This document discusses high tibial osteotomy (HTO), a surgical procedure to treat varus deformity and medial compartment osteoarthritis of the knee. It outlines the indications, contraindications, surgical techniques, preoperative planning, alignment goals, and complications of HTO. The goals of HTO are to relieve pain, improve function, and extend the life of the knee joint for active patients who are too young for knee replacement surgery. Attention to patient selection, preoperative planning, surgical accuracy, and rehabilitation are important for achieving successful outcomes.

1. HIGH TIBIAL OSTEOTOMY (HTO)
BY DR. RANVEER PATEL
ORTHOPAEDIC SURGEON, SHREEJI ORTHOPAEDIC CARE

2. Introduction
 Prior to development of TKA, HTO was the most common surgical
treatment for varus gonarthrosis
 The surgical technique was primarily a closing wedge or dome
osteotomy
 The prevalence of the HTO has declined because of the success TKR
and UKA

3. Introduction
 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. Indications
 The ideal candidate for a proximal valgus osteotomy is a young, physically
active patient with medial compartment osteoarthritis of the knee and varus
tibiofemoral alignment
 The patients have pain on the medial aspect of the knee and radiographic
evidence of medial arthrosis demonstrated by less than 4 mm of medial joint
space on a standing knee film
 It is generally agreed that no lateral pain should exist preoperatively
R.P.Jakob, MD et al
ICL 2015

5. Absolute Contraindications
 Inflammatory disease
 Stiffness (90°- 120°)
 Severe patellofemoral arthrosis (?)
 Meniscectomy in the compartment intended for weight bearing
 Unrealistic patient expectations

6. Relative Contraindications
 Obesity (BMI > 30 ?)
 Age older than 60 years
 Severe arthrosis in the medial compartment (Ahlback or Outerbridge grade 3 or
higher)
 Tibiofemoral subluxation
 Moderate or severe ligamentous instability
 Smoking

7. Surgical Techniques
 Lateral closing tibial wedge osteotomy
 Medial opening tibial wedge osteotomy
 Dome tibial osteotomy
 Double-osteotomy

8. Preoperative Planning
 AP , Lat. , Intercondylar notch views
 Skyline view of patella in 30 flexion
 Full-length, weight-bearing hip-knee-ankle radiographes
 CT-Scan
 MRI

9. Preoperative Varus
 The principal considerations include the
location, direction, and magnitude of
malalignment

10. Preoperative Varus
 Tibial bone varus angle (TBVA), is the angle between the mechanical axis of the
tibia and the epiphyseal axis of the proximal tibia.
 TBVA is an important prognostic factor (>5°)

11. Preoperative Varus
 Age 37/ Female
 Varus (Mechanical Femorotibial
Angle): 11°
 mLDFA (Mechanical Lateral
Distal Femoral Angle): 89°
 MPTA (Medial Proximal Tibial
Angle): 80°
 CA (Convergence Angle): 2°

12. Postoperative X-Ray

13. Preoperative Varus

14. Preoperative Varus
 Age 38 years/ Female
 Varus (Mechanical
Femorotibial Angle): 18°
 mLDFA (Mechanical
Lateral Distal Femoral
Angle): 96°
 MPTA (Medial Proximal
Tibial Angle): 85°
 CA (Convergence Angle):
7°

15. Postoperative X-Ray

16. Preoperative Varus

17. Preoperative Varus
 There is no consensus on the minimum amount of varus that indicates the need
for HTO
 Patients with as little as 4° of varus of the mechanical axis and
unicompartmental medial disease can benefit from HTO

18. Postoperative Alignment
 Undercorrection of varus during a tibial osteotomy is associated with inferior
results.
 The consensus opinion is that correction in the presence of degeneration
should be to beyond neutral.

19. Postoperative Alignment
 Some authors recommend correction to 1-2° of
mechanical axis valgus. Weight bearing axis
slightly lateral to the center of the knee.
 Some recommend a correction that results in
passage of the W-B line through the 62%
coordinate of the tibial articular surface

20. Intraoperative Alignment
 Precise intraoperative measurements of correction are difficult to achieve.
 The mechanical axis can be estimated intraoperatively using a Bovie cord or an
alignment rod.
 Meticulous preoperative planning.
 Navigation

21. Postoperative Alignment
 Mechanical axis valgus is
beneficial regarding knee pain
outcomes , it also produces a
visually obvious alignment.
 The patient may be dissatisfied
with this procedure due to
cosmetic.

22.  Infection
 Loss of alignment
 Nerve and vessel injury
 Hardware problems
 Nonunion
 Persistent or Recurrent pain
Complications

23. Persistent Or Recurrent Pain
 It’s important for patients to understand that a successful result is a substantial
reduction in pain, not necessarily the elimination of pain.
 Studies commonly report a 4-to 5- point improvement on a 0-to 10- point pain
scale.
 A small percentage of patients treated with HTO (4% to 26%) do not have
satisfying pain relief.

24. HTO vs. Arthroplasty
 Valgus HTO is more appropriate for younger patients who accept a slight
decrease in their physical activity
 Medial UKA is appropriate for younger patients obtaining sufficient pain relief
but with reduced physical activity

25. Clinical results
 Studies have reported 10-year
survival rates ranging from 74% to
96%.
 Reports for opening and closing
wedge osteotomies have been
similar.

26. ..

27. 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