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A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The recent ESSKA consensus recommendations defined indications and outlined parameters for osteotomies around a degenerative varus knee. The consensus collated these guidelines based on the published literature available to answer commonly asked questions including the importance of identifying the site and degree of the lower limb deformity. In the consensus, the authors suggest that a knee joint line obliquity (JLO) greater than 5° or a planned medial proximal tibial angle (MPTA) > 94° preferentially indicates a double level osteotomy (DLO) compared to an isolated opening wedge high tibial osteotomy (OWHTO). This study aimed to analyze the corrections performed on a cohort of isolated opening wedge high tibial osteotomies (OWHTOs) prior to the recent ESSKA recommendations, with a focus on the impact of knee joint line obliquity (JLO) and medial proximal tibial angle (MPTA) on the choice of osteotomy procedure.

Methods

This monocentric, retrospective study included 129 patients undergoing medial OWHTO for symptomatic isolated medial knee osteoarthritis (Ahlbäck grade I or II) and a global varus malalignment (hip–knee–ankle angle ≤ 177°). An automated software trained to automatically detect lower limb deformity was implemented using patients preoperative long leg alignment X-rays to identify suitability for an isolated HTO in knee varus deformity. Based on the ESSKA recommendations, the site of the osteotomy was identified as well as the degree of correction required. The ESSKA consensus considers avoiding an isolated high tibial osteotomy if the planned resultant knee joint line orientation exceeds 5 ̊ or MPTA exceeds 94°. A preoperative abnormal MPTA was defined by a value lower than 85° and a preoperative abnormal LDFA by a value greater than 90°. The cases of DLO or DFO suggested by the software and the number of extra-tibial anomalies were collected. Multiple linear regression models were developed to establish a relationship between preoperative values and the risk of being outside of ESSKA recommendations postoperatively.

Results

Based on ESSKA recommendations and on threshold values considered abnormal, the software suggested a DLO in 17.8% (n = 23/129) of cases, a distal femoral osteotomy in 27.9% (n = 36/129) of cases and advised against an osteotomy procedure in 24% (n = 31/129) of cases. The software detected a femoral anomaly in 34.9% (n = 45/129) of cases and an JLCA > 6° in 9.3% (n = 12/129). Postoperatively, the MPTA exceeds 94° in 41.1% (n = 53/129) and the JLO exceeds 5° in 29.4% (n = 38/129).

On multivariate analysis, a high preoperative MPTA was associated with higher risk of postoperative MPTA > 94° (R2 = 0.36; p < 0.001). Similarly, the probability of the software advising a DLO or DFO was associated with the presence of an “normal” preoperative MPTA (R2 = 0.42; p < 0.001) or an abnormal preoperative LDFA (R2 = 0.48; p < 0.001) or a planned JLO > 5° (R2 = 0.27; p < 0.001).

Conclusions

Analysis of patients who underwent an isolated OWHTO prior to the ESSKA guidelines, demonstrated a significant rate of post-operative tibial overcorrection and a resultant increased JLO. Pre-operative planning that considers the ESSKA guidelines, allows for better identification of those patients requiring a DFO or DLO and avoidance of resultant post-operative deformities.

Level of evidence

IV, case-series.

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Data availability

Radiographic measurements were analysed with long leg alignment X-rays obtained for each patients.

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Funding

No funding was needed for this study.

Author information

Authors and Affiliations

  1. APHM, CNRS, ISM, Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, Aix Marseille University, Sainte-Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France

    Matthieu Ollivier & Jae-Sung An

  2. Orthoprofis Hannover Luisenstraße, 10/11, 30539, Hannover, Germany

    Kristian Kley

  3. Guys and St. Thomas’ Hospitals, Great Maze Pond, London, SE1 9RT, England

    Raghbir Khakha

  4. Department of Orthopedics and Traumatology, Hospital Pedro Hispano, Matosinhos, Portugal

    Levi Reina Fernandes

  5. Institute for Locomotion and Sports, iULS-University, Pasteur 2 Hospital, University Côte d’Azur, UR2CA, Nice, France

    Grégoire Micicoi

Authors
  1. Matthieu Ollivier
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  2. Jae-Sung An
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  3. Kristian Kley
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  4. Raghbir Khakha
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  5. Levi Reina Fernandes
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  6. Grégoire Micicoi
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Contributions

MO designed the protocol and performed statistical analysis. JA and LFR collected the Data. GM and MO wrote the initial draft and performed revisions of subsequent drafts. MO, KK and RK corrected the different versions of the draft. All the authors approved the submitted version.

Corresponding author

Correspondence to Matthieu Ollivier.

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Conflict of interest

GM, JA, RK and LRF have nothing to disclose. KK and MO are educational consultant for Newclip.

Ethical approval

The local ethics committee approved our study protocol prior to investigation.

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Ollivier, M., An, JS., Kley, K. et al. A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus. Knee Surg Sports Traumatol Arthrosc 31, 4927–4934 (2023). https://doi.org/10.1007/s00167-023-07518-5

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