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High tibial osteotomy increases patellofemoral pressure if adverted proximal, while open-wedge HTO with distal biplanar osteotomy discharges the patellofemoral joint: different open-wedge high tibial osteotomies compared to an extra-articular unloading device

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Valgus high tibial osteotomy (HTO) and a recently introduced extra-articular absorber have been shown to efficiently unload the medial compartment of the knee. However, only little is known about the influence of these treatment modalities on biomechanics of the patellofemoral joint. The purpose of this study was to investigate and compare the impact of different HTO techniques and implantation of an extra-articular absorber on patellofemoral contact forces.

Methods

Fourteen fresh frozen cadaveric knees were tested in a specially designed knee simulator that allowed simulation of isokinetic flexion–extension motions under physiological loading. Mean contact pressure (ACP) and peak contact pressure (PCP) of the patellofemoral joint was measured continuously between 0° and 120° of knee flexion using a pressure sensitive film in the following conditions: native, after biplanar medial open-wedge HTO with 5° and 10° correction angle performing an ascending frontal osteotomy of the tibial tuberosity, and after implantation of an extra-articular absorber system (KineSpring®). Including a second testing cycle with a biplanar medial open-wedge HTO with 5° and 10° correction angle performing descending frontal osteotomy of the tibial tuberosity. Values after each procedure were compared to the corresponding values of the native knee.

Results

Biplanar proximal osteotomy leaded to a significant increase of retropatellar compartment area contact pressure compared to the first untreated test cycle (Δ 0.04 ± 0.01 MPa, p = 0.04). Similar results were observed measuring peak contact pressure (Δ 1.41 ± 0.15 MPa, p = 0.03). With greater correction angle 5°, respectively, 10° peak and contact pressure increased accordingly. In contrast, the biplanar distal osteotomy group showed significant decrease of pressure values (p = 0.004). The extracapsular, extra-articular absorber had no significant influence on pressure levels in the patellofemoral joint.

Conclusion

HTO with a proximal biplanar osteotomy of the tuberositas tibia significantly increased patellofemoral pressure conditions depending on the correction angle. In contrast a distally directed biplanar osteotomy diminished these effects while implantation of an extracapsular, extra-articular absorber had no influence on the patellofemoral compartment at all. Consequently, patients with varus alignment with additional retropatellar chondropathia should be treated with a distally adverted osteotomy to avoid further undesirable pressure elevation in the patellofemoral joint.

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References

  1. Agneskirchner JD, Hurschler C, Stukenborg-Colsman C, Imhoff AB, Lobenhoffer P (2004) Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: a biomechanical study in human cadaveric knees. Winner of the AGA-DonJoy Award. Arch Orthop Trauma Surg 2004;124(9):575–584

  2. Block JA, Shakoor N (2009) The biomechanics of osteoarthritis: implications for therapy. Curr Rheumatol Rep 11(1):15–22

    Article  PubMed  Google Scholar 

  3. Bode G, Kloos F, Feucht MJ et al (2016) Comparison of the efficiency of an extra-articular absorber system and high tibial osteotomy for unloading the medial knee compartment: an in vitro study.;. Knee Surg Sports Traumatol Arthrosc 25(12):3695–3703

    Article  PubMed  Google Scholar 

  4. Bode G, Ogon P, Pestka J et al (2015) Clinical outcome and return to work following single-stage combined autologous chondrocyte implantation and high tibial osteotomy. Int Orthop 39(4):689–696

    Article  PubMed  Google Scholar 

  5. Bode G, Schmal H, Pestka JM, Ogon P, Südkamp NP, Niemeyer P (2013) A non-randomized controlled clinical trial on autologous chondrocyte implantation (ACI) in cartilage defects of the medial femoral condyle with or without high tibial osteotomy in patients with varus deformity of less than 5°. Arch Orthop Trauma Surg 133(1):43–49

    Article  PubMed  Google Scholar 

  6. Brandt KD, Dieppe P, Radin E (2009) Etiopathogenesis of osteoarthritis. Med Clin North Am 93(1):1–24

    Article  PubMed  Google Scholar 

  7. Brandt KD, Dieppe P, Radin EL (2009) Commentary: is it useful to subset “primary” osteoarthritis? A critique based on evidence regarding the etiopathogenesis of osteoarthritis. Semin Arthritis Rheum 39(2):81–95

    Article  PubMed  Google Scholar 

  8. Clifford A, O’Connell M, Gabriel S, Miller LE, Block JE (2011) The KineSpring load absorber implant: rationale, design and biomechanical characterization. J Med Eng Technol 35(1):65–71

    Article  CAS  PubMed  Google Scholar 

  9. Clifford AG, Gabriel SM, O’Connell M, Lowe D, Miller LE, Block JE (2013) The KineSpring(®) knee implant system: an implantable joint-unloading prosthesis for treatment of medial knee osteoarthritis. Med Devices Auckl NZ 6:69–76

    Google Scholar 

  10. 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. Am J Sports Med 38(2):323–329

    Article  PubMed  Google Scholar 

  11. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P (2014) Does obesity and nicotine abuse influence the outcome and complication rate after open-wedge high tibial osteotomy? A retrospective evaluation of five hundred and thirty three patients. Int Orthop 38(1):55–60

    Article  PubMed  Google Scholar 

  12. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P (2014) Does obesity and nicotine abuse influence the outcome and complication rate after open-wedge high tibial osteotomy? A retrospective evaluation of five hundred and thirty three patients. Int Orthop 38(1):55–67

    Article  PubMed  Google Scholar 

  13. Gaasbeek R, Welsing R, Barink M, Verdonschot N, Kampen A van (2007) The influence of open and closed high tibial osteotomy on dynamic patellar tracking: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 15(8):978–984

    Article  PubMed  Google Scholar 

  14. Gstöttner M, Michaela G, Pedross F et al (2008) Long-term outcome after high tibial osteotomy. Arch Orthop Trauma Surg 128(1):111–115

    PubMed  Google Scholar 

  15. Hinterwimmer S, Beitzel K, Paul J et al (2011) Control of posterior tibial slope and patellar height in open-wedge valgus high tibial osteotomy. Am J Sports Med 39(4):851–856

    Article  PubMed  Google Scholar 

  16. Javidan P, Adamson GJ, Miller JR et al (2013) The effect of medial opening wedge proximal tibial osteotomy on patellofemoral contact. Am J Sports Med 41(1):80–86

    Article  PubMed  Google Scholar 

  17. Kim K-I, Kim D-K, Song S-J, Lee S-H, Bae D-K (2017) Medial open-wedge high tibial osteotomy may adversely affect the patellofemoral joint. Arthroscopy J 33(4):811–816

    Article  Google Scholar 

  18. Krause M, Drenck TC, Korthaus A, Preiss A, Frosch K-H, Akoto R (2017) Patella height is not altered by descending medial open-wedge high tibial osteotomy (HTO) compared to ascending HTO. Knee Surg Sports Traumatol Arthrosc 26(6):1859–1866

    Article  PubMed  Google Scholar 

  19. Lobenhoffer P, Agneskirchner J, Zoch W (2004) Open valgus alignment osteotomy of the proximal tibia with fixation by medial plate fixator. Orthopade 33(2):153–160

    Article  CAS  PubMed  Google Scholar 

  20. Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11(3):132–138

    Article  PubMed  Google Scholar 

  21. Lützner J, Gross AF, Günther KP, Kirschner S (2010) Precision of navigated and conventional open-wedge high tibial osteotomy in a cadaver study. Eur J Med Res 15(3):117–120

    Article  PubMed  PubMed Central  Google Scholar 

  22. Messier SP, DeVita P, Cowan RE, Seay J, Young HC, Marsh AP (2005) Do older adults with knee osteoarthritis place greater loads on the knee during gait? A preliminary study. Arch Phys Med Rehabil 86(4):703–709

    Article  PubMed  Google Scholar 

  23. Messier SP, Gutekunst DJ, Davis C, DeVita P (2005) Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 52(7):2026–2032

    Article  PubMed  Google Scholar 

  24. Minzlaff P, Saier T, Brucker PU, Haller B, Imhoff AB, Hinterwimmer S (2015) Valgus bracing in symptomatic varus malalignment for testing the expectable “unloading effect” following valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23(7):1964–1970

    Article  PubMed  Google Scholar 

  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(12):1607–1616

    Article  PubMed  Google Scholar 

  26. Ostermeier S, Friesecke C, Fricke S, Hurschler C, Stukenborg-Colsman C (2008) Quadriceps force during knee extension after non-hinged and hinged TKA: an in vitro study. Acta Orthop 79(1):34–38

    Article  PubMed  Google Scholar 

  27. Ostermeier S, Hurschler C, Stukenborg-Colsman C (2004) Quadriceps function after TKA–an in vitro study in a knee kinematic simulator. Clin Biomech Bristol Avon 19(3):270–276

    Article  CAS  Google Scholar 

  28. Staubli AE, De Simoni C, Babst R, Lobenhoffer P (2003) TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia–early results in 92 cases. Injury 34(2):B55-62

    PubMed  Google Scholar 

  29. Stoffel K, Willers C, Korshid O, Kuster M (2007) Patellofemoral contact pressure following high tibial osteotomy: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 15(9):1094–1100

    Article  PubMed  Google Scholar 

  30. Waller C, Hayes D, Block JE, London NJ (2011) Unload it: the key to the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 19(11):1823–1829

    Article  PubMed  Google Scholar 

  31. Yang JS, Fulkerson JP, Obopilwe E, Voss A (2017) Patellofemoral contact pressures after patellar distalization: a biomechanical study. Arthroscopy 33(11):2038–2044

    PubMed  Google Scholar 

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Acknowledgements

Funding was provided by Müller-Fahnenberg Stiftung.

Funding

The study was funded by the Müller-Fahnenberg Study of Freiburg University.

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Authors and Affiliations

  1. Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany

    Ferdinand Kloos, Matthias J. Feucht, Lisa Hohloch, Norbert Südkamp, Philipp Niemeyer & Gerrit Bode

  2. Orthopaedic Department, Hannover Medical School, Hannover, Germany

    Christoph Becher & Benjamin Fleischer

Authors
  1. Ferdinand Kloos
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  2. Christoph Becher
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  3. Benjamin Fleischer
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  4. Matthias J. Feucht
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  5. Lisa Hohloch
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  6. Norbert Südkamp
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  7. Philipp Niemeyer
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  8. Gerrit Bode
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Correspondence to Ferdinand Kloos.

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Conflict of interest

None of the authors has any conflict of interest.

Ethical approval

The ethics committee of Hannover University approved this study (ID 3083-2016).

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Kloos, F., Becher, C., Fleischer, B. et al. High tibial osteotomy increases patellofemoral pressure if adverted proximal, while open-wedge HTO with distal biplanar osteotomy discharges the patellofemoral joint: different open-wedge high tibial osteotomies compared to an extra-articular unloading device. Knee Surg Sports Traumatol Arthrosc 27, 2334–2344 (2019). https://doi.org/10.1007/s00167-018-5194-x

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