Summary

A paper describing the feasibility and usefullness of a bilateral simultaneous high tibial osteotomy in a select patient group and an accelerated rehabilitation programme

Abstract

Background

High tibial osteotomy (HTO), an established procedure for medial unicompartment osteoarthritis(OA) of the knee, is often required bilaterally. The longer period of rehabilitation associated with bilateral HTO as compared to bilateral TKR was an important consideration in doing this procedure. Tomofix®(Depuy, Synthes, Warsaw,IN,USA) permits early mobilisation, and thus reduces recovery period.When done sequentially it involves double hospitalization, repeated hospital visits and an extended period of recuperation. This has been shown to minimise cost, reduce hospitalisation and maximise clinical benefits without any added complications. This motivated us to do bilateral HTO’s in same sitting and present our results of the same.
Materials & Methods:We performed bilateral simultaneous HTO using Tomofix®(Depuy, Synthes, Warsaw,IN,USA) for medial compartment OA knee in 9 patients (18 knees), between April 2010 and August 2012, in the age group of 45-55 yrs. The selection criteria for HTO were the same as those recommended in the literature. For this group undergoing bilateral simultaneous HTO, our additional selection criteria was a strong family/nursing support, with family members motivated to attend to the needs of an in-bed bound patient for a period of two weeks post surgery. We excluded patients with deformity >10 degree varus, body mass index (BMI)> 35, those with previous history of DVT, and those with diabetes mellitus. Prior to surgery, all patients had standard knee radiographs and a long leg hip-knee-ankle radiograph for pre-op planning. Hip knee ankle X-rays were taken at one month post op when the patient was weight bearing without crutches and again at ne year. The standard technique of open wedge biplanar HTO recommended in literature was used11.Post-operatively special care was taken to avoid DVT by use of oral rivaroxaban 10 mg daily for 4 weeks. The patient’s family was educated to take care of the patient in bed in the immediate post-op period for preventing bed sores. Range of motion exercises, and active and active-assisted exercises for quadriceps strengthening were started on the first post operative day. The patients were discharged on the fourth day post surgery. The patients were kept non weight bearing for 2 weeks followed by weight bearing as tolerated with crutches from 2-4weeks followed by full weight bearing without crutches Follow up was for one year. The primary outcome measures of Knee Function Score (Insall modification),Visual Analogue Scale (VAS) and the correction achieved in femoro-tibial angle measured on standing hip-knee-ankle X-ray were recorded pre-op and at the end of one year (Fig 2). Intra operative, post-operative and rehabilitation difficulties, and complications were recorded.
Results:The Knee score (Insall modification) improved from mean 54.2 ± 4.6 pre-op to a mean 89.9± 5.8 at one year. Pain score (VAS) improved from mean of 66.3± 4.1 to a mean 11.5 ±3.6.The femoro-tibial angle from mean 3.6 degree varus to 1.77 degree valgus. The osteotomy healed in a median 5.2 months (4-7 months). There were no complications.

Conclusions

Bilateral HTO in the same sitting for selected patients is a feasible option without any added complications.