|Year : 2015 | Volume
| Issue : 2 | Page : 87-91
Evidence-based medicine in high tibial osteotomy for knee osteoarthritis
Ahmed Mohamed Hassanin, El-Husseiny Mustafa El-Husseiny, Mohamed Gouda Montaser, Sayed Mahmoud Baioumy
Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||13-Jun-2015|
|Date of Acceptance||15-Jun-2015|
|Date of Web Publication||14-Apr-2016|
Ahmed Mohamed Hassanin
BB.Ch, 63 Atlas Qoda, 8 Distinct, 11762, Nasr city, Cairo
Source of Support: None, Conflict of Interest: None
Knee osteoarthritis is the most common joint disorder, and symptomatic disease occurs in 10% of men and 13% of women older than 60 years. Patients with osteoarthritis of the medial compartment often have varus alignment, and the mechanical axis and load-bearing axis pass through the medial compartment. The medial compartment is almost 10 times more frequently involved than that of the lateral compartment. Moreover, varus but not valgus alignment increases the risk for incident tibiofemoral osteoarthritis. An osteotomy is a surgical procedure, which implies that the bone is cut. A correction osteotomy at the knee is used to realign the leg and to transfer the weight-bearing axis from the pathological compartment to the healthy compartment. Patients with osteoarthritis of the medial compartment and varus alignment can be treated with a valgus osteotomy. Several correction osteotomy techniques are available for unicompartmental knee osteoarthritis, such as the closing wedge technique with removal of a wedge of bone, the opening-wedge technique with creation of a wedge, a combined (opening and closing wedge) technique, and techniques that are performed without creating a wedge in the bone, including dome osteotomy and hemicallotasis osteotomy with an external fixator. Unloading will result in slowing down of the osteoarthritis process. In retrospective studies, this procedure resulted in pain relief, improved function, and postponement of knee arthroplasty for 7-20 years, depending on participant selection, stage of osteoarthritis, and achievement and maintenance of adequate operative correction.
Keywords: High tibial, knee osteoarthritis, osteotomy
|How to cite this article:|
Hassanin AM, El-Husseiny EHM, Montaser MG, Baioumy SM. Evidence-based medicine in high tibial osteotomy for knee osteoarthritis. Benha Med J 2015;32:87-91
|How to cite this URL:|
Hassanin AM, El-Husseiny EHM, Montaser MG, Baioumy SM. Evidence-based medicine in high tibial osteotomy for knee osteoarthritis. Benha Med J [serial online] 2015 [cited 2018 Jan 23];32:87-91. Available from: http://www.bmfj.eg.net/text.asp?2015/32/2/87/180319
| Introduction|| |
Knee osteoarthritis (OA) causes considerable pain and immobility ,. High tibial osteotomy (HTO) for the treatment of OA of the knee gained acceptance in the 1960s . HTO alters the alignment of the knee to reduce the load on the medial compartment and has been reported to be successful in relieving pain and improving function ,. Various techniques such as closing wedge, opening wedge, and dome osteotomy are available ,. Successful outcome requires good selection of patients and achievement and maintenance of sufficient correction of alignment ,. Loss of correction correlates with the type of fixation of the osteotomy site, grade of correction, and time to union ,.
In a randomized controlled trial (RCT), 77 participants were allocated to the normal correction group (n = 40) or the 5° overcorrection group (n = 37). The closing-wedge high tibial osteotomy (CW-HTO) technique was the same in both groups, but the inclusion criterion was varus alignment. The study included 32 men and 45 women. The mean age of participants was 61 years. All participants had a follow-up of 1 year .
In a RCT conducted on 32 participants, 17 were assigned to cylinder plaster cast and 14 to hinged cast brace after HTO. Because of a complication, one participant in the brace group was excluded from the analysis. Individuals with stages I to III medial gonarthrosis were included in the study. Follow-up period was 1 year .
A double-blind study was conducted on 40 participants. The participants were randomly assigned to the intervention group postoperatively (long plaster cast with an electromagnetic field stimulation; 20 participants), or the control group (a long plaster cast with a dummy stimulator; 20 participants). The study included nine men and 31 women. The mean age of participants was 62 years. Follow-up period was 60 days .
In a RCT conducted on 59 participants, HTO (n = 23) was compared with unicompartmental knee arthroplasty (n = 36). Individuals with medial OA grade I to II and between 55 and 70 years of age were included in the study. This study included 28 men and 31 women. The mean age of participants was 64 years. The mean BMI was 28.5. The mean degree of varus was 9°. Follow-up period was 5 years .
In a RCT conducted on 79 participants, a total of 45 participants were treated with osteotomy together with arthroscopic abrasion arthroplasty, and 34 participants were treated with osteotomy alone. The inclusion criterion was medial compartment OA. The study included nine men and 70 women. The mean age of participants was 64 years. The mean degree of varus was 5°. Follow-up was for a period of 4.8 years in the osteotomy together with abrasion group and for a period of 3.5 years in the osteotomy group .
In a comparative study of two techniques, the hemicallotasis opening-wedge osteotomy was performed on 24 participants and the CW-HTO was performed on 22 participants. The inclusion criteria were medial knee OA and younger, active patients. The study included 32 men and 14 women. The mean age of participants was 55 years. The mean degree of varus was 9°. Follow-up period was 2 years .
In another RCT, the inclusion criterion was medial gonarthrosis grade I to III. A total of 33 participants (22 men and 11 women) were studied. Hemicallotasis opening-wedge osteotomy was performed on 18 participants/19 knees, and HTO was performed on 15 participants with a baseline grade I to III. The mean age of participants was 54 years, and the mean degree of varus knee was 9°. Follow-up period was 1 year .
A RCT was conducted on 65 participants to study the side effects of HTO - that is, the incidence of thrombosis in HTO with (n = 37) and without (n = 28) the use of a tourniquet. A dimer test and phlebography were used to confirm the diagnosis. The inclusion criterion was varus OA. The study included 30 men and 35 women. The mean age of participants was 61 years. Follow-up period was 9 weeks .
In a RCT including 46 participants, hemicallotasis opening-wedge osteotomy was performed on 23 participants and dome osteotomy was performed on 23 participants. The inclusion criterion was medial OA. This study included nine men and 37 women. The mean age of participants was 63 years. The mean degree of varus. Follow-up period was 1 year .
A RCT conducted on 60 participants compared HTO (n = 32) with unicompartmental knee arthroplasty (n = 28). The inclusion criteria were medial unicompartmental OA, varus less than 10°, flexion contracture less than 15°, age more than 60 years, and ligament instability less than grade II. This study included 25 men and 35 women. The mean age of participants was 67 years. The mean degree of varus was 9°. Follow-up period was 7.5 years. The funding source was not reported .
A comparative study of two techniques was carried out: osteotomy with the Ilizarov apparatus and the Coventry-type closing-wedge osteotomy. The inclusion criteria were varus alignment and medial compartment OA. The study included 20 men and 10 women. The mean age of participants was 52, and the BMI was 32.8. Follow-up was for a period of 25.4 months in the Ilizarov group and for period of 30.9 months in the Coventry group .
In a RCT, two techniques were evaluated: the opening-wedge HTO and the CW-HTO. Criteria for inclusion were OA of the medial compartment with medial pain and varus malalignment of the mechanical axis measured on long-standing radiographs. Outcome measures were factors that may cause difficulties in conversion to total knee arthroplasty and were scored as side effects. A total of 51 participants (33 men and 18 women) were randomly assigned to either opening-wedge HTO (n = 26) or CW-HTO (n = 24). The mean age of participants was 50. The mean degree of varus was 7°. Follow-up period was 1 year .
Another RCT compared opening-wedge HTO with CW-HTO. Criteria for inclusion were OA of the medial compartment with medial pain and varus malalignment of the mechanical axis measured on long-standing radiographs. A total of 92 participants (59 men and 33 women) were randomly assigned to either opening-wedge HTO (n = 45) or CW-HTO (n = 47). The mean age of participants was 50. The mean degree of varus was 6°. Outcome measures were accuracy of the operative correction, pain severity, knee function, and walking distance. Follow-up was for a period of 1 year .
In a RCT comparing the strength of different types of pin fixation in hemicallotasis opening-wedge osteotomy, a total of 50 participants (37 men and 13 women) with a mean age of 51 years were included. Participants were subjected to fixation with either standard pins or X-Caliber pins, both of which are hydroxyapatite coated. X-Caliber pins are self-drilling and are less conical compared with standard pins. Inclusion criteria was medial OA and a varus alignment (n = 42), and those with lateral compartment and a valgus alignment (n = 8) were included as well. Follow-up period was for less than 6 months .
A comparative study was conducted on 42 participants (27 men and 15 women); 23 participants were subjected to the opening-wedge technique and 19 were subjected to CW-HTO. Inclusion criteria were OA of the medial compartment and a varus deformity less than 12°. No participant was lost to follow-up .
A RCT compared the CW-HTO with the combined osteotomy, which is a combination of an opening-wedge high tibial osteotomy and a CW-HTO. Criteria for inclusion were pain on the medial side of the knee and varus malalignment. A total of 91 participants (52 men and 49 women) were randomly assigned (CW-HTO, n = 46; combined osteotomy, n = 45). The mean age of participants was 52 years. Follow-up period was 1 year; three participants were excluded from the analysis, and six were lost to follow-up .
A RCT compared the opening-wedge HTO with the CW-HTO. Criteria for inclusion were active participants, between 18 and 70 years of age, and presence of varus alignment. A total of 50 participants (30 men and 20 women) (opening-wedge HTO, n = 25; CW-HTO, n = 25) were included in the study. The mean age of participants was 49 years. The mean degree of varus was 4.1°. Follow-up period was 1 year .
A RCT evaluated the effect of a single infusion of bisphosphonate (zoledronic acid) on fracture healing at 4 weeks after hemicallotasis osteotomy (HCO) and compared it with that of a placebo (an infusion of sodium chloride). Individuals between 35 and 65 years of age and OA or deformity of the knee requiring an HCO were included in the study. A total of 46 participants (36 men) with a mean age of 49 years were included in the study. Of them, 25 participants were included in the zoledronic group and 21 in the sodium chloride control group. The mean preoperative varus angle was 7°. A total of 41 participants had medial compartment OA, and five had lateral compartment OA. Follow-up duration was 1.5 years .
In a RCT including 24 participants, 13 participants were treated with opening-wedge osteotomy with navigation and 11 were treated with opening-wedge osteotomy without navigation. Inclusion criteria were age less than 65 years, Kellgren-Lawrence symptomatic grade III or lower, isolated medial compartment knee OA, failed conservative treatment, absence of additional cartilage treatment, and concomitant ligamentous lesions. The study included 14 men and 10 women. The mean age of participants was 55 years. The mean degree of varus was 6.8°. Follow-up duration was 39 months .
Another RCT compared opening-wedge HTO with and without autologous bone iliac bone graft. Inclusion criteria were varus alignment of the limb that could be corrected with a plate with at least a 12.5-mm spacer, associated with OA, and pain limited to the medial side that did not improve with conservative management. A total of 46 participants were included (43 men and three women): 23 in each group. The mean age of participants was 42 years, and BMI was 27.6. In 33 participants, knee instability was present in addition to varus OA. Follow-up was carried out for at least 1 year .
A RCT compared the removal torque of different types of pin fixation in hemicallotasis opening-wedge osteotomy. A total of 20 participants were included in the study. Participants were subjected to bisphosphonate-coated pin and hydroxyapatite-coated pin fixation. Patients were treated with HCO technique for medial or lateral OA. Follow-up period was 8-15 weeks .
| Outcomes|| |
Treatment failure rate, which generally implicates revision to total knee prosthesis, was not an objective in all nine trials comparing different HTO techniques. The relatively short maximum follow-up time of 2.5 years is the reason for lack of this important outcome. Pain was measured in four studies ,,,. In these studies, including 216 participants, another type of HTO was compared with the CW-HTO. On the basis of these four studies, we found no differences in pain between the two interventions. Function (knee score) was measured in four studies ,,,. All of these studies used different outcome measures. None reported a statistically significant difference between groups. Serious adverse events were reported in four studies ,,,. Deep venous thrombosis was reported in three studies ,,. Deep infection was reported in one study . Nonunion of an opening-wedge osteotomy was reported in one study .
Reoperation rate was evaluated as early hardware removal caused by pain and pin track infection due to the external fixator. Four studies including 224 participants scored this outcome. Compared with the CW-HTO group, the reoperation rate was significantly higher in another HTO technique group ,,. In particular, an opening-wedge HTO with plate and screws on the medial side of the tibia caused complaints ,. Pooling of study results (reoperation rate after HTO) for ,,, was possible, and this rate was significantly higher in participants undergoing another HTO technique compared with the closing wedge technique.
A RCT was conducted to compare the radiographic and clinical midterm results and survival rates between closing-wedge and opening-wedge osteotomies used to treat varus knee deformity. The results were examined preoperatively at 1 year and at 6 years postoperatively. The criteria for inclusion in the study were radiographic evidence of medial compartment knee OA less than grade III, medial joint pain, and varus malalignment .
An overall 84% of the patients did not require a total knee arthroplasty after HTO within a mean follow-up period of 6 years; this is in accordance with the results of other studies. Conversion rates ranging from 51 to 98% at 10 years after closing-wedge osteotomy have been reported . The rates for opening-wedge osteotomy ranged from 74 to 92%. Thus, both closing-wedge and opening-wedge osteotomies have good survival rates ,.
Opening-wedge osteotomy was associated with a higher complication rate. Morbidity caused by harvesting cancellous bone at the iliac crest to perform the bone-grafting accounted for nearly half of the early complications. Thus, a recent RCT concluded that autologous bone graft is unnecessary for wedges less than 12.5 mm. It is clear that avoidance of cancellous bone graft will decrease the complication rate of the opening-wedge procedure .
It has been reported that the Puddu plate is not strong enough to sustain perioperative correction . Therefore, the use of a rigid locking plate for both opening-wedge and closing-wedge osteotomies provides better stability . An implant removal rate of 50% has been reported in patients treated with an opening-wedge osteotomy and significantly higher implant removals have been reported in patients treated with opening-wedge osteotomy than in patients treated with closing-wedge osteotomy .
Achievement and maintenance of an adequate operative correction are required for a successful outcome .
| Conclusion|| |
HTO is a well-established procedure for the treatment of unicompartmental OA of the knee. Most reports have shown ∼80% satisfactory results 5 years after osteotomy. Varus or valgus deformities are fairly common and cause an abnormal distribution of the weight-bearing stresses within the joint. The most common deformity in patients with OA of the knee is a varus position, which causes stresses to be concentrated medially, accelerating degenerative changes in the medial part of the joint; if the deformity is one of valgus position, changes are accelerated in the lateral part. The biomechanical rationale for proximal tibial osteotomy in patients with unicompartmental OA of the knee is 'unloading' of the involved joint compartment by correcting the malalignment and redistributing the stresses on the knee joint. Many techniques have been described for valgus proximal tibial osteotomy. Four basic types are most commonly used: medial opening wedge, lateral closing wedge, dome, and medial opening hemicallotasis.
The indications for proximal tibial osteotomy were as follows: pain and disability resulting from OA that significantly interfere with high-demand employment or recreation; evidence on weight-bearing radiographs of degenerative arthritis that is confined to one compartment with a corresponding varus or valgus deformity; the ability of the patient to use crutches after the operation and the possession of sufficient muscle strength and motivation to carry out a rehabilitation program; and good vascular status without serious arterial insufficiency or large varicosities. Contraindications to a proximal tibial osteotomy are narrowing of lateral compartment cartilage space, lateral tibial subluxation of more than 1 cm, medial compartment tibial bone loss of more than 2 or 3 mm, flexion contracture of more than 15°, knee flexion of less than 90°, more than 20° of correction needed, and rheumatoid arthritis.
The author express his thanks and deepest gratitude to Professor E.M. El-Husseiny, Professors of Orthopedic Surgery, Benha University, for giving him the privilege to work under their supervision and for giving him their valuable advices. Many thanks to Professor M.G. Montaser and Dr E.M. Baioumy for their great support and encouragement throughout this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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