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High Tibia Osteotomy

Categories
  • Joint/Tendon
  • Knee
Tags
  • knee injury
Knee Anatomy & Examination

High Tibia Osteotomy (HTO) for early medial knee degeneration

HTO

High tibia osteotomy for early medial knee arthritis is a surgical intervention that shifts the mechanical axis from the medial to the lateral side of the knee joint, thereby unloading the medial early degenerative knee compartment by shifting the force/area from the medial compartment to the lateral outer 1/3 of the knee joint.

Patient suitable for osteotomy include:
  • ≤ 60 – 65 years
  • ≤ Grade I or II unicompartmental osteoarthritis
  • Range of motion ≥ 90º
  • Flexion deformity of <15º
  • Mechanical axis deviation <15º

This intervention is also an augment to address knee instability
Ideal for the relatively young active individual with early medial knee arthritis that meets the osteotomy criteria (Feeley B T et al)

Wedge Osteotomy
  • A: closing wedge osteotomy
  • B: opening wedge osteotomy

Valgus knee arthritis with an abnormal lateral femoral condyle may be addressed by a distal femur osteotomy procedure.

ICRS Hyaline Cartilage Lesion Classification System

ICRS Hyaline Cartilage Lesion Classification System
    • ICRS 0: normal.
    • ICRS 1a: Intact surface but fibrillation ± softening.
    • ICRS 1b: fissuring.
    • ICRS 2: Defect < 50%.
    • ICRS 3: Lesions > 50%.
    • 3a: lesions > 50% but not to calcified layer.
    • 3b: lesions > 50% to calcified layer but not through subchondral bone.
    • 3c: lesions extending to subchondral bone plate.
    • 3d: blisters.

ICRS 4: full thickness osteochondral lesions.

Osteochondritis dissecans (OCD) excluded from this classification system.

OCD (Osteochondral Defect) Lesion Classification

OCD (Osteochondral Defect) Lesion Classification
    • OCD classification
    • Type 1: stable but softened area covered by intact cartilage
    • Type 2: partial discontinuity but stable on probing
    • Type 3: complete discontinuity but in situ
    • Type 4: empty defect with dislocated fragment or loose fragment in situ

Subgroup ICRS OCD 1-4 B: defects >10mm in depth

Surgical Options

    • OCD classification
    • Type 1: stable but softened area covered by intact cartilage
    • Type 2: partial discontinuity but stable on probing
    • Type 3: complete discontinuity but in situ
    • Type 4: empty defect with dislocated fragment or loose fragment in situ

Subgroup ICRS OCD 1-4 B: defects >10mm in depth

Surgical Options

Top left arthroscopy pic of cartilage wear. Top right surgery technique using microfracture. Healing 9bottom right) with fibrocartilage.

HTO surgery option for Ahlbäck < Grade 3

Osteotomy Indications (Rossi et al)

  • Gonarthrosis in Patients With Varus Limb Alignment
  • Adult Osteochondritis Dissecans
  • Osteonecrosis
  • Adult Osteochondritis Dissecans
  • Posterolateral Instability
  • Chondral Resurfacing

Osteotomy Contraindications (Rossi et al)

  • Lateral compartment degenerative joint disease
  • Loss of a significant portion of the lateral meniscus
  • Symptomatic patellofemoral degenerative joint disease
  • Non-concordant pain (ie, patellofemoral pain with medial compartment osteoarthritis)
  • Patient unwillingness to accept the anticipated cosmetic appearance of the desired amount of angular correction
  • and Inflammatory arthritis

Osteotomy surgery options

  • Lateral closing wedge
  • Medial opening wedge
  • Dome osteotomy
Osteotomy surgery options

Patellar Alta associated with Lateral Closing Wedge

Patella Baja associated with Lateral Closing Wedge
The red arrow demonstrating the gain in patellar height after closing wedge osteotomy

Pre-operative Planning

Osteotomy Radiologic Workup

X-rays:
  • Mechanical axis: measure osteotomy angle
  • AP weight bearing in full extension
  • Rosenberg views at 30° & 40°- 45° knee flexion
  • Lateral view
MRI:
  • Provides additional information regarding meniscus, cartilage wear & bone oedema
Osteotomy Radiologic Workup

Osteotomy

Osteotomy angle calculation

Dugdale technique:
  • Line drawn from the centre of femoral head to outer 62.5 % tip of tibia width
  • Second line drawn from centre of the ankle to the outer 62.5 % tip of tibia width
  • The bisector angle is the osteotomy angle
Osteotomy

Surgical Technique

Skin Incision

Tibia tuberosity
Right knee skin incision

After skin incision, release superficial MCL at the level of the osteotomy site.
Release yet protect the Pes tendons

Infrapatellar tendon

Preparation of Tibia osteotomy

Preparation of Tibia osteotomy

Use 2 parallel K wires, this is a guide for the osteotomy bone incision. Drill with oscillating saw below the K wires. Do not saw through the outer tibia cortex as this must remain intact & serves as the centre of rotation of the opening wedge osteotomy

Proximal Osteotomy

Proximal Osteotomy

Protect neurovascular & infrapatellar tendon soft tissue structures

Osteotomy Wedge

Osteotomy Wedge

X-ray showing the osteotomy with osteotomy wedge in situ.
Calculated osteotomy wedge inserted. Allow adequate time for bone expansion when preparing the osteotomy

After Osteotomy: Plate Fixation

After Osteotomy: Plate Fixation

If osteotomy angle ≥12° consider bone grafting at the osteotomy site

Potential Complications

  • Patella Baja (closing wedge osteotomy)
  • Patellar tendon or neurovascular injury
  • Fracture
  • Compartment Syndrome
  • Thromboembolism
  • Non-union
  • Hardware irritation
  • Infection

Download ASSIC Performance Fingerprint and Strength & Conditioning apps for guideline DVT prevention routines and post surgery rehabilitation routines

apple app store  google play store

References

  • The role of high tibial osteotomy in the varus knee. Rossi R R, Bonasia D E, Amendola A. J Am Acad Orthop Surg 2011; 19:590-599
  • Management of Osteoarthritis of the Knee in the Active Patient. Feeley B T, Gallo R A, Sherman S, Williams R J. J Am Acad Orthop Surg 2010;18: 406-416

Contributor:

Dr M Y Hassan

Learn More

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