Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: a randomized controlled trial with a six-year follow-up

BACKGROUND

Varus deformity increases the risk of progression of medial compartment knee osteoarthritis. The aim of this study was to investigate the clinical and radiographic mid-term results of closing-wedge and opening-wedge high tibial osteotomy when used to treat this condition.

METHODS

From January 2001 to April 2004, ninety-two patients were randomized to receive either a closing-wedge or an opening-wedge high tibial osteotomy. The clinical outcome and radiographic results were examined preoperatively; at one year; and, for the present study, at six years postoperatively. The outcomes that we reviewed included maintenance of the achieved correction, progression of osteoarthritis (based on the Kellgren and Lawrence classification), severity of pain (as assessed on a visual analog scale [VAS]), knee function (as measured with the Hospital for Special Surgery [HSS] score and Knee injury and Osteoarthritis Outcome Score [KOOS]), walking distance, complications, and survival with conversion to a total knee arthroplasty as the end point. The results were analyzed on the basis of the intention-to-treat principle.

RESULTS

Six years postoperatively, the mean hip-knee-ankle (HKA) angle (and standard deviation) was 3.2° ± 4.1° of valgus after a closing-wedge high tibial osteotomy and 1.3° ± 5.0° of valgus after an opening-wedge high tibial osteotomy (p = 0.343). In both groups, the six-year postoperative HKA angles did not differ from the respective one-year postoperative angles. No difference in the severity of pain or in knee function was found between the two groups. Four complications (9%) occurred in the closing-wedge group and seventeen (38%), in the opening-wedge group. Ten (22%) of the patients in the closing-wedge group and three (8%) in the opening-wedge group needed conversion to a total knee arthroplasty within the six-year period (p = 0.05). The difference in the percentage of cases with conversion to total knee arthroplasty was 14% (95% confidence interval [CI] = 21.7 to 0.2).

CONCLUSIONS

In the group of patients without conversion to a total knee arthroplasty, there was no difference between the high tibial closing-wedge and opening-wedge osteotomies in terms of clinical outcomes or radiographic alignment at six years postoperatively. Opening-wedge osteotomy was associated with more complications, but closing-wedge osteotomy was associated with more early conversions to total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Abstract P6-10-03: Bilateral Prophylactic Mastectomy in Swedish Women at High Risk of Breast Cancer — A National Survey

Background: Prophylactic mastectomy is the most efficient risk-reducing strategy for women with hereditary increased risk of breast cancer. Usually it is combined with immediate breast reconstruction. Unpublished data show that about 60% of Swedish female BRCA1/2 mutation carriers undergo bilateral prophylactic mastectomy (BPM) within eight years after mutation status disclosure. This study attempted a national inventory of all bilateral prophylactic mastectomies performed between 1995 and 2005 in high-risk women without a previous breast malignancy. The primary aim was to investigate the breast cancer incidence after surgery. Secondary aims were to describe the preoperative risk assessment, operation techniques, histopathological findings, complications, and regional differences. Methods: Geneticists, oncologists, and surgeons performing prophylactic breast surgery were asked to identify all women eligible for inclusion in their region. The medical records were reviewed in each region during 2006 and 2007 and the data were analyzed centrally. Information about cancer and death was recorded through 2008. The BOADICEA risk assessment model was used to calculate the number of expected/prevented breast cancers during the follow-up period. Women with incidental cancer in the breast specimens and women treated for ovarian cancer were excluded from the calculation. Prophylactic salpingo-oophorectomy performed before BPM was considered to have reduced the risk of breast cancer by 50%.

Results: A total of 223 women operated on were identified. During a mean postoperative follow-up of 6.6 years (range 2.1-14.0), no primary breast cancer was observed. However, one woman succumbed nine years after BPM to widespread adenocarcinoma of uncertain origin. According to our risk calculation, based on 204 women and 1362 woman-years, approximately 12 breast cancers would have been expected, had BPM not been performed. Eight of these would have occurred in mutation carriers.

The operations had been performed in eight hospitals throughout the country. One hospital performing BPMs declined participation in the study. Median age at BPM was 40 years. A total of 58% were BRCA1/2 mutation carriers. Five women (2%) had a lifetime risk of breast cancer <30% but no woman had a risk below 20%. All but three women underwent breast reconstruction, 208 with implants and 12 with autologous tissue. Four small (≥8 mm), invasive cancers and four DCIS were found in the mastectomy specimens. Three of the women with invasive cancer did not have recent preoperative breast imaging. The incidence of non-breast related complications was low (3%). Implant loss due to infection/necrosis occurred in 10% of the implant-based reconstructions. Conclusions: As only one hospital performing BPMs declined participation, we estimate that the 223 identified women are representative of Swedish conditions. In accordance with previous international series, we conclude that BPM is efficacious in reducing future breast cancer risk in high-risk women. Preoperative imaging and careful histopathological examination of the breast specimens is important, as incidental breast cancers occur. Given the small numbers of operations performed, centralization of this patient group seems justified.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-10-03.