Alignment changes after open-wedge high tibial osteotomy result in offloading in the patellofemoral joint: a SPECT/CT analysis

Abstract

Purpose

The patellofemoral (PF) joint may be adversely affected by medial open-wedge high tibial osteotomy (OWHTO). This study aimed to evaluate the PF compartmental changes using combined single-photon emission computed tomography (SPECT) and conventional computed tomography (CT) after OWHTO to provide clinical guidance regarding the PF joint pressure and force.

Methods

Patients with medial osteoarthritis and varus malalignment > 5° were treated using OWHTO. Patients with a minimum 2-year follow-up were included in the study. The patellar positions were evaluated based on the radiographic parameters. The changes in chondral lesions during second-look arthroscopic examination were evaluated, and the PF joint arthritis grade was recorded on patellar Merchant radiographs using Kellgren–Lawrence classification. The PF compartmental changes according to SPECT/CT analysis after OWHTO were evaluated in all patients. The scintigraphic uptake was graded on four scales. Patients were divided into improved and unimproved groups according to the PF compartmental grade using the SPECT/CT uptake grading system.

Results

At a mean follow-up period of 47.0 months (range 25–74 months), the mean mechanical femorotibial angle changed significantly from varus 6.3° (range 5–12°) to valgus 2.6° (range 0–8°); p < 0.001) postoperatively. The radiological parameters presenting patellar positions, including the tibial slope, patellar convergence angle, and lateral tilt angle, did not change significantly between the preoperative values and the 2-year follow-up values. The mean patellar height significantly decreased (0.07 ± 0.14, p = 0.001 according to the Blackburn–Peel index and 0.32 ± 0.23, p < 0.001 using the modified Insall–Salvati ratio). The average tibial tubercle to trochlear groove (TT–TG) distance significantly decreased from 14.1 to 12.2 mm (p < 0.001). The Q angle also significantly decreased from 9.8o to 7.7o (p = 0.008). Chondral lesions of the patella and trochlear groove revealed significant deterioration; at 2 years after OWHTO, the arthritic grades of the PF joints worsened significantly, as determined by radiography (p = 0.007). Scintigraphic uptake in the PF joint was significantly lower (from 2 to 1) at 2 years postoperatively compared to that immediately after the index operation (p < 0.001). Only 4 of 56 (7.1%) patients showed increased uptake. Comparison between the improved and unimproved groups according to scintigraphic uptake changes revealed that the changes in the cartilage status on the patellar undersurface and TT–TG distance were the most significant predictive factors of increased scintigraphic uptake in the PF joint after OWHTO.

Conclusion

Alignment correction by OWHTO result in PF compartment offloading and should be considered when identifying the surgical indications for OWHTO.

Level of evidence

Therapeutic, Level IV.

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References

  1. 1.

    Chae DJ, Shetty GM, Lee DB, Choi HW, Han SB, Nha KW (2008) Tibial slope and patellar height after opening wedge high tibia osteotomy using autologous tricortical iliac bone graft. Knee 15:128–133

    Article  Google Scholar 

  2. 2.

    Dordevic M, Hirschmann MT, Rechsteiner J, Falkowski A, Testa E, Hirschmann A (2016) Do chondral lesions of the knee correlate with bone tracer uptake by using SPECT/CT? Radiology 278:223–231

    Article  Google Scholar 

  3. 3.

    Ducat A, Sariali E, Lebel B, Mertl P, Hernigou P, Flecher X et al (2012) Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study. Orthop Traumatol Surg Res 98:68–74

    CAS  Article  Google Scholar 

  4. 4.

    El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S (2010) Patellar height and posterior tibial slope after open- and closed-wedge high tibial osteotomy: a radiological study on 100 patients. Am J Sports Med 38:323–329

    Article  Google Scholar 

  5. 5.

    Elahi S, Cahue S, Felson DT, Engelman L, Sharma L (2000) The association between varus-valgus alignment and patellofemoral osteoarthritis. Arthritis Rheum 43:1874–1880

    CAS  Article  Google Scholar 

  6. 6.

    Elias JJ, Kilambi S, Goerke DR, Cosgarea AJ (2009) Improving vastus medialis obliquus function reduces pressure applied to lateral patellofemoral cartilage. J Orthop Res 27:578–583

    Article  Google Scholar 

  7. 7.

    Felli L, Formica M, Lovisolo S, Capello AG, Alessio-Mazzola M (2018) Clinical Outcome of Arthroscopic Lateral Retinacular Release for Symptomatic Bipartite Patella in Athletes. Arthroscopy 34:1550–1558

    Article  Google Scholar 

  8. 8.

    Fujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am 10:585–608

    CAS  PubMed  Google Scholar 

  9. 9.

    Gaasbeek R, Welsing R, Barink M, Verdonschot N, van Kampen A (2007) The influence of open and closed high tibial osteotomy on dynamic patellar tracking: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 15:978–984

    Article  Google Scholar 

  10. 10.

    Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Nakanishi A, Ueoka K (2017) Patellofemoral osteoarthritis progression and alignment changes after open-wedge high tibial osteotomy do not affect clinical outcomes at mid-term follow-up. Arthroscopy 33:1832–1839

    Article  Google Scholar 

  11. 11.

    Hinterwimmer S, Feucht MJ, Paul J, Kirchhoff C, Sauerschnig M, Imhoff AB et al (2016) Analysis of the effects of high tibial osteotomy on tibial rotation. Int Orthop 40:1849–1854

    Article  Google Scholar 

  12. 12.

    Hirschmann MT, Iranpour F, Davda K, Rasch H, Hugli R, Friederich NF (2010) Combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT): clinical value for the knee surgeons? Knee Surg Sports Traumatol Arthrosc 18:341–345

    Article  Google Scholar 

  13. 13.

    Hudson Z, Darthuy E (2009) Iliotibial band tightness and patellofemoral pain syndrome: a case-control study. Man Ther 14:147–151

    Article  Google Scholar 

  14. 14.

    Hurley MV, Scott DL, Rees J, Newham DJ (1997) Sensorimotor changes and functional performance in patients with knee osteoarthritis. Ann Rheum Dis 56:641–648

    CAS  Article  Google Scholar 

  15. 15.

    Javidan P, Adamson GJ, Miller JR, Durand P Jr, Dawson PA, Pink MM et al (2013) The effect of medial opening wedge proximal tibial osteotomy on patellofemoral contact. Am J Sports Med 41:80–86

    Article  Google Scholar 

  16. 16.

    Jingbo C, Mingli F, Guanglei C, Zheng L, Shuai A, Jiang H (2019) Patellar height is not altered when the knee axis correction is less than 15 degrees and has good short-term clinical outcome. J Knee Surg. https://doi.org/10.1055/s-0039-1681051

    Article  PubMed  Google Scholar 

  17. 17.

    Kan H, Arai Y, Kobayashi M, Nakagawa S, Inoue H, Hino M et al (2017) Radiographic measurement of joint space width using the fixed flexion view in 1,102 knees of japanese patients with osteoarthritis in comparison with the standing extended view. Knee Surg Relat Res 29:63–68

    Article  Google Scholar 

  18. 18.

    Kaper BP, Bourne RB, Rorabeck CH, Macdonald SJ (2001) Patellar infera after high tibial osteotomy. J Arthroplasty 16:168–173

    CAS  Article  Google Scholar 

  19. 19.

    Kijowski R, Blankenbaker D, Stanton P, Fine J, De Smet A (2006) Correlation between radiographic findings of osteoarthritis and arthroscopic findings of articular cartilage degeneration within the patellofemoral joint. Skeletal Radiol 35:895–902

    Article  Google Scholar 

  20. 20.

    Kim KI, Kim DK, Song SJ, Lee SH, Bae DK (2017) Medial open-wedge high tibial osteotomy may adversely affect the patellofemoral joint. Arthroscopy 33:811–816

    Article  Google Scholar 

  21. 21.

    Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163

    CAS  Article  Google Scholar 

  22. 22.

    Lee TQ, Sandusky MD, Adeli A, McMahon PJ (2002) Effects of simulated vastus medialis strength variation on patellofemoral joint biomechanics in human cadaver knees. J Rehabil Res Dev 39:429–438

    PubMed  Google Scholar 

  23. 23.

    Lee YS, Lee SB, Oh WS, Kwon YE, Lee BK (2016) Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 24:129–133

    Article  Google Scholar 

  24. 24.

    Leitch KM, Birmingham TB, Dunning CE, Giffin JR (2015) Medial opening wedge high tibial osteotomy alters knee moments in multiple planes during walking and stair ascent. Gait Posture 42:165–171

    Article  Google Scholar 

  25. 25.

    Lorberboym M, Ami DB, Zin D, Nikolov G, Adar E (2003) Incremental diagnostic value of 99mTc methylene diphosphonate bone SPECT in patients with patellofemoral pain disorders. Nucl Med Commun 24:403–410

    CAS  Article  Google Scholar 

  26. 26.

    Mainil-Varlet P, Aigner T, Brittberg M, Bullough P, Hollander A, Hunziker E et al (2003) Histological assessment of cartilage repair: a report by the Histology Endpoint Committee of the International Cartilage Repair Society (ICRS). J Bone Joint Surg Am 85:45–57

    Article  Google Scholar 

  27. 27.

    Mikesky AE, Meyer A, Thompson KL (2000) Relationship between quadriceps strength and rate of loading during gait in women. J Orthop Res 18:171–175

    CAS  Article  Google Scholar 

  28. 28.

    Mucha A, Dordevic M, Hirschmann A, Rasch H, Amsler F, Arnold MP et al (2015) Effect of high tibial osteotomy on joint loading in symptomatic patients with varus aligned knees: a study using SPECT/CT. Knee Surg Sports Traumatol Arthrosc 23:2315–2323

    Article  Google Scholar 

  29. 29.

    Mucha A, Dordevic M, Testa EA, Rasch H, Hirschmann MT (2013) Assessment of the loading history of patients after high tibial osteotomy using SPECT/CT–a new diagnostic tool and algorithm. J Orthop Surg Res 8:46

    Article  Google Scholar 

  30. 30.

    Murayama K, Nakayama H, Murakami T, Yoshiya S, Otsuki S, Tachibana T (2018) The effect of concomitant arthroscopic lateral retinacular release on postoperative patellar position and orientation in open wedge high tibial osteotomy. Knee Surg Relat Res 30:241–246

    Article  Google Scholar 

  31. 31.

    Nha KW, Shin YS, Kwon HM, Sim JA, Na YG (2019) Navigated versus conventional technique in high tibial osteotomy: a meta-analysis focusing on weight bearing effect. Knee Surg Relat Res. https://doi.org/10.5792/ksrr.17.090

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Prakash J, Seon JK, Woo SH, Jin C, Song EK (2016) Comparison of radiological parameters between normal and patellar dislocation groups in korean population: a rotational profile CT-based study. Knee Surg Relat Res 28:302–311

    Article  Google Scholar 

  33. 33.

    du Ro H, Lee HY, Chang CB, Kang SB (2015) Value of SPECT-CT imaging for middle-aged patients with chronic anterior knee pain. BMC Musculoskelet Disord 16:169

    Article  Google Scholar 

  34. 34.

    Samim M, Smitaman E, Lawrence D, Moukaddam H (2014) MRI of anterior knee pain. Skeletal Radiol 43:875–893

    Article  Google Scholar 

  35. 35.

    Schön SN, Afifi FK, Rasch H, Amsler F, Friederich NF, Arnold MP et al (2014) Assessment of in vivo loading history of the patellofemoral joint: a study combining patellar position, tilt, alignment and bone SPECT/CT. Knee Surg Sports Traumatol Arthrosc 22:3039–3046

    Article  Google Scholar 

  36. 36.

    Singerman R, Davy DT, Goldberg VM (1994) Effects of patella alta and patella infera on patellofemoral contact forces. J Biomech 27:1059–1065

    CAS  Article  Google Scholar 

  37. 37.

    Slevin O, Schmid FA, Schiapparelli F, Rasch H, Hirschmann MT (2018) Increased in vivo patellofemoral loading after total knee arthroplasty in resurfaced patellae. Knee Surg Sports Traumatol Arthrosc 26:1805–1810

    Article  Google Scholar 

  38. 38.

    van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW (1999) Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. Arthritis Rheum 42:1361–1369

    Article  Google Scholar 

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Acknowledgments

The authors would like to thank Oh YJ for his illustration.

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Correspondence to Byung Hoon Lee.

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Sim, J.A., Na, Y.G., Lee, B.K. et al. Alignment changes after open-wedge high tibial osteotomy result in offloading in the patellofemoral joint: a SPECT/CT analysis. Knee Surg Sports Traumatol Arthrosc (2020). https://doi.org/10.1007/s00167-020-06115-0

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Keywords

  • Alignment
  • Knee
  • Osteotomy
  • Patellofemoral joint
  • SPECT/CT