Acute correction of severe complex adolescent late-onset tibia vara by minimally invasive osteotomy and simple circular fixation: a case series with 2-year minimum follow-up

Background Despite multiple published reviews, the optimum method of correction and stabilisation of Blount’s disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. Weighing up the pros and cons and to establish if this method would be the method of choice in similar severe cases especially in a context of limited resources. Methods This study was conducted between November 2016 and July 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32 tibiae) who had correction of severe late-onset tibia vara by proximal tibial osteotomy and Ilizarov external fixator. The mean age at the time of the operation was 16.6 (± 2.7) years (range 13–22). Results The mean proximal tibial angle was 65.7° (± 7.8) preoperatively and 89.8° (± 1.7) postoperatively (p < 0.001). The mean mechanical axis deviation improved from 56.2 (± 8.3) preoperatively to 2.8 (± 1.6) mm postoperatively (p < 0.001). The mean femoral-tibial shaft angle was changed from –34.3° (± 6.7) preoperatively to 5.7° (± 2.8) after correction, with degree of correction ranging from 25° to 45°. Complications included overcorrection (three cases 9%) and pin tract infection (eight cases 25%). The mean Hospital for Special Surgery knee scoring system (HSS) improved from 51.03 (± 11.24) preoperatively to 94.2 (± 6.8) postoperatively (p < 0.001). The mean length of follow up period 33.22 (± 6.77) months, (rang: 25–46 months). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity. Conclusion This simple procedure provides secure fixation allowing early weight bearing and early return to function. It can be used in the context of health care systems with limited resources. It has a relatively low complication rate. Our results suggest that acute correction and simple circular frame fixation is an excellent treatment choice for cases of late-onset tibia vara, especially in severe deformities.

Return to Work and Sport After Proximal Tibial Osteotomy and the Effects of Opening Versus Closing Wedge Techniques on Adverse Outcomes: A Systematic Review and Meta-analysis

Background: Although many studies have reported successful functional outcomes after proximal tibial osteotomy (PTO), a paucity of literature has sought to quantify outcomes and current rates of return to sport (RTS) and return to work (RTW) after PTO. Purpose: To (1) determine current rates of RTS and RTW after PTO and (2) quantify the incidence of complications and conversion to total knee arthroplasty (TKA) after PTO for all patients as well as those undergoing opening and closing wedge PTO. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) databases were queried. Data pertaining to article information, patient demographics, surgical techniques, rates of complication and conversion to TKA, patient-reported outcome scores, RTS, and RTW were extracted. Data were synthesized, and a random effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients receiving opening and closing wedge PTO who experienced adverse events. Results: The review and meta-analysis included 33 studies involving 1914 patients who underwent PTO with a weighted mean ± SD age of 50.3 ± 9.9 years and body mass index of 26.9 ± 2.3 kg/m2. The pooled RTS and RTW rates were 75.7% (range, 55%-100%) in 814 patients and 80.8% (range, 41%-100%) in 505 patients, respectively. The pooled TKA rate was 12.5% (range, 0%-35.7%) at a mean of 70.6 months and the pooled complication rate was 11.1% (range, 0%-28.6%). The overall random pooled summary estimate of the proportion of patients who underwent opening wedge PTO and subsequently converted to TKA was 2.0% (95% CI, 1.0%-4.0%; I2 = 63.65) at a mean of 43.4 ± 31.9 months and who experienced a complication was 6.0% (95% CI, 3.0%-9.0%; I2 = 87.10%). For closing wedge PTO, the proportion of patients who converted to TKA was 5.0% (95% CI, 1.0%-9.0%; I2 = 93.1%) and experienced a complication was 2.0% (95% CI, 1.0%-3.0%; I2 = 90.0%). Only 53.8% of studies that referenced RTS provided postoperative RTS rates, and 80% of studies that referenced RTW provided RTW rates. Only 1 study defined RTS criteria, no studies defined RTW criteria, and 31 different outcome measures were reported across all studies. Conclusion: Patients undergoing PTO for osteoarthritis, cartilage defects, and symptomatic malalignment of the knee experience high rates of RTS and RTW. These patients also experience low rates of complications and conversion to TKA, regardless of opening or closing wedge technique. Significant heterogeneity exists with regard to criteria used to define RTS and RTW and patient-reported outcome measures used to assess clinical and functional improvements after PTO.