Results of high tibial osteotomy in young patients at 30-year follow-up were superior to UKA or TKA

Investigators found acceptable overall results through the 20-year follow-up, but they dropped off in the next decade.

Issue: April 2014

Researchers found patients younger than 50 years old had fewer complications and better survivorship at the 30-year follow-up when they first underwent high tibial osteotomy rather than unicompartmental or total knee arthroplasty as treatment for medial compartment osteoarthritis, based on results of a study scheduled to be presented at the 15th EFORT Congress – a combined program in partnership with the BOA in London.

Perspective from John Nyland, EdD, PT

“The patients who first had high tibial osteotomy were better than those we began with an arthroplasty in the long-term and the reason is when we began with high tibial osteotomy, there was only one revision or no revision,” Philippe Hernigou, MD, professor of orthopaedic surgery at CHU Henri Mondor, in Créteil, France, told Orthopaedics Today Europe. “When we first began with total knee or unicompartmental arthroplasty, there were several revisions,” said Hernigou, who is scheduled to present the study.

In the retrospective study, Hernigou and colleagues compared 218 knees in 116 men and 70 women. Mean age was 42 years when the patients underwent high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) between 1973 and 1982. There was a minimum follow-up of 30 years and maximum follow-up of 40 years. Patients underwent 138 HTOs, 30 UKAs and 50 TKAs in all.

Among the 138 patients who underwent HTO first, eight knees underwent no revisions. Thirty-nine knees underwent a repeat osteotomy, but did not undergo TKA, according to Hernigou.

Philippe Hernigou, MD — Philippe Hernigou

Of the patients who underwent UKA or TKA first, 44 knees required one revision TKA, 28 knees required two revisions and eight knees required three revisions and one amputation. Surgeons performed 204 revision arthroplasties in patients who underwent UKA or TKA first, which were due to loose components (164), deep infection (8), instability (16) and patellar maltracking (14).

When done at 10 years, the survivorship of the first revision was 80% for HTO, 75% for UKA and 77% for TKA, Hernigou said. When the first revision was at 20 years, survivorship was 50% for HTO, 0% for UKA and 35% for TKA. When the first revision was done at 30 years, survivorship was 6% for HTO and 0% for both UKA and TKA.

For the second revision done at 20 years, survivorship was 100% for HTO, 40% for UKA and 65% for TKA, and for a second revision done at 30 years, survivorship was 100% for HTO, 0% for UKA and 35% for TKA.

Concerning repeat revisions, when three revisions were done by the 30-year follow-up, survivorship was 50% for UKA and 70% for TKA, according to study results.

The International Documentation Knee Committee (IKDC) score was higher in patients who had repeat osteotomies or TKA after HTO, but it was lower in patients who had multiply revised arthroplasties. Results showed IKDC scores did not improve in patients with two or more revision arthroplasties. Hernigou noted the study did not account for differences in surgical techniques and arthroplasties used now and those used 30 years ago, which was a limitation of the study.

“Young patients should avoid arthroplasties. After three or four revisions, there is a high risk of complications, for example, infection or amputation,” Hernigou said. – by Renee Blisard Buddle

Reference:
Hernigou P. Paper #14-813. Scheduled to be presented June 6 at: 15th EFORT Congress – a combined program in partnership with the BOA; June 4-6, 2014; London.

For more information:
Philippe Hernigou, MD, can be reached at 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; email: philippe.hernigou@wanadoo.fr.

Disclosure: Hernigou has no relevant financial disclosures.

Perspective

John Nyland, EdD, PT

In this study by one of the world’s leading experts in unicompartmental knee osteoarthritis (OA), we find the comparison of the three surgical methods, high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) for the patient under the age 50 years over a follow-up period of 30 years. The author’s firm recommendation is to start with an osteotomy that will be, if needed, revised into a single TKA with which the patient can function to the end of his days. His conclusion makes sense to the surgeon who believes in a sustainability principle in the way he manages younger patients with OA and it must be a warning to those who believe that a partial or total inner amputation of the knee and the replacement by plastic and metal is the way to go.

At the recent American Academy of Orthopaedic Surgeons Annual Meeting, I (Jakob) participated in a “uni” symposium where a famous “uni” surgeon showed a radiograph of a 28-year-old woman with moderate OA of the lateral compartment cartilage for which he replaced the lateral compartment with a “uni.” Not one member of the panel raised concerns that this was too courageous or even irresponsible as concerns the patient or the health care system.

With our aging population we will have to perform many possible revisions and re-revisions for the most predictable outcomes. On one hand, we want our patients to live to 85-years-old and lead an active life through an advanced age. However, we often recommend inserting artificial parts into the knee joint for moderate OA in patients younger than 60 years and may disregard the possibility of preserving that joint for another 15 years to 20 years with a well-planned, performed osteotomy. High tibial osteotomy will allow patients to retain their range of motion and continue to perform most of their preferred activities. Obviously, the surgery is only as effective as the rehabilitation and the patient’s acceptance of needed behavioral changes, weight loss, etc. To sell any surgery totally for pain relief reasons without instructing patients in the needed behavioral change is short-sighted at best, unethical at worst.

Is it possible that the teaching by the experts in our domain to the pupils has completely deleted osteotomy from among the surgical options? Lastly, if all of this is the consequence, is it justifiable to divide surgeons into arthroplasty surgeons and sports orthopaedic surgeons with osteotomy falling between the two groups? This would disregard the necessity of teaching comprehensive knee surgery, as we have taught our residents, so that the orthopaedic surgeon has the ability and competence to practice as a knee doctor, offering patients the right treatment at the right time from among a spectrum of procedures. These are the questions that go through our minds as we read the “truth” in this study by Hernigou and colleagues yet live with the realities of today where medical business overrides medical care.

Roland P. Jakob, MD
Member of Orthopaedics Today Europe Editorial Board
Hopital Cantonal
Fribourg, Switzerland

John Nyland, EdD, PT

Department of Orthopedic Surgery

University of Louisville

Louisville, USA

Disclosures: Jakob is a consultant for Geistlich Surgical, Switzerland, from which he receives a cartilage repair honorarium. Nyland has no relevant financial disclosures.