Effects of different hinge positions and coronal correction angle on tibial rotation in uniplanar medial opening wedge high tibial osteotomy with three-dimensional tibial models

doi:10.21203/rs.3.rs-3589890/v1

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Effects of different hinge positions and coronal correction angle on tibial rotation in uniplanar medial opening wedge high tibial osteotomy with three-dimensional tibial models

https://doi.org/10.21203/rs.3.rs-3589890/v1

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Purpose: There is a lack of studies investigating the distal tibial rotation (DTR) during medial opening wedge high tibial osteotomy (MOWHTO). The purpose of the present study was to evaluate the impacts of different hinge positions in the sagittal and axial planes and coronal correction angle on the axial rotation of tibia in uniplanar MOWHTO with three-dimensional tibial models.

Methods: Preoperative CT data from 30 knee joints in 30 patients who underwent surgery for varus malalignment of knee were included. 1 standard hinge position (0°), 6 axial planes (±5°, ±10°, ±15°), and 6 sagittal planes (±5°, ±10°, ±15°) hinge positions were defined and virtual osteotomy was performed. The correction angle of each model was generated using Fujisawa’s point. The correction angle, preoperative medial proximal tibial angle, and DTR were measured.

Results: A significant linear correlation was observed between changes in hinge position in the sagittal plane and DTR. The changes in DTR were the smallest when the hinge position was at 5°, where internal or external rotation of the DTR may occur. When the front aspect of hinge axis rotated distally, DTR tended towards internal. Meanwhile, when the front aspect of hinge axis rotated proximally, DTR tended towards external. There were no correlations with every hinge axis position in the axial plane. There were linear correlations between the correction angle and DTR in varying degrees dependent on different hinge positions.

Conclusions: Both hinge position and coronal correction angle resulted in tibial rotation in uniplanar MOWHTO. In the sagittal plane, every change in hinge position was significantly linearly correlated with tibial rotation. However, no linear correlations were observed between every hinge position change in the axial plane. In addition, there were linear correlations between the coronal correction angle and tibial rotation in varying degrees dependent on the different hinge positions.

High tibial osteotomy

Varus deformity

hinge axis

distal tibial rotation

Medial opening wedge high tibial osteotomy (MOWHTO) is the primary surgical option for active young patients with varus malalignment of the knee. By correcting the varus malalignment, the pressure and pain of the medial compartment of the knee joint can be reduced[1]. In addition to biplanar MOWHTO, uniplanar MOWHTO has also been reported by some literatures[2–5].

In addition to correcting coronal alignment, MOWHTO can unintentionally influence the Posterior Tibial Slope (PTS) in the sagittal plane and tibial rotation in the axial plane due to the triangular shape of the proximal tibia [6–10]. Moreover, relevant studies on 3D rotation have mostly focused on changes in the PTS, including clinical observation studies [8], cadaveric studies [10, 11] and 3D surgical simulation studies [6, 12]. One widely discussed factor responsible for the PTS change is hinge axis position, and the general belief is that an anterolateral axial hinge axis could reduce PTS while a posterolateral position could increase PTS [6, 12–14].

However, there is a lack of relevant studies investigating the axial rotation of the distal tibia relative to the proximal tibia during MOWHTO, and the conclusions drawn from existing studies are controversial. Some studies have reported internal rotation, while others have reported external rotation of the distal tibia [9, 10, 15–17]. Factors influencing tibial rotation have also been reported, including tuberosity osteotomy angle[9, 15], flange angle [16], hinge axis angle in axial plane [17] and correction angle [9, 15, 16], but a consensus has yet to be reached. Considering adverse influences of tibial rotation on the contact pressures and kinematics of the knee and ankle[18, 19], further research is necessary.

The use of software to perform virtual osteotomy on a 3D model can eliminate the influence of complex factors such as soft tissue and allow for a more focused investigation of the bone structure, which is a reliable research method. Only two studies were found to have explored the impact of hinge axis angle on PTS using 3D surgical simulation studies [6, 12]. Notably, no study has explored the effect of the hinge axis angle on tibial rotation at the osteotomy site during MOWHTO by this method.

As such, the aim of the present study was to evaluate the effects of hinge positions in the sagittal and axial planes and the correction angle on the axial rotation of the tibia in uniplanar MOWHTO, as well as to quantify the impact of hinge positions and correction angle on axial rotation. A hypothesis was formulated that both sagittal and axial hinge positions would influence tibial rotation in uniplanar MOWHTO, as demonstrated by 3D tibial models. A further hypothesis was established that the degree of coronal correction angle would be correlated with the axial rotation of the tibia.

Patients

From May 2020 to May 2021, 30 knee joints in 30 patients who underwent surgery for varus malalignment of the knee in our hospital were enrolled. Each patient underwent preoperative full-length lower-extremity CT and standing hip-to-ankle anteroposterior radiography. Every patient met the following inclusion criteria: symptomatic medial compartment of knee joint; varus malalignment over 4° between the tibial and femoral mechanical axis and medial proximal tibial angle (MPTA) less than 84° measured on a hip-to-ankle standing AP radiograph; osteoarthritis grades 0–2 of the medial compartment according to Kellgren and Lawrence. Exclusion criteria: a mechanical lateral distal femoral angle (mLDFA) > 91° in the deformity analysis; severe varus malalignment considering the double level osteotomy (open wedge HTO and closed wedge distal femoral osteotomy); and severe medial compartment osteoarthritis (grades 3–4). Additionally, the Ethics Committee of our hospital gave approval to the present study, and every patient gave informed consent.

CT Data and 3D bony geometry Acquisition

All CT data were obtained by means of the same CT scanner (Revolution 256 CT; GE Healthcare, Milwaukee WI, USA). The slice thickness was 0.625 mm, and the acquisition matrix was 512×512 pixels. The DICOM (Digital Imaging and Communications in Medicine) data were downloaded using INFINITT PACS (INFINITT Healthcare, Seoul, Korea) and imported into Mimics (Materialise, Leuven, Belgium). The 3D models of the tibia and fibula were subsequently created. After the surface smoothness of the 3D models was processed using Geomagic Wrap (3D Systems Co. Ltd. USA) software, the bony geometry was imported into Geomagic Design X (Geomagic Inc., Morrisville, NC, USA) for the establishment of Coordinate System and virtual osteotomy, similar to the method described by Teng et al. [12].

The Establishment of the Coordinate System

First, the Z-axis, also known as the tibial axis, was defined as the axis passing through the center of both the tibial plateau and ankle. The center of the tibial plateau was determined as the midpoint of the centers of the lateral and medial plateaus of the tibia, which were manually determined using the method of the best-fit circle that covered both plateaus (Fig. 1). The center of the ankle was defined as the midpoint of the articular surface of the talar dome. Second, the X-axis was defined as the axis intersecting at right angles with the Z-axis and passing through the center of the tibial plateau, parallel to the Akagi line, which connects the middle of the posterior cruciate ligament (PCL) and the medial edge of the patellar tendon attachment [20]. Third, the Y-axis was defined as the axis intersecting at right angles with the X-axis and Z-axis through the center of the tibial plateau. Finally, the XY plane, XZ plane, and YZ plane were defined, respectively (Fig. 2).

Virtual Osteotomy and Hinge Axis

A middle plane was created between the XZ plane and the plane parallel to the XZ plane, tangent to the interior edge of medial tibial plateau. The line through the anterior and posterior cortical edge of medial tibial plateau in the middle plane was defined as the medial tibial slope line. The hinge point was located at the tip of the fibular head level and 5 mm medial to the lateral cortex of tibia. The standard hinge position (0°) was defined as the hinge axis through the hinge point and parallel to the medial tibial slope line in the sagittal plane and Akagi line in the axial plane. A total of six hinge positions in the axial plane (± 5°, ± 10°, ± 15°) were defined by rotating the hinge axis internally and externally around the midpoint of the standard hinge axis in the axial plane by different angles. Positive angles indicated that the front aspect of the hinge axis rotated externally, while negative angles indicated internal rotation. Similarly, six hinge positions in the sagittal plane (± 5°, ± 10°, ± 15°) were defined by rotating the hinge axis proximally and distally around the midpoint of the standard hinge axis in the sagittal plane by different angles. Positive angles indicated that the front aspect of the hinge axis rotated distally, while negative angles indicated proximal rotation (Fig. 3A B). The osteotomy plane passed immediately over the tibial tubercle to obtain a uniplanar osteotomy. In order to reduce the measuring error of tibial rotation, a sharp protrusion at the position of the middle of the PCL was highlighted manually before virtual osteotomy (Fig. 4).

Measurement result evaluation

The preoperative MPTA, coronal correction angle and the axial rotation of distal tibia relative to the proximal tibia during MOWHTO were recorded and evaluated. The correction angle of each patient was generated using Miniaci’s method [21] and Fujisawa’s point by means of preoperative standing hip-to-ankle AP radiography [22]. The method of measuring rotational change in Geomagic Design X software was as follows: preoperative and postoperative 3D tibial models were overlaid manually; Akagi's lines of preoperative and postoperative 3D tibial models were drawn and projected to the XY plane; and the angles between the two Akagi's lines were measured, being defined as the rotational changes at the osteotomy site for each change in hinge axis position [17]. Two researchers were trained before measurement.

Statistical Analysis

SPSS 26.0 and GraphPad Prism 8.0 were used for analyses in the present study. To reduce error due to inter-observer changes, all measurements were taken twice by 2 researchers independently. Intra-group correlation coefficients (ICC) were used to calculate the reliability of all results. One-Way ANOVA was used to compare tibial rotation changes between different groups of hinge positions. Pearson correlation analysis was used to investigate the correlations between the coronal correction angle and tibial rotation with different hinge positions in the sagittal plane. The regression equations were produced for (1) tibial rotation and hinge position in the sagittal plane, (2) tibial rotation and correction angles with different hinge positions in the sagittal plane. P < 0 .05 was considered statistically significant.

A total of 30 knee joints in 30 patients were included. Demographic characteristics of all patients are presented in Table 1. The axial rotations of the distal tibia in standard hinge position (0°), 6 axial planes (± 5°, ± 10°, ± 15°), and 6 sagittal planes (± 5°, ± 10°, ± 15°) hinge positions are shown in Table 2. The ICC values ranged from 0.70 to 0.95, indicating the good reliability of the measurements.

Table 1

Participants' demographics and baseline characteristics
Characteristic	Outcome: N or Mean ± SD
Numbers Sex (female/ male) Side (right/ left) Age (year) Height (cm) Weight (kg) BMI (kg/m²) mLDFA (°) Pre-MPTA (°) Pre-aFTA (°) Correction angle (°)	30 21/9 12/18 35.4 ± 10.5 164.33 ± 8.78 61.09 ± 11.80 22.25 ± 3.13 88.07 ± 1.48 80.69 ± 1.91 181.14 ± 2.28 10.59 ± 2.40

BMI: Body Mass Index; mLDFA: mechanical lateral distal femoral angle; MPTA: medial proximal tibial angle; aFTA: anatomical femoral tibial angle.

Table 2

Tibial rotation in different groups (Mean ± SD°)
Parameter	Outcome	P value	Parameter	Outcome	P value
Standard group Sagittal 5 group Sagittal 10group Sagittal 15 group Sagittal − 5 group Sagittal − 10 group Sagittal − 15 group	0.52 ± 0.73 -0.01 ± 0.68 -0.61 ± 0.65 -1.17 ± 0.82 1.05 ± 0.84 1.48 ± 0.89 2.12 ± 1.09	-- <0.001 <0.001 <0.001 <0.001 <0.001 <0.001	Axial 5 group Axial 10 group Axial 15 group Axial − 5 group Axial − 10 group Axial − 15 group	0.47 ± 0.77 0.52 ± 0.81 0.54 ± 0.74 0.49 ± 0.79 0.53 ± 0.80 0.51 ± 0.82	0.43 0.98 0.78 0.66 0.91 0.86

P value, tibial rotation compared with that in standard group

There were strong linear correlations between tibial rotation and each hinge position change in the sagittal plane (Fig. 5). The change in tibial rotation was smallest when the hinge position was at 5° in the sagittal plane, -0.01 ± 0.68°, and internal or external rotation of the distal tibia may occur at such hinge position (P<0.001). When the front aspect of hinge axis rotated distally, the rotations of the distal tibias of all the models tended towards internal, -0.61 ± 0.65° and − 1.17 ± 0.82° when the hinge axis was at 10° and 15° in the sagittal plane, respectively (P<0.001). Moreover, each 5° hinge axis rotation would result in an increase in the tibial rotation by about 0.5° internally. Meanwhile, when the front aspect of hinge axis rotated proximally, the rotation of the distal tibia tended towards external, 0.52 ± 0.73°, 1.05 ± 0.84°, 1.48 ± 0.89° and 2.12 ± 1.09° when the hinge axis was at 0°, -5°, -10°and − 15° in the sagittal plane, respectively (P<0.001). Similarly, each 5° hinge axis rotation would result in an increase in the tibial rotation by about 0.5° externally.

There were no correlations with each hinge position change in the axial plane when compared with that in standard hinge position(P>0.5). The average tibial rotation was always about 0.5° externally in different hinge positions in the axial plane.

At the same time, there were linear correlations between the coronal correction angle and tibial rotation with each hinge position change in the sagittal plane except for 10° and 15°. The best-fit equations for predicting tibial rotation based on coronal correction angle and different hinge positions in sagittal plane are presented in Fig. 6.

The most significant finding in the present study is that both hinge position and coronal correction angle cause tibial rotation to some extent during uniplanar MOWHTO. Sagittal hinge position changes can influence tibial rotation, while axial hinge position changes cannot. Further, linear correlations were observed between the coronal correction angle and tibial rotation at varying degrees, depending on different hinge positions.

The direction and extent of tibial rotation during MOWHTO have been controversial, but only a few studies have reported on such issues. In clinical settings, Jang et al.[9] observed a wide range of DTR after biplane MOWHTO, from 9.5° externally to 20.9° internally. Li et al.[5] reported DTR with a range of − 9.6° to + 2.8° after uniplane MOWHTO in 41 knees. In a study involving 60 knees, Sasaki et al.[16]found that 32% had internal rotations, 67% had external rotations, and 1% had no rotation. In Jing’s study[23], a total of 106 knee joints were included, being 60% cases internal rotation of distal tibia, 38% external rotation, and 2% no rotation. As a new direction, Hinterwimmer et al. [24] measured the axial rotation of the tibia using two K-wires fixed to the tibia distal and proximal to the osteotomy during MOWHTO by using a sterile goniometer involving 50 patients. The average rotation of the distal tibia was 4.4°±2.8° internally. A study by Kendoff et al.[11] demonstrated that in 13 cadavers, all osteotomies fixated with opening width of 12.5mm using a tapered Puddu plate, the distal tibia was externally rotated in 10 of the 13 cadavers and the mean rotation increased by 2°± 6°, ranging from a maximal internal rotation of 9°to a maximal external rotation of 12°. A study by Jacobi et al. [10] demonstrated that in 11 cadaver limbs, the average rotation change of distal tibia was 1.5°±2.9° internally with a range of 4.5° external rotation to 15° internal rotation. By means of virtual osteotomy with 3D tibial models, we found external, unchanged and internal rotation may occur and more cases tended to internal rotation as mentioned above.

The related influencing factors of tibial rotation have been investigated by several researchers, but an uncontested result has yet to be provided. Clinically, Kim et al. [8] found that the degree of DTR was not related to the amount of coronal correction after MOWHTO. Kim et al.[15] reported that the correction angle was the only predictor of DTR, with a larger correction angle observed in the group with distal tibial rotation > 3° compared to the group with rotation ≤ 3°. Lee et al.[17] found a positive correlation between the hinge axis angle and internal rotation of the distal tibia when the hinge axis was positioned more posterolaterally, while the gap ratio was negatively correlated. Kuwashima et al.[25]suggested that the postoperative tibial rotation was related to the degree of coronal correction. In Jing’s[23] study, DTR change was significantly associated with angles between standard and actual hinge in the sagittal planes, followed by opening width and flange angle. In a cadaveric study conducted by Jacobi et al.[10], advanced OA with concomitant flexion contracture was found to be associated with a significantly decreased tibial rotation change. In a 3D surgical simulation study by Chang et al.[14], a large angle of wedge inclination, which was the incline angle of the bone saw relative to the plateau plane, was found to be an indicator of horizontal rotation. In such study, the results showed that the distracted plateau rotated medially or anteriorly according to different angle of wedge inclination. The aim of Chang’s study was partially similar to that of the present study, but obviously, the deficiency of his study was that the sample size was too small, and only a proximal tibia of a healthy subject was reconstructed and printed as a 3D model. Meanwhile, through further research with virtual osteotomy involving 30 cases, the direction and extent of tibial rotation was found to be related to the hinge position and coronal correction angle, as previously mentioned in our study.

In the clinical practice of MOWHTO, preoperative planning for coronal correction angle is mainly dependent on standing hip-to-ankle AP radiography. Obviously, the hinge position and inclination in the 3D space cannot be considered in two-dimensional imaging, as described in our study and several previous studies. The hinge position has an effect on both PTS and tibial rotation [6, 12, 14, 26]. In a 3D simulation uniplanar MOWHTO study, Teng et al. [12] found that axial hinge position changes significantly influenced PTS in MOWHTO, but sagittal hinge position changes had no effect on changes in PTS. Notably, in the present study, sagittal hinge position changes could more obviously influence tibial rotation in uniplanar MOWHTO compared with the axial hinge position. Combined with clinical practice, both the axial and sagittal positions of the hinge must be carefully considered at the same time during MOWHTO to avoid unintended PTS and DTR.

Though an osteotomy line parallel to the medial joint line in sagittal plane has been recommended in previous studies[7, 27, 28], such method cannot be performed easily. Lee et al.[28] reported there was only 12.9% of cases in which a preoperative plan was performed parallel to the medial joint line, with most osteotomy lines being anteriorly inclined. Similarly, Chung et al. [7] noted that 72.5% of cases showed anteriorly inclined osteotomy, while the remaining cases showed posteriorly inclined osteotomy. In order to achieve an osteotomy line parallel to the medial joint line, Lee et al. [28] recommended a technique in which two syringe needles are used to identify the medial joint line and the pes anserine tendon is completely detached from its insertion.

There are some limitations in the present study. First, there was a relatively small sample size with only 30 models. Second, the uniplanar osteotomy performed is different from biplanar osteotomy which is more popular in clinical practice, because an ascending osteotomy plane would have an effect on tibial rotation in the biplanar osteotomy. Third, the present study is a virtual surgical study conducted using software, and the soft tissue around osteotomy site, the position of plate or bone density were not considered. In addition, clinical outcomes such as the influence on articular cartilage and function were not included. However, to the best of our knowledge, there has been no 3D simulation MOWHTO study focusing on tibial rotation yet, and further investigations with a larger sample size and clinical researches are needed.

Both hinge position and coronal correction angle cause tibial rotation to some extent in uniplanar MOWHTO. Significant linear correlations were observed between every hinge position change in the sagittal plane and tibial rotation, but there were no such correlations observed with every hinge position in the axial plane. Additionally, there were linear correlations between the coronal correction angle and tibial rotation in varying degrees dependent on different hinge position.

MOWHTO: medial opening wedge high tibial osteotomy；DTR: distal tibial rotation；PTS: Posterior Tibial Slope; mLDFA: mechanical lateral distal femoral angle; MPTA: medial proximal tibial angle; aFTA: anatomical femoral tibial angle.

Conflict of interest

The authors declare that they have no conflict of interest.

Author contributions

LZJ contributed to the literature search, data collection and analysis and manuscript preparation. YRC contributed to statistics analysis and manuscript editing. XZ and WGW contributed to the data collection and analysis. JSY contributed to the conceptualization and manuscript review. JW contributed to the substantial conceptualization, supervision and final approval of the draft version. All authors read and approved the final manuscript.

Funding

This work was supported by grants from China Research and Promotion of Traditional Chinese Medicine (2021-18) and grants from the Traditional Chinese Medicine Technology of Shandong Province（2021M173）

Ethics approval and consent to participate

This study was approved by the Board of Research Ethics of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine (2021-059-KY) and informed consent was signed by each patient.

Data availability

The data are available on request from Lizhong Jing(email: [email protected]).

Consent for publication

Not applicable.

Acknowledgments

None.

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No competing interests reported.

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Effects of different hinge positions and coronal correction angle on tibial rotation in uniplanar medial opening wedge high tibial osteotomy with three-dimensional tibial models

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Abstract

Figures

Background

Materials and Methods

Patients

CT Data and 3D bony geometry Acquisition

The Establishment of the Coordinate System

Virtual Osteotomy and Hinge Axis

Measurement result evaluation

Statistical Analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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