indian population is prone for osteoarthritis of knee. also in indian children due to rickets genu varum is common. high tibial osteotomy is a procedure to correct the deformity & resolve unicompartmental arthritis

1. HIGH TIBIAL OSTEOTOMY
By Dr. Ranveer Patel
Orthopaedic Surgeon,
Shreeji Orthopaedic Care

2. INTRODUCTION
• High tibial osteotomy is effective for managing
a variety of knee conditions, including
1) gonarthrosis with varus malalignment
2) osteochondritis dissecans,

3. ..
Goals of osteotomy include pain relief, functional
improvement, and increase the life span of the
knee joint
With appropriate patient selection, accurate pre-
operative planning, modern surgical fixation
techniques and rapid rehabilitation, osteotomy
around the knee is now an effective biological
treatment for degenerative, deformity, knee
instability

4. …
The fundamental goals of the procedure are
to unload diseased articular surfaces and to
correct angular deformity at the tibiofemoral
articulation.
the procedure remains very useful in
appropriately selected patients with
unicompartmental knee disease.

5. WHAT HISTORY SAYS…
• JACKSON IS CREDITED BEING THE 1ST
PERFORMING PROXIMAL (HIGH) TIBIAL
OSTEOTOMY TO TREAT OSTEOARTHRITIS OF
THE KNEE
• JACSON’S CONCEPT THEN ADOPTED BY
COVENTRY ET AL & INSALL ET AL, WHO
REFINED & POPULARIZED LATERAL CLOSING
WEDGE HTO

6. ..
• OSTEOTOMY OF THE PROXIMAL TIBIA HAS
BEEN USED FOR MORE THAN A CENTURY TO
CORRECT ANGULAR DEFORMITY IN
 RICKETS
 POLIOMYELITIS
POST TRAUMATIC CONDITIONS

7. Reasons For Renewed interest in
high tibial osteotomy
• The prevalence of physiologically young active patients
presenting with medial compartment osteoarthritis;
• the advent of new techniques for performing the
procedure (ie, improved instrumentation and fixation
plates for medial opening wedge osteotomy, dynamic
external fixation for medial opening wedge osteotomy,
& improved instrumentation for lateral closing wedge
osteotomy)
• the need to concomitantly correct malalignment when
performing chondral resurfacing procedures
(ie,autologous chondrocyte transplantation,
mosaicplasty, and microfracture).

8. INDICATIONS
• OSTEOARTHRITIS PTS. WITH VARUS LIMB
ALIGNMENT
• ADULT OSTEOCHONDRITIS DISSECAN

9. OSTEOARTHRITIS PTS. WITH VARUS
LIMB ALIGNMENT
• MOST COMMON INDICATION
• ISOLATED MEDIAL COMPARTMENT
DEGENERATIVE JOINT DISEASE WITH
ASSOCIATED VARUS TIBIOFEMORAL
MALALIGNMENT
• IDEAL PT. IS YOUNG & ACTIVE

10. CONTRAINDICATIONS
• The principle contraindications to valgus-
producing HTO are
(1) lateral compartment degenerative joint
disease,
(2) loss of a significant portion of the lateral
meniscus
(3) symptomatic patellofemoral degenerative
joint
disease,
(4) Patellofemoral osteoarthritis

11. …
• >20% DEGREES OF CORRECTION NEEDED
• KNEE FLEXION LESS THEN 90 DEGREES
• FLEXION CONTRACTURE OF MORE THAN 15
DEGREES
• LATERAL TIBIAL SUBLUXATION OF MORE
THEN 1 CM

12. OSTEOTOMY TECHNIQUES
• 3 PRINCIPLE TECHNIQUES
1) LATERAL CLOSING WEDGE OSTEOTOMY
2) MEDIAL OPENING WEDGE OSTEOTOMY
3) DOME OSTEOTOMY

13. LATERAL CLOSING WEDGE
OSTEOTOMY
• USED BY COVENTRY ET AL AND INSALL ET AL
• ADVANTAGE OF PRODUCING APPOSITION OF
2 BROAD METAPHYSEAL SURFACES,THUS
OPTIMIZING STABILITY & HEALING POTENTIAL
• IT IS MADE NEAR THE DEFORMITY
• IT PERMITS EXPLORATION OF THE KNEE
THROUGH THE SAME INCISION

14. ..
• More recently calibrated cutting guides, rigid
internal fixation devices,& early
mobilizationhave produed improved results &
low complication rates after lateral closing
wedge osteotomy

15. MEDIAL OPENING WEDGE
OSTEOTOMY
• USED TO TREAT MEDIAL COMPARTMENT
OSTEOARTHRITIS SINCE 1951
• FIXATION IS ACHIEVED BY EITHER A MEDIAL
DISTRACTION PLATE OR EXTERNAL FIXATOR
• IT IS TECHNICALLY EASIER FOR SURGEON TO
ACHIEVE PRECISE DESIRED AMOUNT OF
ANGULAR CORRECTION THEN LATERAL
CLOSING HTO.

16. MERITS & DEMERITS
• INCLUDES LESS SURGICAL DISSECTION & LACK OF
PROXIMITY TO PARONEAL NERVE
• NO NEED TO MOBILISE PROXIMAL FIBULA
• MEDIAL WEDGE COSTRUCTS ARE RELATIVELY UNSTABLE SO
1) LOSS OF FIXATION
2) NON UNION
3) DELAYED UNION
ARE MORE FREQUENT THEN AFTER LATERAL
CLOSING HTO.
• IMMEDIATE WEIGHT BEARING IS NOT POSSIBLE AFTER
MEDIAL OPENING HTO AND DELAYED FOR 6 TO 8 WEEKS.

17. DOME OSTEOTOMY
LESS COMMONLY USED
TO BE A MORE TECHNICALLY DEMANDING
OPERATIONBECAUSE OF CHALLENGES OF
CREATING A CURVE OSTEOTOMY & AVOIDING
IATROGENIC TRAUMA TO PATELLAR TENDON
ADVANTAGE OF INTRAOPERATIVE FLEXIBILITY
WHICH ALLOWS THE SURGEON TO ACHIEVE
PRECISE AMOUNT OF DESIRED ANGULAR
CORRECTION.

18. OUR EXPERIENCE
• CASE NO. 1 :
PT.CAME WITH H/O TRAUMA ON
7/11/2011 AND HAD C/O OF PAIN &
RESTRICTED MOVEMENTS…AFTER 2
YEARS PT. SUBSEQUENTLY DEVELOPED
POST TRAUMATIC OSTEOARTHRITIS &
ADVICED FOR HTO…

19. PRE OPERATIVE X- RAY

20. PT. WAS OPERATED BY HTO ON
12/11/2013

21. POST OP X-RAYS

22. CASE NO.2
• 55 YR OLD PT. CAME WITH C/O SEVERE KNEE
PAIN & VARUS DEFORMITY & TREATED WITH
HTO USING ARTHREX LOCKING HTO PLATES

23. PRE OPERATIVE X-RAY

24. POST OPERATIVE

25. CARTILAGE REGENERATION AFTER HTO
• BRUCE ET AL DOCUMENTED DECREASED MEDIAL
COMPARTMENT SCINTIGRAPHIC UPTAKE
FOLLOWING VALGUS PRODUCING HTO
• ODENBRING ET AL DETECTED FIBROCARTILAGE
PROLIFERATION & INCREASED CELLULARITY OF
HYLINE CARTILAGE AFTER HTO
• REGENERATION IMPROVED WHEN HTO
COMBINED WITH ABRATION ARTHOPLASTY

26. COMPLICATIONSOFHTO
1) PATELLA BAJA
2) FRACTURE
3) NONUNION
4) PERONEAL NERVE PALSY
5) COMPARTMENT SYNDROME
6) INFECTION
7) THROMBOEMBOLISM

27. TOTALKNEEARTHOPLASTYAFTERHTO
• TKA FOLLOWING HTO IS CONSIDERED TO BE
MORE TECHNICALLY DEMANDING THEN TKA
IN ABSENCE OF PRIOR HTO

28. Conclusion
 Realignment osteotomy is a good option in active
patients with symptomatic medial compartment
osteoarthritis of the knee with varus deformity
 The key to success after osteotomy is careful
patient selection combined with skillful surgical
technique
 Accurate and appropriate pre-operative planning
is critical for HTO

29. THANK YOU
THANK YOU