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Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure
Javad Parvizi, MD1; Arlen D. Hanssen, MD2; Mark J. Spangehl, MD3
1 The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address: parvj@aol.com
2 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
3 Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259. E-mail address: spangehl.mark@mayo.edu
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):474-479
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Background: The results of proximal tibial osteotomy are known to deteriorate over time, with the majority of patients eventually requiring total knee arthroplasty. The outcome of total knee arthroplasty in patients who have had a proximal tibial osteotomy, compared with that of routine primary total knee arthroplasty, remains controversial. The purpose of the present study was to evaluate the long-term clinical and radiographic outcome of total knee arthroplasty in patients who had undergone a previous proximal tibial osteotomy and to identify the risk factors that may result in an inferior outcome.

Methods: Between 1980 and 1990, 166 cemented condylar total knee prostheses were implanted in 118 patients who had had a previous proximal tibial osteotomy for the treatment of osteoarthritis. The study group included seventy-seven men and forty-one women who had a mean age of 69.1 years at the time of knee arthroplasty. The average interval between the osteotomy and the total knee arthroplasty was 8.6 years. The average duration of clinical follow-up was 15.1 years, and the average duration of radiographic follow-up was 9.2 years.

Results: The mean Knee Society pain score improved from 34.5 to 82.9 points, and the mean function score improved from 44.6 to 88.1 points. There was also a substantial improvement in the mean arc of motion. Thirteen knees (8%) were revised at a mean of 5.9 years. At the time of the final follow-up, progressive complete radiolucent lines indicating a loose prosthesis were present around seventeen tibial components and seven femoral components.

Conclusions: There was a very high rate of radiographic evidence of loosening. Male gender, increased weight, young age at the time of total knee arthroplasty, coronal laxity, and preoperative limb malalignment were identified as risk factors for early failure. Despite these findings, total knee arthroplasty can provide reliable and durable pain relief and improvement in function for patients who have had a previous proximal tibial osteotomy.

Level of Evidence: Prognostic study. Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mark J. Spangehl
    Posted on April 07, 2004
    Dr. Spangehl responds:
    Mayo Foundation

    To the Editor:

    We wish to thank Dr. Rozbruch for his comments regarding “Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure" (volume 86-A, number 3, March,2004) by J. Parvizi, A. Hanssen, and M. Spangehl.

    Dr. Rozbruch is certainly correct that not all osteotomies are the same. Details of the osteotomies were not included in the study. The osteotomies that were preformed prior to the total knee replacements in this series were lateral closing wedge osteotomies as popularized by Conventry. They were performed by different surgeons, who, while using the same basic technique and principles certainly had small variations in the surgical technique and post-operative management. Unfortunately, detailed data regarding the exact technique of each osteotomy procedure was not available. The authors acknowledge that this is an inherent problem, common to many retrospective studies. The authors do agree that various differences in technique (eg. management of the proximal fibula, early range of motion vs casting, amount of bone resected, etc) could influence the result of the osteotomy and potentially the result of subsequent total knee replacement, but we believe that the results are valid for closing wedge osteotomies, and can be generalized to apply such patients.

    The authors are in agreement with Dr. Rozbruch that newer techniques of osteotomy, such as opening wedge osteotomy, the use of stable fixation allowing for early range of motion, or other techniques as cited by Dr. Rozbruch may make the results of total knee replacement after proximal tibial osteotomy more favorable. The authors are also hopeful that with newer techniques, the results of knee replacement will be more favorable and that the concerns cited in the article will be less of a problem. However, to date, there is insufficient data to support this claim, and further study is now needed on total knee replacement after newer techniques of proximal tibial osteotomy.

    S. Robert Rozbruch, MD
    Posted on March 25, 2004
    Not all Osteotomies are the Same
    Hospital for Special Surgery;

    To the Editor:

    I read with interest “Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure” (volume 86-A, number 3, March 2004) by J. Parvizi, A. Hanssen, and M. Spangehl. The authors review a group of 166 cemented condylar knee replacements done in 118 patients that had previously had a proximal tibia osteotomy. These knee replacements had relatively inferior results, and the authors identified risk factors for early failure.

    The problems cited by the authors were mal-alignment, patella baja, instability, periarticular scarring, proximal tibia bone deficiency, and retained hardware. The great detail about knee arthroplasty, long follow- up, and meticulous study design are all severely compromised by the absence of any detail regarding the technique of osteotomy. Were these opening or closing wedge corrections? Was the fibula osteotomized or was the proximal tibia-fibula joint sprung? Was there internal, external, or no fixation? Were patients casted or allowed to move their knees? Were the corrections done acutely or gradually?

    Do the authors suggest that these techniques are all the same? That would be as ludicrous as clumping together a group of knee replacements to include revision total knee replacements, cemented and uncemented primary total knee replacements, PCL sparing and retaining, and unicondylar knee replacements.

    Presumably, this was predominantly a group of closing wedge Coventry- type high tibial osteotomies. Today, this technique has been largely abandoned because of its association with patella baja, decreased metaphyseal bone stock, lateral knee laxity, and altered proximal tibia anatomy.

    Modern techniques of proximal tibia osteotomy including opening wedge corrections, stable fixation that allows early weight-bearing and knee range of motion, gradual corrections with external fixation after percutaneous osteotomy, and adjunctive ligament tensioning techniques should not be associated with the specific problems cited by the authors.

    The authors have suggested that proximal tibial osteotomy in general will compromise future total knee replacement. This is a dangerous and inaccurate message that is not supported by their data or lack thereof. The authors should give the readers specific information about the osteotomy techniques used. Sincerely, S. Robert Rozbruch, MD Director, Institute for Limb Lengthening and Reconstruction Hospital for Special Surgery Assistant Professor of Orthopedic Surgery Weill Medical College of Cornell University

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