Osteotomy of the proximal tibia has been used formore than a century to correct angular deformityin the setting of rickets, poliomyelitis, andposttraumatic conditions.Jackson is credited being the first in the English-language literature to report performing aproximal (high) tibial osteotomy (HTO) to treatosteoarthritis of the knee.Jackson’s concept was subsequently adopted byCoventry et al and Insall et al,who refined andpopularized the lateral closing wedge HTO
In the United States, initial experience indicatedthat HTO was effective in relieving the pain ofunicompartmental osteoarthritisHTO has been temporized by two factors:recognition of the procedure’s limitationsevolution and clinical success of total kneearthroplasty (TKA)
drawbacks:it is not an ideal treatment option for patientswith significant bicompartmental ortricompartmental diseaseresults of the procedure progressivelydeteriorate
use HTO(1) medial compartment osteoarthritis in physiologicallyyoung, active patients, for whom TKA is imperfect forlong-term solution.(2) HTO imposes no permanent activity restrictions(3) Superior results are more likely with contemporaryfixation and postoperative management techniques afterHTO(4) Evolving chondral resurfacing techniques arecontraindicated in the presence of tibiofemoral malalignmandate concomitant correction of significant coexistentangular deformity.(5) Combining HTOwith chondral resurfacing procedures mayprovide better results than would HTOalone.
Indications for High TibialOsteotomy• 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 theoperation and the possession of sufficient muscle strengthand motivation to carry out a rehabilitation program• good vascular status without serious arterial insufficiencyor large varicosities
Vargus Limb AlignmentThe most common indication for HTOis isolated medialcompartment degenerative joint disease withassociated varus tibiofemoral malalignmentThe rationale behind performing a valgus-producing HTOin the context of unicompartmental degenerative jointdisease is to unload the arthritic medial compartment.The ideal patient for this procedure is physiologicallyyoung and activeElderly patients (chronologically older than 60 years) withlow functional demand typically are more appropriatecandidates for TKA
Valgus Limb AlignmentIsolated lateral compartment osteoarthritis is muchless common than isolated medial compartmentosteoarthritis.Most authorities have a preference for performinga varus-producing distal femoral osteotomyrather than a varus producing HTOCorrecting the valgus angulation on the tibial sideof the knee has been criticized because a valgus-producingHTO produces obliquity of thetibiofemoral joint line
Adult Osteochondritis DissecansHTOshould be considered in physiologicallyyoung, active adults with osteochondritisdissecans of the medial femoral condyleauthor reported that HTO reliably decreasespain and improves function in patients withosteochondritis dissecans.
Osteonecrosisosteonecrosis typically affects individuals older than 60 years,TKA and unicompartmental knee arthroplasty (UKA) are themost commonly considered salvage operations.HTO is a valid alternative to arthroplasty for physiologicallyyoung patients with osteonecrosis of the medial femoralcondyleAccording to author HTO not only decreases discomfort andpostpones the need for TKA, but it also leads to regressionof the underlying diseaseKoshino also observed that the efficacy of HTO was enhancedby concomitant drilling and/or bone grafting of theosteonecrotic lesion.
Posterolateral InstabilityIsolated soft-tissue reconstruction proceduresfor posterolateral insufficiency are likely to failin the setting of varus alignment because thereconstruction is subjected to excessivetensionHence, performing a valgus-producing HTObefore or in conjunction with the ligamentousreconstruction should be considered whenthere is varus malalignment.
Chondral ResurfacingTechniques for repairing focal chondral defectsinclude marrow stimulation (ie, subchondraldrilling, abrasion arthroplasty, microfracture),autologous chondrocyte implantation,osteochondral autograft transplantation , andautogenous periosteal grafting.Because most isolated articular cartilage lesionswithin the knee affect the medial femoralcondyle, the realignment procedure typicallyindicated during knee cartilage repair is a valgus-producing HTO
Contraindications to HighTibial Osteotomy valgus-producingsevere lateral compartment degenerative joint diseaseloss of a significant portion of the lateral meniscussymptomatic patellofemoral degenerative joint diseasenonconcordant pain (ie, patellofemoral pain with medialcompartment osteoarthritis)patient unwillingness to accept the anticipated cosmeticappearance of the desired amount of angular correctionInflammatory arthritis.more than 20 degrees of correction neededknee flexion of less than 90 degreesflexion contracture of more than 15 degreeslateral tibial subluxation of more than 1 cm,
Arthroplasty Versus HighTibial OsteotomyIsolated medial compartment disease in a physiologicallyyoung, high-demand individual is the ideal scenario forHTOMulticompartmental disease in a physiologically old, low-demand individual is the ideal scenario for TKA.Isolated medial compartmental disease in aphysiologically old, low demand individual is anappropriate situation for eitherTKAor UKA.UKA should not be considered a substitute for HTO in thephysiologically young, high demand individual withisolated medial compartment disease.
Techniques for valgus-producing high tibial osteotomy. A, Lateral closing wedge. B,Medial opening wedge. C, Dome osteotomy.
Lateral closing wedge osteotomyused by Coventry et al and Insall et aladvantage of producing apposition of two broadmetaphyseal surfaces, thus optimizing inherent stability andhealing potentialit is made near the deformityit permits exploration of the knee through the same incisiontraditionally performed with freehand cuts and stabilized witheither bone staples or cylinder castsPotential problems associated with these methods includepatella baja and an inability to precisely achieve the desiredamount of correction.
More recently, calibrated cutting guides, rigidinternal fixation devices, and earlymobilization have produced improved resultsand low complication rates after lateral closingwedge osteotomy
Use of an alignment jig allows the surgeonprecise control of angular correctionduring a lateral closing wedge high tibialosteotomy.
medial opening wedgeused to treat medial compartmentosteoarthritis since 1951 in francefixation is achieved by either a medialdistraction plate or an external fixator.it is technically easier for the surgeon to achievethe precise desired amount of angularcorrection than with lateral closing wedgeHTO
Merit and demeritinclude less extensive surgical dissection and lackof proximity to the peroneal nerve.no need to mobilize the proximal fibula.Medial closing wedge constructs are relativelyunstable; hence, loss of fixation, nonunion, anddelayed union are likely to be more frequent thanafter lateral closing wedge osteotomy.immediate weight bearing is not appropriate after amedial opening wedge procedure and typically isdelayed for 6 to 8 weeks.
When medial opening wedge osteotomy fixationis achieved with a distraction plate, autograftand/allograft bone is required, and associatedgraft morbidity issuesIf external fixation is used, the potential for pintract morbidity arises it could jeopardizesubsequent salvage with TKA
Dome osteotomyless commonly usedto be a more technically demanding operationbecause of the challenges of creating a curvedosteotomy and avoiding iatrogenic trauma tothe patellar tendonadvantage of intraoperative flexibility, whichallows the surgeon to achieve the preciseamount of desired angular correction
if combined with external fixation, the amountof angular correction may be adjustedpostoperatively as well.In contradiction to lateral closing wedge andmedial opening wedge techniques, domeosteotomy permits concomitant anteriortranslation of the tibial tubercle, which mayalleviate associated patellofemoral disease
Cartilage Regeneration After HighTibial OsteotomyBruce et al documented decreased medial compartmentscintigraphic uptake following valgus-producingHTO.Odenbring et al detected fibrocartilage proliferation andincreased cellularity of hyaline cartilage afterHTO,MacIntosh and Welsh reported superior clinical outcomeswith combined open débridement and HTO comparedwith HTO aloneSchultz and Gobel documented improved cartilageregeneration when HTO was combined with abrasionarthroplasty
Total Knee ArthroplastyAfter High TibialOsteotomyTKA following HTO is considered to be moretechnically demanding than TKA in theabsence of prior HTO.In some clinical study the results of TKA havebeen inferior following HTO Contracture of thepatellar tendon with resultant patella bajaincreases the technical difficulty of TKA afterHTO
`L-shaped scars from previous lateral closingwedge HTOs pose challenges for the surgeonperforming a subsequent TKA because of thepotential for skin necrosisThe surgeon must aware of the proximal tibialdeformation caused by the HTO whenplanning and executing proximal tibialresection at the time of TKA