Preoperative joint line obliquity, a newly identified factor for overcorrection, can be incorporated into a novel preoperative planning method to optimise alignment in high tibial osteotomy

Abstract

Purpose: The aim of this study was to analyse the factors associated with additional postoperative alignment changes after accurate bony correction by selecting only patients with well-performed bony correction as planned and develop a method of incorporating significant factors into preoperative planning.

Methods: Among 104 consecutive patients who underwent medial open wedge high tibial osteotomy (MOWHTO) between October 2019 and July 2022, 61 with well-performed bony corrections were retrospectively reviewed. The major criterion for well-performed bony correction was a difference of <1° between the simulated medial proximal tibial angle (MPTA) and the actual postoperative MPTA as measured in three dimensions. Radiographic parameters, such as the joint line convergence angle (JLCA) and joint line obliquity (JLO), were measured preoperatively and postoperatively, utilising standing and supine whole lower extremity anteroposterior, valgus and varus stress radiographs. Multiple linear regression analysis identified the factors affecting alignment changes, and a prediction model was developed. A method for applying this prediction model to preoperative planning was proposed.

Results: Preoperative JLCA on standing (preJLCA^std ), preoperative JLCA on 0° valgus stress radiograph (vgJLCA⁰ ), and preoperative JLO (preJLO) were significantly correlated with JLCA change (∆JLCA) (p < 0.001, p < 0.001, p = 0.006). The prediction model was estimated as ∆JLCA = 0.493 × (vgJLCA⁰ ) - 0.727 × (preJLCA^std ) + 0.189 × (preJLO) - 1.587 in. (R = 0.815, modified R² = 0.646, p < 0.001). The proposed method resulted in a reduced overcorrection rate (p = 0.003) and an improved proportion of acceptable alignments (p = 0.013).

Conclusion: PreJLCA^std , vgJLCA⁰ and preJLO can be used to estimate ∆JLCA. PreJLO was recently identified as a significant factor associated with additional alignment changes. Utilising the proposed preoperative planning and a prediction model with these factors shows promise in calibrating postoperative alignment after MOWHTO.

Level of evidence: Level III, retrospective cohort study.

Keywords: high tibial osteotomy; joint line convergence angle; joint line obliquity; overcorrection; preoperative planning.