2. 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.
Jacksonâs concept was subsequently adopted by
Coventry et al and Insall et al,who refined and
popularized the lateral closing wedge HTO
3. 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 procedureâs limitations
evolution and clinical success of total knee
arthroplasty (TKA)
4. drawbacks:
it is not an ideal treatment option for patients
with significant bicompartmental or
tricompartmental disease
results of the procedure progressively
deteriorate
5. 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.
6. Indications for High Tibial
Osteotomy
⢠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
7. Vargus Limb Alignment
The 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
8. 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
9. 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.
10. 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.
11. 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.
12. 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
13. Contraindications to High
Tibial 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,
14. Arthroplasty Versus High
Tibial 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.
15. Osteotomy Techniques
⢠three principle techniques
lateral closing wedge osteotomy,
medial opening wedge osteotomy,
dome osteotomy
16. Techniques for valgus-producing high tibial osteotomy. A, Lateral closing wedge. B,
Medial opening wedge. C, Dome osteotomy.
17. Lateral closing wedge osteotomy
used by Coventry et al and Insall et al
advantage of producing apposition of two broad
metaphyseal surfaces, thus optimizing inherent stability and
healing potential
it is made near the deformity
it permits exploration of the knee through the same incision
traditionally performed with freehand cuts and stabilized with
either bone staples or cylinder casts
Potential problems associated with these methods include
patella baja and an inability to precisely achieve the desired
amount of correction.
18. 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
19.
20. Use of an alignment jig allows the surgeon
precise control of angular correction
during a lateral closing wedge high tibial
osteotomy.
21. 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
22. 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.
23. 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
24. 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
25. 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
26. Cartilage Regeneration After High
Tibial 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 dĂŠbridement and HTO compared
with HTO alone
Schultz and Gobel documented improved cartilage
regeneration when HTO was combined with abrasion
arthroplasty
28. Total Knee Arthroplasty
After 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
29. `
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
