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Purpose To investigate the influence of apical vertebrae difference (AVD) on surgical decision-making and clinical outcomes of single- and two-level osteotomy in ankylosing spondylitis (AS) thoracolumbar kyphoscoliosis with sagittal and coronal imbalance. Methods A total of 27 AS patients with thoracolumbar kyphoscoliosis were enrolled in the study. Patients were divided into single- and two-level osteotomy groups based on the number of osteotomy levels. Coronal, sagittal, and clinical parameters were measured preoperatively, postoperatively, and at the last follow-up. AVD, operation time, blood loss, fused segments and complications were recorded between the two groups. Results Among 27 patients, 11 underwent single-level osteotomy and 16 underwent two-level osteotomy. The operation time, blood loss and number of fused segments were lower in single-level group compared to the two-level group ( P  < 0.001). Coronal, sagittal, and clinical parameters improved significantly after surgery ( P  < 0.05), with only osteotomized vertebral angle (OVA) showing a significant difference between the two groups ( P  < 0.05). The average AVD was 1.50 segments in single-level group and 3.30 segments in two-level group. Additionally, single- and two-level osteotomy accounted for 80% and 20% in group A, 77.8% and 22.2% in group B, and 0% and 100% in group C, respectively. Conclusion AVD was a crucial parameter in determining whether single- or two-level osteotomy was appropriate for AS patients with thoracolumbar kyphoscoliosis. If the AVD was < 3 segments, single-level osteotomy should be considered. If the AVD was ≥ 3 segments, two-level osteotomy was recommended.

Purpose The purpose of this study was to investigate if one level of corrective femoral osteotomy (subtrochanteric or supracondylar) bears an increased risk of unintentional implications on frontal and sagittal plane alignment in a simulated clinical setting. Methods Out of 100 cadaveric femora, 23 three-dimensional (3-D) surface models with femoral antetorsion (femAT) deformities (> 22° or < 2°) were investigated, and femAT normalized to 12° with single plane rotational osteotomies, perpendicular to the mechanical axis of the femur. Change of the frontal and sagittal plane alignment was expressed by the mechanical lateral distal femoral angle (mLDFA) and the posterior distal femoral angle (PDFA), respectively. The influence of morphologic factors of the femur [centrum–collum–diaphyseal (CCD) angle and antecurvatum radius (ACR)] were assessed. Furthermore, position changes of the lesser (LT) and greater trochanters (GT) in the frontal and sagittal plane compared to the hip centre were investigated. Results Mean femoral derotation of the high-antetorsion group ( n  = 6) was 12.3° (range 10–17°). In the frontal plane, mLDFA changed a mean of 0.1° (− 0.06 to 0.3°) (n.s.) and − 0.3° (− 0.5 to − 0.1) ( p  = 0.03) after subtrochanteric and supracondylar osteotomy, respectively. In the sagittal plane, PDFA changed a mean of 1° (0.7 to 1.1) ( p  = 0.03) and 0.3° (0.1 to 0.7) ( p  = 0.03), respectively. The low-antetorsion group ( n  = 17) was rotated by a mean of 13.8° (10°–23°). mLDFA changed a mean of − 0.2° (− 0.5° to 0.2°) ( p  < 0.006) and 0.2° (0–0.5°) ( p  < 0.001) after subtrochanteric and supracondylar osteotomy, respectively. PDFA changed a mean of 1° (− 2.3 to 1.3) ( p  < 0.01) and 0.5° (− 1.9 to 0.3) ( p  < 0.01), respectively. The amount of femAT correction was associated with increased postoperative deviation of the mechanical leg axis ( p  < 0.01). Using multiple regression analysis, no other morphological factors were found to influence mLDFA or PDFA. Internal rotational osteotomies decreased the ischial-lesser trochanteric space by < 5 mm in both the frontal and sagittal plane ( p  < 0.001). Conclusions In case of femAT correction of ≤ 20°, neither subtrochanteric nor supracondylar femoral derotational or rotational osteotomies have a clinically relevant impact on frontal or sagittal leg alignment. A relevant deviation in the sagittal (but not frontal plane) might occur in case of a > 25° subtrochanteric femAT correction. Level of evidence IV.

Purpose To systematically review and critically appraise the literature on double-level osteotomy (DLO) of the knee, and determine the indications, contraindications, targets and outcomes. Materials and methods A systematic literature search was performed on PubMed, Embase®, and Cochrane for studies that reported on DLO by any technique or approach, including indications, contraindications, and targets for DLO, as well as patient-reported outcome measures (pROMS) and radiographic angles. Results Twelve eligible studies were found: 9 case series and 3 studies that compared DLO to high-tibial osteotomy (HTO). In all studies, DLO was performed by medial opening-wedge tibial osteotomy and lateral closing-wedge femoral osteotomy. Seven specified that DLO was performed if simple HTO would exceed thresholds of postoperative medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and/or predicted wedge size. The targets were 88°–95° for MPTA, 84°–89° for LDFA, and 0°–4° for hip–knee–ankle (HKA) angle. The 3 comparative studies reported lower MPTA after DLO (89.6°–92.5°) than after HTO (91.5°–98.3°). All 3 reported similar postoperative HKA after DLO (0.2°–4.4°) as HTO (0.4°–4.8°); only 2 compared postoperative LDFA, which was lower after DLO (85.4° and 84.9°) than HTO (88.7° and 88.8°). Two comparative studies reported postoperative overall KOOS which was slightly lower after DLO (351–403) than HTO (368–410); only 1 study reported separate items of the KOOS. Conclusion There was relative consistency between studies on the indications, targets and techniques for DLO. Furthermore, while the comparative studies reported similar preoperative MPTA, LDFA and HKA, the postoperative MPTA and LDFA were lower after DLO than after HTO, though both treatments achieved equivalent postoperative HKA. Level of evidence IV, systematic review.

Purpose This study indicated the outcomes of three surgical techniques for the treatment of symptomatic unicompartmental knee osteoarthritis (UKOA) with varus malalignment in younger, active patients: distal femoral osteotomy (DFO), double-level osteotomy (DLO) and high tibial osteotomy (HTO). The outcomes measured included the return to sport, sport activity and functional scores. Methods A total of 103 patients (19 DFO, 43 DLO, 41 HTO) were enrolled in the study and were divided into three groups based on their oriented deformity, each undergoing one of the three surgical techniques. All patients underwent pre- and post-operative evaluations including X-rays, physical exams and functional assessments. Results All three surgical techniques were effective in treating UKOA with constitutional malalignment. The average time to return to sport was similar among the three groups (DFO: 6.4 ± 0.3 [5.8–7] months, DLO: 4.9 ± 0.2 [4.5–5.3] months, HTO: 5.6 ± 0.2 [5.2–6] months). The sport activity and functional scores improved significantly for all three groups, with no significant differences observed among the groups. Conclusion Various knee osteotomy procedures, DFO, DLO, and HTO, result in high RTS rates and quick RTS times with satisfactory functional scores. Despite pre- to post-operative improvements in sport activities following DFO and DLO, pre-symptom levels were not reached following all evaluated procedures. Level of evidence Retrospective case–control study, Level III.

Purpose To compare the radiographic, clinical, and arthroscopic outcomes of varus osteoarthritic knees treated with an open-wedge high tibial osteotomy (OWHTO) alone or with a double-level osteotomy (DLO). It was hypothesized that treatment with DLO would maintain the joint line obliquity (JLO) and acquire better arthroscopic and clinical outcomes after surgery than OWHTO alone. Methods Knees with predicted medial proximal tibial angle (MPTA) > 95° were treated with OWHTO alone or with DLO. Preoperatively, age, body mass index, and hip-knee-ankle angle (HKA) differed between the two groups. Therefore, after adjustment for those factors, 34 knees with OWHTO alone and 34 knees with DLO were compared. On whole-leg radiographs for a single leg, HKA, weightbearing line (WBL) ratio, lateral distal femoral angle (LDFA), MPTA, and JLO were measured before and 2 years after surgery. Clinical outcomes were evaluated by the Knee Society Score (KSS) knee, KSS function, Lysholm, and Knee injury and Osteoarthritis Outcome Score (KOOS) scores before and 2 years after surgery. Arthroscopic findings were obtained before and 1 year after surgery. Various factors were compared between the two groups. Results JLO increased significantly from 1.4° to 6.3° in the OWHTO group ( p  < 0.001) and changed from 1.0° to 1.3° in the DLO group (n.s.). Postoperative MPTA and JLO in the OWHTO group were significantly higher than those in the DLO group (both p  < 0.001). There were no significant differences in the KSS knee, KSS function, and KOOS scores between the two groups. Postoperative Lysholm score in the DLO group was higher than that in the OWHTO group ( p  < 0.025). Femoral and tibial cartilage regeneration in the medial condyles and deterioration in the lateral condyles did not differ between the two groups on second-look arthroscopy. Conclusions JLO was not significantly changed after surgery in the DLO group. DLO enabled the acquisition of physiological JLO compared with OWHTO alone. Level of evidence Retrospective comparative study, Level III.

Purpose The purpose of this study was to assess changes in health-related quality of life (HRQL) and work intensity following double-level knee osteotomy (DLO). It was hypothesized that postoperative HRQL would be comparable to that of the general population and that work intensity can be restored in the short term. Methods Twenty-four patients (28 varus knees; mechanical tibiofemoral angle: −11.0 ± 3.0° (−6.0 to −17.0), age: 49.1 ± 9.5 (31–65) years) who underwent DLO were included. The duration the patients were unable to work was evaluated. HRQL was measured with the SF-36 questionnaire, which consists of a physical (PCS) and mental component summary score (MCS). The pre- to postoperative changes in the PCS and MCS were analysed. The PCS and MCS were also compared to those of the general population, who has a reference score value of 50 points. The work intensity measured with the REFA classification and the Tegner activity scale were assessed preoperatively and at the final postoperative follow-up examination (18.0 ± 10.0 (5–43) months). Results The duration that the patients were unable to work was 12.2 ± 4.4 (6–20) weeks. The PCS improved from 32.1 ± 11.3 (14.5–53.3) preoperatively to 54.6 ± 8.5 (25.2–63.7) ( p  < 0.001) at the final follow-up, and the MCS improved from 53.9 ± 11.1 (17.1–67.7) to 57.2 ± 3.1 (47.3–61.7) (n.s). The preoperative PCS was significantly lower than the reference score of the general population ( p  < 0.001), whereas the preoperative MCS was similar between the two groups (n.s . ). At follow-up, no significant differences were observed between the PCS and the MCS of the patient group and those of the general population. Five patients who were unable to work prior to surgery due to knee symptoms returned to work with moderate (four patients) or even very heavy (one patient) workloads. The Tegner activity scale increased significantly from a median of 2.0 (0.0–5.0) to 4.0 (2.0–7.0) ( p  < 0.001). Conclusion Our results demonstrate an improvement in quality of life and return to working activity following DLO in the short term. The HRQL can be improved by DLO in patients with varus knee osteoarthritis to the level of the general population. These results can assist surgeons in discussing realistic expectations when considering patients for DLO. Level of evidence Study type: therapeutic, IV.

IntroductionThe purpose of the study was to describe the development of the surgical technique of double level osteotomy in patients with severe varus malalignment and to investigate the clinical and radiological outcome. It was hypothesized that good clinical results without a higher complication rate can be achieved by double level osteotomy to normalize joint angles and avoid joint line obliquity even in cases of progressed osteoarthritis.Materials and methodsBetween 2011 and 2014, 33 patients (37 knees) undergoing double level osteotomies (open wedge HTO and closed wedge DFO) were included; of these, 24 patients (28 knees) were available in mean of 18 ± 10 months for the follow-up examination. Indication was symptomatic varus malalignment and medial compartment osteoarthritis. Postoperatively, these patients were assigned to 20 kg partial weight-bearing using two crutches for 6 weeks followed by full weight-bearing. No braces or casts were used. Full weight-bearing long leg anteroposterior radiographs were obtained preoperatively, after 6 weeks and at the time of final follow-up. Mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA) and medial proximal tibia angle (MPTA) were measured. Clinical outcome was evaluated using Lequesne-, Lysholm-, Oxford-, and IKDC-score at the time of follow-up.ResultsThe preoperative mTFA of − 11 ± 3° increased to 0 ± 2° at final follow-up. The difference between mTFA-planning and final follow-up was − 2 ± 3° (p < 0.0006). At final follow-up, MPTA and mLDFA were 89.2 ± 2° and 87 ± 2°, respectively. The Lysholm, Oxford, Lequesne, and IKDC scores were 88 ± 13, 44 ± 3, 2 ± 2, and 77 ± 12, respectively.ConclusionsThis study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalises the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis.Level of evidenceCase series, Level IV.

The aim of this study was to explore the validity and safety of the combination of one-level pedicle subtraction osteotomy (PSO) and one-level Smith–Petersen osteotomy (SPO) in correcting severe ankylosing spondylitis kyphosis. Twenty-five AS patients undergoing one-level PSO and one-level SPO with a minimum of 2-year follow-up were included. Radiographical analyses included T5–T12 kyphosis (TK), L1–S1 lordosis (LL), global kyphosis (GK), osteotomized vertebral angle (OVA), sagittal vertical axis (SVA) and pelvic parameters. The computed tomographic (CT) scans of the spine were used to measure the aortic diameter and length. Clinical outcomes were evaluated by Oswestry Disability Index (ODI) questionnaire. The mean correction of OVA at PSO level and SPO level was 33.6° ± 9.2° and 26.0° ± 13.2° respectively. An average correction of 69.3° ± 23.2° in GK was achieved. The mean operation time was 372.6 ± 60.1 min and the estimated blood loss averaged 1790.4 ± 953.3 ml. The mean increase of aortic length after surgery was 3.6 cm. An average decrease of 0.25 cm in aortic diameter at the PSO level was observed after surgery. There was no significant difference in aortic diameter at the SPO level between pre- and post-operation. ODI was improved from 30.2 ± 19.3 before surgery to 15.5 ± 13.9 at the last visit. The combination of one-level SPO and one-level PSO could achieve satisfactory correction outcomes in AS patients with severe kyphosis (GK ≥ 80°) needing a correction of > 60°.

Background Double level osteotomy (DLO) has been introduced to prevent increased postoperative joint line obliquity. However, although DLO is planned, knees with postoperative medial proximal tibial angle (MPTA) > 95° in preoperative surgical planning are present. This retrospective study aimed to evaluate risk factors for an MPTA > 95° in preoperative surgical planning for DLO in patients with varus knee osteoarthritis (OA). Methods A total of 168 knees that underwent osteotomies around the knee for varus knee OA were enrolled. The hip-knee-ankle angle (HKA), weight-bearing line (WBL) ratio, mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA) and mechanical medial proximal tibial angle (mMPTA) were measured on preoperative radiographs. The postoperative WBL ratio was planned to be 62.5%. When the postoperative mMPTA was more than 95° in isolated high tibial osteotomy (HTO), (DLO) was planned so that the postoperative mLDFA was 85°, and residual deformity was corrected by HTO. Knees with postoperative mMPTA ≤ 95° and > 95° were classified into the correctable group and uncorrectable group, respectively. Results DLO was required in 101 knees (60.1%). Among them, 41 knees (40.6%) were classified into the uncorrectable group. Binomial logistic regression analysis showed that preoperative JLCA and mMPTA were independent predictors in the uncorrectable group. Conclusions Even with DLO, postoperative mMPTA was more than 95° in approximately 40% of cases. Preoperative increased JLCA and decreased mMPTA were risk factors for a postoperative mMPTA of > 95° after DLO.

Purpose Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield significantly tilted joint line obliquity (JLO). This study aimed to evaluate the effectiveness of DLO in achieving accurate correction without compromising JLO, using patient-specific cutting guides (PSCGs), in cases of bifocal valgus maligned knees. Methods A single-centre, retrospective analysis of prospectively collected data for a total of 26 patients, who underwent DLO by PSCGs for valgus malaligned knees, between 2015 and 2020. Post-operative alignment was evaluated and the delta for different lower limb0.05, not statistically significant (ns)). All KOOS subs alignment parameters was calculated; the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), and lateral distal femoral angle (ΔLDFA). At the two-year follow-up, changes in the KOOS sub-scores, UCLA scores, lower limb discrepancy (LLD), and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. The Mann–Whitney U test with a 95% confidence interval (95% CI) was used to evaluate the differences between two variables; one-way ANOVA between more than two variables and the paired Student's t -test was used to estimate the evolution of functional outcomes. Results The postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p  > 0.05, not statistically significant (ns)). All KOOS subscore's mean values were improved to an extent two-fold superior to the reported minimal clinically important difference (MCID) (all with p  < 0.0001). There was a significant increase in the UCLA score at the final follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p  < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1 months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3 ± 2 cm) to postoperative measures (LLD = 0.3 ± 0.4 cm), ns. Complications were 2 femoral hinge fractures, 2 deep vein thromboses, 1 delayed tibial healing, and 1 hardware removal for hamstring irritation syndrome. Conclusion DLO is effective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO. Level of evidence III