Double level osteotomy for genu varum: Is a return to sport possible?

INTRODUCTION: A double level osteotomy (DLO) may be indicated in patients with genu varum when the deformity involves both the tibia and femur. These patients, who are often young and active, have a high functional demand and hope for a rapid return to sport. The purpose of our study was to assess return to sport and functional outcomes following DLO for symptomatic genu varum. MATERIALS AND METHODS: A total of 40 patients (mean age 45.5±2 years) who underwent a DLO between 2018 and 2020, performed in 2 different hospitals, were reviewed after a minimum follow-up of 1-year. The mean initial varus was 11±2°. The type of sport and frequency of participation (UCLA activity score) as well as time to return to sport and level of activity recovered were defined as the primary endpoints. Functional scores were also assessed with the knee injury and osteoarthritis outcome score (KOOS). RESULTS: At the last follow-up, 87.5% (n=35) of patients reported that they had returned to sport. The mean time to return to sport was 6±1 months with a significant difference (p<0.001) between the pre- and postoperative UCLA activity scores. There was a strong correlation between the presence of a joint line obliquity >3° and decreased functional outcomes (p<0.0001). The overall KOOS score improved (p<0.001) by a mean of 38.6 points after the correction. The 8 lateral cortical fractures (Takeuchi type I and II) and the 2 medial cortical fractures (Nakayama type 1) that were found had no impact on functional outcomes (p>0.05). CONCLUSION: Our findings demonstrated that DLO provided rapid return to sport, thus making it possible to meet the functional demands and expectations of patients. LEVEL OF EVIDENCE: IV; Retrospective study.

Patellar height is not modified after isolated open-wedge high tibial osteotomy without change in posterior tibial slope.

INTRODUCTION: Open-wedge high tibial osteotomy (OWHTO) corrects coronal deformity and can impact sagittal parameters such as posterior tibial slope and patellar height. The aim of the present study was to analyze change in patellar height after medial OWHTO with respect to tibial and femoral-referenced indices. MATERIAL AND METHOD: This single-center retrospective study included 129 patients undergoing isolated posteromedial OWHTO, without change in tibial slope, using patient-specific cutting-guides. Patellar height was assessed on Caton-Deschamps (CD), Insall-Salvati (IS) and Schröter indices. Posterior tibial slope and coronal femoral and tibial angles were also measured. X-rays were taken preoperatively and at 12 months, and analyzed by 2 independent observers. RESULTS: OWHTO modified the global lower-limb alignment (Δ=6.3±0.95̊, p<0.0001) and the proximal tibial deformity (Δ=7±0.88̊, p<0.0001). Posterior tibial slope and tibial (CD and IS) and femoral (Schröter) patellar height indices were unchanged. Intra- and inter-observer reproducibility was excellent (ICC 0.79-0.91). There were no correlations between HKA or MPTA angles and change in patellar height. CONCLUSION: The present clinical series showed that patellar height was unchanged by isolated posteromedial OWHTO without change in tibial slope, using patient-specific cutting-guides, with whichever femoral or tibial reference index. The Schröter patellar femoral height index was highly reliable and is independent of proximal tibial changes in assessing patellar height, and can thus be recommended in the follow-up of OWHTO. LEVEL OF EVIDENCE: III; retrospective cohort study.

Lateral femoral closing wedge osteotomy in genu varum.

The distal femoral valgisation osteotomy has a variety of indications due to enhanced understanding of segmental deformities of the lower limb. Historically, an overall varus deformity was corrected at the tibia, and a valgus deformity at the femur. This approach of performing an "all in the tibia" correction for an overall varus can nevertheless lead to abnormal postoperative morphology because it is non-anatomical; creating joint line obliquity, and potentially shear stress on the cartilage. An original lateral femoral closing wedge osteotomy technique is described, allowing the correction of a genu varum of femoral or mixed origin, in the event of an associated tibial valgisation osteotomy. The detailed technique minimizes the risk of a hinge fracture while improving post-operative outcomes.