Objective To investigate the feasibility and effectiveness of high tibial osteotomy (HTO) in treatment of chronic multi-ligament knee injury (MLKI) associated with lower extremity malalignment. Methods A clinical data of 14 patients (14 knees) of chronic MLKI associated with lower extremity malalignment, who were treated with HTO between January 2016 and September 2020, was retrospectively analyzed. There were 10 males and 4 females, with an average age of 30.5 years (range, 22-48 years). The causes of injury included traffic accident in 8 cases, bruising by a heavy object in 3 cases, falling from height in 2 cases, and twisting in 1 case. According to Schenck classification of knee dislocation (KD), there were 4 cases of KD-Ⅰ [2 cases of anterior cruciate ligament (ACL) and posterolateral complex (PLC) injuries and 2 cases of posterior cruciate ligament (PCL) and PLC injuries], 7 cases of KD-Ⅲ (all of ACL, PCL, and PLC injuries), and 3 cases of KD-Ⅳ. The preoperative hip-knee-ankle angle (HKA) was (167.1±4.7)°, and the posterior tibial slope angle (PTSA) was (16.3±2.7)°. The knee joint was severely unstable and the patients could not stand and walk normally. Among them, 5 cases of medial compartment cartilage were severely worn out (3 cases of Kellgren-Lawrence grading Ⅱ, 2 cases of grading Ⅲ) causing pain. After admission, 2 cases of KD-Ⅰ underwent HTO and ligament reconstruction in the first stage, 1 case of KD-Ⅲ and 1 case of KD-Ⅳ underwent HTO in the first stage and ligament reconstruction in the second stage; the remaining 10 patients only underwent HTO. Results All patients were followed up 12-50 months, with an average of 30 months. The incisions healed by first intention after operation, and no complications such as infection and deep vein thrombosis of the lower extremities occurred. At 12 months after operation, knee range of extension was –5°-0° (mean, –1.2°) and range of flexion was 110°-140° (mean, 125.5°). The Lachman test was negative in 11 cases and positive in 3 cases. The posterior drawer test was negative in 9 cases and positive in 5 cases. The 0/30° varus stress test was negative in 10 cases and positive in 4 cases. The 0/30° valgus stress test was negative in 13 cases and positive in 1 case. The visual analogue scale (VAS) score was significantly lower than that before operation (P<0.05), and the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were all significantly higher than those before operation (P<0.05). The X-ray film reexamination at 12 months after operation showed that the HKA was (178.2±3.8)° and the PTSA was (8.6±2.4)°, which were significantly different from those before operation (P<0.05). All osteotomies achieved bone union, and the healing time was 3-11 months, with an average of 6.8 months. Conclusion For chronic MLKI associated with lower extremity malalignment, HTO can restore normal lower extremity alignment and improve knee joint function, which is a feasible salvage operation.
ObjectiveTo summarize the related research results of open wedge high tibial osteotomy (OWHTO) complicated with lateral hinge fracture. MethodsTo review the relevant literature of OWHTO at home and abroad in recent years and summarize and analyse the clinical experience. ResultsThe lateral hinge rupture may occur during the OWHTO, which may lead to the loss of correction angle after operation, delayed healing or non-union of osteotomy and so on. The lateral hinge plays an important role in the stability of the osteotomy. During the operation, the " safe zone” internal osteotomy can be used to protect the bone. Once the lateral hinge breaks, the TomoFix plate can be used to obtain the sufficient stability. For patients with lateral hinge rupture, functional exercise and full weight loading time should be guided by hinge breakage classification. ConclusionThe intact lateral hinge is beneficial to the healing and rehabilitation of OWHTO. The lateral hinge should be paid enough attention by clinicians.
ObjectiveTo compare the clinical and radiologic effectiveness in patients with versus without lateral hinge fracture during medial opening-wedge high tibial osteotomy (MOWHTO) to evaluate the effect of lateral hinge fracture on short-term effectiveness.MethodsThe clinical data of 84 patients (97 knees) with medial compartment osteoarthritis who treated with MOWHTO between September 2015 and July 2018 was retrospectively analyzed. There were 10 males (10 knees) and 74 females (87 knees). The age ranged from 45 to 65 years with an average of 57.7 years. Lateral hinge fracture was recognized by the intraoperative fluoroscopy or immediate postoperative X-ray film. Fractures were classified into types Ⅰ, Ⅱ, and Ⅲ according to the Takeuchi classification. The healing of osteotomy was observed by radiographs during follow-up; the femur tibia angle (FTA), medialproximal tibial angle (MPTA), and hip-knee-ankle angle (HKA) were also calculated. The knee joint function was evaluated by Hospital for Special Surgery (HSS) score and knee society score (KSS).ResultsThe incision healed by first intention. All patients were followed up 15-48 months with an average of 24.8 months. No hinge fracture occurred in 78 knees (80.41%, group A), and lateral hinge fractures were observed in 19 knees (19.59%, group B) and were divided into the type Ⅰ (13 knees, 13.40%) and type Ⅲ (6 knees, 6.19%) groups. Type Ⅰ fractures were not additionally treated, type Ⅲ fractures were anatomic reduced fixed with additional lag screws. X-ray film and CT examination showed that all patients had bone healing at 3 months after operation without delayed healing or nonunion. During follow-up, there was no loosening or fracture of internal fixation plates and screws. HKA, FTA, and MPTA of patients in group A and group B (type Ⅰ and Ⅲ) were significantly improved at each time point after operation compared with preoperative values (P<0.05); there was no significant difference between groups at each time point before and after operation (P>0.05). After operation, the pain of knee joint was alleviated and the function of joint was improved. At last follow-up, KSS score and HSS score of groups A and B were significantly improved compared with those before operation (P<0.05), but there was no significant difference between the two groups (P>0.05).ConclusionThe lateral hinge fracture may occur during MOWHTO. As long as the treatment and rehabilitation were guided according to the fracture classification of the hinge, the effectiveness can be similar to those without the hinge fracture.
Objective To investigate the accuracy of split three-dimensional (3D) printing patient-specific instrumentation (PSI) in medial open-wedge high tibial osteotomy (MOWHTO) and its effectiveness in treating medial knee osteoarthritis.MethodsClinical data of 14 patients with medial knee osteoarthritis and treated with split 3D printing PSI-assisted MOWHTO between August 2019 and August 2020 were retrospectively analyzed. There were 5 males and 9 females with an average age of 61 years (range, 43-68 years). The disease duration ranged from 1 to 16 years, with an average of 4.7 years. Preoperative Kellgren-Lawrence grading of knee osteoarthritis included grade Ⅰ in 2 cases, grade Ⅱ in 6 cases, and grade Ⅲ in 6 cases. The Hospital for Special Surgery (HSS) score was 59.1±4.9. The weight bearing line ratio (WBL), hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), posterior tibial slope angle (PTSA), and actual correction angle of the lower limbs were measured on postoperative imaging data, and compared with the preoperative measurements and the designed target values to evaluate the accuracy of the PSI-assisted surgery. The patients’ knee function were evaluated with the HSS score at 3 and 6 months postoperatively, and at last follow-up.ResultsOne patient suffered from an incision exudation at 2 weeks postoperatively, and the incision healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 7-19 months (mean, 14.8 months). There was no neural injuries, hinge fracture, plate or screw fractures, loosening, or other complications. The WBL was maintained at the postoperative level according to the X-ray examination during the follow-up period. The WBL, HKA, MPTA, and PTSA were all within a satisfactory range after operation. The WBL, HKA, and MPTA were significantly improved when compared with the preoperative measurements (P<0.05). There was no significant difference between preoperative and postoperative PTSA (P>0.05). The differences in postoperative WBL, HKA, MPTA, and correction angle compared with the preoperative designed target values were not significant (P>0.05). The HSS scores were 69.2±4.7, 77.7±4.3, and 88.1±5.4 at 3 and 6 months postoperatively, and last follow-up, respectively. The differences between time points were significant (P<0.05).ConclusionFor patients with medial knee osteoarthritis, the split 3D printing PSI can assist the surgeon in MOWHTO with accurate osteotomy orthopedics and achieve favorable effectiveness.
Objective To investigate the effect of body mass index (BMI) on the short-term effectiveness of high tibial osteotomy (HTO) in the treatment of varus knee arthritis. Methods The clinical data of 84 patients (84 knees) with varus knee arthritis treated with HTO between May 2016 and August 2020 were retrospectively analyzed. According to BMI, the patients were divided into normal group (32 patients in group A, BMI<25 kg/m2), overweight group (27 patients in group B, BMI>30 kg/m2), and obese group (25 patients in group C, BMI>30 kg/m2). The BMI of groups A, B, and C were (23.35±0.89), (26.65±1.03), and (32.05±1.47) kg/m2, respectively. There was no significant difference (P>0.05) in gender, age, surgical side, disease duration, and preoperative Hospital for Special Surgery (HSS) score, visual analogue scale (VAS) score, knee range of motion, and hip-knee-ankle angle (HKA) between groups. The operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation were recorded and compared between groups. The improvement of knee joint function and pain status were evaluated by knee joint HSS score, knee range of motion, and VAS score before and after operation, and measuring the HKA of patients on X-ray film. During the follow-up, the X-ray films of the knee joint were reexamined to observe the position of the internal fixator and the healing of osteotomy. Results All patients completed the operation successfully and were followed up 8-40 months (mean, 19.3 months). There was no significant difference in follow-up time, operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation between groups (P>0.05). No operative complications such as severe vascular or nerve injury occurred. After operation, deep venous thrombosis of lower extremities occurred in 1 case in groups A and B respectively, and fat liquefaction of surgical incision occurred in 2 cases in group C. There was no significant difference in the incidence of perioperative complications between groups (3.1% vs. 3.7% vs. 8.0%) (P=0.689). During the follow-up, there was no bone nonunion, plate fracture or loosening. At last follow-up, HSS score, VAS score, knee range of motion, and HKA significantly improved in the 3 groups when compared with those before operation (P<0.05), but there was no significant difference in the differences of the above indexes between groups before and after operation (P>0.05). Conclusion BMI does not affect the short-term effectiveness of HTO in the treatment of varus knee arthritis. HTO can be selected for overweight and obese patients after standard medical treatment is ineffective.
Objective To investigate interleukin-1β (IL-1β), IL-6, and IL-17 levels in both synovial fluid and serum of patients with primary knee medial osteoarthritis (OA) after high tbial osteotomy (HTO). Methods Twenty-six patients with primary knee medial OA undergoing HTO between January 2011 and June 2014 (experimental group) and 30 healthy individuals (control group) were recruited into the study. There was no significant difference in gender, age, and body mass index between 2 groups (P>0.05). The X-ray film was taken to record healing time at osteotomy site, to measure the tibiofemoral angle, and to assess limb alignment after HTO. Visual analogue scale (VAS) pain score and knee society score (KSS) were used to evaluate pain level and function of the knee. The IL-1β, IL-6, and IL-17 concentrations in both plasma and synovial fluid were measured before operation and at 6, 12, and 18 months after operation in the experimental group using ELISA method; the levels in plasma were measured in control group. Results Primary healing of incisions was achieved in patients. All patients were followed up 18-24 months (mean, 21 months). The X-ray film showed osseous healing at osteotomy site at 9-14 weeks (mean, 11.5 weeks). The average tibiofemoral angle was 167.5° (range, 165-170°) after bone healing. Satisfactory limb alignment was obtained in all patients. The postoperative VAS pain score was significantly decreased and KSS score was significantly improved when compared with preoperative scores (P<0.05), but no significant difference was found between different time points after operation (P>0.05). The preoperative plasma and synovial fluid IL-1β, IL-6, and IL-17 concentrations were significantly higher in patients than controls (P<0.05). The postoperative IL-1β, IL-6, and IL-17 concentrations in plasma and synovial fluid were significantly lower than preoperative ones in patients (P<0.05), but the concentrations were significantly higher than those in controls (P<0.05). The postoperative plasma and synovial fluid IL-1β, IL-6, and IL-17 concentrations were significantly declined in patients, but there was no significant difference between different time points after operation (P>0.05). Conclusion HTO can significantly improve the pain symptom and joint function and reduce IL-1β, IL-6, and IL-17 levels in both plasma and synovial fluid of patients with medial compartment knee OA, but these cytokines can not return to normal level.
Objective To investigate the effectiveness of high tibial osteotomy (HTO) combined with arthroscopic surgery to treat medial compartment knee osteoarthritis (KOA) and secondary arthroscopic exploration to evaluate the outcome of cartilage and meniscus.Methods A clinical data of 57 patients with medial compartment KOA with varus deformity of lower extremities admitted between August 2014 and October 2018 were retrospectively analyzed. There were 23 males and 34 females with an average age of 51.2 years (range, 41-63 years). The disease duration ranged from 2 to 8 years, with an average of 4.7 years. The preoperative femorotibial angle was (179.86±4.69)°, the relative position of the lower limb mechanical axis passing through the tibial plateau was 24.21%±6.98%, and the posterior slope of the tibial plateau was (5.23±1.45)°. The Kellgren-Lawrence grade of knee joint was grade Ⅱ in 22 cases and grade Ⅲ in 35 cases. The preoperative Hospital for Special Surgery (HSS) score, Lysholm score, and visual analogue scale (VAS) score were 59.1±7.3, 48.8±7.6, and 6.2±1.1, respectively. Arthroscopic exploration was performed during the operation to record the articular cartilage degeneration in the weight-bearing area of the medial compartment (Outerbridge grade Ⅰ in 18 cases, grade Ⅱ in 30 cases, and grade Ⅲ in 9 cases) and the condition of the medial meniscus injury, and the corresponding treatment was performed. The coronal force line was adjusted according to the preoperative Kellgren-Lawrence grade of the knee joint during the operation. After operation, the relative position of the lower limb mechanical axis passing through the tibial plateau, the femorotibial angle, and the posterior slope of the tibial plateau were measured; the Kellgren-Lawrence grade of the knee joint was recorded; the Outerbridge grade of articular cartilage degeneration and the meniscus outcome were evaluated by combining with the MRI of the knee joint at 1 year after operation and the second arthroscopic exploration when the internal fixator was removed. The function and pain of the knee were evaluated by Lysholm score, HSS score, and VAS score. ResultsAll the 57 patients were followed up 36-58 months with an average of 42.1 months. Incisions healed by first intention, and no neurovascular injury, intraarticular or hinge fractures occurred during operation, and no postoperative complications such as deep vein thrombosis of lower limbs and internal fixation failure occurred. All the osteotomy sites healed at 3 months after operation. At 1 year after operation, the internal fixator was removed, and the second arthroscopic exploration showed that there were 15 cases of Outerbridge grade Ⅰ, 31 cases of grade Ⅱ, and 11 cases of grade Ⅲ in the weight-bearing area of the medial compartment, and there was no significant difference when compared with preoperative grade (Z=31.992, P=0.997); there was no cartilage degeneration in other compartments. Meniscus healing was seen in the injured meniscus, and no injury was seen in the normal meniscus. At last follow-up, there were 19 cases of Kellgren-Lawrence grade Ⅱ and 38 cases of grade Ⅲ, and there was no significant difference when compared with preoperative grade (Z=49.049, P=0.764). The relative position of the lower limb mechanical axis passing through the tibial plateau was 59.16%±2.87%, and the femorotibial angle was (171.54±3.39)°, which significantly improved when compared with those before operation (P<0.001). The posterior slope of the tibial plateau was (5.65±1.22)°, which was not significantly different from that before operation (t=−1.673, P=0.096). The HSS score, Lysholm score, and VAS score were 82.3±7.7, 83.4±6.4, and 1.6±1.1 respectively, which were significantly different from those before operation (P<0.001). Conclusion HTO combined with arthroscopic surgery for medial compartment KOA with varus deformity of lower extremities can effectively improve the force line of lower extremities, relieve pain symptoms, and improve joint function, with satisfactory short-term effectiveness, and without significant progress in articular cartilage or meniscus injury after operation.
The use of a filling block can improve the initial stability of the fixation plate in the open wedge high tibial osteotomy (OWHTO), and promote bone healing. However, the biomechanical effects of filling block structures and materials on OWHTO remain unclear. OWHTO anatomical filling block model was designed and built. The finite element analysis method was adopted to study the influence of six filling block structure designs and four different materials on the stress of the fixed plate, tibia, screw, and filling block, and the micro-displacement at the wedge gap of the OWHTO fixation system. After the filling block was introduced in the OWHTO, the maximum von Mises stress of the fixation plate was reduced by more than 30%, the maximum von Mises stress of the tibia decreased by more than 15%, and the lateral hinge decreased by 81%. When the filling block was designed to be filled in the posterior position of the wedge gap, the maximum von Mises stress of the fixation system was 97.8 MPa, which was smaller than other filling methods. The minimum micro-displacement of osteotomy space was –2.9 μm, which was larger than that of other filling methods. Compared with titanium alloy and tantalum metal materials, porous hydroxyapatite material could obtain larger micro-displacement in the osteotomy cavity, which is conducive to stimulating bone healing. The results demonstrate that OWHTO with a filling block can better balance the stress distribution of the fixation system, and a better fixation effect can be obtained by using a filling block filled in the posterior position. Porous HA used as the material of the filling block can obtain a better bone healing effect.
ObjectiveTo investigate the effectiveness of arthroscopy combined with high tibial osteotomy (HTO) in the treatment of knee medial compartment osteoarthritis and its influence on cartilage injury.MethodsThe clinical data of 57 patients with knee medial compartment osteoarthritis treated with arthroscopy combined with HTO between March 2017 and March 2019 were retrospectively analyzed. There were 27 males and 30 females with an average age of 52.4 years (range, 44-57 years). The disease duration ranged from 3 to 6 years, with an average of 3.6 years. Twenty-one cases were grade Ⅰ and 36 cases were grade Ⅱ according to Kellgren-Lawrence classification. Flexion contracture of knee joint ranged from 0° to 8° with an average of 1.36° and varus deformity ranged from 5° to 10° with an average of 7.60°. Preoperative arthroscopic evaluation showed that there were 11 cases with grade Ⅰ, 42 cases with gradeⅡ, and 4 cases with grade Ⅲ according to the international cartilage repair classification system (ICRS). Lysholm score, American Hospital for Special Surgery (HSS) score, and International Knee Documentation Committee (IKDC) score were used to evaluate knee function before operation, at 3 months, at 1 year after operation, and at last follow-up. Visual analogue scale (VAS) score was used to evaluate pain. The mechanical medial proximal tibial angle (mMPTA) and femoral tibial angle (FTA) were measured before operation and at last follow-up. When the internal fixator was removed, the knee arthroscopy was performed again to explore the cartilage repair condition, and the regeneration level and maturity level were selected for cartilage grading evaluation.ResultsAll patients’ incisions healed by first intention after operation, and no incision infection or skin necrosis occurred. After operation, the knee joint function of the patients was significantly improved, the pain symptoms were relieved, and the force line measurement reached the target set before operation. The VAS score, Lysholm score, HSS score, and IKDC score were significantly improved at 3 months, 1 year after operation, and at last follow-up when compared with those before operation. They were gradually improved with the time and there were significant differences between time points (P<0.05). mMPTA and FTA were significantly improved at last follow-up when compared with those before operation (P<0.05). When the internal fixator was removed, the arthroscopic re-assessment found that the cartilage regeneration was classified into 10 cases of grade Ⅰ and 47 cases of grade Ⅱ; 18 cases of immature cartilage regeneration and 29 cases of mature cartilage regeneration were found in the knee joints of grade Ⅱ cartilage regeneration. There was no significant difference in the cartilage regeneration grade between different ICRS gradings (H=0.176, P=0.916), and the difference in maturity grading was significant (H=10.500, P=0.005).ConclusionArthroscopy combined with HTO for the treatment of knee medial compartment osteoarthritis can effectively improve the symptoms and function of the knee joint, and can promote the regeneration of articular cartilage.