The document discusses various osteotomy techniques around the knees, detailing their physiological considerations and specific indications for genu varum and genu valgum conditions. It covers different types of wedge osteotomies, high tibial osteotomies, and preoperative planning including patient assessment and imaging. Additionally, it highlights the goals, mechanisms, contraindications, and specific surgical techniques associated with each type of osteotomy to address knee alignment and pain relief.

1. OSTEOTOMIES AROUND THE
KNEES

2. PHYSIOLOGICAL AXES OF THE LEG

5. Genu varum
• Anatomical femorotibial angle > 173–175°
• MAD > 15 mm medial to the center of the knee joint
• Increased intercondylar distance
• JLCA is opened laterally.
Genu valgum
• Anatomical femorotibial angle < 173–175°
• MAD > 10 mm lateral to the center of the knee joint
• Increased intermalleolar distance
• JLCA is opened medially.

6. WEDGE OSTEOTOMY
Opening wedge osteotomy
• Opening wedge CORA- Point at which the transverse
bisector line intersects the convex cortex.
• Osteotomy line also passes through this point.
• The convex cortex remains in contact and a wedge shaped
bone defect with its base on the concave side.

7. • The final length of the bone is that of
convex cortex.
• All the points on the convex side
ACA(angulation correction axis) CORA will
be compressed.
• All the points on the concave side ACA
CORA will be distracted.

8. Closing wedge osteotomy
• Closing wedge CORA- Point at which transverse
bisector line intersects the concave cortex.
• If the osteotomy and ACA passes through this
point, closing wedge correction results.

9. • It requires removal of bone to allow angular correction and full bone to
bone contact at the end of the correction.
• Final length of the bone is shorter than in opening wedge type and equal
to the length of the concave cortex.

10. Neutral wedge osteotomy
• Neutral wedge CORA- CORA between the
convex and concave cortices on the transverse
bisector line.
• If osteotomy and ACA passes through this
point partial open and partial closing wedge
correction results.
• Half a wedge is removed and half a wedge is
opened.
• It has no effect on bone length.

11. • If osteotomy is made at different level from that of CORA on bisector line
and the angular correction is performed around a point on the osteotomy
line, translational deformity is produced.
• Amount of translation is greater for opening than for a closing wedge
osteotomy.

12. • If the opening or closing wedge osteotomy is made through the opening or
closing wedge point irrespective of the orientation of osteotomy, no
translation deformity will arise.
• As a consequence of inclination of osteotomy site- a bump in the concavity
may arise with the opening wedge corrections.
• May arise as a defect with closed wedge corrections.

13. DOME OSTEOTOMY
• Cylindrical or circular shaped bone cut with which
CORA corresponds to center of the circular cut.
• For each CORA, there are circular cuts of different
radii that can be made.
• Limiting factor is the amount of bone to bone
contacted the osteotomy line.
• Larger the radius of the focal dome osteotomy, the
more translation and less bone contact.

14. • If the central axis of the dome osteotomy does not correspond to the CORA
on the bisector line, secondary translational deformity of the axis of the
bone is produced when the deformity is corrected.

15. BASIC PRINCIPLES OF OSTEOTOMIES
Planning step A
Level of the osteotomy
• The osteotomy should be performed at the apex of the deformity.
• Performing an osteotomy at a different level will not restore the physiological axis
but create a new deformity.
• The metaphysis of a long bone is the region of best healing capacity.
• Tibial osteotomy can easily be performed in the metaphysis. Therefore, healing time
favors tibial osteotomy.
• Distal femur-osteotomy at the meta-diaphyseal junction.
• Especially open-wedge osteotomy of the distal femur can result in delayed union or
nonunion.

16. • Open-wedge osteotomies are generally easier and more precise to
perform than closed-wedge osteotomies.
• Restoring or preserving the horizontal joint line (midjoint line) is
mandatory for achieving a good result

17. Correction of the sagittal plane
• If anterior knee instability (ie, ACL
insufficiency) is present, the tibial
slope should be decreased.
• If the slope exceeds 8–10° in case
of chronic anterior knee instability,
it is advisable to decrease the slope
to 5° in order to minimize the
anterior force vector

18. • Posterior cruciate ligament (PCL)
insufficiency, the slope should be
increased.
• Chronic PCL instability will
improve at a tibial slope of about
12° since the increased slope
creates an anterior force vector.

20. Correction of the transversal plane
• Transversal plane or rotation deformities should be corrected at the
level where the deformity is present.
• As patellar tracking may be changed significantly after corrections
around the knee, it is important to analyze patellofemoral alignment.

22. Amount of correction
• In a well-aligned knee, load distribution is not well-balanced but
physiologically 60 % in the medial and 40 % in the lateral compartment.
• Not sufficient to restore a physiological alignment in cases of medial
osteoarthritis.
• Instead, overcorrection by shifting the weight-bearing line slightly to the
lateral compartment is recommended.
• The authors define the corrected axis between 10 % and 35 % laterally on
the Fujisawa-scale.
• Higher corrections are chosen for cases with more severe osteoarthritis.

23. • In patients with valgus deformity together with lateral compartment
osteoarthritis, the corrected mechanical axis can be planned at 0–20%
medially on the scale depending on cartilage loss.
• Overcorrection to the opposite compartment does not seem to be as
important as in case of varus osteoarthritis.

24. Planning step B (Miniaci method)
Step 1
• The first step is only necessary in cases of lateral knee
instability in a valgization osteotomy
• To avoid overcorrection, instability or laxity of the
lateral collateral ligament must be taken into account.
• Valgus and varus stress x-rays are required. A virtual
‘‘push view’’ image is drawn.
• This method helps to avoid overcorrection due to
lateral instability.

25. Step 2
• In a valgization osteotomy, the mechanical axis is planned between 10
and 35 % in the lateral compartment on the Fujisawa scale depending
on the severity of medial cartilage loss
• Between 0 and 20 % in the medial compartment for varization
osteotomy.

26. Step 3
• The new weight-bearing line is drawn from the center of the
femoral head, passing the knee at the point defined in step 2
to the height of the ankle joint line.
• The hinge of the osteotomy (H) is defined at the lateral cortex
of the tibia and connected distally with the new and the old
center of the ankle joint.
• The angle of correction at the proximal tibia corresponds to
angle α between lines A and B.

27. HIGH TIBIAL OSTEOTOMY
Introduction
• It is a procedure for treating varus alignment of the knee associated
with medial compartment overload/osteoarthritis
• It was introduced by Jackson and Waugh in 1961
• Popularised by Conventry since 1965

28. HIGH TIBIAL OSTEOTOMY
Goals of HTO
1) To reduce knee pain by transferring weight-bearing loads to the
relatively unaffected lateral compartment in varus knees
2) To delay the need for a knee replacement by slowing or stopping
destruction of the medial joint compartment.

29. HIGH TIBIAL OSTEOTOMY
Pain relief mechanism of HTO
• Due to change in load distribution in the knee
joint due to alignment correction
• By reducing intraosseous venous pressure in tibia

30. HIGH TIBIAL OSTEOTOMY
Indications
• Isolated medial compartmental OA
• Normal lateral and patellofemoral compartments
• Malunited medial condyle fractures with varus
• Metaphyseal varus
• Age 40 to 60 years
• BMI < 30
• High-demand activity except running or jumping
• Malalignment < 15°
• Full ROM

31. HIGH TIBIAL OSTEOTOMY
Contraindications
• Pagoda type tibiae (severe medial bone loss & sloped lateral compartment)
• Bi- or tri-compartmental joint destruction
• Lateral meniscectomy and OA
• Flexion contracture > 10 degrees
• Overall ROM < 90 degrees
• Varus deformation > 15 degrees
• Joint instability
• >1cm lateral tibial thrust
• >20 degrees correction
• Rheumatoid arthritis

32. PREOP PLANNING
• Patient assessment
• Radiographic assessment
• Correction angle calculation

33. PATIENT ASSESSMENT
• Patient’s age, career, level of activity, previous history of surgery on
the knee, and expectation should be taken into consideration
• ROM, degree of deformity, ligamentous instability, weight and leg
length discrepancy should be assessed through physical examination

34. ACL intact medial OA
• Relative position of tibia on femur is constant
• OA is obligatory anterior on tibia and distal on femur
• Posterior femur and tibial chondral surface is intact
• Deformity is restricted to extended and slightly flexed knee and reduce in
complete knee flexion
• MCL is lax in extension and becomes taught in flexion

35. ACL deficient medial OA
• Tibia will shift to an anterior position
• Contact point will shift posteriorly on plateau
• OA will develop posteromedially and develop dished form
of defect called cupula
• Now ant subluxation is fixed and cannot be reduced
• So clinical instability appear less obvious

36. UKA AND HTO
• The correct function of UKA depend on intact ACL
• So these ACL deficient knee OA cannot be treated by UKA
• It is another indication of HTO

37. Intraarticular wear, eventually combined
with loss of the medial
meniscus may cause collapse of the
medial joint space.
No extraarticular deformity exists and
the entire pathology is intraarticular.
This is the ideal scenario for a UKA, as
long as the ACL is functionally intact.
Preexisting metaphyseal varus induces
overload and degeneration
of the medial joint space.
Implantation of a UKA will not correct the
extraarticular deformity and a residual
varus will exist which induces significant
load on the implant.
This is the ideal scenario for a HTO

38. THE IDEAL PATIENT
UKA
• Older than 55 years
• No osseous deformity and mere
intraarticular wear
• Intact ligaments (ie ACL, MCL)
• Deformity which reduces completely
in 20° of flexion under valgus stress
• Intact lateral compartment
HTO
• Younger than 65 years (male) and 55
years (female)
• Osseous metaphyseal varus
deformity of the tibia (TBVA > 5°)
• ACL or PCL deficiency (can be
addressed by the surgery)
• Almost normal range of motion (10°
extension deficit may be corrected
by the surgery)
• Intact lateral compartment

39. RADIOGRAPHIC EVALUATION
Bilateral weight bearing AP views in full extension- Standard evaluation
and deformity analysis
Rosenberg views - Weight bearing PA view knee in 45 degree of flexion
1.For deformity associated with cruciate insufficiency
resulting in anterior tibial subluxation
2.Chondral wear prevalent in posterior area of
medial tibial plateau

40. DOUBTFUL CASES-VARUS & VALGUS STRESS X RAYS
Varus stress demonstrating full
thickness cartilage defect on
medial side
Valgus stress showing functionally
intact lateral compartment.

41. • Tunnel views with the knee in 30 degree flexion
• Lateral views and skyline views.
• MRI to look for intraosseous lesions, meniscal tears, ligamentous
lesions, osteochondral defects, osteonecrosis or subchondral edema.

42. DIAGNOSTIC ARTHROSCOPY BEFORE OSTEOTOMY
• It is recommended to be performed routinely in the same operative
session for diagnostic or therapeutic purposes.
• It helps to determine the cartilage status to modify type/degree of
correction osteotomy accordingly.
• It is also helpful in cases of intraarticular pathologies.

43. TYPES OF OSTEOTOMIES
• Lateral closing wedge osteotomy
• Medial opening wedge osteotomy
• Other HTO Techniques
Dome osteotomy
Progressive callus distraction using an external fixator
Chevron osteotomy

44. MEDIAL OPENING WEDGE OSTEOTOMY
Advantages:
• Ability to correct the alignment in two planes (coronal and sagittal)
• No need for fibular osteotomy
• Little risk of peroneal nerve injury
• No limb shortening
• No bone loss
• Easier conversion to arthroplasty
• Ability to adjust the amount of correction during surgery

45. Disadvantages:
• The need for bone graft
• Delayed union or nonunion
• Long period of weight-bearing restriction
• Leg lengthening

46. LATERAL CLOSING WEDGE OSTEOTOMY (LCWO)
Advantages
• Effective for correction near maximal point of deformity
• Allows rapid bone union - large contact surface of cancellous
bone at the osteotomy site
• Early weight bearing and rehabilitation
• Early use of quadriceps muscle
• Risk of loss of correction is low

47. Disadvantages
• Requires a fibular osteotomy
• Release of the proximal tibiofibular joint
• Shortening of the lower limb
• Stem impingement or metal augmentation - subsequent TKR due
to the proximal tibial deformity and bone loss of the lateral
condyle

48. DOME OSTEOTOMY
• Indication
• Large degree of correction involving 18-20 mm opening or closing
• ≥20 degrees angular correction is necessary for traumatic varus
deformity or Blount disease
• Procedure using an inverse U-shaped proximal tibial bone cut and a metal
plate for fixation or an external fixator for progressive correction
• Useful for achieving correction without any changes in the patellar height

49. PATELLAR HEIGHT AFTER HTO
PATELLA ALTA PATELLA BAJA

50. IMPLANTS FOR FIXATION AT OSTEOTOMY SITES

51. Tomofix plates
• Maintains fixation on the bone using fixed-angle plate concept
• Uses principles of LCP
• Better choice in situation where the lateral cortex is damaged

52. Puddu plates
• Uses the dynamic compression plate (DCP) concept
• Fixed to the medial side of the tibial plateau, and a spacer is inserted into
the osteotomy gap, thus preventing gap closure
• Higher complication rates
• Nonunion
• Fixation failure
• Correction loss-due to unstable fixation in medial opening HTO

53. Puddu plate system
• Less stresses
• Conventional screws has Less
anchorage than LS
• Less rigid
• The micromotion appears to be
greater in the Puddu system
• Result in implant loosening and
loss of fracture stability
● Tomofix system
• Higher amount of stress
• Utilizes the LS provide a better
anchorage
• Angular stability of the LS is more
rigid
• Small amounts of motion good for
fracture healing

54. STEPS OF MEDIAL OPENING WEDGE OSTEOTOMY BY
ANGULAR STABLE IMPLANT
• a T-shaped TomoFix plate fixator with threaded screw holes in
the proximal arm and combination holes in the longitudinal arm.
• b Self-tapping bicortical locking screws (diameter 3.7 mm) with
threaded head (diameter 5 mm) available in different lengths
(green).
• c Self-drilling and self-tapping monocortical locking screws
(diameter 3.7 mm) with threaded head (diameter 5 mm)
available in lengths 18 mm and 26 mm (blue).
• d–e TomoFix plate fixator with guide sleeves and two 3 mm
distance holders (pink).

55. The landmarks are drawn on the
skin: medial joint line, cranial margin
of the pes anserinus (1), line of the
superfi cial medial collateral
ligament (2), and the tibial
tuberosity. The skin incision (red)
runs from the insertion of the pes
anserinus about 6–8 cm ascending
posterocranially
Two 2.3 mm guide wires are drilled
into the tibial head under image
intensification to mark the direction
of the osteotomy. The wires aim at
the upper third of the proximal
tibiofibular joint, the tips of the
wires end exactly at the lateral
tibial cortex.
Operation site: medial border of
the patellar tendon (1), superfi
cial medial collateral ligament (2),
cranial border of the pes
anserinus (3).

56. Measuring the length of the wires. A third wire of the same length
is placed on the cortex and the exceeding length is measured in
comparison to the inserted wires.
Marking the horizontal and
the anterior osteotomy at an
angle of 110° with an
electrocautery.

57. Principle of the biplanar osteotomy.
Horizontal osteotomy in the posterior 2/3 of
the tibia and anterior osteotomy ascending at
an angle of 110° behind the tibial tuberosity.
During spreading osteotomy the two surfaces
of the anterior ascending part stay in contact
and ensure postoperative stability in the
sagittal plane.
Insertion of the flat chisels to the
measured depth of the osteotomy.
When the desired width has
been achieved, an arthrodesis
spreader is placed on the
posteromedial cortex of the
osteotomy.

58. a. If the tibial slope is to remain unchanged, the horizontal osteotomy gap must be opened symmetrically.
b. The caudal inclination of the tibial plateau may be altered by asymmetric opening of the osteotomy. Hyperextension of the knee
and posterior subluxation of the tibia due to posterior knee instability can both be treated by increasing the tibial slope (so-called
flexion osteotomy).
c. The slope can be reduced by extension osteotomy (opening the posterior part of the osteotomy more than the anterior part)
and may produce stability in patients with anterior knee instability.

59. The immediate postoperative x-rays show
an intact lateral bone bridge and the
osteotomy gap (10 mm) in both planes.
Follow-up x-ray after 24 months showing
consolidation of the osteotomy gap
especially posteromedially.

60. SUPRACONDYLAR VARIZATION OSTEOTOMY OF THE
FEMUR WITH PLATE FIXATION
• The aim of varization osteotomy of the distal femur is to relieve lateral
single-compartment degeneration at the knee by shifting the mechanical
axis media
• Can be performed by a medial closed-wedge or lateral open-wedge
technique.
• Generally performed as a medial closed-wedge osteotomy.
• Stabilization is achieved by application of conventional blade plates,
angular-stable plates, or insertion of a distal femoral nail.

61. • Type, direction, and localization of the osteotomy as well as the fixation
technique- primary stability of the osteotomy.
• An incomplete medial closed wedge osteotomy with an intact lateral
cortical bridge- more stable than an osteotomy that cuts through the bone
bridge.
• Oblique, proximal to distal descending osteotomies are more stable than
transverse osteotomies.
• Primary stability is also markedly increased by compression of the
osteotomy surfaces, where optimal cortical contact is essential.

62. TomoFix MDF plate for closed-wedge correction osteotomy at the medial
distal femur designed with four threaded holes in the distal part and four
combination holes in the proximal part

63. Indications
• Single-compartment lateral joint degeneration with valgus deformity
• Patients aged 55–60 years.
Contraindications
• Obesity
• Extension deficit of >20°
• Loss of the inner meniscus,
• Third degree cartilage injury of the medial compartment
• Insufficient soft-tissue situation

64. Planning a varization osteotomy of the distal femur
• The postoperative mechanical axis should be
somewhat medial of the medial intercondylar
eminence (C).
• Position E is at the level of the center of the femoral
head (D) on a connecting line between C and the
center of the upper ankle joint (A).
• Position F is the hinge point of the closed-wedge
osteotomy.
• The angle between the lines DF and EF correspond to
the correction angle at the distal femur.

65. • First, the osteotomy can be placed under
compression by insertion of a lag screw in the
dynamic part of the combination hole
• The lag screw should be replaced by a locking
head screw after fi xation of the plate.

66. Biplanar osteotomy technique
• The cuts are made at the posterior 2/3 of the distal
femur after which the wedge is removed.
• Starting at the lower cut of the osteotomy cuts, an
ascending bone cut is made parallel to the posterior
side of the femur.
• In normal femurs the ascending bone cut has an angle
between 90–100° to the closed wedge osteotomy cuts
in the sagittal plane.
• After the anterior bone cut is completed the osteotomy
cut can be closed and the plate fi xator is applied

67. Advantage
• Increased postoperative stability against rotational instability.
• Ability to position the closed-wedge saw cuts more distal in the femur
condyles as the trochlea does not limit the height of the closed-wedge
cuts.

68. DOUBLE OSTEOTOMY

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