Summary

DOUBLE LEVEL OSTEOTOMY FOR THE MANAGEMENT OF SEVERE VARUS MALALIGNMENT

Abstract

Introduction. The aim of this study was to analyze the clinical, functional, and radiographic outcomes at a minimum of two years of follow-up in 34 patients with severe varus deformities of the knee (≥15°), treated with combined lateral closing wedge distal femoral osteotomy (DFO) and medial open-wedge high tibial osteotomy (MOW-HTO). The hypothesis of this study was that the use of combined osteotomies produces a statistically and clinically significant improvement in functional scores, pain, and radiological parameters at two years of follow-up, with a low rate of intra- and postoperative complications.

Methods. 34 patients with clinical and radiographic follow-up of at least two years, with a diagnosis of symptomatic severe genu varus osteoarthritis (≥15°), were included. They were treated with a double varus osteotomy (MOW-HTO + DFO). The inclusion criteria were the performance of a primary surgery, the presence of a bone deformity in the coronal plane, selective medial osteoarthritis grade III-IV (Albach classification), mixed deformity (tibial + femoral), not candidates for simple osteotomy as a sole treatment, stable knees, without previous surgeries on the knee. VAS, IKDC, OXFORD and Lysholm functional scales were applied preoperatively and at 6, 12 and 24 months postoperatively. The degree of radiographic correction, time for osteotomy consolidation, time to stop using crutches and return to work, the degree of subjective approval of the patients and the improvement in radiographic parameters (HKA, MPTA, LDFA and JLCA) were analyzed.

Results. The mean age of the patients was 44.2 years ±6.1 years. 20 of the 22 patients were male. All functional and pain scales showed a statistically significant improvement (p< 0.001) when comparing their results with the preoperative values at the 3 postoperative evaluation times (6, 12 and 24 months postoperative). The mean time for consolidation of the osteotomy site was 10.3 weeks ±2.4, the time to stop using crutches was 7.8 weeks ±1.5, 100% of the patients answered YES to the question of whether they would undergo another operation to treat their symptoms, which was applied at 3 months postoperatively. The mean time to return to sports (non-competitive, recreational only) was 6.2 months ±1.4. The mean postoperative HKA was 1.3° ±0.8 in valgus. There were two cases of cortical fractures, 1 of the lateral cortex when performing the OWHTO (Takeuchi type I) and one fracture of the medial cortex of the femur when performing the DFO (Nakayama type 1) that were found to have no impact on functional outcomes (p > 0.05), no other intra- or postoperative complications occurred (pseudoarthrosis, arthrofibrosis or delayed consolidation).

Conclusions. This study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalizes the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis.