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