JBJS | Total Knee Arthroplasty After High Tibial Osteotomy : A Comparison Study in Patients Who Had Bilateral Total Knee Replacement*

The Journal of Bone & Joint Surgery, Volume 82, Issue 9

Articles | September 01, 2000

Total Knee Arthroplasty After High Tibial Osteotomy : A Comparison Study in Patients Who Had Bilateral Total Knee Replacement*

John B. Meding, M.D.†; E. Michael Keating, M.D.†; Merrill A. Ritter, M.D.†; Philip M. Faris, M.D.†

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Investigation performed at The Center for Hip and Knee Surgery, St. Francis Hospitals-Mooresville, Mooresville, Indiana
*Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Biomet Incorporated, Warsaw, Indiana.
†The Center for Hip and Knee Surgery, 1199 Hadley Road, Mooresville, Indiana 46158.

The Journal of Bone & Joint Surgery. 2000; 82:1252-1252

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Abstract

Background: The outcome of total knee replacement after high tibial osteotomy remains uncertain. We hypothesized that the results of total knee replacement with or without a previous high tibial osteotomy are similar.

Methods: The results of a consecutive series of thirty-nine bilateral total knee arthroplasties performed with cement at an average of 8.7 years after unilateral high tibial osteotomy were reviewed. There were twenty-seven men and twelve women. Preoperatively, the knee scores according to the system of the Knee Society were similar for all of the knees; however, valgus alignment and patella infera were more common in the knees with a previous high tibial osteotomy. Bilateral total knee replacement was staged in seven patients and was simultaneous in thirty-two patients. The results of the total knee arthroplasties were retrospectively reviewed with respect to the knee and function scores according to the system of the Knee Society, the radiographic findings, and the complications.

Results: Intraoperatively, no notable differences were identified in the number of medial, lateral, or lateral patellar releases required. However, less lateral tibial bone was resected in the group with a previous high tibial osteotomy (average, 3.3 millimeters) than in the group without a high tibial osteotomy (average, 7.5 millimeters). The average duration of follow-up was 7.5 years (range, three to sixteen years) in the group with a previous high tibial osteotomy and 6.8 years (range, two to ten years) in the group without a high tibial osteotomy. At the time of the final follow-up, the knee and function scores were similar for the two groups (89.0 and 81.0 points, respectively, for the group with a previous high tibial osteotomy, and 89.6 and 83.9 points, respectively, for the group without a high tibial osteotomy). Although more knees were free of pain in the group without a previous high tibial osteotomy (thirty-six) than in the group with a previous osteotomy (thirty-three), this difference was not found to be significant with the numbers available (p = 0.4810). Knee alignment and stability, femoral and tibial component alignment, and range of motion also were similar in both groups postoperatively. One all-polyethylene tibial component was revised in the high tibial osteotomy group. Two knees in each group required manipulation. There were no deep infections.

Conclusions: While patients with a previous high tibial osteotomy may have important differences preoperatively, including valgus alignment, patella infera, and decreased bone stock in the proximal part of the tibia, the present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different. In our relatively small group of patients, the previous high tibial osteotomy had no adverse effect on the outcome of the subsequent total knee replacement.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

High tibial osteotomy has proven to be successful for the treatment of unicompartmental osteoarthritis of the knee^5,7,12,15,18. Early rates of success of between 80 and 90 percent have been reported in series ranging in size from fifty-one to 139 knees^1,12,26. With proper indications and avoidance of overcorrection or undercorrection, the longevity of a high tibial osteotomy may be greater than that of a total knee replacement²². With longer follow-up, however, results are known to deteriorate^{1,6,9,11,18,26}. Indeed, survivorship analysis has shown that the reliable longevity of a high tibial osteotomy is approximately six years²³. Thus, while a high tibial osteotomy is capable of providing adequate pain relief to a younger patient, it is unlikely to give permanent relief and may simply "buy time"¹³ so that the need for total knee replacement is at least delayed.

Controversy exists, however, as to whether or not high tibial osteotomy can have any deleterious effects on the outcome of a subsequent total knee replacement^{2,3,16,21,24,25,27}. Several authors have compared the results of total knee replacement in patients who had had a previous high tibial osteotomy with those in a control group of patients who had a primary total knee replacement without a previous high tibial osteotomy^{2,3,16,20,21,25}. These matched and comparison studies have had conflicting conclusions; some studies have shown inferior results after total knee replacement in patients who had had a high tibial osteotomy^16,20, and others have demonstrated similar results in patients with and without a previous high tibial osteotomy^2,3,21,25. If high tibial osteotomy eventually results in an increased rate of failure of subsequent total knee replacement, then the indications for the procedure may be more limited.

To determine what effect, if any, a previous high tibial osteotomy has on the outcome of total knee replacement, a comparison study of patients who underwent bilateral total knee replacement after unilateral high tibial osteotomy was performed. We hypothesized that the results of total knee replacement after high tibial osteotomy are no different from those of total knee replacement without a previous high tibial osteotomy.

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Fig. 1:: Photograph showing the minimal amount of lateral tibial bone that was resected in order to reestablish the anatomical (preosteotomy) position of the lateral joint line. Despite resection of less than one millimeter of lateral bone, a considerably thicker tibial component was required. In this case, a ten-millimeter tibial prosthesis was used.

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Fig. 2-A:: Figs. 2-A, 2-B, and 2-C: Anteroposterior radiographs of the same patient as in Fig. 1.
Fig. 2-A: Preoperative radiograph showing the position of the proximal fibular head (black line) in reference to the lateral joint line. Note the minimal amount of proximal lateral tibial bone proximal to the fibular head in the knee that had had a high tibial osteotomy.

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Fig. 2-B:: Radiographs made after total knee arthroplasty, showing the knee that had not had a high tibial osteotomy (Fig. 2-B) and the knee that had had a high tibial osteotomy (Fig. 2-C). Although a relatively thicker tibial component was used in the knee that had had a high tibial osteotomy, the anatomical (preosteotomy) position of the lateral joint line has been reestablished. In this patient, the distance between the lateral joint line and the fibular head measured twenty-three millimeters in both knees postoperatively.

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Fig. 2-C:: Radiographs made after total knee arthroplasty, showing the knee that had not had a high tibial osteotomy (Fig. 2-B) and the knee that had had a high tibial osteotomy (Fig. 2-C). Although a relatively thicker tibial component was used in the knee that had had a high tibial osteotomy, the anatomical (preosteotomy) position of the lateral joint line has been reestablished. In this patient, the distance between the lateral joint line and the fibular head measured twenty-three millimeters in both knees postoperatively.

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TABLE I: Preoperative Data

*Significant values are given in bold.†The values are given as the average, with the range in parentheses.‡Positive values indicate valgus alignment, and negative values indicate varus alignment.§Positive values indicate the distance proximal to the fibular head, and negative values indicate the distance distal to the fibular head.

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Age† (yrs.)	66.9 (50-80)	67.4 (52-80)	0.1532
Weight† (kg)	82.7 (52.2-113.0)	82.6 (52.3-113.0)	0.1626
Knee score† (points)	44.8 (30-59)	44.8 (36-57)	0.8915
Range of motion (degrees)
Average extension	5.5	6.1	0.2417
Average flexion	112.0	113.5	0.0537
Alignment †‡(degrees)	3.2 (-11-20)	-0.7 (-15-14)	0.0188
Distance between lateral joint line and fibular head†§ (mm)	11.4 (-3-35)	18.3 (8-25)	0.0001
Insall-Salvati ratio†	1.11 (0.65-1.67)	1.22 (0.94-1.54)	0.0288

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TABLE I: Preoperative Data

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Age† (yrs.)	66.9 (50-80)	67.4 (52-80)	0.1532
Weight† (kg)	82.7 (52.2-113.0)	82.6 (52.3-113.0)	0.1626
Knee score† (points)	44.8 (30-59)	44.8 (36-57)	0.8915
Range of motion (degrees)
Average extension	5.5	6.1	0.2417
Average flexion	112.0	113.5	0.0537
Alignment †‡(degrees)	3.2 (-11-20)	-0.7 (-15-14)	0.0188
Distance between lateral joint line and fibular head†§ (mm)	11.4 (-3-35)	18.3 (8-25)	0.0001
Insall-Salvati ratio†	1.11 (0.65-1.67)	1.22 (0.94-1.54)	0.0288

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TABLE II: Operative Data

*The values are given as the number of knees, with the percentage in parentheses.†NA = not applicable.

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Prostheses
Posterior cruciate condylar component	1 (3)	1 (3)
Anatomic graduated component	38 (97)	38 (97)
Metal-backed patellar component	4 (10)	4 (10)
All-polyethylene tibial component	4 (10)	4 (10)	NA
Lateral patellar release	18 (46)	13 (33)	0.247
Medial release			1.000
Deep tibial collateral ligament	37 (95)	37 (95)
+ Superficial tibial collateral ligament	1 (3)	2 (5)
+ Semimembranosus	1 (3)	0
Lateral release			0.423
None	35 (90)	38 (97)
+ Iliotibial band	2 (5)	1 (3)
+ Capsule and popliteus	2 (5)	0
Posterior release			0.732
None	24 (62)	28 (72)
Osteophytes	14 (36)	10 (26)
+ Posterior aspect of capsule	1 (3)	1 (3)

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TABLE II: Operative Data

*The values are given as the number of knees, with the percentage in parentheses.†NA = not applicable.

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Prostheses
Posterior cruciate condylar component	1 (3)	1 (3)
Anatomic graduated component	38 (97)	38 (97)
Metal-backed patellar component	4 (10)	4 (10)
All-polyethylene tibial component	4 (10)	4 (10)	NA
Lateral patellar release	18 (46)	13 (33)	0.247
Medial release			1.000
Deep tibial collateral ligament	37 (95)	37 (95)
+ Superficial tibial collateral ligament	1 (3)	2 (5)
+ Semimembranosus	1 (3)	0
Lateral release			0.423
None	35 (90)	38 (97)
+ Iliotibial band	2 (5)	1 (3)
+ Capsule and popliteus	2 (5)	0
Posterior release			0.732
None	24 (62)	28 (72)
Osteophytes	14 (36)	10 (26)
+ Posterior aspect of capsule	1 (3)	1 (3)

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TABLE III: Clinical Results

*NA = not applicable.†The values are given as the average, with the range in parentheses.‡The values are given as the numbers of knees, with the percentage in parentheses.

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Duration of follow-up† (yrs.)	7.5 (3-16)	6.8 (2-10)	NA
Knee score† (points)	89.0 (72-97)	89.6 (79-96)	0.6765
Function score† (points)	81.0 (20-100)	83.9 (35-100)	0.4098
Range of motion† (degrees)
Extension	0.26 (0-5)	0.64 (0-5)	0.8319
Flexion	113.0 (75-130)	117.8 (85-130)	0.9717
Pain‡
None	33 (85)	36 (92)	0.4810
Mild or occasional	5 (13)	3 (8)
Moderate or continuous	1 (3)	0

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TABLE III: Clinical Results

*NA = not applicable.†The values are given as the average, with the range in parentheses.‡The values are given as the numbers of knees, with the percentage in parentheses.

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Duration of follow-up† (yrs.)	7.5 (3-16)	6.8 (2-10)	NA
Knee score† (points)	89.0 (72-97)	89.6 (79-96)	0.6765
Function score† (points)	81.0 (20-100)	83.9 (35-100)	0.4098
Range of motion† (degrees)
Extension	0.26 (0-5)	0.64 (0-5)	0.8319
Flexion	113.0 (75-130)	117.8 (85-130)	0.9717
Pain‡
None	33 (85)	36 (92)	0.4810
Mild or occasional	5 (13)	3 (8)
Moderate or continuous	1 (3)	0

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TABLE IV: Radiographic Results

*The values are given as the average, with the range in parentheses.†Significant values are given in bold.‡Positive values indicate valgus alignment, and negative values indicate varus alignment.§Positive values indicate the distance proximal to the fibular head, and negative values indicate the distance distal to the fibular head.#Measurement made from the fibular head.

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Alignment‡(degrees)	6.3 (-3-15)	5.2 (0-10)	0.0744
Insall-Salvati ratio	1.10 (0.67-1.49)	1.23 (0.90-1.59)	0.0110
Distance between lateral joint line and fibular head§ (mm)	6.9 (-8-27)	-1 (-10-10)	0.0001
Amount of lateral tibial bone removed# (mm)	3.3 (1-17)	7.5 (0-18)	0.0001

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TABLE IV: Radiographic Results

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Alignment‡(degrees)	6.3 (-3-15)	5.2 (0-10)	0.0744
Insall-Salvati ratio	1.10 (0.67-1.49)	1.23 (0.90-1.59)	0.0110
Distance between lateral joint line and fibular head§ (mm)	6.9 (-8-27)	-1 (-10-10)	0.0001
Amount of lateral tibial bone removed# (mm)	3.3 (1-17)	7.5 (0-18)	0.0001

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between 1980 and 1995, a consecutive series of 5043 primary total knee arthroplasties was performed at this institution. In this group, a consecutive series of thirty-nine patients underwent bilateral total knee replacement with cement at an average of 8.7 years after unilateral high tibial osteotomy. There were twenty-seven men and twelve women. The same prosthesis was implanted in both knees with use of the same operative technique in all thirty-nine patients. (To eliminate a potential variable due to side-by-side differences, patients were excluded from this study if different prostheses were used in the right and left knees.) Bilateral total knee replacement was staged in seven patients, with an average interval of sixty months (range, ten to ninety-seven months) between the procedures, and it was simultaneous in thirty-two patients. Seven patients initially had only unilateral total knee replacement rather than simultaneous bilateral total knee replacement, regardless of whether a previous osteotomy had been performed, because the degree of pain in the contralateral knee was not sufficiently severe, at that point in time, to warrant bilateral total knee replacement.

The indication for high tibial osteotomy was medial compartment osteoarthritis in all cases but one; the remaining osteotomy was performed because of osteonecrosis of the medial femoral condyle. In all cases, the indication for conversion from the osteotomy to the arthroplasty included both radiographic progression of the disease and increasing pain. There were no known complications associated with the high tibial osteotomy. Thus, poor operative technique at the time of the high tibial osteotomy was not considered to be a factor in determining the need for a total knee arthroplasty. Eleven high tibial osteotomies (28 percent), all of which were a closing-wedge type without hardware, were performed by one of us (M. A. R.). The remainder of the osteotomies were performed by multiple surgeons, and the patients were referred to our institution for conversion to the arthroplasty.

The knees were evaluated preoperatively and postoperatively according to the clinical¹⁴ and radiographic⁸ scoring systems of the Knee Society. The Knee Society clinical rating system assigns both a knee score and a function score; the function score tends to diminish as patients get older, whereas the knee score may remain unchanged. A well aligned knee with no pain and 125 degrees of motion is given a knee score of 100 points. The function score is based on an evaluation of walking distance and stair-climbing, with deductions made for the use of walking aids. A function score of 100 points indicates that a patient is able to walk an unlimited distance and to climb up and down stairs normally. The Knee Society radiographic scoring system allows for standardization of the measurement of knee alignment and component position as well as for evaluation of the prosthesis-cement-bone interface. The data were collected prospectively at the time of each clinical follow-up and were compiled through the time of the most recent complete evaluation. The patients were questioned by the surgical assistant with regard to subjective data. Objective data, including range-of-motion measurements and radiographic findings, were recorded by the attending physician. Preoperative and postoperative anteroposterior tibiofemoral alignment as well as the Insall-Salvati patellar position ratio¹¹ were also retrospectively recorded by one author (J. B. M.). Furthermore, the location of the lateral joint line, measured from the fibular head, was retrospectively recorded on the preoperative and postoperative radiographs. The amount of resected lateral tibial bone was similarly measured and recorded. The present study represents a retrospective review of these data.

A cruciate-retaining prosthesis was used in all knees. The bilateral arthroplasties were performed by all four of us (M. A. R. [twenty-three patients], E. M. K. [ten patients], P. M. F. [four patients], and J. B. M. [two patients]). Thirty-eight patients (97 percent) had bilateral implantation of an anatomic graduated component (AGC; Biomet, Warsaw, Indiana). Four of these thirty-eight patients had bilateral implantation of an all-polyethylene tibial component with cement, and another four had bilateral implantation of a metal-backed patellar component with cement. One of these thirty-eight patients had bilateral implantation of the femoral component without cement. The remaining patient had bilateral implantation of a posterior cruciate condylar prosthesis (Howmedica, East Rutherford, New Jersey).

Knee arthroplasty after high tibial osteotomy has been found to be technically demanding^19-21,25,27, and careful consideration to operative detail is required. All knees were approached through a standard medial parapatellar incision. As reported by Mont et al.¹⁹, soft-tissue scarring was noted between the osteotomy site and the soft tissues. Care was required to release these adhesions during exposure of the proximal part of the tibia. While a lateral release may be required for exposure^19,27, a simple release of the patellofemoral ligament was found to be adequate to complete the tibial exposure in each case. Resection of a minimal amount of lateral tibial bone was required in order to reestablish the preosteotomy position of the lateral joint line in reference to the proximal aspect of the fibula. A much thicker tibial component was commonly required despite the minimal amount of resection of lateral tibial bone (Fig. 1). Hardware was removed only if it interfered with placement of the tibial component. Hardware was removed at the time of the total knee replacement in thirteen knees (33 percent) and prior to the total knee replacement in five knees (13 percent). In seven knees (18 percent), fixation staples were left in place at the time of the total knee replacement. Intraoperative ligament releases were also recorded (Table II).

The average duration of follow-up was 7.5 years (range, three to sixteen years) in the knees with a previous high tibial osteotomy and 6.8 years (range, two to ten years) in the knees without a high tibial osteotomy. Statistical analysis, which included the Student t test, Wilcoxon's rank-sum test, and the chi-square test, was performed with use of the SAS software program (SAS Institute, Cary, North Carolina).

Results

Introduction | Materials and Methods | Results | Discussion | References

The average interval from the high tibial osteotomy to the total knee replacement was 104 months (range, twenty-four to 220 months). A dome-type osteotomy had been performed in five knees (13 percent) and a closing-wedge osteotomy, in thirty-four (87 percent). Internal fixation had been used in twenty-five knees (64 percent). The average distance from the knee joint to the osteotomy site was 23.1 millimeters (range, five to sixty-five millimeters).

No significant differences between the two groups were noted with respect to the age and weight of the patients, the preoperative clinical knee scores, or the range of motion at the time of the operation (Table I). However, several significant differences were detected. The preoperative alignment averaged 3.2 degrees of valgus in the group with a previous high tibial osteotomy compared with 0.7 degree of varus in the group without an osteotomy (p = 0.0188). Furthermore, less lateral tibial bone was noted proximal to the fibular head in the group that had had a previous high tibial osteotomy; the position of the lateral joint line was an average of 11.4 millimeters from the fibular head in the group that had had a high tibial osteotomy compared with 18.3 millimeters in the group that had not (p = 0.0001). The Insall-Salvati patellar position ratio was also significantly lower in the high tibial osteotomy group (p = 0.0288). Excluding high tibial osteotomy, at least one previous operation (arthroscopy or arthrotomy) had been performed in seven knees (18 percent) that had had an osteotomy and in four knees (10 percent) that had not. This difference was not found to be significant (p = 0.117).

No significant differences were noted in the number of medial (p = 1.000), posterior (p = 0.732), or lateral patellar (p = 0.247) releases performed intraoperatively (Table II). Although four knees in the group with a high tibial osteotomy and only one knee in the group without a high tibial osteotomy required release of the iliotibial band or release of the lateral part of the joint capsule and the popliteus tendon, 90 percent (thirty-five) of the thirty-nine knees that had had a high tibial osteotomy did not require a lateral knee release. No significant difference was detected between this rate and that for the knees that had not had a high tibial osteotomy (p = 0.423).

At the time of the final follow-up, the knee and function scores were similar for the two groups (89.0 and 81.0 points, respectively, for the group with a previous high tibial osteotomy, and 89.6 and 83.9 points, respectively, for the group without a high tibial osteotomy) (Table III). Although more knees were free of pain in the group without a high tibial osteotomy (thirty-six) than in the group with a previous osteotomy (thirty-three), this difference was not found to be significant (p = 0.4810). As was the case preoperatively, the postoperative range of motion, including average extension and flexion, was similar for the two groups.

Knee alignment was also similar in both groups postoperatively (Table IV). The average alignment was 6.3 degrees of valgus in the group with a high tibial osteotomy and 5.2 degrees of valgus in the group without a high tibial osteotomy. Furthermore, the average anteroposterior alignment of the femoral component was 8.2 degrees of valgus (range, 3 to 15 degrees of valgus) in the group with a high tibial osteotomy compared with 7.0 degrees of valgus (range, 2 to 10 degrees of valgus) in the group without a high tibial osteotomy (p = 0.398). No significant difference was noted between these two groups with respect to the alignment of the tibial component on the postoperative anteroposterior and lateral radiographs. As noted preoperatively, more cases of patella infera (an Insall-Salvati ratio of less than 0.8) were noted in the high tibial osteotomy group (p = 0.0110) postoperatively.

More lateral tibial bone was removed in the group without a high tibial osteotomy (p = 0.0001) (Table IV). An average of only 3.3 millimeters of lateral tibial bone was removed at the time of the operation in the high tibial osteotomy group. Interestingly, an average of 2.8 millimeters (range, zero to nine millimeters) of lateral tibial bone was removed in the group of five knees that had had the dome-type osteotomy compared with 3.4 millimeters (range, zero to seventeen millimeters) in the group of thirty-four knees that had had the closing-wedge-type osteotomy, which is a small difference. Consistent with this finding, the postoperative lateral joint line was raised an average of approximately seven millimeters proximal to the fibular head in the group that had had a high tibial osteotomy and was lowered an average of approximately one millimeter distal to the fibular head in the group that had not had a high tibial osteotomy (p = 0.0001). It is of note that the difference between the two groups with regard to the average preoperative position of the lateral joint line, measured from the fibular head (Table I), was the exact distance that the lateral joint line was raised during total knee replacement in the high tibial osteotomy group (6.9 millimeters) (Table IV). Thus, with minimal resection of the lateral tibial bone and with use of a relatively thicker tibial component, the anatomical (preosteotomy) position of the lateral joint line was reestablished at the time of the total knee replacement (Fig. 2-A, Fig. 2-B, and Fig. 2-C).

At the time of the most recent follow-up, tibial radiolucent lines were identified in five knees (three with a previous high tibial osteotomy and two without a high tibial osteotomy). The number of knees with patellar and femoral radiolucent lines was also similar in both groups. Only one revision was required in the entire study group: specifically, one knee with a high tibial osteotomy was revised three years postoperatively because of loosening of the all-polyethylene anatomic graduated tibial component (AGC; Biomet).

Additional complications included stiffness in two patients (four knees; two knees in each group), which required bilateral manipulation at approximately two and four months postoperatively. There were no cases of deep infection. A superficial infection was noted in four knees without a high tibial osteotomy and in two knees with a high tibial osteotomy. All of the infections resolved following treatment with oral antibiotics. Partial avulsion of the patellar tendon, resulting in a temporary 30-degree extensor lag, was noted at three months postoperatively in one knee without a high tibial osteotomy. The patient was treated nonoperatively with a hinged knee brace that allowed limited yet progressive knee flexion. There were no cases of patellofemoral subluxation. Four knees (three with a high tibial osteotomy and one without a high tibial osteotomy) were revised because of loosening of the patellar component. All four components were metal-backed. Furthermore, three knees (two with a high tibial osteotomy and one without a high tibial osteotomy) had a patellar fracture that was treated effectively without an operation. Finally, mild asymptomatic medial instability (zero to five millimeters) was noted in one knee that had had a high tibial osteotomy. No cases of instability were noted in the group without a high tibial osteotomy.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The results of total knee replacement after high tibial osteotomy have been reviewed with and without patient-matched comparisons. Staeheli et al.²⁴, in a review of thirty-five knees with an average duration of follow-up of less than four years, reported an 89 percent rate of good or excellent results and confirmed the clinical impression that "no bridges are burned" by performing a high tibial osteotomy. Some residual instability was noted, however, in thirteen patients. Conversely, Windsor et al.²⁷, in a review of forty-five knees with an average duration of follow-up of less than five years, found only an 80 percent rate of good and excellent results and noted that the results of total knee replacement after high tibial osteotomy were not as good as those after other primary arthroplasties.

In an attempt to minimize the effect of variables such as age, gender, prosthetic selection, use of cemented or uncemented components, and duration of follow-up, authors of patient-matched studies have also reviewed the results of total knee replacement after a previous high tibial osteotomy. These results have differed as well. Katz et al.¹⁶ compared the results of total knee arthroplasty in twenty-one patients who had had a previous high tibial osteotomy with those in a matched group of twenty-one patients who had not had a previous osteotomy. After an average duration of follow-up of less than three years, only 81 percent of the patients who had had a previous osteotomy had a good or excellent result compared with 100 percent of those who had not. However, the high tibial osteotomy did not adversely affect component fixation. In a later report from the same institution, Mont et al.²⁰ compared the results of total knee arthroplasty in seventy-three knees that had not had a previous osteotomy. After an average duration of follow-up of approximately six years, only 64 percent of the knees that had had a previous osteotomy had a good or excellent result compared with 89 percent of those that had not.

In contrast, Amendola et al.² compared the results of total knee arthroplasty in a group of forty-two knees that had had a previous high tibial osteotomy with those in a control group of forty-one knees that had not and found no clinical differences between the groups after an average of approximately three years. Furthermore, Toksvig-Larsen et al.²⁵, in a radiostereometric study, compared the results of forty cemented and uncemented knee replacements in patients who had had a previous high tibial osteotomy with those in a matched group of forty patients who had had a primary total hip arthroplasty and found similar clinical scores in the two groups, with no difference in migration of the tibial component, after one to ten years of follow-up.

Nizard et al.²¹ compared the results of sixty-three total knee arthroplasties performed after high tibial osteotomy with the results in a group of matched patients who had had primary total knee arthroplasty. After an average duration of follow-up of fifty-five months, there was no difference between the two groups with regard to The Hospital for Special Surgery knee score. However, the average International Knee Society score was significantly higher in the control group (p = 0.001). Yet, among the parameters included in the International Knee Society score, only pain was significantly lower in the control group (p = 0.03). The range of motion, stability, and alignment were not different. Thus, except for pain, the results for the two groups were similar.

Although concerns have been raised about the diminished range of motion^2,17 and residual instability²⁴ in patients managed with total knee arthroplasty after high tibial osteotomy, these concerns have not been supported by other studies^3,21,25. In the present study, there were no notable differences between the groups with regard to range of motion in either flexion or extension, and only one knee, in the high tibial osteotomy group, had mild medial instability.

Because of the adhesions that are present after high tibial osteotomy, patellar eversion is a potential problem. Several authors have stressed the need for lateral patellar release not only for operative exposure^19,27 but also for the correction of patellar maltracking (which has been known to be more common after high tibial osteotomy^2,21). In the present study, however, lateral release was not required for proper exposure in any knee. Furthermore, although the number of knees that required a lateral patellar release was slightly greater in the group with a previous high tibial osteotomy than it was in the group without a previous osteotomy (eighteen compared with thirteen), this difference was not found to be significant.

As in the present study, patella infera has been found to be more common after high tibial osteotomy^20,27. This finding did not appear to adversely affect the result of total knee arthroplasty. Mont et al.²⁰, who noted more poor results in the group that had had a previous high tibial osteotomy, found no adverse effect of patella infera. Interestingly, Nizard et al.²¹ found no significant difference between the group that had had a high tibial osteotomy and the matched group that had not with respect to the Insall-Salvati ratio.

Cameron and Welsh⁴ and Krackow and Holtgrewe¹⁷ recognized the possible need for lateral ligamentous balancing, especially in knees with severe overcorrection after a high tibial osteotomy. In the present study, we noted no significant difference between the groups with respect to the number of lateral knee-joint releases required. This finding may have been due to the small number of knees that had severe overcorrection in the group that had had a high tibial osteotomy (average alignment, 3.2 degrees of valgus). Furthermore, precise attention was given to removing a minimal amount of lateral tibial bone at the time of tibial resurfacing.

Lastly, although no deep infections were noted in the present review, Windsor et al.²⁷ noted an infection in two (4.4 percent) of forty-five knees that had had a high tibial osteotomy. If retained hardware cannot be removed without extensive operative dissection at the time of knee arthroplasty, it is a common practice at our institution to remove retained hardware through the previous lateral incision and then to delay total knee arthroplasty until after that wound has healed.

The relatively high rate of complications in both groups is not reflective of our present experience with total knee arthroplasty at this institution.

One strength of the present study is the elimination of the potential differences that may be found when two separate groups of patients are compared, regardless of whether the groups are patient-matched or not. These differences may be somewhat controlled by evaluating potential side-to-side differences in the same patient. However, the retrospective nature of the present review is a potential weakness. The present study was designed to use data gathered in a prospective nature but without a specific protocol in order to test a hypothesis, which was conceived in retrospect. Furthermore, the examiners were not blinded with regard to the type of operation at the time of the clinical evaluation. Thus, there is a possibility that a difference between the groups was not found because of the study design.

Instead of patient-matching, we evaluated potential side-by-side differences in thirty-nine patients who had had bilateral total knee replacement after unilateral high tibial osteotomy. Although substantial differences (with regard to valgus alignment, patella infera, and decreased bone stock in the proximal part of the tibia) between the groups were present preoperatively, no differences were noted in the clinical and radiographic results of primary total knee arthroplasty for the knees with and without a previous high tibial osteotomy. Furthermore, thirty-six of the thirty-nine patients noted no side-to-side difference in the amount of pain relief; at the time of the most recent follow-up, 85 percent of the knees with a high tibial osteotomy had no pain. The previous high tibial osteotomy had no deleterious effect on the outcome of the subsequent total knee replacement. Potential factors other than the osteotomy itself, including the operative technique, the location of the osteotomy, and the number of knees that were severely overcorrected after the high tibial osteotomy, may account for the inferior results previously seen in such patients.

References

Introduction | Materials and Methods | Results | Discussion | References

Aglietti, P.; Rinonapoli, E.; Stringa, G.; and Taviani, A.: Tibial osteotomy for the varus osteoarthritic knee. Clin. Orthop.,176: 239-251, 1983.176239 1983 [PubMed]

Amendola, A.; Rorabeck, C. H.; Bourne, R. B.; and Apyan, P. M.: Total knee arthroplasty following high tibial osteotomy for osteoarthritis. J. Arthroplasty,,4 (Supplement): 11-S17, 1989.4 (Supplement)11 1989

Bergenudd, H.; Sahlström, A.; and Sanzén, L.: Total knee arthroplasty after failed proximal tibial valgus osteotomy. J. Arthroplasty,12: 635-638, 1997.12635 1997 [PubMed]

Cameron, H. U., and Welsh, R. P.: Potential complications of total knee replacement following tibial osteotomy. Orthop. Rev.,17: 39-43, 1988.1739 1988 [PubMed]

Coventry, M. B.: Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee: a preliminary report. J. Bone and Joint Surg.,47-A: 984-990, July 1965.47-A984 1965

Coventry, M. B., and Bowman, P. W.: Long-term results of upper tibial osteotomy for degenerative arthritis of the knee. Acta Orthop. Belgica,48: 139-156, 1982.48139 1982

Coventry, M. B.; Ilstrup, D. M.; and Wallrichs, S. L.: Proximal tibial osteotomy: a critical long-term study of eighty-seven cases. J. Bone and Joint Surg.,75-A: 196-201, Feb 1993.75-A196 1993

Ewald, F. C.: The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin. Orthop.,248: 9-12, 1989.2489 1989 [PubMed]

Hernigou, P. H.; Medevielle, D.; Debeyre, J.; and Goutallier, D.: Proximal tibial osteotomy for osteoarthritis with varus deformity. J. Bone and Joint Surg.,69-A: 332-354, March 1987.69-A332 1987

Holden, D. L.; James, S. L.; Larson, R. L.; and Slocum, D. B.: Proximal tibial osteotomy in patients who are fifty years old or less: a long-term follow-up study. J. Bone and Joint Surg.,70-A: 977-982, Aug 1988.70-A977 1988

Insall, J.,, and Salvati, E.: Patella position in the normal knee joint. Radiology,101: 101-104, 1971.101101 1971 [PubMed]

Insall, J.; Shoji, H.; and Mayer, V.: High tibial osteotomy: a five-year evaluation. J. Bone and Joint Surg.,56-A: 1397-1405, Oct 1974.56-A1397 1974

Insall, J. N.; Joseph, D. M.; and Msika, C.: High tibial osteotomy for varus gonarthrosis: a long-term follow-up study. J. Bone and Joint Surg.,,66-A: 1040-1048, Sept 1984.66-A1040 1984

Insall, J. N.; Dorr, L. D.; Scott, R. D.; and Scott, W. N.: Rationale of the Knee Society clinical rating system. Clin. Orthop.,248: 13-14, 1989.24813 1989 [PubMed]

Jackson, J. P.: Osteotomy for osteoarthrosis of the knee. In Proceedings of the British Orthopaedic Association. J. Bone and Joint Surg.,40-B(4): 826, 1958.40-B(4)826 1958

Katz, M. M.; Hungerford, D. S.; Krackow, K. A.; and Lennox, D. W.: Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J. Bone and Joint Surg.,69-A: 225-233, Feb 1987.69-A225 1987

Krackow, K. A., and Holtgrewe, J. L.: Experience with a new technique for managing severely overcorrected valgus high tibial osteotomy at total knee arthroplasty. Clin. Orthop.,,258: 213-224, 1990.258213 1990

MacIntosh, D. L., and Welsh, R. P.: Joint dÇ¢ridement È a complement to high tibial osteotomy in the treatment of degenerative arthritis of the knee. J. Bone and Joint Surg.,59-A: 1094-1097, Dec 1977.59-A1094 1977

Mont, M. A.; Alexander, N.; Krackow, K. A.;; and Hungerford, D. S.: Total knee arthroplasty after failed high tibial osteotomy. Orthop. Clin. North America,25: 515-525, 1994.25515 1994

Mont, M. A.; Antonaides, S.; Krackow, K. A.; and Hungerford, D. S.: Total knee arthroplasty after failed high tibial osteotomy: a comparison with a matched group. Clin. Orthop.,,299: 125-130, 1994.299125 1994

Nizard, R. S.; Cardinne, L.; Bizot, P.; and Witvoet, J.: Total knee replacement after failed tibial osteotomy: results of a matched-pair study. J. Arthroplasty,,13: 847-853, 1998.13847 1998

Odenbring, S.; Egund, N.; Knutson, K.; Lindstrand, A.; and Larsen, S. T.: Revision after osteotomy for gonarthrosis. A 10-19-year follow-up of 314 cases. Acta Orthop. Scandinavica,61: 128-130, 1990.61128 1990

Ritter, M. A., and Fechtman, R. A.: Proximal tibial osteotomy. A survivorship analysis. J. Arthroplasty,3: 309-311, 1988.3309 1988 [PubMed]

Staeheli, J. W.; Cass, J. R.; and Morrey, B. F.: Condylar total knee arthroplasty after failed proximal tibial osteotomy. J. Bone and Joint Surg.,69-A: 28-31, Jan 1987.69-A28 1987

Toksvig-Larsen, S.; Magyar, G.; Önsten, I.; Ryd, L.; and Lindstrand, A.: Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy. A matched radiostereometric study. J. Bone and Joint Surg.,80-B(2): 295-297, 1998.80-B(2)295 1998

Vainionpää, S.; Läike, E.; Kirves, P.; and Tiusanen, P.: Tibial osteotomy for osteoarthritis of the knee. A five to ten-year follow-up study. J. Bone and Joint Surg.,63-A: 938-946, July 1981.63-A938 1981

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TABLE I: Preoperative Data

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Age† (yrs.)	66.9 (50-80)	67.4 (52-80)	0.1532
Weight† (kg)	82.7 (52.2-113.0)	82.6 (52.3-113.0)	0.1626
Knee score† (points)	44.8 (30-59)	44.8 (36-57)	0.8915
Range of motion (degrees)
Average extension	5.5	6.1	0.2417
Average flexion	112.0	113.5	0.0537
Alignment †‡(degrees)	3.2 (-11-20)	-0.7 (-15-14)	0.0188
Distance between lateral joint line and fibular head†§ (mm)	11.4 (-3-35)	18.3 (8-25)	0.0001
Insall-Salvati ratio†	1.11 (0.65-1.67)	1.22 (0.94-1.54)	0.0288

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TABLE I: Preoperative Data

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Age† (yrs.)	66.9 (50-80)	67.4 (52-80)	0.1532
Weight† (kg)	82.7 (52.2-113.0)	82.6 (52.3-113.0)	0.1626
Knee score† (points)	44.8 (30-59)	44.8 (36-57)	0.8915
Range of motion (degrees)
Average extension	5.5	6.1	0.2417
Average flexion	112.0	113.5	0.0537
Alignment †‡(degrees)	3.2 (-11-20)	-0.7 (-15-14)	0.0188
Distance between lateral joint line and fibular head†§ (mm)	11.4 (-3-35)	18.3 (8-25)	0.0001
Insall-Salvati ratio†	1.11 (0.65-1.67)	1.22 (0.94-1.54)	0.0288

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TABLE II: Operative Data

*The values are given as the number of knees, with the percentage in parentheses.†NA = not applicable.

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Prostheses
Posterior cruciate condylar component	1 (3)	1 (3)
Anatomic graduated component	38 (97)	38 (97)
Metal-backed patellar component	4 (10)	4 (10)
All-polyethylene tibial component	4 (10)	4 (10)	NA
Lateral patellar release	18 (46)	13 (33)	0.247
Medial release			1.000
Deep tibial collateral ligament	37 (95)	37 (95)
+ Superficial tibial collateral ligament	1 (3)	2 (5)
+ Semimembranosus	1 (3)	0
Lateral release			0.423
None	35 (90)	38 (97)
+ Iliotibial band	2 (5)	1 (3)
+ Capsule and popliteus	2 (5)	0
Posterior release			0.732
None	24 (62)	28 (72)
Osteophytes	14 (36)	10 (26)
+ Posterior aspect of capsule	1 (3)	1 (3)

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TABLE II: Operative Data

*The values are given as the number of knees, with the percentage in parentheses.†NA = not applicable.

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Prostheses
Posterior cruciate condylar component	1 (3)	1 (3)
Anatomic graduated component	38 (97)	38 (97)
Metal-backed patellar component	4 (10)	4 (10)
All-polyethylene tibial component	4 (10)	4 (10)	NA
Lateral patellar release	18 (46)	13 (33)	0.247
Medial release			1.000
Deep tibial collateral ligament	37 (95)	37 (95)
+ Superficial tibial collateral ligament	1 (3)	2 (5)
+ Semimembranosus	1 (3)	0
Lateral release			0.423
None	35 (90)	38 (97)
+ Iliotibial band	2 (5)	1 (3)
+ Capsule and popliteus	2 (5)	0
Posterior release			0.732
None	24 (62)	28 (72)
Osteophytes	14 (36)	10 (26)
+ Posterior aspect of capsule	1 (3)	1 (3)

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TABLE III: Clinical Results

*NA = not applicable.†The values are given as the average, with the range in parentheses.‡The values are given as the numbers of knees, with the percentage in parentheses.

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Duration of follow-up† (yrs.)	7.5 (3-16)	6.8 (2-10)	NA
Knee score† (points)	89.0 (72-97)	89.6 (79-96)	0.6765
Function score† (points)	81.0 (20-100)	83.9 (35-100)	0.4098
Range of motion† (degrees)
Extension	0.26 (0-5)	0.64 (0-5)	0.8319
Flexion	113.0 (75-130)	117.8 (85-130)	0.9717
Pain‡
None	33 (85)	36 (92)	0.4810
Mild or occasional	5 (13)	3 (8)
Moderate or continuous	1 (3)	0

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TABLE III: Clinical Results

*NA = not applicable.†The values are given as the average, with the range in parentheses.‡The values are given as the numbers of knees, with the percentage in parentheses.

	Group with High Tibial Osteotomy	Group without High Tibial Osteotomy	P Value*
Duration of follow-up† (yrs.)	7.5 (3-16)	6.8 (2-10)	NA
Knee score† (points)	89.0 (72-97)	89.6 (79-96)	0.6765
Function score† (points)	81.0 (20-100)	83.9 (35-100)	0.4098
Range of motion† (degrees)
Extension	0.26 (0-5)	0.64 (0-5)	0.8319
Flexion	113.0 (75-130)	117.8 (85-130)	0.9717
Pain‡
None	33 (85)	36 (92)	0.4810
Mild or occasional	5 (13)	3 (8)
Moderate or continuous	1 (3)	0

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TABLE IV: Radiographic Results

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Alignment‡(degrees)	6.3 (-3-15)	5.2 (0-10)	0.0744
Insall-Salvati ratio	1.10 (0.67-1.49)	1.23 (0.90-1.59)	0.0110
Distance between lateral joint line and fibular head§ (mm)	6.9 (-8-27)	-1 (-10-10)	0.0001
Amount of lateral tibial bone removed# (mm)	3.3 (1-17)	7.5 (0-18)	0.0001

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TABLE IV: Radiographic Results

	Group with High Tibial Osteotomy*	Group without High Tibial Osteotomy*	P Value†
Alignment‡(degrees)	6.3 (-3-15)	5.2 (0-10)	0.0744
Insall-Salvati ratio	1.10 (0.67-1.49)	1.23 (0.90-1.59)	0.0110
Distance between lateral joint line and fibular head§ (mm)	6.9 (-8-27)	-1 (-10-10)	0.0001
Amount of lateral tibial bone removed# (mm)	3.3 (1-17)	7.5 (0-18)	0.0001