Aims. Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group. Methods. The inclusion criteria consisted of patients who underwent simultaneous or staged bilateral TKA after prior unilateral DFO between 1972 and 2023. The type of osteotomy performed, osteotomy hardware fixation, implanted TKA components, and revision rates were recorded. Postoperative outcomes including the Forgotten Joint Score-12 (FJS-12), Tegner Activity Scale score, and subjective knee preference were also obtained at final follow-up. Results. A total of 21 patients underwent bilateral TKA following unilateral DFO and were followed for a mean of 31.5 years (SD 11.1; 20.2 to 74.2) after DFO. The mean time from DFO to TKA conversion was 13.1 years (SD 9.7) with 13 (61.9%) of DFO knees converting to TKA more than ten years after DFO. There was no difference in arthroplasty implant systems employed in both the DFO-TKA and TKA-only knees (p > 0.999). At final follow-up, the mean FJS-12 of the DFO-TKA knee was 62.7 (SD 36.6), while for the TKA-only knee it was 65.6 (SD 34.7) (p = 0.328). In all, 80% of patients had no subjective knee preference or preferred their DFO-TKA knee. Three DFO-TKA knees and two TKA-only knees underwent subsequent revision following index arthroplasty at a mean of 12.8 years (SD 6.9) and 8.5 years (SD 3.8), respectively (p > 0.999). Conclusion. In this self-matched study, DFOs did not affect subsequent TKA function as clinical outcomes, subjective knee preference, and revision rates were similar in both the DFO-TKA and TKA-only knees at mean 32-year follow-up. Cite this article: Bone Jt Open 2024;5(11):1013–1019

Aims. There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome. Patients and Methods. We retrospectively reviewed 29 patients (17 women, 12 men) from our total joint registry who had undergone 31 cemented TKAs after a DFO between 2000 and 2012. Their mean age at TKA was 51 years (22 to 76) and their mean body mass index 32 kg/m. 2. (20 to 45). The mean time between DFO and TKA was ten years (2 to 20). The mean follow-up from TKA was ten years (2 to 16). The prostheses were posterior-stabilized in 77%, varus-valgus constraint (VVC) in 13%, and cruciate-retaining in 10%. While no patient had metaphyseal fixation (e.g. cones or sleeves), 16% needed a femoral stem. Results. The ten-year survivorship was 95% with aseptic loosening as the endpoint, 88% with revision for any reason as the endpoint, and 81% with re-operation for any reason as the endpoint. Three TKAs were revised for instability (n = 2) and aseptic tibial loosening (n = 1). No femoral component was revised for aseptic loosening. Patients under the age of 50 years were at greater risk of revision for any reason (hazard ratio 7; p = 0.03). There were two additional re-operations (6%) and four complications (13%), including three manipulations under anaesthetic (MUA; 10%). The Knee Society scores improved from a mean of 50 preoperatively (32 to 68) to a mean of 93 postoperatively (76 to 100; p < 0.001). Conclusion. A cemented posterior-stabilized TKA has an 88% ten-year survivorship with revision for any reason as the endpoint. No femoral component was revised for aseptic loosening. Patients under the age of 50 years have a greater risk of revision. The clinical outcome was significantly improved but balancing the knee was challenging in 13% of TKAs requiring VVC. Overall, 10% of TKAs needed an MUA, and 6% of TKAs were revised for instability. Cite this article: Bone Joint J 2019;101-B:660–666

Aims

To assess the effect of high tibial and distal femoral osteotomies (HTO and DFO) on the pressure characteristics of the ankle joint.

Abstract. Background. Distal femoral osteotomy is an established successful procedure which can delay the progression of arthritis and the need for knee arthroplasty. The surgery, however, is complex and lengthy and consequently it is generally the preserve of highly experienced specialists and thus not widely offered. Patient specific instrumentation is known to reduce procedural complexity, time, and surgeons’ anxiety levels. 1. in proximal tibial osteotomy procedures. This study evaluated a novel patient specific distal femoral osteotomy procedure (Orthoscape, Bath, UK) which aimed to use custom-made implants and instrumentation to provide a precision correction while also simplifying the procedure so that more surgeons would be comfortable offering the procedure. Presenting problem. Three patients (n=3) with early-stage knee arthritis presented with valgus malalignment, the source of which was predominantly located within the distal femur, rather than intraarticular. Using conventional techniques and instrumentation, distal femoral knee osteotomy cases typically require 1.5–2 hours surgery time. The use of bi-planar osteotomy cuts have been shown to improve intraoperative stability as well as bone healing times. 2. This normally also increases surgical complexity; however, multiple cutting slots can be easily incorporated into patient specific instrumentation. Clinical management. All three cases were treated at a high-volume tertiary referral centre (Istituto Ortopedico Rizzoli, Bologna) using medial closing wedge distal femoral knee osteotomies by a team experienced in using patient specific osteotomy systems. 3. Virtual surgical planning was conducted using CT-scans and long-leg weight-bearing x-rays (Orthoscape, Bath, UK). Patient specific surgical guides and custom-made locking plates were design for each case. The guides were designed to allow temporary positioning, drilling and bi-planar saw-cutting. The drills were positioned such that the drills above and below the osteotomy became parallel on closing following osteotomy wedge removal. This gave reassurance of the achieved correction allowed the plate to be located precisely over the drills. All screw lengths were pre-measured. Discussion. The surgical time reduced to approximately 30 minutes by the third procedure. It was evident that surgical time was saved because no intraoperative screw length measurements were required, relatively few x-rays were used to confirm the position of the surgical guide, and the use of custom instrumentation significantly reduced the surgical inventory. The reduced invasiveness and ease of surgery may contribute to faster patient recovery compared to conventional techniques. The final post-operative alignment was within 1° of the planned alignment in all cases. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Introduction. In the setting of periprosthetic joint infection, the complete removal of implants and cement can be challenging with well-fixed, cemented implants about the knee. This can get especially complex in the setting of long cemented femoral stems. Osteotomies are well described in the proximal femur and tibia for removal of implants and cement. There is little information available on distal femoral osteotomies to facilitate knee implant and retained cement removal. Methods. We describe a novel anterolateral oblique distal femoral osteotomy for the removal of well-fixed, cemented components during resection knee arthroplasty that preserves vascularity to the osteotomized segment. Cadaveric anatomic vascular injection studies were performed to document vascularity of the osteotomized segment. Clinical examples, and results will be presented. Results. Anatomic vascular studies documented preserved vascularity to the osteotomized segment. In two patients intramedullary infected implant and cement was completely removed. At reimplantation and final followup the osteotomy was radiographically healed, implants well fixed, and no recurrent infections were noted. Conclusions. This osteotomy appears to be useful when removing well fixed, cemented femoral components during periprosthetic infection. Vascularity and union was preserved and obtained in all patients. For figures, tables, or references, please contact authors directly

Valgus deformity of the knee in relation to femoral dysplasia and post-traumatic varus deformity in relation to supracondylar fracture often needs to be corrected with varus or valgus distal femoral osteotomy. This procedure must be very precise to avoid compartimental overstress. However, in valgus knee the deformity is very often not only bi-planar but also tri-planar. In fact, the rotational defect of the distal femur can play an important role in determining the clinical symptoms and in altering the pathway of patello-femoral joint. Therefore, correcting only the valgus deformity does not solve the clinical symptoms related to incorrect rotation of distal femur. The same problem is often encountered in distal femoral deformity in relation to supracondylar fracture. The bad alignment of the healed fracture is very often on the three planes and this fact has always to be taken into account during the pre-operative planning. The pre-operative planning is fundamental and CT of the knee joint with reference to hip and ankle must be performed to evaluate the degree of rotational deformity that must be corrected. During surgery after the correction of valgus or varus deformity is fundamental to re-check the femur rotation, because the osteotomy automatically changes also the rotation of the distal femur. However, this correction may be insufficient to correct the rotation that can maintain clinical symptoms in the patello-femoral joint. If this is the case, an additional correction in external rotation is usually necessary to achieve an overall correction of distal femoral deformity. In our opinion, the difficulties and accuracy necessary to correct this type of pathology are often underestimated

Introduction

Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results.

Distal femoral varus osteotomy is a procedure intended to relieve pain, correct valgus deformity, and delay or possibly prevent the progression of lateral compartment osteoarthritis in the knee. It is indicated in patients who are considered too young or are too active to be considered candidates for total knee arthroplasty. It also allows protection of the lateral compartment in cases of meniscal or cartilage allograft. In patients who are a good candidate for total knee replacement, TKR is the procedure of choice.

A sloping joint line requires that the correction be performed above the knee. Several methods of distal femoral varus osteotomy have been proposed. These include a medial closing wedge, a lateral opening wedge, and a dome osteotomy. In the author's experience, the medial closing wedge has proven reliable. This technique uses a 90-degree blade plate, and does not require any angle measurements during surgery. Fixation is secure, allowing early motion. Healing proceeds rapidly in the metaphyseal bone, and non-unions have not occurred. The desired final alignment was zero degrees, which was reliably achieved using this method.

Medium to long-term results are generally satisfactory. When conversion to total knee replacement is required, standard components may generally be used, and function was not compromised by the prior osteotomy.

Distal femoral varus osteotomy is a successful procedure for lateral compartment osteoarthritis in a valgus knee. It is indicated in patients who are too young or active for total knee arthroplasty, and provides an excellent functional and cosmetic result.

Distal femoral varus osteotomy is a procedure intended to relieve pain, correct valgus deformity, and delay or possibly prevent the progression of lateral compartment osteoarthritis in the knee. It is indicated in patients who are considered too young or are too active to be considered candidates for total knee arthroplasty. It also allows protection of the lateral compartment in cases of meniscal or cartilage allograft. In patients who are a good candidate for total knee replacement, TKR is the procedure of choice.

A sloping joint line requires that the correction be performed above the knee. Several methods of distal femoral varus osteotomy have been proposed. These include a medial closing wedge, a lateral opening wedge, and a dome osteotomy. In the author's experience, the medial closing wedge has proven reliable. This technique uses a 90-degree blade plate, and does not require any angle measurements during surgery. Fixation is secure, allowing early motion. Healing proceeds rapidly in the metaphyseal bone, and non-unions have not occurred. The desired final alignment was zero degrees, which was reliably achieved using this method.

Medium to long-term results are generally satisfactory. When conversion to total knee replacement is required, standard components may generally be used, and function was not compromised by the prior osteotomy.

Distal femoral varus osteotomy is a successful procedure for lateral compartment osteoarthritis in a valgus knee. It is indicated in patients who are too young or active for total knee arthroplasty, and provides an excellent functional and cosmetic result.

Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique. 89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months. All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies. Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity

Abstract. Introduction. Knee osteotomy, both high tibial and distal femoral osteotomy, is a well-recognised treatment for young, active patients with unicompartmental knee osteoarthritis. Osteotomy around the knee is usually performed as an inpatient procedure. The aim of this study was to assess the effectiveness and patient satisfaction of our day-case protocol for knee osteotomy. Methodology. All patients who underwent day-case knee osteotomy at the study unit, over a three-year period, were reviewed to assess the success of ambulatory care for knee osteotomy. Patients were sent questionnaires to assess functional outcome and patient satisfaction with our day-case process. Results. Thirty-three knee osteotomies were performed as a day-case protocol, of which same day discharge was achieved in 24 patients (73%) and discharge within 24 hours achieved in 32 patients (97%). The mean post-operative Knee Osteoarthritis Outcome Score (KOOS) was 67.1 and 79% of patients rated their care as good or excellent. Return to sporting activities was achieved in 75% of patients, and 88% of patients reported they would be happy to undergo day-case knee osteotomy again. Conclusion. Knee osteotomy, both high tibial and distal femoral osteotomy, can be successfully performed as a day-case procedure with similar improvements in functional outcomes and no increased complication rate, compared to in-patient osteotomy

Abstract. Introduction. Osteotomy is recognised treatment for osteoarthritis of the knee. Evidence suggests favourable outcomes when compared to arthroplasty, for younger and more active individuals[1]. Double level osteotomy (DLO) is considered when a single level is insufficient to restore both joint line obliquity and adequate realignment[2]. This paper aims to establish the functional outcomes up to two years post operatively for patients undergoing DLO, using patient reported outcome measures (PROMs). Methodology. All patients who underwent a DLO at either Lister Hospital, Stevenage, or One Hatfield Hospital, Hertfordshire, between 1st January 2018 and 1st October 2020 were identified. DLO were performed by two specialist consultants, independently or in combination. PROMs including pain scores, health score, Oxford knee score (OKS) and knee injury and osteoarthritis outcome score (KOOS) were recorded pre-operatively and at six month, one and two year post operative intervals. Results. 24 patients underwent DLO; a medial opening wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy. The cohort comprised 21 males, 3 females with an average age of 54.09 (38–77) years. Preoperative pain scores graded from 0–10 improved from 6.86 to 2.0 at 2 years. OKS improved from 23.94 to 47.88, as did KOOS 43.55 to 87.51, over the same duration. Conclusion. DLO was associated with improvements in pain and functional outcomes, compared to pre-operative levels. In patients for whom arthroplasty may be unfavourable, this provides an alternative to non-operative management, the options for which are frequently exhausted early in the disease process

Introduction. Two principal targets are dominating the spectrum of goals in total knee arthroplasty: first of all the orthopedic surgeon aims at achieving an optimal pain-free postoperative kinematic motion close to the individual physiologic range of the individual patient and secondly he aims for a concurrent high ligament stability within the entire range of movement in order to establish stability for all activities of daily living. This study presents a modified surgical procedure for total knee replacement which is ligament-controlled in order to put both component into the “ligamentous frame” of the patients individual kinematics. Methods. The posterior femero-condylar index (PFC-I) is defined as being the posterior condylar offset divided by the distal antero-posterior diameter on a lateral radiograph. After careful preoperative planning the positions and orientations of the osteotomies is controlled intraoperatively via ligamentous guidance. Anterior and distal femoral osteotomy are planned on antero-posterior and lateral radiographs considering intramedular and mechanical axes as well as the orientation of the posterior condyles. Osteotomies are carried out in a stepwise fashion, starting with the anterior femoral osteotomy followed by the distal femoral osteotomy as planned. Then the extension gap is finalized by tensioning the ligaments and “top-down” referencing the level of the tibial osteotomy. After rotating the femur into the 90°-flexion position the flexion gap is finalized by referencing the level of the posterior condyle osteotomy in a “bottom-up” fashion to the tibial osteotomy. Hence, this technique determines the size of the femoral component with the last osteotomy. It likewise respects the new, ACL-lacking ligamentous framework and it drives the prosthetic components to fit into the new ligamentous envelope to follow the modified kinematics. Results. More than 130 patients have been operated on using this surgical technique, 104 of them have been followed-up after a minimum of one year: age 73+/−9, m/f 37/67, 71% had a varus, 29% a valgus-deformity. In all patients a subvastus approach was applied, 12 from medial, 92 from lateral. Mean flexion reached 122°+/−7.4 and a 120°-flexion or more was achieved by 86% of the patients. All patients reveived a LCS total knee prosthesis with either a rotating or an antero-posterior gliding inlay. No fixed tibial inlays were used. Antero-posterior translation of the APG-insert was 13 to 16mm immediately postoperatively whereas after one year it decreased to 4 to 10mm. We succeeded in reconstructing the posterior femero-condylar index (PFC-I) and found a linear correlation of 0.98 +/−0.06 of pre- to postoperative PFC-I. Conclusion. This PCL-retaining surgical technique respects the new, ACL-lacking kinematics in total knee replacement. The anterior and distal femoral osteotomies are femur-axis-controlled while the extension and flexion gaps are ligament-controlled. The size of the femoral component is regarded as a variable within the procedure and is only determined while performing the last osteotomy, i.e. the posterior condylar osteotomy. This technique is suitable for both PCL-retaining and also for PCL–sacrificing techniques

Introduction. Intraoperative assessment of coronal alignment is important when performing corrective osteotomies around the knee and ankle, limb lengthening and trauma surgery. The Joint Angle Tool (JAT) provides surgeons with information about the anatomic and mechanical axes intraoperatively based on true anteroposterior radiographs. Aim: Presentation of the JAT, a low-cost goniometer for intraoperative assessment of the lower limb alignment. Materials and Methods. The JAT consists of pre-printed joint orientation angles of the anatomic and mechanical axis including normal variations on a plastic sheet. It is placed on the screen of the image intensifier after obtaining a true anterior-posterior image. The pre-printed joint orientation angles can intraoperatively assist the surgeons in achieving the pre-planned axis correction. Here, its feasibility is demonstrated in four cases. Results. Here, we present the intraoperative use of JAT in four cases:. 77 mm femoral bone transport due to non-union utilizing a bone transport nail,. distal femoral osteotomy correcting coronal and torsional malalignment using a retrograde intramedullary trauma nail,. proximal / high tibial open wedge osteotomy with an intramedullary implant correcting varus malalignment in a hypophosphatemic rickets patient, and. a supramalleolar, closing wedge osteotomy realigning the anatomic axis with a plate and screws. Conclusions. The JAT is a modified goniometer which allows intraoperative assessment of the mechanical and anatomic axis. JAT is applicable throughout the entire surgical procedure irrespective of the method of internal fixation and may provide additional reassurance of correct alignment. The JAT consists of a plastic sheet with printed joint orientation angles and their normal variation. JAT is freely available from . profeedback.dk/JAT/JAT.pdf. for use and modification according to Creative Commons license (CC BY-SA 4.0)

Introduction. The popliteus tendon is a component of the posterolateral corner of the knee, which controls the external rotation of the tibia. In our clinical practice, the femoral footprint of the popliteus tendon is occasionally excised as the bone is resected during total knee arthroplasty (TKA). Although the excision of the popliteus tendon femoral footprint could result in excessive external rotation of the tibia and may have adverse effects on the long-term outcomes of TKA, little attention has been paid to the popliteus tendon femoral footprint during TKA. The purpose of the present study is to assess the frequency of the excision and its associated risk factors. Methods. One hundred eleven knees of 90 patients with varus knee osteoarthritis who underwent primary TKA were included in the present study. There were 13 males and 77 females, and their average age was 74 years. The NexGen knee replacement system (Zimmer, Warsaw, IN, USA) was used in all cases. The excision of the popliteus tendon femoral footprint was intraoperatively evaluated, and the patients were divided into three groups depending on the status of the femoral footprint, i.e., the preserved, partially excised, and completely excised groups. The thickness of the distal femoral osteotomy, femoral component size, and background data including height, body weight, gender, and age were compared among these groups. Analysis of variance followed by Student–Newman–Keuls test were used to compare the continuous values and ordinal scales. Gender was compared using Fisher's exact test and residual analysis. Statistical significance was set at p < 0.05. Results. The popliteus tendon femoral footprint was preserved in 48 knees (43.2%), partially excised in 45 knees (40.5%), and completely excised in 18 knees (16.2%). The mean patient height was 154.6, 150.1, and 148.7 cm in the preserved, partially excised, and completely excised groups, respectively, and these differences were statistically significant (p < 0.01). Femoral component size was significantly smaller in the partially and completely excised groups compared with that in the preserved group (p < 0.05). The preserved group included more male patients (p < 0.01). There were no significant differences in body weight, age, and thickness of the distal femoral osteotomy among the groups. Conclusion. The partial or complete excision of the popliteus tendon femoral footprint was observed in more than half of the evaluated knees. Shorter height, smaller femoral component size, and female sex were considered to be the possible risk factors for the excision of the popliteus tendon femoral footprint

Introduction: The relationship between the axial alignment of the knee and symptomatic instability of the collateral ligament is very important. This paper presents an approach to the management of chronic collateral ligament instability. Reconstruction of the MCL in the valgus knee and of the LCL in the varus knee is usually unsuccessful without re-alignment of the knee. Method: The gait pattern of the patient with valgus alignment and MCL laxity demonstrates a medial thrust on weight-bearing. Laxity may involve the MCL alone, in combination with ACL laxity, or associated with LCL laxity. MCL laxity in the valgus knee is best managed with a varus distal femoral osteotomy. MCL laxity with medial osteoarthritis is best managed with an open wedge valgus tibial osteotomy. LCL laxity in the varus knee responds well to valgus correction with a high tibial osteotomy. LCL laxity secondary to malunion of a lateral tibial plateau fracture can be managed with an open wedge varus high tibial osteotomy. Results: Fifty-two patients with chronic, symptomatic collateral ligament instability have been surgically reconstructed. Most cases involved multiple ligament injury and most were seen after the initial surgical procedure. Twenty-eight of 52 patients underwent two or more operative procedures before osteotomy. Twenty-one cases involved the MCL and 3l involved the LCL. Varus distal femoral osteotomy was performed for isolated symptomatic MCL laxity. The average resultant anatomical axis was zero degrees. This resulted in loss of the medial thrust on weightbearing. Patients with injuries resulting in early medial OA with varus alignment and MCL laxity were treated with open wedge valgus high tibial osteotomy. The majority of patients with LCL laxity and varus alignment responded to closing wedge valgus high tibial osteotomy. A smaller number (six) with depression of the lateral tibial plateau two degrees to fracture and associated LCL laxity responded to open wedge varus high tibial osteotomy. ACL patients were followed for over two years (range two to four years) post-surgery. All patients were assessed clinically and radiographically. Clinical examinations included a Lysholm functional score and Tegner activity scale. Radiographic examination included pre- and post-operative three foot x-rays and pre-operation valgus, varus stem x-rays

Introduction. Osteotomy for medial gonarthrosis is most often done as a proximal tibial valgus osteotomy, either as a closing wedge osteotomy (HTO) or as an opening wedge osteotomy including hemicallostasis (HCO). In case of lateral gonarthrosis the osteotomy is done as a proximal tibial varus osteotomy, closing or opening wedge or as a distal femoral varus osteotomy depending on the anatomy of the knee. The early period after osteotomy is influenced by complications to osteotomy. Complications depend on the operative method and localisation of surgery. Short- and long-term results are presented as knee scores or survivorship of high tibial osteotomy. Most often used scores are the HSS-score, NHP-score and the knee scores according to Lysholm and Tegner. Scores from the patient’s perspective are NHP, SF-36. KOOS (Knee Injury and Osteoarthritis Outcome Score) was introduced recently, and only short-term results are available. Results. Osteotomy for medial gonarthrosis. Immediate postoperative results. The closing wedge osteotomy is the golden standard and reported complications are peroneal palsy in 0 – 8%, infection in 1 – 3%, fracture of the tibial plateau and delayed union in 3 – 5% and thromboembolism in 2 – 4%. When the opening wedge method including HCO is used peroneal palsy is extremely seldom, delayed union is reported in 2%, major pin-tract infection in 2 – 20 % and thromboembolism in 2 – 4%. Short-term results. The short-term results are generally good and one to two years after osteotomy excellent and good results are reported in 85 – 97 %. All five partial scales in KOOS with the exception of sports/ recreation function were significantly improved 3 – 4 months postoperatively. Long term results 5 – 20 years after surgery. Evaluations of osteotomies using survivorship of the osteotomy, with conversion to a total knee as the endpoint, show an expected rate of survival of 73–94% at 5 years, 51–85 % at ten years, 39–68 % at 15 years and 30% at 20 years. Analysis of risk factors show that age older than 50 years, presence of lateral tibial thrust and insufficient valgus correction were significantly associated with probability of early failure. Evaluations using knee scores with a mean follow-up time of 5 – 10 years show excellent and good result in 64 – 80%. At follow-up 11– 15 years after surgery the fraction good and excellent knees is 55 – 60% and 16– 20 years after osteotomy a minority of the knees are good or excellent, at most 46%. Stage of arthrosis: Good long-term results are reported for knees with early medial arthrosis with at most obliteration of the medial joint space or just minimal bone attrition. Results after HCO on knees with more advanced gonarthrosis are reported with a short follow-up and the change of osseous correction after osteotomy was less compared to HTO. Only minimal progress of arthrosis after osteotomy is reported in most papers. The results of some studies indicate that the greater the surgical correction, the slower the progress of the medial joint arthrosis. Alignment of the knee:. Most reports find better clinical results and less risk for failure when the osteotomy is corrected to a slight over-correction of the knee alignment. There is however no consensus on the smallest correction needed to change the load on the medial arthrotic compartment. Osteotomy for lateral gonarthrosis. The condition is uncommon and a minority of the papers on osteotomy for gonarthrosis concern osteotomy for lateral gonarthrosis. The aim of osteotomy for lateral gonarthrosis is to achieve a varus alignment of the knee with a joint line obliquity, which after surgery is less than 10 degrees. That affects the method, which is either a proximal tibial osteotomy or a distal femoral osteotomy. Most often the aetiology of the deformity is posttraumatic. Immediate postoperative results. When using the opening wedge osteotomy on tibia transient nerve palsy is reported in 9–50%. Infection is reported in 2% and thromboembolism in 2 – 4%. Pin tract infection when using HCO is reported in 2 – 20%. In a multicenter follow-up distal femoral varus osteotomy 11 complications were recorded in 32 patients (five non unions, three deep infections and three cases with a stiff knee). Short-term results. Short-term results one to two years after surgery are reported excellent and good in 85 – 95%. Results 5 – 15 years. Five to ten years after surgery good and excellent results are reported in 75 − 77%, and in 11 – 15 years after surgery in 50 – 80%. Results are much better in recent reports because of better patient selection and operative technique. The tibial varus osteotomy can be used in knees with less than 12 degrees of valgus. Furthermore the tilting of the tibiofemoral joint line should postoperatively be less than 10 degrees. Otherwise a distal femoral osteotomy should be used. Persistent excessive obliquity of the tibiofemoral joint line predisposes instability with risk of compromising the result. To summarize: Osteotomy is effective in a patient with a medial or a lateral gonarthrosis at most Stage II according to the classification of Ahlbäck, under the age of between 50 and 60 years and of high demands by reason of lifestyle and occupation. Aim at an overcorrection so when the osteotomy is healed you should have a slight overcorrection in valgus in medial gonarthrosis and in varus when you have a lateral gonarthrosis. Furthermore the joint line obliquity should postoperatively be less than 10 degrees. With this selection of patients and with a good surgical technique your patient can expect a probability of having a good knee in about 70 % after ten years. After ten years it is more difficult to make a prognosis for your patients knee

Background. Post-operative (postop) lower limb alignment in unicompartmental knee arthroplasty (UKA) has been reported to be an important factor for postop outcomes. Slight under-correction of limb alignment has been recommended to yield a better clinical outcomes than neutral alignment. It is useful if the postop limb alignment can be predicted during surgery, however, little is known about the surgical factors affecting the postop limb alignment in UKA. The purpose of this study was to examine the influence of the medial tibial joint line elevation on postop limb alignment in UKA. Methods. Seventy-four consecutive medial UKAs were enrolled in this study. All the patients received a conventional fixed bearing UKA. Pre-operative (preop) and postop limb alignment was examined using long leg radiograph and lower limb alignment changes were calculated. Femoral and tibial osteotomy thickness were measured during surgery. Medial tibial joint line change was defined as polyethylene thickness minus tibial osteotomy thickness and sawblade thickness (1.27mm). Positive values indicated a tibial joint line elevation. Medial femoral joint line change was defined as femoral distal component thickness (6.5mm) minus femoral distal osteotomy thickness and sawblade thickness. Positive values indicated a femoral joint line reduction. Medial joint distraction width was also calculated by tibial joint line elevation plus femoral joint line reduction. The correlation of lower limb alignment change with polyethylene insert thickness, the medial tibial joint line elevation, femoral joint line reduction, or joint distraction width were analyzed. Results. The mean preop hip-knee-ankle (HKA) angle was 7.1 ± 3.3° in varus and postop was 2.1 ± 3.0° in varus. The mean lower limb alignment change was 5.0 ± 2.6°. The mean polyethylene insert thickness was 8.5 ± 0.8mm, the tibial joint line elevation was 4.4 ± 1.3mm and the medial femoral joint line reduction was 0.0 ± 1.1mm, the joint distraction width was 4.5 ± 1.5mm. The polyethylene insert thickness, the medial tibial joint line elevation, and the joint distraction width were positively correlated with the lower limb alignment change (R=0.27; P<0.05, R=0.47; P<0.001, R=0.53; P<0.001, respectively) (Figure 1a,b,d). There was no correlation between the medial femoral joint line reduction and the lower limb alignment change (Figure 1c). Discussion. The postop limb alignment in total knee arthroplasty (TKA) is determined by the osteotomy angle of the femur and tibia. On the other hand, it has been reported that the postop alignment in UKA is not influenced by the osteotomy angle but by the insert thickness. Our results indicated that the medial tibial joint line elevation and the joint distraction width were more useful to predict lower limb alignment change than the insert thickness itself. Measuring the medial tibial osteotomy thickness during surgery will help surgeon to predict postop lower limb alignment in UKA. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Purpose. The tibia first technique in unicompartmental knee arthroplasty (UKA) may have the advantage that surgeons can obtain a balanced flexion-extension gap. However, changes of the soft tissue tension during UKA has not been elucidated yet. The purpose of this study was to examine the correlation between the soft tissue tension before the femoral osteotomy and after the femoral component in place using the tensor in UKA. Methods. Thirty UKAs for isolated medial compartmental osteoarthritis or idiopathic osteonecrosis were assessed. The mean age was 71.8±8.5 years old (range: 58–85), and the average coronal plane femorotibial angle (FTA) was 181.2±3.2 degree preoperatively. All the patients received a conventional medial Zimmer Unicompartmental High Flex Knee System (Zimmer Inc, Warsaw, Ind). The actual values of the proximal and posterior femoral osteotomy were calculated by adding the thickness of the bone saw blades to the thickness of the bony cut. Using a UKA tensor which designed to facilitate intra-operative soft tissue tension throughout the range of motion (ROM), the original gap before the femoral osteotomy, the component gap after the femoral osteotomy, and component placement were assessed under 20 lb distraction forces. (Figure 1). Results. The mean actual thickness of the distal femoral osteotomy 6.5 ± 1.3 mm and the posterior femoral osteotomy was 7.4 ± 1.3 mm. The distal thickness of the Zimmer UKA was set to 6.5 mm and the mean posterior thickness of the prosthesis used in this study was 5.8 ± 0.3 mm. There is a positive correlation between the original and component gap throughout the ROM (R > 0.5). The original and component gap showed the same kinematic pattern from full extension to 90 degrees of knee flexion. However, the component gap showed significantly higher compared to the original gap after 120 degrees of knee flexion (p < 0.001). (Figure 2). Conclusions. Despite the fact that the component gap showed significantly higher compared to the original gap in deep flexion, there is a positive correlation between the original and component gap throughout the ROM. The discrepancy during deep flexion was due to the posterior design of the prosthesis that is designed to be thinner than the actual thickness of the posterior osteotomy in order to prevent flexion gap tightness. These results suggest that the tibia first technique with the tensor have the advantage that surgeons can predict final soft tissue tension before femoral osteotomies with the comprehension of the prosthetic design and help restore natural knee kinematics, potentially improving implant survival and functional outcomes

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.