Double-level osteotomy for severe varus osteoarthritic knees can prevent change in leg length and restore physiological joint geometry

Iseki, Tomoya; Onishi, Shintaro; Kanto, Makoto; Kanto, Ryo; Kambara, Shunichiro; Yoshiya, Shinichi; Tachibana, Tetsuya; Nakayama, Hiroshi

doi:10.1016/j.knee.2021.04.011

Cited by 18 publications

(25 citation statements)

References 22 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: 73%

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: 73%

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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“…Based on the short follow-up period of the present study, the mid- and long-term quality of life remains unclear and needs further investigation. In addition to improvement in quality of life following DLO, previous studies reported good clinical midterm outcomes [ 5 , 22 , 28 ]. DLO can restore lower limb alignment and joint angles by preventing changes in leg length in varus malalignment.…”

Section: Discussionmentioning

confidence: 99%

Work intensity and quality of life can be restored following double-level osteotomy in varus knee osteoarthritis

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et al. 2022

Knee Surg Sports Traumatol Arthrosc

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Purpose The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term. Methods Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: −11.0 ± 3.0° (−6.0 to −17.0), age: 49.1 ± 9.5 (31–65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5–43) months). Results The duration that the patients were unable to work was 12.2 ± 4.4 (6–20) weeks. The PCS improved from 32.1 ± 11.3 (14.5–53.3) preoperatively to 54.6 ± 8.5 (25.2–63.7) (p < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1–67.7) to 57.2 ± 3.1 (47.3–61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population (p < 0.001), whereas the preoperative MCS was similar between the two groups (n.s.). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0–5.0) to 4.0 (2.0–7.0) (p < 0.001). Conclusion Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO. Level of evidence Study type: therapeutic, IV.

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“…It is indicated in varus knee with reduced mechanical medial proximal tibia angle (mMPTA) [ 3 ]. Overcorrection producing a mMPTA out of the normal range (85–90°) is not recommended because this would lead to unphysiological joint-line orientation [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

Iatrogenic ischiofemoral impingement due to high tibial osteotomy with overvalgization: a case report

et al. 2022

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Background Open wedge high tibial osteotomy is a standard procedure for frontal realignment. It is indicated in varus knee with reduced mechanical medial proximal tibia angle. Overcorrection producing a mechanical medial proximal tibia angle out of the normal range (85–90°) is not recommended because this would lead to unphysiological joint-line orientation. Osteotomies around the knee also influence the adjacent ankle and hip joints. For the hip, it is known that frontal alignment of the leg influences the ischiofemoral space. A decreased ischiofemoral space can lead to painful impingement between the ischial bone and the lesser trochanter. Case presentation A 53-year-old German woman presented with severe ischiofemoral impingement symptoms and valgus malalignment of the left leg after open wedge high tibial osteotomy, which was indicated and performed by an orthopedic surgeon with intention to treat medial knee pain due to degenerative arthritis of the medial compartment years after medial meniscectomy. The mechanical medial proximal tibia angle was 100.5°. We performed closed wedge high tibial osteotomy producing a mechanical medial proximal tibia angle of 90.0° and normal joint-line orientation. The hip pain was gone immediately after the surgery, and the patient had no signs of ischiofemoral impingement or hip pain at last follow-up 12 months after closed wedge high tibial osteotomy. Conclusions Frontal realignment osteotomy around the knee can create problems at adjacent joints. Overvalgization of the proximal tibia made the patient compensate by hyperadduction of the hip to enable full foot sole contact with the floor. Hyperadduction of the hip decreased the ischiofemoral space, leading to severe impingement. Therefore, meticulous planning of osteotomies is important not to produce unphysiological situations or unwanted negative effects at the level of an adjacent joint.

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Double-level osteotomy for severe varus osteoarthritic knees can prevent change in leg length and restore physiological joint geometry

Cited by 18 publications

References 22 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

Work intensity and quality of life can be restored following double-level osteotomy in varus knee osteoarthritis

Iatrogenic ischiofemoral impingement due to high tibial osteotomy with overvalgization: a case report

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