Abstract. Background. Proximal fibular osteotomy (PFO) was defined to provide a treatment option for knee pain caused by gonarthrosis(1). Minor surgical procedure, low complication rate and dramatic pain relief were the main reasons for popularization of this procedure(2, 3). However, changes at the knee and ankle joint after PFO were not clarified objectively in the literature. Questions/purposes. We asked: 1) Does PFO change the maximum and average pressures at the medial and lateral chondral surface of the tibia plateau? 2) Are chondral surface stresses redistributed at the knee and ankle joint after PFO? 3)Does PFO change the distribution of total load on the knee joint? 4) Can PFO lead to change in alignment of lower limb?. Methods. This study was conducted at Maltepe University Faculty of Medicine Hospital, Orthopedics and Traumatology Department and Yildiz Technical University Mechanical Engineering Department in Istanbul, Turkey, between September 2019 and February 2020. Finite element analysis (FEA) was used to evaluate effects of PFO(4). One 62 years old, female volunteer's X-ray, computer tomography and magnetic resonance imaging images were used for creating right lower limb model. Two different lower limb models were created. One of them was osteotomized model (OM) which was created according to definition of PFO and the other was non-osteotomized model (NOM). To obtain a stress distribution comparison between the two models, 350 N of axial force was applied to the femoral heads of the models. Results. After PFO, the maximum contact pressures at the medial and lateral tibial cartilages decreased 83.2% and 66.9%, respectively at the knee joint. The average contact pressure decreased 26.1% at the medial tibial cartilage and increased 42.4% at the lateral tibial cartilage. The Von Mises stresses decreased 57.1% at the femoral cartilage and decreased 79.1% at tibial cartilage. The stress on the tibial cartilage increased 44.6%, and stress on the talar cartilage increased 7.1% at the ankle joint. Under a 350 N axial force, distribution of the total load at the knee joint was changed and become more homogenous in OM compared to NOM. Change in lower extremity alignment after PFO could not be evaluated with FEA. Conclusion. FEA revealed that PFO causes some changes in knee and ankle joint kinematics. Main loading at the knee joint shifted from medial tibial cartilage to the lateral tibial cartilage after PFO. Additionally, the stresses on each cartilage were redistributed across a wider and more peripheral area. These changes could be the main reason for pain relief at the knee joint. FEA also demonstrated that the Von Mises stresses of the tibial and talar cartilages of the ankle joint increased after PFO. This stress increase may cause long-term arthritic changes in the ankle joint. Level IV; in silico study

Medial opening wedge high tibial osteotomy (MOWHTO) is the workhorse procedure for correcting varus malalignment of the knee. There have been recent developments in the synthetic options to fill the osteotomy gap. The current gold standard for filling this osteotomy gap is autologous bone graft which is associated with donor site morbidity. We would like to introduce and describe the process of utilizing the novel Osteopore® 3D printed, honeycomb structured, Polycaprolactone and β-Tricalcium Phosphate wedge for filling the gap in MOWHTO. In the advent of additive manufacturing and the quest for more biocompatible materials, the usage of the Osteopore® bone wedge in MOWHTO is a promising technique that may improve the biomechanical stability as well the healing of the osteotomy gap

Reorientating pelvic osteotomies are performed to improve femoral head coverage and secondary degenerative arthritis. A rectangular triple pelvic innominate osteotomy (3PIO) is performed in symptomatic cases. However, deciding optimal screw fixation type to avoid complications is questionable. Therefore, this study aimed to investigate the biomechanical behavior of two different acetabular screw configurations used for rectangular 3PIO osteosynthesis. It was hypothesized that bi-directional screw fixation would be biomechanically superior to mono-axial screw fixation technique. A rectangular 3PIO was performed in twelve right-side artificial Hemi-pelvises. Group 1 (G1) had two axial and one transversal screw in a bi-directional orientation. Group 2 (G2) had three screws in the axial direction through the iliac crest. Acetabular fragment was reoriented to 10.5° inclination in coronal plane, and 10.0° increased anteversion along axial plane. Specimens were biomechanically tested until failure under progressively increasing cyclic loading at 2Hz, starting at 50N peak compression, increasing 0.05N/cycle. Stiffness was calculated from machine data. Acetabular anteversion, inclination and medialization were evaluated from motion tracking data from 250-2500 at 250 cycle increments. Failure cycles and load were evaluated for 5° change in anteversion. Stiffness was higher in G1 (56.46±19.45N/mm) versus G2 (39.02±10.93N/mm) but not significantly, p=0.31. Acetabular fragment anteversion, inclination and medialization increased significantly each group (p≤0.02) and remained non-significantly different between the groups (p≥0.69). Cycles to failure and failure load were not significantly different between G1 (4406±882, 270.30±44.10N) and G2 (5059±682, 302.95±34.10N), p=0.78. From a biomechanical perspective, the present study demonstrates that a bi-directional screw orientation does not necessarily advantageous versus mono-axial alignment when the latter has all three screws evenly distributed over the osteotomy geometry. Moreover, the 3PIO fixation is susceptible to changes in anteversion, inclination and medialization of the acetabular fragment until the bone is healed. Therefore, cautious rehabilitation with partial weight-bearing is recommended

Introduction. Curved varus intertrochanteric osteotomy of the femur is an excellent and minimally invasive method for the treatment of osteonecrosis of the femoral head or osteoarthritis of the hip for joint preservation. However, the early postoperative complications of this procedure may be due to separation at the osteotomy site and an increase in varus angle due to early partial weight bearing. Methods. We modified the curved varus intertrochanteric osteotomy of the femur by performing an additional rotation. Regarding the surgical technique, curved varus osteotomy is performed at an angle of 30 degrees to the femoral shaft and an additional rotational osteotomy is also performed at an angle of 15 or 20 degrees to the osteotomy plane. Partial weight bearing with one-third body weight is permitted 3 weeks after surgery. Results. Curved varus intertrochanteric osteotomy of the femur was designed for developmental dysplastic hip by Nishio in 1969 and reported to have good outcomes in 1971. An important feature of this method is that the incidence of high riding of the greater trochanter or shortening of leg length is less than that in varus intertrochanteric osteotomy. Moreover, good contact at the osteotomy site and less lateral shift of the femoral shaft is observed. However, we have experienced a case of separation at the osteotomy site and increase of the varus angle in our hospital. Previous reports recommended that partial weight bearing with one-third body weight should be initiated after 5 weeks and full weight bearing after 6 months because the contact area is decreased at the osteotomy site by varus osteotomy. The post-operative recovery of the patients with total hip arthroplasty is rapid, therefore, we must consider important issues such as initiating the rehabilitation program early and reducing the duration of hospitalization. As per our experience, we think that partial weight bearing with one-third body weight should be initiated at 3 weeks. At the osteotomy site, we rotated the nearest bone segment to move it such that it intersects the proximal and distal bone cortex. Therefore, the osteotomy site will be stabilized and will have the ability to endure load. Another feature of this technique is that the partial removal of the necrotic area leads to an increase in the healthy load-bearing area. A limitation of this method is that an angle of an additional rotation is up to 30 degrees, because the joint capsule cannot be incised circumferentially and the short external rotator tendons should also be preserved. Conclusion. Modified curved varus intertrochanteric osteotomy is a useful method for the prevention of increased degree of a varus angle as well as for obtaining more intact area of femoral head in osteonecrosis

High tibial osteotomy (HTO) is an effective surgical treatment for isolated medial compartment knee osteoarthritis; however, widespread adoption is limited due to difficulty in achieving the planned correction, and patient dissatisfaction due to soft tissue irritation. A new HTO system – Tailored Osteotomy Knee Alignment (TOKA®, 3D Metal Printing Ltd, Bath, UK) could potentially address these barriers having a custom titanium plate and titanium surgical guides featuring a unique mechanism for precise osteotomy opening as well as saw cutting and drilling guides. The aim of this study was to assess the accuracy of this novel HTO system using cadaveric specimens; a preclinical testing stage ahead of first-in-human surgery according to the ‘IDEAL-D’ framework for device innovation. Local ethics committee approval was obtained. The novel opening wedge HTO procedure was performed on eight cadaver leg specimens. Whole lower limb CT scans pre- and post-operatively provided geometrical assessment quantifying the discrepancy between pre-planned and post-operative measurements for key variables: the gap opening angle and the patient specific surgical instrumentation positioning and rotation - assessed using the implanted plate. The average discrepancy between the pre-operative plan and the post-operative osteotomy correction angle was: 0.0 ± 0.2°. The R2 value for the regression correlation was 0.95. The average error in implant positioning was −0.4 ± 4.3 mm, −2.6 ± 3.4 mm and 3.1 ± 1.7° vertically, horizontally, and rotationally respectively. This novel HTO surgery has greater accuracy and smaller variability in correction angle achieved compared to that reported for conventional or other patient specific methods with published data available. This system could potentially improve the accuracy and reliability of osteotomy correction angles achieved surgically

Introduction and Objective. Several studies have described double and triple femoral neck lengthening osteotomies to correct coxa brevis deformity, however, no overview exists in literature. Our aim was to perform the first systematic review of the outcomes of double and triple femoral neck lengthening. Materials and Methods. After an extensive search in Pubmed, CINAHL and Embase libraries for published articles using the following search strategy: ‘(((proximal femoral deformity) OR hip dysplasia) OR coxa brevis) AND (((femoral neck lengthening) OR double proximal femoral osteotomy) OR triple proximal femoral osteotomy)’, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results. After evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported. Conclusions. This first systematic review of double and triple femoral neck lengthening osteotomies shows that favorable outcomes and few complications can be expected in coxa brevis, however, excessive caution is required in older patients with incongruent hips

It is still difficult to determine an appropriate hinge position to prevent fracture in the lateral cortex of tibia in the process of making an open wedge during biplane open wedge high tibial osteotomy. The objective of this study was to present a biomechanical basis for determining the hinge position as varus deformity. T Three-dimensional lower extremity models were constructed using Mimics. The tibial wedge started at 40 mm distal to the medial tibial plateau, and osteotomy for three hinge positions was performed toward the head of the fibula, 5 mm proximal from the head of the fibula, and 5 mm distal from the head of the fibula. The three tibial models were made with varus deformity of 5, 10, 15 degrees with heterogeneous material properties. These properties were set to heterogeneous material properties which converted from Hounsfield's unit to Young's modulus by applying empirical equation in existing studies. For a loading condition, displacement at the posterior cut plane was applied referring to Hernigou's table considering varus deformity angle. All computational analyses were performed to calculate von-mises stresses on the tibial wedges. The maximum stress increased to an average of 213±9% when the varus angle was 10 degrees compared to 5 degrees and increased to an average of 154±8.9% when the varus angle was 15 degrees compared to 10 degrees. In addition, the maximum stress of the distal position was 19 times higher than that of the mid position and 5 times higher than that of the proximal position on average. Conclusion:. For varus deformity angles, the maximum stress of the tibial wedge tended to increase as the varus deformity angle increased. For hinge position of tibial wedge, maximum stress was the lowest in the mid position, while the highest in the distal position. *This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (NRF-2022R1A2C1009995)

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

High tibial osteotomy (HTO) is a joint preserving alternative to knee replacement for medial tibiofemoral osteoarthritis in younger, more active patients. The procedure is technically challenging and limited also by ‘one size fits all’ plates which can result in patient discomfort necessitating plate removal. This clinical trial evaluated A novel custom-made HTO system – TOKA (3D Metal Printing LTD, Bath, UK) for accuracy of osteotomy correction and improvements in clinical outcome scores. The investigation was a single-arm single-centre prospective clinical trial (IRCCS Istituto Ortopedico Rizzoli; ClinicalTrials.gov NCT04574570), with recruitment of 25 patients (19M/6F; average age: 54.4 years; average BMI: 26.8), all of whom received the TOKA HTO 3D planning and surgery. All patients were predominantly diagnosed with isolated medial knee osteoarthritis and with a varus deformity under 20°. Patients were CT scanned pre- and post-operatively for 3D virtual planning and correctional assessment. All surgeries were performed by the lead clinical investigator – a consultant knee surgeon with a specialist interest in and clinical experience of HTO. On average, Knee Society Scores (KSS) improved significantly (p<0.001) by 27.6, 31.2 and 37.2 percentage points respectively by 3-, 6- and 12-months post-surgery respectively. Other measures assessed during the study (KOOS, EQ5D) produced similar increases. Our early experience using custom implants is extremely promising. We believe the reduced profile of the plate, as well as the reduced invasiveness and ease of surgery contributed to faster patient recovery, and improved outcome scores compared to conventional techniques. These clinical outcome results compare very favourably other case-series with published KOOS scores using different devices

Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are well-established operative interventions in the treatment of knee osteoarthritis (KOA). However, which of these interventions is more beneficial, to patients with KOA, is not known and remains a topic of much debate. Aims: (i) To determine whether UKA or HTO is more beneficial in the treatment of isolated medial compartment KOA, via an assessment of patient-reported outcome measures (PROMs). (ii) To investigate the relationship between PROMs and radiographic parameters of knee joint orientation/alignment. This longitudinal observational study assessed a total of 42 patients that had undergone UKA (n=23) or HTO (n=19) to treat isolated medial compartment KOA. The PROMs assessed, pre-operatively and 1-year post-operatively, consisted of the: self-administered comorbidity questionnaire; short form-12; oxford knee score; knee injury and osteoarthritis outcome score; and the EQ-5D-5L. The radiographic parameters of knee joint alignment/orientation assessed, pre-operatively and 8-weeks post-operatively, included the: hip-knee-ankle angle; mechanical axis deviation; and the angle of the Mikulicz line. Statistical analysis demonstrated an overall significant (p<0.001), pre-operative to post-operative, improvement in the PROM scores of both groups. There were no significant differences in the post-operative PROM scores of the UKA and HTO group. Correlation analyses revealed that pre-operatively, a more distolaterally angled Mikulicz line was associated with worse knee function (p<0.05) and overall health (p<0.05); a relationship that, until now, has not been investigated nor commented upon within the literature. UKAs and HTOs are both efficacious operations that provide a comparable degree of clinical benefit to patients with isolated medial compartment KOA. To further the scientific/medical community's understanding of the factors that impact upon health-outcomes in KOA, future research should seek to investigate the mechanism underlying the relationship, between Mikulicz line and PROMs, observed within the current study

Abstract. Objectives. The ability to predict which patients will improve following routine surgeries aimed at preventing the progression of osteoarthritis is needed to aid patients being stratified to receive the most appropriate treatment. This study aimed to investigate the potential of a panel of biomarkers for predicting (prior to treatment) the clinical outcome following treatment with microfracture or osteotomy. Methods. Proteins known to relate to OA severity, with predictive value in autologous cell implantation treatment or that had been identified in proteomic analyses (aggrecanase-1/ ADAMTS-4, cartilage oligomeric matrix protein (COMP), hyaluronic acid (HA), Lymphatic Vessel Endothelial Hyaluronan Receptor-1, matrix metalloproteinases-1 and −3, soluble CD14, S100 calcium binding protein A13 and 14-3-3 protein theta) were assessed in the synovial fluid (SF) of 19 and 13 patients prior to microfracture or osteotomy, respectively, using commercial immunoassays. Levels of COMP and HA were measured in the plasma of these patients. To find predictors of postoperative function, multiple linear regression analyses were performed. Results. Linear regression analyses demonstrated that a lower concentration of HA in pre-operative SF was predictive of improved knee function (higher Lysholm score) following microfracture surgery. Further, lower pre-operative activity of ADAMTS-4 in SF was a significant, independent predictor of higher post-operative Lysholm score (improved joint function) following osteotomy surgery. Conclusion. This study is novel in identifying biomarkers with the potential to predict clinical outcome in patients treated with microfracture or osteotomy of the knee. Lower concentrations of HA and undetectable activity of ADAMTS-4 in the joint fluid of individuals with cartilage defects/early-OA may be used in algorithms to stratify patients to the most appropriate surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Bernese periacetabular osteotomy (PAO) repositions the acetabulum to increase femoral head coverage (FHC) in hip dysplasia. Currently, there is a paucity of objective peri-operative metrics to plan for optimal acetabular fragment repositioning. The MSk Lab Hip 3D Planner (MSkL-HP) measures acetabular morphology and simulates PAO cuts to achieve optimal FHC. We evaluated how adjusting location and orientation of cutting planes can alter FHC. Method. MSkL-HP simulated 274 feasible PAOs on four dysplastic hips. Femoroacetabular anatomy was landmarked to simulate cutting planes. Posterior column and ischial cuts were standardised, whilst iliac and pubic cut combinations varied. The slope of the iliac cut was either neutral (aligned to pelvis), exit point 5mm above the entry point (+5), or 5mm below (-5). The slope of the pubic cut was either 90°, 50°, or 70° (medial-to-lateral). Iliac and pubic cuts were simulated 0, 5 and 15mm - distal and medial – to a classic cut. Outcome measures were achieved LCEA, Tönnis, FHC and % bone overlap at the pubic cut. Targets were LCEA >30°, Tönnis angle <10°, and FHC >70% and minimum bone overlap ≥10%. Results. All feasible PAOs resulted in improvement from pre-operative metrics. Personalised cutting planes provided greater benefit than standard planes. Kruskal Wallis tests showed that the iliac cut at 5mm or 15mm resulted in a greater LCEA and lower Tönnis compared to the classic cut (p<0.05). Changing location of the pubic cut, and slope of the iliac and pubic cuts did not significantly affect LCEA and Tönnis in all hips (p<0.05). Cut combinations optimising metrics were associated with a lower % pubic cut overlap. Conclusion. MSkL-HP feasibly and reliably planned personalised PAO, measuring pre-operative and simulated post-operative objective metrics. Patient-specific pubic and iliac cuts enable greater correction whilst maintaining bone overlap. Further simulations on patients with varying morphology may improve standard techniques

Introduction. Symptomatic hip dysplasia is often treated with periacetabular osteotomy (PAO). Studies investigating the effect of PAO have primarily focused on radiographic measurements, pain-related outcomes, and hip survival whereas evidence related to sport participation is limited. Methods. All patients in our institutional database were deemed eligible for this cohort study if they underwent PAO and had answered at least one question related to sport participation. Patients were asked if they were playing sport preoperatively, 6 months after PAO as well as 2, 5, 10, 15 and 20 years after. In addition, patients were asked if they were able to play their preferred sport, what type and at what level they were playing sport, and if surgery had improved their sport performance. Results. Among 2398 patients surveyed, 1926 (80%) were included and 56% were playing sport 6 months after PAO. This number was 61% two years after PAO, and remained around that for the following years, before dropping 15 years after PAO. Between 56% and 71% of patients felt that their sporting performance improved following PAO at the different time points. Between 39% (6 months after PAO) and 63% (15 years after PAO) were able to participate in their preferred sport. Conclusion. The majority of patients undergoing PAO due to hip dysplasia will return to, and maintain, sport after PAO. More than half of patients undergoing PAO believe that the surgery improved their sports performance, and long after the surgery more than half of patients undergoing PAO are able to play their preferred sport

Abstract. OBJECTIVES. Although surgical periacetabular osteotomy (PAO) for hip dysplasia aims to optimise acetabular coverage and restore hip function, it is unclear how surgery affects capsular mechanics and joint stability. The purpose was to examine how the reoriented acetabular coverage affects capsular mechanics and joint stability in dysplastic hips. METHODS. Twelve cadaveric dysplastic hips (n = 12) were denuded to the capsule and mounted onto a robotic tester. The robot positioned each hip in multiple flexion angles (Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°) and performed internal-external rotations and abduction-adduction to 5 Nm in each rotational or planar direction. Each hip underwent a PAO, preserving the capsule, and was retested postoperatively in the robot. Paired sample t-tests compared the range of motion before and after PAO surgery (CI = 95%). RESULTS. Pre-operatively, the dysplastic hips demonstrated large ranges of internal-external rotations and abduction-adduction motions throughout all flexion positions. Post-operatively, the PAO slackenend the anterosuperior capsule and tightened the inferior capsule. This increased external rotation in Flexion 60° and Flexion 90° (∆. ER. = +16 and +23%) but provided lateral coverage to decrease internal rotation at Flexion 90° (∆. IR. = –15%). The PAO also reduced abduction throughout, but increased adduction in Neutral 0°, Flexion 30°, and Flexion 60° (∆. ADD. = +34, +30%, +29% respectively). CONCLUSIONS. The PAO provided crucial osseous structural coverage to the femoral head, decreasing hypermobility and adverse loading at extreme hip flexion-extension. However, it also slackened the anterosuperior capsule and increased adduction and external rotation, which may lead to ischiofemoral impingement and adductor irritations. Capsular instability may be secondary to acetabular undercoverage, thus capsular alteration may be warranted for larger corrections or rotational osteotomies. To preserve native hip and delay joint degeneration, it is crucial to preserve capsule and elucidate amount of reorientation needed without causing iatrogenic instability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Medial open wedge high tibial osteotomy (MOWHTO) has been accepted as a highly effective option for the treatment of medial unicompartmental osteoarthritis of the knee. Although pain in the medial joint line is significantly relieved after MOWHTO, some patients complain of pain over pes anserinus after the osteotomy, necessitating implant removal for pain relief. Purpose. The purpose of this study is to define the implant removal rate after MOWHTO due to patient complaints. Methods. 103 knees of 72 patients who underwent MOWHTO for medial unicompartmental osteoarthritis between 2010 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Visual Analogue Score (VAS) for pain in the medial knee joint (VAS-MJ). All tests were performed before the surgery, at 12 months after surgery. VAS value for pain over pes anserinus (VAS-PA) was recorded at 12 months after MOWHTO and at 3 months after implant removal. Results. Mean follow-up was 31±5.4 months. TomoFix® medial high tibia plate (DePuy Synthes, Raynham, MA, USA) was used for the fixation of osteotomy in all cases. Significant improvement in KOOS, OKS and VAS-MJ were observed 12 months after MOWHTO. Average values of VAS-MJ and VAS-PA were 21.7±7.1 and 34±8.4, respectively. Implant removal was needed for 65 (63.1%) knees. There were no significant differences in regard of postoperative KOOS (p=0.134), OKS (p=0.287) and VAS-MJ (p=0.416) scores between patients for which implant removal was needed or not. VAS-PA value decreased significantly at 3 months after implant removal (p<0.001). Conclusion. A large portion of patients needed implant removal after MOWHTO to relieve pain over pes anserinus even if knee function was significantly improved. Lower profile plates may be preferred to avoid secondary implant removal surgery after MOWHTO

Abstract. Objectives. High tibial osteotomy for knee realignment is effective at relieving symptoms of knee osteoarthritis but the operation is surgically challenging. A new personalised treatment with simpler surgery using pre-operatively planned measurements from computed tomography (CT) imaging and 3D-printed implants and instrumentation has been designed and is undergoing clinical trial. The aim of this study was to evaluate the early clinical results of a preliminary pilot study evaluating the safety of this new personalised treatment. Methods. The single-centre prospective clinical trial is ongoing (IRCCS Istituto Ortopedico Rizzoli; IRB-0013355; ClinicalTrials.gov NCT04574570), with recruitment completed and all patients having received the novel custom surgical treatment. To preserve the completeness of the trial reporting, only surgical aspects were evaluated in the present study. Specifically, the length of the implanted osteosynthesis screws was considered, being determined pre-operatively eliminating intraoperative measurements, and examined post-operatively (n=7) using CT image processing (ScanIP, Synopsys) and surface distance mapping. The surgical time, patient discharge date and ease of wound closure were recorded for all patients (n=25). Results. Over the study period the average surgical time (skin incision to suture) reduced from 54 to 31 minutes (range: 17–62, n=25). It was noted that wound closure was easier than the conventional surgery due to the lower profile of the implant. Over seventy percent of patients were discharged day 2 post-op. The position, orientation and length of all screws matched the pre-operative configuration to within approximately 1mm. Conclusions. The early trial results are promising from a clinical perspective. It was evident that surgical time was saved because no intraoperative screw length measurements were required, 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 full trial results will be reported later this year. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Objective. To analyze the short-term outcome after medial open-wedge high tibial osteotomy with a 3D-printing technology in early medial keen osteoarthritis and varus malalignment. Design and Method. 32 knees(28 cases) of mOWHTO (fixation with an angular-stable TomoFix implant(Synthes)) with a 3D-printing technology combined with arhtroscopy were prospectively surveyed with regard to functional outcome(Hospital for special knee score [HSS] score). Pre- and postoperative tibial bone varus angle (TBVA), mechanical medial proximal tibial angle (MPTA), and alignment were analyzed with regard to the result. Results. 32 knees were included (28 patients; mean age 46.5±9.3 years). The follow-up rate was 100% at 1.7±0.6 years (range, 1.2–3.2 years). Pre- and postoperative mechanical tibiofemoral axis were 6.8°±2°of varus and 1.2°± 3.4° of valgus, respectively. HSS score significantly improved from 46.0±18.3 preoperatively to 84±12 at one, 80±7 at two years (P<0.01). Conclusions. Medial open-wedge high tibial osteotomy with a 3D-printing technology combined with arthroscopy in medial keen osteoarthritis and varus malalignment is an accurate and good treatment option. High preoperative TBVA and appropriate corrected angle(0–3° of valgus)) was associated with better functional outcome at final follow-up

Varus malalignment increases the susceptibility of cartilage to mechanical overloading, which stimulates catabolic metabolism to break down the extracellular matrix and lead to osteoarthritis (OA). The altered mechanical axis from the hip, knee to ankle leads to knee joint pain and ensuing cartilage wear and deterioration, which impact millions of the aged population. Stabilization of the remaining damaged cartilage, and prevention of further deterioration, could provide immense clinical utility and prolong joint function. Our previous work showed that high tibial osteotomy (HTO) could shift the mechanical stress from an imbalanced status to a neutral alignment. However, the underlying mechanisms of endogenous cartilage stabilization after HTO remain unclear. We hypothesize that cartilage-resident mesenchymal stem cells (MSCs) dampen damaged cartilage injury and promote endogenous repair in a varus malaligned knee. The goal of this study is to further examine whether HTO-mediated off-loading would affect human cartilage-resident MSCs' anabolic and catabolic metabolism. This study was approved by IACUC at Xi'an Jiaotong University. Patients with medial compartment OA (52.75±6.85 yrs, left knee 18, right knee 20) underwent open-wedge HTO by the same surgeons at one single academic sports medicine center. Clinical data was documented by the Epic HIS between the dates of April 2019 and April 2022 and radiographic images were collected with a minimum of 12 months of follow-up. Medial compartment OA with/without medial meniscus injury patients with unilateral Kellgren /Lawrence grade 3–4 was confirmed by X-ray. All incisions of the lower extremity healed well after the HTO operation without incision infection. Joint space width (JSW) was measured by uploading to ImageJ software. The Knee injury and Osteoarthritis Outcome Score (KOOS) toolkit was applied to assess the pain level. Outerbridge scores were obtained from a second-look arthroscopic examination. RNA was extracted to quantify catabolic targets and pro-inflammatory genes (QiaGen). Student's t test for two group comparisons and ANOVA analysis for differences between more than 2 groups were utilized. To understand the role of mechanical loading-induced cartilage repair, we measured the serial changes of joint space width (JSW) after HTO for assessing the state of the cartilage stabilization. Our data showed that HTO increased the JSW, decreased the VAS score and improved the KOOS score significantly. We further scored cartilage lesion severity using the Outerbridge classification under a second-look arthroscopic examination while removing the HTO plate. It showed the cartilage lesion area decreased significantly, the full thickness of cartilage increased and mechanical strength was better compared to the pre-HTO baseline. HTO dampened medial tibiofemoral cartilage degeneration and accelerate cartilage repair from Outerbridge grade 2 to 3 to Outerbridge 0 to 1 compared to untreated varus OA. It suggested that physical loading was involved in HTO-induced cartilage regeneration. Given that HTO surgery increases joint space width and creates a physical loading environment, we hypothesize that HTO could increase cartilage composition and collagen accumulation. Consistent with our observation, a group of cartilage-resident MSCs was identified. Our data further showed decreased expression of RUNX2, COL10 and increased SOX9 in MSCs at the RNA level, indicating that catabolic activities were halted during mechanical off-loading. To understand the role of cartilage-resident MSCs in cartilage repair in a biophysical environment, we investigated the differentiation potential of MSCs under 3-dimensional mechanical loading conditions. The physical loading inhibited catabolic markers (IL-1 and IL-6) and increased anabolic markers (SOX9, COL2). Knee-preserved HTO intervention alleviates varus malalignment-related knee joint pain, improves daily and recreation function, and repairs degenerated cartilage of medial compartment OA. The off-loading effect of HTO may allow the mechanoregulation of cartilage repair through the differentiation of endogenous cartilage-derived MSCs

Introduction. Simultaneous correction of knee varus malalignment with medial open wedge high tibial osteotomy (MOWHTO) combined with anterior cruciate ligament (ACL) surgery aims to address symptomatic unicompartmental osteoarthritis in addition to restore knee stability in order to improve outcomes. The aim of this study is to present at least 5 years results of 32 patients who underwent simultaneous knee realignment osteotomy with ACL surgery. Methods. Patients with symptomatic instability due to chronic ACL deficiency or failed previous ACL surgery together with a varus malalignment of ≥6°, previous medial meniscectomy and symptomatic medial compartment pain who were treated with MOWHTO combined with ACL surgery were enrolled. ACL surgery was performed with the anatomical single bundle all-inside technique using TightRope. ®. RT (Arthrex, Naples, FL, USA) and MOWHTO using TomoFix. ®. medial high tibia plate (DePuy Synthes, Raynham, MA, USA) in all cases. Patients were evaluated preoperatively and at 6 months, 12 months and annually postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Euroqol's Visual Analogue Score (VAS) for pain. Results. 32 patients (22 men and 10 women) with a mean age of 41.2 years and mean BMI of 28.6 kg/m. 2. , underwent the combined procedures. Tibiofemoral neutral re-alignment was achieved in all patients with HTO. Complete subjective and objective scores have been obtained in 84.4% of patients with at least 5 years of follow-up (mean 8.7 years). An improvement in total KOOS of 27.1 points (p<0.003), OKS of 15.1 (p<0.003) and VAS for pain of 24.7 points (p<0.001) were detected. No ACL reconstruction failure was noted. Complications consisted of one superficial wound infection and one delayed union. Plate removal was needed in 20 (62.5%) patients due to pes anserinus pain. Conclusions. Simultaneous restoration of coronal knee axis by applying HTO and stability by ACL reconstruction/revision were reported to offer excellent improvement in early outcomes in patients with ACL rupture and symptomatic unicompartmental osteoarthritis. The combined procedure requires careful pre-operative planning and is therefore technically challenging. However, by restoring the neutral axis and providing stability, it represents a good joint preserving alternative to arthroplasty for active middle-aged patients

The medial opening-wedge high tibial osteotomy (OW-HTO) is an accepted option to treat the isolated medial compartment osteoarthritis (OA) in varus knee. Despite satisfactory outcomes were described in literature, consistent complication rate has been reported and the provided accuracy of coronal alignment correction using conventional HTO techniques falls short. Patient specific instrumentations has been introduced with the aim to reduce complications and to improve the intra-operative accuracy according to the pre-operative plan, which is responsible for the clinical result of the surgery. In this talk, an overview of the clinical results of HTO patient specific instrumentation available in literature will be performed. Moreover, preliminary intra-operative and clinical results of a new customised 3-D printed cutting guide and fixation plate for OW-HTO will be presented