The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 3

Scientific Articles | March 01, 2004

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

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (2)

text A A A

Abstract

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.

Figures in this Article

Valgus-producing proximal tibial osteotomy is a treatment option for unicompartmental disease of the knee in young patients^1-6. While proximal tibial osteotomy is known to provide excellent pain relief and some improvement in function, the results are known to deteriorate with time^1-3,7. The gonarthritis continues to progress, and many patients eventually require total knee arthroplasty⁷. There have been conflicting reports in the literature regarding the outcome of total knee arthroplasty in patients who have had a previous proximal tibial osteotomy^8-14. Some studies have demonstrated substandard results^9,11,14 while others have not^{8,10,12,13,15}. In particular, a recent comparative study of thirty-nine patients who had undergone bilateral total knee arthroplasty demonstrated that the clinical and radiographic results for knees with and without a previous proximal tibial osteotomy were not substantially different after a mean duration of follow-up of 8.7 years¹⁰.

The purposes of the present study were (1) to report the long-term radiographic and clinical results of total knee arthroplasty, performed with a cemented condylar prosthesis, following proximal tibial osteotomy in a large group of patients from a single institution and (2) to report the results for a subset of patients who underwent bilateral total knee arthroplasty following a previous unilateral proximal tibial osteotomy with the intention of identifying differences in outcome between the two sides (if any) as well as factors that may contribute to an inferior outcome.

Materials and Methods

Materials and Methods | Results | Discussion | References

Demographic Data

All patients with a history of a prior proximal tibial osteotomy who underwent total knee arthroplasty with use of a modern cemented condylar knee prosthesis were identified. During the period of this study, between 1980 and 1990, 11,912 total knee arthroplasties were carried out at our institution; 166 of these procedures were performed in 118 patients who had had a prior proximal tibial osteotomy. These patients included seventy-seven men and forty-one women who had a mean age of 69.1 years (range, fifty-two to eighty-five years) at the time of the arthroplasty. Within this group, thirty-four patients with a history of unilateral proximal tibial osteotomy underwent bilateral total knee arthroplasty (Table I). This subgroup included eleven women and twenty-three men. The underlying diagnosis for all patients was osteoarthritis. The average interval between the osteotomy and the total knee arthroplasty was 8.6 years (range, two to eighteen years).

View Larger

TABLE I Comparative Data for Thirty-four Patients Who Underwent Bilateral Total Knee Arthroplasty After a Previous Unilateral Proximal Tibial Osteotomy

	Previous Osteotomy
	Yes (N = 34)	No (N = 34)	P Value
Demographic data (at time of total knee arthroplasty)
Age (yr)	63.2 ± 6.5	67.1 ± 10.1	0.5
Weight (kg)	72 ± 23.2	70 ± 21.8	0.6
Clinical outcome
Duration of follow-up (yr)	15.1	15.4	0.7
Knee Society score (cumulative) (points)
Preoperative	82	84	0.8
Postoperative	189	175	0.07
Arc of motion (deg)
Preoperative	93	97	0.4
Postoperative	103	109	0.2
Coronal instability (no. of knees)
Preoperative	5	1	0.01
Postoperative	3	1	0.08
Operative data
Lateral release (no. of knees)	9	2	0.002
Radiographic data
Malalignment (no. of knees)
Preoperative	22	14	0.002
Postoperative	6	2	0.01
Insall-Salvati ratio	0.89	1.02	0.01
Radiolucent lines (no. of knees)
Tibia	12	7	0.03
Femur	8	4	0.03
Survivorship data
Revision (no. of knees)	2	0	0.05

Add to My JBJS

TABLE I Comparative Data for Thirty-four Patients Who Underwent Bilateral Total Knee Arthroplasty After a Previous Unilateral Proximal Tibial Osteotomy

	Previous Osteotomy
	Yes (N = 34)	No (N = 34)	P Value
Demographic data (at time of total knee arthroplasty)
Age (yr)	63.2 ± 6.5	67.1 ± 10.1	0.5
Weight (kg)	72 ± 23.2	70 ± 21.8	0.6
Clinical outcome
Duration of follow-up (yr)	15.1	15.4	0.7
Knee Society score (cumulative) (points)
Preoperative	82	84	0.8
Postoperative	189	175	0.07
Arc of motion (deg)
Preoperative	93	97	0.4
Postoperative	103	109	0.2
Coronal instability (no. of knees)
Preoperative	5	1	0.01
Postoperative	3	1	0.08
Operative data
Lateral release (no. of knees)	9	2	0.002
Radiographic data
Malalignment (no. of knees)
Preoperative	22	14	0.002
Postoperative	6	2	0.01
Insall-Salvati ratio	0.89	1.02	0.01
Radiolucent lines (no. of knees)
Tibia	12	7	0.03
Femur	8	4	0.03
Survivorship data
Revision (no. of knees)	2	0	0.05

Follow-up

Clinical and radiographic data on all patients were collected prospectively. Patients were contacted on a regular basis and most had a follow-up examination at three months, one year, two years, five years, and every five years thereafter. Some follow-up evaluations were conducted by means of questionnaires or letters. The approval of the Institutional Review Board and the consent of all patients were obtained prior to the study, and no patient refused to participate. The average duration of clinical follow-up was 15.1 years (range, six to twenty-two years), and the average duration of radiographic follow-up was 9.2 years (range, two to nineteen years). All patients were followed for a minimum of two years, until failure of the prosthesis, or until death. No patient was lost to follow-up. There were thirty-eight deaths during the study period, all of which were unrelated to the knee arthroplasty.

Radiographic Evaluation

Serial preoperative and postoperative anteroposterior, lateral, Merchant view, and standing long-leg radiographs were reviewed to assess limb alignment, the degree of arthritis, patellar height, component positioning, loosening, and polyethylene wear. Definite loosening was defined as the presence of a complete radiolucent line on any radiograph or femoral or tibial subsidence of =2 mm¹⁶. Radiolucent lines were classified as grade I (<1 mm wide), grade II (1 to 2 mm wide), or grade III (>2 mm wide). A radiolucent line was considered to be progressive if it increased over time or if it was present on the final follow-up radiograph but had not been present on the immediate postoperative radiograph. The data were then analyzed to determine the prevalence of progressive radiolucent lines among these patients. A detailed analysis was carried out to determine the mechanical axis on the standing long-limb radiographs¹⁷, the tibiofemoral angle, the femoral tilt (the angle between the intercondylar line and a line perpendicular to the longitudinal axis of the femur), the femoral flexion angle (the angle between the longitudinal axis of the femur and a line across the anterior flange of the prosthesis), the tibial angle (the angle between the joint line of the tibia and a line perpendicular to the longitudinal axis of the tibia), the tibial slope (the angle between the longitudinal axis of the tibia on the lateral radiograph and a line drawn on the undersurface of the tibial component), the varus-valgus angle of the tibial component on the anteroposterior radiograph, and the Insall-Salvati ratio (the ratio of the length of the patellar ligament to the length of the patella)¹⁸. Malalignment was considered to be present when the tibiofemoral angle was >10° of valgus or any degree of varus.

Functional Evaluation

Knee scores were calculated with use of the system of the Knee Society¹⁹, which consists of a score for pain (maximum, 100 points) and a score for function (maximum, 100 points). These scores were assessed before surgery, at two years, and at the time of the latest follow-up examination. The result was considered to be excellent or good if the knee score was >160 points, no walking aid was used, the knee was painless, and the minimum arc of motion exceeded 100°. The outcome was defined as fair if one of the above parameters was not met and as poor if more than one of the above parameters was not met.

Statistical Analysis

Changes in the pain and function scores were evaluated with the Wilcoxon signed-rank test. Individual risk factors were analyzed with the Fisher exact test. Continuous risk factors were analyzed with a two-sample t test. A 95% confidence level was used for all tests.

Results

Materials and Methods | Results | Discussion | References

The data are presented for the overall group as well as for the subgroup of thirty-four patients who underwent bilateral total knee arthroplasty and unilateral proximal tibial osteotomy. Table I outlines the demographic data, the preoperative and operative data, the clinical outcomes, and the radiographic findings for the thirty-four patients in the subgroup. Table II shows the influence of various factors on outcome (as measured with use of knee scores, the revision rate, and the prevalence of radiolucent lines) for the overall group.

View Larger

TABLE II Influence of Factors on Clinical and Radiographic Outcome for the Overall Group

Factors Analyzed	Knee Score	Rate of Revision	Prevalence of Radiolucent Lines
Gender
Male (n = 105)	77 (preop.)/182 (postop.)	9.3% (10/108)	16.6% (18/108)
Female (n = 61)	79 (preop.)/168 (postop.)	5.2% (3/58)	10.3% (6/58)
	p < 0.01	p < 0.04	p < 0.003
Age
<60 yr	80 (preop.)/178 (postop.)	10.7% (6/56)	17.8% (10/56)
=60 yr	76 (preop.)/169 (postop.)	6.4% (7/110)	12.7% (14/110)
	p < 0.01	p < 0.04	p < 0.03
Weight
Normal (n = 92)	69 (preop.)/178 (postop.)	6.5% (6/92)	13.1% (12/92)
Obese (>2 standard deviations) (n = 74)	80 (preop.)/164 (postop.)	9.5% (7/74)	16.2% (22/74)
	p < 0.001	p < 0.04	p < 0.02
Axial alignment* (before total knee arthroplasty)
Malaligned (n = 128)	78 (preop.)/172 (postop.)	7.8% (10/128)	14.8% (19/128)
Normal (n = 38)	78 (preop.)/166 (postop.)	7.9% (3/38)	13.2% (5/38)
	NS†	NS†	0.06
Coronal laxity
Preoperative	p < 0.003	NS†	p < 0.04
Postoperative	p < 0.01	NS†	p < 0.02
Axial alignment* (after total knee arthroplasty)
Malaligned (n = 14)	78 (preop.)/170 (postop.)	21.4% (3/14)	14.2% (2/14)
Normal (n = 152)	81 (preop.)/172 (postop.)	6.6% (10/152)	14.5% (22/152)
	NS†	p < 0.02	NS†
Bilateral total knee arthroplasty	NS†	NS†	NS†
Height	NS†	NS†	NS†
Body mass index	NS†	NS†	NS†

Malalignment was considered to be present when the tibiofemoral angle was > 10° of valgus or any degree of varus. †NS = not significant.

Add to My JBJS

TABLE II Influence of Factors on Clinical and Radiographic Outcome for the Overall Group

Factors Analyzed	Knee Score	Rate of Revision	Prevalence of Radiolucent Lines
Gender
Male (n = 105)	77 (preop.)/182 (postop.)	9.3% (10/108)	16.6% (18/108)
Female (n = 61)	79 (preop.)/168 (postop.)	5.2% (3/58)	10.3% (6/58)
	p < 0.01	p < 0.04	p < 0.003
Age
<60 yr	80 (preop.)/178 (postop.)	10.7% (6/56)	17.8% (10/56)
=60 yr	76 (preop.)/169 (postop.)	6.4% (7/110)	12.7% (14/110)
	p < 0.01	p < 0.04	p < 0.03
Weight
Normal (n = 92)	69 (preop.)/178 (postop.)	6.5% (6/92)	13.1% (12/92)
Obese (>2 standard deviations) (n = 74)	80 (preop.)/164 (postop.)	9.5% (7/74)	16.2% (22/74)
	p < 0.001	p < 0.04	p < 0.02
Axial alignment* (before total knee arthroplasty)
Malaligned (n = 128)	78 (preop.)/172 (postop.)	7.8% (10/128)	14.8% (19/128)
Normal (n = 38)	78 (preop.)/166 (postop.)	7.9% (3/38)	13.2% (5/38)
	NS†	NS†	0.06
Coronal laxity
Preoperative	p < 0.003	NS†	p < 0.04
Postoperative	p < 0.01	NS†	p < 0.02
Axial alignment* (after total knee arthroplasty)
Malaligned (n = 14)	78 (preop.)/170 (postop.)	21.4% (3/14)	14.2% (2/14)
Normal (n = 152)	81 (preop.)/172 (postop.)	6.6% (10/152)	14.5% (22/152)
	NS†	p < 0.02	NS†
Bilateral total knee arthroplasty	NS†	NS†	NS†
Height	NS†	NS†	NS†
Body mass index	NS†	NS†	NS†

Malalignment was considered to be present when the tibiofemoral angle was > 10° of valgus or any degree of varus. †NS = not significant.

Functional Outcome

The mean Knee Society pain score for the entire group improved from 34.5 points (range, 0 to 85 points) preoperatively to 82.9 points (range, 30 to 95 points) at the time of the latest follow-up (p < 0.0001). The mean Knee Society function score for the entire group improved from 44.6 points (range, 0 to 90 points) preoperatively to 88.1 points (range, 30 to 100 points) at the time of the latest follow-up (p < 0.0001). This improvement was somewhat greater for patients who had not had a previous osteotomy than for those who had had a previous osteotomy (Table I). The outcome was considered to be excellent or good for 113 knees, fair for forty, and poor for thirteen. Of the fifty-three knees with a fair or poor outcome, twenty-nine were in patients who used a walking aid, sixteen had poor motion, and eight had persistent pain.

The mean arc of motion for the overall group improved significantly from 68.9° (range, 20° to 120°) preoperatively to 100.5° (range, 80° to 130°) postoperatively (p = 0.03).

Instability

Before total knee arthroplasty, forty-six (28%) of the 166 knees had mild medial instability (1 to 2 mm) and fourteen (8%) had moderate medial instability (>2 to 3 mm), thirty had mild lateral instability and three had moderate lateral instability, and three had moderate anterior instability. After total knee arthroplasty, nine knees had moderate medial instability and four had moderate lateral instability. There was a higher rate of preoperative coronal instability in patients who had had a previous proximal tibial osteotomy. With the numbers available, the rate of coronal instability following knee arthroplasty was not significantly different between knees with and without a previous tibial osteotomy (Table I).

Radiographic Findings

When the entire study group was examined, the mean axial alignment was 4.8° of valgus (range, 10° of varus to 24° of valgus) preoperatively and 6.1° of valgus (range, 4° of varus to 13° of valgus) postoperatively. The mean Insall-Salvati ratio¹⁸ changed slightly, from 0.89 (range, 0.7 to 1.3) preoperatively to 0.94 (range, 0.6 to 1.5) at the time of the latest follow-up. Postoperative radiographs of the entire group revealed a mean femoral flexion angle of 96.6° (range, 88° to 104°), a mean tibial angle of 1.1° of valgus (range, 10° of valgus to 8° of varus), a mean femoral tilt of 5.9° of valgus (range, 0° to 25° of valgus), and a mean posterior tibial slope of 4° (range, 13° of anterior slope to 6° of posterior slope).

At the time of the final follow-up of the 166 knees in the overall group, progressive complete radiolucent lines, indicating a loose prosthesis, were present around seventeen tibial components (10%) and seven femoral components (4%). An incomplete radiolucent line was detected around sixty-nine tibial components (42%) and around thirty-seven femoral components (22%). In the subgroup of patients who had had bilateral total knee arthroplasty following a previous unilateral tibial osteotomy, the prevalence of radiolucent lines around the tibial and femoral components was significantly higher for knees that had had a previous osteotomy than for those that had not (p < 0.03) (Table I).

Revisions and Reoperations

Revision total knee arthroplasty was performed in thirteen knees at a mean of 5.9 years (range, 2.2 to nine years). The reasons for revision included failure of the tibial polyethylene (four knees), loosening of the patellar component (three knees), loosening of the tibial component (three knees), deep infection (one knee), instability (one knee), and patellar fracture (one knee). Eight knees that had failed to achieve an adequate range of motion despite extensive physical therapy required manipulation following the knee arthroplasty. One of these knees required an arthroscopic release and a second attempt at manipulation six months later. Patellar clunk developed in one knee, necessitating excision at three years following the knee replacement.

The survival rate for the entire series, with revision as the end point, was 97.5% (95% confidence interval, 94.7% to 100%) at five years, 92.3% (95% confidence interval, 87.3% to 97.6%) at ten years, and 89.0% (95% confidence interval, 81.3% to 97.5%) at fifteen years (Fig. 1).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: Kaplan-Meier curve representing survival free of revision and symptomatic loosening.

Complications

Partial detachment of the patellar ligament from the tibial tubercle occurred in one knee during the procedure. Stapling and primary repair were performed at the time of the arthroplasty. The knee was immobilized for six weeks postoperatively, with subsequent uncomplicated healing and full restoration of extensor mechanism function. Symptomatic patellar subluxation developed in one knee; however, the patient was unwilling to undergo additional surgery. An intra-articular hematoma developed in two knees; both resolved without specific intervention. A deep infection developed fifteen months after the arthroplasty in one patient (one knee) who had diabetes mellitus. The infection was successfully treated with two-stage reimplantation. Severe instability developed in one knee after the arthroplasty and necessitated revision to a semiconstrained prosthesis.

Discussion

Materials and Methods | Results | Discussion | References

The question of whether a previous proximal tibial osteotomy can have a deleterious effect on the outcome of total knee arthroplasty remains unanswered. Therefore, it is important to consider what factors, if any, contribute to differences in the outcome. The findings of the present study indicate that the overall functional outcome (as measured with use of the Knee Society scores) and the radiographic outcome are somewhat inferior for knees that have had a previous proximal tibial osteotomy. We found that the prevalence of tibial and femoral radiographic radiolucent lines was higher in this patient population as compared with knees without previous tibial osteotomy in the same series and a previous series from this institution²⁰. We believe that there are several reasons for this suboptimal outcome in knees that have had a previous osteotomy, including higher rates of preoperative limb malalignment, patella baja, and instability. It is possible that, in some cases, technical difficulties with exposure led to suboptimal component positioning, soft-tissue balancing, and limb alignment¹⁴. Although we did not detect gross component malpositioning, we found that more knees that had had a previous tibial osteotomy exhibited instability, limb malalignment, and extensor mechanism maltracking.

Instability was observed in a considerable number of knees in this study. Prior to total knee arthroplasty, more than one-third of the knees exhibited instability in the coronal plane. Although the instability was corrected in most cases, as in other series¹⁵, there was still a fair number of knees with clinical evidence of instability following arthroplasty. However, only a few of these knees were symptomatic, with one knee requiring revision to a semiconstrained prosthesis. Again, the reason for this finding may be multifactorial. It is plausible that patella baja, periarticular scarring, preoperative malalignment because of undercorrection or overcorrection, proximal tibial bone deficiency, and retained hardware contributed to the technical difficulty of obtaining optimal soft-tissue balancing during total knee arthroplasty in these patients^14,21.

An important finding of the present study was the identification of factors that directly affected the outcome of total knee arthroplasty in these patients. Because of surgical selection, the majority of patients undergoing proximal tibial osteotomy are young, active, and frequently heavy men who are deemed to be too young for total knee arthroplasty. One might therefore argue that, from the start, patients who have had a previous osteotomy are a highly selected population with an unfavorable demographic status. By analyzing the subgroup of patients who underwent bilateral total knee arthroplasty after a previous unilateral proximal tibial osteotomy, we were able to confirm that the above factors did affect the outcome. The rate of revision and the prevalence of radiolucent lines were higher in patients who were young, heavy males with preoperative malalignment. It is possible that failure to match for these differences in age, gender, and weight may account for the disparity in conclusions that has been reported in various other well-conducted studies^7,8,10-12,15.

Despite the increased prevalence of radiolucent lines and the higher rate of revision, the prosthetic survival rate after total knee arthroplasty in patients who have had a previous proximal tibial osteotomy is still very high (Fig. 1). The improved outcome in our series is likely due to refinements in prosthetic design and improvements in surgical technique that occurred during the time of the study. In addition, we excluded prostheses with known poor outcomes, such as older designs with metal-backed patellar components^22,23, all-polyethylene tibial components, uncemented prostheses, and rotating-hinge condylar prostheses.

In conclusion, proximal tibial osteotomy continues to be a very effective and successful treatment for arthritis of the medial compartment of the knee. Although the long-term clinical and radiographic results of primary total knee arthroplasty in knees that have had a previous proximal tibial osteotomy are slightly inferior to the results in knees that have not, factors such as weight, age, gender, and limb malalignment appear to account in part for this difference. Patients who have had a previous tibial osteotomy should be made aware of the influence of these factors on the outcome of total knee arthroplasty. Close radiographic follow-up should be carried out as these patients are at an increased risk for the development of progressive radiolucent lines.

References

Materials and Methods | Results | Discussion | References

Coventry MB. Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am.1985;67: 1136-40.671136 1985 [PubMed]

Coventry MB, Ilstrup DM. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am.1993;75: 196-201.75196 1993 [PubMed]

Healy WL, Riley LH Jr. High tibial valgus osteotomy. A clinical review. Clin Orthop.1986;209: 227-33.209227 1986

Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am.1987;66: 332-54.66332 1987

Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am.1984;66: 1040-8.661040 1984 [PubMed]

Rudan JF, Simurda MA. Valgus high tibial osteotomy: a long-term follow-up study. Clin Orthop.1991;268: 157-60.268157 1991

Ritter MA, Fechtman RA. Proximal tibial osteotomy. A survivorship analysis. J Arthroplasty.1988;3: 309-11.3309 1988 [CrossRef]

Amendola A, Rorabeck CH, Bourne RB, Apyan PM. Total knee arthroplasty following high tibial osteotomy for osteoarthritis. J Arthroplasty.1989;4 Suppl: S11-7.4S11 1989 [PubMed][CrossRef]

Katz M, Hungerford DS, Krackow KA, Lennox DW. Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J Bone Joint Surg Am.1987;69: 225-33.69225 1987 [PubMed]

Meding JB, Keating EM, Ritter MA, Faris PM. Total knee arthroplasty after high tibial osteotomy. A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am.2000;82: 1252-9.821252 2000 [PubMed]

Mont MA, Alexander N, Krackow KA, Hungerford DS. Total knee arthroplasty after failed high tibial osteotomy. Orthop Clin North Am.1994;25: 515-25.25515 1994 [PubMed]

Nizard RS, Cardinne L, Bizot P, Witvoet J. Total knee replacement after failed high tibial osteotomy: results of a matched-pair study. J Arthroplasty.1998;13: 847-53.13847 1998 [PubMed][CrossRef]

Toksvig-Larsen S, Magyar G, Onsten I, Ryd L, Lindstrand A. Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy: a matched radiostereometric study. J Bone Joint Surg Br.1998; 80: 295-7.80295 1998 [PubMed][CrossRef]

Windsor RE, Insall JN, Vince KG. Technical considerations of total knee arthroplasty after proximal tibial osteotomy. J Bone Joint Surg Am.1988; 70: 547-55.70547 1988 [PubMed]

Staeheli JW, Cass JR, Morrey BF. Condylar total knee arthroplasty after failed proximal tibial osteotomy. J Bone Joint Surg Am.1987;69: 28-31.6928 1987 [PubMed]

Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop.1989;248: 9-12.2489 1989 [PubMed]

Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am.1987;69: 745-9.69745 1987 [PubMed]

Insall J, Salvati E. Patellar position in the normal knee joint. Radiology.1971;101: 101-4.101101 1971 [PubMed]

Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop.1989;248: 13-4.24813 1989

Rand JA, Ilstrup DM. Survivorship analysis of total knee arthroplasty. Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am.1991;73: 397-409.73397 1991 [PubMed]

Scuderi GR, Windsor RE, Insall JN. Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am.1989;71: 245-8.71245 1989 [PubMed]

Rand JA. Comparison of metal-backed and all-polyethylene tibial components in cruciate condylar total knee arthroplasty. J Arthroplasty.1993;8: 307-13.8307 1993 [PubMed][CrossRef]

Lombardi AV Jr, Engh GA, Volz RG, Albrigo JL, Brainard BJ. Fracture/dissociation of the polyethylene in metal-backed patellar components in total knee arthroplasty. J Bone Joint Surg Am.1988;70: 675-9.70675 1988

Topics

knee joint ; osteotomy ; prosthesis implantation ; tibia ; knee replacement arthroplasty ; tibia, proximal, osteotomy of

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

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.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

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 â€œTotal 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 â€œTotal Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failureâ€ (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

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Javad Parvizi, Arlen D. Hanssen, Mark J. Spangehl; Total Knee Arthroplasty Following Proximal Tibial Osteotomy: Risk Factors for Failure. The Journal of Bone & Joint Surgery. 2004 Mar;86(3):474-479.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment