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Joint Preservation Surgery for Medial Compartment Osteoarthritis

Open AccessPublished:June 05, 2017DOI:https://doi.org/10.1016/j.eats.2017.01.020

      Abstract

      Single compartment osteoarthritis is a commonly encountered condition in the middle-aged population, with the medial compartment being the most commonly involved compartment. Medial compartment osteoarthritis becomes seriously disabling for these active patients, with a very few definitive solutions. These patients quickly stop responding to the conservative methods such as lifestyle modification, drugs, physiotherapy, and rehab programs. Less invasive procedures such as intra-articular injections or joint debridement also do not give a long-lasting relief. On the other hand, this population is too young to undergo a knee replacement surgery because the failure rate of a knee replacement surgery is too high in the middle-aged patients as compared with the elderly population. A combination of biological stimulation of the damaged single compartment cartilage and biomechanical correction surgery can give a long-lasting relief in the middle-aged population. Because the medial compartment osteoarthritis is increasingly being treated with joint preservation surgeries, it is important to lay out the step-by-step surgical technique of a joint preservation surgery. This Technical Note presents the detailed technique, patient selection flow chart, tips, pearls, and surgical decision making, along with a surgical video of a joint preservation surgery.

      Technique Video

      See video under supplementary data.

      Single compartment osteoarthritis in middle-age-group patients is a challenge, because both conservative therapies and replacement surgeries have higher chances of patients' dissatisfaction and failures.
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      Surgical treatment for early osteoarthritis. Part I: Cartilage repair procedures.
      Good results of unicondylar knee replacements have been shown in systematic reviews, but only in the mean patient age group of >60 years.

      Campi S, Pandit HG, Dodd CA, Murray DW. Cementless fixation in medial unicompartmental knee arthroplasty: A systematic review [published online July 19, 2016]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4244-5.

      Joint preservation surgeries are challenging and usually comprise biomechanical correction and biological stimulation.
      • Gomoll A.H.
      • Filardo G.
      • Girolamo L.
      • et al.
      Surgical treatment for early osteoarthritis. Part I: Cartilage repair procedures.
      Traditionally, cartilage repair techniques are not recommended for the treatment of osteoarthritis, more so when kissing lesions are present or with significant unicompartmental changes.
      • Gomoll A.H.
      • Filardo G.
      • Girolamo L.
      • et al.
      Surgical treatment for early osteoarthritis. Part I: Cartilage repair procedures.
      Although biomechanical correction using high tibial osteotomy (HTO) is the most commonly used joint preservation technique, the additional role of biological stimulation (cartilage repair surgeries) is frequently challenged in the orthopaedic literature.
      • Jung W.-H.
      • Takeuchi R.
      • Chun C.-W.
      • et al.
      Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy.
      Many authors have shown a good regenerated cartilage after HTO alone, performed without any cartilage repair procedure.
      • Jung W.-H.
      • Takeuchi R.
      • Chun C.-W.
      • et al.
      Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy.
      However, combining the principles of biomechanical correction along with the cartilage repairs has also given encouraging results with a longer duration of follow-up and better clinical scores.
      • Sterett W.I.
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      • Matheny L.M.
      • Briggs K.K.
      Chondral resurfacing and high tibial osteotomy in the varus knee: Survivorship analysis.
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      Do microfractures improve high tibial osteotomy outcome?.
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      Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees.
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      • Flanigan D.C.
      Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction.
      Somewhere, it is the synergistic role of both the principles that leads to a better outcome with the combined procedure.
      Careful selection of the right case for the joint preservation surgery is crucial (Fig 1), because not all the patients suffering from medial compartment osteoarthritis (MCOA) are the ideal candidates (Table 1). The surgical technique of a joint preservation surgery is presented here, comprising microfracture (MF) as the principal biological stimulation technique and open wedge high tibial osteotomy (OWHTO) as the principal biomechanical correction technique. Additional procedures such as lateral patellar release, notchplasty, partial meniscectomy, and minor medial collateral ligament (MCL) release might be needed and the surgeon should select the use of additional procedures as the case may be. The purpose of presenting this technique is to set a step-by-step guideline for the joint preservation surgery while treating MCOA.
      Fig 1
      Fig 1Patient selection while performing a joint preservation surgery for medial compartment osteoarthritis (MCOA). (BMI, body mass index; MRI, magnetic resonance imaging; PCL, posterior cruciate ligament.)
      Table 1Patient Selection Tips for the Joint Preservation Surgery in Medial Compartment Osteoarthritis
      Clinical profileAgeBest results are obtained in patients who have better regenerative capacity. Hence an age group between 40 and 55 yr is recommended
      SexEither sex is okay
      BMIAvoid patients with BMI >30
      SmokersAvoid
      Laboratory investigationsInflammatory diseasesAvoid
      Radiology findingsStandard knee joint radiographsShould primarily be a medial compartment disease. Minor changes in the lateral and patellofemoral compartment are acceptable
      Long limb alignment radiographValgus correction angle (measured as per Fujisawa point)
      • Fujisawa Y.
      • Masuhara K.
      • Shiomi S.
      The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints.
      of 9° to 15° is the best case selection. More than 15° correction makes postoperative period painful and very uncomfortable to the patients
      MRI findingsMedial compartmentEven extensive damage or bone-on-bone picture should not be a contraindication as long as other conditions are satisfied
      Lateral compartmentMinor grade 1 changes or a few fibrillations in the lateral compartment are not a deterrent. Similarly, small flap tear can be treated and the joint preservation surgery should not be abandoned
      Patellofemoral compartmentMinor grade 1 changes or a few fibrillations in the patellofemoral compartment are not a deterrent. Significant patellar maltracking can be combined with the lateral patellar release procedure
      CollateralsMust be normal
      Cruciate ligamentsMust be normal. An ACL tear can be reconstructed
      ACL, anterior cruciate ligament; BMI, body mass index; MRI, magnetic resonance imaging.

      Surgical Technique

      The joint preservation surgery for MCOA consists of 2 parts: the arthroscopy part and the osteotomy part. Both the parts are described here in detail (Video 1).

      Patient's and Surgeon's Position; Instrumentation

      While the patient is lying supine, the lateral thigh support is placed a little higher at the level of greater trochanter so that the affected limb can be hanged by the side of the table for the arthroscopy procedure. The surgeon stands on the side of the affected limb, whereas the arthroscopy tower remains on the opposite side. For the osteotomy procedure, the patient's limb is brought back on the table. It is advisable to put a sandbag under the affected hip, because this rotates the limb to a neutral position. The surgical table should have a radiolucent bottom to allow the use of the “C-arm” during the osteotomy procedure. The surgeon stands on the opposite side of the affected limb while performing the osteotomy part of the procedure. The C-arm is prepared so as to bring it in the surgical area from the affected side of the patient.
      There are a few special instruments needed for the procedure along with the routine arthroscopy and the plating instruments (Table 2, Fig 2).
      Table 2List of Instruments Required for Performing a Joint Preservation Surgery for Medial Compartment Osteoarthritis
      • Standard arthroscopy procedure equipment
      • Arthroscopy hand instruments
      • C-arm
      • Microfracture instrument set including awls, sharp cartilage curettes, and periosteum
      • ACL reconstruction tray if simultaneous ACL reconstruction is attempted
      • 8-mm/10-mm thin periosteum
      • Two large Hohmann retractors and one small Hohmann retractor
      • 2.7-mm guide pin
      • Osteotomy tray containing 10-, 12-, and 16-mm osteotomes (J. J. International Instruments, Kerala, India)
      • Osteotomy gauge (Anujay Engineering, Ahmedabad, India)
      • Lamina spreader (Anujay Engineering)
      • Standard plate fixation set (Hib Surgicals, Mumbai, India)
      ACL, anterior cruciate ligament.
      Fig 2
      Fig 2The special instruments required for the joint preservation surgery apart from the instruments used in a routine arthroscopy and osteotomy procedure. (1) Curved lamina spreader. (2) Straight lamina spreader (J. J. International Instruments, Kerala, India). (3) Osteotomy gauze (Anujay Engineering, Ahmedabad, India). (4) A series of thin and long osteotomes (J. J. International Instruments, Kerala, India).

      Part 1: Arthroscopy Procedure

      Each compartment of the knee should be examined in the standard manner. The first author (D.G.) performs a diagnostic arthroscopy of the knee in the following order: the suprapatellar pouch, the patellofemoral compartment, the medial gutter, the medial compartment, the anterior compartment, the lateral compartment, the lateral gutter, and the posterolateral corner. Later, each compartment is addressed, and decision taken depending on the pathology encountered in the respective compartments (Table 3).
      Table 3Decision Making While Encountering Various Pathologies During the Arthroscopy Part of the Joint Preservation Surgery for Medial Compartment Osteoarthritis
      RegionTissueFindingsProposed Action
      General findingsSynoviumSynovial proliferationPartial synovectomy
      Synovial inflammatory diseasePartial synovectomy and abandon procedure
      Loose bodyRemoval
      Medial jointMedial meniscusTearPartial meniscectomy
      Reparable tearMeniscus repair
      Medial cartilageSmall to moderate size defect with healthy marginsMF for small lesion, consider the osteochondral cylinder transfer technique for moderate lesion
      Large defects to kissing lesionsMF
      Medial borderOsteophyteOsteophytectomy
      Lateral jointLateral meniscusSmall insignificant tearPartial meniscectomy
      Major tearReconsider decision to proceed with HTO
      Lateral cartilageSmall fibrillationsDebride
      Small cartilage defectsConsider MF, reconsider decision to proceed with HTO
      Large defectsAbandon HTO
      Anterior compartmentACLTearConsider reconstruction
      HypertrophiedDebulking
      NotchOsteophytesNotchplasty
      PCLTearAbandon HTO
      Patellofemoral compartmentPatellar maltrackingTight lateral retinaculumLateral patellar release
      Patellofemoral cartilageSmall area of defect in patellaAbrasion chondroplasty
      Small defect in trochleaMF
      Large patellar defectReconsider decision to proceed with HTO
      Large trochlear defectReconsider decision to proceed with HTO
      ACL, anterior cruciate ligament; HTO, high tibial osteotomy; MF, microfracture; PCL, posterior cruciate ligament.

      Portals

      Standard anteromedial and anterolateral portals are used. Additional portals may also be required.

      Suprapatellar Pouch

      The presence of any generalized inflammatory synovial disease (e.g., rheumatoid) should be looked for in the suprapatellar pouch, because it might indicate an inflammatory condition and not a purely degenerative condition. Occasionally, a loose body is seen that may have been diagnosed preoperatively on magnetic resonance imaging or on the radiographs.

      Medial Compartment

      Careful partial synovectomy is essential to have a clear vision of the compartment. Often an area of cartilage defect is found in both the medial femoral and the medial tibial chondral surfaces, corresponding with the pre-existing meniscus tear. The partial meniscectomy in such a case is the best choice, because it not only removes the pathology responsible for the cartilage damage but also helps in protecting the healing cartilage after surgery. Very rarely, the pattern of the tear is good enough to perform a meniscus repair surgery. However, before proceeding for a meniscus repair surgery, one must ascertain the predictable good results of the meniscus repair at middle age and the associated pathology.
      The next step is assessing the chondral defect, its size, location, and the International Cartilage Repair Society grading. There are often areas of fibrillations hanging from the damaged cartilage that requires careful debridement using a shaver blade to clear the damaged chondral surface. It is not common to find a small to mid-size area of cartilage damage in the femur with the surrounding healthy area of the cartilage; however if found, this lesion can be treated either with MF or with osteochondral cylinder transfer techniques provided other parameters are favorable. Commonly, there are large areas of complete cartilage loss on the femoral chondral surface and a major area of cartilage damage on the tibial chondral surface (Fig 3). Using a sharp vertical periosteum, perpendicular cuts are put on the cartilage at the junction of healthy cartilage and the unhealthy cartilage so as to stabilize the cartilage margins (Fig 4). It is advisable to start cartilage stabilization from the most posterior part of the lesion and then progress anteriorly in a circular fashion through the medial and the lateral part of the lesion. Various areas of the chondral defect can be accessed by changing the flexion arc of the knee. After stabilizing the cartilage margins, the same periosteum or a ring curette is used to clear the unhealthy cartilage from the center of the lesion. All the calcified cartilage is also removed from the surface of the lesion, and the standardized MF procedure is carried out (Fig 5).
      Fig 3
      Fig 3Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Assessment of the chondral lesion while performing the arthroscopy part of the joint preservation surgery. The medial meniscus is normal in this case, whereas a large degenerative lesion is seen at the medial femoral condyle articular surface.
      Fig 4
      Fig 4Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Cartilage lesion preparation while performing the arthroscopy part of the joint preservation surgery. A sharp curette is used to sharply demarcate and stabilize the degenerated cartilage from the healthy surrounding cartilage of medial femoral condyle. The scrapping is performed till all the unhealthy cartilage and the calcified cartilage are removed.
      Fig 5
      Fig 5Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Assessment of bone marrow access after microfracture (hollow black arrows) while performing the arthroscopy part of the joint preservation surgery. The degenerative lesion is scrapped and then microfracture is performed as part of the cartilage repair technique. The freshly bleeding microfracture holes (solid black arrows) indicate a good access to subchondral bone marrow and its autogenous stem cells.
      The commonly detected area of chondral damage on the tibial surface is the medial or posteromedial half of the medial tibial plateau. It is not easy to separate the unhealthy cartilage from the healthy cartilage sharply on the tibial plateau surface, and hence an angular periosteum or a sharp curette should be used. Similarly, it is difficult to perform MF using a 45° or less angular MF awl. Hence, a 90° awl is preferable to perform MF on the tibial chondral surface.
      The area that had been bare of cartilage for a longer duration will be hard to penetrate because of more sclerosis. However, an area that had been bare for a smaller duration will be easy to penetrate using the MF awls.

      Anterior Compartment

      A long existing degenerative disease is usually associated with osteophytes formation in the notch. Occasionally, these osteophytes impinge on the anterior cruciate ligament (ACL) leading to a compromised excursion of the ligament in the notch. A thin 8-mm periosteum is used to gently separate the osteophytes from the boundaries of the notch and then the rough base of the osteophytes is smoothened. The free movement of the ACL may be appreciated as soon as these osteophytes are removed.
      Occasionally, the ACL is found hypertrophied or stretched out due to impingement by the osteophytes. It is important to ascertain the strength of the ACL and its viability before proceeding further, in the presence of a compromised ACL. If other parameters permit, it is advisable to perform the ACL reconstruction either at the same stage or as a delayed procedure. A debulking procedure for the hypertrophied ACL can be performed after ascertaining its strength. A torn posterior cruciate ligament does not indicate a favorable condition for the joint preservation surgery, and hence HTO should not be attempted in the presence of a posterior cruciate ligament tear.

      Lateral Compartment

      A detailed assessment of the meniscus and the cartilage in this compartment is very important to determine the longevity of the planned HTO. A small tear in the lateral meniscus or a few fibrillated cartilage fibers are not a contraindication for the joint preservation surgery (Table 3).

      Both Gutters

      Any loose body if present should be removed. If an osteophyte is present medially, an osteophytectomy using an 8-mm periosteum should be carried out because this helps in relaxing the medial structures.

      Patellofemoral Compartment

      A few fibrillations or a small area of cartilage damage on the patella is not a contraindication for the procedure and can be managed with shaving or abrasion chondroplasty. Similarly, a small defect on the trochlea can be managed with a standardized MF procedure. However, a large defect in the patellofemoral compartment should prompt the surgeon to abandon the knee preservation surgery. A maltracking patella with a tight lateral retinaculum and a tender lateral patellar margin is an indication for the requirement of a lateral patellar release. A lateral patellar release is performed at this stage, if planned during the clinical examination. The portals are closed after completing the lavage of the joint and removing the fluids.

      Part 2: Biomechanical Correction

      The authors prefer to do a biomechanical correction using an OWHTO, the technique of which is described here.

      Incision

      A mid-medial approach to the proximal tibia is used, starting approximately 1 cm below the joint line and extending for around 2″ till the lower half of the palpable pes tendons.

      Surgical Exposure

      The combination of a dry gauze dissection and a sharp periosteum dissection is the key for complete surgical exposure of the proximal medial tibia (Table 4). After incising the superficial and the deep fascia, a blunt gauze dissection is carried out to clear all the fibroadipose tissues. It is very easy to identify the pes tendons traversing the lower half of the incision horizontally, from posterior to the anterior side and inserting near the anterior border of the tibia just below the tibial tuberosity (TT). Using a No. 15 knife, an incision is put on the periosteum starting from the proximal part of the incision while remaining exactly in the middle of the medial surface of the proximal tibia till the superior border of the pes tendons. On reaching the pes tendons, the incision is rotated 90° anteriorly along the superior border of the pes tendons till the anterior border of the tibia is reached. Again the incision is rotated 90° distally and the pes tendons are cut near their insertion keeping around 2 mm of the insertion on the tibial surface (Fig 6). The incision is carried distally till the inferior border of the pes tendons. Anteriorly, the periosteum is erased using an 8-mm periosteum till the retropatellar tendon fat pad is reached. Just proximal to the TT, a small Hohmann retractor is inserted underneath the patellar tendon thereby securing the patellar tendon from any inadvertent injury while performing osteotomy. Posteriorly, the periosteum is erased till the posteromedial border of the tibia and a wide Hohmann retractor is inserted between the bare bone and the retracted periosteum. The pes tendons are simultaneously erased along with the MCL from its attachment along with the underlying periosteum, and the whole pes complex is retracted posteriorly using another Hohmann retractor. Both the posterior Hohmann retractors play a vital role in protecting the medial as well as the posterior structures. A gauze swab is used to further erase the periosteum from the posteromedial border and the medial half of the posterior surface of the tibia. This maneuver makes the medial surface of the proximal tibia totally bare of all the soft tissues (Fig 7).
      Table 4Pearls and Pitfalls While Performing a Joint Preservation Surgery for Medial Compartment Osteoarthritis
      Surgical Dissection StepExpected ProblemSolution
      Pes complex exposureAs the pes complex crosses the surgical field, any sharp dissection should be avoidedPerform an extensive blunt gauze dissection after incising the deep fascia superficial to the pes complex. This blunt gauze dissection helps in removing all fibroadipose tissues that lie over the pes complex, thereby exposing it nicely for further dissection
      Exposure of the posteromedial, medial, and posterior surface of the tibiaTransversely crossing pes complex and vertically oriented medial collateral ligament near the posteromedial border and posterior neurovascular bundle interfere with surgical exposureUse a sharp periosteum for subperiosteal dissection on the posteromedial and the medial surface of the tibia, after reflecting the pesmedial collateral ligament complex. Insert 2 large Hohmann retractors on either side of the planned osteotomy site, flex the knee by 20° so that the posterior neurovascular structures fall back, and then perform the blunt gauze dissection on the posterior tibial surface. This helps in a complete exposure of the medial surface, the posteromedial border, and the medial half of the posterior surface of the proximal tibia
      Osteotomy planeAny tilted osteotomy plane will alter the tibial slopeThe osteotomy blade should remain parallel to the tibial slope all the times. Superimpose the anterior and the posterior cortex of the tibial plateau on the C-arm and then position the blade at the osteotomy site in such a way that only a thin line (end-on view) of the blade is seen on the C-arm
      Osteotomy cut on the posteromedial borderThis corner of the bone is the thickest of all but is close to important structuresA sharp manual osteotome to cut the posteromedial corner of the tibia is a better option rather than a motorized osteotome, because a manual osteotome gives a better feeling of completing the bone cut at the posteromedial corner
      Osteotomy cut on the posterior surfacePosterior neurovascular structures are at riskIt is advised to avoid putting the rolled towel sheets at the level of popliteal fossa or at the level of the proximal tibia because this can push the posterior neurovascular structures toward the bone and put those structures at a risk. However, a rolled towel at the level of the distal femur is helpful while keeping the knee flexed
      Biplanar osteotomy at the level of tibial tuberosityPatellar tendon must not be injured while keeping the optimum size of the tibial tuberosity tongueA too small tongue carries a higher risk of fracturing the tibial tuberosity, whereas a large tongue carries a risk of entering the articular surface. Hence, a small Hohmann retractor must be used at all the times that will clearly show the size of the osteotomy tongue being created. The retractor also protects the patellar tendon throughout the procedure. A manual osteotome is advisable
      Osteotomy termination near the lateral cortexThe lateral cortex must not be compromisedIt is important to reach just short of the lateral cortex with the osteotome before attempting to open up the osteotomy. There are high chances of lateral tibial plateau fracture if a premature attempt of opening the osteotomy site is made. Do not break the lateral cortex of the tibia because it acts as an elastic hinge that has a stabilizing role. There are also high chances of translation developing at the osteotomy site, if the lateral cortex is breached
      Requirement of bone graftingAn early bone healing is expectedFor a 10-mm open wedge osteotomy, no bone grafting or artificial bone is required to fill the gap. For a bigger open wedge osteotomy, either a tricortical bone strut or an artificial bone wedge should be used to fill the gap and promote healing
      Fig 6
      Fig 6Vertical incision on the medial surface of the proximal tibia over the pes complex while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. After exposure of pes complex, an “S”-shaped incision is put on the medial surface of the proximal tibia (black arrows). The upper arm of “S” is in the center of the proximal part of the medial surface of the tibia. The center of “S” is along the upper border of the pes tendons, whereas the lower vertical arm of “S” is along the anterior border of the tibia, just medial to the pes tendon insertion. Solid blue arrow, tibial tuberosity; solid white arrows, arthroscopy portals.
      Fig 7
      Fig 7Exposure of the medial surface of the proximal tibia while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Two large Hohmann retractors along the posterior border of the tibia to protect the medial structures such as the medial collateral ligament and the pes tendons (black arrows). These retractors also protect the posterior structures. Also note a small Hohmann retractor proximal to the tibial tuberosity (blue arrow) protecting the patellar tendon (white arrow).

      Point of Entry

      Gradually, the finger is moved on the proximal medial tibial flange from proximal to distal. Around 3 cm below the joint line, one can notice the end of the flange merging with the shaft of the tibia. This point generally corresponds with a sharp turn on the medial tibial surface curvature, under the C-arm. The guide pin is inserted from here obliquely upward so that it reaches the lateral tibial cortex just above the level of the superior tibiofibular joint, under the C-arm control (Fig 8).
      Fig 8
      Fig 8Guide pin insertion while performing the osteotomy part of the joint preservation surgery. Left knee peroperative C-arm anteroposterior view, the patient lying supine with the leg straight on the table and the hip internally rotated. The C-arm is introduced to the surgical field from the lateral side of the left knee while the surgeon is standing on the right side of the patient. A guide pin is passed from the medial side aiming just superior to the proximal tibiofibular joint. A small retractor is retracting the patellar tendon (while arrow), whereas the large retractor is retracting the pes-medial collateral ligament complex (black arrow). Note that the anterior and posterior borders of the medial tibial plateau are overlapping with each other.

      Plane of Osteotomy

      It is important to select the plane of osteotomy that should be parallel to the proximal tibial slope. The knee is flexed in such a way that both the anterior cortex and the posterior cortex of the tibial articular surface become superimposed on each other, under the C-arm. A few rolled towel sheets are put under the knee at the level of the distal thigh, so that the position is maintained. The next step is to decide the angle of the cutting blade that should remain parallel to the tibial slope. The osteotomy blade is put flush with the guide pin and then the blade is tilted either upward or downward till it is seen as a thin line under the C-arm. At this position, both the borders of the osteotomy blade are superimposed and are parallel to both the cortices of the tibial slope. A small cut on the bone is put using the blade so that a plane of osteotomy parallel to the tibial slope is fixed (Fig 9).
      Fig 9
      Fig 9Osteotomy plane demarcation while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. A motorized saw is used to put an osteotomy cut (solid black arrows) on the medial surface adjacent to the guide pin and parallel to the medial articular surface. Note that the posteromedial structures are retracted safely using the Hohmann retractor (empty black arrows), whereas the patellar tendon is retracted anteriorly using a small Hohmann retractor (white arrow), just above the tibial tuberosity (blue arrow).

      Accommodating the Tibial Tuberosity

      The next step is to note the position of the TT. Often the TT is little superior to the finalized plane of the osteotomy. In such conditions, osteotomy is modified to a biplanar osteotomy, by making a superiorly directed small tongue to the previously decided plane. A 10-mm osteotome is put obliquely in such a way that the anterior border of the osteotome is in a retropatellar tendon area above the TT, whereas the posterior border of the osteotome touches the main osteotomy plane obliquely (Fig 10). Thereafter, the anterior cortex of the tibia just proximal to the TT is osteotomized till it breaks into the anterolateral cortex.
      Fig 10
      Fig 10Biplanar osteotomy demarcation while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Because the tibia tuberosity comes in the plane of osteotomy cut (solid black arrows), a biplanar osteotomy is recommended. A 10-mm osteotome (hollow white arrow) is used to angulate the osteotomy toward proximal direction so that a biplanar osteotomy passes just above the tibia tuberosity (blue arrow), whereas the patellar tendon is safely retracted using a small Hohmann retractor (solid white arrow). Note that the posteromedial structures are kept retracted using large Hohmann retractors (hollow black arrows).

      Osteotomy Procedure

      For the main osteotomy, a motorized osteotomy blade is used and is inserted sliding along the guide pin toward the lateral cortex. Caution should be exercised not to violate the lateral cortex. The osteotomy blade is then directed toward the posteromedial border of the tibia, where cortical bone is quite thick and important. Both the Hohmann retractors are used to protect the posterior structures while the posteromedial cortex is osteotomized. A manual osteotome is further used to osteotomize the remaining bone in the posteromedial border. Multiple thin osteotomes (J. J. International Instruments, Kerala, India) are stacked one after another along the main osteotomy plane, so that valgus osteotomy gradually opens up (Fig 11). At this stage, occasionally a few tight bands of tissues are found on the medially erased MCL-pes complex. These tight bands comprise fibers of MCL or a thickened periosteum. A No. 15 blade is used to put small incomplete cuts on these bands at different intervals. As soon as these tight bands are partly released, the osteotomy opens up like a spring. An osteotomy gauge (Anujay Engineering, Ahmedabad, India) (Fig 12) is inserted at the osteotomy site and gradually hammered toward the lateral cortex. This wedge-shaped gauze not only opens the osteotomy but also measures the amount of opening created on the medial cortex. We use the 1° = 1 mm formula to decide the amount of opening versus the degree of correction required.
      Fig 11
      Fig 11Gradual opening of osteotomy while performing a joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Stacking of long thin osteotomes helps in a gradual opening of the osteotomy (solid black arrows). A simultaneous opening of biplanar osteotomy (hollow white arrow) takes place just above the tibial tuberosity (blue arrow). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows) and the patellar tendon is continuously retracted using a small Hohmann retractor (solid white arrow).
      Fig 12
      Fig 12Measuring the osteotomy opening using the osteotomy gauze while performing the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. An osteotomy gauze (Anujay Engineering, Ahmedabad, India) not only helps in a gradual opening of the osteotomy (hollow white arrow) but also helps in measuring the size of opened-up osteotomy (solid black arrows). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows) and the patellar tendon is continuously retracted using a small Hohmann retractor (solid white arrow) just above the tibial tuberosity (solid blue arrow).

      Bone Grafting or Artificial Bone Wedges

      For an osteotomy opening of around 10 mm, no bone grafting or artificial bone wedge is needed. However, for a bigger osteotomy opening, either a tricortical iliac strut graft or an artificial bone wedge of the similar size is strongly recommended.

      Osteotomy Fixation

      Lamina spreaders are used to keep the osteotomy open while the fixation plate is put in the defect. Depending on the predetermined correction angle, an osteotomy plate (Hib Surgicals, Mumbai, India) of size either 10 or 12.5 or 15 is used. The first author (D.G.) does not recommend the correction of more than 15° for the knee preservation surgery, because higher correction puts lot of stress on the soft tissues around the knee, making postoperative rehabilitation painful for the patient. The osteotomy plate is fixed using 2 proximal cancellous screws and 2 cortical screws (Fig 13). The C-arm is used for the anteroposterior and the lateral view to cross-check the position of the screws and to reconfirm the plane of osteotomy. The periosteum and the pes are sutured back using Vicryl 1-0 sutures (Fig 14). Closure is performed using skin staples. A bulky dressing is provided and the limb is put in a long limb brace.
      Fig 13
      Fig 13Fixation of an osteotomy plate. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Osteotomy plate fixation using 2 proximal cancellous screws and 2 distal cortical screws (Hib Surgicals, Mumbai, India). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows).
      Fig 14
      Fig 14Suturing of the pes complex while performing a joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. The pes complex (hollow black arrows) is brought back to its original insertion site near the tibial tuberosity (solid blue arrow) and the anterior border.

      Postoperative Rehabilitation

      Local ice application over the dressing is started in a few hours after surgery. This helps in reducing the postsurgery hematoma formation. Toe movements, calf pumps, and static quadriceps exercises are encouraged as soon as the patient is out of the effect of the anesthesia. Early calf and foot muscle movements help in dissipating the postoperative edema that might collect in the operative region. In the evening, the patient is encouraged to sit on the bed and do spine mobilization exercises and deep breathing exercises. Such exercises help in relaxing the back muscles and ease out the stress of a major surgery. Static quadriceps and static hamstring strengthening exercises are started from day 1, and are gradually increased in intensity as the stamina builds up.
      The continuous passive motion (CPM) machine is also started from the evening of the operation day and is used for a duration that is comfortable for the patient. From day 1, the patient is encouraged to use the CPM machine for 4-6 hours in a day and to gradually increase its use to 6-8 hours in the subsequent days. The use of CPM for 6 weeks is strongly recommended, and a preoperative counseling is required to convince the patient for the same.
      The patient is allowed to walk non-weight-bearing from day 1, with the use of a 4-legged walker/frame. For 10 mm of opening, around 4 weeks of non-weight-bearing is recommended, whereas for 15 mm of opening, around 6 weeks of non-weight-bearing is recommended. Partial weight-bearing is allowed for the next 15 days after which full weight-bearing is started.

      Discussion

      The MF technique is considered as the first line of treatment for small, localized cartilage defects in the young population.
      • Goyal D.
      • Keyhani S.
      • Lee E.H.
      • Hui J.H.P.
      Evidence-based status of microfracture technique: A systematic review of Level I and II studies.
      Traditionally, such cartilage repair techniques are not recommended for large widespread osteoarthritic lesions. However, there are multiple reports of good long-term results of MF used for the treatment of the degenerative lesions in the elderly, more so if combined with HTO.
      • Schuster P.
      • Schulz M.
      • Richter J.
      Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees.
      • Harris J.D.
      • McNeilan R.
      • Siston R.A.
      • Flanigan D.C.
      Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction.
      Encouraged by these good results of cartilage repair treatment and because of a higher chance of patients' dissatisfaction and failure after replacement surgeries in the middle age, cartilage surgeons are increasingly shifting their focus to the arthritic cases.
      • Gomoll A.H.
      • Filardo G.
      • Girolamo L.
      • et al.
      Surgical treatment for early osteoarthritis. Part I: Cartilage repair procedures.
      • Sterett W.I.
      • Steadman J.R.
      • Huang M.J.
      • Matheny L.M.
      • Briggs K.K.
      Chondral resurfacing and high tibial osteotomy in the varus knee: Survivorship analysis.
      • Pascale W.
      • Luraghi S.
      • Perico L.
      • Pascale V.
      Do microfractures improve high tibial osteotomy outcome?.
      A detailed step-by-step surgical technique is thus important to lay down the standardized procedure. Because of the degenerative nature of the joint, it is important to address each intra-articular pathology individually. A guideline for decision making while performing arthroscopy is thus presented (Table 3). The surgical tips advised while performing the osteotomy part are also discussed (Table 4).
      Recently Schuster et al.
      • Schuster P.
      • Schulz M.
      • Richter J.
      Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees.
      published 5-year results of 23 knees with a mean age of 47 years, treated with HTO combined with ACL reconstruction and MF/abrasion in patients having osteoarthritis Kellgren-Lawrence grades 3 and 4. These cases were evaluated clinicoradiologically and arthroscopically between 1 and 2 years, and with outcome scores for 5 years. Good cartilage regeneration was seen in most of the cases and the mean subjective International Knee Documentation Committee score improved from 47.7 ± 11.1 to 73.1 ± 16.4 at 5 years (P < .001). Sterett et al.
      • Sterett W.I.
      • Steadman J.R.
      • Huang M.J.
      • Matheny L.M.
      • Briggs K.K.
      Chondral resurfacing and high tibial osteotomy in the varus knee: Survivorship analysis.
      published 91% survival at 7 years after MF and HTO procedure in MCOA cases. Harris et al.
      • Harris J.D.
      • McNeilan R.
      • Siston R.A.
      • Flanigan D.C.
      Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction.
      in their systematic review of 69 studies (mean age of 53 years) found that 5-year survival of HTO was significantly better when combined with cartilage repair (97.7%) as compared with HTO performed alone (92.4%).
      Orthopaedic literature is controversial about the use of an additional cartilage repair procedure with HTO. Jung et al.
      • Jung W.-H.
      • Takeuchi R.
      • Chun C.-W.
      • et al.
      Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy.
      claimed that the degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by the newly regenerated cartilage at 2 years after HTO, without cartilage regeneration strategies. However, Schuster et al.
      • Schuster P.
      • Schulz M.
      • Richter J.
      Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees.
      claimed that HTO in combination with a chondral resurfacing procedure is effective in the treatment of severe medial osteoarthritis and varus malalignment. Cartilage critics have always given the credit to osteotomy for the pain relief, whereas the cartilage surgeons have given the credit to the additional cartilage surgeries.
      • Pascale W.
      • Luraghi S.
      • Perico L.
      • Pascale V.
      Do microfractures improve high tibial osteotomy outcome?.
      However, the role of additional cartilage surgeries in better survival and higher clinical scores cannot be ruled out.
      • Schuster P.
      • Schulz M.
      • Richter J.
      Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees.
      • Harris J.D.
      • McNeilan R.
      • Siston R.A.
      • Flanigan D.C.
      Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction.
      For any joint preservation surgery to be successful, a cartilage surgeon must select the “best of two worlds” and perform both the procedures as a single-stage procedure.
      Although joint preservation surgery offers many advantages, it is not free of some limitations (Table 5). The biggest advantage of a joint preservation surgery is preserving the natural knee joint during the more active middle age. The patient still retains the possibility of converting to an arthroplasty procedure during the elderly age as the advantages of the preserved joint wane over a decade. Intra-articular pathologies are often the major culprits for the beginning of degenerative process and should not be left untreated. The simultaneous arthroscopy procedure also offers an opportunity to handle the intra-articular pathologies related to the meniscus, the ligaments, the synovium, and the osteophytes, apart from an opportunity to perform the cartilage repair. As discussed above, a simultaneous cartilage repair procedure has a synergistic role in the cartilage regeneration when performed along with HTO. Adding an arthroscopy procedure before HTO is not a major issue for an arthroscopy surgeon; however, it can be a major deterrent for a general orthopaedic surgeon who is not accustomed to the arthroscopy procedure.
      Table 5Advantages of Combining Arthroscopy and Open Wedge High Tibial Osteotomy (OWHTO) While Performing a Joint Preservation Surgery for Medial Compartment Osteoarthritis
      Advantages
       Simultaneous arthroscopy allows tackling the intra-articular issues such as meniscus tear, synovial proliferation, impingement, loose body, and osteophytes
       A simultaneous cartilage repair is possible that has a synergistic advantage in cartilage repair
       One osteotomy cut is more precise than 2 osteotomy cuts
       Open wedge osteotomy allows fine tuning of the osteotomy, whereas close wedge osteotomy does not
       No need to perform an additional fibular osteotomy
       No major musculature detachment needed from the bone except the pes tendons
       The bone stock is added in an open wedge osteotomy that is good for the future arthroplasty
       The medial tibial flange maintains its natural curve, as against a step-off created in close wedge osteotomy
      Limitations
       Not good with involvement of the lateral and patellofemoral compartment
       Should not be attempted in the presence of major ligament instability
       A high tibial correction makes postoperative rehabilitation very painful and hence should be avoided
      Selection of OWHTO as against close wedge osteotomy also offers many advantages. OWHTO adds to the bone stock of the proximal tibia and also maintains the profile of proximal tibial architecture, as against close wedge osteotomy that takes away the bone stock and creates a step in the proximal tibial contour on the medial side. Because there is no step-off on the medial side, a future arthroplasty procedure is easy to carry out. Another advantage of this osteotomy is that the fibula and the proximal tibiofibular joint are spared without the need for any bony procedure. OWHTO also offers the advantage of a single cut on the bone as against 2 cuts needed for the close wedge osteotomy. A single cut also allows fine tuning of the osteotomy opening peroperatively, which is not possible with the close wedge osteotomy. A good fixation also offers the advantage of early mobilization that not only helps in gaining full movement quickly but also in the cartilage regeneration.
      The joint preservation surgery, however, has certain important limitations. The surgeon must rule out a major pathology in the lateral and patellofemoral compartment, because it can deteriorate the results of joint preservation surgery very fast. A very high tibia vara correction leads to too much opening at the proximal tibia that can cause very uncomfortable and painful postoperative period to the patient. Hence, any correction that requires more than 15° of the opening should be avoided. The rehabilitation after a joint preservation surgery is always more difficult than the rehabilitation required after an arthroplasty procedure. This can be a major deterrent for patients and hence a proper preoperative counseling is a must.
      This Technical Note, along with the surgical video, describes a joint preservation surgery for MCOA that deals with the various intra-articular pathologies along with the cartilage damage and varus malalignment as a single-stage procedure. A carefully selected patient and a well-planned surgical procedure can give long-term results in the middle-age-group patients.

      Acknowledgment

      The surgical video presented was edited from the live surgery performed by the first author (D.G.) during the 3rd congress of Indian Cartilage Society, held at Ahmedabad, India, on November 28, 2015. The authors acknowledge Indian Cartilage Society for allowing the use of this video in this Technical Note.

      Supplementary Data

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