High Tibial Osteotomies

Dr.Ghazwan A. Hasan

5th year Arab Board Trainee

2015

Introduction

• The complex etiology of knee osteoarthritis includes overuse,geneticfactors, prior knee trauma, chronic ligamentous instability, cartilage andmeniscal defects, obesity, and biomechanical derangements such asanatomic malalignment.

• The most definitive surgical option for the symptomatic, aging patient witharthritis remains total knee arthroplasty In younger patients withunicompartmental chondral injuries secondary to lower-extremitymalalignment,

• High tibial osteotomy is a well-established procedure for the treatment ofunicompartmental osteoarthritis of the knee.

• Most reports have shown approximately 80% satisfactory results at 5 yearsand 60% at 10 years after high tibial osteotomy.

Biomechanics

• The knee is a pivotal weight-bearing hinge joint characterizedprimarily by flexion and extension movements with slight internal andexternal rotation.

• Joint reactive forces across the knee may be up to six times bodyweight when climbing stairs

• The weight-bearing load distribution in the normal knee is 60% to75% in the medial compartment.

• The most common deformity in patients with osteoarthritis of the knee is a varus position.

High Tibial Osteotomies

• Basically presented with 4 types:

1. Medial opening wedge.

2. Lateral closing wedge.

3. Medial opening Hemicallotasis.

4. Dome.

• A recent meta analysis however revealed no significant differences in union

rate between closing and opening-wedge HTOs.Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: a meta-analysis of clinical and radiological outcomes. Knee. 2011 Dec;18(6):361-8. Epub 2010 Oct 29

Indications

• Symptomatic osteoarthritis.

• Medial compartment of the varus knee.

• Active patient.

• Additional indications for this procedure include unloading a cartilagerestoration site after a cartilage preservation procedure or changing thesagittal slope to address cruciate ligament insufficiency with or without aconcomitant ligament reconstruction

Contraindications

• Narrowing of lateral compartment cartilage space.

• Lateral tibial subluxation of more than 1 cm.

• Medial compartment tibial bone loss of more than 2 or 3 mm.

• Flexion contracture of more than 15 degrees.

• knee flexion of less than 90 degrees.

• More than 20 degrees of correction needed.

• Inflammatory arthritis.

• Significant peripheral vascular disease

Preoperative Planning.

• Full Length X-ray from the hip to ankle.

• We measure the Mechanical axis.

• Overcorrection of 3-5 degree is recommended.

• The correction angle is generally proportional to

the osteotomy distraction at the level of the medial

cortex in roughly a 1-to-1-mm relationship

LATERAL CLOSING WEDGE OSTEOTOMY• Coventry described a closing wedge osteotomy made proximal to the tibial

tuberosity.

• He recommended a lateral approach to correct a varus deformity and amedial approach to correct a valgus deformity.

• The advantages of this osteotomy are .1. it is made near the deformity, that is, the knee joint.2. it is made through cancellous bone, which heals rapidly.3. it permits the fragments to be held firmly in position by staples or a rigid fixation

device, such as a plate-and-screw construct.4. it permits exploration of the knee through the same incision

• Due to Recurrence of pain he recommended the overcorrection up to 8degree.

MEDIAL OPENING WEDGE OSTEOTOMY

• Hernigou et al. described a medial opening wedge tibial osteotomy.

• They believed is more precise and allows more exact correction thandoes a lateral closing wedge osteotomy.

• It is preferable when the involved extremity is 2 cm or more shorterthan the contralateral extremity or laxity of the medial collateralligament or combined anterior cruciate ligament deficiency.

• It is critical to identify the superficial medial collateral ligament(sMCL) and elevate its entire insertion on the medial aspect of thetibia

Medial Opening-Wedge Osteotomy

OPENING WEDGE HEMICALLOTASIS

• Schwartsman advocated the use of circular external fixation after percutaneous tibial osteotomy (Ilizarov technique).

• He suggested that:• Healing is better.• Placement of the osteotomy below the tibial tubercle minimizes the chance

of patella infera and • Loss of proximal tibial bone stock that may complicate later TKA.

• Disadvantage:• Poor Patient acceptance. • Risk of Pin loosening and Infection.• Close follow up reuired.

Dome Osteotomy

• Maquet described a “barrel vault,” or dome, osteotomy, which hebelieved allowed more accuracy and adjustability of correction.

• It may be considered if a correction angle of >20 is desired.

• An osteotomy cut in the shape of an inverted U is made above thelevel of the tibial tubercle

• Stable , no need for fixations but pins or External fixation can be usedif necessary.

• Disadvantages1. technical difficulty,

2. Intraarticular fracture.

3. scarring around the patellofemoral extensor mechanism.

Complications

Reported complication rates for HTO are 7% to 55%• Recurrence of deformity (loss of correction) in 5% to 30%• Irritation to implant & Implant Failure.• Peroneal nerve palsy. • Nonunion• Infection.• knee stiffness or instability,• Intraarticular fracture.• DVT.• Compartment syndrome.• Patella baja. • Osteonecrosis of the proximal fragment

HTO Versus Unicompartmental Knee Arthroplasty (UKA)

• The outcomes of HTO and UKA are similar.Dettoni F, Bonasia DE, Castoldi F, Bruzzone M, Blonna D, Rossi R. High tibial osteotomy versus unicompartmental kneearthroplasty for medial compartment arthrosis of the knee: a review of the literature. Iowa Orthop J. 2010;30:131-40.

• A meta-analysis by Spahn et al. found that after a nine totwelve-year follow-up, survivorship of HTO was 84.4% andUKA was 86.9%, with comparable clinical results and nodifference in the complication rates.

Spahn G, Hofmann GO, von Engelhardt LV, Li M, Neubauer H, Klinger HM. The impact of a high tibial valgus osteotomy andunicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis. Knee Surg Sports TraumatolArthrosc. 2013 Jan;21(1):96-112. Epub 2011 Nov 11.

TKA After HTO

• At 10 to 15 years after proximal tibial osteotomy, 40% of patients require conversion to total knee arthroplasty

• Both opening and closing-wedge osteotomies change anatomic relationships within the knee, potentially complicating subsequent TKA.

• Historically, lateral closing-wedge HTOs created problems with everting the patella,balancing ligaments, and removing retained implants. In addition, the increased risk ofpatella baja.

• A study by van Raaij et al. showed increased operative time, an increased number ofcombined procedures, and less postoperative knee motion for patients undergoing TKAafter HTO.

• Erak et al. compared a group of thirty-six TKAs performed after opening-wedge HTO witha group of 1315 primary TKAs and found that patients in whom the TKA followedopening-wedge HTO had a poorer knee score and greater pain.

Erak S, Naudie D, MacDonald SJ, McCalden RW, Rorabeck CH, Bourne RB. Total knee arthroplasty following medial opening wedge tibial osteotomy: technical issuesearly clinical radiological results. Knee. 2011 Dec;18(6):499-504. Epub 2010 Dec 8.

HTO and Concomitant Cartilage Procedures

• Bauer et al. evaluated eighteen patients who underwent HTOcombined with matrix-induced autologous chondrocyte implantation(MACI) and reported clinical improvement at five years. However,magnetic resonance imaging demonstrated poor graft survival andcartilage infill.

Bauer S, Khan RJ, Ebert JR, Robertson WB, Breidahl W, Ackland TR, Wood DJ. Knee joint preservation with combined neutralising high tibial osteotomy (HTO) andmatrix-induced autologous chondrocyte implantation (MACI) in younger patients with medial knee osteoarthritis: a case series with prospective clinical and MRIfollow-up over 5 years. Knee. 2012 Aug;19(4):431-9. Epub 2011 Jul 22.

• Wong etal. showed good short-term clinical outcomes after HTOperformed in combination with intra-articular injection ofmesenchymal stem cells.

Wong KL, Lee KB, Tai BC, Law P, Lee EH, Hui JH. Injectable cultured bone marrow-derived mesenchymal stem cells in varus knees with cartilage defects undergoing high tibial osteotomy: a prospective, randomized controlled clinical trial with 2 years’ follow-up. Arthroscopy. 2013 Dec;29(12):2020-8

• In a recent systematic review, Harris et al. analyzed HTO performedwith or without articular cartilage restoration surgery and/or allograftmeniscal transplantation. They found that HTO performed incombination with other procedures led to excellent short-term andintermediateterm survival and clinical outcomes; however, there wasa deterioration in outcomes at ten years.

Harris JD, McNeilan R, Siston RA, Flanigan DC. Survival and clinical outcome of isolated high tibial osteotomy and combinedbiological knee reconstruction. Knee. 2013 Jun;20(3):154-61. Epub 2013 Mar 9.