High tibial osteotomy (HTO) is a realignment procedure that unloads the diseased knee joint surface and corrects angular deformities. It has regained popularity for treating medial compartment osteoarthritis in young, active patients. The goals of HTO are to redistribute weight bearing forces across the knee joint. It is commonly performed using either a closing or opening wedge technique. Patient factors like age, activity level, and alignment/deformity guide whether HTO or knee replacement is most appropriate. Long term studies show HTO effectiveness declines over 7-10 years.

1. HIGH TIBIAL OSTEOTOMY

2. • Type of realignment osteotomy
• Fundamental goals of the procedure are to
unload the diseased articular surface and to
correct angular deformity at tibiofemoral
articulation
• Due to success of TKR, number of HTO came
down.

3. • Renewed interest in recent times due to
1. Prevalence of physiologically young active
Pts with medial comp OA.
2. Advent of new techniques for performing
the procedure.
3. Need to concomitantly correct the
malalignment when performing chondral
resurfacing procedures.

4. DRAWBACKS
• Not an ideal option for Pts with significant
bicomp & tricompartmental OA.
• Results of the procedure progressively
detoriates.

5. INDICATIONS
• Gonarthrosis in Pts with varus limb alignment.
• Gonarthrosis in Pts with valgus limb
alignment.
• Aduit osteochondritis dissecans.
• Osteonecrosis [Medial condyle]
• Posterolateral instability.

6. CONTRAINDICATIONS
• Dffuse nonspecific knee pain
• Primary compliant of patellofemoral pain
• Menisectomy in the compartment intended
for Wt bearing.
• Arthrosis in the compartment intended for Wt
bearing.
• Inflammatory arthritis, chondrocalcnosis
• Unrealistic Pt expectation.

7. • Medial compartment tibial bone loss of > 2 or
3 mm
• Flexion contracture > 15*

8. RELATIVE C.I
• Age older than 60 yrs
• ROM arc less than 90 degrees
• Obesity [> 80 kg]
• Severe arthrosis
• Tibiofemoral subluxation [> 1 cm]
• Moderate to severe ligamentous instability.
• ACL tear.

9. CLASSIFICATION
• Gariepy and Coventry: lateral based closing
wedge osteotomy, proximal to anterior tibial
tubercle.
• Slocum et al: Modification of coventry, leaving
a posterior lip of cortex in proximal tibial
segment.
• Macquet: Barrel vault or dome osteotomy,
stabilised with Ext. compression device

10. used for larger deformities and for knees with
tibiofemoral subluxation.
• Wagner: Oblique metaphyseal P.T.O just
below the tibial tubercle, displacement
osteotomy of proximal tibia for larger defects.

11. • Varus deformity up to 10* off the mechanical
axis  transverse laterally based closed
wedge P.T.V.O
• Up to 20* Wagner’s oblique P.T.O
• > 20* dome osteotomy of proximal tibia or
metaphyseal osteotomy of proximal tibia.

12. VARUS OSTEOTOMY
• For isolated lateral comp, OA & valgus knee.
• Valgus up to 12* can be corrected.
• For deformities with > 12* valgus, distal
femoral osteotomy is preferred in order to
maintain Jt line parellel to floor.

13. Closing wedge osteotomy
• Most commonly performed HTO
• C.I: when the affected limb is shorter than
other side
• Fixation: plate system / staples.
• ADVANTAGES:
1. More aggressive weight bearing and
rehablitation
2. Doesn’t require a graft.

14. • DISADVANTAGES
1. More difficult to control tibial slope often
decreased.
2. Intraop adjustments more difficult.
3. Proximal tibiofibular Jt violated
4. Increased risk of peroneal N. injury
5. Alters the shape of proximal tibia with
implications for TKR.

15. 6. Bone loss and shortening
7. May alter patellar Ht.

16. Opening wedge osteotomy
• Now a days commonly used.
• Indicated when affected side is shorter.
• Fixation: Plares, external fixator or spatial
frame [larger corrections], bone graft alone.

17. Advantages
• Potentially simpler
• Avoids proximal tibiofibular jt
• Avoids peroneal N.
• More control of multiplanar correction
• Avoid anterior compartment
• No bone loss.

18. disadvantages
• Less aggressive Wt bearing/ rehablitation
• Often requires a graft with potential
implications of healing/ union
• May overlengthen the limb
• May alter the patellar Ht.

19. Osteotomy site
• Proximal to the tibial tuberosity is preferred
• Quadriceps can exert compressive effect at
O.S
• Cancellous bone allows faster healing
• Osteotomy generally performed 1.5-2 cm
distal to the Jt line.

20. • More proximal resection causes proximal
fragment to be too thin and at a risk of intraop
# or AVN.
• Osteotomy too distal can disrupt the extensor
mech at T. tubercle.

21. Wedge size
• As a rule of thumb, removing 1 mm of tibial
wedge will provide 1 deg of correction.
• This is precisely true for a tibia which is 56 mm
wide.

22. X ray
• Full length supine and weight bearing AP X
rays are used to determine the desired
amount of correction.
• Radiographic methods for planning:
1. Mechanical axis method
2. Anatomic axis method
3. Supine over correction method.

23. Supine over correction method
• Based on the permise that patients whose
varus deformity is based in part on
ligamentous laxity needs less correction than
Pts with out laxity.
• Assumption: mechanical axis value just prior
to heal strike is similar to supne mechanical
axis
• Measure the supine mech axis and add 10
degrees of correction.

24. Management of fibula
• Proximal tibiofibular jt will prevent valgus
correction unless fibula is shortened or
tibiofibular lig are removed.
1. Transection of tibiofibular ligaments
[preferred tech]
2. Fibular head transection
3. Fibular transection.

25. complications
• Patellar baja [lateral closing wedge o.
associated with high incidence], arises due to
contracture of patellar lig.
• Fracture of the far cortex or the intra-articular
#. [restrict osteotomy to 10 mm of far cortex]
• Osteonecrosis of prximal frag.

26. • Non union
• Neurological injuries. [1-10%]
when ext, fix is used, osteotomy of fibular
head, corrections greater than 15*.
• Incomplete correction
• DVT
• Compartment syndrome.

27. TKR vs HTO
• Disease distribution
• Age
• Patient activity level.
physiologically young high demand Pts are
suitable candidates for HTO.

28. • Long term studues indicate clinical success of
HTO detoriate with time.
• Most studies suggest that more than 50% HTO
remain effective at 7-10 yrs.
• Arguably TKR canbe successfully postponed
for at least 7-10 yrs in most appropriately
selected pts.