Osteotomy and Lower Extremity Realignment Procedures


143 Osteotomy and Lower Extremity Realignment Procedures


Jayson Lian BA1,2, Darren de SA MD3, João V. Novaretti MD1,4, and Volker Musahl MD1


1 Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA


2 Albert Einstein College of Medicine, Bronx, NY, USA


3 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


4 Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil


Clinical scenario



  • A 49‐year‐old male runner with a history of bilateral partial medial meniscectomies (six years prior), and worsening medial‐sided right knee pain of several months’ duration, refractory to cortisone injection, and conservative treatment.
  • Body mass index (BMI) 27.3. Bilateral varus alignment, normal range of motion (ROM) (0–130), right knee medial joint line tenderness and pain with McMurray maneuvers.
  • Radiographs demonstrate medial joint space narrowing and moderate Fairbank’s changes. Long cassette radiograph reveals bilateral varus (8°).

Top three questions



  1. In middle‐aged patients with varus malalignment and medial osteoarthritis (OA), does high tibial osteotomy (HTO) result in superior outcomes (i.e. survivorship, function, complications) compared to unicompartmental knee arthroplasty (UKA)?
  2. In middle‐aged patients with lower limb varus malalignment, concomitant meniscal deficiency, and OA, does medial open‐wedge high tibial osteotomy (OWHTO) result in improved outcomes (i.e. limb length alignment, function, time‐dependent improvement) compared to lateral closed‐wedge high tibial osteotomy (CWHTO)?
  3. In middle‐aged patients undergoing HTO, does bone graft supplementation improve bone healing and patient outcomes compared to no bone graft supplementation?

Question 1: In middle‐aged patients with varus malalignment and medial osteoarthritis (OA), does high tibial osteotomy (HTO) result in superior outcomes (i.e. survivorship, function, complications) compared to unicompartmental knee arthroplasty (UKA)?


Rationale


HTO and UKA are both indicated for the active, middle‐aged patient suffering medial‐sided knee OA. However, the superiority of one technique over the other with regards to function, survivorship, and complication profiles is controversial. Currently, a paucity of high‐level evidence exists to suggest a clear benefit of one procedure over the other.


Clinical comment


It is unclear whether HTO or UKA is superior for treatment of varus‐associated medial knee OA.


Available literature and quality of the evidence


To date, only three prospective, randomized controlled trials (RCTs),13 performed in 1991, 2001, and 2004, have compared risks and benefits of HTO versus UKA – all specifically using CWHTO. Two nonrandomized prospective studies,4,5 one utilizing CWHTO and one OWHTO, were published in 1989 and 2008, respectively. More recently, numerous retrospective analyses have also been included for systematic review.6


Findings


The highest‐quality evidence comparing HTO and UKA for medial‐sided OA rests with three RCTs, all using CWHTO, and published many years ago.13 There was no statistical significance in 10‐year survival for patients with a mean age of 67 years (77% UKA; 60% HTO).3 Both groups had similar mean knee scores, functional Knee Society Scores, and British Orthopaedic Association scores at one, five,2 and seven, 10 years.3 Range of motion did not differ significantly between cohorts.1,2 In terms of muscle torque, maximal gait velocity, and duration of single support, UKA patients demonstrated superior results at six months postoperatively compared to HTO patients at 12 months.1 However, while UKA patients showed significantly greater free walking speed, step frequency, and step length at three months postoperatively, these differences disappeared at one and five years.2 Lastly, only one of three studies investigated intraoperative and postoperative complication rates, revealing higher complication rates in HTO (28.1%) versus UKA (7.1%), including deep vein thrombosis, superficial wound infection, pseudarthrosis, hardware failure, and fracture in the HTO cohort versus arthrofibrosis with UKA.3 In summary, comparable outcomes with regard to survivorship, patient‐reported outcomes, ROM, and gait were found, with possible increased complication rates in HTO over UKA.13 From these studies alone, however, superiority cannot be established. Furthermore, with increasing prevalence of OWHTO versus CWHTO, RCTs comparing OWHTO and UKA are required.


A systematic review and meta‐analysis of pooled results was conducted on studies of all levels of evidence: nine retrospective, three prospective randomized, and two prospective non‐RCTs (total 1041 knees undergoing HTO and 5497 knees undergoing UKA). The meta‐analysis demonstrated superior ROM following HTO, but less pain, higher rates of self‐perceived outcome as excellent/good, and fewer perioperative complications after UKA. However, the procedural indications and patient characteristics vary among studies. Indeed, both procedures yield satisfactory outcomes, though it appears that valgus HTO may be more appropriate for younger active patients and UKA more appropriate for older patients.6


Resolution of clinical scenario



  • HTO and UKA are reasonable options for this middle‐aged, active individual.
  • Older, high‐quality trials show similar results between CWHTO and UKA.
  • With the advent of OWHTO and improved technology, consideration may be given to recent, lower‐level studies.
  • Pooled meta‐analyses showed HTO patients had better ROM, but UKA patients reported less pain, better patient scores, and fewer perioperative complications.
  • As this patient is young, nonobese, and possesses full ROM, and a desire to return to activity, a joint preserving procedure may be more appropriate.

Question 2: In middle‐aged patients with lower limb varus malalignment, concomitant meniscal deficiency, and OA, does medial open‐wedge high tibial osteotomy (OWHTO) result in improved outcomes (i.e. limb length alignment, function, time‐dependent improvement) compared to lateral closed‐wedge high tibial osteotomy (CWHTO)?


Rationale


HTO is a well‐established procedure for the treatment of patients with varus malalignment and OA of the medial knee. The most commonly performed techniques of HTO are lateral CWHTO and the medial OWHTO. Both techniques have their advantages and disadvantages. Still, no consensus has been reached in the literature regarding the optimal approach.


Clinical comment


As lateral‐closing and medial‐opening HTO are both frequently performed procedures in this aforementioned patient population, elucidating the optimal technique is critical for a more individualized and appropriate treatment plan.


Available literature and quality of the evidence


To date, several RCTs have been published comparing lateral‐closing wedge and medial‐opening wedge HTOs. Additionally, prospective and retrospective cohort studies have been performed.


Findings


Several differences have been reported between OWHTO and CWHTO. For example, OWHTO has been shown to lead to greater incidences of patella baja,7,8 the effects of which may alter knee kinematics, decrease ROM, increase patellofemoral contact pressures, and lead to anterior knee pain.7

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Osteotomy and Lower Extremity Realignment Procedures
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