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High Tibial Osteotomy

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Topic updated on 05/29/16 6:51pm
Introduction
  • High tibial osteotomy (HTO)
    • predominately done for varus deformities
    • less common for valgus deformities
  • Angular deformity in the knee leads to abnormal distribution of weight bearing stresses
    • can accelerate wear in medial or lateral compartments of the knee and lead to degeneration
    • HTO is commonly combined with cartilage restoration procedures to provide better mechanical environment for biologic repair
  • Prognosis
    • varus-producing high tibial osteotomy
      • success rate is 87% patients in 10 years
    • valgus-producing high tibial osteotomy
      • success rate is 50-85% of patients in 10 years
Indications
  • Indications
    • young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear
    • healthy patient with good vascular status
    • non-obese patients
    • pain and disability interfering with daily life
    • only one knee compartment is affected
    • compliant patient that will be able to follow postop protocol
  • General contraindications
    • inflammatory arthritis
    • obese patient BMI>35
    • flexion contracture >15 degrees
    • knee flexion <90 degrees
    • procedure will need >20 degrees of correction
    • patellofemoral arthritis
    • ligament instability
    • varus thrust during gait
Anatomy
  • Mechanical axis of lower extremity
    • can be assessed by drawing straight line from center of femoral head to the center of the ankle joint
    • line axis should pass just medial to the medial tibial spine
Presentation
  • Symptoms
    • pain on medial or lateral side of knee
  • Exam
    • knee malalignment
Imaging
  • Radiographs
    • show knee malalignment using mechanical axis line
Varus-producing tibial osteotomy
  • Surgical goals
    • unload the involved joint compartment by correcting tibial malalignment
    • maintain the joint line perpendicular to mechanical axis of the leg
  • Indications
    • can done for valgus knee with lateral compartment degeneration
      • deformity should be <12 degrees or else the joint line will become oblique
    • specific contraindications
      • medial compartment arthritis
      • loss of medial meniscus
      • distal femoral osteotomy better if lateral femoral condyle hypoplasia present
Valgus-producing tibial osteotomy
  • Goals
    • unload the involved joint compartment by correcting tibial malalignment
    • maintain the joint line perpendicular to mechanical axis of the leg
  • Indications
    • can done for varus knee with medial compartment degeneration (more common)
    • best results achieved by overcorrection of the anatomical axis to 8-10 degrees of valgus
    • specific contraindications
      • narrow lateral compartment cartilage space with stress radiographs
      • loss of lateral meniscus
      • lateral tibial subluxation >1cm
      • medial compartment bone loss >2-3mm
      • varus deformity >10 degrees
  • Technique
    • lateral closing wedge technique
      • most common technique
      • wedge of bone removed with tibia via an anterolateral approach
      • ORIF of wedge
      • has advantages
        • more inherent stability allows for faster rehab and weight bearing
        • no required bone grafting
    • medial opening wedge technique
      • transverse bone cut made in proximal tibia, and wedged open on medial side
      • ORIF of wedge
      • has advantages
        • of maintaining posterior slope
        • avoids proximal tibiofibular joint
        • avoids peroneal nerve in anterior compartment
    • focal dome osteotomy (concavity proximal) 
      • the center of the dome is located at the center of rotation of angulation (CORA) 
      • has advantages
        • corrects limb alignment with the least translation of bone ends
        • least translation of anatomical axis
        • minimal shortening
Complications
  • Recurrence of deformity
    • 60% failure rate after 3 years when
      • failure to overcorrect
      • patients are overweight
  • Loss of posterior slope
  • Patella baja
    • refers to a shortened patellar tendon which decreases the distance of the patellar tendon from the inferior joint line
      • can be caused by raising tibiofemoral joint line in opening wedge osteotomies
      • can be caused by retropatellar scarring and tendon contracture
      • can cause bony impingement of patella on tibia
  • Compartment syndrome
  • Peroneal nerve palsy
    • more common in lateral opening wedge osteotomy
  • Malunion or nonunion

 

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Qbank (1 Questions)

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(OBQ11.105) Patella baja is most likely to occur after which of the following procedures? Topic Review Topic

1. Arthroscopic ACL reconstruction with cadaver allograft
2. PCL reconstruction using tibial inlay technique
3. High tibial osteotomy
4. MPFL reconstruction with semitendinosus autograft
5. Total knee arthroplasty (TKA)

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Cases

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