Summary

A value of 92° for postoperative MPTA is potentially the optimal threshold to predict intra-articular correction.

Abstract

Purpose

The tipping point (TP) is the centre of rotation of the joint in the coronal plane. This study aimed to define the TP in medial opening wedge high tibial osteotomy (MOWHTO).

Methods

Data from 154 consecutive patients with varus knee malalignment, who underwent MOWHTO between 2017 and 2021, was retrospectively reviewed. The degree of preoperative osteoarthritis (OA) using Kellgren Lawrence (KL) was recorded. Long-leg standing radiographs were used to record the alignment parameters including the hip-knee-ankle angle (HKA), the mechanical lateral distal femoral angle (mLDFA), the medial proximal tibial angle (MPTA), the joint line convergence angle (JLCA) and the joint line obliquity angle (JLO). Postoperative Tegner activity scores, Western Ontario And McMaster University Scores, and patients’ satisfaction were recorded. To define the tipping point (TP), the relationship of all variables to ? JLCA (Absolute difference between preoperative to postoperative JLCA values) was analyzed. Linear regression was employed for ? JLCA to preoperative JLCA, and postoperative and ? MPTA (Absolute difference between preoperative and postoperative values). k-means clustering was used to partition observations into clusters, in which each observation belongs to the cluster with the nearest mean serving as a prototype of the cluster, and analysing if there was any specific threshold influencing ? JLCA. After defining the TP, further sub-analysis of the TP based on the preoperative KL OA grade and analysis of variance of this TP to the KL OA grade, was performed.

Results

A total of 154 patients (77.9% males and 22.1% females ) were included. The mean age was 48.2 ± 11 years and the mean BMI was 27.1 ± 4 Kg/m2. Preoperatively, 26 (16.9%) patients had KL grade IV OA. The mean preoperative, and postoperative JLCA and the significance of their relation to ? JLCA were 2.6 °± 1.8° (P < 0.0001), and 1.9° ± 1.8° (p = 0.6), respectively. The mean ? JLCA was 1.4° ± 1.5°. The mean pre- and postoperative MPTA and the significance of their relation to ? JLCA were 84.6 ± 2.2 (p = 0.005), and 91.8 ± 2.5 (p < 0.0007), respectively. The mean delta MPTA was 7.2 ± 2.3 (p = 0.3). The mean preoperative and postoperative HKA and the significance of their relation to ? JLCA were 174.6 ± 2.5 (p = 0.2) and 181.9 ± 2.4 (p = 0.7), respectively. The overall linear regression for ? JLCA was statistically significant for preoperative JLCA (R2 = 0.3, p < 0.0001), and postoperative MPTA, (R2 = 0.09, p = 0.0001), and statistically insignificant for delta MPTA (R2 = 0.01, p = 0.2), and postoperative HKA (R2 = 0.04, p = 0.7). MPTA > 91.5° was the optimal threshold dividing this series dataset between substantial and non-significant ? JLCA.

Conclusion

In this study, the main predictive factors for intra-articular correction (delta JLCA) after MOWHTO were the preoperative value of JLCA and the postoperative value of MPTA. A value of 92° for postoperative MPTA is potentially the optimal threshold to predict intra-articular correction.

Level of Evidence: IV Retrospective Cohort Study

Key Words: Tipping point, Hypomochlion, Joint line convergence angle, Medial opening wedge high tibial osteotomy.