrections. MATERIALS AND METHODS The study included 1140 patients: 560 women and 580 men, with a mean age of 61.7±16.5 years (18-98) and a mean body mass index (BMI) of 24.9±4.9kg/m2 (13.3-54.6). This analysis was done with the Stryker Orthopaedics Modeling and Analytics (SOMA) system which uses a database of computed tomography (CT) scans and 3D bone models. A statistical assessment was performed to determine the mean position of the lateral tibial spine. These measurements were then compared according to ethnicity, sex, age, BMI, knee side (right and left) and the overall mechanical axis of the leg. RESULTS The mean tibial plateau width was 72.9±5.7mm (59.1-91.1). The mean position of the lateral tibial spine was 53.6±1.1% (48.9-57.2). The mean position of the medial tibial spine was 48.4±2.5% (43.6-56.1) while the center of the tibial spines was 51.0±1.5% (46.4-56.1). Africans had a significantly more lateral mean tibial spine position than Asians (54.7% vs. 53.3%, p=0.001), Caucasians (54.7% vs. 53.7%, p=0.002) and Middle Easterners (54.7% vs. 53.6%, p=0.034). CONCLUSION The lateral tibial spine is a simple and reproducible bony landmark. This landmark can be used when planning valgus osteotomies aiming for a "Fujisawa point" at 54%. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Martin Tripon
- Institut du mouvement et de l'appareil locomoteur, hôpital Sainte-Marguerite, Aix-Marseille université, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Pierre Sautet
- Institut du mouvement et de l'appareil locomoteur, hôpital Sainte-Marguerite, Aix-Marseille université, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Jean-Noël Argenson
- Institut du mouvement et de l'appareil locomoteur, hôpital Sainte-Marguerite, Aix-Marseille université, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Christophe Jacquet
- Institut du mouvement et de l'appareil locomoteur, hôpital Sainte-Marguerite, Aix-Marseille université, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Pierre Martz
- Service de chirurgie orthopédique, centre-hospitalo-universitaire de Dijon, Dijon, France
| | - Matthieu Ollivier
- Institut du mouvement et de l'appareil locomoteur, hôpital Sainte-Marguerite, Aix-Marseille université, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Siboni R, Vialla T, Joseph E, LiArno S, Faizan A, Martz P, Ollivier M. Coronal and sagittal alignment of the lower limb in Caucasians: Analysis of a 3D CT database. Orthop Traumatol Surg Res 2022; 108:103251. [PMID: 35183757 DOI: 10.1016/j.otsr.2022.103251] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/26/2021] [Accepted: 08/05/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Lower limb alignment is a major determinant of long-term outcomes after osteotomy or total knee replacement. The aim of this paper is to define the mean values of coronal and sagittal lower limb alignment for Caucasians as a function of sex using 3D reconstructions from CT-scans. MATERIALS AND METHODS The analysis involved 586 Caucasian patients (269 males and 317 females) who had their hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), posterior proximal tibial angle (PPTA), lateral and medial proximal posterior tibial angles (LPPTA/MPPTA), posterior distal femoral angle (PDFA), and non-weightbearing joint convergence angle (nwJLCA) measured. This analysis was performed using a CT-scan-based modelling system (SOMA). Differences between sexes and morphotypes (neutral, varus and valgus) were analyzed statistically. RESULTS The mean HKA was 180±2.57°, LDFA 86.1±1.87°, MPTA 86.1±2.15°, PPTA 84.6±2.58°, LPPTA 84.9±3.17°, MPPTA 85.1±3.21°, PDFA 85.3±1.50° and nwJLCA 0.82±1.32°. There was a significant difference between sexes for the HKA (180.3±2.46° and 179.0±2.52°), LDFA (85.6±1.90° and 86.8±1.61°), MPPTA (84.7±3.06° and 85. 6±3.31°). The neutral morphotype was more frequent in women than men (78% vs. 73%), the varus morphotype was more frequent in men than women (20% vs. 7.6%) and the valgus morphotype was more frequent in women than men (15% vs. 6.7%). CONCLUSION Normal parameters for lower limb alignment in Caucasian patients were described in the coronal and sagittal planes. There was a significant influence of sex in the coronal plane, which was not found in the sagittal plane. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- Renaud Siboni
- Department of Orthopedics and Traumatology, CHU of Reims, 51100 Reims, France.
| | - Tristan Vialla
- Department of Orthopedics and Traumatology, CHU of Reims, 51100 Reims, France
| | - Etienne Joseph
- Department of Orthopedics and Traumatology, CHU of Reims, 51100 Reims, France
| | | | | | - Pierre Martz
- Department of Orthopedics and Traumatology, CHU of Dijon, 21100 Dijon, France
| | - Matthieu Ollivier
- Department of Orthopedics and Traumatology, APHM, CNRS, ISM, Institute for Locomotion, Aix Marseille University, Sainte-Marguerite Hospital, Marseille, France; Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, Saint-Marguerite Hospital, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille, France
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35
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Hiramatsu K, Yamada Y, Nakamura N, Mitsuoka T. Factors Associated with Postoperative Knee Joint Line Obliquity After Medial Open Wedge High Tibial Osteotomy. Am J Sports Med 2022; 50:1651-1658. [PMID: 35293800 DOI: 10.1177/03635465221079343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are still few reports on factors associated with postoperative knee joint line obliquity (KJLO). PURPOSE The purpose was to determine preoperative radiographic factors that are associated with KJLO postoperatively after open wedge high tibial osteotomy (OWHTO) using multivariable linear regression analysis and multivariable logistic regression analysis. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A total of 60 patients with 65 varus knees who underwent OWHTO between December 2012 and June 2018 at a single institution were retrospectively enrolled in this study. The authors evaluated radiologic parameters including the weightbearing line ratio, femorotibial angle, medial proximal tibial angle, mechanical lateral distal femoral angle (LDFA), lateral distal tibial angle, joint line convergence angle (JLCA), KJLO, and ankle joint obliquity. They also categorized these radiographic parameters as preoperative and postoperative and calculated the difference (Δ) between preoperative and postoperative values. To determine which of the radiographic parameters were most associated with postoperative KJLO, multivariable linear regression analysis was performed using the stepwise method. Multivariable logistic regression analysis was used to examine the relative contribution of the preoperative radiographic parameters to an abnormal postoperative KJLO (>4°). RESULTS In the multivariable linear regression analysis, the preoperative LDFA and JLCA showed a statistically significant correlation. Multivariable logistic regression analysis revealed that the mean preoperative LDFA was significantly larger in the group with abnormal KJLO than in the group with the control group (odds ratio, 1.84; 95% CI, 1.12-3.02; P = .02), while preoperative JLCA tended to be larger in the abnormal KJLO group than the control group but not statistically significantly different. CONCLUSION KJLO after OWHTO was associated with preoperative LDFA and JLCA in multivariable linear regression analysis, and preoperative LDFA was the most important factor associated with abnormal KJLO after OWHTO in multivariable logistic regression analysis.
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Affiliation(s)
- Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Tamai Hospital, Osaka, Japan.,Department of Orthopaedic Surgery, Yao Municipal Hospital, Osaka, Japan
| | - Yuzo Yamada
- Department of Orthopaedic Surgery, Yao Municipal Hospital, Osaka, Japan
| | - Norimasa Nakamura
- Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan
| | - Tomoki Mitsuoka
- Department of Orthopaedic Surgery, Yao Municipal Hospital, Osaka, Japan
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Bode L, Eberbach H, Brenner AS, Kloos F, Niemeyer P, Schmal H, Suedkamp NP, Bode G. 10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy. Orthop J Sports Med 2022; 10:23259671221078003. [PMID: 35224123 PMCID: PMC8873560 DOI: 10.1177/23259671221078003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Good-to-excellent midterm results after high tibial osteotomy (HTO) to treat
medial compartment cartilage defects or osteoarthritis (OA) have been
published, but little is known about long-term survival rates in terms of
conversion to total knee arthroplasty (TKA) using angular stable internal
plate fixation. Purpose: To determine TKA-free survival rates and functional and radiological outcomes
at 10 years after HTO. A subgroup analysis of patients who underwent
combined HTO and autologous cartilage implantation (ACI) was also
performed. Study Design: Case series; Level of evidence, 4. Methods: Included were 125 patients with a mean follow-up of 9.90 ± 2.25 years; 90
patients underwent HTO for medial OA, and 35 patients underwent ACI and HTO
for medial focal cartilage defects. Functional outcome measures included
visual analog scale (VAS) for pain, Lysholm, International Knee
Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome
Score (KOOS) subscales and KOOS4 (average of 4 KOOS subscales:
Pain, Symptoms, Sport, and Quality of Life). Radiological outcomes included
lateral distal femoral angle, medial proximal tibial angle, and joint line
convergence angle. Results: Overall, 16 patients required conversion to TKA at a mean 86.75 ± 25.73
months (10-year survival rate, 87.2%). Only 2 patients in the HTO+ACI
subgroup required a conversion to TKA (10-year survival rate, 94.3%). The
complication rate for all patients was 8.8%. In both the HTO and HTO+ACI
subgroups, VAS pain levels decreased and Lysholm scores increased
significantly from pre- to postoperatively (P < .001). A
higher preoperative Tegner score led to a significantly lower risk for
conversion to TKA (P = .001), and a preoperative body mass
index of ≥35 was associated with a significantly higher risk
(P = .019), as was female sex (P =
.046). Radiological parameters remained within physiological ranges. The
postoperative joint line conversion angle did correlate with postoperative
functional outcome but not with TKA conversion. Conclusion: Long-term results of HTO for medial compartment OA or cartilage defects with
underlying varus deformity were good to excellent. In particular, patients
who underwent HTO+ACI presented excellent long-term survival rates. HTO,
therefore, delays or prevents TKA implantation, especially in young, active
patients with medial compartment damage.
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Affiliation(s)
- Lisa Bode
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Helge Eberbach
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Anna-Sophie Brenner
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Ferdinand Kloos
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Philipp Niemeyer
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- OCM Clinic, Munich, Germany
| | - Hagen Schmal
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Department of Orthopaedic Surgery, University Hospital Odense, Odense, Denmark
| | - Norbert P. Suedkamp
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Gerrit Bode
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Sporthopaedicum, Straubing, Straubing, Germany
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Kang BY, Lee DK, Kim HS, Wang JH. How to achieve an optimal alignment in medial opening wedge high tibial osteotomy? Knee Surg Relat Res 2022; 34:3. [PMID: 35135631 PMCID: PMC8822774 DOI: 10.1186/s43019-021-00130-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/24/2021] [Indexed: 11/10/2022] Open
Abstract
Medial opening wedge high tibial osteotomy (MOWHTO) is a widely used surgical treatment option for medial compartmental osteoarthritis with varus deformity. It is important that proper lower limb alignment is achieved. However, there has been no consensus about an optimal alignment in MOWHTO. Most studies suggest that achieving valgus alignment is necessary, and recent studies support slight valgus mechanical alignment of less than 3° of mechanical femorotibial angle. Overcorrection and undercorrection is not recommended for achieving good surgical outcomes. To prevent undercorrection and overcorrection in MOWHTO, the method of placing the weight-bearing line in the target range must be precise. There are several ways to place a weight-bearing line within the target range. While the most important factor for a successful MOWHTO is achieving an ideal mechanical axis correction, there are a few other factors to consider, including joint line obliquity, posterior tibial slope, ligament balancing, and patellar height. Several factors exist that lead to undercorrection and overcorrection. Preoperative amount of varus deformity, lateral hinge fracture, and fixation failure can result in undercorrection, while medial soft tissue laxity and the amount of correction angle and target point beyond hypomochlion can result in overcorrection. This study aimed to review the literature on optimal alignment in MOWHTO and report on the factors to be considered to prevent correction errors and how to achieve an optimal alignment.
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Affiliation(s)
- Byoung Youl Kang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Hyeon Soo Kim
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea.
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Tseng TH, Wang HY, Tzeng SC, Hsu KH, Wang JH. Knee-ankle joint line angle: a significant contributor to high-degree knee joint line obliquity in medial opening wedge high tibial osteotomy. J Orthop Surg Res 2022; 17:79. [PMID: 35123546 PMCID: PMC8818150 DOI: 10.1186/s13018-022-02976-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/25/2022] [Indexed: 10/29/2022] Open
Abstract
Abstract
Background
Medial opening wedge high tibial osteotomy (MOWHTO) changes the knee joint inclination in the coronal plane, which can be compensated by the ankle joint. Once there is a decompensated knee joint obliquity, it can induce excessive shear force on the articular cartilage. This study aimed to investigate the capacity of the compensation by analyzing the correlation of the knee-ankle joint line angle (KAJA) and the knee joint line obliquity (KJLO).
Patients and Methods
Ninety-six patients undergoing MOWHTO were included. We measured potential predictors including preoperative or postoperative body mass index (BMI), weight-bearing line (WBL) ratio/correction amount, knee-ankle joint line angle(KAJA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibia angle (MPTA), ankle joint line obliquity (AJLO), mechanical hip-knee-ankle angle (mHKA) and joint line convergence angle (JLCA). The correlations of these predictors and postoperative KJLO were determined using Pearson correlation coefficient. The contribution of significant predictors was further analyzed using multiple linear regression. Finally, the cutoff value of the most contributing factor resulting in decompensated KJLO was derived with receiver operating characteristic (ROC) curve analysis.
Results
Preoperative AJLO, JLCA, MPTA, mHKA and KJLO and postoperative KAJA and MPTA correlated with postoperative KJLO. After multiple linear regression, only preoperative AJLO and JLCA and postoperative KAJA still showed significant contribution to postoperative KJLO. Postoperative KAJA made the greatest contribution. The cutoff value of postoperative KAJA was at 9.6° after ROC analysis. The incidence rate of high-grade KJLO was 69.6% when postoperative KAJA exceeded 9.6°.
Conclusions
Postoperative KAJA is a significant contributor to high-grade KJLO after MOWHTO. The incidence was increased at angles greater than 9.6°. The results suggest that KAJA should be carefully assessed during preoperative planning or intraoperative evaluation. Postoperative KAJA < 9.6° can lower the rate of early high-degree KJLO.
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Konrads C, Ahmad SS, Histing T, Ibrahim M. Iatrogenic ischiofemoral impingement due to high tibial osteotomy with overvalgization: a case report. J Med Case Rep 2022; 16:43. [PMID: 35115048 PMCID: PMC8815136 DOI: 10.1186/s13256-022-03257-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Open wedge high tibial osteotomy is a standard procedure for frontal realignment. It is indicated in varus knee with reduced mechanical medial proximal tibia angle. Overcorrection producing a mechanical medial proximal tibia angle out of the normal range (85–90°) is not recommended because this would lead to unphysiological joint-line orientation. Osteotomies around the knee also influence the adjacent ankle and hip joints. For the hip, it is known that frontal alignment of the leg influences the ischiofemoral space. A decreased ischiofemoral space can lead to painful impingement between the ischial bone and the lesser trochanter. Case presentation A 53-year-old German woman presented with severe ischiofemoral impingement symptoms and valgus malalignment of the left leg after open wedge high tibial osteotomy, which was indicated and performed by an orthopedic surgeon with intention to treat medial knee pain due to degenerative arthritis of the medial compartment years after medial meniscectomy. The mechanical medial proximal tibia angle was 100.5°. We performed closed wedge high tibial osteotomy producing a mechanical medial proximal tibia angle of 90.0° and normal joint-line orientation. The hip pain was gone immediately after the surgery, and the patient had no signs of ischiofemoral impingement or hip pain at last follow-up 12 months after closed wedge high tibial osteotomy. Conclusions Frontal realignment osteotomy around the knee can create problems at adjacent joints. Overvalgization of the proximal tibia made the patient compensate by hyperadduction of the hip to enable full foot sole contact with the floor. Hyperadduction of the hip decreased the ischiofemoral space, leading to severe impingement. Therefore, meticulous planning of osteotomies is important not to produce unphysiological situations or unwanted negative effects at the level of an adjacent joint.
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Affiliation(s)
- Christian Konrads
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany.
| | - Sufian S Ahmad
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany.,Center for Musculoskeletal Surgery, Charité - University Medical Center Berlin, Berlin, Germany
| | - Tina Histing
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany
| | - Maher Ibrahim
- Department of Orthopaedic Surgery, Nyon Hospital, Nyon, Switzerland
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Rosso F, Rossi R, Cantivalli A, Pilone C, Bonasia DE. Joint Line Obliquity Does Not Affect the Outcomes of Opening Wedge High Tibial Osteotomy at an Average 10-Year Follow-up. Am J Sports Med 2022; 50:461-470. [PMID: 34854734 DOI: 10.1177/03635465211059811] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A significant number of high tibial osteotomies (HTOs) result in an overcorrected tibia and subsequent excessive lateral joint line obliquity (JLO). The correlation between excessive JLO and poor outcomes is controversial. PURPOSE To evaluate the prognostic factors (including a pathological postoperative JLO) related with the outcomes of opening wedge HTO at 10 years of follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients undergoing HTO between 2004 and 2017 for medial osteoarthritis and with a postoperative hip-knee-ankle angle between 176° and 185° were included. Clinical evaluation included Knee Society Score (KSS; knee score and function score), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and visual analog scale for pain. Several mechanical and anatomic angles were measured pre- and postoperatively on long-leg weightbearing radiographs. Abnormal JLO was defined as a Mikulicz-joint line angle (MJL) ≥94° or a mechanical medial proximal tibial angle (mMPTA) ≥95°. Regression analysis was performed to evaluate the association between independent variables and each outcome. A Kaplan-Meier cumulative survival analysis was performed. RESULTS A total of 92 knees in 76 patients were included. The mean age of the patients was 53.5 years (SD, 9.7 years), and the mean follow-up was 129.4 months (SD, 44.4 months). Increased JLO was associated with a significant preoperative varus deformity (small preoperative hip-knee-ankle angle), increased mechanical lateral distal femoral angle, increased joint line congruency angle, and increased knee-ankle joint angle. Male sex was associated with better WOMAC scores (P = .0277), and increased body mass index (BMI) was associated with inferior WOMAC scores (P = .0024). A good preoperative range of motion was associated with better knee score (P = .0399) and function score (P = .0366) on the KSS. An increased BMI was associated with inferior KSS function scores (P = .0317). MJL ≥94° and mMPTA ≥95° were not associated with inferior WOMAC or KSS outcomes. With indication to total knee arthroplasty as an endpoint, Kaplan-Meier analysis showed a survival rate of 98.7% at 5 years, 95.5% at 10 years, and 92.7% at 12 years. CONCLUSION Increased lateral JLO (MJL ≥94° or mMPTA ≥95°) was not correlated with the clinical outcomes of opening wedge HTO at 10 years of follow-up.
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Affiliation(s)
- Federica Rosso
- AO Ordine Mauriziano Hospital, Department of Orthopaedics and Traumatology, University of Torino, Torino, Italy
| | - Roberto Rossi
- AO Ordine Mauriziano Hospital, Department of Orthopaedics and Traumatology, University of Torino, Torino, Italy
| | - Antonino Cantivalli
- AO Ordine Mauriziano Hospital, Department of Orthopaedics and Traumatology, University of Torino, Torino, Italy
| | - Carola Pilone
- AO Ordine Mauriziano Hospital, Department of Orthopaedics and Traumatology, University of Torino, Torino, Italy
| | - Davide Edoardo Bonasia
- AO Ordine Mauriziano Hospital, Department of Orthopaedics and Traumatology, University of Torino, Torino, Italy
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Dislocated hinge fractures are associated with malunion after lateral closing wedge distal femoral osteotomy. Knee Surg Sports Traumatol Arthrosc 2022; 30:982-992. [PMID: 33638683 PMCID: PMC8901490 DOI: 10.1007/s00167-021-06466-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/19/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the incidence, morphology, and associated complications of medial cortical hinge fractures after lateral closing wedge distal femoral osteotomy (LCW-DFO) for varus malalignment and to identify constitutional and technical factors predisposing for hinge fracture and consecutive complications. METHODS Seventy-nine consecutive patients with a mean age of 47 ± 12 years who underwent LCW-DFO for symptomatic varus malalignment at the authors' institution between 01/2007 and 03/2018 with a minimum of 2-year postoperative time interval were enrolled in this retrospective observational study. Demographic and surgical data were collected. Measurements evaluating the osteotomy cut (length, wedge height, hinge angle) and the location of the hinge (craniocaudal and mediolateral orientation, relation to the adductor tubercle) were conducted on postoperative anterior-posterior knee radiographs and the incidence and morphology of medial cortical hinge fractures was assessed. A risk factor analysis of constitutional and technical factors predisposing for the incidence of a medial cortical hinge fracture and consecutive complications was conducted. RESULTS The incidence of medial cortical hinge fractures was 48%. The most frequent morphological type was an extension fracture type (68%), followed by a proximal (21%) and distal fracture type (11%). An increased length of the osteotomy in mm (53.1 ± 10.9 vs. 57.7 ± 9.6; p = 0.049), an increased height of the excised wedge in mm (6.5 ± 1.9 vs. 7.9 ± 3; p = 0.040) as well as a hinge location in the medial sector of an established sector grid (p = 0.049) were shown to significantly predispose for the incidence of a medial cortical hinge fracture. The incidence of malunion after hinge fracture (14%) was significantly increased after mediolateral dislocation of the medial cortical bone > 2 mm (p < 0.05). CONCLUSION Medial cortical hinge fractures after LCW-DFO are a common finding. An increased risk of sustaining a hinge fracture has to be expected with increasing osteotomy wedge height and a hinge position close to the medial cortex. Furthermore, dislocation of a medial hinge fracture > 2 mm was associated with malunion and should, therefore, be avoided. LEVEL OF EVIDENCE Prognostic study; Level IV.
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Snow M, Jermain P, Mandalia V, Murray J, Khakha R, McNicholas M, Dawson M. A 2021 consensus statement on osteotomies around the knee by the UK Knee Osteotomy consensus Group (KOG). Knee 2021; 33:73-83. [PMID: 34562741 DOI: 10.1016/j.knee.2021.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There are significant deficiencies in the evidence base of modern-day osteotomy which result in significant variation in practice between surgeons. The purpose of this statement was to develop a consensus statement on the practice of osteotomy so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined. The article is also intended to educate and inform the practice of individuals who are early in their experience and/or clinical practice. METHOD A group of 29 specialist knee surgeons who regularly perform osteotomy was convened to form the Knee Osteotomy consensus Group (KOG). Consensus was determined utilizing the consensus group technique described by List. A total of 37 questions were asked covering all aspects of clinical practice. RESULTS 20 statements were generated and debated until a criterion level of 70% was met. CONCLUSIONS Consensus was achieved regarding 20 statements concerning Indications for surgery, decision making, surgical planning, technique, post-operative assessment and recovery.
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Affiliation(s)
- Martyn Snow
- The Royal Orthopaedic Hospital, Birmingham, UK; The Robert Jones and Agnes Hunt Hospital, UK; The Robert Jones and Agnes Hunt, Oswestry, UK.
| | | | | | - James Murray
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK.
| | | | | | - Matt Dawson
- North Cumbria University Hospital NHS Trust, UK.
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Park JG, Han SB, Jang KM. Association of Preoperative Tibial Varus Deformity With Joint Line Orientation and Clinical Outcome After Open-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis: A Propensity Score-Matched Analysis. Am J Sports Med 2021; 49:3551-3560. [PMID: 34623942 DOI: 10.1177/03635465211044146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The correction of lower limb deformity should be performed at the site of deformity to maintain knee joint orientation. However, the effectiveness of open-wedge high tibial osteotomy (OWHTO) for treatment of medial osteoarthritis in varus malalignment without definite tibial varus deformity has not been confirmed. PURPOSE/HYPOTHESIS This study aimed to compare the clinical and radiologic outcomes after OWHTO in patients without tibial varus deformity versus patients with tibial varus deformity after matching for confounding factors. We hypothesized that these outcomes would be inferior in patients without tibial varus deformity. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The outcomes of 133 OWHTO operations for medial osteoarthritis in 107 patients were retrospectively reviewed after follow-up for >2 years. The patients were divided into group 1 (tibia with varus deformity, preoperative medial proximal tibial angle [MPTA] <85°) and group 2 (tibia without varus deformity, preoperative MPTA ≥85°). The confounding factors, including patient characteristics, preoperative limb alignment, degree of osteoarthritis, and correction angle, were matched using propensity score matching. The radiologic parameters, including MPTA and joint line obliquity, were evaluated preoperatively, between 6 and 12 months postoperatively, and at the last follow-up. The radiologic outcomes were assessed using the medial joint space width and mechanical hip-knee-ankle angle. The clinical outcomes were evaluated by the Hospital for Special Surgery knee score, Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The clinical and radiologic outcomes were compared between the groups. The proportions of patients achieving improvement in the clinical outcome beyond the minimal clinically important difference (MCID) or minimally important change were compared between the groups. RESULTS After propensity score matching, 32 patients were selected for each group. The mechanical hip-knee-ankle angle was corrected without significant difference from a mean ± SD varus angle of 8.0°± 3.3° to valgus angle of -3.2°± 2.5° in group 1 and from varus 8.0°± 3.6° to valgus -3.9°± 1.7° in group 2. The preoperative joint line obliquity was greater in group 2 as compared with group 1 (2.2°± 2.2° vs -0.4°± 1.8°, P < .001). With a similar 10° correction angle, the postoperative MPTA and joint line obliquity were 96.6°± 2.5° and 5.3°± 2.3°, respectively, in group 2, which were greater than 94.0°± 2.6° and 3.5°± 1.8°, respectively, in group 1 (both P < .001). The changes in joint space width and mechanical hip-knee-ankle angle were not significantly different between the groups over the follow-up period. At the last follow-up, the postoperative KSS objective score and WOMAC pain score in terms of symptom improvement were not significantly different between groups (P = .092 and .068). However, the postoperative KSS and WOMAC functional scores were significantly worse in group 2 than in group 1 (77.3 ± 14.1 vs 84.4 ± 11.6, P = .044; 10.3 ± 9.2 vs 5.6 ± 7.2, P = .001). In group 1, 96.9% and 100% of patients showed improvements of >10 points in the KSS functional score and 15 points in the WOMAC functional score based on MCID or minimally important change. Meanwhile, 65.6% and 81.3% of patients in group 2, which were significantly lower than those of group 1, were improved beyond the MCID or minimally important change (P = .001 and .024, respectively). CONCLUSION In varus malalignment, the knee joint line was more oblique in patients without tibial varus deformity after OWHTO pre- and postoperatively. The clinical outcomes in terms of functional scores were inferior in patients without tibial varus deformity. However, the radiologic outcomes and symptomatic improvement after OWHTO were comparable regardless of the preoperative tibial varus deformity on midterm follow-up.
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Affiliation(s)
- Jun-Gu Park
- Department of Orthopaedic Surgery, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
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Lee SM, Bin SI, Kim JM, Lee BS, Suh KT, Song JH. Joint Space Width Increases Medially and Decreases Laterally at Different Time Points After Medial Open-Wedge High Tibial Osteotomy. Arthroscopy 2021; 37:3316-3323. [PMID: 33933572 DOI: 10.1016/j.arthro.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the serial changes in the joint space width (JSW) of the medial and lateral compartments after medial open-wedge high tibial osteotomy (MOWHTO) and its associated factors. METHODS The medial and lateral weight-bearing JSWs were measured on serial radiographs and analyzed preoperatively and postoperatively within 2 weeks, as well as at 3 months, 6 months, 1 year, and 2 years. Associations between the medial and lateral JSWs and age, body mass index, mechanical axis, correction angle, lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle (JLCA), JLCA on stress radiographs, and arthroscopic cartilage status were examined. Clinical outcome was measured according to the Knee Society objective and functional scores. RESULTS Seventy-one patients who underwent MOWHTO with locking-plate fixation were analyzed. The respective mean medial and lateral JSWs on serial radiographs were as follows: 3.08 mm and 5.14 mm preoperatively, 3.10 mm and 4.63 mm postoperatively, 3.37 mm and 4.57 mm at 3 months, 3.40 mm and 4.59 mm at 6 months, 3.44 mm and 4.57 mm at 1 year, and 3.42 mm and 4.64 mm at 2 years. At 3 months, the medial JSW increased (P < .001), whereas the lateral JSW decreased immediately (P < .001). JSW showed no significant differences at other time points. Preoperative and postoperative JLCAs and medial femoral and tibial cartilage grades were associated with medial JSW changes (P = .021). However, no significant parameters were associated with decreases in the lateral JSW (P > .05). The postoperative Knee Society objective and functional scores improved and were maintained. CONCLUSIONS After MOWHTO, the medial JSW increased at 3 months postoperatively and the lateral JSW decreased immediately. The preoperative and postoperative JLCAs and the medial femoral and tibial cartilage grades were associated with the change in the medial JSW. However, no significant parameters were associated with the decrease in the lateral JSW. LEVEL OF EVIDENCE Level IV, case series of therapeutic study.
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Affiliation(s)
- Sang-Min Lee
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Yangsan, Republic of Korea; Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Jong-Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kuen Tak Suh
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Yangsan, Republic of Korea; Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Republic of Korea
| | - Ju-Ho Song
- Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Republic of Korea
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Ollivier M, Fabre-Aubrespy M, Micicoi G, Ehlinger M, Hanak L, Kley K. Lateral femoral closing wedge osteotomy in genu varum. Orthop Traumatol Surg Res 2021; 107:102989. [PMID: 34144255 DOI: 10.1016/j.otsr.2021.102989] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 02/03/2023]
Abstract
The distal femoral valgisation osteotomy has a variety of indications due to enhanced understanding of segmental deformities of the lower limb. Historically, an overall varus deformity was corrected at the tibia, and a valgus deformity at the femur. This approach of performing an "all in the tibia" correction for an overall varus can nevertheless lead to abnormal postoperative morphology because it is non-anatomical; creating joint line obliquity, and potentially shear stress on the cartilage. An original lateral femoral closing wedge osteotomy technique is described, allowing the correction of a genu varum of femoral or mixed origin, in the event of an associated tibial valgisation osteotomy. The detailed technique minimizes the risk of a hinge fracture while improving post-operative outcomes.
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Affiliation(s)
- Matthieu Ollivier
- Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille Univ, APHM, CNRS, ISM, Institute of Movement and Locomotion, 270, Boulevard Sainte Marguerite, BP 29, 13274 Marseille, France.
| | - Maxime Fabre-Aubrespy
- Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille Univ, APHM, CNRS, ISM, Institute of Movement and Locomotion, 270, Boulevard Sainte Marguerite, BP 29, 13274 Marseille, France
| | - Grégoire Micicoi
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, UR2CA, University Côte d'Azur, Nice, France
| | - Matthieu Ehlinger
- Service de Chirurgie Orthopédique et de Traumatologie du Membre Inférieur, Hôpital de Hautepierre II, Hôpitaux Universitaires de Strasbourg, 67098 Strasbourg, France
| | | | - Kristian Kley
- Orthoprofis Hannover Luisenstraße 10/11, 30539 Hannover, Germany
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Grasso F, Martz P, Micicoi G, Khakha R, Kley K, Hanak L, Ollivier M, Jacquet C. Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients. INTERNATIONAL ORTHOPAEDICS 2021; 46:473-479. [PMID: 34536082 DOI: 10.1007/s00264-021-05194-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/15/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Double level osteotomy (DLO) (femoral and tibial) is a technically demanding procedure for which pre-operative planning accuracy and intraoperative correction are key factors. The aim of this study was to assess the accuracy of the achieved correction using patient-specific cutting guides (PSCGs) compared to the planned correction, its ability to maintain joint line obliquity (JLO), and to evaluate clinical outcomes and level of patient satisfaction at a follow-up of two years. METHODS A single-centre, prospective observational study including 22 patients who underwent DLO by PSCGs between 2014 and 2018 was performed. Post-operative alignment was evaluated and compared with the target angular values to define the accuracy of the correction for the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), lateral distal femoral angle (ΔLDFA), and posterior proximal tibial angle (ΔPPTA). Pre- and post-operative JLO was also evaluated. At two year follow-up, changes in the KOOS sub-scores and patient satisfaction were recorded. The Mann-Whitney U test with 95% confidence interval (95% CI) was used to evaluate the differences between two variables; the paired Student's t test was used to estimate evolution of functional outcomes. RESULTS The mean ΔHKA was 1.3 ± 0.5°; the mean ΔMPTA was 0.98 ± 0.3°; the mean ΔLDFA was 0.94 ± 0.2°; ΔPPTA was 0.45 ± 0.4°. The orientation of the joint line was preserved with a mean difference in the JLO of 0.4 ± 0.2. At last follow-up, it was recorded a significant improvement in all KOOS scores, and 19 patients were enthusiastic, two satisfied, and one moderately satisfied. CONCLUSION Performing a DLO using PSCGs produces an accurate correction, without modification of the joint line orientation and with good functional outcomes at two year follow-up.
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Affiliation(s)
- Francesco Grasso
- IRCCS-Istituto Ortopedico Galeazzi, University of Milan, Milan, Italy
| | - Pierre Martz
- Service de Chirurgie Orthopédique, Centre-Hospitalo-Universitaire de Dijon, Dijon, France
| | - Grégoire Micicoi
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France
| | - Raghbir Khakha
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France
| | - Kristian Kley
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France
| | - Lukas Hanak
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France
| | - Matthieu Ollivier
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France.
- Aix-Marseille Université, CNRS, ISM UMR 7287, 13288, Marseille Cedex 09, France.
| | - Christophe Jacquet
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29 13274, Marseille, France
- Aix-Marseille Université, CNRS, ISM UMR 7287, 13288, Marseille Cedex 09, France
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Lateral tibial intercondylar eminence is a reliable reference for alignment correction in high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2021; 31:1515-1523. [PMID: 34491381 DOI: 10.1007/s00167-021-06736-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of the study is to determine whether the lateral tibial intercondylar eminence (LTIE) is a reliable reference for alignment correction in high tibial osteotomy (HTO). METHODS A total of 1954 consecutive standing whole-leg radiography (WLR) examinations of 1373 adult patients with knee osteoarthritis between 2012 and 2019 were reviewed retrospectively; 145 patients were included, 53 males and 92 females, with a mean age of 63.3 years. Virtual simulation of HTO was performed to measure weight-bearing line (WBL) percentages and hip-knee-ankle (HKA) angles when the WBL passed through the Fujisawa, top, bottom, upper 1/3, and middle points of the lateral slope of the LTIE, and the positional relationship between the Fujisawa point and the lateral slope of the LTIE was determined. RESULTS When the WBL passed through the top, bottom, upper 1/3, and middle points of the lateral slope of the LTIE, the mean WBL percentages were 57.7% ± 2.1%, 74.6% ± 3.3%, 63.4% ± 2.1%, and 66.2% ± 2.3%, respectively, and the mean HKA angles were 182.1° ± 0.5°, 185.9° ± 0.8°, 183.3° ± 0.5°, and 184.0° ± 0.5°, respectively. When the WBL passed through the Fujisawa point, it was passing through 28.6% ± 12.7% of the width of the lateral slope (the top and bottom points were defined as 0% and 100%, respectively). When the WBL passed through the middle and upper 1/3 points of the lateral slope of the LTIE, the majority of cases (96.1%-100%) were within the limits of acceptability, as defined by the widely accepted standard of a postoperative HKA angle ranging from 183° to 186°. CONCLUSION The upper 1/3 and middle points of the lateral slope of the LTIE are reliable references for guiding the alignment correction in HTO. In clinical application, if 62%-66% of the postoperative WBL percentage is the acceptable target range, the upper 1/3 point of the lateral slope of the LTIE may be a better alternative than the midpoint. If the postoperative HKA angle between 183° and 186° is acceptable, the midpoint of the lateral slope of the LTIE may be better than the upper 1/3 point. These findings are crucial for the accuracy of the traditional intraoperative alignment assessment techniques. LEVEL OF EVIDENCE IV.
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48
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Park JG, Bin SI, Kim JM, Lee BS. Using the Lower Limb Adduction Angle to Predict Postoperative Knee Joint-Line Obliquity After Open-Wedge High Tibial Osteotomy. Orthop J Sports Med 2021; 9:23259671211003991. [PMID: 34026916 PMCID: PMC8120547 DOI: 10.1177/23259671211003991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/14/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Knee joint-line orientation is altered after open-wedge high tibial osteotomy (OWHTO), and excessive joint-line obliquity (JLO) can adversely affect outcomes. Little is known regarding preoperative prediction of postoperative knee JLO. Purpose/Hypothesis: The purpose of this study was to assess the correlation between the amount of lower limb adduction and changes in knee JLO after OWHTO. The hypothesis was that postoperative knee JLO could be predicted using the amount of lower limb adduction after OWHTO. Study Design: Case series; Level of evidence, 4. Methods: The records of 67 patients (77 knees) who underwent OWHTO for medial compartment osteoarthritis were retrospectively reviewed. The mechanical hip-knee-ankle (HKA) axis, lateral distal femoral angle, medial proximal tibial angle (MPTA), knee JLO, ankle JLO, and joint-line convergence angle were measured on standing whole-leg plain radiographs preoperatively and at 1 year postoperatively. The limb adduction angle was defined as the angle between the native weightbearing line (WBL) and the planned WBL on preoperative standing whole-leg plain radiographs. The predicted knee JLO was calculated as the sum of the preoperative knee JLO and the limb adduction angle. Multivariable linear regression analysis was used to identify the preoperative radiologic factors associated with the postoperative knee JLO. The agreement between postoperative and predicted values was determined using intraclass correlation coefficients (ICCs). Results: The estimated limb adduction angle was 4.2° ± 1.3°, and the predicted knee JLO was 4.9° ± 3.0°. The actual postoperative knee JLO was 4.5° ± 2.4°, which was a significant increase from 0.7° ± 2.4° preoperatively (P < .001). Excellent agreement was found between the predicted knee JLO and postoperative knee JLO (ICC = 0.928; P < .001). Limb adduction angle and changes in preoperative MPTA were significantly associated with changes in knee JLO (P < .001). On multivariable linear regression analysis, preoperative knee JLO and limb adduction angle were significantly associated with postoperative knee JLO (P < .001; R2 = 0.83). Conclusion: Changes in knee JLO after OWHTO were associated with adduction of the lower limb after OWHTO. During preoperative planning, postoperative knee JLO can be predicted as the sum of the preoperative knee JLO and the limb adduction angle between the preoperative WBL and planned WBL.
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Affiliation(s)
- Jun-Gu Park
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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49
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Imhoff FB, Fucentese SF, Harrer J, Tischer T. [The influence of axial deformities and their correction on the development and progression of osteoarthritis]. DER ORTHOPADE 2021; 50:378-386. [PMID: 33844033 PMCID: PMC8081714 DOI: 10.1007/s00132-021-04103-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 12/02/2022]
Abstract
Die Beachtung der Beinachse und die Möglichkeiten zur deren Korrektur stellen beim jungen Patienten mit Arthrose ein Grundpfeiler der Therapie dar. Die Kombination einer Gelenksverletzung und einer Achsdeviation führt unweigerlich, je nach Ausmaß und Komorbiditäten, schon nach wenigen Jahren zur fortschreitenden Gonarthrose. Neben der genauen Deformitätenanalyse zur Osteotomieplanung, gilt es, Normbereiche der entsprechenden Winkel zu kennen und eine Zielgröße zur Achskorrektur festzulegen. Aus dem Repertoire der verschiedenen kniegelenksnahen Osteotomien sind dann die Nebeneffekte in Bezug auf patellofemorales Maltracking, ligamentäres Balancing und die Beinlänge abzuschätzen. Gerade im Hinblick auf mögliche (und wahrscheinliche) Folgeoperationen beim jungen Patienten müssen neue knöcherne Deformitäten oder ligamentäre Insuffizienzen, welche potenziell bei Überkorrektur entstehen, unbedingt vermieden werden.
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Affiliation(s)
- Florian B Imhoff
- Orthopädie, Universitätsklinik Balgrist, Forchstrasse 340, 8008, Zürich, Schweiz.
| | - Sandro F Fucentese
- Orthopädie, Universitätsklinik Balgrist, Forchstrasse 340, 8008, Zürich, Schweiz
| | - Jörg Harrer
- Abteilung für Orthopädie und Unfallchirurgie, Helmut-G.-Walther-Klinikum, Lichtenfels, Deutschland
| | - Thomas Tischer
- Sektion Sportorthopädie, Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Rostock, Deutschland
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