Contemporary Knee Osteotomy in the United States: High Tibial Osteotomy and Distal Femoral Osteotomy Have Comparable Complication Rates despite Differing Demographic Profiles

Delva, Mona L.; Samuel, Linsen T.; Roth, Alexander; Yalçın, Sercan; Kamath, Atul F.

doi:10.1055/s-0039-3400742

Cited by 8 publications

(7 citation statements)

References 44 publications

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“…UKA is a surgical option for patients with only a single arthritic compartment, most commonly the medial compartment. High tibial osteotomy and distal femoral osteotomy are also potentially options in this patient population, particularly in the younger population 2 .…”

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confidence: 99%

Unicompartmental Knee Arthroplasty: Survivorship and Risk Factors for Revision

Ekhtiari

Bozzo

Madden

et al. 2021

Journal of Bone and Joint Surgery

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Background:Operative management for end-stage knee osteoarthritis (OA) primarily consists of arthroplasty. Total knee arthroplasty (TKA) is the so-called gold standard for multicompartmental OA. In selected patients, specifically those with unicompartmental OA and no definite contraindications, realignment osteotomies and unicompartmental knee arthroplasty (UKA) are viable options. UKA offers several advantages over TKA, including preservation of both cruciate ligaments, faster recovery, and less osseous resection. The purpose of this study was to determine the survivorship of UKAs and risk factors for all-cause revision surgery in patients with a minimum follow-up of 10 years in a large population-based database.Methods:We performed a population-based cohort study using linked administrative databases in Ontario, Canada. We identified all UKAs performed from January 2002 through December 2006. All patients had a minimum 10-year follow-up. Demographic data and outcomes were summarized using descriptive statistics. We used a Cox proportional hazards model with the Fine and Gray method accounting for competing risks such as death to analyze the effect of surgical and patient factors on the risk of revision of UKA.Results:A total of 4,385 patients were identified as having undergone primary UKA from 2002 through 2006 in Ontario. Of these patients, 779 underwent revision surgery, for a cumulative risk for all-cause revision of 16.5% at 10 years (95% confidence interval [CI]: 15.4% to 17.7%). Mechanical loosening was the reason for 83.4% of all revisions. Male sex, diabetes, an age younger than 50 years, and cementless implants were significant risk factors for revision surgery. Residence in a rural or urban setting, income quintile, discharge destination, and type of OA were not associated with the risk of revision. Survivorship at 1, 5, 10, and 15 years was 97.2%, 90.5%, 83.5%, and 81.9%, respectively.Conclusions:This study demonstrated a >80% long-term survivorship for UKA based on a large administrative database sample and identified important risk factors for failure including male sex, younger age, diabetes, and cementless fixation. This study found rates of survivorship similar to those previously reported in the literature, while identifying key risk factors for failure. Patient selection has always been identified as a key factor in ensuring successful UKA, and the risk factors identified in this study may help guide decision-making for surgeons and patients dealing with unicompartmental knee OA.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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confidence: 99%

Unicompartmental Knee Arthroplasty: Survivorship and Risk Factors for Revision

Ekhtiari

Bozzo

Madden

et al. 2021

Journal of Bone and Joint Surgery

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“…Nevertheless, DFO has been shown to achieve satisfactory pain relief and functional improvement in patients with unicompartmental OA, with a complication rate comparable with that of high tibial osteotomy. [1][2][3]5,8,10,11 Previous studies investigating DFO have been limited by small sample sizes, constraining the generalizability of the results, especially pertaining to survivorship estimates. In their retrospective review, Backstein et al 1 identified only 38 patients (40 knees), despite analyzing records from a 30-year time period.…”

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confidence: 99%

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confidence: 99%

Factors Associated With Distal Femoral Osteotomy Survivorship: Data From the California Office of Statewide Health Planning and Development (OSHPD) Registry

Mayfield

Bolia

Mayer

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: Malalignment of the lower extremity can lead to early functional impairment and degenerative changes. Distal femoral osteotomy (DFO) can be performed with arthroscopic surgery to correct lower extremity malalignment while addressing intra-articular abnormalities or to help patients with knee osteoarthritis (OA) changes due to alignment deformities. Purpose: To examine survivorship after DFO and identify the predictors for failure. Study Design: Case series; Level of evidence, 4. Methods: Data from the California Office of Statewide Health Planning and Development, a statewide discharge database, were utilized to identify patients between the ages of 18 and 40 years who underwent DFO from 2000 to 2014. Patients with a history of lower extremity trauma, infectious arthritis, rheumatological disease, skeletal dysplasia, congenital deformities, malignancy, or concurrent arthroplasty were excluded. Failure was defined as conversion to total or unicompartmental knee arthroplasty, and the identified cohort was stratified based on whether they went on to fail. Age, sex, race, diagnoses, concurrent procedures, and comorbidities were recorded for each admission. Statistically significant differences between patients who required arthroplasty and those who did not were identified using the Student t test for continuous variables and a chi-square test for categorical variables. Kaplan-Meier survivorship curves were constructed to estimate 5- and 10-year survival rates. A Cox proportional hazards model was used to analyze the risk for conversion to arthroplasty. Results: A total of 420 procedures were included for analysis. Overall, 53 knees were converted to arthroplasty. The mean follow-up time was 4.8 years (range, 0.0-14.7 years). The 5-year survivorship was 90.2% (range, 85.7%-93.4%), and the 10-year survivorship was 73.2% (range, 64.7%-79.9%). The mean time to failure was 5.9 years (range, 0.4-13.9 years). Survivorship significantly decreased with increasing age ( P = .004). Hypertension and a primary diagnosis of osteoarthrosis were significant risk factors for conversion to arthroplasty (odds ratio [OR], 3.12 [95% CI, 1.38-7.03]; P = .006, and OR, 2.42 [95% CI, 1.02-5.77]; P = .045, respectively), along with a primary diagnosis of traumatic arthropathy (OR, 10.19 [95% CI, 1.71-60.65]; P = .01) and a comorbid diagnosis of asthma (OR, 2.88 [95% CI, 1.23-6.78]; P = .02). Patients with Medicaid were less likely (OR, 0.11 [95% CI, 0.01-0.88]; P = .04) to undergo arthroplasty compared with patients with private insurance, while patients with workers’ compensation were 3.1 times more likely (OR, 3.08 [95% CI, 1.21-7.82]; P = .02). Conclusion: Older age was an independent risk factor for conversion to arthroplasty after DFO in patients ≥18 years but ≤60 years. Hypertension, asthma, and a diagnosis of osteoarthrosis or traumatic arthropathy at the time of surgery were predictors associated with failure, reinforcing the need for careful patient selection. The high survivorship rate of DFO in this analysis supports this procedure as a reasonable alternative to arthroplasty in younger patients with valgus deformities about the knee and symptomatic unicompartmental OA.

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“…DFO patients experienced increased rates of sepsis, acute kidney injury, and infection in the short-term compared to HTO patients. The DFO cohort had, on average, more medical comorbidities than the HTO cohort, echoing the indings of a recent national database study in which DFO patients had higher rates of hypertension and lung disease compared to their HTO counterparts [9]. Poorer pre-operative health among DFO patients may leave them more vulnerable to short-term postoperative complications.…”

Section: Discussionmentioning

confidence: 73%

Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use

Kucirek

Anigwe

Zhang

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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Purpose The purpose of this study was to assess complications, reoperations, and their risk factors at 90 days and 2 years after high tibial osteotomy (HTO) and distal femoral osteotomy (DFO) in a national cohort. Methods The PearlDiver Mariner Dataset was queried using International Classiication of Diseases (ICD) and Current Procedural Terminology (CPT) codes for HTO and DFO, complications, and subsequent surgery. Minimum follow-up was 2 years and complications were assessed at 90 days and 2 years. Hospital readmission in the irst 90 days was also assessed. Univariate and multiple logistic regression were utilized to identify risk factors for complications and re-operation. ResultsThe 90-day and 2-year complication rates after HTO (n = 1780) were 11.6% and 31.7%, compared to 21.5% (p < 0.0001) and 41.5% (p = 0.0001) after DFO (n = 446). Infection was the most frequent early (90-day) complication for both HTO and DFO cohorts, while hardware problems were most common at 2 years. Increasing Elixhauser Comorbidity Index (ECI) was associated with increased odds of infection, readmission, and hardware-associated complications in both cohorts. Gender and tobacco use were also associated with various complications after HTO. At 2 years, 23.7% of HTO patients and 26.2% of DFO patients had undergone subsequent surgery. Hardware removal occurred in 16.4% of HTO and 18.4% of DFO patients (n.s.), while 4.5% of HTO and 5.2% of DFO patients underwent total knee arthroplasty (TKA) within 2 years (n.s.). Conclusion HTO and DFO have substantial complication rates in the short and mid term, with a higher rate of overall complications observed after DFO as compared to the HTO cohort. After both procedures, roughly one quarter of patients will undergo subsequent surgery within 2 years. Patients with tobacco use and numerous medical co-morbidities may not be optimal candidates due to increased complication rates. Elixhauser Comorbidity Index (ECI) may be an useful tool for risk assessment prior to surgery. Level of evidence Retrospective cohort study, III.

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Contemporary Knee Osteotomy in the United States: High Tibial Osteotomy and Distal Femoral Osteotomy Have Comparable Complication Rates despite Differing Demographic Profiles

Cited by 8 publications

References 44 publications

Unicompartmental Knee Arthroplasty: Survivorship and Risk Factors for Revision

Unicompartmental Knee Arthroplasty: Survivorship and Risk Factors for Revision

Factors Associated With Distal Femoral Osteotomy Survivorship: Data From the California Office of Statewide Health Planning and Development (OSHPD) Registry

Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use

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