Knee joint distraction compared with high tibial osteotomy: a randomized controlled trial

Abstract

PurposeBoth, knee joint distraction as a relatively new approach and valgus-producing opening-wedge high tibial osteotomy (HTO), are knee-preserving treatments for knee osteoarthritis (OA). The efficacy of knee joint distraction compared to HTO has not been reported.MethodsSixty-nine patients with medial knee joint OA with a varus axis deviation of <10° were randomized to either knee joint distraction (n = 23) or HTO (n = 46). Questionnaires were assessed at baseline and 3, 6, and 12 months. Joint space width (JSW) as a surrogate measure for cartilage thickness was determined on standardized semi-flexed radiographs at baseline and 1-year follow-up.ResultsAll patient-reported outcome measures (PROMS) improved significantly over 1 year (at 1 year p < 0.02) in both groups. At 1 year, the HTO group showed slightly greater improvement in 4 of the 16 PROMS (p < 0.05). The minimum medial compartment JSW increased 0.8 ± 1.0 mm in the knee joint distraction group (p = 0.001) and 0.4 ± 0.5 mm in the HTO group (p < 0.001), with minimum JSW improvement in favour of knee joint distraction (p = 0.05). The lateral compartment showed a small increase in the knee joint distraction group and a small decrease in the HTO group, leading to a significant increase in mean JSW for knee joint distraction only (p < 0.02).ConclusionCartilaginous repair activity, as indicated by JSW, and clinical outcome improvement occurred with both, knee joint distraction and HTO. These findings suggest that knee joint distraction may be an alternative therapy for medial compartmental OA with a limited mechanical leg malalignment.Level of evidenceRandomized controlled trial, Level I.

Knee Joint Distraction as Treatment for Osteoarthritis Results in Clinical and Structural Benefit: A Systematic Review and Meta-Analysis of the Limited Number of Studies and Patients Available

“…Of these, 3 were excluded, since they reported on a subgroup from other included articles without reporting extra information on primary outcomes, leaving 11 articles included for analysis. [12][13][14][15][16][17][18][19][20][21][22] As multiple articles reported on different follow-up moments in the same patient cohorts, the overview of selected studies is separated per cohort of KJD-treated patients and control groups ( Table 1). 23 A total of 7 patient cohorts were treated with KJD, of which 2 in combination with another treatment: 1 cohort of 6 patients was treated with KJD and microfracture 13 and 1 cohort of 19 patients treated with KJD, microfracture, and debridement 15 that also had a control group of 42 patients treated with microfracture and debridement alone.…”

“…As blinding of patients and personnel was not possible in any study and blinding of outcome measures only for structural parameters, none of the included articles had a completely low risk of bias. Only the RCTs [20][21][22] had a low selection bias and only Jansen et al same research group. Last, Jansen et al 12,14 had a lot of unclear bias since they are conference abstracts and as such did not report all information required to judge.…”

<p>The role of joint distraction in the treatment of knee osteoarthritis: a systematic review and quantitative analysis</p>

“…Nine studies comprising of four RCTs, five prospective cohort studies, and one case series published between 2007 and 2019 were included in this systematic review (Figure 1) (Table 1). 14–19,24–26 The sample size of each study ranged from 6 to 138, giving rise to a total of 507 patients. The outcomes reported in four studies were based on follow-up of the same cohort of patients at 12, 24, 60, and 108 months 15,16,18.…”

“…One of the studies compared 6 weeks of continuous distraction with 8 weeks of intermittent distraction 17. There were two RCTs, one of which compared KJD with total knee arthroplasty (TKA), and the other which compared KJD with high tibial osteotomy (HTO) 24,25Table 1Study characteristicsStudyStudy designNumber of patientsAge (years)M:FStudy duration (months)Kellgren and Lawrence gradeDeie et al (2007)14Case series651.7±8.52:421Grade 3 (17%), Grade 4 (83%)Intema et al (2011)a,15Prospective study2048.0±7.011:912Grade 1 (15%), Grade 2 (20%), Grade 3 (55%), Grade 4 (10%)Wiegant et al (2013)a,16Prospective study2048.0±7.011:924Grade 1 (15%), Grade 2 (20%), Grade 3 (55%), Grade 4 (10%)van der Woude et al (2016)17Prospective study406-weeks: 48.6±3.08-weeks: 54.6±1.76-weeks: 1:18-weeks: 11:9126-weeks: Grade 1 (10%), Grade 2 (15%), Grade 3 (45%), Grade 4 (30%)8-weeks: Grade 1 (15%), Grade 2 (20%), Grade 3 (55%), Grade 4 (10%)van der Woude et al (2016)b,24Randomized controlled trial67Knee joint distraction: 51.2±1.1High tibial osteotomy: 49.4±1.0Knee joint distraction: 8:3High tibial osteotomy: 27:1812Knee joint distraction: Grade 1 (27%), Grade 2 (18%), Grade 3 (50%), Grade 4 (5%)High tibial osteotomy: Grade 0 (2%), Grade 1 (11%), Grade 2 (27%), Grade 3 (51%), Grade 4 (9%)van der Woude et al (2017)a,18Prospective study2048.0±7.011:960Grade 1 (15%), Grade 2 (20%), Grade 3 (55%), Grade 4 (10%)van der Woude et al (2017)b,25…”

“…The outcomes following KJD and HTO were compared 69 patients in another RCT 24,26. In this study, the WOMAC index increased by 22 points (41%) from a baseline of 54 points in the KJD group and 38 points (73%) from a baseline of 52 points in the HTO group after 1 year, both of which were statistically significant.…”