High Tibial Osteotomy

Planning and Indications

• 45yo female• Active lifestyle• Not overweight

12 weeks

• Goals of Treatment– Pain Relief– Maintain or Improve function• Stay in the work force• Sport

Non – Operative Treatment

• Lifestyle Modification– Weight loss– Low impact– Change occupation– Change sport

Non – Operative Treatment

• Paracetamol• NSAIDs

– significant reduction in pain compared to placebo– GIT risks

• Glucosamine / Chondroitin Sulfate– Cochrane review = no definitive clinical benefit vs placebo

• Steroid Injection– Effective short term

• Viscosupplementation– Cochrane review no benefit over placebo

Non – Operative Treatment

• Physiotherapy– Relationship / painful treatment– Quads strengthening– Stretching

Non – Operative Treatment

• Bracing and heel wedges– Some effect– Daily use?– 2 years - 25% compliance

Operative Treatment Options

• Needle Lavage– Not significant benefit

• Arthroscopic Debridement– Reserved for mechanical symptoms

Operative Treatment Options• UKA

– Good patient satisfaction– Physiologic function– Accelerated rehab and

recovery time– Discharge day 1-3– Conversion to TKR improving

– Double the revision rate compared to TKR– labour– Bone stock

• TKR

• TKR

Operative Treatment Options• HTO• Morrey JBJS 1989

– 34 osteotomies– 7.5 yr fu– 73% satisfactory results

• Bourne 1999– 106 Osteotomies– Survivorship 5yrs = 73%, 10yrs = 51%– In patient <50 5yrs = 95%, 10yrs = 80%

• Hui Am J Sports Med 2010– 349 osteotomies– Mean fu 12 years (1-19yrs), avg age 50yrs– Survival 5yrs = 95%, 10yrs = 79%, 15yrs = 56%– 10yrs = 21% failure rate (reoperation)

• Results for conversion HTO to Primary TKR not different to primary OA to TKR• Results UKR to TKR slightly better than a TKR to revision TKR

Operative Treatment Options

• HTO downside• General risks• Non-union• Fracture• Painful• Long rehab• Pain not all gone• Arthroplasty in the future

Lateral Closing Wedge

12 weeks

Medial Opening Wedge

Indications

• Genu Varum with medial OA

• Adult OCD• Osteonecrosis• PLC instability

Appropriate Patient

• Young patient (<60 relative)

• Active

• Motivated for rehabilitation

• BMI <30 (<1.32x ideal bw)

Appropriate Joint

• Unicompartmental pathology• Correlation with XRs• Non Inflammatory• FFD <15degrees• Flexion arc >90 degrees• Varus <15 degrees, Valgus <12

degrees

Contraindications

• Smokers• Lateral compartment OA or previous

injury / menesectomy• Inconsistent pain• Inflammatory arthritis• Obese (BMI >30)• FFD >15 degrees

Pre – op Planning

• Correct patient• Deformity

– Tibial– Femoral– Both

• Axes– Mechanical– Anatomical

• Correction desired• Implant choice• Graft type

Pre – op Planning - Deformity

• Standing Long leg views• MRI to check other compartments

Pre – op Planning - Deformity

mLDFA = 88o

mPTA = 81o

Pre – op Planning - Axis

• Mechanical Axis• Femoral – Tibial – 2o varus med 75%, lat 25%– 0o (centre) med 60% lat 40%– 4o valgus med 50% lat 50%– 6o valgus med 40% lat 60%

• Correction angle– Angle of deformity + 4-6o = 14o

8o

mLDFA = 88o

mPTA = 81o

Pre – op Planning – Fujisawa point

• Simplify

• 14 degrees14o

Pre – op Planning – Correction

• Now we know the angle of correction - ?

• mm opening• First 10mm : 1mm = 1o correction– Variation in tibial length and

metaphyseal width– 14mm < 14o

• C- arm II• Navigation

Pre – op Planning – Correction

• Now we know the angle of correction - ?

• mm opening• First 10mm : 1mm = 1o

correction– Variation in tibial length and

metaphyseal width– 14mm < 14o

Fixation

• Spacer plate

• Rigid locked plates

Bone Graft

• Opening wedge• Structural support• Biological healing• Scaffold

• Autograft vs Allograft vs Synthetic substitute• No need?

1 2 3

Summary

• Correct patient• Locate the deformity for

correction• Axes• Correction• Implant• Graft