|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2023 | Volume
: 6
| Issue : 2 | Page : 179-182 |
|
A prospective and retrospective study of the outcome of high tibial osteotomy in osteoarthritis of the knee with varus deformity
Prashant Kumar1, Swarnava Dattagupta2, Kunal Mondal1, Dipak Kumar Jha2, Prasanta Kumar Pujari2
1 Department of Orthopaedics, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karni Memorial Hospital, Kolkata, West Bengal, India
2 Department of Orthopaedics, Ramakrishna Mission Seva Pratishthan Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| Date of Submission | 12-Jan-2023 |
| Date of Decision | 08-Feb-2023 |
| Date of Acceptance | 15-Feb-2023 |
| Date of Web Publication | 3-May-2023 |
Correspondence Address:
Kunal Mondal
Subuddhipur, Beltala, Green Park, P.O- Baruipur, Kolkata - 700 144, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jodp.jodp_4_23
Introduction: Knee osteoarthritis (OA) degenerative condition causes progressive wear in the articular cartilage and rises pressure over the medial compartment of the knee joint which will end up as a varus deformity. High tibial osteotomy (HOT) is one of the surgical managements in treatment of OA. The goal of the treatment is to relieve medial compartment knee pain and slowdown the arthritic progression. Materials and Methods: This prospective observational study was done on 20 patients of all ages and both genders having medial compartment OA with varus deformity of all grades over 24-month duration. Functional evaluation was done by the Knee Society Score, functional score, and the Lysholm score, whereas radiological evaluation was done by calculating various angles in orthoroentgenogram. Results: All the function scores hold high statistical significance. Changes in hip knee axis (HKA), medial proximal tibial angle, and tibial joint angle were statistically significant. All osteotomy sites consolidated in 6 months with not a single case of nonunion. Conclusion: HOT is an effective technique and has excellent functional and radiological outcomes with minimal complications in the management of OA. Appropriate patient selection, proper osteotomy type, and precise surgical techniques are essential for the success of HOT.
Keywords: High tibial osteotomy, KSS, Lysholm, TomoFix
How to cite this article:
Kumar P, Dattagupta S, Mondal K, Jha DK, Pujari PK. A prospective and retrospective study of the outcome of high tibial osteotomy in osteoarthritis of the knee with varus deformity. J Orthop Dis Traumatol 2023;6:179-82 |
How to cite this URL:
Kumar P, Dattagupta S, Mondal K, Jha DK, Pujari PK. A prospective and retrospective study of the outcome of high tibial osteotomy in osteoarthritis of the knee with varus deformity. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:179-82. Available from: https://jodt.org/text.asp?2023/6/2/179/375546 |
| Introduction | |  |
The current prevalence rate of knee osteoarthritis (OA) in the Indian population is nearly 41.1%.[1] This degenerative condition causes progressive wear in the articular cartilage and rises pressure over the medial compartment of the knee joint which will end up as a varus deformity. High tibial osteotomy (HOT) is one of the surgical managements in treatment of OA. It was first introduced by Jackson in 1958 and popularized by Coventry in 1973.[2] Many techniques are used to do HOT such as medial wedge opening osteotomy, lateral close wedge osteotomy, dome osteotomy, and chevron osteotomy.[3] The goal of the treatment is to relieve medial compartment knee pain and slowdown the arthritic progression. The surgery is described as a biomechanical intervention designed to alter dynamic knee joint loading, with the aim of improving patient function and decreasing pain. This is achieved by unloading of the medial compartment with a slight overcorrection 3°–5° valgus of the mechanical axis.
| Materials and Methods | | |
The study was institution based, conducted at a tertiary health-care center, Vivekananda Institute of Medical Sciences, Kolkata, with osteoarthritis of knee or follow up, serving people of Eastern India as a prospective observational study of 24 months duration. This prospective observational study was done on 20 patients of all ages and both genders having medial compartment OA with varus deformity of all grades. We have excluded bi/tricompartmental OA and patients having fixed flexion deformity and ligamentous laxity of the knee. All patients were assessed clinically, functionally, and radiologically [Figure 1]a and [Figure 1]b. Functional evaluation was done by the Knee Society Score, functional score, and Lysholm score, whereas radiological evaluation was done by calculating various angles in orthoroentgenogram.[2],[3],[4] Estimation of deformity correction was done preoperatively by Fujisawa point, which is at 62.5% of tibial plateau width when measured from medial side.[5] The alpha angle, which was our correction angle, is created by intersection of corrected mechanical axis of femur and tibia passing through Fujisawa point. A biplanar osteotomy [Figure 2]a, in both axial and frontal planes, was performed using an oscillating saw with special precautions not to damage the posterior neurovascular bundle.[6],[7] A triangle was created below the tibial tuberosity with apex directed toward the fibular head with same alpha angle on a true-size radiograph of the knee [Figure 2]b. Wedge opening was calculated by measuring base of this triangle. Osteotomy site was opened by keeping lateral cortex as a hinge with help of laminar spreader and fixed by TomoFix as an internal fixation [Figure 2]c. Full weight-bearing was encouraged from day 1 along with all physiotherapy exercises. Stitches were removed on day 14. Postoperative clinicoradiological evaluation is done on every 2-month interval up to 6 months [Figure 3]a and [Figure 3]b. | Figure 1: (a) Preoperative clinical evaluation. (b) Preoperative radiographic evaluation
Click here to view |
 | Figure 2: (a) Biplanar medial open-wedge osteotomy. (b) Radiographic evaluation intraoperatively. (c) TomoFix plate
Click here to view |
 | Figure 3: (a) Postoperative clinical evaluation. (b) Postoperative radiographic evaluation
Click here to view |
| Results | | |
For statistical analysis, data were entered into a Microsoft Excel spreadsheet and then analyzed by Statistical Package for the Social Sciences (SPSS) (version 27.0; SPSS Inc, Chicago, IL, USA) and Graphpad Prism software, Graphstat Technology, India. Data had been summarized as the mean and standard deviation for numerical variables and count and percentages for categorical variables. The two-sample t-tests for a difference in mean involved independent samples or unpaired samples. A P ≤ 0.05 was considered statistically significant. Among all the patients, 60% were in the sixth and 20% in the fifth decade with female predominance of 63%. Sixty-seven percent of the study population were overweight and the remaining were of normal weight. Functional evaluation was done by comparing pre- and postoperative scores. The mean Knee Society Score increased from 54.66 to 82.06, the mean functional score increased from 51.53 to 84.26, and the mean Lysholm score increased from 56.86 to 83.66 after 6 months of operation [Table 1]. All the scores hold high statistical significance (P < 0.001). In radiological evaluation HKA, medial proximal tibial angle (MPTA), lateral distal femur angle (LDFA), and femoral angle increased from 170 to 177, 84–88, 87–88 and 2.6–2.9, respectively, whereas tibial angle, weight bearing line angle (WBLA), joint angle was reduced from 8.8– to 4.4, 3.4–2.7 and 6–4.3, respectively [Table 2]. Out of these, changes in HKA, MPTA, and tibial joint angle were statistically significant. All osteotomy sites consolidated in 6 months with not a single case of nonunion. Among all patients, two had break of lateral cortex wall and two had pin-tract infection. Three patients lost their correction of deformity and one had premature consolidation of osteotomy.
| Discussion | | |
HTO is genuinely a very good option in isolated medial compartment OA of the knee. It works by unloading the medial compartment and shifts the weight-bearing axis to the lateral compartment. Obesity has significant correlation with OA. Fixation with TomoFix is more acceptable to patients and corrects deformity immediately but the amount of correction is limited. After HTO, the knee became clinically more stable without any major limb length discrepancy. HTO also delays the need of total knee replacement (TKR) and is an economically reasonable option comparative to TKR. HTO for the treatment of OA was popularized by Coventry. In our study of 15 cases done in 1 year showed impressive results. The study group had average age of 51.4 years, which was similar to the study by Brouwer et al.[8] on 92 patients with mean age of 50.2 years. There was female predominance of 63.4% and male of 36.6%, whereas in the study of Spahn et al.,[9] male predominance was seen with 56.4% and female 44.6%. There is significant correlation of OA with obesity as 66.67% of patients were overweight (body mass index [BMI] - 25–29.9). Bonasia et al.[10] studying 99 OWHTOs, concluded that in patients with a BMI >30 the risk of unsuccessful surgery is 10 times higher, and Akizuki et al.[11],[12],[13] stated that a BMI >27.5 is associated with early failure of the osteotomy. Three scoring systems (KSS1, KSS2, Lysholm) were used to evaluate the functional outcome and all three results were highly significant. The mean score of the Knee Society Score was increased from 54 to 82 and the functional score from 51 to 84 after 6 months of operation. We had some cases of extreme HKA values due to which mean correction was less. In our study, the average correction in MPTA was 4.5° which was comparable to the study of Yoo et al.[14] which was 4.8. This angle was most affected and important in HTO. 0.4° of average correction in LDFA was noted which was comparable to 0.6 in the study of Bull and Amis.[15] The change of LDFA was not so much significant in HTO because the bony cuts were done only in the tibia. All osteotomy healed radiologically uneventful in 2–3 months and consolidated after 6 months. Neither bone grafts nor fibular osteotomy were done in any of these cases.
| Conclusion | | |
HOT is an effective technique and has excellent functional and radiological outcomes with minimal complications in the management of OA. Appropriate patient selection, proper osteotomy type, and precise surgical techniques are essential for the success of HOT.
Limitations
First, sample size was small comprising 20 patients despite the large number of patients presenting to our outpatient department. Many patients opted for a medical management and refused surgery. Second, due to the limited study period, the impact of the surgery on the biomechanics of the ankle or hip could not be assessed. A longer follow-up period will be required to assess the long-term effect of this surgery on OA of the knee. And finally, as this was not a multicentric and multiobserver study, biasness may be there for the chosen surgical methods.
Acknowledgment
We would like to acknowledge all the faculty members and junior residents who helped relentlessly in conducting our research work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Singh AK, Kalaivani M, Krishnan A, Aggarwal PK, Gupta SK. Prevalence of osteoarthritis of knee among elderly persons in urban slums using American college of rheumatology (ACR) criteria. J Clin Diagn Res 2014;8:C09-11.  |
| 2. | Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G. The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch Orthop Trauma Surg 2005;125:638-43. |
| 3. | Lee DC, Byun SJ. High tibial osteotomy. Knee Surg Relat Res 2012;24:61-9. |
| 4. | Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150-4. |
| 5. | Cooke TD, Sled EA, Scudamore RA. Frontal plane knee alignment: A call for standardized measurement. J Rheumatol 2007;34:1796-801. |
| 6. | Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am 1979;10:585-608. |
| 7. | Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003;11:132-8. |
| 8. | Brouwer RW, Huizinga MR, Duivenvoorden T, van Raaij TM, Verhagen AP, Bierma-Zeinstra SM, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev 2014;2014:CD004019. |
| 9. | Spahn G, Kirschbaum S, Kahl E. Factors that influence high tibial osteotomy results in patients with medial gonarthritis: A score to predict the results. Osteoarthritis Cartilage 2006;14:190-5. |
| 10. | Bonasia DE, Dettoni F, Sito G, Blonna D, Marmotti A, Bruzzone M, et al. Medial opening wedge high tibial osteotomy for medial compartment overload/arthritis in the varus knee: Prognostic factors. Am J Sports Med 2014;42:690-8. |
| 11. | Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H. The long-term outcome of high tibial osteotomy: A ten- to 20-year follow-up. J Bone Joint Surg Br 2008;90:592-6. |
| 12. | Ganeshsankar DK, Praneshkumar DM, Radhakrishnan DS. Functional outcome of high tibial osteotomy among patients with osteoarthritis. Int J Orthop Sci 2017;3:72-4. |
| 13. | Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: A meta-analysis of clinical and radiological outcomes. Knee 2011;18:361-8. |
| 14. | Yoo MJ, Shin YE. Open wedge high tibial osteotomy and combined arthroscopic surgery in severe medial osteoarthritis and varus malalignment: Minimum 5-year results. Knee Surg Relat Res 2016;28:270-6. |
| 15. | Bull AM, Amis AA. Radiographic analysis of lower limb axial alignments. Vol. 2205. Knie: Orthopädie und Orthopädische Chirurgie; 2005. p. 36-52. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
|
Search Pubmed for