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HIgh Tibial Osteotomy: when and how
- 1. HTO Planning : Howto do it Dr Abhishek Kaushik AO Fellow (Austria) AO National Faculty FJR (USA, UK and Germany)
- 2. Learning objectives • Historicalaspects • Physiological axis and anomalies • Indications • Principle of osteotomy • Planning (Medial Open Wedge) • Techniques • Complications • Take home
- 3. History Those who cannotremember the past, are condemned to repeat it • First modern osteotomy was done by American John Rhea Barton (1794– 1871) on sub-trochanteric femur. • Bernhard Heine (1800– 1846) from Germany designed first working osteotome
- 4. • Bernhard RudolfKonrad von Langenbeck (1810–1887) professor in Göttingen, Kiel, and Berlin, Germany, was the first to describe a subcutaneous osteotomy technique • Theodor Billroth (1829–1894) Professor in Zürich, Switzerland and Wien, Austria designend a chisel.
- 5. • Sir WilliamMacewen (1848–1924), Professor in Glasgow, performed the first antiseptic osteotomy in Great Britain on April 11, 1875. • In 1884, he presented his series of 1,800 cases without major complications. • His major work was on supracondylar region of humerus.
- 6. • Jackson, Waugh,Gariépy, Coventry were first to perform proximal tibial osteotomy for osteoarthritis knee. • Jackson did it distal to tibial tubercle • Coventry “Classical” lateral closed wedge valgization type with fibular osteotomy done proximal to tibial tubercle.
- 7. • Open-wedge osteotomywas first described by Lexer (1931). • In 1969 the AO advocated fixation using an angular plate for either varization or valgization osteotomy on the distal femur
- 8. Knee Axis • Theknee joint is the largest and most complex joint in the human body and has the longest lever arms.
- 9. • The mechanicalaxis of the leg (Mikulicz line) runs from the center of the femoral head to the center of the ankle joint. • Under physiological conditions this line runs on average 4 (± 2) mm medial to the center of the knee joint. (MAD) • The anatomical and mechanical femoral axes form an angle of 6° (± 1°) (aMFA).
- 10. • The tibialplateau is slightly shifted in a posterior direction in relation to the axis of the femoral diaphysis • Tilted caudally by 10° in relation to the horizontal line in the sagittal plane (tibial slope).
- 11. Deformed Leg /Knee • Deformities of the lower limb are defined as a deviation of the physiological axes • Can be pathologically altered in the frontal, sagittal or transverse or torsional plane. • The most frequent pathologies and therefore those of greatest clinical relevance are varus- valgus deformities in the frontal plane.
- 12. Varus • Anatomical femorotibial angle> 173–175° • Mikulicz line runs medial to the 4 mm point, significant in MAD > 15mm medial to the center of the knee joint • Increased intercondylar distance
- 13. Valgus • Anatomical femorotibial angle< 173–175° • Mikulicz line runs lateral to the 4 mm point, significant in MAD > 10 mm lateral to the center of the knee joint • Increased inter-malleolar distance
- 14. Causes • Congenital deformities •Constitutional deformities • Growth disorders with premature partial closure of the epiphyseal plate • Metabolic diseases (eg, rachitis) • Osteopathies (eg, renal osteopathy) • Posttraumatic deformities • Secondary deviation due to destruction of the joint surface (infection, Tumors) • Degenerative
- 15. Evaluation MAD –Mechanical AxisDeviation
- 16. • Clinical evaluationfor ligaments, skin and soft tissues. • Examination of Hips, knee and spine must be done. • X-rays standing and Stress views and patella views. • CT scannogram for measurement of angles. • MRI for evaluating cartilage, ligaments.
- 17.
- 18.
- 19. Indications • Oseoarthritis PatientsWith Varus Limb Alignment • Oseoarthritis Patients With Valgus Limb Alignment • Adult Osteochondritis Dissecans. • Osteonecrosis • Postero-lateral Instability • Chondral Resurfacing
- 20. Planning • Selection ofpatient: Most Important • Determining the deformity (Plane , Angle) • Determine the amount of correction desired • Choice of osteotomy • Implant selection • Develop a surgical plan • Execute
- 21. Patient Selection Guidelines •Stage of osteoarthritis (Uni / Bi/Advanced) • Ligamentous status • Type of deformity and reducibility • Age • Range of motion • Obesity • General medical status • Activity levels • Patient’s expectations.
- 22. The Ideal patientfor a HTO • Younger than 65 years (male) respectively 55 years (female) • Metaphyseal varus deformity of the tibia (TBVA > 5°) • Intact lateral compartment • Normal range of motion (<10° extension deficit) • Non-smoker (better healing) • Has a certain pain tolerance • May have ACL or PCL deficiency (can be addressed by the surgery by correcting slope) • BMI under 30
- 23. The ideal candidatefor a UKA • Older than 55 years • Has no osseous deformity and mere intra- articular wear. • Intact ligaments ( ACL, MCL) • Has a deformity which reduces completely in 20° of flexion under valgus stress • Has an intact lateral compartment • Has an almost normal range of motion • Has no inflammatory disease • Should preferably have a BMI under 30
- 24. The ideal candidatefor a TKA • Is older than 75 years • Has generalized and manifest osteoarthritis of the knee • Has significant and continuous pain during activities of daily life • May have extension or flexion deficits • May have axis deviation and bone deficiencies • Has limited expectations regarding activity and range of motion • May have ligament balance issues.
- 25. Contraindications of HTO •Correction needed >20 • Flexion contracture >15 ̊ • Knee flexion <90 ̊ • Tibial subluxation >1cm • Medial compartment tibial bone loss >3mm • Patella baja* • Inflammatory arthritis • Morbid obesity • Advancing Age
- 26. Other Factors • Surgeons'Skillset ( UKA/HTO/TKR) • Infrastructure available • Financial factors
- 27. Nature and localization •Prerequisites for the planning process are • A good quality weight-bearing x-ray of the entire lower extremity • Definition of the type and localization of the deformity • Knowledge of any associated ligament instability
- 28. Nature of Deformity •Varus deformity with • No loss of med cartilage • 1/3 loss of medial cartilage • 2/3 loss of medial cartilage • Bone on bone arthrosis • ACL Deficiency • PCL deficiency • Axial Rotation components • Femoral deformity components
- 29. Localization • Frontal andsagittal plane evaluation • a. Weight-bearing line b. Mechanical axis of femur and tibia c. Joint orientation angles d. Location of deformity (CORA) • Bowing of femur or tibia may coexist • Deformity in distal femur may coexist • Deformity in ankle
- 30. • Effect ofankle joint line inclination on HTO • Ankle joint inclined: corrects to normal after closed Wedge HTO • Ankle joint parallel to knee: gets inclined after surgery.
- 31. Planning • Level ofosteotomy: • Should be performed at the apex of the deformity for optimal correction. • The metaphysis of a long bone is the region of best healing capacity; Healing time favors tibia over femur. • Double osteotomy may sometime be needed in complex deformities.
- 32. Planning • Open v/sClosed: • Open-wedge are generally easier and more precise to perform. • Opening procedure allows for intraoperative “fine-tuning” by adjusting the opening. • Open wedge may require bone grafting. ( not in angle stable devices) • Open may have more chances of delay union.
- 33. Open v/s Closed •Patella baja (Rel elevation of Joint line) • Insufficient medial collateral ligament (open-wedge technique allows tensioning) • Simultaneous medial arthrotomy is required. • Patella alta (Relative lowering of joint) • Intact medial collateral ligament • Simultaneous lateral arthrotomy is required
- 34. • Open-wedge HTO •Faster surgery • Bone graft necessary in case of high correction • Higher precision • Risk of saphenus nerve lesion • Gain in Limb length ( av 5.5 mm) • Longer consolidation • Closed-wedge HTO • Longer surgery • No graft necessary • Lower precision • Risk of peroneus nerve lesion • Shorter consolidation • Loss of limb length (2.4 mm)
- 35. • Correction ofSagittal Plane: • If anterior knee instability ( ACL insufficiency) is present, the tibial slope should be decreased (<5ᴼ ) to minimize anterior force. • Posterior cruciate ligament (PCL insufficiency) the slope should be increased (up to 12ᴼ) to reduce posterior force vector.
- 36. Effect of slopecorrection on tibial translation
- 37. • Correction attransverse plane • Should be corrected at the level of deformity to achieve optimal patellar tracking • Location of Hinge points: • Importance of choosing correct hinge points of osteotomies in open or closed wedge procedures can’t be overemphasized.
- 38. Amount of correction •Goal is to normalize the mechanical axis or to overcorrect it to valgus side. • Determination of the correction depending on residual cartilage thickness in the involved compartment : Fujisawa Scale
- 39. Fujisawa Point • Itsan imaginary point on lateral tibial condyle at 62% of scale of tibia from medial to lateral ( 0 to 100%) or at 31% of lateral tibial plateau from center.
- 40. Fujisawa scale • Ina well-aligned knee, load distribution is not well-balanced but physiologically 60% in the medial and 40% in the lateral compartment
- 41. • Overcorrection byshifting the weight-bearing line slightly to the lateral compartment is required. • The correction between 10% and 35% laterally on the Fujisawa-scale is adv.
- 42. Angle of Correctionrequired • Mathematical method • c × (ΔS) β= ------------- TW • C constant 76.4 • ∆ S : incremental lateral joint separation
- 43. • In thegiven case. • TW 80 mm • ∆S is 4 mm (7-3 mm) • So the angle required will be 3.8 ∘
- 44. Amount of Wedgerequired • It depends upon width of proximal tibia and angle of correction required. • Length = Diameter of tibia X 0.02 X Angle
- 45. Table for measuringresection size
- 46. Correction Angle • Onpaper tracings of x-rays • Draw a line from Head of femur to Fujisawa point. • Second line from just above tip of fibula to center of ankle
- 47. • Calculate theangle between two lines. • Draw that angle on proximal tibia with apex at just above tip of fibula. • Cut the line and open the wedge to see the correction.
- 49.
- 51. • Superficial MCLis identified and divided • And pes is identified.
- 52. • Osteotomy ismarked in an reverse L shaped line with horizontal limb parallel to Pes anserinus and then turning the vertical limb to an angle of 110 ᴼ just medial to tibial tuberosity and then going anteriorly across.
- 54. • Parallel guidewires are placed usually using the jig
- 55. • Length ismeasured to know the length of osteotomy
- 56. • Osteotomy is performedusing saw or osteotome with desired angle using markings or angle guides. • Do not pierce the lateral cortex.
- 57. • Anterior partof osteotomy completed taking care not to injure tibial tuberosity or patellar tendon.
- 58. • Lateral cortexs not fully broken while performing osteotomy to keep the medial hinge intact. • Chisels are inserted one over other to distract the osteotomy
- 59. • Osteotomy further openedup using spreader chisel to desired correction angle and also advanced till lateral cortex to open it fully.
- 60. • Finally usinglaminar spreader the osteotomy is opened up and fine tuning can be done here.
- 61. • Osteotomy tunedto see the axis correction using long rods and C arm
- 62. • When desired correctionis achieved , osteotomy kept open and plate fixation starts. • Proximal parallel screws guide pins inserted • Plate is pre-loaded by putting spacer screws in proximal and distal holes
- 63. • Position shouldbe checked under c arm
- 64. • After applyingproximal locking screws one cortical screw is applied in first distal hole.
- 65. • Cortical screwshould be applied little obliquely to avoid interfering with lock screw to be used later
- 66. • Tightening ofcortical screw would cause the compression of lateral cortex • This is caused by pre- loading effect of block/spacer screws used previously.
- 67. Sagittal correction • Conceptof sagittal correction • Neutral • Flexion( for Posterior instabilities) • Extension (for Anterior Instability)
- 68. • Sagittal correctioncan be done and position finalized
- 69. Case example • Varusdeformity with medial joint involvement.
- 70.
- 71. Problems • Unhappy patient( unsuitable patient selected) • Under and overcorrection. • Delayed healing • Non healing • Implant related problems • Problems related to patella • Persistent/New instability
- 72. • Plate causingimpingement to hamstring tendons. • Compartment syndrome *
- 73.
- 75. Take home message •Lateral Opening wedge osteotomy is a useful procedure in addressing medial joint arthritis in young adults • Requires suitable patient selection and meticulous planning • Long term Results are good and can be easily converted to total knee whenever required.
- 76.
Editor's Notes
- #45 So if length of tibia is 80 mm and to correct the angle of 15 degrees : 80 x 0.02 x 15= 24 mm wedge is required.