Review Question - QID 219925

The patient is a young, high-impact athletic coach with varus knee arthritis who would be best served by a medial opening wedge high tibial osteotomy (HTO), given his age, symptoms, and degree of deformity.

High tibial osteotomy (HTO) is a powerful treatment option for varus deformity with medial compartment osteoarthritis in young patients in whom the longevity of a joint replacement procedure would be of concern. Medial unicompartmental knee arthroplasty is equally effective in terms of restoring patients’ activity levels, but high tibial osteotomy allows a faster return to sporting and impact work. In terms of patient selection for HTO, contraindications include obesity (BMI over 35), flexion contracture > 15°, total knee flexion less than 90°, required deformity correction of over 20°, concomitant patellofemoral arthritis, and ligamentous instability with evidence of varus thrust during gait.

Murray et al. review high tibial osteotomy (HTO) for the treatment of varus deformity of the knee. The authors note that indications include varus deformity with medial compartment osteoarthritis, cartilage, or meniscus pathology, and that HTO is a powerful technique to treat symptomatic varus deformity of the knee and is successful when properly indicated and performed. They conclude that evidence supporting high tibial osteotomy for symptomatic medial compartment pathology exists, which provides a durable solution for joint preservation.

Belsey et al. published a systematic review and pooling data analysis of return to physical activity after high tibial osteotomy (HTO) versus unicompartmental knee arthroplasty (UKA). The authors included 13 eligible studies consisting of 401 knees that received HTO (399 patients) and 1622 that received UKA (1400 patients). They found that the HTO group reported higher activity levels pre- and post-operatively than the UKA group, who exhibited greater overall pre- to postoperative physical activity improvement according to the Tegner scores. They concluded that activity after HTO may be influenced by intraoperative factors such as the implant used and the decision to include graft material in the osteotomy gap, although this requires further research.

Jacquet et al. performed a retrospective review comparing opening wedge high tibial osteotomy to unicompartmental knee arthroplasty regarding outcomes in patients expecting to return to impact sports. The authors identified 91 patients who underwent open-wedge HTO and 117 patients who underwent UKA. They found the mean time to return to sport activities or previous professional activities was significantly lower for the HTO group than for the UKA group [respectively, 4.9 ± 2.2 months for the HTO group vs 5.8 ± 6.2 months for the UKA group], leading them to conclude that HTO offers a statistically significant quicker return to sports activities with a higher rate of patients able to practice impact activity (62% for HTO vs 28% for UKA) and better sports-related functional scores at two years after surgery compared to UKA.

Figure A is a weight-bearing AP radiograph of the knee showing varus-pattern osteoarthritis. Figure B is a graphic representing five different potential treatment methods for knee osteoarthritis: Treatment 1- Total knee arthroplasty, Treatment 2 - Medial opening wedge HTO, Treatment 3 - Medial unicompartmental knee arthroplasty, Treatment 4 - bone marrow aspirate concentrate (BMAC) harvest, Treatment 5 - Varus-producing, distal femoral osteotomy (DFO).

Incorrect Answers:
Answer 1: Despite significant advances in wear properties of total knee arthroplasty, the patient would be unlikely to return to his current level of sporting activity after a total knee replacement at his young age.
Answer 3: As mentioned above, though medial unicompartmental knee arthroplasty is equally effective in terms of restoring activity levels, high tibial osteotomy allows a faster return to sporting and impact work.
Answer 4: Though PRP may be effective in mild-to-moderate osteoarthritis for pain relief, harvesting BMAC alone, in this case, would not correct the patient's deformity. However, combining this procedure with an HTO may improve healing rates for opening wedge techniques.
Answer 5: A varus-producing DFO would exacerbate this patient's pattern of arthritis.