High Tibial Osteotomy

Osteotomy of the proximal tibia has been used for more than a century to correct angular deformity in the setting of rickets, poliomyelitis, and posttraumatic conditions.

Jackson is credited being the first in the English-language literature to report performing a proximal (high) tibial osteotomy (HTO) to treat osteoarthritis of the knee.

Jackson’s concept was subsequently adopted by Coventry et al and Insall et al,who refined and popularized the lateral closing wedge HTO

In the United States, initial experience indicated that HTO was effective in relieving the pain of unicompartmental osteoarthritis

HTO has been temporized by two factors: recognition of the procedure’s limitations evolution and clinical success of total knee arthroplasty (TKA)

drawbacks:

it is not an ideal treatment option for patients with significant bicompartmental or tricompartmental disease

results of the procedure progressively deteriorate

use HTO(1) medial compartment osteoarthritis in physiologically young,

active patients, for whom TKA is imperfect for long-term solution.

(2) HTO imposes no permanent activity restrictions(3) Superior results are more likely with contemporary fixation

and postoperative management techniques after HTO (4) Evolving chondral resurfacing techniques are contraindicated

in the presence of tibiofemoral malalign mandate concomitant correction of significant coexistent angular deformity.

(5) Combining HTOwith chondral resurfacing procedures may provide better results than would HTOalone.

Indications for High TibialOsteotomy

• Oseoarthritis Patients WithVarus Limb Alignment• Oseoarthritis Patients WithValgus Limb Alignment• Adult Osteochondritis Dissecan• Osteonecrosis• Posterolateral Instability• Chondral Resurfacing• the ability of the patient to use crutches after the

operation and the possession of sufficient muscle strength and motivation to carry out a rehabilitation program

• good vascular status without serious arterial insufficiency or large varicosities

Vargus Limb AlignmentThe most common indication for HTOis isolated medial

compartment degenerative joint disease with associated varus tibiofemoral malalignment

The rationale behind performing a valgus-producing HTO in the context of unicompartmental degenerative joint disease is to unload the arthritic medial compartment.

The ideal patient for this procedure is physiologically young and active

Elderly patients (chronologically older than 60 years) with low functional demand typically are more appropriate candidates for TKA

Valgus Limb Alignment

Isolated lateral compartment osteoarthritis is much less common than isolated medial compartment osteoarthritis.

Most authorities have a preference for performing a varus-producing distal femoral osteotomy rather than a varus producing HTO

Correcting the valgus angulation on the tibial side of the knee has been criticized because a valgus-producingHTO produces obliquity of the tibiofemoral joint line

Adult Osteochondritis Dissecans

HTOshould be considered in physiologically young, active adults with osteochondritis dissecans of the medial femoral condyle

author reported that HTO reliably decreases pain and improves function in patients with osteochondritis dissecans.

Osteonecrosis

osteonecrosis typically affects individuals older than 60 years, TKA and unicompartmental knee arthroplasty (UKA) are the most commonly considered salvage operations.

HTO is a valid alternative to arthroplasty for physiologically young patients with osteonecrosis of the medial femoral condyle

According to author HTO not only decreases discomfort and postpones the need for TKA, but it also leads to regression of the underlying disease

Koshino also observed that the efficacy of HTO was enhanced by concomitant drilling and/or bone grafting of the osteonecrotic lesion.

Posterolateral Instability

Isolated soft-tissue reconstruction procedures for posterolateral insufficiency are likely to fail in the setting of varus alignment because the reconstruction is subjected to excessive tension

Hence, performing a valgus-producing HTO before or in conjunction with the ligamentous reconstruction should be considered when there is varus malalignment.

Chondral Resurfacing

Techniques for repairing focal chondral defects include marrow stimulation (ie, subchondral drilling, abrasion arthroplasty, microfracture), autologous chondrocyte implantation, osteochondral autograft transplantation , and autogenous periosteal grafting.

Because most isolated articular cartilage lesions within the knee affect the medial femoral condyle, the realignment procedure typically indicated during knee cartilage repair is a valgus-producing HTO

Contraindications to HighTibial Osteotomy valgus-producing

severe lateral compartment degenerative joint disease loss of a significant portion of the lateral meniscus symptomatic patellofemoral degenerative joint disease nonconcordant pain (ie, patellofemoral pain with medial

compartment osteoarthritis) patient unwillingness to accept the anticipated cosmetic appearance

of the desired amount of angular correction Inflammatory arthritis. more than 20 degrees of correction needed knee flexion of less than 90 degrees flexion contracture of more than 15 degrees lateral tibial subluxation of more than 1 cm,

Arthroplasty Versus HighTibial Osteotomy

Isolated medial compartment disease in a physiologically young, high-demand individual is the ideal scenario for HTO

Multicompartmental disease in a physiologically old, low-demand individual is the ideal scenario for TKA.

Isolated medial compartmental disease in a physiologically old, low demand individual is an appropriate situation for eitherTKAor UKA.

UKA should not be considered a substitute for HTO in the physiologically young, high demand individual with isolated medial compartment disease.

Osteotomy Techniques

• three principle techniques lateral closing wedge osteotomy, medial opening wedge osteotomy, dome osteotomy

Techniques for valgus-producing high tibial osteotomy. A, Lateral closing wedge. B, Medial opening wedge. C, Dome osteotomy.

Lateral closing wedge osteotomy

used by Coventry et al and Insall et aladvantage of producing apposition of two broadmetaphyseal surfaces, thus optimizing inherent stability and

healing potentialit is made near the deformityit permits exploration of the knee through the same incisiontraditionally performed with freehand cuts and stabilized with

either bone staples or cylinder castsPotential problems associated with these methods include

patella baja and an inability to precisely achieve the desired amount of correction.

More recently, calibrated cutting guides, rigid internal fixation devices, and early mobilization have produced improved results and low complication rates after lateral closing wedge osteotomy

Use of an alignment jig allows the surgeon precise control of angular correctionduring a lateral closing wedge high tibial osteotomy.

medial opening wedge

used to treat medial compartment osteoarthritis since 1951 in france

fixation is achieved by either a medial distraction plate or an external fixator.

it is technically easier for the surgeon to achieve the precise desired amount of angular correction than with lateral closing wedgeHTO

Merit and demerit

include less extensive surgical dissection and lack of proximity to the peroneal nerve.

no need to mobilize the proximal fibula. Medial closing wedge constructs are relatively

unstable; hence, loss of fixation, nonunion, and delayed union are likely to be more frequent than after lateral closing wedge osteotomy.

immediate weight bearing is not appropriate after a medial opening wedge procedure and typically is delayed for 6 to 8 weeks.

When medial opening wedge osteotomy fixation is achieved with a distraction plate, autograft and/allograft bone is required, and associated graft morbidity issues

If external fixation is used, the potential for pin tract morbidity arises it could jeopardize subsequent salvage with TKA

Dome osteotomy

less commonly used to be a more technically demanding operation

because of the challenges of creating a curved osteotomy and avoiding iatrogenic trauma to the patellar tendon

advantage of intraoperative flexibility, which allows the surgeon to achieve the precise amount of desired angular correction

if combined with external fixation, the amount of angular correction may be adjusted postoperatively as well.

In contradiction to lateral closing wedge and medial opening wedge techniques, dome osteotomy permits concomitant anterior translation of the tibial tubercle, which may alleviate associated patellofemoral disease

Cartilage Regeneration After HighTibial Osteotomy

Bruce et al documented decreased medial compartment scintigraphic uptake following valgus-producingHTO.

Odenbring et al detected fibrocartilage proliferation and increased cellularity of hyaline cartilage afterHTO,

MacIntosh and Welsh reported superior clinical outcomes with combined open débridement and HTO compared with HTO alone

Schultz and Gobel documented improved cartilage regeneration when HTO was combined with abrasion arthroplasty

Complications of HighTibial Osteotomy

• Patella Baja• Fracture• Nonunion• Peroneal Nerve Palsy• Compartment Syndrome• Infection• Thromboembolism

Total Knee ArthroplastyAfter High Tibial

Osteotomy

TKA following HTO is considered to be more technically demanding than TKA in the absence of prior HTO.

In some clinical study the results of TKA have been inferior following HTO Contracture of the patellar tendon with resultant patella baja increases the technical difficulty of TKA after HTO

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L-shaped scars from previous lateral closing wedge HTOs pose challenges for the surgeon performing a subsequent TKA because of the potential for skin necrosis

The surgeon must aware of the proximal tibial deformation caused by the HTO when planning and executing proximal tibial resection at the time of TKA

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