High Tibial Osteotomy: Indications, Techniques, and ...

© 2015 AAOS Instructional Course Lectures, Volume 64 555

49

Prior to the development of total knee arthroplasty (TKA) as a reliable proce-dure in the 1980s, high tibial osteotomy (HTO) was the most common surgical treatment for varus gonarthrosis. The surgical technique was primarily a clos-ing wedge osteotomy, often with only a staple for fi xation along with a cast.1 A

“dome” sliding osteotomy also was used by some surgeons.2 More rigid fi xation with large plates became the dominant mode of fi xation in the 1990s.

As TKA became more reliable, HTO was less widely used in the United States. However, HTO has remained more popular outside the United States,

partially for economic reasons and par-tially because of a greater interest in knee repair in other countries.

Whereas HTO was initially per-formed almost exclusively as a clos-ing wedge procedure, in the past two decades it has come to be performed primarily using opening wedge tech-niques. Initially, external fi xation open-ing wedge procedures were widely used, but more recently, internal fi xation with limited or large plates has become more popular and external fi xation less common.

IndicationsMedial Pain and PathologyThere is consensus that candidates for HTO are patients with pain located primarily on the medial aspect of the knee and radiographic evidence of me-dial arthrosis demonstrated by less than 4 mm of medial joint space on a stand-ing knee fi lm along with mechanical overload associated with a varus defor-mity. Young patients undergoing artic-ular cartilage restoration procedures or

High Tibial Osteotomy: Indications, Techniques, and Postoperative Management

Chadwick C. Prodromos, MDAnnunziato Amendola, MD

Roland P. Jakob, MD

Dr. Amendola or an immediate family member has received royalties from Arthrex and Arthrosurface; serves as a paid consultant to or is an employee of Arthrex; serves as an unpaid consultant to MTP Solutions; has stock or stock options held in Arthrosurface and MTP Solutions; and serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons; the American Board of Orthopaedic Surgery; the American Orthopaedic Society for Sports Medicine; and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. Dr. Jakob or an immediate family member has received royalties from Geistlich Biomaterials Switzerland and serves as a paid consultant to or is an employee of Geistlich Biomaterials Switzerland. Neither Dr. Prodromos nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

AbstractHigh tibial osteotomy is a safe and effective treatment for medial compartment arthrosis of the knee accompanied by varus alignment. This procedure has seen increasing use as an adjunct to cartilage restoration procedures, such as autologous chondrocyte and meniscal allograft transplantation, when angular deformity exists. The overall goals of high tibial osteotomy can be accomplished by several different techniques. The main indications for high tibial osteotomy are as a primary treatment for varus gonarthrosis and in conjunc-tion with cartilage restoration procedures, such as autologous chondrocyte implantation or microfracture, where success rates are enhanced by correcting the varus deformity.

Instr Course Lect 2015;64:555–565.

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556 © 2015 AAOS Instructional Course Lectures, Volume 64

medial meniscal transplantation who have the mechanical axis lying within that compartment also are candidates for an unloading osteotomy. It is gen-erally agreed that no lateral pain should exist preoperatively.

Preoperative VarusFor HTO to be indicated, some degree of preoperative varus must exist. It is essential to measure alignment on long, hip-knee-ankle mechanical axis radio-graphs (orthoradiograms) (Figure 1). There is no consensus on the minimum amount of varus that indicates the need for HTO. Patients with as little as 4° of varus of the mechanical axis and unicompartmental medial disease can benefi t from HTO.

ContraindicationsStiffnessA markedly decreased range of motion predisposes patients to poor results. This is usually considered fl exion of less than 90°, although less than 100° and less than 120° also have been reported as showing fewer good results.3-6 One of this chapter’s authors (RPJ) found that stiffness in younger patients is caused by posterior condylar osteophytes; good outcomes are possible if the osteophytes are removed concurrently.

Symptomatic Patellofemoral DiseaseThe presence of patellofemoral pain and arthrosis is often a concern when deciding on whether to perform an osteotomy; however, in the experience of this chapter’s authors, it is not a con-traindication. Patellofemoral pathol-ogy (articular cartilage attrition in the absence of substantial patellofemoral

symptoms) is common and consistent with a good result if the patient clearly identifi es his or her medial knee as the overriding problem.

Relative Contraindications and IndicationsObesityCoventry et al7 reported poorer results in patients who were 1.32 times heavier than their ideal body weight. Although this does not directly translate to the more commonly used body mass in-dex, this in general translates to a body mass index of 30 or greater. To varying degrees, outcomes have been worse in patients who are obese.8-11 Not only are success rates lower, but complications are higher. However, some surgeons have achieved good results in patients who are obese. One of this chapter’s authors (CCP) has found obesity to be an important relative contraindication to HTO, whereas another author (AA) believes that patients who are obese may be better served by osteotomy than arthroplasty. The other author (RPJ) has found that HTO may be preferable to TKA in a young patient who is obese. However, care is needed to ensure fi x-ation stability using techniques such as a small lateral plate to fi x the hinge, in addition to a medial plate (Figure 2).

SmokingMany authors have reported higher nonunion rates in patients who smoke; this is an even greater concern when performing opening wedge techniques. Among opening wedge osteotomy pro-cedures, the risk of nonunion is partic-ularly high when external fi xators are used and the procedure is performed below the tibial tubercle. Many sur-geons decline to perform HTO on a patient who smokes.12-15 If HTO is

Mechanical axis radio-graph. A line is drawn from the fem-oral head through the center of the knee, and a second line is drawn from the ankle through the center of the knee. The angle between the lines is the degree of varus or valgus. A well-aligned knee should be 0° (±1°).

Figure 1

AP radiograph shows an opening wedge osteotomy with a lateral small plate to fi x the hinge in addition to a medial plate.

Figure 2

High Tibial Osteotomy: Indications, Techniques, and Postoperative Management Chapter 49


believed to be indicated in a patient who smokes, a closing wedge osteotomy per-formed above the tubercle with a plate may be the best option. Alternatively, a cancellous graft can be used in an open-ing wedge HTO if the opening exceeds 8 to 9 mm.

AgeYounger patient age is a relative indi-cation and one of the key factors in the decision to perform HTO. In the Unit-ed States, the generally accepted max-imum age of a patient considered for HTO is 60 years, with TKA preferred in older patients.16 Outside the United States, HTO is often performed in older patients who are physically fi t and have been informed that their pain will be diminished but likely not eliminated.

Female SexIt was believed that female sex is a rela-tive contraindication for HTO because of the possibility of unsightly excessive postoperative valgus alignment for which women may have a lower toler-ance. It is, however, important to dis-cuss this possibility with all patients to avoid dissatisfaction because of poor cosmesis in an otherwise relatively painless knee. With current techniques that make substantial overcorrection unlikely, the sex of the patient is less of an issue.

OtherPatients younger than 50 years who have better preoperative knee function and range of motion usually have the best outcomes. Ligamentous instability and more severe articular cartilage destruc-tion in the medial compartment (Ahl-back or Outerbridge grade 3 or higher) have been associated with poorer out-comes in some studies.17-20 Overall, if

the main indications for HTO are met, most patients can be expected to ben-efi t from the procedure, although it is important to take all these factors into consideration when discussing options with a patient.

HTO is generally believed to be con-traindicated in patients with an infl am-matory arthropathy.

Surgical TechniquePreoperative PlanningObtaining full-length, weight-bearing, mechanical axis hip-knee-ankle radio-graphs is mandatory (Figure 1). Lines are drawn on the radiograph from the center of the knee to the center of the head of the femur and from the center of the knee to the center of the ankle joint. The angle between these two

lines is measured. The lower extremi-ties must be equally rotated. Valgus and varus stress views may be used to show the thickness of the medial and lateral compartment of the articular cartilage and provide an index of the amount of ligamentous stretching (Figure 3). This often adds an additional 2° to 3° to the actual deformity, which can be sub tracted from the total angular cor-rection or overcorrection results. The size of the opening wedge should be calculated from the preoperative radio-graphs, and magnifi cation should be taken into account. An example of this preoperative planning technique and the fi nal results are shown in Figures 4, 5, and 6. This information is used during surgery to check the osteotomy. Meticulous preoperative planning is of paramount importance. Although information on relevant techniques is beyond the scope of this chapter, such information is available in the

Illustrations of pres-sure applied for a valgus stress view (A) and a varus stress view (B). Radiographs show the same knee with valgus (C) and varus (D) stress. The lines show the align-ment changes.

Figure 3 Preoperative mechan-

ical axis AP radiograph with the mechanical axis deviation shown.

Figure 4

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literature.21,22 The work of Coventry1 suggests that correction to some degree of valgus is the chief goal; this avoids residual varus. This chapter’s authors recommend correction to 1° to 2° of mechanical axis valgus.

External Fixation of an Opening Wedge Osteotomy Below the TubercleOne of this chapter’s authors (CCP) uses an external fi xation opening wedge hemicallotasis exclusively for HTO. This original technique fi rst defi nes the lateral bony hinge. A Gigli saw is then used to complete the osteotomy in a lateral to medial direction (Figures 7, 8, and 9). A video of this technique is available.23 There are several advantages

to this technique, including the use of 2-inch incisions to accomplish the oste-otomy. The cut is made from the lat-eral hinge medially, ensuring the proper hinge thickness and minimizing the risks of tibial plateau and hinge frac-ture. The external fi xator and pins are removed after healing has progressed suffi ciently, resulting in no retained hardware. Detailed presurgical plan-ning is unnecessary because the cor-rection takes place after surgery as the fi xator is opened slowly until the desired correction is reached. This technique allows precise correction, with the fi -nal alignment radiographically checked before the fi xator is locked and healing occurs. The achievement of 1° to 2° of mechanical axis valgus is recom-mended. The experience of one of this chapter’s authors (CCP) has shown that this is suffi cient to produce posi-tive clinical outcomes while preventing unsightly and unnecessary overcorrec-tion. The main disadvantage of using

an external fi xator is the possibility of pin tract infection, which is common but easily treatable. In addition, this technique has a longer recovery time. Patients can return to seated work in 1 week after the surgery; however, re-turn to heavy labor generally requires approximately 9 months.

Opening Wedge Osteotomy With Plate FixationAn opening wedge osteotomy with plate fi xation can be performed with a variety of plates. The open space can be fi lled with autograft, allograft, or syn-thetic bone substitutes or can remain empty. There is no good evidence fa-voring one option over another, and different surgeons have different pref-erences. Most authors, however, rec-ommend some form of grafting for an opening wedge osteotomy. One of this chapter’s authors (RPJ) believes that the use of bone substitutes may increase the risk of infection. There is a tendency to-ward more stable implants with angular screws, which lower the risk of loss of

For preoperative planning, a line is drawn from the center of the hip to the lateral tibial spine (AB) to intersect a line from the center of the ankle to the lat-eral tibial spine (CD). The location of the osteotomy is then drawn, and the length of the osteotomy is measured (EF). The line is then transposed (ef) from the intersec-tion point to determine the size (in millimeters) of the opening wedge correction.

Figure 5 Postoperative radio-

graph after a high tibial osteotomy shows the plate in place and good alignment of the knee as shown by the mechanical axis line.

Figure 6

The blue dot marks the spot for the osteotomy, which was identifi ed under fl uoroscopy. The tibial crest is marked immediately anteriorly to this dot. An incision is made over the tibial crest and car-ried down to the bone. Two proximal pins are in place for attaching an external fi xator after the osteotomy is performed.

Figure 7



correction or overcorrection and allow for more rapid weight bearing.

Regardless of the technique used, arthroscopy can be performed to man-age and assess associated pathologies. An anteromedial longitudinal incision is made 1 cm distal to the joint line be-tween the tibial tubercle and the poste-rior medial border of the tibia. Wound healing seems to favor a longitudinal incision over a transverse incision.24 Sharp dissection is made down to the fascial layer. The exposed sartor-ial fascia is then incised, ending at the superior portion of the pes anserinus. The proximal aspect is extended me-dially. The medial border of the patel-lar tendon is identifi ed and retracted. A Cobb elevator is used to dissect subperiosteally the medial tibia, allow-ing a retractor to be placed posteriorly around the tibia. This allows release of the medial collateral ligament distally. Under fl uoroscopic control, a guidewire is positioned from medial to lateral. The guidewire is placed at the level of the superior aspect of the tibial tubercle, ap-proximately 4 cm anteromedially distal from the joint line. On insertion, the

guidewire is aimed to the fi bular head, approximately 1 cm below the lateral articular margin of the tibia. The tibial osteotomy is performed immediately distal to the guidewire by cutting the cortex with a thin oscillating saw. It is then continued with a thin osteotome under fl uoroscopic control.

Calibrated wedges are then impacted into the osteotomy and slowly advanced until the desired opening is achieved. The position of the wedge is very important to correct the deformity on the sagittal plane: a wedge placed anteri-orly causes an increase in posterior tibial slope, whereas a posterior wedge tends to slightly decrease the posterior tibial slope. Anterior and posterior gaps of the osteotomy can be measured with a ruler to calculate the amount of increase of the posterior slope. If the anterome-dial gap is half of the posteromedial gap, the slope will not change; for each millimeter of increase of the anterior gap, the posterior tibial slope will in-crease 2°.

An image intensifi er and an align-ment rod are used to control coronal and sagittal alignment of the joint. A modifi ed tibial tubercle osteotomy can be performed if the anterior gap is greater than 1 cm to avoid patella baja. After the desired correction has been achieved, plating is performed, and the wedges are removed. Generally, bone graft (autograft, allograft, or synthetic bone substitute) is used to fi ll the oste-otomy gap. The fi nal result and fi xation is checked under fl uoroscopic control before the tourniquet is defl ated; he-mostasis is then confi rmed, and skin suturing is performed.

This technique can be modifi ed to perform a biplanar osteotomy by mak-ing a transverse osteotomy cut, plus a more vertical anterior cut to the proxi-mal end of the tibial tuberosity to avoid damage.

Distal Fibular OsteotomyAlthough a distal fi bular osteotomy is unnecessary with plate fi xation as per-formed by two of this chapter’s authors (AA and RPJ), if correction greater than 10° is desired with an opening wedge hemicallotasis procedure below the tubercle, a distal fi bular osteotomy is necessary to prevent the fi bula from acting as a strut that blocks opening of the tibia. An oblique sliding osteotomy through a small incision just above the fi bular metaphysis is performed with an oscillating saw.

Postoperative AlignmentIt has been shown that undercorrec-tion of varus during a tibial osteotomy is associated with inferior clinical re-sults.7 However, precise intraoperative measurements of correction are diffi -cult to achieve, even with navigational assistance, and are subject to a reported

A 0.25-inch osteotome is used to defi ne the lateral plane of the tibia and fl attened against the bone to use as a guide for a 3.2-mm drill bit. The bone is drilled just inside and parallel to the lateral tibial cortex. After the hole is drilled, the bit is removed and replaced in the hole as a marker.

Figure 8 A 1-inch incision is made at the posterior medial border of the tibia and directed toward the drill bit. The drill bit is removed, and a Gigli saw (arrows) is inserted through the drill hole and gently pulled out the medial incision. The saw is used to cut through the bone while maintaining a greater than 90° angle to prevent the saw from catching on the bone. A laterally applied stress is then used to com-plete the osteotomy.

Figure 9

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error rate that varies from 1° (with navigation) to 8.6° (without naviga-tion), with most surgeons planning on a variability of 2° to 3°.25-28 In addition to this expected variability, signifi cant outliers to this range are reported with nonnavigational techniques, with ap-proximately 23% of the results falling into the expected range,27,28 and 85% when navigation is used.26,27 Because of this variability, most surgeons attempt to achieve intraoperative mechanical axis valgus of approximately 1° to 2° to ensure against undercorrection. How-ever, this means that some patients will have postoperative valgus of 5° or possibly more. Although this degree of valgus is benefi cial regarding knee pain outcomes, it also produces a visually ob-vious valgus alignment. As previously mentioned, a patient who is pain free may still be dissatisfi ed with the proce-dure if cosmesis is unsatisfactory. The patient should be counseled preopera-tively concerning this possible outcome.

The mechanical axis can be esti-mated intraoperatively using a Bovie cord or an alignment rod to span the distance between the femoral head and the center of the ankle. The location of the joint center can be radiographically confi rmed; however, substantial error can result from rotation. One of this chapter’s authors (RPJ) believes that such methods should be used with great caution because of their inherent inac-curacies. To achieve excellent results, RPJ recommends relying on meticulous preoperative planning and a perfect or-thoradiogram.21 The goal is to position the weight-bearing axis slightly lateral to the center of the knee to varying de-grees, depending on the patient.

When external fi xation opening wedge hemicallotasis techniques are used, precise intraoperative alignment

measurements are unnecessary. The only requirement is that the osteotomy opens suffi ciently to allow an adequate opening postoperatively. This generally does not need to be precisely measured; rather, the surgeon can measure the size of the opening between the medial tib-ial cortices, and this can be compared with the preoperatively calculated opening necessary to achieve suffi cient correction. This technique uses cutouts preoperatively to determine the amount of osteotomy opening that correlates approximately with the desired amount of angular correction. The general es-timate of 1° of opening per degree of correction is usually close, but it should not be relied on.

Associated ProceduresArthroscopy With HTOMany surgeons perform arthroscopic examination of the knee for débride-ment of unstable meniscal tears or loose fl aps of articular cartilage immediately before performing an HTO. Alterna-tively, a preoperative MRI can be ob-tained and, in the absence of substantial pathology, arthroscopy can be avoided.

Microfracture With HTOAlthough there are few data to guide treatment regarding microfracture with HTO, many surgeons routinely perform microfracture at the time of an HTO.29 Although HTO by itself has been associated with cartilage regener-ation in the medial compartment with-out micro fracture, the minimal added risk and reported good outcomes ap-pear to justify the addition of this quick arthroscopic procedure at the time of HTO.29-34 Microfracture should not be performed in asymptomatic patel-lofemoral or lateral compartments to avoid inciting pain in these areas.

When used as a stand-alone pro-cedure in the presence of varus great-er than 4°, microfracture has a lower success rate than if it is performed in cases with less varus.35,36 Therefore, HTO may be indicated as an adjunct to a planned microfracture procedure in patients with less severe knee arthritis in whom microfracture is believed to be the indicated primary procedure.

Anterior Cruciate Ligament Reconstruction and Posterolateral Rotatory InstabilitySuitable patients may benefi t from an-terior cruciate ligament reconstruction and HTO, which can be accomplished simultaneously or as a staged proce-dure. Simultaneous HTO and ante-rior cruciate ligament reconstruction is technically challenging and limits the aggressiveness of passive range-of-motion exercises that may be needed after anterior cruciate ligament recon-struction. Two of this chapter’s authors (AA and RPJ) generally combine these procedures,37 whereas the other chapter author (CCP) rarely uses that technique. In patients with moderate arthrosis, the anterior cruciate ligament reconstruc-tion can be performed fi rst. If ade-quate improvement occurs, HTO may be unnecessary. Alternatively, HTO performed fi rst may render an ante-rior cruciate ligament reconstruction unnecessary. If posterolateral rotatory instability is present, then repair of this instability can be performed with HTO.

Cartilage Restoration ProceduresThe literature has shown that results of autologous chondrocyte implantation are compromised by angular defor-mity toward the affected compartment



(varus for a medial lesion and proce-dure; valgus for a lateral lesion and procedure).38,39 Although the data are less clear for osteochondral allograft or autograft implantation and meniscal allograft implantation, most surgeons believe that a varus deformity of greater than 4° should be corrected for optimal results. Any cartilage restoration proce-dure can be performed simultaneously with HTO, although such combined surgical procedures are long and diffi -cult. The decision to stage or simultane-ously perform the procedures depends on the preference of the patient and the experience of the treating surgeon.

Postoperative CarePatients are allowed partial weight bear-ing (with or without a brace) for varying periods of time to protect the oste-otomy. Patients with an external fi xator who also had microfracture performed are kept on partial weight bearing with two crutches for the fi rst 6 weeks to protect the microfracture. Immediate, unlimited range of motion is allowed and encouraged. After 6 weeks, patients progress to full weight bearing as toler-ated, fi rst with one crutch or a cane and fi nally with no assistance. Toleration of each stage is defi ned as the patient having no pain and no limp and not using pain medications. With internal fi xation, 6 to 8 weeks of touch-down or protected weight bearing is usu ally or-dered, with increased loading as radio-graphic healing is demonstrated.

ComplicationsInfectionDeep infections are uncommon after HTO with plates. When deep infections occur, grafts should be removed and the area débrided. However, healing can oc-cur when antibiotics are administered;

the plate is removed as soon as radio-logic healing is assured.

Superfi cial pin tract infections are common after HTO with an external fi xator. When pin tract infections oc-cur, suppressive antibiotics are used for management until the pins are re-moved. Early recognition and a high index of suspicion for infection are necessary so that oral antibiotics can be administered at the fi rst sign of a pin tract infection. These infections always manifest with redness and tenderness at the pin tracts, which are several cen-timeters below the joint line and are easy to distinguish from a knee joint infection. One of this chapter’s authors (CCP) commonly uses postoperative, low-dose, broad-spectrum cephalospo-rin therapy to suppress infection until the fi xator pins are removed.

Loss of AlignmentInitial undercorrection has been asso-ciated with recurrent varus and initial overcorrection with progressive valgus. Mild overcorrection to a few degrees of mechanical axis valgus offers the best chance for an enduring and satisfactory alignment. Because late postoperative loss of alignment has not been inde-pendently correlated with lower late postoperative knee scores,40 the original correction may be more important than late changes in alignment.

Nerve and Vessel InjuryNerve injury, specifi cally peroneal nerve injury, was more common with closing wedge osteotomy and dome procedures than with the opening wedge techniques in current use. These injuries resulted from direct injury to the peroneal nerve at the time of surgery. Popliteal artery injury, in the area of the trifurcation, also is a risk, particularly if substantial

rotational correction is performed. Use of a curved, blunt Hohmann retractor posteriorly can protect against popliteal artery injury.

Hardware ProblemsPainful hardware may require removal. In the absence of infection, however, hardware removal is generally not per-formed in the United States, although it is routinely performed in Europe and Asia. Advantages of hardware removal are that the surgeon has the opportu-nity to resurvey the condition of the joint and confi rm the state of previously performed microfracture or perform additional microfracture if needed.

NonunionNonunion may require bone grafting and hardware replacement. Nonunion is more common with opening wedge procedures than with closing wedge procedures, but it is still uncommon overall. This complication occurs more often in patients who smoke.12 Patients should be counseled about this risk and preferably required to stop smoking be-fore the surgery is performed.

Persistent or Recurrent PainA small percentage of patients treated with HTO (4% to 26%) do not have satisfactory pain relief, and this is the primary reason for revision to TKA.8,41-

45 It is important for patients to un-derstand that a successful result is a substantial reduction in pain, not nec-essarily the elimination of pain. Stud-ies commonly report a 4- to 5-point improvement on a 0- to 10-point pain scale.27,41,46 Patients with severe pain may be better candidates for TKA, al-though many patients who are younger than 60 years will have inadequate pain relief after TKA.47,48

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Tibial Plateau FractureTibial plateau fractures have been re-ported in as many as 11% of patients after opening wedge HTO and are com-mon after closing wedge HTO.49 The key to avoiding fracture is to complete the osteotomy so only a very thin lat-eral hinge remains. However, complete propagation of the osteotomy can lead to instability. Lateral hinge fractures have

been classifi ed by Takeuchi et al.50 Type I is a fracture that reaches just proximal to or within the tibiofi bular joint. A type II fracture reaches the distal portion of the proximal tibiofi bular joint. Type III is a lateral plateau fracture.

StiffnessStiffness is uncommon if preoperative motion is satisfactory. Stiffness is a more common complication after a closing

wedge osteotomy with staple fi xation and postoperative casting. Stiffness is best avoided by beginning early motion. Usually early, unlimited active range of motion is allowed and encouraged.

Deep Vein Thrombosis and Pulmonary EmbolismSome form of prophylaxis is indicated after extensive procedures about the knee. Aspirin (100 mg/d) for up to

Table 1 Clinical Results of High Tibial Osteotomy Studies

Author

(Year)

No. of

Knees/

Patients Technique

Mean Patient

Age in Years

(Range)

Males/

Females

Length of

Follow-up in

Years (Range)

Failure

Endpoint Outcomes

Coventry et al7 (1993)

87/73 Closing wedge with staple fi xation

63

(41-79)

48/25 10

(3-14)

Arthroplasty 90% survivorship at 5 years; 65% at 10 years in patients with 8° valgus, weight 1.32 times normal

Koshino et al42 (2004)

75/53 Closing wedge above tibial tuberosity

59.6

(46-73)

11/42 19

(15-28)

Looked at Knee Society Scores; Arthroplasty (excluding those who died)

Knee score went from 37 ± 20 to 87 ± 13; function score went from 38 ± 16 to 80 ± 19; survivorship 96% at 10 years, 93% at 15 years

Hernigou et al43 (2010)

53–all with varus >15° preopera-

tively

Opening wedge with beta-TCP wedge and buttress plate

60

(43-67)

15/26 10

(8-12)

Arthroplasty 81% survivorship at 10 years

Efe et al44 (2011)

199 Closing wedge with AO plate

54

(27-72)

110/89 9.6

(1-18)

Arthroplasty 84% survivorship at 9.6 years, 68% at 15 years

Hui et al8 (2011)

413 Closing wedge with staple and cast or brace

50

(24-70)

326/87 12

(1-19)

Revision HTO or arthro-plasty

79% 10-year sur-vivorship; 85% satisfi ed with procedure

Saragaglia et al45 (2011)

124/110 Opening wedge with Biosorb wedge (SBM Corp) and plate

53.2

(32-74)

74/36 10.4

(8-14)

Arthroplasty 89% survivorship at 5 years, 74% at 10 years

Schal l-berger et al41 (2011)

54 Opening wedge with plate and bone graft and closing wedge with plate

40

(15-69)

37/17 16.5 (13-21) Arthroplasty 92% survivorship at 10 years;71% after 15 years; no differences between opening and closing wedge procedures

HTO = high tibial osteotomy, TCP = tricalcium phosphate



14 days or mechanical methods are most commonly used in the Unit-ed States. Portable foot compression units are available and usually covered by insurance for use in the home for the fi rst week after surgery. If not cov-ered by insurance, they can usually be rented at low cost. In Europe, low-mo-lecular-weight heparin administered by injection or orally is often used for prophylaxis.

Clinical ResultsA review of the literature shows that HTO produces excellent intermediate- and long-term survivorship (with con-version to arthroplasty as the end point) and allows patients to resume manual labor and active lifestyles.7,8,41-45 In 1993, Coventry et al7 reported a 65% sur vival rate at 10 years in a subpopulation of patients whose preoperative weight was 1.32 times ideal weight or less and whose postoperative valgus angulation was 8° or more at 1 year after surgery. Since that time, studies have reported 10-year survival rates ranging from 74% to 96%8,41-45 (Table 1). Koshino et al42 followed 75 knees for 15 to 28 years af-ter osteotomy and found that 94% could walk more than 1 km without pain. In 2011, Hui et al8 reported that 85% of the patients were satisfi ed with their HTO procedure. Reports for opening and closing wedge osteotomies have been similar, with a study by Schallberger et al41 reporting no differences between the two techniques in terms of survi-vorship and symptom relief.

Results of TKA after HTOIf HTO fails to halt the progression of osteoarthritis, TKA is usually indi-cated. In general, TKA after an opening wedge HTO has outcomes as good as TKA without prior HTO;51-56 however,

a prior HTO appears to increase the technical diffi culties of performing TKA.53,54,56,57 Opinion has varied on whether opening or closing wedge HTO is associated with poorer results after TKA. Recent studies have not found any differences in the outcome of TKA after the two procedures.58,59

HTO Versus ArthroplastyThe choice between HTO and unicom-partmental knee arthroplasty or TKA is often controversial and may depend on both surgeon training and patient preferences or perceptions. In general, a frank discussion regarding the pros and cons of each procedure is advised. In many instances, consultation with another physician (particularly if the treating surgeon performs either HTO or arthroplasty but not both) can be helpful in educating the patient preop-eratively so that an informed decision can be made.

SummaryProperly performed HTO is a safe and effective procedure in appropriately se-lected patients. These procedures are particularly valuable in avoiding TKA in young patients in whom TKA often results in poor outcomes and implant survivorship and in whom a failed TKA may be diffi cult to salvage. Os-teotomy can usually sustain function in younger and more active patients until a more appropriate age is reached for arthroplasty.

References 1. Coventry MB: Osteotomy about the

knee for degenerative and rheuma-toid arthritis. J Bone Joint Surg Am 1973;55(1):23-48.

2. Maquet P: Valgus osteotomy for osteoarthritis of the knee. Clin Orthop Relat Res 1976;120:143-148.

3. Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr: Factors infl uencing long-term results in high tibial osteotomy. Clin Orthop Relat Res 1991;272:192-198.

4. Lee DC, Byun SJ: High tibial osteotomy. Knee Surg Relat Res 2012;24(2):61-69.

5. Parker DA, Viskontas DG: Osteot-omy for the early varus arthritic knee. Sports Med Arthrosc 2007;15(1):3-14.

6. Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H: The long-term outcome of high tibial oste-otomy: A ten- to 20-year follow-up. J Bone Joint Surg Br 2008;90(5):592-596.

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Sports Medicine


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Video Reference Prodromos CC, Amendola A, Jakob RP: Video. Minimally Invasive Inside-Out High Tibial Osteotomy, Glenview, IL, 2014.

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