|Year : 2021 | Volume
| Issue : 2 | Page : 3-7
Comparitive study of functional and radiological outcome of open-wedge high tibial osteotomy versus proximal fibular osteotomy in patients with osteoarthritis knee
Sparsh Jaiswal, Parit Mangal, Arunim Swarup, Avinash Rastogi
Department of Orthopaedics, Subharti Medical College, Meerut, Uttar Pradesh, India
|Date of Submission||24-Jun-2021|
|Date of Decision||28-Jun-2021|
|Date of Acceptance||30-Jun-2021|
|Date of Web Publication||02-Aug-2021|
Department of Orthopaedics, Subharti Medical College, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aim: Proximal fibular osteotomy (PFO) and valgus high tibial osteotomy (HTO) are the well-established treatment options for patients with K-L grade 2, 3 medial compartment knee osteoarthritis where replacement may not be the treatment of choice. The aim of the present study was to compare the radiological and clinical outcomes following HTO and PFO. Materials and Methods: During the duration of 2 years, two groups of 30 patients each undergoing PFO with a mean age of 53.9 years (range 40–65 years) and HTO with a mean age of 54.7 years (range 40–65 years) were compared and followed up for 1 year. They were compared on the basis of preoperative and postoperative range of walking distance, Numerical Pain Rating Score, American Knee Society Score, Knee Injury and Osteoarthritis Outcome Score, femorotibial angle, and medial joint space narrowing. Results: In PFO group, immediate postoperative functional scores improved and maintained for 3 months during follow-up. Following which there was the decline in the functional score up to 1-year follow-up, whereas in the HTO group, the improvement is seen with a gradual increase in postoperative functional scores that progressed positively for the entire follow-up period of 1 year. Conclusion: Both PFO and HTO lead to good and comparable radiological and functional results. However, HTO provided slow but long-term success in terms of functional and radiological scores after the follow-up period of 1 year.
Keywords: High-tibial osteotomy, knee injury and osteoarthritis outcome score, knee society score, proximal fibular osteotomy
|How to cite this article:|
Jaiswal S, Mangal P, Swarup A, Rastogi A. Comparitive study of functional and radiological outcome of open-wedge high tibial osteotomy versus proximal fibular osteotomy in patients with osteoarthritis knee. J Bone Joint Dis 2021;36:3-7
|How to cite this URL:|
Jaiswal S, Mangal P, Swarup A, Rastogi A. Comparitive study of functional and radiological outcome of open-wedge high tibial osteotomy versus proximal fibular osteotomy in patients with osteoarthritis knee. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:3-7. Available from: http://www.jbjd.org/text.asp?2021/36/2/3/322952
| Introduction|| |
Osteoarthritis of knee is a common, progressive disorder affecting primarily weight-bearing joints, characterized by pain, limitation of motion, progressive deterioration and loss of articular cartilage, osteophyte formation, disability, and deformity. Osteoarthritis, particularly in elderly patients is one of the most prevalent conditions resulting to disability. An estimated 10%–15% of all adults over 60 year's age have some degree of OA, with prevalence higher in men.
The prevalence of OA is increasing due to population aging and an increase in related factors such as obesity. Worldwide, by 2050, people over 60 years of age will account for more than 20% of the world's population. About one-third of the patients scheduled for total joint replacement of the knee are the potential candidates for an osteotomy.
The development of new techniques for axis correction around the knee has led to its revival. Of all osteotomies around the knee 90% are for valgization of tibia (high-tibial osteotomy [HTO]). Whereas in the past closed-wedge osteotomy from the lateral side with fibula osteotomy was the gold standard in many countries, and in the 1990s, fixation plate by Puddu came to vogue. This procedure looked very attractive to many surgeons because of the small incision and the simple surgical steps.
Many of the authors carried fibular cuff resection from the proximal 1/3rd to offload the medial compartment of the knee joint as this reduces the lateral support and shifts the mechanical forces more laterally with a correction of genu varum deformity resulting in pain reduction and satisfactory restoration of knee function.
In this study, we analyze a functional outcome of open-wedge high tibial osteotomy (HTO) with reference to proximal fibular osteotomy (PFO) in patients with medial compartment OA knee (radiographic Kellgren–Lawrence Grade 2–3) in terms of relief of pain, improvement in walking distance and in going up and down the stairs, Kellgren-Lawrence grading, femoro-tibial angle, medial joint space narrowing, American Knee Society Score (KSS), knee injury, and osteoarthritis outcome score (KOOS).
| Materials and Methods|| |
The present study was conducted in the Department of Orthopedics at Chatrapati Shivaji Subharti Hospital affiliated to N. S. C. B. Subharti Medical College of Swami Vivekananda University, Meerut, during a period of 2 years.
The study design was prospective study.
Patients treated in Subharti hospital over the period of 2 years (2018–2020) of adult age group with proven primary medial compartment knee osteoarthritis. Inclusion criteria: All patients irrespective of gender, <65 years of age presenting with symptomatic medial compartment knee joint osteoarthritis substantiated by radiographic Kellgren–Lawrence Grade 2 and 3 evidences, in whom conservative treatment has yielded little or no response for at least 6 months duration and are willing to undergo mentioned operative procedure with informed consent. Random selection of patients for HTO and PFO was done. Exclusion criteria: Patients with bi/tri compartmental OA, patients with secondary OA, and any patient with varus deformity more than 15°. <90° of range of movement. >15° of flexion contracture. Very obese patients (Body mass index >30). Joint instability.
All patients were evaluated clinically in terms of severity of pain, assessment of abilities of walking, and going up and down the stairs and radiographic evaluation (Kellgren–Lawrence grading). All patients were evaluated clinically in form of Numerical Rating Scale for pain (NRS, a modified version of VAS), KOOS Survey and American KSS, radiologically in form of radiograph of both knees in the standing position for anteroposterior view and lateral views for evidence of OA and hematologically for Complete Blood Counts, Coagulation Profile.
Open wedge high tibial osteotomy
After spinal anesthesia, the patient is laid supine and a tourniquet is applied over the thigh, the lower limb is prepared from mid-thigh to ankle joint and is draped and tourniquet is inflated after exsanguinations of the limb with Eschmarc bandage.
HTO with plating
5–6 cm incision given distally such that it lies 2–3 cm posterior to the tibial tubercle and 1 cm distal to the joint line, the skin and subcutaneous tissues are reflected on either side, and the deep fascia is incised in the line of skin incision. Plane made between the bursa and underlying medial collateral ligament.
The long fibers of the superficial medial collateral ligament are then carefully detached until the posteromedial cortex of the proximal tibia is exposed [Figure 1]. Two 2 mm parallel k-wires aiming toward the upper third of the proximal tibiofibular joint are drilled into the tibial head under image intensification to mark the direction of the osteotomy. First, the posterior wire is inserted at the cranial border of the pes anserinus just in front of the posterior tibial ridge. The second wire is placed about 2 cm anterior and parallel to the first wire. The depth of the saw cut is 10 mm less than the value measured against the wires in order to leave a lateral bone hinge.
The horizontal osteotomy is performed with the oscillating saw below the two guide wires that act as guide rails, with very little pressure, and under constant cooling of the saw blade by irrigation.
After spreading of the osteotomy gap to the desired width, the legs again placed in extension. In this position, the leg axis can be evaluated clinically and radiologically. Puddu plate fixed anteriorly and posteriorly with appropriate screws. Wound was irrigated, closure done in layers.
HTO with orthofix
The first pin was introduced about 2 cm below the joint line and as posterior as possible, followed by the remaining proximal pins.
Two or three pins were placed in the tibial diaphysis. An oblique osteotomy of the medial two-thirds of the tibia, passed just distal to the tibial tuberosity and directed toward the proximal tibiofibular joint, was performed and its completion confirmed under imaging. Finally, the fixator was locked in the perfect alignment, aided by a guide wire placed through a hole in the hinge.
Postoperative protocol for the patients is: (1) Immobilization in slab was done for 3 weeks, (2) Knee brace was applied, and the patients were encouraged to do partial weight bearing using crutches or walker till the end of 7 weeks, and (3) the patients were then allowed to weight bear completely.
Technique of proximal fibular osteotomy
After spinal anesthesia, the patient is laid supine and a tourniquet is applied over the thigh, the lower limb is prepared from mid-thigh to ankle joint and is draped and tourniquet is inflated after exsanguinations of the limb with Esmarch's bandage. A sandbag is applied under the gluteal region to keep the lower limb in slight internal rotation [Figure 2]. The caput fibula is palpated, and a 5–7 cm longitudinal incision is given over the proximal fibula starting about 5 cm distal to its caput, the skin and subcutaneous tissues are reflected on either side and the deep fascia is incised in the line of skin incision.
A plane is developed between peroneus and soleus muscles which are then subperiosteally erased, and fibula is exposed. About 2–3 cm long cuff resection from shaft of fibula at a level about 6–10 cm from caput fibulae is performed with a power saw, and the cut ends of the fibula are sealed with bone wax. Wound is irrigated and closed in layers.
Full weight-bearing ambulation was allowed with quadriceps drill and knee range of motion exercises from day 1 depending upon the tolerance of postoperative pain by the patient. Full weight-bearing radiographs of both knee joints were obtained the next morning.
All patients were followed up monthly with a total duration of 6–12 months from the date of surgery.
| Results|| |
In this study, 63 patients were enrolled, of which 3 were lost in follow-up and 60 patients completed the follow-ups, of which 33 patients were treated with PFO and other 30 patients were treated with HTO and were followed up for 1 year. We have got following observations and results according to the data analyzed.
More number of patients was in the age group of 40–55 years (60%) than in 56–65 years (40%) in PFO group, whereas in HTO group, a greater number of patients are in the age group of 55–65 years (53.33%) than in 40–55 years age group. The youngest patient was 40 years and oldest patient was 65 years. The mean age of our study is 53.9 years in PFO group and 54.7 in HTO group.
In this study, [Table 1] a total of 30 patients were in PFO group, of which 12 (40%) were male and 18 (60%) were female, whereas in HTO group, of 30 patients, 13 (43.33%) were male and 17 (56.66%) were female.
In PFO group, 10 patients (33.33%) were affected with K-L Grade 2 knee osteoarthritis and 20 patients (66.66%) were affected with K-L Grade 3 knee osteoarthritis. In HTO group, 12 patients (40%) were affected with K-L Grade 2 knee osteoarthritis and 18 patients (60%) were affected with K-L Grade 3 knee osteoarthritis. In this study, the patients with K-L Grade 3 knee osteoarthritis (63.33%) are more common than the patients with K-L Grade 2 knee osteoarthritis (36.66%).
The mean FTA improved from 190.26° ± 3.39° to 180.93° ± 2.86° in patients with PFO and FTA improved from 190.13° ± 2.45° to 173.33° ± 2.42° in patients with HTO at 1 year of follow-up.
The mean medial joint space narrowing in patients with PFO is 3.5 mm preoperatively and 3.5 mm at the 1-year follow-up, whereas in HTO group, the mean medial joint space narrowing improved from 4 mm preoperatively to 5.5 mm at 1 year of follow-up.
In PFO group, the patients could walk pain free up to 158.33 m preoperatively which improved to 456.66 m at 1 month, 601.66 m at 3 months, 510 m at 6 months, and 398.33 m at 1 year. Whereas in HTO group, patients could walk pain free up to 141.87 m preoperatively which improved to 146.66 m at 1 month, 288.33 m at 3 months, 443.33 m at 6 months, and 681.66 m at 1 year.
The mean NRS preoperatively was 8.066 ± 1.01 and 7.9 ± 1.12 in patients with PFO and HTO. Postoperatively, the mean immediate NRS in PFO group was 2.66 ± 0.95, 0.9 ± 0.6 at 1 month, 0.6 ± 0.37 at 3 month, 2.63 ± 0.71 at 6 months, and 4.33 ± 0.71 at 1 year. Postoperatively, the mean immediate NRS in HTO group was 5.6 ± 0.96, 2.7 ± 0.79 at 1 month, 2.2 ± 0.55 at 3 months, 1.2 ± 0.48 at 6 months, and 0.3 ± 0.46 at 1 year.
The mean KSS preoperatively was 52.93 ± 10.93 and 46.93 ± 10.37 in patients with PFO and HTO. Postoperatively, the mean KSS in PFO group was 79.73 ± 5.48 at 1 month, 86.8 ± 5.03 at 3 months, 75.1 ± 4.20 at 6 months, and 64.03 ± 6.68 at 1 year. Postoperatively, the mean KSS in HTO group was 45.56 ± 7.39 at 1 month, 50.3 ± 7.50 at 3 months, 61 ± 6.16 at 6 months, and 76.46 ± 4.83 at 1 year.
The mean KOOS preoperatively was 46.03 ± 8.62 and 45.40 ± 7.82 in patients with PFO and HTO. Postoperatively, the mean KOOS in PFO group was 75.33 ± 8.11 at 1 month, 85.06 ± 5.87 at 3 months, 69.86 ± 4.38 at 6 months, and 57.53 ± 4.51 at 1 year. Postoperatively, the mean KOOS in HTO group was 45.73 ± 6.05 at 1 month, 51.53 ± 5.00 at 3 months, 62.03 ± 4.86 at 6 months, and 77.83 ± 4.40 at 1 year.
| Discussion|| |
Osteoarthritis knee is a very common disorder that usually starts after 40 years of age and progresses to affect about 30% population beyond 60 years of age involving the medial compartment more frequently than the lateral one.
In this prospective study, during the duration of 2 years, 63 patients were enrolled of which three patients treated with PFO were lost in follow-up and 60 patients who completed the 1-year follow-up were included. The study compared the functional outcome of open medial wedge HTO (n = 30) in reference to PFO (n = 30) in patients with medial compartment osteoarthritis knee. The sample selected was comparable in the two groups in terms of age, sex, functional, and radiological parameters [Table 2]. In the study done by Laik et al. (2020), 27 patients undergone PFO with a mean age of 55.8 years and Weale et al. (2001), 76 patients undergone HTO with a mean age of 54.8 years which was comparable to this study where the mean age of patient was 53.9 years and 54.7 years in the PFO and HTO group.
In a study done by Zou et al., (2017) the preoperative mean femoro-tibial angles were 182.6° ± 2.3° and 183.4° ± 2.5° in PFO and HTO groups while postoperatively were 175.3° ± 1.6° and 168.9° ± 1.3°, respectively, similar to this study. This study emphasizes that HTO group has better restoration of femoro-tibial angle as compared to PFO group at 1-year follow-up. In our study, no significant difference in the medial joint space in both PFO and HTO groups was observed at the end of 1-year follow-up.
Yang et al. (2015) conducted a study on 150 patients with medial compartment knee osteoarthritis treated by PFO with a follow-up of 2 years found that mean preoperative KSS score which was 45 ± 21.3 improved to 92.3 ± 31.7 at final follow-up.
Similar results were found in studies done by Liu et al. and Wang et al. In this study, it was found that KSS score in HTO group was improved better than PFO group at the end of 1-year follow-up. However, change in mean KSS scores in PFO group from preoperative (52.93 ± 10.93) to postoperative (64.03 ± 6.68) after 1-year follow up in PFO group is not in accordance with above studies.
Utomo et al. conducted a study on 15 patients with medial compartment knee osteoarthritis treated by PFO found that mean preoperative KOOS score which was 45.27 ± 3.28 improved to 86.25 ± 1.10 postoperatively. Similar study conducted by Roos and Lohmander showed improvement in mean KOOS score from 44.79 ± 13.05 to 71.91 ± 9.08 in patients treated with HTO. In this study, it was observed that mean preoperative score in PFO group was 46.03 ± 8.62 which improved to 57.53 ± 4.51 at the 1-year follow-up, whereas in HTO group, mean preoperative KOOS score was 45.40 ± 7.82 which improved to 77.83 ± 4.40 at 1-year follow-up. In this study, in HTO group, initially the KOOS score was constant but gradually improved after 3 months of follow-up.
Whereas in PFO group, KOOS score improved maximum in the immediate postoperative phase and gradually decreased after 3 months of follow-up showing short-term pain relief in PFO as compared to HTO group. However, KOOS score in HTO group is in accordance with a study conducted by Roos and Lohmander while KOOS scores in PFO group are poorer than those claimed in study by Utomo et al.
In this study, HTO and PFO groups were compared based on the functional parameters such as NRS, use of stairs, and walking distance. It was observed that in PFO group, immediate postoperative functional scores improved and maintained for 3 months during follow-up. Following which there was the decline in the functional score up to 1-year follow-up. Whereas in the HTO group, the improvement is seen with a gradual increase in postoperative functional scores that progressed positively for the entire follow-up period of 1 year taken here in our study.
The present study found agreement with the literature in recommending medial open wedge HTO as a safe surgical procedure with better long-term pain relief and good functional restoration with reference to PFO, which has a short-term relief in symptoms.
| Conclusion|| |
From this study, we conclude, HTO and PFO is a valid treatment option for medial compartment osteoarthritis knee. Although PFO is a simple, safe and cost-effective, easy to perform, it is associated with only short-term pain relief. HTO shows slow recovery rate but has long-term success in terms of functional and radiological outcomes with no hazardous complications showing it to be superior to PFO. As the bone stock is preserved in both the procedures, future surgical intervention, namely a vis, total knee arthroplasty is an option in both modalities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]