Purpose: To clinically evaluate the medium term outcome of a patient cohort age 55 years or older at the time of medial opening wedge high tibial osteotomy (MOWHTO).

Methods: Between January 1997 and January 2003, 60 patients (52 males) underwent 66 MOWHTOs. Following a systematic chart review 56 returned for follow up. Outcomes measures were KOOS, LEFS, SF-12, Cincinnati, Tegner scores, a new activity score and physical examination. Routine knee and long leg standing radiographs were compared to pre and early postoperative radiographs.

Results: Thirteen patients were not assessed further, 6 (7 MOWHTOs) had undergone total knee arthroplasty (TKA), 3 had passed away and 4 were lost to follow up. Thus the probability of survival (not converting MOWHTO to TKA) was 0.966 at 3 years, 0.927 at 4 years and 0.878 at 5 years. Quality of life, functional status and general health of the remaining 47 patients (52 HTOs) with a mean age of 62 years (55–75) at the time of surgery were assessed. At a mean follow up of 62 months (26–98), on the author’s activity score, 83% performed at least one high impact activity at moderate to high intensity an average of 4–7 times per week and 6% did not participate in any sport. Average participation in activities/sports was 3 per person at a participation level of 4.6 (Tegner). The mean Cincinnati score was 75% (SD=23, 14–95%). Mean scores for the KOOS and LEFS were 66% (SD=22, 7–99%) and 49 (SD=18, 5–80) respectively. Seventy–two percent were fully weight bearing by 3 months. There were 6 revisions for a combination of delayed and non-unions.

Conclusions: MOWHTO remains a viable alternative for patients over the age of 55 with knee osteoarthritis and varus malalignment who would otherwise be candidates for arthroplasty and particularly for those wishing to maintain or regain a high level of activity.

There are many procedures described to address recurrent patellar instability. This study evaluated the clinical and radiological outcome of a cohort of patients who had been treated using an algorithm based on plain radiography and CT findings to select the appropriate surgical procedure.

64 knees in 49 consecutive skeletally mature patients were treated by one surgeon over 4.8 years. They underwent either tibial tuberosity transfer and lateral release (TTT/LR) or lateral release alone (LR) based on their patellar height and tibial tuberosity trochlear groove (TTTG) distance. Of the knees that were reviewed, 33 underwent TTT/LR and 13 LR. 46 knees in 35 patients were evaluated clinically (42 in 32) or by phone (4 in 3) at a minimum of 1 year. Evaluation included the Kujala and IKDC (subjective and objective) scores and 31 knees underwent repeat radiological examination.

There had been one or more further episodes of instability in 6/46 knees (13%). Only one knee had more than one further episode of instability. The rate of further instability was 8% in the LR group and 15% in the TTT/LR group. The mean overall subjective IKDC score was 80 (LR: 85, TTT/LR: 79). The mean overall objective IKDC scores were 79% A and 21% B (LR: 67% A, 33% B; TTT/LR: 83% A, 17% B). The mean overall Kujala score was 88 (LR:86, TTT/LR: 88). Three patients developed a clinically significant haemarthrosis (LR: 2, TTT/LR: 1), one of whom required an arthroscopic washout. The mean postoperative TTTG distance in the TTT/LR group was 8.5mm compared to the mean preoperative value of 16.2mm (p < 0001). However, there was also a mean reduction in the TTTG distance in the non operated knees of 2.6mm, suggesting a clinically relevant measurement error for this variable.

The algorithm resulted in satisfactory outcomes for most patients. However, changes have subsequently been made in an attempt to further improve outcomes. These include using medial patellar glide to assess the requirement for a lateral release, measuring the TTTG distance with the knee extended, lowering the threshold for distal TTT, raising the threshold for medial TTT, and adding medial patellofemoral ligament reconstruction to the surgical options.

Purpose: To clinically and radiologically evaluate medium term outcome of a patient cohort age 55 years or older at the time of medial opening wedge high tibial osteotomy (MOWHTO).

Methods: Between January 1997 and January 2003, 60 patients (52 males) underwent 66 MOWHTOs. Following a systematic chart review 56 returned for follow up. Outcomes measures were KOOS, LEFS, SF-12, Cincinnati, Tegner scores, a new activity score and physical examination. Routine knee and long leg standing radiographs were compared to pre and early postoperative radiographs.

Results: Thirteen patients were not assessed further, 6 (7 MOWHTOs) had undergone total knee arthroplasty (TKA), 3 had passed away and 4 were lost to follow up. Thus the probability of survival (not converting MOWHTO to TKA) was 0.966 at 3 years, 0.927 at 4 years and 0.878 at 5 years. Quality of life, functional status and general health of the remaining 47 patients (52 HTOs) with a mean age of 62 years (55–75) at the time of surgery were assessed. At a mean follow up of 62 months (26–98), on the author’s activity score, 83% performed at least one high impact activity at moderate to high intensity an average of 4–7 times weekly and 6% did not participate in any sport. Average participation in activities/sports was 3 per person at a participation level of 4.6 (Tegner). The mean Cincinnati score was 75% (SD=23, 14–95%). Mean scores for the KOOS and LEFS were 66% (SD=22,7–99%) and 49 (SD=18, 5–80) respectively. The mean physical component score of the SF-12 was 42 (SD=11, 21.7–60.4) and the mean mental component score, 54 (SD=11, 26–68). Seventy–two percent were fully weight bearing by 3 months. There were 6 revisions performed for a combination of delayed and non-unions.

Conclusions: MOWHTO remains a viable alternative for patients over the age of 55 with knee osteoarthritis and varus malalignment who would otherwise be candidates for arthroplasty and particularly for those wishing to maintain or regain a high level of activity.

Purpose: To compare lateral closing to medial opening wedge HTO for a similar angle of correction with regard to change in proximal tibial bony anatomy and posterior cruciate ligament tibial attachment integrity following standard tibial arthroplasty resection.

Methods: Ten cadaveric lower limbs were randomized by side to receive a 12° lateral closing or 12.5mm medial opening wedge HTO. Anteroposterior, lateral and long leg AP radiographs were performed before and after each osteotomy. Pre and post osteotomy measurements of the coronal proximal tibial angle (PTA), sagittal tibial slope and anatomical femorotibial angle were completed and change in angles calculated. Prior to osteotomy, the tibial PCL attachment area was calculated. Post osteotomy, a standardized tibial arthroplasty resection was performed and the remaining percentage PCL attachment area recorded.

Results: Initial radiographs demonstrated little variation between matched pairs. Compared to the medial opening wedge group, the lateral closing wedge specimens demonstrated a statistically significant greater mean change in the PTA of 3.5° (95% C.I., 2.0 to 5.1°, p = 0.003) and an overall tendency for posterior tibial slope reduction with a mean change of −3.4 ± 4.9°. The average osteotomy angle in the medial opening wedge specimens was 11.9 ± 0.7°. Following tibial arthroplasty resection, there was a significant difference in the remaining PCL tibial attachment percentage area of 84.6 ±14.9 % for medial opening wedge and 50.8 ± 19.3 % for lateral closing wedge for a statistically significant mean difference of 33.8 % (95% C.I. 5.1 to 62.4, p = 0.031).

Conclusions: Despite similar correction angles of 12° for lateral closing and 11.9° for medial opening, the former specimens demonstrated a greater alteration in proximal tibial bony anatomy compared to the latter. In the lateral closing wedge group, the tendency to reduce posterior tibial slope and produce a greater than anticipated change in PTA had a significant effect on the integrity of the PCL’s tibial attachment following tibial arthroplasty resection.