Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity

Nakayama, Hiroshi; Iseki, Tomoya; Kanto, Ryo; Kambara, Shunichiro; Kanto, Makoto; Yoshiya, Shinichi; Schröter, Steffen

doi:10.1007/s00167-018-5103-3

Cited by 69 publications

(114 citation statements)

References 38 publications

(62 reference statements)

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“…2). Therefore, it cannot be concluded from our data that overcorrections must be avoided and double level osteotomies should be performed, but other clinical and experimental data indicate this very strongly [7,9,10,23,24]. The maximum overcorrection that can be tolerated in femoral and tibial osteotomies should be examined more closely in further studies.…”

Section: Mechanical Axis and Joint Anglesmentioning

confidence: 79%

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome

Fürmetz

Patzler

Wolf

et al. 2020

BMC Musculoskelet Disord

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Background: Varus deformities of the knee are frequently corrected by osteotomies, which should be performed at the level of origin. But in contrast to high tibial osteotomies (HTO), little data exists for distal femoral osteotomies (DFO). This study evaluates radiological and clinical outcomes after valgisation osteotomies in the proximal tibia and distal femur. Methods: We used an observational cohort study design and prospectively performed preoperative long standing radiographs (LSR), lateral x-rays and clinical questionnaires (SF-36, Lysholm score, VAS). Postoperative LSR and lateral x-rays were obtained on average 18 months postoperative and postoperative clinical questionnaires at final visit (mean follow up 46 months). A subgroup analysis of the different surgical techniques (oHTO vs. cDFO) was performed, with regards to radiological and clinical outcomes. Results: Finally 28 osteotomies with medial tibial opening (oHTO) or lateral femoral closing (cDFO) wedge osteotomies in 25 consecutive patients (mean age 40 years) were identified. There were 17 tibal and 11 femoral procedures. All osteotomies were performed at the origin of deformity, which was of different etiology. The average deviation of the final HKA compared to the preoperative planning was 2.4°± 0.4°. Overall, there was a significant improvement in all clinical scores (SF-36: 61.8 to 79.4, p < 0.001; Lysholm-score: 72.7 to 90.4, p < 0.001; VAS: 3 to 1, p < 0.001). There was no significant correlation between surgical accuracy and outcome scores. Conclusion: Valgisation osteotomies lead to a significant improvement in all clinical scores with the demonstrated treatment protocol. An appreciable proportion of varus deformities are of femoral origin. Since cDFO provides comparable radiological and clinical results as oHTO, this is an important treatment option for varus deformities of femoral origin.

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Section: Mechanical Axis and Joint Anglesmentioning

confidence: 79%

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome

Fürmetz

Patzler

Wolf

et al. 2020

BMC Musculoskelet Disord

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“…• [36]. With regard to the mMPTA, two different simulations were performed: one simulation with a postoperative upper limit of 90° (anatomic correction) and another simulation with a postoperative upper limit of 95° (overcorrection).…”

Section: Deformity Analysismentioning

confidence: 99%

Isolated high tibial osteotomy is appropriate in less than two-thirds of varus knees if excessive overcorrection of the medial proximal tibial angle should be avoided

Feucht

Winkler

Mehl

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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Purpose To perform a detailed deformity analysis of patients with varus alignment and to define the ideal osteotomy level (tibial vs. femoral vs. double level) to avoid an oblique joint line. Methods A total of 303 digital full-leg standing radiographs of patients aged 18-60 years and varus alignment [mechanical tibiofemoral varus angle (mFTA) ≥ 3°] were included. All legs were analyzed regarding mFTA, mechanical medial proximal tibia angle (mMPTA), mechanical lateral distal femur angle (mLDFA), and joint line convergence angle. Based on mFTA, varus alignment was categorized as "mild" (3°-5°), "moderate" (6°-8°), or "severe" (≥ 9°). Deformity location was determined according to the malalignment test described by Paley. Two osteotomy simulations were performed with different upper limits for mMPTA: anatomic correction (mMPTA ≤ 90°, mLDFA ≥ 85°) and overcorrection (mMPTA ≤ 95°, mLDFA ≥ 85°). If a single osteotomy exceeded these limits at the intended mFTA of 2° valgus, a double-level osteotomy was simulated. If even a double-level osteotomy resulted in deviations from the defined limits, the leg was categorized as "uncorrectable". Results Mean mFTA was 6° ± 11° of varus (range 3°-15°). A tibial deformity was observed in 28%, a femoral deformity in 23%, a combined tibial and femoral deformity in 4%, and no bony deformity in 45%. The prevalence of a tibial deformity did not differ between varus severity groups, whereas a femoral and bifocal deformity was significantly more prevalent in knees with more distinct varus (p < 0.001). Osteotomy simulation revealed that isolated high tibial osteotomy (HTO) was appropriate in only 12% for anatomic correction, whereas a double-level osteotomy was necessary in 63%. If overcorrection of mMPTA was tolerated, the number of HTOs significantly increased to 57% (p < 0.001), whereas the number of doublelevel osteotomies significantly decreased to 33% (p < 0.001). Isolated DFO was considered ideal in 8% for both simulations. Significantly more knees were considered "uncorrectable" by simulating anatomic correction (18 vs. 2%; p < 0.001). A double-level osteotomy was significantly more often necessary in knees with "severe" varus (p < 0.001). Conclusion Less than one-third of patients (28%) with mechanical varus ≥ 3° have a tibial deformity. If anatomic correction (mMPTA ≤ 90°) is intended, only 12% of patients can be corrected via isolated HTO, whereas 63% of patients require a double-level osteotomy. If slight overcorrection is accepted (mMPTA ≤ 95°), 57% of patients can be corrected via isolated HTO, whereas 33% of patients would still require a double-level osteotomy. Level of evidence III, cross-sectional study.

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“…DLO was indicated for knees exhibiting deformity in both the femur and tibia, and for patients with high activity level who wished to retain the level of activity after surgery. 13 Preoperative surgical planning was performed using digital planning software (mediCADR, Hectect, Germany) on a standing full-length anteroposterior radiograph. 15 The indication for DLO was severe varus malalignment and medial compartment osteoarthritis.…”

Section: Methodsmentioning

confidence: 99%

“…There have been several studies reporting favorable surgical outcomes of DLO. 12 , 13 , 14 Those reports have shown that DLO enables restoration of normal limb alignment without causing non-physiologic joint line inclination as observed in isolated MOWHTO knees; however, most of the previous relevant studies dealt with correction of the femoro-tibial alignment, and associated changes in the patellofemoral joint have not been addressed. Although there have been studies investigating the changes in the patellar position and orientation following MOWHTO, there is lack of information regarding the effects of DLO on patellar height or patellofemoral alignment.…”

Section: Introductionmentioning

confidence: 99%

Changes in patellar height and patellofemoral alignment following double level osteotomy performed for osteoarthritic knees with severe varus deformity

Akaoka

Iseki

Kanto

et al. 2020

Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilit

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Purpose To evaluate the effect of double level osteotomy (DLO), a combination of a lateral closed distal femoral osteotomy (LCWDFO) and medial opening wedge high tibial osteotomy (MOWHTO), on patellar height and patellofemoral alignment as compared to those of isolated MOWHTO. Methods Twenty-six consecutive knees in 26 patients who underwent DLO (DLO group) constituted the study population. For comparative purpose, a control cohort (N: 26) matched for age, sex, and body mass index with the study group were selected from the patients who underwent isolated MOWHTO with an opening gap of more than 10 mm during the same period (MOWHTO group). Patellar height and patellofemoral alignment were assessed on radiographs preoperatively and at 2 years after surgery. For the patellar height, following parameters were measured on a lateral radiograph: Modified Insall-Salvati Index (mISI), modified Caton–Deschamps Index (mCDI), and modified Blackburne-Peel Index (mBPI). In the assessment of patellofemoral alignment, lateral patellar tilt (LPT) and lateral patellar shift (LPS) were measured on a skyline view. The measured values were statistically compared using the Student’s t-test. Results In the DLO group, the patellar height measured by mCDI and mPBPI significantly decreased after surgery. As regards the patellofemoral alignment, LPT significantly decreased with no significant postoperative change detected for LPS. When the amounts of postoperative changes in radiological indices were compared between the DLO and isolated MOWHTO groups, no significant differences were detected for all parameters. Conclusion DLO induced reduction in patellar height and decreased lateral patellar tilt. Those changes in patellar position and orientation were similarly observed in isolated MOWHTO knees. Although DLO is specifically indicated for knees with severe varus deformity, the two surgical options for correction of varus knee deformity exerted similar influences on patellofemoral biomechanics.

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Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity

Abstract: Retrospective case series, Level IV.

Cited by 69 publications

References 38 publications

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome

Isolated high tibial osteotomy is appropriate in less than two-thirds of varus knees if excessive overcorrection of the medial proximal tibial angle should be avoided

Changes in patellar height and patellofemoral alignment following double level osteotomy performed for osteoarthritic knees with severe varus deformity

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