Summary

Double-level osteotomy (DLO) effectively improves patient-reported outcomes, corrects alignment, and has low complication and TKA conversion rates in treating severe varus malalignment and medial compartment osteoarthritis.

Abstract

Background

Double-level osteotomy (DLO), comprising a medial open wedge high tibial osteotomy (MOWHTO) combined with a lateral closing wedge distal femoral osteotomy (LCWDFO), is an advanced surgical intervention for correcting severe varus malalignment and medial compartment osteoarthritis. While DLO has shown promising clinical outcomes, there is currently no comprehensive systematic review evaluating patient-reported outcomes (PROMs), conversion rates to total knee arthroplasty (TKA), complication rates, and alignment results.

Objectives:
This systematic review aims to critically assess and synthesize the current literature on patient-reported outcomes, conversion rates to TKA, complication rates, and alignment results following DLO. The goal is to provide evidence-based guidance to physicians for optimizing treatment decisions and improving patient care in individuals with severe varus malalignment and/or symptomatic medial compartment osteoarthritis.

Methods

Following the PRISMA guidelines, a systematic search was conducted in Scopus, PubMed, and Embase up to July 10th, 2024. The search terms included "double level osteotomy," "high tibial osteotomy," and "distal femoral osteotomy." Studies were included if they had over 5 participants and reported outcomes of DLO (MOWHTO + LCWDFO) with a mean follow-up greater than 1 year. Two independent researchers reviewed the articles, with disagreements resolved by consensus.

Results

Patient-Reported Outcomes: Patient-reported outcomes (PROMs) following double-level osteotomy (DLO) demonstrated significant improvements across multiple studies. The Knee Injury and Osteoarthritis Outcome Score (KOOS), UCLA Activity score, and International Knee Documentation Committee (IKDC) subjective scores consistently increased postoperatively. Patient satisfaction was notably high, with a majority of patients reporting positive outcomes and significant improvements in quality of life.

Complications: Complication rates varied across studies but were generally low. Minor complications included postoperative hematomas and scar dehiscences, while major complications were rare, ranging from deep wound infections to hinge fractures.

Conversion to Total Knee Arthroplasty (TKA): Conversion rates to TKA were minimal with only one study reporting a clinical failure after DLO at follow-up periods of at least one year. The preservation of joint integrity post-DLO suggests that this procedure may delay or prevent the need for TKA in patients with severe varus deformity.

Alignment: While studies reported varying alignment outcomes, most found that DLO effectively corrected all radiological parameters to normal ranges, successfully restoring limb alignment.

Conclusion

Double-level osteotomy (DLO) results in significant improvements in patient-reported outcomes such as KOOS, IKDC, and Lysholm scores, with high patient satisfaction. The procedure effectively corrects radiological parameters to normal ranges, while complications are generally low and conversion rates to total knee arthroplasty (TKA) are minimal. This systematic review addresses a critical gap in the literature by providing a comprehensive evaluation of DLO outcomes. By synthesizing available evidence, it guides clinicians in optimizing patient care and offers valuable insights into the effectiveness and safety of this complex surgical approach.