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Early results of medial opening wedge high tibial osteotomy using an intraosseous implant with accelerated rehabilitation

Authors:
Jodie Morris at James Cook University
Jodie Morris
Andrea Grant at Orthopaedic Research Institute of Queensland
Andrea Grant
  • Orthopaedic Research Institute of Queensland
Rohit Kulkarni
Rohit Kulkarni
Rohit Kulkarni
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Kenji Doma at James Cook University
Kenji Doma
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Background: Accelerated rehabilitation protocols for medial opening wedge high tibial osteotomy (MOW HTO) using intraosseous implants have not previously been described. The present study provides early clinical and radiological outcomes of MOW HTO using a polyetheretherketone (PEEK) intraosseous system, in combination with an early weight-bearing protocol. Methods: Twenty consecutive knees (17 patients) underwent navigated MOW HTO using a PEEK implant with accelerated rehabilitation. Time to union and maintenance of correction were assessed radiographically for 12 months post-operative. Patient outcomes were monitored for a mean follow-up of 38 months (range 23-42) using standardised instruments (WOMAC, IKDC and Lysholm scores). Results: All knees were corrected to valgus. The mean time to unassisted weight-bearing was 55 days (SD 24, range 21-106). Bone union occurred in 95% of knees by 6 months, with correction maintained for 15 knees at 12 months post-operative. Knees for which correction was lost within 1 year of surgery had significantly greater preoperative varus alignment. Implant survivorship was 95% and 80% at 12 and 38 months post-operative, respectively. Significant improvements in patient-reported satisfaction, knee function and return to daily activities from preoperative to 38 months post-operative were reported (WOMAC 36 v 0; IKDC 35.6 v 96; Lysholm 44.5 v 100). Conclusions: Accelerated rehabilitation following MOW HTO with an intraosseous PEEK implant did not delay bone union, with significantly improved functional outcomes within 3 months post-operative. Early findings suggest that this approach may be suitable for a defined patient subset, with consideration for the extent of preoperative genu varum.
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Vol.:(0123456789)
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European Journal of Orthopaedic Surgery & Traumatology (2019) 29:147–156
https://doi.org/10.1007/s00590-018-2280-1
ORIGINAL ARTICLE • KNEE - OSTEOTOMY
Early results ofmedial opening wedge high tibial osteotomy using
anintraosseous implant withaccelerated rehabilitation
JodieMorris1 · AndreaGrant1 · RohitKulkarni1 · KenjiDoma1,2 · AliciaHarris1 · KaushikHazratwala1
Received: 1 May 2018 / Accepted: 20 July 2018 / Published online: 1 August 2018
© Springer-Verlag France SAS, part of Springer Nature 2018
Abstract
Background Accelerated rehabilitation protocols for medial opening wedge high tibial osteotomy (MOW HTO) using intra-
osseous implants have not previously been described. The present study provides early clinical and radiological outcomes of
MOW HTO using a polyetheretherketone (PEEK) intraosseous system, in combination with an early weight-bearing protocol.
Methods Twenty consecutive knees (17 patients) underwent navigated MOW HTO using a PEEK implant with acceler-
ated rehabilitation. Time to union and maintenance of correction were assessed radiographically for 12months post-oper-
ative. Patient outcomes were monitored for a mean follow-up of 38months (range 23–42) using standardised instruments
(WOMAC, IKDC and Lysholm scores).
Results All knees were corrected to valgus. The mean time to unassisted weight-bearing was 55days (SD 24, range 21–106).
Bone union occurred in 95% of knees by 6months, with correction maintained for 15 knees at 12months post-operative.
Knees for which correction was lost within 1year of surgery had significantly greater preoperative varus alignment. Implant
survivorship was 95% and 80% at 12 and 38months post-operative, respectively. Significant improvements in patient-
reported satisfaction, knee function and return to daily activities from preoperative to 38months post-operative were reported
(WOMAC 36 v 0; IKDC 35.6 v 96; Lysholm 44.5 v 100).
Conclusions Accelerated rehabilitation following MOW HTO with an intraosseous PEEK implant did not delay bone union,
with significantly improved functional outcomes within 3months post-operative. Early findings suggest that this approach
may be suitable for a defined patient subset, with consideration for the extent of preoperative genu varum.
Keywords Medial opening wedge· High tibial osteotomy· Medial osteoarthritis· Navigation· PEEK· Accelerated
rehabilitation
Abbreviations
HKA Hip-knee-ankle angle
HTO High tibial osteotomy
IKDC International Knee Documentation Committee
MCL Medial collateral ligament
MOW Medial opening wedge
PCN Precision computer navigation
PEEK Polyetheretherketone
ROM Range of motion
TKA Total knee arthroplasty
WOMAC Western Ontario and McMaster Universities
Osteoarthritis Index
Introduction
Medial opening wedge (MOW) high tibial osteotomy
(HTO), a technique used for the treatment of medial knee
osteoarthritis (OA), is commonly performed with an extraos-
seous plate-fixation under tension [1]. Non-plate, intraosse-
ous wedge implants constructed from polyetheretherketone
(PEEK) and inserted under compression are also available
[2]. In addition to the fixation hardware and surgical tech-
nique used, the long-term outcome of MOW HTO depends
on the correction achieved after the osteotomy and the pres-
ervation of this alignment during bone healing [3, 4]. Factors
such as appropriate patient selection and the post-operative
* Jodie Morris
jodie.morris@oriql.com.au
1 Orthopaedic Research Institute ofQueensland, Townsville,
QLD4812, Australia
2 College ofHealthcare Sciences, James Cook University,
Townsville4811, Australia
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... 8 However, it is important to note that there is a limited number of studies that thoroughly evaluate key factors such as the VAS, independence in ADL, and the resumption of work following HTO. [9][10][11] For active individuals living with osteoarthritis, a primary concern is the timing of their return to daily work activities after surgery. Therefore, the present observational study was designed to assess early postoperative pain, independence in ADL, and the prompt return to one's respective occupation with minimal discomfort, all achieved through an optimal early rehabilitation protocol. ...
... 32 In contrast, Moris et al. reported a mean time for unassisted weight-bearing walking was 55 days with an early weight-bearing protocol. 11 In their comparative study, Schroter et al. advocated for the early weight-bearing rehabilitation protocol, noting that the functional scores at 6 months were significantly superior in the early weight-bearing group compared to the partial weight-bearing group. 10 While there are concerns associated with early weight bearing like tibial plateau fractures, implant failure, loss of correction, lateral hinge fractures, compartment syndrome, and infections, this study did not encounter such complications despite the early weight-bearing rehabilitation protocol. ...
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... Rehabilitasyon programı tam ekstansiyonda izometrik quadriseps femoris kontraksiyonları ve düz bacak kaldırma egzersizleri ile sürdürülür. Bu sürede diz eklemi tam ekstansiyonda kilitlenir ve etkilenen ekstremite üzerine hiç ağırlık verilmemesine dikkat edilerek iki koltuk değneği ile transfer eğitimlerine başlanır (24,25). Faz II: Ağırlık Vermeden Kuvvetlendirme Dönemi (2-6 Hafta) Bu dönemde hastalar ağrının ve ödemin yavaş yavaş azalacağı konusunda bilgilendirilir. ...
... Ancak cerrahi sonrasında yük verme kısıtlamasından dolayı basit açık kinetik zincir egzersizlerinden sonra kapalı kinetik zincir egzersizlerine geçilir. Diz ekleminin stabilitesinin sağlanmasında kapalı kinetik kontrol daha önemli olmasına rağmen günlük yaşam aktiveleri sırasında hem açık kinetik zincir hem de kapalı kinetik zincir hareketleri önem taşımaktadır (24,29). Etkilenen ekstremite üzerine yük verme süreci rehabilitasyonda önemli ve sıklıkla en çok tartışılan basamaklardan birisidir. ...
Yüksek Tibial Osteotomide Fizyoterapi Rehabilitasyon Physiotherapy and Rehabilitation After High Tibial Osteotomy
Article
Full-text available
  • Jun 2020
zet Yüksek tibial osteotomi özellikle genç ve aktif hastaların alt ekstremite dizilim bozukluğuyla birlikte seyreden medial kompartman tutulumlu diz osteoartritinin tedavisinde kabul edilen ve yaygın olarak kullanılan cerrahi bir yöntemdir. Bu yöntem ile alt ekstremite mekanik ekseninin düzeltilmesi ile dizin medial kompartmanına binen yükün ve buna bağlı olarak ağrının da azaltılması sağlanır. Yüksek tibial osteotomide kullanılan cerrahi teknikler yıllar içinde değişse de temel prensipler hep aynı kalmıştır. Bununla birlikte son yıllarda fiksasyon cihazları ve tekniklerinin geliştirilmesi ile daha erken yük verme ve daha agresif rehabilitasyon programları denenmektedir. Cerrahide kullanılan fiksasyon araçlarının gelişmesi ile birlikte aktiviteye dönüşün daha erken ve daha agresif izin verilmesi açısından rehabilitasyon ve egzersiz programlarının güncellenmesini gerektirmektedir. Bu derlemenin amacı gelişen cerrahi yöntemlere uygun olarak yüksek tibial osteotomide en güncel fizyoterapi ve rehabilitasyon uygulamalarına genel bir bakış açısı sunmaktır. Yüksek tibial osteotomi ile birlikte uygulanan fizyoterapi ve rehabilitasyon programı cerrahinin başarısı ve iyileşme açısından oldukça önemlidir. Rehabilitasyon süreci cerrahiden hemen sonra hastane ortamında başlamalı günlük yaşam aktivitelerine bağımsız ve ağrısız dönüşe kadar devam etmelidir. Cerrahi tekniğe ve fiksasyon tipine bağlı olarak ağırlık verme eğitiminin osteotomi sonrası iki ay içinde hiç yük vermeden kısmi ağırlık vermeye doğru ilerlemesi önerilmektedir. Cerrahi sonrası rehabilitasyon ve egzersiz uygulamalarında hedef günlük yaşam aktivitelerinde optimal düzeyde fonksiyonel bağımsızlığı kazandırmak ve yaşam kalitesini arttırmaktır. Ek olarak rehabilitasyon programının her fazı hastanın fonksiyonel değerlendirmelerini içermelidir. Hastalara uygulanan fizyoterapi ve rehabilitasyon programı her hastaya özgü olmalı ve egzersiz uygulamaları basamak basamak ilerlemelidir. Ayrıca hastanın özellikle ekstremite üzerine ağırlık verme ve fiziksel aktiviteye dönüş zamanı açısından uygun bir şekilde bilgilendirilmesi ve yönlendirilmesi gerekmektedir. Abstract High tibial osteotomy is an accepted and widely used surgical method in the treatment of knee osteoarthritis with medial compartment involvement especially in young and active patients with lower extremity malalignment. With this method, the load on the medial compartment of the knee is reduced by correcting the mechanical axis of the lower limbs, and therefore the pain is reduced. Although the surgical techniques used in high tibial osteotomy have changed over the years, the basic principles have always remained the same. In addition, with the development of fixation devices and techniques, earlier loading and more aggressive rehabilitation programs have been tried in recent years. By the advanced fixation tools used in surgery, it requires updating of rehabilitation and exercise programs in order to allow return to activity earlier and more aggressively. The goal of this review is provide an overview of current physiotherapy and rehabilitation program options for high tibial osteotomy in accordance with the developing surgical methods. The physiotherapy and rehabilitation program implemented with high tibial osteotomy is very important for the success of the surgery and recovery. The rehabilitation process should start immediately after surgery in the hospital room and continues until the independent and painless return to the activities in daily living. Depending on the surgical technique and type of fixation, it is recommended that non-weight bearing training should proceed to partial weight-bearing training within two months after osteotomy. In post-surgical rehabilitation and exercise applications, the goal is to provide optimal functional independence in daily life activities and increase the quality of life. In addition, each phase of the rehabilitation program should include functional assessment of the patient. The physiotherapy and rehabilitation program applied to patients should be specific to each patient and exercise practices should progress step by step. Besides, the patient should be informed and directed appropriately especially in terms of weighting on the limb and returning to physical activity.
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... Rehabilitation should focus on quadriceps strength and improved joint mobility to recover long-term function in individuals with medial knee OA. Although there are reports detailing rehabilitation 1 2 2 2 1 3 programs customized to the specific needs of particular surgical procedures [7][8][9], there is an absence of reports regarding the existence of a dedicated rehabilitation regimen with a primary focus on targeting the knee extensor mechanism for individuals undergoing OWHTO. ...
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... Improvements of surgical techniques and xation devices in OWHTO have enabled early recovery with full-weight bearing, accelerated postoperative rehabilitation, and minimized muscle weakness [12,13]. Accelerated rehabilitation protocols for OWHTO were introduced and lead to earlier improvement of the clinical results [12,14]. In elderly patients, recent accelerated postoperative rehabilitation programs seems to work in favor of preventing muscle weakness and increasing RTS. ...
Return to Sports Activity After Opening Wedge High Tibial Osteotomy in Elderly Patients
Preprint
Full-text available
  • Aug 2021
Background: The purpose of this study was to evaluate return to sports (RTS) after opening wedge high tibial osteotomy (OWHTO) in elderly patients and associated factors affecting RTS. Methods: Seventy-four patients (mean age 68 years) who underwent OWHTO were enrolled. Clinical outcomes were evaluated using the Knee Society Score (KSS). Patients were asked regarding types of sports activities and their levels of participation within preoperative 1 year and postoperative 1 year. Levels of participation in sports and recreational activities were examined using the Tegner activity scale. The outcomes were compared between two age groups (≥70 years vs <70 years). Results: Of the 74 patients overall, 59 participated in at least one sport preoperatively, and 55 returned to sports postoperatively (RTS 93%). The KSS knee score and function score were significantly improved after surgery in both age groups (P<0.05), but no significant differences were found between the age groups. The Tegner activity scales for ≥70 years and <70 years were 2.9±1.1 and 4.0±1.9 preoperatively (P<0.01) and 2.7±1.2 and 3.3±1.4 postoperatively (P=0.16), respectively. RTS was reported by 24 of 25 (96.0%) in the age <70 years group and 31 of 34 (91.2%) in the age ≥70 years group. Of the patients who reported RTS, 66.7% in the age <70 years group and 77.4% in the age ≥70 years group could return to the same or higher level. Conclusions: The rate of RTS after OWHTO was high in elderly patients. OWHTO is a preferred surgical option for elderly patients who desire RTS.
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... To summarize, early loss of correction after HTO has sporadically been published as a minor percentage in large case series or in the form of a single case report [25,37,57,61,89,90,106]. If correction loss is already described in clinical studies, the timing of revision is largely underreported. ...
Osteotomy around the painful degenerative varus knee. ESSKA formal consensus project.
Article
Full-text available
  • Apr 2022
The aim of this ESSKA Consensus is to provide a fusion of the scientific evidence and expert opinion (where it is appropriate) regarding the indications, planning, surgical strategy, rehabilitation and complications for the most widespread application of osteotomy: management of the painful, degenerative varus knee. Modern osteotomy has evolved dramatically from the accepted dogma of 50 years ago. In the 1960s through to the 1990s a valgising osteotomy for the painful degenerative varus knee conventionally involved a lateral closing wedge high tibial osteotomy (LCWHTO) for which bone staples and protection in plaster of Paris were routine methods of fixation and support. These established techniques have now been largely superseded by techniques of medial opening wedge high tibial osteotomy (MOWHTO), lateral closing wedge distal femoral osteotomy (LCWDFO) or a combination of the two with double level osteotomy (DLO). These techniques have been accompanied by the invention of angle stable locking plate fixators which have permitted earlier range of movement exercise and weight-bearing to enhance rehabilitation of patients. Development of new radiology techniques has led to the planning of osteotomies via PACS annotation or by digital software planning platforms. Computer navigation and patient specific instrumentation technologies have introduced options for improving accuracy and precision. Indications have broadened as experience has been gained and greater awareness of complications has led to fine tuning of technical procedures and modification of medical treatments for prevention of adverse events. Whilst convention has changed, this consensus does not intend to suggest that a lateral closing wedge high tibial osteotomy may not be the preferred option in specific situations. The advent of modern fixation methods reduces some of the inherent fallibility of previous routine practice which may therefore be a thoroughly appropriate strategy in the correct setting. Similarly, the convention adopted in this consensus for distal femoral osteotomy will be the lateral closing wedge procedure as this is the logical procedure for this indication. This consensus acknowledges that each patient has different characteristics, deformity, severity of arthritis severity and indication for osteotomy surgery. Therefore, an individualized approach is promoted which incorporates the degree of deformity according to Paley and radiologic arthritis classification grading OA. This consensus does not purport to provide a specific prescription with precise advice for each patient but offers general 2 advice. It is a work of best practice guidance and not a list of strict guidelines. The intention is to describe the current perceived best 'every day' mainstream practice in osteotomy for the painful degenerate varus knee. The terminology we have chosen around the most common procedure-high tibial osteotomy reflects popular convention. Whilst the word 'high' is not necessarily as precise an anatomical term as the word 'proximal', we have acknowledged that the abbreviation 'HTO' has usually been preferred in the orthopaedic literature to another accepted term of 'PTO'. This was also reflected in our consensus process with frequent reference to literature and discussions where this choice of terminology was accepted. Whilst substantial elements of current osteotomy practice are built on solid foundations with a strong scientific evidence base there are ever greater choices available to the inexperienced surgeon and accompanying areas where robust scientific evidence is absent. So, in addition to scrutiny of the scientific evidence this consensus also draws upon the knowledge of experts in the field with an in-depth experience of indications, planning, surgical strategy, rehabilitation and complications over a period of years in busy osteotomy practices. This consensus does not attempt to cover the expanding variety and scope of highly specialized periarticular osteotomy techniques nor their extended indications. It is a work directed at the surgeon with an 'every day' osteotomy practice to provide the clearest statements possible to educate, guide and instruct. Methodology: The aim of the ESSKA consensus is to provide guidance to the everyday knee surgeon for the most common application of osteotomy around the knee: the painful, degenerative varus joint. This is a "Formal Consensus" (derived from a Delphi methodology) to address 5 specific sections upon the subject of osteotomy around the knee for this application. The sections are Indications, Planning, Surgical Strategy, Rehabilitation and Complications. The project steering group was formed by the Osteotomy committee of ESSKA, and 2 further osteotomy experts chosen for their skillset of literature analysis. 5 experienced osteotomy experts from the committee formed the Questions Group. This group formulated a series of enquiries to cover the relevant and important aspects of osteotomy surgery under each of the headings above. All sections were then individually allocated to a different osteotomy expert whose brief it was to scrutinize the available scientific evidence in the orthopaedic literature and to distill the important and relevant findings. These 5 surgeons, the Literature Group, reported back to the Questions Group who then formulated statements drawn from the scientific evidence and from their own expert opinion. The respective statements were given a scientific grade based upon existing literature (screened from 2000-2020) and their expert opinion. Grade A: high scientific level Grade B: scientific presumption Grade C: low scientific level Grade D: expert opinion 3 A first draft was reviewed and amended twice by another independent panel of 26 experienced osteotomy surgeons (rating group). The final text underwent a second review process by an additional peer review group comprising 50 clinicians and clinical scientists from different European countries. This complex and long process has two main advantages. It limits any individual or organizational bias or conflict of interest, and it may have a better chance of general acceptance due to the involvement of a large number of participants of different countries. This "consensus investigation" has attempted to bring some light into these mundane but extremely important clinical entities. In addition, the recommendations are presented free from economic constraints. We hope the following recommendations will consider these messages, avoid any conflicting or political statements, and provide a well-balanced treatment instruction for the 'every day' surgeon undertaking osteotomy surgery for patients with a painful degenerative varus knee.
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... Early bone healing with a stimulatory device may also accelerate the weight bearing activities [17]. Accelerated rehabilitation protocols for OWHTO were introduced and lead to earlier improvement of the clinical results [15,18]. In elderly patients, recent accelerated postoperative rehabilitation programs seems to work in favor of preventing muscle weakness and increasing RTS. ...
Return to sports activity after opening wedge high tibial osteotomy in patients aged 70 years and older
Article
Full-text available
  • Sep 2021
  • J Orthop Surg Res
Background The purpose of this study was to evaluate return to sports (RTS) after opening wedge high tibial osteotomy (OWHTO) in elderly patients and associated factors affecting RTS. Methods Seventy-four patients (mean age 68 years) who underwent OWHTO were enrolled. Clinical outcomes were evaluated using the Knee Society Score (KSS). Patients were asked regarding types of sports activities and their levels of participation within preoperative 1 year and postoperative 1 year. Levels of participation in sports and recreational activities were examined using the Tegner activity scale. The outcomes were compared between two age groups (≥ 70 years vs. < 70 years). Results Of the 74 patients overall, 59 participated in at least one sport preoperatively, and 55 returned to sports postoperatively (RTS 93%). The KSS knee score and function score were significantly improved after surgery in both age groups ( P < 0.05), but no significant differences were found between the age groups. The Tegner activity scales for ≥ 70 years and < 70 years were 2.9 ± 1.1 and 4.0 ± 1.9 preoperatively ( P < 0.01) and 2.7 ± 1.2 and 3.3 ± 1.4 postoperatively ( P = 0.16), respectively. RTS was reported by 24 of 25 (96.0%) in the age < 70 years group and 31 of 34 (91.2%) in the age ≥ 70 years group. Majority of age ≥ 70 years participated in low-impact sports preoperatively and returned to the same impact level postoperatively. Conclusions The rate of RTS after OWHTO was high in patients aged 70 years and older with low-impact level. OWHTO is a preferred surgical option for elderly patients who desire RTS.
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Effects of 24 Weeks Combined Rehabilitation Exercise Program on Functional Recovery in Obsess High Tibial Osteotomy Patients
Article
Full-text available
  • Apr 2022
OBJECTIVES This study aims to investigate the effects of a 24 weeks combined rehabilitation exercise program on the subjective questionnaire, isokinetic muscle function test and dynamic balance test of high tibial osteotomy patients with normal weights and obese individuals.METHODS Sixteen tibial osteotomy patients were recruited in the study. They were divided into two groups(normal weight group[n=8] or obesity weight group[n=8]). A pre-test consisting of subjective questionnaire, isokinetic muscle function test and Y balance test. Using the same test in 12 weeks, 24 weeks after the surgery. All groups completed the rehabilitation exercise program for the duration of 24 weeks.RESULTS The significant interaction was observed between group and time on the involve bilateral flexor strength deficits ( p =.045) and the posteromedial reach distance ( p =.041).CONCLUSIONS These results suggest that a 24 weeks rehabilitation exercise program is needed after high tibial osteotomy in order to restore the same level of activity as before surgery.
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Vancomycin-soaked femoral head allograft in opening wedge high tibia osteotomy enables earlier postoperative recovery and reduces infection rates compared to allogenic bone chips
Article
  • Feb 2022
Purpose: To investigate the benefits of vancomycin-soaked femoral head allograft versus allogenic bone chips as an osteotomy gap filler in reducing infection rates and perioperative pain control after medial opening wedge high tibial osteotomy (MOW-HTO). Methods: Retrospective analysis of 114 knees that underwent MOW-HTO between 2013 and 2020. Osteotomy gaps were filled with vancomycin-soaked femoral head allograft (Study Group) or allogenic bone chips (Control Group). Both groups received systemic antibiotics. Perioperative parameters studied included pain, blood loss, length of stay, postoperative day (POD1) pain scores at rest, with activity as well as ambulatory distance. Patients in the Study Group were also followed up prospectively and clinical outcome scores, namely Knee Society Score, Oxford knee score (OKS) and Physical and Mental Component of the Short-Form 36 Questionnaire (PCS and MCS, respectively). Statistical analyses using Student's T-test were performed between the groups. Results: Patients of the study group had significantly better POD1 visual analogue scale (VAS) at rest (0.9 ± 1.6 vs 2.9 ± 1.2, p < 0.001) as well as when active (3.0 ± 1.9 vs 5.8 ± 1.5, p < 0.001). A greater proportion of patients in the study group ambulated on POD 1, (90.6% vs 26.0%, p < 0.001). Of those who ambulated on POD1, study group patients managed to cover a greater ambulatory distance (13.9 ± 7.4 m vs 8.4 ± 9.3 m, p < 0.05). The proportion of study group patients requiring patient-controlled analgesia (PCA) was also significantly less compared to the control group (32.8% vs 58.0%, p < 0.05). Of those requiring PCA, the amount of morphine requirement was also significantly reduced in the group with vancomycin-soaked allograft (8.7 ± 8.1 mg vs 23.9 ± 33.0 mg, p < 0.05). The study group also had a reduced length of stay (3.5 ± 2.0 days vs 5.5 ± 2.6 days, p < 0.001). Patients in the study group demonstrated significant improvement in Knee Society Knee Score (KSKS), OKS, PCS and MCS at 12 months postoperatively. The study group had a significantly reduced incidence of superficial wound infections compared to the control group (3.1% vs 18.0%, p < 0.05). Conclusion: Vancomycin-soaked femoral head allograft reduced superficial and deep wound infections in MOW-HTO. It was also effective in reducing postoperative pain, thereby enabling early ambulation and shorter hospital stays. Level of evidence: Retrospective comparative study, III.
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Polyetheretherketone for orthopedic applications: a review
Article
  • Jun 2021
Polyetheretherketone (PEEK) has been widely used as substitute for metal in implants, especially in orthopedic surgery. Popular clinical applications of PEEK implants include interbody fusion and instrumentations in spinal surgery, component alternatives in joint arthroplasty, interference screws and fixation implants for osteotomy in sports surgery, and fracture implants for osteosynthesis. Several modification methods such as materials incorporation, surface treatments, and manufacturing processes are also available to overcome the bio-inertness of PEEK and improve its osseointegration and clinical performance. Furthermore, PEEK has prospective therapeutic applications as a carrier for bioactive agent and material for 3D printing. This short review summarizes recent studies and applications of PEEK materials in orthopedic surgery.
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High tibial osteotomy performed with PEEK implant demonstrated a failure rate of 28%
Article
Full-text available
  • Nov 2020
Objectives Opening-wedge high tibia osteotomies (HTO) can be technically challenging. The HTO iBalance system was designed to reduce vascular complications and to avoid secondary plate removal. The purpose of the study was to evaluate the performance of the HTO iBalance system in patients with symptomatic medial osteoarthritis and varus malalignment. Methods The study was performed as a retrospective cohort study investigating a consecutive series of patients who underwent HTO with the iBalance system performed by a single surgeon from August 2013 to March 2016 at Zealand University Hospital, Koege, and Aleris-Hamlet Hospital. The primary outcome was the degree of realignment. The secondary outcome was Knee injury and Osteoarthritis Outcome Score (KOOS). Follow-up was performed at mean (SD) 25 (9.7) months. Weight-bearing long-leg standing radiographs were taken before surgery and at follow-up. Failure was defined as collapse of the HTO defined as a correction <50% of the intended correction at time of follow-up. Logistic regression was used to identify risk factors for failure. Results 44 patients and a total of 47 knees were included in this study. Preoperatively the mechanical axis was a mean (SD) 5.8° (2.9) varus and postoperatively 2.3° (3.7) varus . The HTO failed in 13 of 47 knees (28%). Patients with failure showed no statistically significant differences to non-failure in any KOOS subscore (p>0.05). American Society of Anesthesiologists (ASA) score (p=0.01) and body mass index (BMI) (p=0.05) were correlated with failure, whereas bone transplantation and smoking were not. Conclusion In this study, the failure rate of HTO was 28%. High BMI and ASA-score were the only risk factors associated with failure while bone grafting and smoking were not. Level of evidence Retrospective cohort study, level III.
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Effect of Computer Navigation on Accuracy and Reliability of Limb Alignment Correction following Open-Wedge High Tibial Osteotomy: A Meta-Analysis
Article
Full-text available
Background It is unclear whether computer navigation can improve the accuracy and reliability of targeted lower limb alignment correction following open-wedge high tibial osteotomy (HTO). This meta-analysis was designed to compare the accuracy and reliability of limb alignment correction between computer navigated and conventional open-wedge HTOs. Methods Studies that compared postoperative coronal alignment, including mechanical axis (MA) and weight bearing line (WBL) ratio, outliers of alignment correction, and change in tibial posterior slope, following open-wedge HTO performed using computer navigated and conventional methods were included. Results Ten studies were included in the meta-analysis. The MA (0.93°; 95% confidence interval [CI]: 0.45–1.41°; P < 0.001) and WBL ratio (1.5%; 95% CI: 0.03–2.98%; P = 0.048) were significantly greater for computer navigated HTO than for conventional HTO. Outliers of alignment correction after surgery were significantly lower in patients who underwent computer navigated HTO than in those who underwent conventional HTO (odds ratio: 0.25; 95% CI: 0.08–0.79; P = 0.02). Changes in posterior tibial slope from before to after surgery, however, were similar for the two approaches. Conclusion Computer navigated HTO resulted in slightly more valgus postoperative alignment and effectively reduced outliers of alignment correction but had no effect on change in posterior tibial slope when compared with conventional HTO.
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Effect and safety of early weight-bearing on the outcome after open-wedge high tibial osteotomy: a systematic review and meta-analysis
Article
Full-text available
  • Jul 2017
  • ARCH ORTHOP TRAUM SU
Introduction: The purpose of this systematic review and meta-analysis was to evaluate the effectiveness and safety of early weight-bearing by comparing clinical and radiological outcomes between early and traditional delayed weight-bearing after OWHTO. Materials and methods: A rigorous and systematic approach was used. The methodological quality was also assessed. Results that are possible to be compared in two or more than two articles were presented as forest plots. A 95% confidence interval was calculated for each effect size, and we calculated the I (2) statistic, which presents the percentage of total variation attributable to the heterogeneity among studies. The random-effects model was used to calculate the effect size. Results: Six articles were included in the final analysis. All case groups were composed of early full weight-bearing within 2 weeks. All control groups were composed of late full weight-bearing between 6 weeks and 2 months. Pooled analysis was possible for the improvement in Lysholm score, but there was no statistically significant difference shown between groups. Other clinical results were also similar between groups. Four studies reported mechanical femorotibial angle (mFTA) and this result showed no statistically significant difference between groups in the pooled analysis. Furthermore, early weight-bearing showed more favorable results in some radiologic results (osseointegration and patellar height) and complications (thrombophlebitis and recurrence). Conclusion: Our analysis supports that early full weight-bearing after OWHTO using a locking plate leads to improvement in outcomes and was comparable to the delayed weight-bearing in terms of clinical and radiological outcomes. On the contrary, early weight-bearing was more favorable with respect to some radiologic parameters and complications compared with delayed weight-bearing.
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Comparing the Accuracy of High Tibial Osteotomies Between Computer Navigation and Conventional Methods
Article
Full-text available
  • Dec 2016
Background The accuracy of correction has been shown to be an important determinant in long term outcomes of patients who were treated with a medial open-wedge high tibial osteotomy (HTO) who suffer from unicompartmental osteoarthritis (OA). Computer navigation systems have the potential to improve surgical precision. The purpose of this study was to compare radiographic outcomes between patients treated with a navigation system and those treated through conventional methods of assessing alignment intra-operatively. The null hypothesis was that the method of assessing the alignment intra-operatively would make no difference in the accuracy of correction. Methods In this retrospective study, 107 patients with medial varus OA who were managed by open-wedge HTO were included. Of the 107 patients, 41 were treated using an intraoperative navigation system and 66 were treated using conventional methods. Pre-operative and post-operative single-leg, long-leg standing alignment films were used to determine the extent of pre-operative varus deformity and the post-surgical correction achieved compared to the predetermined target range. Results The navigational system had 8 instances of software malfunction (19.5%) intra-operatively and correction was determined using the cable method. These results were analyzed as part of the conventional group. Post-operative radiographic differences were significant between the two groups. In the navigation group, 75.8% of patients were corrected within the target range compared to 66.2% in the conventional group. More patients were also under corrected (to the point of remaining in varus) using conventional methods compared to a navigation system. There was no statistically significant difference in the degree of correction in the sagittal plane between the two groups. Regardless of the method used for checking alignment intra-operatively, there was a statistically significant difference in post-operative weight-bearing measurements when the surgeon had intra-operative axial loading versus when they did not. Conclusion For coronal plane corrections, the navigation system was shown to have greater success in achieving the desired correction value and in having fewer patients who were under corrected. Despite the measurement technique a surgeon chooses to assess the accuracy of correction, axial loading the extremity in order to simulate the weight bearing film alignment post-operatively is important to maximize the accuracy of correction needed.
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Computer-Assisted Navigation in High Tibial Osteotomy
Article
Full-text available
  • Dec 2016
Computer-assisted navigation is used to improve the accuracy and precision of correction angles during high tibial osteotomy. Most studies have reported that this technique reduces the outliers of coronal alignment and unintended changes in the tibial posterior slope angle. However, more sophisticated studies are necessary to determine whether the technique will improve the clinical results and long-term survival rates. Knowledge of the navigation technology, surgical techniques and potential pitfalls, the clinical results of previous studies, and understanding of the advantages and limitations of the computer-assisted navigation are crucial to successful application of this new technique in high tibial osteotomy. Herein, we review the evidence concerning this technique from previous studies.
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High Tibial Osteotomy: A Systematic Review and Current Concept
Article
Full-text available
  • Jul 2016
High tibia osteotomy is a common procedure in orthopedic surgery. A precise overview on indications, patients selection, pre-operative planning, surgical technique, methods of fixation, and complications have been presented. This paper focused on the points that should be considered to achieve good long-term outcomes. High tibia osteotomy is a common procedure in orthopedic surgery. A precise overview on indications, patients selection, pre-operative planning, surgical technique, methods of fixation, and complications have been presented. This paper focused on the points that should be considered to achieve good long-term outcomes.
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High tibial osteotomy for the treatment of medial osteoarthritis of the knee with new iBalance system: 2 years of follow-up
Article
Full-text available
  • Jul 2016
  • EUR J ORTHOP SURG TR
Background A new system for performing open-wedge high tibial osteotomy (HTO), the iBalance HTO System-Arthrex, has been recently developed in order to make the surgery more reproducible and safe. The aim of this study was to determine the short-term outcomes of the iBalance technique in medial compartment osteoarthritis and varus malalignment of the knee. Methods Fifteen patients with a mean age of 50.7 years (SD 5.09), affected by symptomatic varus knee, with medial compartment osteoarthritis (1–2 Ahlbäck degree), were treated with iBalance HTO between July 2011 and February 2012 and evaluated retrospectively. Patients were assessed against the following benchmarks: subjective International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and VAS for pain and Tegner scores, along with X-rays and MRI, before surgery and after a 2-year follow-up. Results No severe intraoperative complications or implant failures occurred. The mean preoperative scores were as follows: subjective IKDC 66.8 (SD 1.18), KOOS 61.3 (SD 0.86), Vas for pain 8.6 (SD 1.72) and Tegner 4.1 (SD 2.06), while at follow-up the scores were 73.6 (SD 1.01), 88.1 (SD 1.23), 2.9 (SD 2.35) and 3.1 (SD 1.83), respectively. Correction ranged between 3° and 8°. All patients showed complete articular recovery, no loss of correction, no substantial variation in A/P slope and no hardware problems. Conclusions iBalance proved to be effective and safe and produced good overall results. Consolidation and osseointegration of the system took place rapidly, while recovery was precocious, comparable with traditional methods and with no severe complications. Level of evidence Case series, Level IV.
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Determination of the Accuracy of Navigated Kinematic Unicompartmental Knee Arthroplasty: A 2-Year Follow-Up
Article
  • Nov 2016
Background: Unicompartmental knee arthroplasty (UKA) lacks history of patient satisfaction and research addressing technique validity. The aim of this study was to determine minimally invasive navigated kinematic UKA accuracy by comparing postoperative limb alignment with preoperative stress values. Methods: A single-center retrospective study was conducted on 53 consecutive patients (postoperative alignment: varus n = 51, valgus n = 2) who underwent computer navigation assisted UKA. Two patient groups (A and B) predetermined by joint deformity cut-off points (B included valgus deformity) underwent preoperative magnetic resonance imaging and x-ray evaluation to assess limb alignment and exclude lateral and patellofemoral osteoarthritis. Preoperative and postoperative joint alignment, stress value, and range of movement were recorded with navigation. Outcome measures include comparison of postoperative alignment to the preoperative stress values for varus and valgus postoperative alignment groups and preoperative and/or postoperative Western Ontario and McMaster Universities and Knee Society Score evaluations. Results: Minor systematic bias was found between stress value and postoperative alignment; however, the magnitude of difference was clinically acceptable. Score evaluations, prosthesis size or alignment didn't differ between groups. Furthermore, there was no significant increase in range of movement at 2 years. There was a high degree of agreement between stress value and postoperative alignment values suggesting strong validity for the surgical technique to determine optimal postoperative alignment. Conclusion: This study validates our surgical technique. Minimally invasive navigated UKA allows us to predict predisease alignment and recreates it with high accuracy. Our clinical results at 2 years are comparable with other published data.
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Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy
Article
  • Mar 2016
Purpose This study documented the healing potential of degenerated articular cartilage after opening-wedge valgus high tibial osteotomy (HTO) in patients with osteoarthritis of the knee. It was hypothesized that regeneration of articular cartilage is affected by several factors, including preoperative cartilage degeneration grade, difference between the medial femoral condyle (MFC) and the medial tibial condyle (MTC), and postoperative knee alignment. Methods Medial opening-wedge valgus HTO was performed in 131 knees of 100 patients (mean age 66 ± 7.7 years). Initial arthroscopy was performed at the time of HTO, and a second-look arthroscopy was performed at the time of plate removal (20.8 ± 6.5 months after HTO). Status of articular cartilage was assessed according to the ICRS grade. Cartilage regeneration was also evaluated by the presence of newly formed cartilaginous tissue. All subjects were followed up postoperatively at 2 years for assessment of clinical and radiographic outcomes. Results The number of subjects in ICRS grade 1/2/3/4 was significantly altered from 0/11/53/67 preoperatively to 14/21/56/40 postoperatively in the MFC (P < 0.05) and 0/12/62/57 preoperatively to 9/24/64/34 postoperatively in the MTC (P < 0.05). Newly formed cartilaginous tissue was found in 71 % of MFCs and 51 % of MTCs. Incidence of cartilage regeneration was significantly higher in lower BMI cases, MFC, preoperatively advanced ICRS grade and overcorrected knees. Age, gender and clinical outcomes did not affect cartilage regeneration. Conclusion Cartilage regeneration in degenerated articular cartilage is induced after opening-wedge valgus HTO, which is affected by BMI, the difference between the MFC and MTC, preoperative cartilage degeneration grade, and postoperative limb alignment. Therefore, patient selection by BMI rather than age, and surgical techniques maintaining valgus knee alignment should be considered for cartilage regeneration. Level of evidence Level IV, therapeutic case series.
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Surgical accuracy in high tibial osteotomy: coronal equivalence of computer navigation and gap measurement
Article
  • Jan 2016
Purpose Medial opening wedge high tibial osteotomy (MOW HTO) is now a successful operation with a range of indications, requiring an individualised approach to the choice of intended correction. This manuscript introduces the concept of surgical accuracy as the absolute deviation of the achieved correction from the intended correction, where small values represent greater accuracy. Surgical accuracy is compared in a randomised controlled trial (RCT) between gap measurement and computer navigation groups. Methods This was a prospective RCT conducted over 3 years of 120 consecutive patients with varus malalignment and medial compartment osteoarthritis, who underwent MOW HTO. All procedures were planned with digital software. Patients were randomly assigned into gap measurement or computer navigation groups. Coronal plane alignment was judged using the mechanical tibiofemoral angle (mTFA), before and after surgery. Absolute (positive) values were calculated for surgical accuracy in each individual case. Results There was no significant difference in the mean intended correction between groups. The achieved mTFA revealed a small under-correction in both groups. This was attributed to a failure to account for saw blade thickness (gap measurement) and over-compensation for weight bearing (computer navigation). Surgical accuracy was 1.7° ± 1.2° (gap measurement) compared to 2.1° ± 1.4° (computer navigation) without statistical significance. The difference in tibial slope increases of 2.7° ± 3.9° (gap measurement) and 2.1° ± 3.9° (computer navigation) had statistical significance (P < 0.001) but magnitude (0.6°) without clinical relevance. Conclusion Surgical accuracy as described here is a new way to judge achieved alignment following knee osteotomy for individual cases. This work is clinically relevant because coronal surgical accuracy was not superior in either group. Therefore, the increased expense and surgical time associated with navigated MOW HTO is not supported, because meticulously conducted gap measurement yields equivalent surgical accuracy. Level of evidence I.
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Complications associated with opening wedge high tibial osteotomy — A review of the literature and of 15years of experience
Article
  • Nov 2015
  • KNEE
Background: Complication rates following opening wedge high tibial osteotomy (OWHTO) is an issue that has not been comprehensively addressed in current literature. Methods: We performed a retrospective study of local patients who underwent OWHTO for isolated medial compartment knee osteoarthritis from 1997 to 2013. We analysed survivorship and complication rates and compared this to a literature review of previously reported data. Results: One hundred and fifteen patients met the inclusion criteria. Mean follow-up=8.4years. Mean age=47 (range 32 to 62). Mean Body Mass Index (BMI)=29.1 (range 20.3 to 40.2). Devices used consisted of Tomofix (72%), Puddu plate (21%) and Orthofix (seven percent) (no significant differences in age/sex/BMI). Wedge defects were filled with autologous graft (30%), Chronos (35%) or left empty (35%). Five years survival rate (without requiring conversion to arthroplasty)=80%. Overall complication rate=31%. Twenty five percent of patients suffered 36 complications including minor wound infections (9.6%), major wound infections (3.5%), metalwork irritation necessitating plate removal (seven percent), non-union requiring revision (4.3%), vascular injury (1.7%), compartment syndrome (0.9%), and other minor complications (four percent). No thromboembolic complications were observed. Conclusion: No significant differences existed in complication rates following OWHTO relative to BMI, implant type, type of bone graft used or patient age at surgery. When the complications from OWHTO were analysed closely they appear higher than previously reported in the literature; however serious complications appear rare. LEVEL OF EVIDENCE 3: Retrospective cohort study.
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