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Effect of high tibial osteotomy on joint loading in symptomatic patients with varus aligned knees: a study using SPECT/CT

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose was to prospectively evaluate the outcome, in particular the SPECT/CT bone tracer uptake (BTU) after high tibial osteotomy (HTO) due to symptomatic varus malalignment. It was the hypothesis that the BTU after HTO decreases in the medial compartment, clinical outcome and the degree of correction correlates with BTU and asymptomatic patients after HTO reveals a significantly decreased BTU in the medial subchondral areas.

Methods

Twenty-two consecutive patients with 23 knees undergoing medial opening-wedge HTO for medial compartment overloading were assessed pre- and postoperatively (12 and/or 24 months) using Tc-99m-HDP-SPECT/CT including our 4D-SPECT/CT protocol. BTU was quantified and localized to specific biomechanically relevant joint areas. Maximum absolute and relative values (mean ± standard deviation, median and range) for each area were recorded. Pre- and postoperative mechanical alignment was measured. At 24 months after HTO, the WOMAC score was used.

Results

A significant decrease of BTU in the medial subchondral zones after HTO was found (preoperatively to 12 and 24 months postoperatively, p < 0.01). BTU normalized in all asymptomatic patients within 24 months. This decrease was partly seen in the lateral compartments, but significantly higher in the medial compartments (p < 0.0001). A significant increase of the BTU was noted in zones directly adjacent to the plate or within the osteotomy zone (p < 0.01). Decreased BTU was observed in osteotomy zones at 24 months postoperatively following higher uptake values at 12 months postoperatively. The average valgus correction of the tibiofemoral angle was 5.9° ± 2.8°. Less stiffness correlated significantly with a higher decrease in BTU (p < 0.05). Higher postoperative BTU significantly correlated with more pain (p < 0.05). No statistical significant associations between BTU and alignment correction were found.

Conclusion

In patients with medial compartment, overloading due to varus malalignment HTO led to a significant decrease in BTU in the medial joint compartments. SPECT/CT BTU patterns and intensity in these patients pre- to 12 and 24 months postoperatively were seen. These correlated significantly with pain and stiffness. Hence, SPECT/CT could be used for assessment of adequate correction and healing after HTO. SPECT/CT could be further used to identify the optimal individualized correction for each patient and clinical scenario.

Clinical evidence

Diagnostic prospective study, Level II.

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References

  1. Amis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21:197–205

    Article  PubMed  Google Scholar 

  2. Arnold MP, Hirschmann MT, Verdonk PC (2012) See the whole picture: knee preserving therapy needs more than surface repair. Knee Surg Sports Traumatol Arthrosc 20:195–196

    Article  PubMed  Google Scholar 

  3. Briem K, Ramsey DK, Newcomb W, Rudolph KS, Snyder-Mackler L (2007) Effects of the amount of valgus correction for medial compartment knee osteoarthritis on clinical outcome, knee kinetics and muscle co-contraction after opening wedge high tibial osteotomy. J Orthop Res 25:311–318

    Article  PubMed Central  PubMed  Google Scholar 

  4. Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, Pols HA, Bierma-Zeinstra SM (2007) Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum 56:1204–1211

    Article  CAS  PubMed  Google Scholar 

  5. Coventry MB (1965) Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report. J Bone Joint Surg Am 47:984–990

    CAS  PubMed  Google Scholar 

  6. Crema MD, Roemer FW, Felson DT, Englund M, Wang K, Jarraya M, Nevitt MC, Marra MD, Torner JC, Lewis CE, Guermazi A (2012) Factors associated with meniscal extrusion in knees with or at risk for osteoarthritis: the Multicenter Osteoarthritis study. Radiology 264:494–503

    Article  PubMed Central  PubMed  Google Scholar 

  7. Derfus BA, Kurian JB, Butler JJ, Daft LJ, Carrera GF, Ryan LM, Rosenthal AK (2002) The high prevalence of pathologic calcium crystals in pre-operative knees. J Rheumatol 29:570–574

    PubMed  Google Scholar 

  8. Dugdale TW, Noyes FR, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264

    PubMed  Google Scholar 

  9. Eckstein F, Hudelmaier M, Cahue S, Marshall M, Sharma L (2009) Medial-to-lateral ratio of tibiofemoral subchondral bone area is adapted to alignment and mechanical load. Calcif Tissue Int 84:186–194

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Fuerst M, Lammers L, Schafer F, Niggemeyer O, Steinhagen J, Lohmann CH, Ruther W (2010) Investigation of calcium crystals in OA knees. Rheumatol Int 30:623–631

    Article  CAS  PubMed  Google Scholar 

  11. Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987) Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69:332–354

    CAS  PubMed  Google Scholar 

  12. Hirschmann MT, Adler T, Rasch H, Hugli RW, Friederich NF, Arnold MP (2010) Painful knee joint after ACL reconstruction using biodegradable interference screws-SPECT/CT a valuable diagnostic tool? A case report. Sports Med Arthrosc Rehabil Ther Technol 2:24

    Article  PubMed Central  PubMed  Google Scholar 

  13. Hirschmann MT, Davda K, Rasch H, Arnold MP, Friederich NF (2011) Clinical value of combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) in sports medicine. Sports Med Arthrosc 19:174–181

    Article  PubMed  Google Scholar 

  14. Hirschmann MT, Schmid R, Dhawan R, Skarvan J, Rasch H, Friederich NF, Emery R (2011) Combined single photon emission computerized tomography and conventional computerized tomography: clinical value for the shoulder surgeons? Int J Shoulder Surg 5:72–76

    Article  PubMed Central  PubMed  Google Scholar 

  15. Hirschmann MT, Schon S, Afifi FK, Amsler F, Rasch H, Friederich NF, Arnold MP (2013) Assessment of loading history of compartments in the knee using bone SPECT/CT: a study combining alignment and 99mTc-HDP tracer uptake/distribution patterns. J Orthop Res 31:268–274

    Article  CAS  PubMed  Google Scholar 

  16. Hirschmann MT, Wagner CR, Rasch H, Henckel J (2012) Standardized volumetric 3D-analysis of SPECT/CT imaging in orthopaedics: overcoming the limitations of qualitative 2D analysis. BMC Med Imaging 12:5

    Article  PubMed Central  PubMed  Google Scholar 

  17. Jackson JP, Waugh W (1961) Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br 43:746–751

    PubMed  Google Scholar 

  18. Johnson F, Leitl S, Waugh W (1980) The distribution of load across the knee. A comparison of static and dynamic measurements. J Bone Joint Surg Br 62:346–349

    CAS  PubMed  Google Scholar 

  19. Kolb W, Guhlmann H, Windisch C, Kolb K, Koller H, Grutzner P (2009) Opening-wedge high tibial osteotomy with a locked low-profile plate. J Bone Joint Surg Am 91:2581–2588

    Article  PubMed  Google Scholar 

  20. Konala P, Iranpour F, Kerner A, Rasch H, Friederich NF, Hirschmann MT (2010) Clinical benefit of SPECT/CT for follow-up of surgical treatment of osteochondritis dissecans. Ann Nucl Med 24:621–624

    Article  PubMed  Google Scholar 

  21. Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132–138

    PubMed  Google Scholar 

  22. Lustig S, Scholes CJ, Costa AJ, Coolican MJ, Parker DA (2013) Different changes in slope between the medial and lateral tibial plateau after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21:32–38

    Article  CAS  PubMed  Google Scholar 

  23. Marti CB, Gautier E, Wachtl SW, Jakob RP (2004) Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 20:366–372

    Article  PubMed  Google Scholar 

  24. McNamara I, Birmingham TB, Fowler PJ, Giffin JR (2013) High tibial osteotomy: evolution of research and clinical applications-a Canadian experience. Knee Surg Sports Traumatol Arthrosc 21:23–31

    Article  CAS  PubMed  Google Scholar 

  25. Mucha A, Dordevic M, Testa EA, Rasch H, Hirschmann MT (2013) Assessment of the loading history of patients after high tibial osteotomy using SPECT/CT—a new diagnostic tool and algorithm. J Orthop Surg Res 8:46

    Article  PubMed Central  PubMed  Google Scholar 

  26. Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, Helwig P, Suedkamp NP (2008) Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy 24:796–804

    Article  PubMed  Google Scholar 

  27. Niemeyer P, Schmal H, Hauschild O, von Heyden J, Sudkamp NP, Kostler W (2010) Open-wedge osteotomy using an internal plate fixator in patients with medial-compartment gonarthritis and varus malalignment: 3-year results with regard to preoperative arthroscopic and radiographic findings. Arthroscopy 26:1607–1616

    Article  PubMed  Google Scholar 

  28. Pape D, Seil R, Adam F, Rupp S, Kohn D, Lobenhoffer P (2004) Imaging and preoperative planning of osteotomy of tibial head osteotomy. Orthopade 33:122–134

    Article  CAS  PubMed  Google Scholar 

  29. Rasch H, Falkowski AL, Forrer F, Henckel J, Hirschmann MT (2013) 4D-SPECT/CT in orthopaedics: a new method of combined quantitative volumetric 3D analysis of SPECT/CT tracer uptake and component position measurements in patients after total knee arthroplasty. Skeletal Radiol 42:1215–1223

    Article  PubMed  Google Scholar 

  30. Schaefer TK, Majewski M, Hirschmann MT, Friederich NF (2008) Comparison of sagittal and frontal plane alignment after open- and closed-wedge osteotomy: a matched-pair analysis. J Int Med Res 36:1085–1093

    Article  CAS  PubMed  Google Scholar 

  31. Sharma L, Song J, Dunlop D, Felson D, Lewis CE, Segal N, Torner J, Cooke TD, Hietpas J, Lynch J, Nevitt M (2010) Varus and valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis 69:1940–1945

    Article  PubMed Central  PubMed  Google Scholar 

  32. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286:188–195

    Article  CAS  PubMed  Google Scholar 

  33. Staubli AE, De Simoni C, Babst R, Lobenhoffer P (2003) TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia–early results in 92 cases. Injury 34(Suppl 2):B55–B62

    Article  PubMed  Google Scholar 

  34. Stucki G, Meier D, Stucki S, Michel BA, Tyndall AG, Dick W, Theiler R (1996) Evaluation of a German version of WOMAC (Western Ontario and McMaster Universities) Arthrosis Index. Z Rheumatol 55:40–49

    CAS  PubMed  Google Scholar 

  35. van de Pol GJ, Arnold MP, Verdonschot N, van Kampen A (2009) Varus alignment leads to increased forces in the anterior cruciate ligament. Am J Sports Med 37:481–487

    Article  PubMed  Google Scholar 

  36. W-Dahl A, Toksvig-Larsen S, Roos EM (2009) Association between knee alignment and knee pain in patients surgically treated for medial knee osteoarthritis by high tibial osteotomy. A one year follow-up study. BMC Musculoskelet Disord 10:154

    Article  PubMed Central  PubMed  Google Scholar 

  37. Wenham CY, Conaghan PG (2009) Imaging the painful osteoarthritic knee joint: what have we learned? Nat Clin Pract Rheumatol 5:149–158

    Article  PubMed  Google Scholar 

  38. Ziegler R, Goebel L, Cucchiarini M, Pape D, Madry H (2013) Effect of open wedge high tibial osteotomy on the lateral tibiofemoral compartment in sheep. Part II: standard and overcorrection do not cause articular cartilage degeneration. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2410-6

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Acknowledgments

We greatly thank the Deutsche Arthrose Hilfe e.V., Germany, for financial support of the study and Jürg Schmutz for his illustrative work explaining the algorithm.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland

    Armin Mucha, Milos Dordevic, Markus P. Arnold & Michael T. Hirschmann

  2. Department of Radiology, University Hospital Basel, Basel, Switzerland

    Anna Hirschmann

  3. Institute for Radiology and Nuclear Medicine, Kantonsspital Baselland, 4101, Bruderholz, Switzerland

    Helmut Rasch

  4. Amsler Consulting, Basel, Switzerland

    Felix Amsler

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  1. Armin Mucha
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  2. Milos Dordevic
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  3. Anna Hirschmann
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Correspondence to Michael T. Hirschmann.

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Mucha, A., Dordevic, M., Hirschmann, A. et al. Effect of high tibial osteotomy on joint loading in symptomatic patients with varus aligned knees: a study using SPECT/CT. Knee Surg Sports Traumatol Arthrosc 23, 2315–2323 (2015). https://doi.org/10.1007/s00167-014-3053-y

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  • DOI: https://doi.org/10.1007/s00167-014-3053-y

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