Functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of knee joint

Gangdayal Sharma; Vidya Sagar; Raman Kumar; Akhilesh Kumar Sharma; Manish Kumar; Satendra Kumar Sinha

doi:10.4103/jodp.jodp_55_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 6 | Issue : 2 | Page : 190-193

Functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of knee joint

Gangdayal Sharma¹, Vidya Sagar¹, Raman Kumar¹, Akhilesh Kumar Sharma¹, Manish Kumar¹, Satendra Kumar Sinha²
¹ Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
² Department of Orthopaedics, Nalanda Medical College and Hospital, Patna, Bihar, India

Date of Submission	07-Jul-2022
Date of Decision	15-Feb-2023
Date of Acceptance	24-Feb-2023
Date of Web Publication	3-May-2023

Correspondence Address:
Vidya Sagar
Room No. 325, Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_55_22

Abstract

Introduction: Due to the shifting of weight more on the medial side of the knee, more cartilage destruction occurs medially, and subsequently, varus deformity occurs. A corrective osteotomy to alter the weight-bearing axis will be ideal to slow down the degenerative process. The success of an osteotomy around the knee depends on the biomechanics of the lower extremity, load distribution in the knee, and also on the mechanical properties of the implants used for osteotomy fixation. The aim of the study is to know the functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of the knee joint. Materials and Methods: This prospective study was done at the tertiary center of Bihar between May 2016 and September 2018. Bilateral weight-bearing anteroposterior view in full extension and standing scannogram was taken preoperatively. Patients were operated and evaluated at 3, 6, and 12 months by the Japanese Orthopaedic association knee score and Japanese Orthopaedic association system. Results: Medial opening-wedge osteotomy was performed in 26 knees of 24 in which there were 10 male and 14 female patients. Of the 26 knees operated, 16 were of the left side and 10 of the right side. Of the 26 knees operated, 6 (23%) had excellent outcome, 12 (47%) had good outcome, 4 (15%) had fair, and 4 (15%) had poor outcome. The poor result of three patients was correlated to superficial infection and the other patients due to inadequate correction. Five patients had superficial infection and one patient had hardware prominence causing pain and two patients had under correction of varus. Conclusion: From this prospective study, it can be concluded that medial open-wedge high tibial osteotomy is a useful option in medial compartmental osteoarthritis of the knee joint and relieves pain and improves functional outcomes in patients.

Keywords: High tibial osteotomy, open wedge, osteoarthritis of the knee

How to cite this article:
Sharma G, Sagar V, Kumar R, Sharma AK, Kumar M, Sinha SK. Functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of knee joint. J Orthop Dis Traumatol 2023;6:190-3

How to cite this URL:
Sharma G, Sagar V, Kumar R, Sharma AK, Kumar M, Sinha SK. Functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of knee joint. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:190-3. Available from: https://jodt.org/text.asp?2023/6/2/190/375549

Introduction

Due to the shifting of weight more on the medial side of the knee, more cartilage destruction occurs medially, and subsequently, varus deformity occurs. In these cases, a unicondylar knee replacement will not correct the alignment. There are many ways to correct alignment, which include a closing wedge osteotomy, opening-wedge osteotomy, dome osteotomy, progressive corrective osteotomy, and other modifications.^[1] A corrective osteotomy to alter the weight-bearing axis will be ideal to slow down the degenerative process.^[2],[3]

The osteotomy has been fixed using staples, plates, external fixators, Kirschner wires, plaster casts, and combinations.^[4],[5] The success of an osteotomy around the knee depends on the biomechanics of the lower extremity, load distribution in the knee and also on the mechanical properties of the implants used for osteotomy fixation.

Osteotomies around the knee have had a significant complication rate in the past, and many surgeons abandoned these procedures, although the favorable long-term results were well known. The main problems were the intraoperative choice of the correction angle and the risk of a postoperative loss of correction. After many years of closed-wedge osteotomy, open-wedge osteotomy has become popular. The aim of the study is to know the functional outcome of open-wedge high tibial osteotomy in medial compartmental osteoarthritis of the knee joint.

Materials and Methods

This prospective study was done at the tertiary center of Bihar between May 2016 and September 2018.

Inclusion criteria

Pain and disability resulting from osteoarthritis that interferes with high-demand employment or recreation
Evidence on weight-bearing radiographs of degenerative arthritis that is confined to one compartment with a corresponding varus 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 suitable rehabilitation program
Good vascular status without serious arterial insufficiency or large varicosities
Age <60 years.

Patient exclusion criteria

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 <90°
More than 20° of correction needed
Arthritis due to other causes (trauma, rheumatoid).

Bilateral weight-bearing anteroposterior (AP) view in full extension and standing scannogram was taken preoperatively.

Surgical technique

Under spinal anesthesia in a supine position, a lateral support and foot pad were attached to the operating table so that the leg can be easily positioned in 90°flexion and in full extension. The entire leg, including the iliac crest, was draped to allow harvesting of cancellous bone and intraoperative assessment of the leg axis. Preoperative systemic single-shot antibiotic prophylaxis was applied. The image intensifier for intraoperative fluoroscopy was placed on the opposite side.

The skin incision is made in the medial aspect of the proximal tibia with the knee in 90° flexion. The subcutaneous tissue dissected, and the pes tendons retracted. This exposes the medial collateral ligament, which was elevated from the tibia with a raspatorium. The long fibers of the superficial medial collateral ligament were then carefully detached until the posteromedial cortex of the proximal tibia was exposed. A Hohmann retractor was inserted behind the tibial ridge. At the anterior edge of the incision, the insertion of the patellar tendon at the tibial tuberosity and the medial border of the patellar ligament was exposed. The cranial border of the patellar tendon insertion must be clearly visualized so that the destination of the ascending osteotomy can be defined later in the procedure. The leg was now positioned in full extension, and the knee joint adjusted in exact AP view under fluoroscopy. The medial and lateral compartments were fully aligned in AP projection, and the leg was held exactly anterior. While this position was maintained, two 2 mm k-38 wires were drilled into the tibial head under image intensification to mark the direction of the osteotomy. Both wires should run parallel and aim toward the upper third of the proximal tibiofibular joint. When placing the two wires, it was important to ensure that there was sufficient space cranial to the saw cut for the three locking bolts in the C-arm and the first proximal screw in the longitudinal shaft of the plate. First, the posterior wire was inserted at the cranial border of the pes anserinus just in front of the posterior tibial ridge. The second wire was placed about 2 cm anterior and parallel to the first wire. Since both wires end at the lateral tibial cortex, the width of the tibial head was measured with reference to the two inserted wires. This was done by holding a third wire of the same length onto the cortex and measuring the excess length compared to the inserted wires. The tibial diameter was generally 5–10 mm smaller anteriorly than posteriorly. The measured values were noted. The depth of the saw cut was 10 mm less than the value measured against the wires in order to leave a lateral bone hinge.

The knee was positioned in 90° flexion again. Electrocautery was used to mark the course which was at an angle of 110° to the horizontal saw cut ending behind the patellar tendon insertion. This tuberosity segment was at least 15–20 mm wide. The horizontal osteotomy was performed with the oscillating saw below the two guide wires that act as guide rails. The anatomical structures dorsal of the posterior tibial surface tibia were protected by a Hohmann retractor. The entire sawing procedure was performed slowly, with very little pressure, and under constant cooling of the saw blade by irrigation. The osteotomy was opened slowly over a period of several minutes in order to prevent fracturing of the lateral cortex. Leaving the two guide wires in place while opening the gap leads to stiffening of the proximal segment and prevents fracture of the articular surface of the tibia. When the planned width was achieved, an arthrodesis spreader was placed in the posteromedial corner of the osteotomy. Due to the medial collateral ligament complex, the osteotomy tends to open more anteriorly during spreading, thus increasing the caudal inclination of the tibial plateau. After spreading of the osteotomy gap to the desired width, the leg was again placed in extension. In this position, the leg axis was evaluated clinically and radiologically. The plate fixator with its preassembled proximal drill sleeves and distance holders, was slid into a subcutaneous tunnel. The longitudinal arm was aligned with the tibial diaphysis avoiding anterior or posterior cortical overhang, the solid mid-portion of the fixator lies over the osteotomy, and the proximal locking screws lied subchondral near the joint line. The implant was temporarily stabilized by the insertion of a K-wire into the central drill sleeve. After predrilling with a 4.3 mm drill bit, the three proximal self-tapping locking screws of the C-arm are inserted one after the other. Next, a temporary lag screw was inserted into the first plate hole distal to the osteotomy. This compresses the lateral hinge by pulling the distal osteotomy segment toward the plate fixator. The distal locking screws are introduced through a stab incision over the distal distance holder, which was palpated easily through the skin. The lag screw distal to the osteotomy gap was replaced by a bicortical locking screw, and a locking head screw was inserted proximal of the gap. After locking all screws with the torque screwdriver, the arthrodesis spreader was removed. The long fibers of the medial collateral ligament were repositioned. If the gap width exceeds 13 mm, autogenous cancellous bone graft was harvested from the anterior iliac crest and is transplanted in the osteotomy gap. The soft tissue and especially the skin, was closed with extraordinary accuracy to ensure sufficient implant cover. Elastic bandaging of the leg was applied in the operation room.

Postoperative protocol

Postoperative protocol for the patients was as follows:

Immobilization in slab for 3 weeks
Knee brace was applied and the patient was encouraged to do partial weight bearing using crutches or walker till the end of 7 weeks
The patient was then allowed to weight bear completely
The patient was advised to refrain from high-demanding activities till signs of the complete bone union in wedge are evident. The patients were evaluated at 3, 6, and 12 months by the Japanese Orthopaedic association knee score and Japanese Orthopaedic association system.^[6]

Results

Medial opening-wedge osteotomy was performed in 26 knees of 24 patients with a minimum age of 40 and maximum age of 60 and the average age was 50 years. Of the 24 patients there were 10 male and 14 female patients. Of the 26 knees operated, 16 were of left side and 10 of right side [Figure 1]. The minimum BMI (Body Mass Index) was 21.5 and the maximum was 36.5. Two patients were severely obese, four patients were moderately obese, ten patients were overweight, and eight patients were of normal weight.

Figure 1: (a) Picture of the knee of the of the patient before surgery. (b) Long standing Xray image of the lower limb AP view before surgery

Click here to view

Of the 26 knees operated, 6(23%) had excellent outcome, 12(47%) had good outcome [Figure 2], 4(15%) had fair and 4(15%) had poor outcome. The poor result of three patients was correlated to superficial infection and the other patients due to inadequate correction. Five patients had superficial infection and one patient had hardware prominence causing pain and two patients had under correction of varus. The patients with infection were treated with appropriate antibiotics and regular dressings. They were followed up closely and their implants were removed after 6 months. Subsequently, they were followed up. One patient had hardware prominence causing anterior leg pain and the implant was removed in her after 6 months.

Figure 2: (a) Preoperative Xray image of the knee lateral view. (b) Post operative Xray image of the knee AP & lateral view

Click here to view

Discussion

The experience and the development of new techniques for axis correction around the knee have led to the revival of the osteotomy. Open-wedge osteotomy of the tibia can be performed with or without bone grafting. This procedure looked very attractive to many surgeons because of the small incision and the simple surgical steps. Osteotomy delays the need of total knee replacement for 5–10 years.

Kelly et al. have stated osteotomy as a reasonable option to treat active, physiologically young patients.^[7] Although age is not a definitive criterion, the patients must be active enough to undergo rehabilitation and have good bone quality. Body weight is definitely an independent risk factor for complications.

Song et al. have analyzed the complications of 104 lateral closing wedge and 90 medial opening-wedge osteotomies and stated that the latter had slightly lesser complications.^[8]

Kolb et al. have analyzed good results with locked low-profile plates. They have analyzed 51 medial open-wedge osteotomies and found that 50 osteotomies healed in an average period of 3 months without bone grafts and had excellent grading in 57%, good in 24% of patients by one rating system and 18% excellent, 63% good by another rating system.^[9]

Asik et al assessed 65 knees with osteotomies and found that it resolves pain and improves knee function significantly. But he has stressed that long term studies are required in elderly patients to know whether the results are satisfactory.^[10]

Tuli et al. performed closing wedge osteotomy in 78 knees in 65 patients. Eighty percent of patients perceived relief of pain by 75% or more; in the remaining 16, there was the relief of pain by 40%–70%, which is more than our study.^[11]

Limitation of the study

Smaller study population and shorter follow-up period.

Conclusion

From this prospective study, it can be concluded that medial open-wedge high tibial osteotomy is a useful option in medial compartmental osteoarthritis of the knee joint and relieves pain and improves functional outcomes in patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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