Differences between opening versus closing high tibial osteotomy on clinical outcomes and gait analysis

doi:10.1016/j.knee.2014.04.007

The Knee

Volume 21, Issue 6, December 2014, Pages 1046-1051

https://doi.org/10.1016/j.knee.2014.04.007 Get rights and content

Abstract

Background

High tibial osteotomy (HTO) for medial knee osteoarthritis (OA) is mainly performed via two procedures: closing wedge HTO (CW) and opening wedge HTO (OW). In this study, differences between these procedures were assessed by serial clinical evaluation and gait analysis before and after surgery.

Methods

Twenty-one patients underwent HTO for medial knee OA in 2011 and 2012, with 12 patients undergoing CW and nine undergoing OW. The severity of OA was classified according to the Kellgren–Lawrence classification. The Japanese Orthopedic Association score for assessment of knee OA (JOA score), the Numeric Rating Scale (NRS), and the femoral tibial angle (FTA) on X-ray were evaluated. For gait analysis, gait speed, varus moment, varus angle and lateral thrust were calculated.

Results

The JOA score and NRS were improved significantly one year postoperatively in both groups. The FTA was maintained in both groups at one year. Varus angle and varus moment were significantly improved in both groups at each postoperative follow-up, when compared preoperatively. Lateral thrust was significantly improved at three months postoperatively in both groups. However, the significant improvement in lateral thrust had disappeared in the CW group six months postoperatively, whereas it was maintained for at least one year in the OW group.

Conclusions

This study found that clinical outcomes were well maintained after HTO. OW reduced knee varus moment and lateral thrust, whereas CW had little effect on reducing lateral thrust.

Level of evidence

Level IV

Introduction

Japan's population is rapidly aging, and together with this aging, the number of patients with degenerative changes of knee osteoarthritis (OA) is increasing. Yoshimura et al. estimated that 25.3 million people (8.6 million men, 16.7 million women) aged 40 years and older have radiographic findings of knee OA, and that 7.8 million (2.2 million men, 5.6 million women; 42.6% of men and 62.4% of women aged ≥ 40 years) have symptoms such as pain [1].

Knee OA is a disease associated with joint dysfunction due to degeneration, destruction, and loss of articular cartilage. In Japan, more than 90% of patients with knee OA develop a varus deformity. Varus malalignment overloads the medial tibiofemoral compartment, causing degenerative changes in the articular cartilage, which lead to pain and dysfunction [2].

Treatment of pain and dysfunction in knee OA includes conservative treatment and surgical treatment. Improvement with conservative treatment becomes difficult if symptoms progress and surgical treatment may be indicated. In patients with severe knee OA, surgical treatment may include arthroscopic surgery, a high tibial osteotomy (HTO), or total knee arthroplasty. HTO is generally indicated in relatively young and more active patients [3]. HTO is a load-shifting procedure which transfers the mechanical axis more laterally. As a result, this surgery improves pain and delays the progression of arthritis [4].

HTO is broadly divided into two surgical procedures. The first is a lateral closing wedge HTO (CW) in which a wedge-shaped cut is made in the lateral tibia. The second is a medial opening wedge HTO (OW) in which the medial tibia is cut (Fig. 1A, B). OW has been performed more recently. The difference between CW and OW is that OW does not need a fibula osteotomy. This reduces the incidence of complications such as peroneal nerve palsy, but increases the tibial slope [4], [5].

Clinical outcomes and problems associated with CW and OW have been compared in some studies [5], [6]. However, these studies often compare subjective symptoms and static data such as radiographic findings. Our literature review found no studies that compared serial changes from a kinetic and kinematic perspective such as walking in activities of daily living.

Therefore, the present study aimed to investigate serial changes in clinical symptoms and knee joint kinetics and kinematics during free walking in patients who underwent CW and OW. We examined gait analysis using a three-dimensional (3D) motion analysis system (Vicon 612) with 7 infrared cameras and four force plates to find any differences in knee kinetics and kinematics between CW and OW. We hypothesized that there would be no differences found between CW and OW using gait analysis.

Section snippets

Patients

This study included 21 patients (six men, 15 women) diagnosed with unilateral or bilateral knee OA at the Department of Orthopedic Surgery at Hiroshima University Hospital between 2011 and 2012, and in whom HTO was indicated. Indications for HTO were patients less than 65 years old with medial compartmental osteoarthritis and a femoral tibial angle (FTA) of more than 178°. The measured leg was the operated side, and the contralateral leg did not undergo any surgical procedures for one year

Clinical knee score, pain evaluation, and femoral tibial angle (Table 3)

The JOA score in both the CW and OW groups increased gradually after surgery. There was significant improvement 1 year postoperatively compared to preoperatively. The NRS in both the CW and OW groups was decreased significantly three months postoperatively. Radiographic imaging showed bone union in all cases by 8–10 weeks postoperatively. Compared to the preoperative FTA, the angle of correction was significantly maintained in both groups one year postoperatively.

Gait speed (Table 4)

Compared to before surgery, gait

Discussion

This study evaluated clinical findings and serial changes in gait kinetics and kinematics (preoperatively, and at three, six and 12 months postoperatively) in patients with medial knee OA who underwent lateral CW or medial OW HTO. To our knowledge, this is the first report investigating consecutive cases of CW HTO and OW HTO using 3D motion analysis. Previous reports have only looked at clinical results and evaluated static images, such as radiographic, computed tomography and magnetic resonance

Conflict of interest statement

All the authors of this study declare that they have no conflicts of interest.

Contributions

The authors have made substantial contributions to the following three sections:

1.
The conception and design of the study, or acquisition of data, or analysis and interpretation of data.
2.
Drafting the article or revising it critically for important intellectual content.
3.
Final approval of version to be submitted.

Masataka Deie, MD: Sections 1 and 2.

Takayuki Hoso, PT: Sections 1 and 2.

Noboru Shimada PT: Section 1.

Daisuke Iwaki PT: Section 1.

Atsuo Nakamae MD: Section 3.

Nobuo Adachi MD: Sections 1 and 2.

Acknowledgments

The authors would like to thank Prof. Hiroaki Kimura, Department of Rehabilitation, Hiroshima University Hospital for his assistance in the preparation of this manuscript.

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Citation Excerpt :
We also found that knees with varus thrust had increased varus knee alignment and a more severe form of tibiofemoral joint OA. Deie and colleagues showed that surgical procedures, which correct mechanical axis, such as high tibial osteotomy and total knee arthroplasty (TKA), reduce knee varus angle at the initial stance phase of gait [45,46]. Furthermore, realignment of the knee following TKA results in changes in frontal plane rearfoot alignment [47].
The foot is speculated to play a role in knee joint kinematics. This exploratory cross-sectional study examined the association between static foot posture and the presence of varus thrust visualized during gait in patients with medial knee osteoarthritis (OA). Patients (n = 88 patients and 134 knees; age, 61–91 years; 68.2% female) with Kellgren/Lawrence (K/L) grade ≥1 in the medial compartment were included in this study and underwent gait observation for varus thrust. These patients’ three-dimensional static foot posture while standing was evaluated and their tibiofemoral joint K/L grades and anatomical axis angles were also assessed as covariates. Knees with varus thrust (22 knees, 16.4%) on average had a 4° more inverted calcaneus relative to the floor than those without varus thrust (P < 0.001). A logistic regression analysis showed that an increased calcaneus inversion angle was significantly associated with higher odds of the presence of varus thrust with adjustments for age, sex, body mass index, K/L grade, and anatomical axis angle. The other predictors, such as navicular height, navicular height/foot length, and rearfoot angle relative to the lower leg, were not significantly associated with varus thrust. These results suggest that patients with varus thrust had a different static rearfoot posture as compared with those without varus thrust, a finding that may indicate an important role of static rearfoot posture in the pathogenesis of varus thrust. Furthermore, investigating the potential influence of foot posture on the efficacy of biomechanical interventions, such as lateral wedge insole use, on varus thrust would be of particular interest in the further studies.

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Differences between opening versus closing high tibial osteotomy on clinical outcomes and gait analysis

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Introduction

Section snippets

Patients

Clinical knee score, pain evaluation, and femoral tibial angle (Table 3)

Gait speed (Table 4)

Discussion

Conflict of interest statement

Contributions

Acknowledgments

Osteoarthritis Cartilage

Arthroscopy

Knee

Knee

Osteoarthritis Cartilage

J Biomech

Prevalence of knee osteoarthritis, lumbar spondylosis, and osteoporosis in Japanese men and women: the research on osteoarthritis/osteoporosis against disability study

J Bone Miner Metab

Results of high tibial osteotomy review of the literature

Int Orthop