|Year : 2021 | Volume
| Issue : 2 | Page : 21-26
To assess the functional and radiological outcomes in patients of medial compartment osteoarthritis of knee undergoing medial open-wedge high tibial osteotomy
Najmul Huda, Mir Shahid Ul Islam, Shubham Aggarwal, Sandeep Bishnoi, Sudhir Beri, Ravi Dholariya
Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Centre, TMU, Moradabad, Uttar Pradesh, India
|Date of Submission||31-May-2021|
|Date of Decision||25-Jun-2021|
|Date of Acceptance||30-Jun-2021|
|Date of Web Publication||02-Aug-2021|
Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Centre, TMU, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Varus malalignment at the knee can lead to medial compartment overload and progression of ipsilateral compartment osteoarthritis (OA). In such cases, a valgus-producing medial open-wedge high tibial osteotomy (MOWHTO) has been proposed to restore neutral mechanical alignment and alleviate excess load on the medial compartment. One distinct advantage of this procedure is the ability to correct deformities in the sagittal and coronal planes. The present study was conducted with the aim to analyze the difference in the pre- and postoperative functional scores and to estimate the changes in the pre- and postoperative radiological alignment in the patients managed by MOWHTO for uni/medial compartmental OA knee. Materials and Methods: Fifteen patients with medial compartment OA knee Kellgren–Lawrence Grade II and III with a mean age of 54.46 years were managed with MOWHTO. Clinical assessment was done using the Knee Society Score (KSS) preoperatively and postoperatively at 3, 6, and 9 months. Radiological assessment was done using the Puddu technique on the load-bearing lower limb antero-posterior X-ray extending from the hip joint up to the ankle preoperatively at postoperatively at 3 and 9 months. Results: All patients had pain relief and improvement in walking ability after the procedure. The mean KSS significantly improved from 35.50 ± 9.78 preoperatively to 55.07 ± 9.13, 67.14 ± 10.06, and 74.14 ± 4.09 at 3, 6, and 9 months postoperatively, respectively (P < 0.01). The mean varus angle significantly improved from 9.06° preoperatively to 1.43° varus at 3 months postoperatively (P = 0.001) and 1.64° varus at 9 months postoperatively and was found to be significant. Conclusion: After a follow-up of 9 months, we found that the MOWHTO of the tibia is an effective method to treat the medial compartment OA knees. It leads to significant improvement in both the clinical and radiological outcomes.
Keywords: High tibial osteotomy, knee ostrearthritis, medial open-wedge high tibial osteotomy
|How to cite this article:|
Huda N, Islam MS, Aggarwal S, Bishnoi S, Beri S, Dholariya R. To assess the functional and radiological outcomes in patients of medial compartment osteoarthritis of knee undergoing medial open-wedge high tibial osteotomy. J Bone Joint Dis 2021;36:21-6
|How to cite this URL:|
Huda N, Islam MS, Aggarwal S, Bishnoi S, Beri S, Dholariya R. To assess the functional and radiological outcomes in patients of medial compartment osteoarthritis of knee undergoing medial open-wedge high tibial osteotomy. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:21-6. Available from: http://www.jbjd.org/text.asp?2021/36/2/21/322949
| Introduction|| |
In India, osteoarthritis (OA) is among the top five chronic diseases, and it is the most frequent joint disease with a prevalence of 22%–39%., A community-based cross-sectional study conducted in 2016 across five sites of India in big city, small city, town, and village has reported the prevalence of OA of knee to be as high as 28.7% and the global prevalence of OA knee was found to be 16% with incidence of 203/10,000 per-years in 2020.
The American College of Rheumatology has developed the criteria for the classification and early diagnosis of OA of the knee using the combinations of clinical, laboratory, and radiographic parameters. Initial therapy conducted for OA is remained in the form of pharmacological agents focusing symptomatic treatment only and not addressing the joint disorder. In the absence of proven disease-modifying drugs and lack of initiation or maintenance of adherence with lifestyle modification, OA knee progresses and eventually biomechanical changes occur; therefore, early diagnosis and treatment are considered a key to preserve the native knee.,,
In normally aligned knee, load is transmitted disproportionately to the medial compartment and varus alignment of knee as is commonly seen in OA further increases load over medial compartment during standing/walking. The studies have showed that more load is borne medially in valgus knee until severe valgus is present. Varus malalignment is not only a cause but also an important factor in the progression of medial compartment OA which occurs at an early stage.
Wide variety of nonoperative and operative treatment options are available for early OA knee ranging from rapidly emerging techniques such as intra-articular injection of platelet-rich plasma (PRP) and growth factor concentrate to uni-compartmental knee replacement (UKR), total knee replacement (TKR), and high tibial osteotomy (HTO). Long-term efficacy of biologics is still a debatable issue due to the lack of studies. TKR is defined as a clear end-point after both HTO and unicompartmental knee arthroplasty and should not be performed in the early stage disease. The principle of UKR is based on intra-articular deformity correction caused by cartilage loss without changing the knee alignment. The patient selection criteria for UKR are very strict, and the procedure is associated with complications such as polyethylene dislocation, polyethylene wear, and aseptic loosening. HTO works on the principle of alteration in the mechanical axis of the lower limb which offload the arthritic medial compartment and thereby relieving the pain with improved function. There are much less contraindications for HTO as compared to UKR, although the functional results of both procedures are comparable. In a meta-analysis published in 2019, the mean longevity for UKR was found to be around 5 years, whereas in HTO, 10-year survival rates were 89.6%.
The present study was undertaken with the aim to analyze the difference in the preoperative and postoperative functional scores and to estimate the changes in the pre- and postoperative radio-logical alignment in the patients managed by medial open wedge HTO (MOWHTO) for uni/medial compartmental OA knee.
| Materials and Methods|| |
This is a single-center observational study done from January 2019 to June 2020 in patients of medial compartment OA knee Kellgren–Lawrence (K-L) Grade II and III after taking clearance from the ethical committee. The exclusion criteria included any previous history of knee surgery/trauma, range of motion (ROM) <90°, flexion contracture more than 15°, rheumatoid arthritis, joint instability, varus more than 20°, bone loss more than 5 mm, and lateral tibial thrust more than or equal to 1 cm.
Clinical assessment was done using the Knee Society Score (KSS) preoperatively. Radiological assessment was done by taking the load bearing lower limb anteroposterior (A-P) X-ray extending from the hip joint up to the ankle. Using the Puddu technique, a line was drawn from the middle of the femoral head through a point 62.5% of the breadth of the proximal tibia measured from the medial side. One more line was drawn from this point to the middle of ankle joint. An angle was made at the intersection of these two lines [Figure 1]. Normal physiological valgus (7°) was added to this, this was the degree of correction required.
After the preanesthetic checkup and spinal anesthesia, with the patient in the supine position, linear but oblique incision was given 4.5 cm posterior to tibial tuberosity and 1 cm below the joint line and subcutaneous fascia was dissected. Guide pin was inserted from medial to lateral across proximal tibia, 1 cm below and parallel to the joint surface. Location of guide pin was checked by fluoroscopy and osteotomy guide pin assembly was placed. Two guide pins were placed from medial to lateral, along the orientation of the line of osteotomy and verified under C arm. With the help of oscillating saw, medial opening wedge HTO was done within 1 cm of the lateral cortex. Osteotomy was distracted to desired correction with the help of lamina spreader. Lateral cortex was left intact, and proper alignment was established. For defects > =10 mm, contralateral iliac crest graft was taken under aseptic precautions and placed at the osteotomy site. Osteotomy site was secured by proximal tibial plate followed by closure. [Figure 2] shows the intraoperative pictures.
Starting on day 1, supervised physical therapy program was initiated, particularly on the activation of quadriceps. Straight leg raises and quadriceps sets were performed daily for 3–5 times. During the first 2 weeks, passive knee ROM was limited from 0° to 90°. Weight bearing was allowed after 3 months.
Clinical assessment was done at 3, 6, and 9 months on the basis of KSS, and results were analyzed using the SPSS 20, IBM Cloud Pak®, (Chicago, Illinois, US) software by Bonferroni post hoc test (P < 0.01) to determine the differences in the values between all-time points by pair wise comparison. Radiological assessment was done by the weight-bearing long leg A-P radiographs from the hip to the ankle at 3 and 9 months and varus angle was calculated. The results were analyzed using the Friedman test (r2 = 26.53, P < 0.001).
| Results|| |
[Table 1] shows that majority (60.0%) of the participants were between 50 and 59 years with a mean age of 54.46 ± 5.09 years. Most (86.7%) of them were females and around 60% of them were diagnosed with OA knee K-L Grade 2.
|Table 1: Frequency and percentage distribution of participants based on background characteristics (n=15)|
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[Table 2] shows pairwise comparison and found that the intervention was effective, i.e., (P < 0.01) in all point times. Hence, participants had significant improvement in the KSS. This shows that MOWHTO is an effective intervention on improving KSSs among patients with medial compartment OA knee.
|Table 2: Bonferroni post hoc test to determine the differences in knee society scores values between all-time points by pair wise comparison|
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[Table 3] reveals that, the median of the differences between varus angle values at preoperative and follow-up at 3 months (postoperative 1) is significantly different (P = 0.001), the median of the differences between varus angle values at preoperative and follow-up at 9 months (postoperative 2) is significantly different (P = 0.001). However, the median of the differences between varus angle values at follow-up at 3 months (postoperative 1) and follow-up at 9 months (postoperative 2) is not significantly different (P = 0.08). There is a statistically significant decrease in the values of varus angle after intervention.
|Table 3: Comparison of pre- and post-operative median and interquartile ranges of versus angle among participants|
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| Discussion|| |
In this study, we observed that the majority (60.0%) of the participants were between 50 and 59 years, with a mean age of 54.46 ± 5.09 years. This age distribution coincided with the research by Patel et al. and Brouwer et al.
Majority of our patients were females (86.7%, n = 13). This ratio was coinciding with the research in studies by Patel et al., and Deie et al. Brouwer et al., Luo et al., Spahn, and El-Azab et al. reported a male preponderance in their studies.
We observed that majority of the patients had OA over the right knee (8 of 15 patients, i.e. 53.33%). Our result coincided with the studies by Spahn, and Brouwer et al. However, the study by Luo et al. showed left knee predominance.
In our study, 60% (n = 9) patients had Grade II disease and 40% (n = 6) had K-L Grade III OA knees. Our result coincided with the results of Smith in which there were 18 of 30 cases (60%) in Grade 2 and 40% in Grade 3. In the studies by Lana et al. (Grade 1:2:3 = 25:44:31%), (Grade 1:2:3 = 25:39:36%), and (Grade 1:2:3 = 15.2:42.4:42.4%) in the PRP, hyaluronic acid (HA), and PRP + HA group, respectively, Knoop et al. (Grade 1:2:3:4 = 31:27:25:18%) – Majority of the cases were of K-L Grade 2 followed by K-L Grade 3.
The present study shows that there is significant improvement in KSS at subsequent follow-ups. Preoperatively, the mean KSS was 35.50 ± 9.78, and postoperatively, it was 55.07 ± 9.13, 67.14 ± 10.06, and 74.14 ± 4.09 at 3, 6, and 9 months, respectively. This difference is found to be significant. At the last follow-up, two (14.28%) patients had excellent outcome, 10 (71.64%) patients had good outcome, and 2 (14.28%) had fair outcome.
Of the 13 knees operated in the study by Kumar in 2016, four patients had excellent outcome, five patients had good outcome, and 2 each had fair and poor outcome. In the study by Asik et al., mean KSS improved from 44.6 preoperatively to 68.5 after the operative procedure which was same in the study conducted by Kolb et al. Good results using locked low-profile plates were analyzed by Kolb et al. Of 51 medial open-wedge osteotomies performed by Kolb et al., 50 healed at around 3 months without using any graft. Fifty-seven percent and 24% patients had excellent and good grading, respectively, by the “Hospital for Special Surgery Rating System,” and 18% and 63% patients had excellent and good grading by the “Lysholm and Gillquist knee score,” respectively. Lu et al. in their research also concluded that the mean KSS enhanced from 53.63 preoperatively to 86.12 postoperatively with 86.1 ± 6.2 months being the mean duration of follow-up. Many studies have shown clinical improvement after the operative procedure but with different scores.
In our study, the mean varus angle preoperatively is 9.06° which improved to 1.43° varus at 3 months postoperatively and 1.64° varus at 9 months postoperatively. The median of the differences between varus angle values at preoperative and follow-up at 3 months is significantly different, and the median of the differences between varus angle values at preoperative and follow-up at 9 months is also significantly different, but the median of the differences between varus angle values at follow-up at 3 months (postoperative 1) and follow-up at 9 months (postoperative 2) is not significantly different which implies that the alignment was maintained till final follow-up however we suggest longer follow-ups to analyze malalignment does not change with time.
[Figure 3] and [Figure 4] shows radiographs and clinical pictures pre-operatively , and post-operatively at 3 month follow up and 9 month follow up of our patients.
|Figure 3: Radiographs and clinical pictures pre-operatively and postoperatively at 3 and 9 month follow up of patient|
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|Figure 4: Radiographs and clinical pictures pre-operatively and postoperatively at 3 and 9 month follow up of patient 2|
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In the study by Lu et al., valgus angle improved from 0.62 preoperatively to 7.94 postoperatively. Similar results were seen in the research study “the knee” by Smith et al.
Two of 15 patients (13.33%) who underwent surgery suffered from delayed deep infection. One was managed with implant removal and the other with open wound management, wound irrigation, debridement, antibiotics, and at last secondary closure after the subsidence of the infection. The reason for infection might be less soft-tissue cover over the medial aspect of tibia.
Kolb et al. study showed 1 in 51 patients suffering from deep infection after the operative procedure. Smith et al. also had similar complication results. There have been reports about infections in 2.3%–54.5% patients after HTO needing immediate revision. It is due to hematoma. It has been seen that infections are usually seen in patients in whom bone substitutes are used. MOWHTO using rigid plate fixation without bone grafting has been concluded to be the treatment for medial compartment OA knee with varus alignment <12°. This would not only decrease the risk of complication rate but also maximize the survival rate.
| Conclusion|| |
To conclude, MOWHTO is an effective method of managing medial compartment OA knee. It leads to significant improvement in both the clinical and radiological outcomes. It has several advantages of being a simple and accurate procedure with a low morbidity. Our study has its own limitations like there was no comparative arm and short follow-up.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]