Abstract: Lateral compartment osteoarthritis of the knee can be a challenging problem to ... for surgeons on the appropriate surgical approach; however, opening wedge osteotomies ... tibial osteotomies in patients with valgus deformity.4,16.
Editorial Commentary: Limited Data Shows How Little We Know
Abstract: Lateral compartment osteoarthritis of the knee can be a challenging problem to address in the younger, active population. The challenge is compounded by limited treatment options and high patient expectations, with patients often desiring a return to impact high intensity activity. Distal femoral osteotomy has been reported to be one potential treatment option; however, a highly heterogeneous literature exists for both opening and closing wedge distal femoral osteotomies for the treatment of isolated lateral compartment osteoarthritis with valgus malalignment. The literature does not provide significant direction for surgeons on the appropriate surgical approach; however, opening wedge osteotomies allow for fine adjustment and maintain leg length and joint alignment, and are our preferred approach.
See related article on page 2141 he article by Wylie et al.1 seeks to determine the outcomes of medial closing wedge or lateral opening wedge distal femoral osteotomies for correction of valgus deformities of the knee in patients with isolated lateral compartment chondral lesions or osteoarthritis. The authors tackle a topic that remains nebulous to many orthopaedic surgeons: the management of the young patient with isolated unicompartmental osteoarthritis.2-5 Treatment in this young and active patient population can present unique challenges, and appropriate patient counseling on expected outcomes can be difficult given the paucity of literature on the subject. To this end, the authors performed a systematic review of the available literature to evaluate differences in radiographic correction, healing rate, patient-reported outcomes, reoperation rate, and complications of medial and lateral osteotomies about the distal femur. A total of 16 studies were included in this systematic review. The methods of the study were accurate, and it was well executed. Despite appropriate methodology, the heterogeneity of the outcome measures and the nature of the literature being examined (levels of evidence I through IV were included given scarce data) makes the comparison between the cohorts challenging. Moreover, medial closing wedge distal femoral osteotomies were performed before lateral opening osteotomies, and therefore the follow-up for the former can be
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drawn from a longer track record, and is available up to 20 years after the index procedure. However, failure rates between the 2 cohorts were comparable when examined at the same time point (between 6- and 8year follow-up) within separate studies. Overall, both groups demonstrated a relatively low complication rate (10%), with hardware-related issues being the most prevalent. The rate of hardware removal is similar to other procedures,6-11 such as anterior cruciate ligament (ACL) reconstructions, where screws or staple prongs are commonly proud or unicortical due to the nature of this type of hardware.12-14 Hardware function (such as in ACL graft tunnel mismatch) must be considered, because repositioning of the hardware placed around an already well-secured surgical site or ACL graft could lead to significant graft damage. In reality, we all need to expect that some patients will require deep hardware removal because of the bulky fixation plates used, and this should not be considered a true “complication.” In fact, this type of hardware is what is needed to achieve the best healing outcomes for distal femoral osteotomy procedures. In the conclusions of the article, the authors state that “no evidence exists proving better results of either the lateral opening wedge or medial closing wedge techniques.” This is consistent with a recent similar systematic review evaluating the same topic,15 and demonstrates the inherent difficulty in performing systematic reviews revolving around challenging topics that have limited data surrounding their outcomes. Caution must also be advised because, although a distal femoral osteotomy was historically performed primarily for lateral compartment arthritis, more recently it has
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 32, No 10 (October), 2016: pp 2148-2150
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EDITORIAL COMMENTARY
been used for concurrent articular cartilage or meniscal transplant procedures, or for chronic medial knee injuries with valgus malalignment, so comparisons with older studies may not be appropriate. With a highly heterogeneous patient population and body of evidence to examine, the author and reader must come to the conclusion that, in fact, limited conclusions can be drawn. Although this scenario may create more questions than provide answers, we believe that systematic reviews of this type are very useful because they place the available data in one location, unveil the missing information, and often clarify the results by pooling and expanding upon the number of patients scrutinized. Despite the difficulty in analyzing the data, alignment deformities in the lower extremity affect joint loading and can be a significant cause of morbidity. In cases of valgus deformity greater than 12 , using the distal femur as the site of osteotomy is advantageous because correction through the proximal tibia can limit or prevent appropriate correction of the joint line and can result in lateral subluxation of the tibia, and previous studies have demonstrated poor results of proximal tibial osteotomies in patients with valgus deformity.4,16 Our current treatment algorithm for such patients is to correct the deformity with a distal femoral varus producing opening wedge osteotomy. This procedure is advantageous because it allows for accurate correction of the joint alignment, and is versatile for use in associated cartilage procedures or medial ligamentous deficiency17,18 and preservation of the bone stock. However, one must recognize that the tibial sagittal plane slope cannot be adjusted with a distal femoral osteotomy (DFO) and an anterolateral opening wedge osteotomy must be considered for those rare cases in which both valgus alignment and sagittal plane tibial slope increases may be required.19,20 Fixation of the osteotomy is typically performed with a plate and screw construct and the void filled with either an allograft or autograft. Our preference is to use a malleable cancellous allograft to fill the defect created by the DFO, because this limits morbidity associated with autograft harvest and improves surgical efficiency. As has previously been discussed in this journal, systematic reviews such as this are important to keep surgeons and readers up to date,21 and to help provide answers to questions that are not widely prevalent in the literaturedsuch as treatment of unicompartmental osteoarthritis or valgus deformity of the knee. Despite this, there are inherent limitations in systematic reviews, even when performed with appropriate methodology and statistical scrutiny.22 The presented article highlights some of these challenges; however, it also provides useful information that may otherwise not be readily available with a brief literature review. Although limited “answers” may be found when systematic reviews are completed, the promotion of
further research and query into difficult areas is likely worth the effort. Justin J. Mitchell, M.D. Jorge Chahla, M.D. Robert F. LaPrade, M.D., Ph.D. Vail, Colorado
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symptomatic hardware or repeat rupture: a histologic study in 12 patients. Arthroscopy 2003;19:948-954. Chahla J, Mitchell JJ, Liechti DJ, et al. Opening- and closing-wedge distal femoral osteotomy: A systematic review of outcomes for isolated lateral compartment osteoarthritis. Orthop J Sports Med 2016;4:e1-e8. Hanssen AD, Stuart MJ, Scott RD, Scuderi GR. Surgical options for the middle-aged patient with osteoarthritis of the knee joint. Instr Course Lect 2001;50:499-511. Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 2010;92:1266-1280. Paley D, Bhatnagar J, Herzenberg JE, Bhave A. New procedures for tightening knee collateral ligaments in
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conjunction with knee realignment osteotomy. Orthop Clin North Am 1994;25:533-555. Dean CS, Chahla J, Moulton SG, Nitri M, Serra Cruz R, LaPrade RF. Anterolateral biplanar proximal tibial opening-wedge osteotomy. Arthrosc Tech 2016;5:531-540. Gaskill TR, Pierce CM, James EW, LaPrade RF. Anterolateral proximal tibial opening wedge osteotomy to treat symptomatic genu recurvatum with valgus alignment. JBJS Case Connect 2014;4:e71. Lubowitz JH, Brand JC, Provencher MT, Rossi MJ. Systematic reviews keep arthroscopy up to date. Arthroscopy 2016;32:237. Provencher MT, Brand JC, Rossi MJ, Lubowitz JH. Are orthopaedic systematic reviews overly prevalent? Arthroscopy 2016;32:955-956.
