Purpose To compare the radiographic, clinical, and arthroscopic outcomes of varus osteoarthritic knees treated with an open-wedge high tibial osteotomy (OWHTO) alone or with a double-level osteotomy (DLO). It was hypothesized that treatment with DLO would maintain the joint line obliquity (JLO) and acquire better arthroscopic and clinical outcomes after surgery than OWHTO alone. Methods Knees with predicted medial proximal tibial angle (MPTA) > 95° were treated with OWHTO alone or with DLO. Preoperatively, age, body mass index, and hip-knee-ankle angle (HKA) difered between the two groups. Therefore, after adjustment for those factors, 34 knees with OWHTO alone and 34 knees with DLO were compared. On whole-leg radiographs for a single leg, HKA, weightbearing line (WBL) ratio, lateral distal femoral angle (LDFA), MPTA, and JLO were measured before and 2 years after surgery. Clinical outcomes were evaluated by the Knee Society Score (KSS) knee, KSS function, Lysholm, and Knee injury and Osteoarthritis Outcome Score (KOOS) scores before and 2 years after surgery. Arthroscopic indings were obtained before and 1 year after surgery. Various factors were compared between the two groups. Results JLO increased signiicantly from 1.4° to 6.3° in the OWHTO group (p < 0.001) and changed from 1.0° to 1.3° in the DLO group (n.s.). Postoperative MPTA and JLO in the OWHTO group were signiicantly higher than those in the DLO group (both p < 0.001). There were no signiicant diferences in the KSS knee, KSS function, and KOOS scores between the two groups. Postoperative Lysholm score in the DLO group was higher than that in the OWHTO group (p < 0.025). Femoral and tibial cartilage regeneration in the medial condyles and deterioration in the lateral condyles did not difer between the two groups on second-look arthroscopy. Conclusions JLO was not signiicantly changed after surgery in the DLO group. DLO enabled the acquisition of physiological JLO compared with OWHTO alone. Level of evidenceRetrospective comparative study, Level III. Keywords Double-level osteotomy • Open-wedge high tibial osteotomy • Joint line obliquity • Medial proximal tibial angle * Yasushi Akamatsu

PurposeThis study investigated the relationship between femoral shaft bowing and the orientation of the surgical transepicondylar axis (TEA) in the coronal plane in varus knee osteoarthritis (OA). MethodsA total of 82 knees scheduled to undergo total knee arthroplasty (TKA) for the treatment of varus knee OA were enrolled. The hip–knee‐ankle angle (HKA) was measured preoperatively on anteroposterior whole‐leg standing radiographs. The lateral angle between the TEA and the mechanical axis of the femur (MA‐TEA) was measured in the coronal plane from preoperative computed tomography (CT) images. Femoral shaft bowing was measured on CT images. Pearson’s correlation coefficient was used to examine the correlation of the MA‐TEA with the HKA and femoral shaft bowing. ResultsThe MA‐TEA correlated negatively with the HKA (r = − 0.321, P < 0.01) and positively with femoral shaft bowing (r = 0.415, P < 0.01). ConclusionsThe TEA changed to varus as femoral shaft bowing increased in patients with varus knee OA. This suggests that the TEA is not always the centre of the rotational axis of the femur after TKA. In addition, the TEA may not be useful as a consistent parameter in the coronal plane in patients with increasing femoral shaft bowing. Level of evidenceIII.

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