Osteotomy for treating knee osteoarthritis

Reinoud W Brouwer, Maarten R Huizinga, Tijs Duivenvoorden, Tom M van Raaij, Arianne P Verhagen, Sita M A Bierma-Zeinstra, Jan A N Verhaar, Reinoud W Brouwer, Maarten R Huizinga, Tijs Duivenvoorden, Tom M van Raaij, Arianne P Verhagen, Sita M A Bierma-Zeinstra, Jan A N Verhaar

Abstract

Background: Patients with unicompartmental osteoarthritis of the knee can be treated with an osteotomy. The goal of an osteotomy is to unload the diseased compartment of the knee. This is the second update of the original review published in The Cochrane Library, Issue 1, 2005.

Objectives: To assess the benefits and harms of an osteotomy for treating patients with knee osteoarthritis, including the following main outcomes scores: treatment failure, pain and function scores, health-related quality of life, serious adverse events, mortality and reoperation rate.

Search methods: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE (Current Contents, HealthSTAR) were searched until November 2013 for this second update.

Selection criteria: Randomised and controlled clinical trials comparing an osteotomy with other treatments for patients with unicompartmental osteoarthritis of the knee.

Data collection and analysis: Two review authors independently selected trials, extracted data and assessed risk of bias using the domains recommended in the 'Risk of bias' tool of The Cochrane Collaboration. The quality of the results was analysed by performing overall grading of evidence by outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

Main results: Eight new studies were included in this update, for a total of 21 included studies involving 1065 people.In four studies, the randomised sequence was adequately generated and clearly described. In eight studies, allocation concealment was adequately generated and described. In four studies, the blinding procedures were sufficient. In six studies, incomplete outcome data were not adequately addressed. Furthermore, in 11 studies, the selective outcome reporting item was unclear because no study protocol was provided.Follow-up of studies comparing different osteotomy techniques was too short to measure treatment failure, which implicates revision to a knee arthroplasty.Four studies evaluated a closing wedge high tibial osteotomy (CW-HTO) with another high tibial osteotomy (aHTO). Based on these studies, the CW-HTO group had 1.8% (95% confidence interval (CI) -7.7% to 4.2%; low-quality evidence) more pain compared with the aHTO group; this finding was not statistically significant. Pooled function in the CW-HTO group was 0.5% (95% CI -3.8% to 2.8%; low-quality evidence) higher compared with the aHTO group; this finding was not statistically significant. No data on health-related quality of life and mortality were presented.Serious adverse events were reported in only four studies and were not significantly different (low-quality evidence) between groups. The reoperation rate were scored as early hardware removal because of pain and pin track infection due to the external fixator. Risk of reoperation was 2.6 (95% CI 1.5 to 4.5; low-quality evidence) times higher in the aHTO group compared with the CW-HTO group, and this finding was statistically significant.The quality of evidence for most outcomes comparing different osteotomy techniques was downgraded to low because of the numbers of available studies, the numbers of participants and limitations in design.Two studies compared high tibial osteotomy versus unicompartmental knee replacement. Treatment failure and pain and function scores were not different between groups after a mean follow-up of 7.5 years. The osteotomy group reported more adverse events when compared with the unicompartmental knee replacement group, but the difference was not statistically significant. No data on health-related quality of life and mortality were presented.No study compared an osteotomy versus conservative treatment.Ten included studies compared differences in perioperative or postoperative conditions after high tibial osteotomy. In most of these studies, no statistically significant differences in outcomes were noted between groups.

Authors' conclusions: The conclusion of this update did not change: Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee. However, this conclusion is based on within-group comparisons, not on non-operative controls. No evidence suggests differences between different osteotomy techniques. No evidence shows whether an osteotomy is more effective than alternative surgical treatment such as unicompartmental knee replacement or non-operative treatment. So far, the results of this updated review do not justify a conclusion on benefit of specific high tibial osteotomy technique for knee osteoarthritis.

Conflict of interest statement

Potential conflict of interest must be reported because two included studies were conducted by the author of the systematic review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1. Analysis
1.1. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 1 Pain.
1.2. Analysis
1.2. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 2 Stiffness.
1.3. Analysis
1.3. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 3 Function.
1.4. Analysis
1.4. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 4 Walking distance (km).
1.5. Analysis
1.5. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 5 Valgus angle.
1.6. Analysis
1.6. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 6 Participant satisfaction.
1.7. Analysis
1.7. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 7 Willingness to undergo surgery again.
1.8. Analysis
1.8. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 8 Serious adverse events.
1.9. Analysis
1.9. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 9 Reoperation rate.
1.10. Analysis
1.10. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 10 Patellar height (Insall‐Salvati ratio).
1.11. Analysis
1.11. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 11 Inclination of the tibial plateau (degrees).
1.12. Analysis
1.12. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 12 Medial laxity.
1.13. Analysis
1.13. Analysis
Comparison 1 Other type of HTO (aHTO) versus closing wedge high tibial osteotomy (CW‐HTO), Outcome 13 Lateral laxity.
2.1. Analysis
2.1. Analysis
Comparison 2 Closing wedge high tibial osteotomy (HTO) versus UKA, Outcome 1 Survival (revision).
2.2. Analysis
2.2. Analysis
Comparison 2 Closing wedge high tibial osteotomy (HTO) versus UKA, Outcome 2 Adverse events.
2.3. Analysis
2.3. Analysis
Comparison 2 Closing wedge high tibial osteotomy (HTO) versus UKA, Outcome 3 Participant opinion: improvement at 5 years.
2.4. Analysis
2.4. Analysis
Comparison 2 Closing wedge high tibial osteotomy (HTO) versus UKA, Outcome 4 Gait analysis: free walking speed at 5 years.
2.5. Analysis
2.5. Analysis
Comparison 2 Closing wedge high tibial osteotomy (HTO) versus UKA, Outcome 5 Gait analysis: step frequency at 5 years.
3.1. Analysis
3.1. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 1 JOA score.
3.2. Analysis
3.2. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 2 Valgus angle (FTA).
3.3. Analysis
3.3. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 3 Complication (phlebography).
3.4. Analysis
3.4. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 4 Time (weeks) to bony union.
3.5. Analysis
3.5. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 5 KSS (American).
3.6. Analysis
3.6. Analysis
Comparison 3 Differences in perioperative conditions, Outcome 6 Cincinnati Rating System Questionnaire.
4.1. Analysis
4.1. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 1 Less than 50% consolidation.
4.2. Analysis
4.2. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 2 More than 50% consolidation.
4.3. Analysis
4.3. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 3 Complications.
4.4. Analysis
4.4. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 4 Range of motion.
4.5. Analysis
4.5. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 5 Pain‐free walking distance.
4.6. Analysis
4.6. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 6 Pain at rest.
4.7. Analysis
4.7. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 7 Degree of osteoarthritis.
4.8. Analysis
4.8. Analysis
Comparison 4 Differences in postoperative treatment, Outcome 8 Valgus angle (HKA angle).

References

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Iori 2011 {published data only}
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Magyar 1999b {published data only}
    1. Magyar G, Toksvig‐Larsen S, Lindstrand A. Changes in osseous correction after proximal tibial osteotomy. Radiosterometry of closed and open osteotomy in 33 patients. Acta Orthopaedica Scandinavica 1999;70(5):473‐7.
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Toksvig‐Larsen 2013 {published data only}
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References to studies excluded from this review Bae 2009 {published data only}
    1. Bae DK, Song SJ, Yoon KH. Closed‐wedge high tibial osteotomy using computer‐assisted surgery compared to the conventional technique. Journal of Bone and Joint Surgery [British] 2009;91(9):1164‐74.
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Cho 2013 {published data only}
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Gouin 2010 {published data only}
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Maffulli 2013 {published data only}
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Pape 2013 {published data only}
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