High tibial osteotomy (HTO)

Therdsak Homsreprasert MD.

Reference from Campbells 12th
ศศ ลยศาสตรรขอ
ข สะโพกและขอ ล 1
ข เททยม เลม
Indications
 Pain & disability resulting from OA with high-demand
employment or recreation
 One compartment degenerative arthritis
 Ability of patient to use crutches after operation and
have sufficient muscle strength and motivation to carr
y out a rehabilitation program
 Good vascular status without serious arterial
insufficiency or large varicosities
Contraindications
 Narrowing of lateral compartment cartilage space
 Lateral tibial subluxation > 1 cm
 Medial compartment tibial bone loss >2-3 mm
 Flexion contracture >15o
 Knee flexion < 90o
 > 20o of correction needed
 Inflammatory arthritis or Rheumatoid arthritis
 Significant peripheral vascular disease
Valgus proximal tibial osteotomy

4 basic type
◦ Lateral closing wedge
◦ Medial opening wedge
◦ Medial opening hemicallotasis
◦ Dome (barrel vault)
Lateral closing wedge osteotomy
Coventry (1979)
 213 knees: restore function & pain relief > 60% in 10
y F/U
 Major complication: recurrence of deformity + pain
 Undercorrection (<8oof valgus)
 Overweight (≥30% ideal BW)

Campbells 12th
Lateral closing wedge osteotomy
Factors associated with favorable results
◦ Age < 60 years
◦ Purely unicompartment
◦ Ligamentous stability
◦ Preoperative arc of motion at least 90o
Lateral closing wedge osteotomy
Advantages
◦ It is made near deformity (knee joint)
◦ Made through cancellous bone =>heal rapidly
◦ Permits the fragments to be held firmly in position by
staples or a rigid fixation device
◦ Permits exploration of knee through the same incision
If more than 57 mm-undercorrection

Y=X tanø
Lateral closing wedge osteotomy
Postoperative program
◦ Immediately passive motion 0-30o
◦ Increase 10o/day
◦ PWB 50% with crutches 6 wk
FWB after 6 wk
◦ Remove plate 6-12 months after
union
Medial opening wedge
osteotomy
Fujisawa point

Fujisawa Y et al., Orthop Clin North Am 1979

Medial opening wedge osteotomy
Tomofix
Medial opening wedge
osteotomy
Indication
◦ Extremity ≥ 2 mm shorter than contralateral
extremity
◦ Laxity of medial collateral ligament or combined
ACL deficiency
Medial opening wedge
osteotomy
Advantage Disadvantage
• Can fine tune intraop. • Less aggressive rehab
• Good control • Require graft
multiplanar correction • High nonunion
• Avoid proximal T-F • Require rigid fixation
joint • May lengthen limb
• Avoid peroneal nerve • Patella baja
• Low compartment
syndrome
• No bone loss
 Opening Wedge Hemicallotasis

Schwartsman
◦ Percutaneous osteotomy distal to tibial tuberosit
◦ Circular EF(Ilizarov)
◦ Accurate adjustments postoperatively on standing
weight bearing film
Opening Wedge
Hemicallotasis
Turi et al.
◦ Dynamic uniplanar external fixator
◦ Beginning 7 days postoperatively the fixator
◦ Distracted 0.25 mm four times a day
◦ 5 years survivorships 89%,10 years survivorships
63%

Medial opening wedge HTO with distraction osteogenesis

Opening Wedge Hemicallotasis
Advantage Disadvantage

• Ability to translate • Poor acceptance of

distal fragment to external fixator
mechanical axis • Pin loosening
• Improve stabilty of • Pin track infection
fixation
• Immediate weight
bearing and knee
motion
Dome osteotomy(barrel
vault)
Advantage
◦ More accuracy & adjustability of
correction
◦ Internal fixation usually is not
required
◦ Post-op adjustments can be made in
cast
Disadvantages
◦ Technical difficulty
◦ Intraarticular fracture
◦ Scarring around patellofemoral
extensor mechanism
 A 34-year-old woman had right knee pain with failed
conservative treatment. The standing femorotibial axis
measures 20 degrees of valgus. The plain radiographs
show isolate narrowing joint space of lateral
compartment. The optimum treatment of this
condition should include

A.Distal femoral varus osteotomy.

B. Osteoarticular transplant to the lateral femoral
condyle.
C. Lateral unicondylar arthroplasty.
D.High tibial osteotomy.
E. Tibial tubercle transfer
ANS A
Thank you