Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line
The purpose of the study was to describe the development of the surgical technique of double level osteotomy in patients with severe varus malalignment and to investigate the clinical and radiological outcome. It was hypothesized that good clinical results without a higher complication rate can be achieved by double level osteotomy to normalize joint angles and avoid joint line obliquity even in cases of progressed osteoarthritis.
Materials and methods
Between 2011 and 2014, 33 patients (37 knees) undergoing double level osteotomies (open wedge HTO and closed wedge DFO) were included; of these, 24 patients (28 knees) were available in mean of 18 ± 10 months for the follow-up examination. Indication was symptomatic varus malalignment and medial compartment osteoarthritis. Postoperatively, these patients were assigned to 20 kg partial weight-bearing using two crutches for 6 weeks followed by full weight-bearing. No braces or casts were used. Full weight-bearing long leg anteroposterior radiographs were obtained preoperatively, after 6 weeks and at the time of final follow-up. Mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA) and medial proximal tibia angle (MPTA) were measured. Clinical outcome was evaluated using Lequesne-, Lysholm-, Oxford-, and IKDC-score at the time of follow-up.
The preoperative mTFA of − 11 ± 3° increased to 0 ± 2° at final follow-up. The difference between mTFA-planning and final follow-up was − 2 ± 3° (p < 0.0006). At final follow-up, MPTA and mLDFA were 89.2 ± 2° and 87 ± 2°, respectively. The Lysholm, Oxford, Lequesne, and IKDC scores were 88 ± 13, 44 ± 3, 2 ± 2, and 77 ± 12, respectively.
This study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalises the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis.
Level of evidence
Case series, Level IV.
KeywordsDouble level osteotomy Osteotomy HTO DFO High tibial osteotomy Joint line obliquity
The gratitude of the authors goes to the participants who have made this study possible. Furthermore, the authors would particularly like to thank the staff of the Radiology Department of the BG Trauma Center Tübingen.
- 2.Lee OS, Ahn S, Ahn JH, Teo SH, Lee YS (2018) Effectiveness of concurrent procedures during high tibial osteotomy for medial compartment osteoarthritis: a systematic review and meta-analysis. Arch Orthop Trauma Surg 138(2):227–236. https://doi.org/10.1007/s00402-017-2826-4 CrossRefPubMedGoogle Scholar
- 3.Schroter S, Ihle C, Mueller J, Lobenhoffer P, Stockle U, van Heerwaarden R (2013) Digital planning of high tibial osteotomy. Interrater reliability by using two different software. Knee Surg Sports Traumatol Arthrosc 21(1):189–196. https://doi.org/10.1007/s00167-012-2114-3 CrossRefPubMedGoogle Scholar
- 5.Nakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K, Kambara S, Yoshiya S, Higa M (2018) Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc 26(6):1873–1878. https://doi.org/10.1007/s00167-017-4680-x CrossRefPubMedGoogle Scholar
- 7.Saragaglia D, Rubens-Duval B, Chaussard C (2007) [Computer-assisted combined femoral and tibial osteotomy for severe genu varum: early results in 16 patients]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur 93 (4):351–356 (MDOI-RCO-06-2007-93-4-0035-1040-101019-200520006 [pii]) Google Scholar
- 8.Nakayama H, Iseki T, Kanto R, Kambara S, Kanto M, Yoshiya S, Schröter S (2018) Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5103-3 CrossRefPubMedGoogle Scholar
- 13.Niinimaki TT, Eskelinen A, Mann BS, Junnila M, Ohtonen P, Leppilahti J (2012) Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees. J Bone Joint Surg Br 94(11):1517–1521. https://doi.org/10.1302/0301-620X.94B11.29601 CrossRefPubMedGoogle Scholar
- 15.Hernigou P, Duffiet P, Julian D, Guissou I, Poignard A, Flouzat-Lachaniette CH (2013) Outcome of total knee arthroplasty after high tibial osteotomy: does malalignment jeopardize the results when using a posterior-stabilized arthroplasty? Hss J 9(2):134–137. https://doi.org/10.1007/s11420-013-9344-x CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Brinkman JM, Freiling D, Lobenhoffer P, Staubli AE, van Heerwaarden RJ (2014) Supracondylar femur osteotomies around the knee. Patient selection, planning, operative techniques, stability of fixation, and bone healing. Orthopade 43(11):988–999. https://doi.org/10.1007/s00132-014-3036-1 CrossRefPubMedGoogle Scholar
- 19.Brinkman JM, Hurschler C, Agneskirchner JD, Freiling D, van Heerwaarden RJ (2011) Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations. Knee Surg Sports Traumatol Arthrosc 19(4):579–587. https://doi.org/10.1007/s00167-010-1281-3 CrossRefPubMedGoogle Scholar
- 20.Brinkman JM, Hurschler C, Staubli AE, van Heerwaarden RJ (2011) Axial and torsional stability of an improved single-plane and a new bi-plane osteotomy technique for supracondylar femur osteotomies. Knee Surg Sports Traumatol Arthrosc 19(7):1090–1098. https://doi.org/10.1007/s00167-010-1349-0 CrossRefPubMedGoogle Scholar
- 24.Visser J, Brinkman JM, Bleys RL, Castelein RM, van Heerwaarden RJ (2013) The safety and feasibility of a less invasive distal femur closing wedge osteotomy technique: a cadaveric dissection study of the medial aspect of the distal femur. Knee Surg Sports Traumatol Arthrosc 21(1):220–227. https://doi.org/10.1007/s00167-012-2133-0 CrossRefPubMedGoogle Scholar
- 34.Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, Helwig P, Suedkamp NP (2008) Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy 24(7):796–804CrossRefGoogle Scholar