The Barrel Vault Tibial Osteotomy of Maquet for Medial Compartment Arthritis of the Knee.
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ABSTRACT:
SUBMITTER: Miller GK
PROVIDER: S-EPMC6714951 | biostudies-literature | 2019 Jul
REPOSITORIES: biostudies-literature
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The Barrel Vault Tibial Osteotomy of Maquet for Medial Compartment Arthritis of the Knee.
Arthroscopy techniques 20190718 7
The barrel vault tibial osteotomy performed for knee varus osteoarthritis avoids the complications of the opening wedge osteotomy and minimizes the potential complications of the lateral closing wedge osteotomy. It allows correction of large varus deformities in knee medial compartment osteoarthritis. ...[more]
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Project description:BackgroundOsteoarthritis of knee is one of the important causes of knee pain in elderly patients and is a debilitating disease. It often leads to varus deformity of knee. Many treatment options are available for this progressive knee joint disorder. Proximal fibular osteotomy (PFO) is a novel yet simple procedure used to alleviate the symptoms of medial compartment knee osteoarthritis. The present study was undertaken to evaluate whether this procedure improves the symptoms, functions and limb alignment in patients with medial compartment knee osteoarthritis.MethodsFollowing approval by the Institutional Review Board, this prospective study included 42 cases (56 knees) with Kellgren-Lawrence grade II and III medial compartment knee osteoarthritis and underwent proximal fibular osteotomy. Clinical assessment was done by visual analogue scale (VAS) score and The Western Ontario and McMaster universities osteoarthritis Index (WOMAC) score pre-operatively and at 3, 6 and 12 months follow-up for pain and functional improvement. Radiological assessment was done by measuring femoro-tibial angles (FTA) pre-operatively and at 1 year follow-up.ResultsThe mean age was 58.30 years. There were 30 females and 12 males. The preoperative mean WOMAC score was 87.3, at 3 months follow-up it was 29.4 this was significantly better (p < 0.05) but the improvement was not significant at subsequent follow-up visits. Similarly the VAS scores also showed significant improvement at 3 months, but not at 6 and 12 months follow-up. There was no significant improvement in the femoro-tibial angle (FTA) at 1 year follow-up.ConclusionThe study highlights that both the VAS scores and WOMAC scores were significantly better at 3 months after surgery. However these did not show any significant improvement at 6 and 12 months. It does not change the alignment of knee at one year follow-up. The authors conclude that proximal fibular osteotomy provides only short-term relief in patients of medial compartment knee osteo-arthritis.
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Project description:Genu varus malalignment can lead to medial compartment overload and progression of ipsilateral compartment osteoarthritis. To slow this process, a medial opening wedge proximal tibial osteotomy (PTO) can be performed. This type of PTO is indicated in patients with genu varus malalignment and isolated medial compartment osteoarthritis of the knee, prior to or concurrent with medial compartment cartilage procedures or meniscal transplants, chronic posterolateral corner deficiency, or chronic anterior cruciate ligament deficiency. When treating ligamentous instability, a PTO can be performed in isolation, with simultaneous ligament reconstruction, or as a staged procedure with the osteotomy first, followed by ligament reconstruction if instability persists. Failure to address malalignment in cases of concurrent ligament reconstruction leads to increased stress on the graft and potential graft failure. One distinct advantage of this procedure is the ability to correct deformities in the sagittal and coronal planes. The purpose of this article was to describe our technique used to perform a medial opening wedge PTO.
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Project description:Severe varus deformity in osteoarthritic knees is attributed not only to bony deformity but also to intra-articular deformity as a result of medial joint space narrowing with lateral joint space widening (increased joint line convergence angle). In such knees, correction of bony deformity by high tibial osteotomy (HTO) alone may not be capable of restoring physiological joint geometry and biomechanics. Tibial condylar valgus osteotomy (TCVO), an L-shaped osteotomy in the medial tibial condyle, has been proposed to improve articular stability and congruity by elevating the medial tibial joint line and addressing the articular component of the deformity; however, its surgical efficacy for correction of the valgus deformity is limited. Therefore a procedure combining HTO and TCVO can be a reasonable option to achieve restoration of the knee joint physiology in such situations. In our current practice, medial open-wedge distal tuberosity tibial osteotomy (MOW-DTO) has been the procedure of primary option among the HTO procedures to avoid patellofemoral overload which could be an inherent problem in medial open-wedge HTO. In this article, the surgical rationale and the combined procedure of TCVO and MOW-DTO are described.
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Project description:ObjectiveCartilage regeneration is multifactorial. This study aimed to optimize the biomechanical factor of weightbearing loading allowing for cartilage regeneration and elucidate the association between cartilage regeneration and clinical outcomes after medial open-wedge high tibial osteotomy (OWHTO).DesignThis was a retrospective, observational study of 142 patients who underwent OWHTO and subsequently underwent second-look arthroscopic assessment at a single orthopedic surgery center in Japan. Clinical and radiographic outcomes were compared between patients with (group R) and without (group D) cartilage regeneration, measured using the International Cartilage Repair Society grading system and the macroscopic staging system at the time second-look arthroscopy was performed. A receiver operating characteristic curve analysis was used to determine the optimal weightbearing line ratio (WBLR) for cartilage regeneration.ResultsGroup R included 82 knees, and group D 60 knees. The WBLR was higher in group R (60.9% ± 6.7%) than in group D (55.6% ± 7.6%) (P < 0.001) and was associated with a greater improvement in clinical outcomes, namely the Lysholm scale score and all subscales of the Knee Injury and Osteoarthritis Outcome Score (P < 0.01). The WBLR predicted cartilage regeneration with an odds ratio of 1.11 (P = 0.001) and an area under the curve of 0.718, for a WBLR value of 62%.ConclusionsA WBLR of 62% was associated with cartilage regeneration after OWHTO and high patient-reported clinical outcomes.
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Project description:Medial open wedge high tibial osteotomy (OWHTO) is usually performed with proximal tuberosity osteotomy or setting the osteotomy line proximal to the tuberosity. However, OWHTO can result in patellofemoral complications due to postoperative patella infera. A new OWHTO technique, biplanar osteotomy with a distal tuberosity osteotomy, was reported in 2004 to prevent postoperative patella infera. To ensure that the 2 osteotomy lines maintain perpendicular, we describe the OWHTO procedure with a distal tuberosity osteotomy technique using a TriS Medial HTO Plate System (Olympus Terumo Biomaterials Corp., Tokyo, Japan) and a right angle guide we developed. In this Technical Note, we describe the procedure and advantages, risks, and limitations, as well as the pearls and pitfalls based on our experience.
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Project description:High tibial osteotomy (HTO) is used in the treatment of knee osteoarthritis. This surgical procedure is indicated in patients with medial osteoarthritis who are relatively young and active and have a good range of motion. In most medial open-wedge HTO cases, the fascia, medial collateral ligament (MCL), and part of the knee joint capsule are carefully separated and moved to expose the osteotomy site, but many patients experience postoperative swelling and pain in the affected limb due to bleeding from the osteotomy site and MCL failure. We have developed a method of osteotomy followed by a restoration of the MCL to its anatomic position and complete soft-tissue coverage of the osteotomy. This Technical Note aims to provide a comprehensive description of the employment of a soft-tissue envelope for the MOW-HTO protection. Technique Video Video 1 A curved oblique skin incision is made from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. An incision is made in the sartorius fascia. The affected knee is placed in a slightly flexed position to relax the gracilis and semitendinosus tendons. These 2 tendons are then identified and scooped with a Kelly clamp and wet gauze. When the 2 tendons are separated, we can see the shallow layer of the medial collateral ligament (MCL) and the joint capsule. The distal attachments of the 2 tendons are left connected to the proximal tibia, and the boundary between the MCL and the joint capsule is marked with an electrocautery scalpel. A rasp is used at the border between the shallow layer of the MCL and the articular capsule to peel away the matter between the bone and the periosteum, which creates room for expansion. The dissection proceeds toward the posterior surface of the tibia and follows the bone so as not to involve the nerves or blood vessels when the retractor is inserted. At the posterior surface of the tibia, a bent-tip elevators can be used. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles. At this point, the tip of the first Kirschner wire is inserted between the 2 tendons 4 to 4.5 cm below the medial joint line. The second Kirschner wire is then inserted parallel to the first under fluoroscopy. An anterior ascending osteotomy is then performed at an angle of 110° to the horizontal saw cut, ending behind the patellar tendon insertion. An osteotomy is made toward the fibular head, leaving a hinge. With the spreader inserted into the osteotomy site, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is then applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoidal shape and inserted considering the amount of correction required at the osteotomy site. Soft-tissue repair is performed before the plate is applied. With a Kocher, the MCL is pulled into its correct anatomical position and sutured to the surrounding tissue. Then, the ST tendon and G tendon are also returned to their usual anatomical positions, ensuring that they cover the MCL. The excised joint tendons and then the sartorius fascia are sutured to completely cover the osteotomy. A TOMOFIX anatomical medial high tibial plate is applied to the medial side of the proximal tibia. (G, gracilis; ST, semitendinosus.)
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Project description:High tibial osteotomy for medial-compartment knee osteoarthritis (OA) is an established biological knee reconstruction surgical procedure. In open- and closed-wedge high tibial osteotomy, the angulation correction axes are away from the center of rotation and angulation. This results in translation deformity, which alters the orientation of the adjacent joint and the length of the limb. In the present study, we combined the distal tibial tuberosity focal dome osteotomy centered on the center of rotation and angulation with the longitudinal condylar osteotomy (focal dome condylar osteotomy) for knee OA. The advantages of this procedure are as follows: physiological orientation of adjacent joint is achieved; limb length is maintained; joint stabilization in the coronal plane is achieved; patella infra is prevented; sufficient bone contact between the medial and posterior cortex is achieved; early weight-bearing walking is possible; and fibular osteotomy is not required. This study describes the details of the surgical procedure, including our compass cutter for accurate dome osteotomy and the postoperative rehabilitation program for patients with knee OA and moderate-to-severe varus deformity.
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Project description:BackgroundSpacer-type tibial osteotomy have been proven a novel and effective osteotomy to treat osteoarthritis, while lack of comparison with other surgical methods in younger patients. This study aims to evaluate the short-term clinical outcomes of spacer-type tibial osteotomy versus open wedge high tibial osteotomy (OWHTO) and unicompartmental knee arthroplasty (UKA) for Kellgren-Lawrence (K-L) grade 3-4 osteoarthritis (OA) in patients younger than 65 years.MethodsThis retrospective study analyzed a total of 224 patients with K-L grade 3-4 knee OA treated from March 2018 to November 2020. Three groups were created according to the operation type. The clinical outcomes recorded preoperatively and at 6, 12 and 24 months postoperatively were the range of motion (ROM), visual analogue scale (VAS), American Knee Society Score (KSS), Western Ontario and McMaster Universities Global (WOMAC) score, operation time, length of incision, relevant complications and failures. Radiographic parameters were measured to evaluate the correction of varus deformity.ResultsThe cohort comprised 224 patients; 70 underwent spacer-type tibial osteotomy, 73 underwent OWHTO, and 81 underwent UKA. The spacer group had the shortest incision (P = 0.000), least amount of bleeding (P = 0.000), and shortest operation time (P = 0.000). UKA achieved the most significant pain relief based on VAS (P = 0.014), KSS pain score (0.030), and WOMAC score (P = 0.000) at 6 months postoperatively, but there were no differences between three groups at 12 and 24 months postoperatively. The spacer and OWHTO groups achieved significantly greater ROM changes compared with the UKA group (all P = 0.000). The complication rate did not significantly differ between the three groups. No surgical failures were identified in HTO but two spacer dislocations in spacer group and three polyethylene dislocations in UKA.ConclusionFor younger patients with K-L grade 3-4 OA, OWHTO seems to be the most appropriate method through clinical comparisons. Although spacer-type tibial osteotomy offers shorter operation time and comparable clinical outcomes, it also has extended recovery phase, additional fibular incision and the risk of spacer dislocation, which did not appear to be superior to OWHTO and UKA under the indications outlined in this study.Trial registrationRetrospectively registered, QYFY WZLL 27,021.
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Project description:PurposeStanding radiographs are commonly used to plan angular correction in valgus tibial osteotomy for varus gonarthrosis. Most clinical studies have reported postoperative alignment as overall averages or means. The purpose of this study was to compare the preoperatively planned angle of correction measured on weight-bearing radiographs to the follow-up angle measured on weightbearing radiographs in individual patients 6 weeks after surgery and to analyze factors that could potentially affect achieving the planned degree of surgical correction. Our objective was to analyze factors potentially affecting the accuracy and ability to achieve the preoperatively planned correction angle (the target angle) in the individual patient.MethodsWe studied 35 tibial osteotomies (13 Coventry closing wedge osteotomies and 22 Maquet barrel vault osteotomies) performed for varus gonarthrosis between 1981 and 2019 to determine how accurately the target angle, based on preoperative standing weight-bearing radiographs, was achieved according to the postoperative radiographs in each individual. We reviewed 35 knees in 34 patients who had complete pre- and postoperative radiographs for review.ResultsOverall, only 14 of 35 (40%) of the patients were corrected to within ± 2° of the planned target angle. Valgus tibial osteotomy based on preoperative weightbearing radiographs is unpredictable in its ability to achieve the target angle on postoperative weightbearing radiographs when using either the Coventry or the Maquet surgical technique. The tendency was to undercorrect with either of the techniques. Larger (greater than 10°) preoperative varus alignment did not make it more difficult to achieve the target angle. Male or female sex and body mass index had no effect on the ability to achieve the target angle.ConclusionsValgus tibial osteotomy planning based on preoperative weightbearing is unpredictable in its ability to achieve the target angle on postoperative weightbearing radiographs. Overall, only 40% of our patients were corrected to within ± 2° of the planned target angle. The tendency was to undercorrect, with either the Coventry or the Maquet technique. Contrary to our hypothesis, larger preoperative varus alignment (greater than 10°) did not make it more difficult to achieve the target angle. The Coventry technique was as accurate as the Maquet technique.Level of evidenceLevel IV.
| S-EPMC7451877 | biostudies-literature
Project description:BackgroundMedial knee osteoarthritis (OA) is a common health problem resulting in knee pain and limiting patients' physical activity. After failed conservative treatment, unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are possible surgical treatment options for this condition. There is a paucity of high-quality evidence in the literature comparing objective and subjective outcomes of these procedures. Also, there is no common agreement on whether these procedures provide comparable results in late-stage medial knee OA patients.MethodsWe will perform a prospective randomized controlled trial comparing HTO and UKA in patients with late-stage medial knee OA. 100 patients with isolated medial knee OA (KL III-IV) are assigned to either UKA (n = 50) or HTO (n = 50) procedure in patients 45-65 years of age. Our primary outcome will be KOOS5 at one year postoperatively. Secondary outcomes include OARSI physical assessment, length of stay, wearable activity watch, radiographs (OA progression according to Kellgren-Lawrence classification), patient-reported outcomes (KOOS subscales, pain visual analog scale [VAS], Lysholm, and Oxford knee scores), and adverse events (conversion to total knee arthroplasty, surgery-related complications, need for revision surgery) outcomes. Our hypothesis is that neither of the interventions is superior as measured with KOOS5 at 12 months.Ethics and disseminationThe institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings through peer-reviewed publications.Trial registrationClinicalTrials.gov/TooloH NCT05442242. Registered on 7/1/2022.
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