This document discusses the use of osteotomy procedures, specifically high tibial osteotomy (HTO), for treating osteoarthritis (OA) in younger patients with malalignment. It provides details on the purpose and techniques of HTO, including closed-wedge and open-wedge approaches. Ideal candidates for HTO are identified as those under age 60 with isolated medial compartment OA and varus malalignment of under 15 degrees. Complications of HTO procedures are outlined. Studies have found obesity, inadequate correction, and age over 50 to be negative prognostic factors, while joint line preservation is key to success.

1. OA in the ‘Young”
Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader
Knee Surgeon
South West London Elective Orthopaedic Centre
Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University
ICRC Specialist Surgeon (Geneva)

2. Purpose
Not to give you a lecture on OA

3. Purpose
The importance of realignment
procedures in combination with multi-
ligament surgery and chondroplasty
Ligament reconstruction, Chondral
procedures and even meniscal repairs are
all doomed to failure in Malaligned knees

4. 28 yrs old man
Neglected multilligament when he was 18

5. ICRC Weapon wounded Trauma Training
Centre in Tripoli/Lebanon

6. Realignment Procedures (Osteotomy)
Aims of osteotomy
Unload the affected compartment by
slightly overcorrecting into valgus/
varus
Unloading any ligament reconstruction
in patients with a varus thrust
Improve AP instability & reduce
translational forces by changing the
tibial slope

7. Valgus high tibial osteotomy reduces pain and
improves knee function in patients with medial
compartmental osteoarthritis of the knee.

8. Varus malalignment in revision ACL
22% of Revision ACL
reconstruction patients
have varus malalignment

9. Mechanical Axis & Joint orientation angle
of the knee
Vertical axis
mLDFA=87º
MPTA=87º1.2º Varus

10. POSTGRAD ORTH Deiary Kader
Mechanical Axis of the Lower Limb
The line from the centre of
the femoral head to the
centre of the ankle plafond is
called the Mechanical axis of
the lower limb
Normal MAD = 4-8mm medial
Mechanical Axis deviation MAD

11. 33%
20
5%
The Weight Bearing Line in %
X

12. Double Varus
1- Varus alignment
Progressive medial joint narrowing
2- Lateral tibio-femoral opening
LCL laxity
>5 mm laxity ( stress radiograph)
Varus thrust
Curtesy of Prof Reha

13. Triple Varus
Varus alignment
Lateral tibio-femoral opening
Posterolateral corner laxity
Increased Ext-Rotation/Hyperextension
Varus recurvatum deformity
Curtesy of Prof Reha

14. Decision making
Primary varus knees: ACLR alone
Cruciate reconstruction with/without HTO
Double varus knees: HTO alone
HTO first + cruciate & PLC later if required
Triple varus knees: ALL
HTO first + Cruciate & PLC later

15. 11 eligible studies (218 knees)
Curtesy of Prof Reha

16. Lateral closed-wedge high tibial osteotomies
have been the treatment of choice since 1965
(Coventry, 1965).

17. OPEN Wedge HTO 1987
The open-wedge high tibial osteotomy gained
recognition after the encouraging reports of
(Hernigou et al., 1987).
Wedges of bone that were obtained from the iliac
crest were inserted into the defect

18. Open W HTO

19. The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

20. Proximal or High Tibial Osteotomy (HTO)
The IDEAL candidate for HTO
Age <60 years
Isolated medial OA (GI-III)
BMI<30
FFD & Varus of <15°
>120° flexion knee
Patients should be
Able to use crutches
Have no major varicose veins or peripheral
vascular disease

21. Valgus deformity of 12º or more needs distal
femoral varus producing osteotomy to address a
lateral femoral condyle deficiency and to prevent joint
line obliquity and gradual lateral tibial subluxation.
Distal Femur Osteotomy for Valgus
Malalignment

22. Osteotomy Planning
Final alignment should create 10º–13° valgus.
Overcorrection of 3º–5º above the 6º–7º normal
valgus angle
62.5% across tibial plateau from medial side

23. Compensating for
Abnormal AP Laxity
ACL Rupture PCL Rupture

24. HTO Complications
Inadequate valgus correction
Overcorrection – PFJ derangement
Alteration in patella height
Intra-articular fracture
Osteonecrosis of the tibial plateau

25. HTO Complications
Vascular injuries
Peroneal nerve palsy
Delayed or non-union
Compartment syndrome
TKR more difficult

26. Fibular osteotomy, Separating tibiofibular joint
Contracture of the patellar tendon, patellar baja
leg shortening
Nerve injuries
Varus laxity (loose LCL)
High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-
Term Follow-up*
ANNETTE BILLINGS, M.D.†; DAVID F. SCOTT, M.D.‡; MARCELO P. CAMARGO, M.D.§; AARON A. HOFMANN, M.D.§, SALT LAKE
CITY, UTAHJ
Bone Joint Surg Am, 2000 Jan
Closed wedge HTO
Disadvantages

28. Open wedge HTO
Advantages
Easier to achieve precise angular correction
Preserves bone stock (subsequent TKR easier)
Makes tightening of the MCL easier
Allows LCL or PLC Recon
No risk to peroneal nerve
Less dissection

29. Open wedge HTO
Disadvantages
Requires a bone graft (substitute, autograft, Allo)
I incidence of non-union and delayed union
Large correction may affect leg lengthening
Loss of fixation
Worsens patella Baja

30. Outcome
Obesity and inadequate correction were
negative prognostic factors.
Age < 50 years is a positive prognostic
factor
Joint line preservation is key to success.

31. RCT 92 pts and 6 years FU
OW-HTO vs CW-HTO
More Complications in open WHTO & more conversion to TKR in closed WHTO
SEPT 2014

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