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Updated: Aug 3 2023

High Tibial Osteotomy

  • Summary
    • High Tibial Osteotomy (HTO) is a surgical procedure that is performed to correct angular deformities of the knee to prevent development or progression of unicompartmental osteoarthritis. 
    • It is predominately done to correct for varus deformities in young patients but can also be done to correct valgus deformities.
    • Contraindications include inflammatory arthritis, flexion contracture > 15 degrees, bicompartmental osteoarthritis, and ligamentous instability. 
  • Epidemiology
    • Primary or secondary medial knee arthrosis is the most common indication
    • Isolated lateral compartment osteoarthritis is much less common
  • Etiology
    • Use
      • predominately done for varus deformities
      • less common for valgus deformities
    • Angular deformity in the knee leads to abnormal distribution of weight bearing stresses
      • can accelerate wear in medial or lateral compartments of the knee and lead to degeneration
      • HTO is commonly combined with cartilage restoration procedures to provide better mechanical environment for biologic repair
  • Anatomy
    • Mechanical axis of lower extremity
      • can be assessed by drawing straight line from center of femoral head to the center of the ankle joint
      • line axis should pass just medial to the medial tibial spine
  • Classification
    • Varus vs Valgus alignment
  • Presentation
    • Symptoms
      • pain on medial or lateral side of knee
    • Exam
      • knee malalignment
  • Imaging
    • Radiographs
      • standing alignment hip-to-ankle films
        • show knee malalignment using mechanical axis line
  • Studies
  • Treatment
    • Indications
      • young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear
      • healthy patient with good vascular status
      • non-obese patients
      • pain and disability interfering with daily life
      • only one knee compartment is affected
      • compliant patient that will be able to follow postop protocol
    • General contraindications
      • inflammatory arthritis
      • obese patient BMI>35
      • flexion contracture >15 degrees
      • knee flexion <90 degrees
      • procedure will need >20 degrees of correction
      • patellofemoral arthritis
      • ligament instability
      • varus thrust during gait
    • Valgus-producing tibial osteotomy
      • Goals
        • unload the involved joint compartment by correcting tibial malalignment
          • A medial unloader brace can be used for therapeutic and diagnostic purposes. If a patient benefits from the brace, they are likely to benefit from surgery.
        • maintain the joint line perpendicular to mechanical axis of the leg
      • Indications
        • can be done for varus knee with medial compartment degeneration (more common)
        • best results achieved by overcorrection of the anatomical axis to 8-10 degrees of valgus
      • Contraindications
        • narrow lateral compartment cartilage space with stress radiographs
        • loss of lateral meniscus
        • lateral tibial subluxation >1cm
        • medial compartment bone loss >2-3mm
        • varus deformity >10 degrees
    • Varus-producing tibial osteotomy
      • Used less commonly than distal femoral osteotomy
        • produces obliquity of the tibiofemoral joint line
      • Goals
        • unload the involved joint compartment by correcting tibial malalignment
        • maintain the joint line perpendicular to mechanical axis of the leg
      • Indications
        • can be done for valgus knee with lateral compartment degeneration
          • deformity should be <12 degrees or else the joint line will become oblique
      • Contraindications
        • medial compartment arthritis
        • loss of medial meniscus
        • distal femoral osteotomy better if lateral femoral condyle hypoplasia present
        • adjunct to soft tissue reconstructive surgeries (ACL/PCL/MACI) when there is coronal malalignment
  • Technique
    • Lateral closing wedge technique
      • wedge of bone removed with tibia via an anterolateral approach
      • ORIF of wedge
      • has advantages
        • more inherent stability allows for faster rehab and weight bearing
        • no required bone grafting
    • Medial opening wedge technique
      • transverse bone cut made in proximal tibia, and wedged open on medial side
      • ORIF of wedge
      • has advantages
        • of maintaining posterior slope
        • avoids proximal tibiofibular joint
        • avoids peroneal nerve in anterior compartment
    • Focal dome osteotomy (concavity proximal)
      • the center of the dome is located at the center of rotation of angulation (CORA)
      • has advantages
        • corrects limb alignment with the least translation of bone ends
        • least translation of anatomical axis
        • minimal shortening
  • Complications
    • Recurrence of deformity
      • 60% failure rate after 3 years when
        • failure to overcorrect
        • patients are overweight
    • Loss of posterior slope
    • Patella baja
      • refers to a shortened patellar tendon which decreases the distance of the patellar tendon from the inferior joint line
        • can be caused by raising tibiofemoral joint line in opening wedge osteotomies
        • can be caused by retropatellar scarring and tendon contracture
        • can cause bony impingement of patella on tibia
    • Compartment syndrome
    • Peroneal nerve palsy
      • more common in lateral opening wedge osteotomy and lateral closing wedge osteotomy
      • minimal risk in medial opening wedge osteotomy
    • Malunion or nonunion
  • Prognosis
    • Varus-producing high tibial osteotomy
      • success rate is 87% in 10 years
    • Valgus-producing high tibial osteotomy
      • success rate is 50-85% in 10 years
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