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High Tibial Osteotomy
Updated: Oct 4 2016

TKA Revision

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating

  • template implant sizes


Execute surgical walkthrough

  • describe steps of the procedure to the attending prior to the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • knowledge of the particular implant system and instruments


Room setup and equipment

  • required operative table
  • leg holder (optional)


Patient positioning

  • supine position
  • use a bump under the operative hip to minimize hip external rotation. <br>
  • A foot holder is used to hold the knee at 90 degrees or more of flexion for parts of the case.<br />
  • A tourniquet is placed, but must be proximal to allow adequate room for prepping and draping.

Superficial Dissection


Identify previous incision and anatomy

  • identify tibial tubercle, patella, and patellar ligament.
  • extend the midline incision more proximal to allow adequate access


Expose the extensor mechanism

  • expose the entire extensor mechanism (quad tendon, patella, and patellar ligament.)


Create Skin Flaps

  • elevate skin flaps just deep the the fascia
  • the perforating arteries which supply the skin run just superficial to the deep fascia

Arthrotomy and Deep Exposure


Identify medial aspect of patellar tendon and quadriceps tendon

  • identify the medial aspect of the patellar ligament, medial aspect of the patella and the quad tendon lateral to the vastus medialis oblique (VMO).


Perform an extended arthrotomy

  • start from the proximal aspect in a longitudinal manner curving medially around the patella,
  • leave 3-5 mm of soft tissue on the patella
  • complete the arthrotomy by a straight distal cut along the medial border of the patellar ligament.<br>
  • extended exposure is needed to visualize the medial and lateral femoral gutters
  • avoid any disruption of the tendon insertion on the tibial tubercle
  • the main danger of the approach is avulsion of the patellar ligament. <br>


Clear the medial and lateral femoral gutters

  • clear and excise any excessive synovium that is overlying the distal femur in the suprapatellar pouch
  • remove any fibrotic fat pad that is present


Perform quadriceps snip

  • incise the quadriceps tendon
  • incise in a lateral oblique fashion from distal to proximal at a 45 degree angle
  • split the vastus lateralis muscle fibers
  • this will increase lateral patellar subluxation,knee flexion and exposure of the lateral compartment of the knee
  • quadriceps snip should exit the quadriceps tendon distal to the musculotendinous junction of the rectus femoris


Flex knee, and evert patella

  • flex the knee to at least 90 degrees and evert the patella


Place retractors

  • A lateral retractor is then placed under the lateral meniscus near the mid-coronal plane
  • a medial retractor retracts the medial sleeve
  • posterior retractor (PCL or Homan style) is placed in front to the PCL to push the tibia anteriorly

Component Removal


Remove polyethylene

  • place an osteotome at the interface of the polyethylene and the tray
  • use the osteotome to lever the tray out
  • if a pin is present posteriorly, use a saw to divide the post to expose the metal pin
  • remove the pin with a rongeur


Remove tibial component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • externally rotate the tibia to expose the posterior aspect of the tibias component
  • create a clear path for component removal
  • the posterolateral aspect of the tibial component must clear the posterolateral femoral condyle
  • hyperflexion is needed to achieve this
  • disimpact the tray with a punch
  • if does not separate easily then stack osteotomes
  • avoid levering the bone to prevent bone loss
  • remove any remaining cement with rongeurs if needed


Remove femoral component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • use osteotomes to deepen disruption of the interface
  • disrupt the interface from medial and lateral sides
  • don`t try to traverse the entire interface from one side
  • disrupt the posterior condylar interface with a curved or angled osteotoe
  • remove the implant by hand or with a punch after it has been dislodged
  • remove any remaining cement with rongeurs if needed


Remove patellar component

  • identify the prosthesis cement interface or the prosthesis bone interface
  • disrupt the interface
  • use a thin saw blade to disrupt the interface
  • burr out the pegs

Create Tibial Platform


Size the tibial component

  • maximize coverage of the upper end of the tibia


Place the tibial component

  • place the component in slight external rotation
  • align the center of the component with the junction of the medial and middle third of the tibial tubercle

Femoral Trial and Augments


Trial the femoral component with long stem

  • this determines the varus aligment
  • place a posterolateral augment
  • this is to ensure the appropriate external rotation of the revision component

Trialing of Implants


Trial the knee with varying thickness of polyethylene


Balance extension gap

  • balance extension gap in extension.


Balance flexion gap


Check varus valgus balance.

  • perform soft issue release
  • perform appropriate releases (medial, lateral, AP )


Confirm implant size and have team prepare cement.


Place the cement

  • pulse lavage bone to prepare for cementing. <br>
  • place cement on tibia and femur.


Place final implants

  • place tibial, femoral, and patellar components and trial poly liner


Confirm final flexion, extension, varus, valgus stability

  • treat any intraoperative complications

Wound Closure


Irrigate and obtain hemostasis


Place drain (optional)


Repair the quadriceps tendon

  • repair the tendon in a side to side fashion


Closure joint capsule with running suture

  • the joint capsule is closed with interrupted or running suture
  • closing the capsule at the proximal and distal patellar poles works well to line up the remaining capsular closure.


Perform superficial closure

  • use interrupted 3-0 vicryl for subcutaneous tissue
  • run subcutaneous monocryl sutures
  • to approximate the skin edges to lessen tension on the skin closure.
  • apply staples
  • reinforces closure for early rehabilitation


Dressing is applied

  • add xeroform over staples
  • apply soft dressing
Postoperative Patient Care
Private Note

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