Staged medial opening wedge high tibial osteotomy for bilateral varus gonarthrosis: biomechanical and clinical outcomes

Abstract

Purpose

(1) To evaluate the effect of staged bilateral medial opening wedge high tibial osteotomy (HTO) on established biomechanical risk factors for disease progression and on validated measures of pain and function and (2) To compare outcomes in patients having the second surgery staged within or beyond 12 months of the first surgery.

Methods

Thirty-seven patients with bilateral varus alignment and medial compartment osteoarthritis underwent staged bilateral medial opening wedge HTO (21 within and 16 beyond 12 months). Patients underwent full-limb standing anteroposterior radiographs to determine frontal plane alignment (mechanical axis angle) and three-dimensional gait analysis to estimate the distribution of load across the tibiofemoral compartments (external knee adduction moment). Patients also completed the Knee Injury and Osteoarthritis Outcomes Scores (KOOS), the Lower Extremity Functional Scale, the Short Form Health Survey and the six-minute walk test (6MWT). Patients (both limbs) were evaluated before and approximately 6, 12 and 24 months after each surgery.

Results

There were statistically and clinically significant changes in both limbs that were of similar magnitudes and that remained relatively stable over time postoperatively. Mean (95 % CI) improvements in outcomes were as follows. Mechanical axis angle: 9.4° (8.4°, 10.4°) (i.e. average change of both limbs), peak knee adduction moment: −1.7 %BW*Ht (−2.1, −1.4 %BW*Ht) (i.e. average change of both limbs), 6MWT: 36.7 m (19.4, 54.0 m), SF-12 Physical Component Summary: 12.0 (8.5, 15.5) and KOOS Pain: 25.4 (19.6, 31.2). Other than the shorter time period to reach maximum benefit of both surgeries, there were no remarkable differences at final assessment between patients having surgeries staged within or beyond 12 months.

Conclusions

The present findings demonstrate that patients with bilateral varus gonarthrosis experience marked improvements in established biomechanical risk factors for disease progression bilaterally (mechanical axis angles and external knee adduction moments), as well as clinically important improvements in patient-important outcomes, after staged medial opening wedge HTO. Current findings suggest no difference in outcomes for patients who have the second surgery staged within or beyond 12 months of the first surgery.

Level of evidence

IV.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. 1.

    Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P (2007) The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy 23:852–861

    PubMed  Article  Google Scholar 

  2. 2.

    Bennell KL, Bowles KA, Wang Y, Cicuttini F, Davies-Tuck M, Hinman RS (2011) Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis. Ann Rheum Dis 70:1770–1774

    PubMed  Article  Google Scholar 

  3. 3.

    Binkley J, Stratford P, Lott S, Riddle D (1999) The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther 79:371–383

    PubMed  CAS  Google Scholar 

  4. 4.

    Birmingham TB, Hunt MA, Jones IC, Jenkyn TR, Giffin JR (2007) Test-retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis Rheum 57:1012–1017

    PubMed  Article  Google Scholar 

  5. 5.

    Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K, Jenkyn TR, Fowler PF (2009) Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, and patient-reported outcomes. Arthritis Rheum 61:648–657

    PubMed  Article  Google Scholar 

  6. 6.

    Boulougouris A, Birmingham TB, Moyer RF, Jones IC, Giffin J (2011) Increased dynamic knee joint load on the non-operative limb after high tibial osteotomy (Abstract). Osteoarth Cart 19(Suppl 1):17

    Article  Google Scholar 

  7. 7.

    Chang A, Hurwitz D, Dunlop D, Song J, Cahue S, Hayes K, Sharma L (2007) The relationship between toe-out angle during gait and progression of medial tibiofemoral osteoarthritis. Ann Rheum Dis 66:1271–1275

    PubMed  Article  PubMed Central  Google Scholar 

  8. 8.

    Cohen J (1988) Statistical power analysis for the behavioural sciences, 2 edn. Lawrence Erlbaum Associates, Hillside, NJ

  9. 9.

    DeMeo PJ, Johnson EM, Chiang PP, Flamm AM, Miller MC (2010) Midterm follow-up of opening-wedge high tibial osteotomy. Am J Sports Med 38:2077–2084

    PubMed  Article  Google Scholar 

  10. 10.

    Dugdale TW, Noyes FR, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264

    PubMed  Google Scholar 

  11. 11.

    Fowler P, Tan J, Brown G (2000) Medial opening wedge high tibial osteotomy: how I do it. Oper Tech Sports Med 8:32–38

    Article  Google Scholar 

  12. 12.

    Getgood A, Collins B, Slynarski K, Kurowska E, Parker D, Engebretsen L, MacDonald PB, Litchfield R (2013) Short-term safety and efficacy of a novel high tibial osteotomy system: a case controlled study. Knee Surg Sports Traumatol Arthrosc 21:260–269

    PubMed  Article  Google Scholar 

  13. 13.

    Hunt MA, Birmingham TB, Giffin JR, Jenkyn TR (2005) Associations among knee adduction moment, frontal plane ground reaction force, and lever arm during walking in patients with knee osteoarthritis. J Biomech 39:2213–2220

    PubMed  Article  Google Scholar 

  14. 14.

    Hunt MA, Birmingham TB, Bryant D, Jones I, Giffin JR, Jenkyn TR et al (2008) Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis. Osteoarth Cart 16:591–599

    Article  CAS  Google Scholar 

  15. 15.

    Jankiewicz JJ, Sculco TP, Ranawat CS, Behr C, Tarrentino S (1994) One-stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop Relat Res 309:94–101

    PubMed  Google Scholar 

  16. 16.

    Jenkyn TR, Hunt MA, Jones IC, Giffin JR, Birmingham TB (2008) Toe-out gait in patients with knee osteoarthritis partially transforms external knee adduction moment into flexion moment during early stance phase of gait: a tri-planar kinetic mechanism. J Biomech 41:276–283

    PubMed  Article  Google Scholar 

  17. 17.

    Kadaba MP, Ramakrishnan HK, Wootten ME (1990) Measurement of lower extremity kinematics during level walking. J Orthop Res 8:383–392

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthritis. Ann Rheum Dis 16:494–502

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  19. 19.

    Kooistra B, Dijkman B, Einhorn TA, Bhandari M (2009) How to design a good case series. J Bone Joint Surg 91:21–26

    PubMed  Article  Google Scholar 

  20. 20.

    Ledingham J, Regan M, Jones A, Doherty M (1993) Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 52:520–526

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  21. 21.

    Lind M, McClelland J, Wittwer JE, Whitehead TS, Feller JA, Webster KE (2013) Gait analysis of walking before and after medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21:74–81

    PubMed  Article  Google Scholar 

  22. 22.

    Mazzuca SA, Brandt KD, Lane KA, Chakr R (2011) Malalignment and subchondral bone turnover in contralateral knees of overweight/obese women with unilateral osteoarthritis: implications for bilateral disease. Arthritis Care Res 63:1528–1534

    Article  Google Scholar 

  23. 23.

    McNamara I, Birmingham TB, Fowler PJ, Giffin JR (2013) High tibial osteotomy: evolution of research and clinical applications—a Canadian experience. Knee Surg Sports Traumatol Arthrosc 21:23–31

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S (2002) Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann Rheum Dis 61:617–622

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  25. 25.

    Niemeyer P, Schmal H, Hauschild O, von Heyden J, Südkamp NP, Köstler W (2010) Open-wedge osteotomy using an internal plate fixator in patients with medial-compartment gonarthritis and varus malalignment: 3-year results with regard to preoperative arthroscopic and radiographic findings. Arthroscopy 26:1607–1616

    PubMed  Article  Google Scholar 

  26. 26.

    Parent E, Moffet H (2002) Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch Phys Med Rehabil 83:70–80

    PubMed  Article  Google Scholar 

  27. 27.

    Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS (1997) Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res 345:99–105

    PubMed  Article  Google Scholar 

  28. 28.

    Robbins SM, Birmingham TB, Maly MR, Chesworth BM, Giffin JR (2011) Comparative diagnostic accuracy of knee adduction moments in knee osteoarthritis: a case for not normalizing to body size. J Biomech 44:968–971

    PubMed  Article  Google Scholar 

  29. 29.

    Roos EM, Lohmander LS (2003) The Knee Injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes 1:64

    PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Roos E, Toksvig-Larsen S (2003) Knee Injury and Osteoarthritis Outcome Score (KOOS)—validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes 1:17

    PubMed  Article  PubMed Central  Google Scholar 

  31. 31.

    Sharma L, Song J, Dunlop D, Felson D, Lewis CE, Segal N et al (2010) Varus and valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis 69:1940–1945

    PubMed  Article  PubMed Central  Google Scholar 

  32. 32.

    Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E (2001) Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. J Am Med Assoc. 286:188–195. Erratum in. J Am Med Assoc 15(286):792

    Google Scholar 

  33. 33.

    Sim JA, Kwak JH, Yang SH, Choi ES, Lee BK (2010) Effect of weight-bearing on the alignment after open wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 18:874–878

    PubMed  Article  Google Scholar 

  34. 34.

    Specogna A, Birmingham T, DaSilva J, Milner J, Kerr J, Hunt M et al (2004) Reliability of lower limb frontal plane alignment measurements using plain radiographs and digitized images. J Knee Surg 17:203–210

    PubMed  Google Scholar 

  35. 35.

    Thorp LE, Wimmer MA, Block JA, Moisio KC, Shott S, Goker B, Sumner DR (2006) Bone mineral density in the proximal tibia varies as a function of static alignment and knee adduction angular momentum in individuals with medial knee osteoarthritis. Bone 39:1116–1122

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    W-Dahl A, Toksvig-Larsen S, Roos EM (2005) A 2-year prospective study of patient-relevant outcomes in patients operated on for knee osteoarthritis with tibial osteotomy. BMC Musculoskelet Disord 6:18

    PubMed  Article  PubMed Central  Google Scholar 

  37. 37.

    Ware J Jr, Kosinski M, Keller SD (1996) A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220–233

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

The authors acknowledge Mr. Ian C. Jones, MA, for his assistance.

Conflict of interest

This research was undertaken thanks to funding from the Canada Research Chairs Program (TBB), the Canadian Institutes of Health Research (CIHR) and Arthrex Inc.

Author information

Affiliations

Authors

Corresponding authors

Correspondence to Trevor B. Birmingham or J. Robert Giffin.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sischek, E.L., Birmingham, T.B., Leitch, K.M. et al. Staged medial opening wedge high tibial osteotomy for bilateral varus gonarthrosis: biomechanical and clinical outcomes. Knee Surg Sports Traumatol Arthrosc 22, 2672–2681 (2014). https://doi.org/10.1007/s00167-013-2559-z

Download citation

Keywords

  • Medial compartment knee osteoarthritis
  • Alignment
  • Knee adduction moment
  • Staged knee surgery