High Tibial Osteotomy - Recon (2024)

• predominately done for varus deformities

• less common for valgus deformities

• can accelerate wear in medial or lateral compartments of the knee and lead to degeneration

  See Also

  High Tibial Osteotomy Knee Surgery and Realignment | HSSOsteotomy of the Knee - OrthoInfo - AAOSHigh Tibial Osteotomy For Knee Arthritis Pain In Active People

• HTO is commonly combined with cartilage restoration procedures to provide better mechanical environment for biologic repair

Mechanical axis of lower extremity

• can be assessed by drawingstraight line fromcenter of femoral head to the center of theankle joint

• line axisshould pass justmedial to the medial tibial spine

• pain on medial or lateral side of knee

• knee malalignment

• standing alignment hip-to-ankle films

  • show knee malalignment using mechanical axis line

• young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear

• healthy patient withgood 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

• Goals

  • unload the involved joint compartment by correcting tibial malalignment

    • A medial unloader brace can be used for therapeutic and diagnostic purposes. If a patient benefits from the brace, they are likely to benefit from surgery.

  • maintain the joint line perpendicular to mechanical axis of the leg

• Indications

  • can be 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

• 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

• Used less commonly than distal femoral osteotomy

  • produces obliquity of the tibiofemoral joint line

• Goals

  • unload the involved joint compartment by correcting tibial malalignment

  • maintain the joint line perpendicular to mechanical axis of the leg

• Indications

  • can be done for valgus knee with lateral compartment degeneration

    • deformity should be <12 degrees or else the joint line will become oblique

• Contraindications

  • medial compartment arthritis

  • loss of medial meniscus

  • distal femoral osteotomy better if lateral femoral condyle hypoplasia present

  • adjunct to soft tissue reconstructive surgeries (ACL/PCL/MACI) when there is coronal malalignment

Lateral closing wedge 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

• 60% failure rate after 3 years when

  • failure to overcorrect

  • patients are overweight

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

• more common in lateral opening wedge osteotomy and lateral closing wedge osteotomy

• minimal risk in medial opening wedge osteotomy

Malunion or nonunion

• success rate is 87% in 10 years

• success rate is 50-85% in 10 years