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High Tibial Osteotomy
Posted: Dec 8 2020 #(C101665)
A

Medial Knee Pain and Genu Varum in a 45M

HPI

The patient is a 45-year-old male who presents with severe right medial-sided knee pain which has been present for a number of years and progressively worsening. He notes pain is activity-related and associated with mechanical symptoms to include catching and locking, with no feelings of instability. He denies any inciting trauma. He is active duty military and has been on restricted activities for over 3 years, avoiding running or heavy lifting. Feels improvement with medial off-loader brace. He has also had multiple rounds of directed physical therapy and two prior corticosteroid injections prior to being referred to my office.

PMH

He is otherwise healthy with no past medical history.

PE

Focused physical examination demonstrates a profound clinical varus deformity, mildly antalgic gait with no varus thrust, moderate tenderness isolated over the medial joint line and otherwise full range of motion. Strength is 5/5 for knee flexion and extension. The knee is ligamentously stable, with genus varum that does not correct to neutral on manual stress, and the limb is neurovascularly intact. Positive McMurray and Thessaly localizing to the medial joint line. Rotational profile symmetric and within normal limits. Radiographic parameters: Anatomic lateral distal femoral angle: 84 degrees Mechanical lateral distal femoral angle: 90 degrees Anatomic/mechanical medial proximal tibial angle: 81 degrees Posterior tibial slope: 3 degrees

Poll
1 of 10
1. In addition to plain film radiographs of the knee, would you obtain further imaging to guide management?
No - additional imaging would not change my management
24%
238/959
Yes - additional radiographic views (XR) (includes stress films, alignment films, etc.)
7%
73/959
Yes - CT scan of the knee (CT)
1%
15/959
Yes - MRI scan of the knee (MRI)
45%
432/959
Yes - XR + CT
0%
9/959
Yes - XR + MRI
14%
136/959
Yes - CT + MRI
1%
18/959
Yes - XR + CT + MRI
1%
15/959
Outside my area of expertise - best if I don't vote
2%
23/959
2. How would you manage the patient at this time?
Nonoperative (continued physical therapy, activity modification, injections, etc.)
10%
93/917
Operative
86%
797/917
Outside my area of expertise - best if I don't vote
2%
27/917
3. If you choose Operative management, what surgery would you perform?
I would not choose Operative management
1%
15/939
Arthroscopy only (with interventions as indicated)
15%
142/939
Osteotomy only
12%
120/939
Arthroscopy + Osteotomy
64%
603/939
Arthroplasty
3%
32/939
Outside my area of expertise - best if I don't vote
2%
27/939
4. If you choose to perform an Osteotomy, what technique would you use?
I would not choose to perform an Osteotomy
3%
34/906
Medial opening-wedge high tibial osteotomy (HTO)
76%
689/906
Lateral closing-wedge HTO
11%
106/906
Focal dome HTO
1%
12/906
Distal femoral osteotomy (DFO)
1%
18/906
Outside my area of expertise - best if I don't vote
5%
47/906
5. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), how would you perform your cut?
I would not choose a Medial opening-wedge HTO
3%
29/876
Free-hand
25%
226/876
Cutting guide/jig
56%
492/876
Computer navigated
7%
64/876
Robotic
1%
11/876
Outside my area of expertise - best if I don't vote
6%
54/876
6. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), how would you correct the mechanical axis?
I would not choose a Medial opening-wedge HTO
2%
21/793
Under-correct - at or medial to the medial tibial spine (<50% of the tibial width)
7%
62/793
To neutral - through the center of the knee (@ 50% of the tibial width)
25%
200/793
Over-correct - at or lateral to the lateral tibial spine (50-62.5% of the tibial width)
40%
322/793
Over-correct - precisely to 62.5% of the tibial width
11%
94/793
Over-correct - at or lateral to the lateral tibial spine (62.5-75% of the tibial width)
3%
25/793
Outside my area of expertise - best if I don't vote
8%
69/793
7. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), would you address sagittal slope?
I would not choose a Medial opening-wedge HTO
2%
23/799
No - I do not attempt to address sagittal slope
60%
486/799
Yes - I would
28%
229/799
Outside my area of expertise - best if I don't vote
7%
61/799
8. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), how would you stabilize the osteotomy site?
I would not choose a Medial opening-wedge HTO
1%
14/797
Wedge only (includes screws)
4%
36/797
Plate and screws (w/wo partial wedge)
87%
697/797
External fixation (includes ringed circular fixation)
2%
17/797
Other
0%
1/797
Outside my area of expertise - best if I don't vote
4%
32/797
9. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), would you supplement the osteotomy site with any material?
I would not choose a Medial opening-wedge HTO
1%
15/783
No - I would leave the void
19%
151/783
Yes - non-structural allograft (e.g. DBX)
5%
43/783
Yes - structural allograft (e.g. tricortical iliac crest wedges)
23%
184/783
Yes - non-structural autograft (e.g. cancellous bone, BMA)
9%
75/783
Yes - structural autograft (e.g. iliac crest)
12%
100/783
Yes - bone graft substitute (e.g. calcium phosphate)
14%
117/783
Yes - autograft + bone graft substitute
6%
48/783
Yes - other
1%
8/783
Outside my area of expertise - best if I don't vote
5%
42/783
10. If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO) and attained the construct shown below, when would you begin weight-bearing post-operatively?
I would not choose a Medial opening-wedge HTO
1%
14/763
Immediately
8%
68/763
2 weeks
6%
51/763
4 weeks
12%
93/763
6 weeks
44%
342/763
8 weeks
12%
97/763
10 weeks
1%
13/763
12 weeks
6%
48/763
>12 weeks
1%
8/763
Outside my area of expertise - best if I don't vote
3%
29/763
PROCEDURE #1 DOP: 7/1/2019

Right knee diagnostic arthroscopy, medial meniscal debridement, medial opening-wedge high-tibial osteotomy

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