Consistent indications, targets and techniques for double-level osteotomy of the knee: a systematic review

Alves, Philippe; Rooij, Floris van; Kuratle, Thomas; Saffarini, Mo; Miozzari, Hermès Howard

doi:10.1007/s00167-022-06915-6

Cited by 16 publications

(11 citation statements)

References 21 publications

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“…In contrast to the previous studies reporting unfavorable outcome of isolated HTO performed for this group of knees [30,39,42], the present study showed that DLO could yield significant clinical/radiological improvements even for advanced osteoarthritic knees. Consequently, the results of this study support the efficacy and validity of our surgical strategy of anatomical reconstruction of the bone and joint geometry via DLO [5,7,15,27,38]. In recent years, the surgical procedure for DLO has evolved to incorporate biplanar osteotomy and minimally invasive plate osteoosynthesis (MIPO) techniques [10,27,38], and the results have been reported in several studies [10,27,38].…”

Section: Discussionsupporting

confidence: 69%

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

et al. 2023

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Purpose The purpose of this study was to examine the relationship between preoperative Ahlbäck radiographic classification grade and the clinical outcomes of double level osteotomy (DLO) performed for osteoarthritic knees with severe varus deformity. Methods The study population comprised a consecutive series of 99 knees (68 patients) for which DLO was performed and follow-up results for a minimum of two years were available. The Ahlbäck radiographic classification system was used to determine the osteoarthritic grade. The following radiological parameters for alignment and bone geometry were measured: mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint-line convergence angle (JLCA), and mechanical tibiofemoral angle (mTFA). Clinical results were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) subjective score preoperatively and at 2 years after surgery. Difference between preoperative and postoperative measurements as well as relationship between Ahlbäck grade and radiological/clinical results were statistically assessed. Results The average age of the study participants was 60.9 ± 6.2 years and the mean follow-up period was 45.4 ± 15.2 months. Each of the radiological parameters exhibited preoperative abnormal values. Knees with Ahlbäck grade 3 and 4 osteoarthritis exhibited significantly greater JLCA and mTFA than grade 1 knees. Two years post-surgery, all radiological parameter values measured within a normal range. Clinical evaluation showed significant improvement in KOOS after surgery. Analysis of the relationship between Ahlbäck grade and clinical score showed that the 2-year postoperative KOOS scores in grade 3 and 4 osteoarthritic knees were significantly lower than grade 1 knees (with the mean 2-year KOOS scores of 350.0 ± 79.9, 317.9 ± 78.3, and 420.2 ± 42.9, respectively). Conclusions While DLO may produce significant radiological and clinical improvement in knees with joint space obliteration, Ahlbäck grade 3 and 4 osteoarthritic knees associated with larger JLCA and mTFA showed less satisfactory clinical results compared to grade 1 knees. Level of Evidence: IV case series.

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Section: Discussionsupporting

confidence: 69%

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

et al. 2023

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“…This is a novel study. In a recent systematic review by Alves et al [12] on double‐level knee osteotomies, the 12 included studies reported on DLO which was performed by medial opening‐wedge tibial osteotomy and lateral closing‐wedge femoral osteotomy for varus knees. This is the first study to report on double‐level medial closing wedge osteotomies to correct bifocal valgus knee deformity.…”

Section: Discussionmentioning

confidence: 99%

“…In cases of valgus knees, the distal femur and proximal tibia have to be thoroughly assessed preoperatively to determine the site of the deformity and consider a single-or double-level osteotomy (DLO). This latter allows the achievement of a neutral lower extremity alignment while preventing JLO [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees

Pioger

Mabrouk

Jacquet

et al. 2023

Knee Surg Sports Traumatol Arthrosc

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Purpose Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield signiicantly tilted joint line obliquity (JLO). This study aimed to evaluate the efectiveness of DLO in achieving accurate correction without compromising JLO, using patient-speciic cutting guides (PSCGs), in cases of bifocal valgus maligned knees. Methods A single-centre, retrospective analysis of prospectively collected data for a total of 26 patients, who underwent DLO by PSCGs for valgus malaligned knees, between 2015 and 2020. Post-operative alignment was evaluated and the delta for diferent lower limb0.05, not statistically signiicant (ns)). All KOOS subs alignment parameters was calculated; the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), and lateral distal femoral angle (ΔLDFA). At the two-year follow-up, changes in the KOOS sub-scores, UCLA scores, lower limb discrepancy (LLD), and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. The Mann-Whitney U test with a 95% conidence interval (95% CI) was used to evaluate the diferences between two variables; one-way ANOVA between more than two variables and the paired Student's t-test was used to estimate the evolution of functional outcomes. ResultsThe postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p > 0.05, not statistically signiicant (ns)). All KOOS subscore's mean values were improved to an extent two-fold superior to the reported minimal clinically important diference (MCID) (all with p < 0.0001). There was a signiicant increase in the UCLA score at the inal follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1 months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3 ± 2 cm) to postoperative measures (LLD = 0.3 ± 0.4 cm), ns. Complications were 2 femoral hinge fractures, 2 deep vein thromboses, 1 delayed tibial healing, and 1 hardware removal for hamstring irritation syndrome. ConclusionDLO is efective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO. Level of evidence III Keywords Double-level osteotomy • Closed-wedge osteotomy • Patient-speciic cutting guides • Joint line orientation * Charles Pioger

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“…Measuring these angles together helps us determine the necessary surgical approach (total knee arthroplasty, distal femoral osteotomy, high tibial osteotomy, etc.) [3] needed to correct the malignments by immediately identifying whether the patient’s varus or valgus deformity is derived from femur or tibia [17, 21, 25]. In addition, by monitoring changes in measured angles, the rate of malalignment progression can be determined and the prognosis inferred [7].…”

Section: Discussionmentioning

confidence: 99%

Deep learning-based landmark recognition and angle measurement of full-leg plain radiographs can be adopted to assess lower extremity alignment

Hwang

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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PurposeEvaluating lower extremity alignment using full‐leg plain radiographs is an essential step in diagnosis and treatment of patients with knee osteoarthritis. The study objective was to present a deep learning‐based anatomical landmark recognition and angle measurement model, using full‐leg radiographs, and validate its performance. MethodsA total of 11,212 full‐leg plain radiographs were used to create the model. To train the data, 15 anatomical landmarks were marked by two orthopaedic surgeons. Mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and hip‐knee‐ankle angle (HKAA) were then measured. For inter‐observer reliability, the inter‐observer intraclass correlation coefficient (ICC) was evaluated by comparing measurements from the model, surgeons, and students, to ground truth measurements annotated by an orthopaedic specialist with 14 years of experience. To evaluate test–retest reliability, all measurements were made twice by each measurer. Intra‐observer ICCs were then derived. Performance evaluation metrics used in previous studies were also derived for direct comparison of the model’s performance. ResultsInter‐observer ICCs for all angles of the model were 0.98 or higher (p < 0.001). Intra‐observer ICCs for all angles were 1.00, which was higher than that of the orthopaedic specialist (0.97–1.00). Measurements made by the model showed no significant systemic variation. Except for JLCA, angles were precisely measured with absolute error averages under 0.52 degrees and proportion of outliers under 4.26%. ConclusionsThe deep learning model is capable of evaluating lower extremity alignment with performance as accurate as an orthopaedic specialist with 14 years of experience. Level of evidenceIII, retrospective cohort study.

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Consistent indications, targets and techniques for double-level osteotomy of the knee: a systematic review

Cited by 16 publications

References 21 publications

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity

Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees

Deep learning-based landmark recognition and angle measurement of full-leg plain radiographs can be adopted to assess lower extremity alignment

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