High Tibial Osteotomy: Indications, Techniques, and Postoperative Management

Chadwick C. Prodromos, MD Annunziato Amendola, MD Roland P. Jakob, MD

Abstract partially for economic reasons and par- High tibial osteotomy is a safe and effective treatment for medial compartment arthrosis tially because of a greater interest in of the knee accompanied by varus alignment. This procedure has seen increasing use as an knee repair in other countries. adjunct to cartilage restoration procedures, such as autologous chondrocyte and meniscal Whereas HTO was initially per- allograft transplantation, when angular deformity exists. The overall goals of high tibial formed almost exclusively as a clos- osteotomy can be accomplished by several different techniques. The main indications for ing wedge procedure, in the past two high tibial osteotomy are as a primary treatment for varus gonarthrosis and in conjunc- decades it has come to be performed tion with cartilage restoration procedures, such as autologous chondrocyte implantation or primarily using opening wedge tech- microfracture, where success rates are enhanced by correcting the varus deformity. niques. Initially, external fi xation open- Instr Course Lect 2015;64:555–565. ing wedge procedures were widely used, but more recently, internal fi xation with Prior to the development of total knee “dome” sliding osteotomy also was used limited or large plates has become arthroplasty (TKA) as a reliable proce- by some surgeons.2 More rigid fi xation more popular and external fi xation less dure in the 1980s, high tibial osteotomy with large plates became the dominant common. (HTO) was the most common surgical mode of fi xation in the 1990s. treatment for varus gonarthrosis. The As TKA became more reliable, Indications surgical technique was primarily a clos- HTO was less widely used in the United Medial Pain and Pathology ing wedge osteotomy, often with only a States. However, HTO has remained There is consensus that candidates for staple for fi xation along with a cast.1 A more popular outside the United States, HTO are patients with pain located primarily on the medial aspect of the Dr. Amendola or an immediate family member has received royalties from Arthrex and Arthrosurface; serves as a paid knee and radiographic evidence of me- consultant to or is an employee of Arthrex; serves as an unpaid consultant to MTP Solutions; has stock or stock options dial arthrosis demonstrated by less than 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 4 mm of medial joint space on a stand- Society for Sports Medicine; and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. ing knee fi lm along with mechanical Dr. Jakob or an immediate family member has received royalties from Geistlich Biomaterials Switzerland and serves as overload associated with a varus defor- 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 mity. Young patients undergoing artic- related directly or indirectly to the subject of this chapter. ular cartilage restoration procedures or

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 Indications Obesity Coventry 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 index, 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 Figure 2 AP radiograph shows are higher. However, some surgeons an opening wedge osteotomy with a Figure 1 Mechanical axis radio- lateral small plate to fi x the hinge in have achieved good results in patients graph. A line is drawn from the fem- addition to a medial plate. oral head through the center of the who are obese. One of this chapter’s knee, and a second line is drawn authors (CCP) has found obesity to be from the ankle through the center Contraindications an important relative contraindication of the knee. The angle between the lines is the degree of varus or Stiffness to HTO, whereas another author (AA) valgus. A well-aligned knee should A markedly decreased range of motion believes that patients who are obese be 0° (±1°). predisposes patients to poor results. may be better served by osteotomy than This is usually considered fl exion of less arthroplasty. The other author (RPJ) medial meniscal transplantation who than 90°, although less than 100° and has found that HTO may be preferable have the mechanical axis lying within less than 120° also have been reported to TKA in a young patient who is obese. that compartment also are candidates as showing fewer good results.3-6 One of However, care is needed to ensure fi x- for an unloading osteotomy. It is gen- this chapter’s authors (RPJ) found that ation stability using techniques such as erally agreed that no lateral pain should stiffness in younger patients is caused a small lateral plate to fi x the hinge, in exist preoperatively. by posterior condylar osteophytes; good addition to a medial plate (Figure 2). outcomes are possible if the osteophytes Preoperative Varus are removed concurrently. Smoking For HTO to be indicated, some degree Many authors have reported higher of preoperative varus must exist. It is Symptomatic nonunion rates in patients who smoke; essential to measure alignment on long, Patellofemoral Disease this is an even greater concern when hip-knee-ankle mechanical axis radio- The presence of patellofemoral pain performing opening wedge techniques. graphs (orthoradiograms) (Figure 1). and arthrosis is often a concern when Among opening wedge osteotomy pro- There is no consensus on the minimum deciding on whether to perform an cedures, the risk of nonunion is partic- amount of varus that indicates the need osteotomy; however, in the experience ularly high when external fi xators are for HTO. Patients with as little as 4° of this chapter’s authors, it is not a con- used and the procedure is performed of varus of the mechanical axis and traindication. Patellofemoral pathol- below the tibial tubercle. Many sur- unicompartmental medial disease can ogy (articular cartilage attrition in the geons decline to perform HTO on benefi t from HTO. absence of substantial patellofemoral a patient who smokes.12-15 If HTO is

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

Age Younger 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 Figure 4 Preoperative mechan- diminished but likely not eliminated. Figure 3 Illustrations of pres- ical axis AP radiograph with the sure applied for a valgus stress mechanical axis deviation shown. view (A) and a varus stress view Female Sex (B). Radiographs show the same It was believed that female sex is a rela- knee with valgus (C) and varus (D) lines is measured. The lower extremi- tive contraindication for HTO because stress. The lines show the align- ties must be equally rotated. Valgus and ment changes. of the possibility of unsightly excessive varus stress views may be used to show postoperative valgus alignment for the thickness of the medial and lateral which women may have a lower toler- the main indications for HTO are met, compartment of the articular cartilage ance. It is, however, important to dis- most patients can be expected to ben- and provide an index of the amount cuss this possibility with all patients to efi t from the procedure, although it is of ligamentous stretching (Figure 3). avoid dissatisfaction because of poor important to take all these factors into This often adds an additional 2° to 3° cosmesis in an otherwise relatively consideration when discussing options to the actual deformity, which can be painless knee. With current techniques with a patient. subtracted from the total angular cor- that make substantial overcorrection HTO is generally believed to be con- rection or overcorrection results. The unlikely, the sex of the patient is less traindicated in patients with an infl am- size of the opening wedge should be of an issue. matory arthropathy. calculated from the preoperative radiographs, and magnifi cation should be Other Surgical Technique taken into account. An example of this Patients younger than 50 years who have Preoperative Planning preoperative planning technique and better preoperative knee function and Obtaining full-length, weight-bearing, the fi nal results are shown in Figures range of motion usually have the best mechanical axis hip-knee-ankle radio- 4, 5, and 6. This information is used outcomes. Ligamentous instability and graphs is mandatory (Figure 1). Lines during surgery to check the osteotomy. more severe articular cartilage destruc- are drawn on the radiograph from the Meticulous preoperative planning is tion in the medial compartment (Ahl- center of the knee to the center of the of paramount importance. Although back or Outerbridge grade 3 or higher) head of the femur and from the center information on relevant techniques have been associated with poorer out- of the knee to the center of the ankle is beyond the scope of this chapter, comes in some studies.17-20 Overall, if joint. The angle between these two such information is available in the

Figure 7 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 Figure 5 For preoperative Figure 6 Postoperative radio- is performed. planning, a line is drawn from the graph after a high tibial osteotomy center of the hip to the lateral tibial shows the plate in place and good spine (AB) to intersect a line from alignment of the knee as shown by the center of the ankle to the lat- the mechanical axis line. eral tibial spine (CD). The location an external fi xator is the possibility of of the osteotomy is then drawn, pin tract infection, which is common and the length of the osteotomy is to this technique, including the use of but easily treatable. In addition, this measured (EF). The line is then transposed (ef) from the intersec- 2-inch incisions to accomplish the oste- technique has a longer recovery time. tion point to determine the size (in otomy. The cut is made from the lat- Patients can return to seated work in millimeters) of the opening wedge eral hinge medially, ensuring the proper 1 week after the surgery; however, re- correction. hinge thickness and minimizing the turn to heavy labor generally requires risks of tibial plateau and hinge frac- approximately 9 months. literature.21,22 The work of Coventry1 ture. The external fi xator and pins are suggests that correction to some degree removed after healing has progressed Opening Wedge Osteotomy of valgus is the chief goal; this avoids suffi ciently, resulting in no retained With Plate Fixation residual varus. This chapter’s authors hardware. Detailed presurgical plan- An opening wedge osteotomy with recommend correction to 1° to 2° of ning is unnecessary because the cor- plate fi xation can be performed with a mechanical axis valgus. rection takes place after surgery as the variety of plates. The open space can be fi xator is opened slowly until the desired fi lled with autograft, allograft, or syn- External Fixation of an correction is reached. This technique thetic bone substitutes or can remain Opening Wedge Osteotomy allows precise correction, with the fi - empty. There is no good evidence fa- Below the Tubercle nal alignment radiographically checked voring one option over another, and One of this chapter’s authors (CCP) before the fi xator is locked and healing different surgeons have different pref- uses an external fi xation opening wedge occurs. The achievement of 1° to 2° erences. Most authors, however, rec- hemicallotasis exclusively for HTO. of mechanical axis valgus is recom- ommend some form of grafting for an This original technique fi rst defi nes mended. The experience of one of this opening wedge osteotomy. One of this the lateral bony hinge. A Gigli saw is chapter’s authors (CCP) has shown chapter’s authors (RPJ) believes that the then used to complete the osteotomy in that this is suffi cient to produce posi- use of bone substitutes may increase the a lateral to medial direction (Figures 7, tive clinical outcomes while preventing risk of infection. There is a tendency to- 8, and 9). A video of this technique is unsightly and unnecessary overcorrec- ward more stable implants with angular available.23 There are several advantages tion. The main disadvantage of using screws, which lower the risk of loss of

An image intensifi er and an alignment 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 Figure 8 A 0.25-inch osteotome Figure 9 A 1-inch incision is graft (autograft, allograft, or synthetic is used to defi ne the lateral plane made at the posterior medial border bone substitute) is used to fi ll the oste- of the tibia and fl attened against of the tibia and directed toward the the bone to use as a guide for a drill bit. The drill bit is removed, otomy gap. The fi nal result and fi xation 3.2-mm drill bit. The bone is drilled and a Gigli saw (arrows) is inserted is checked under fl uoroscopic control just inside and parallel to the lateral through the drill hole and gently before the tourniquet is defl ated; he- tibial cortex. After the hole is drilled, pulled out the medial incision. The the bit is removed and replaced in saw is used to cut through the bone mostasis is then confi rmed, and skin the hole as a marker. while maintaining a greater than suturing is performed. 90° angle to prevent the saw from This technique can be modifi ed to catching on the bone. A laterally correction or overcorrection and allow applied stress is then used to com- perform a biplanar osteotomy by mak- for more rapid weight bearing. plete the osteotomy. ing a transverse osteotomy cut, plus a Regardless of the technique used, more vertical anterior cut to the proxi- arthroscopy can be performed to man- guidewire is aimed to the fi bular head, mal end of the tibial tuberosity to avoid age and assess associated pathologies. approximately 1 cm below the lateral damage. An anteromedial longitudinal incision articular margin of the tibia. The tibial is made 1 cm distal to the joint line be- osteotomy is performed immediately Distal Fibular Osteotomy tween the tibial tubercle and the poste- distal to the guidewire by cutting the Although a distal fi bular osteotomy is rior medial border of the tibia. Wound cortex with a thin oscillating saw. It is unnecessary with plate fi xation as per- healing seems to favor a longitudinal then continued with a thin osteotome formed by two of this chapter’s authors incision over a transverse incision.24 under fl uoroscopic control. (AA and RPJ), if correction greater than Sharp dissection is made down to Calibrated wedges are then impacted 10° is desired with an opening wedge the fascial layer. The exposed sartor- into the osteotomy and slowly advanced hemicallotasis procedure below the ial fascia is then incised, ending at the until the desired opening is achieved. tubercle, a distal fi bular osteotomy is superior portion of the pes anserinus. The position of the wedge is very necessary to prevent the fi bula from The proximal aspect is extended me- important to correct the deformity on acting as a strut that blocks opening of dially. The medial border of the patel- the sagittal plane: a wedge placed anteri- the tibia. An oblique sliding osteotomy lar tendon is identifi ed and retracted. orly causes an increase in posterior tibial through a small incision just above the A Cobb elevator is used to dissect slope, whereas a posterior wedge tends fi bular metaphysis is performed with an subperiosteally the medial tibia, allow- to slightly decrease the posterior tibial oscillating saw. ing a retractor to be placed posteriorly slope. Anterior and posterior gaps of around the tibia. This allows release of the osteotomy can be measured with a Postoperative Alignment the medial collateral ligament distally. ruler to calculate the amount of increase It has been shown that undercorrec- Under fl uoroscopic control, a guidewire of the posterior slope. If the anterome- tion of varus during a tibial osteotomy is positioned from medial to lateral. The dial gap is half of the posteromedial is associated with inferior clinical re- guidewire is placed at the level of the gap, the slope will not change; for each sults.7 However, precise intraoperative superior aspect of the tibial tubercle, ap- millimeter of increase of the anterior measurements of correction are diffi - proximately 4 cm anteromedially distal gap, the posterior tibial slope will in- cult to achieve, even with navigational from the joint line. On insertion, the crease 2°. assistance, and are subject to a reported

error rate that varies from 1° (with measurements are unnecessary. The When used as a stand-alone pro- navigation) to 8.6° (without naviga- only requirement is that the osteotomy cedure in the presence of varus great- tion), with most surgeons planning on opens suffi ciently to allow an adequate er than 4°, microfracture has a lower a variability of 2° to 3°.25-28 In addition opening postoperatively. This generally success rate than if it is performed in to this expected variability, signifi cant does not need to be precisely measured; cases with less varus.35,36 Therefore, outliers to this range are reported with rather, the surgeon can measure the size HTO may be indicated as an adjunct nonnavigational techniques, with ap- of the opening between the medial tib- to a planned microfracture procedure in proximately 23% of the results falling ial cortices, and this can be compared patients with less severe knee arthritis into the expected range,27,28 and 85% with the preoperatively calculated in whom microfracture is believed to be when navigation is used.26,27 Because of opening necessary to achieve suffi cient the indicated primary procedure. this variability, most surgeons attempt correction. This technique uses cutouts to achieve intraoperative mechanical preoperatively to determine the amount Anterior Cruciate axis valgus of approximately 1° to 2° to of osteotomy opening that correlates Ligament Reconstruction ensure against undercorrection. How- approximately with the desired amount and Posterolateral ever, this means that some patients of angular correction. The general es- Rotatory Instability will have postoperative valgus of 5° or timate of 1° of opening per degree of Suitable patients may benefi t from an- possibly more. Although this degree of correction is usually close, but it should terior cruciate ligament reconstruction valgus is benefi cial regarding knee pain not be relied on. and HTO, which can be accomplished outcomes, it also produces a visually ob- simultaneously or as a staged proce- vious valgus alignment. As previously Associated Procedures dure. Simultaneous HTO and ante- mentioned, a patient who is pain free Arthroscopy With HTO rior cruciate ligament reconstruction may still be dissatisfi ed with the proce- Many surgeons perform arthroscopic is technically challenging and limits dure if cosmesis is unsatisfactory. The examination of the knee for débride- the aggressiveness of passive range-of- patient should be counseled preopera- ment of unstable meniscal tears or loose motion exercises that may be needed tively concerning this possible outcome. fl aps of articular cartilage immediately after anterior cruciate ligament recon- The mechanical axis can be esti- before performing an HTO. Alterna- struction. Two of this chapter’s authors mated intraoperatively using a Bovie tively, a preoperative MRI can be ob- (AA and RPJ) generally combine these cord or an alignment rod to span the tained and, in the absence of substantial procedures,37 whereas the other chapter distance between the femoral head and pathology, arthroscopy can be avoided. author (CCP) rarely uses that technique. the center of the ankle. The location of In patients with moderate arthrosis, the the joint center can be radiographically Microfracture With HTO anterior cruciate ligament reconstruc- confi rmed; however, substantial error Although there are few data to guide tion can be performed fi rst. If ade- can result from rotation. One of this treatment regarding microfracture quate improvement occurs, HTO may chapter’s authors (RPJ) believes that with HTO, many surgeons routinely be unnecessary. Alternatively, HTO such methods should be used with great perform microfracture at the time of performed fi rst may render an ante- caution because of their inherent inac- an HTO.29 Although HTO by itself has rior cruciate ligament reconstruction curacies. To achieve excellent results, been associated with cartilage regener- unnecessary. If posterolateral rotatory RPJ recommends relying on meticulous ation in the medial compartment with- instability is present, then repair of this preoperative planning and a perfect or- out microfracture, the minimal added instability can be performed with HTO. thoradiogram.21 The goal is to position risk and reported good outcomes ap- the weight-bearing axis slightly lateral pear to justify the addition of this quick Cartilage Restoration to the center of the knee to varying de- arthroscopic procedure at the time of Procedures grees, depending on the patient. HTO.29-34 Microfracture should not The literature has shown that results of When external fi xation opening be performed in asymptomatic patel- autologous chondrocyte implantation wedge hemicallotasis techniques are lofemoral or lateral compartments to are compromised by angular defor- used, precise intraoperative alignment avoid inciting pain in these areas. mity toward the affected compartment

(varus for a medial lesion and proce- the plate is removed as soon as radio- rotational correction is performed. Use dure; valgus for a lateral lesion and logic healing is assured. of a curved, blunt Hohmann retractor procedure).38,39 Although the data are Superfi cial pin tract infections are posteriorly can protect against popliteal less clear for osteochondral allograft common after HTO with an external artery injury. or autograft implantation and meniscal fi xator. When pin tract infections oc- allograft implantation, most surgeons cur, suppressive antibiotics are used Hardware Problems believe that a varus deformity of greater for management until the pins are re- Painful hardware may require removal. than 4° should be corrected for optimal moved. Early recognition and a high In the absence of infection, however, results. Any cartilage restoration proce- index of suspicion for infection are hardware removal is generally not per- dure can be performed simultaneously necessary so that oral antibiotics can formed in the United States, although with HTO, although such combined be administered at the fi rst sign of a pin it is routinely performed in Europe and surgical procedures are long and diffi - tract infection. These infections always Asia. Advantages of hardware removal cult. The decision to stage or simultane- manifest with redness and tenderness are that the surgeon has the opportu- ously perform the procedures depends at the pin tracts, which are several cen- nity to resurvey the condition of the on the preference of the patient and the timeters below the joint line and are joint and confi rm the state of previously experience of the treating surgeon. easy to distinguish from a knee joint performed microfracture or perform infection. One of this chapter’s authors additional microfracture if needed. Postoperative Care (CCP) commonly uses postoperative, Patients are allowed partial weight bear- low-dose, broad-spectrum cephalospo- Nonunion ing (with or without a brace) for varying rin therapy to suppress infection until Nonunion may require bone grafting periods of time to protect the oste- the fi xator pins are removed. and hardware replacement. Nonunion otomy. Patients with an external fi xator is more common with opening wedge who also had microfracture performed Loss of Alignment procedures than with closing wedge are kept on partial weight bearing with Initial undercorrection has been asso- procedures, but it is still uncommon two crutches for the fi rst 6 weeks to ciated with recurrent varus and initial overall. This complication occurs more protect the microfracture. Immediate, overcorrection with progressive valgus. often in patients who smoke.12 Patients unlimited range of motion is allowed Mild overcorrection to a few degrees of should be counseled about this risk and and encouraged. After 6 weeks, patients mechanical axis valgus offers the best preferably required to stop smoking be- progress to full weight bearing as toler- chance for an enduring and satisfactory fore the surgery is performed. ated, fi rst with one crutch or a cane and alignment. Because late postoperative fi nally with no assistance. Toleration loss of alignment has not been inde- Persistent or Recurrent Pain of each stage is defi ned as the patient pendently correlated with lower late A small percentage of patients treated having no pain and no limp and not postoperative knee scores,40 the original with HTO (4% to 26%) do not have using pain medications. With internal correction may be more important than satisfactory pain relief, and this is the fi xation, 6 to 8 weeks of touch-down or late changes in alignment. primary reason for revision to TKA.8,41- protected weight bearing is usu ally or- 45 It is important for patients to un- dered, with increased loading as radio- Nerve and Vessel Injury derstand that a successful result is a graphic healing is demonstrated. Nerve injury, specifi cally peroneal nerve substantial reduction in pain, not nec- injury, was more common with closing essarily the elimination of pain. Stud- Complications wedge osteotomy and dome procedures ies commonly report a 4- to 5-point Infection than with the opening wedge techniques improvement on a 0- to 10-point pain Deep infections are uncommon after in current use. These injuries resulted scale.27,41,46 Patients with severe pain HTO with plates. When deep infections from direct injury to the peroneal nerve may be better candidates for TKA, al- occur, grafts should be removed and the at the time of surgery. Popliteal artery though many patients who are younger area débrided. However, healing can oc- injury, in the area of the trifurcation, than 60 years will have inadequate pain cur when antibiotics are administered; also is a risk, particularly if substantial relief after TKA.47,48

Table 1 Clinical Results of High Tibial Osteotomy Studies

No. of Mean Patient Length of Author Knees/ Age in Years Males/ Follow-up in Failure (Year) Patients Technique (Range) Females Years (Range) Endpoint Outcomes Coventry et 87/73 Closing wedge 63 48/25 10 Arthroplasty 90% survivorship at al7 (1993) with staple (41-79) (3-14) 5 years; 65% at 10 ﬁ x a t i o n years in patients with 8° valgus, weight 1.32 times normal Koshino 75/53 Closing wedge 59.6 11/42 19 Looked at Knee score went et al42 above tibial (46-73) (15-28) Knee Society from 37 ± 20 to (2004) tuberosity Scores; 87 ± 13; function Arthroplasty score went from (excluding 38 ± 16 to 80 ± 19; those who survivorship 96% died) at 10 years, 93% at 15 years Hernigou 53–all with Opening wedge 60 15/26 10 Arthroplasty 81% survivorship at et al43 varus >15° with beta-TCP (43-67) (8-12) 10 years (2010) preopera- wedge and tively buttress plate Efe et al44 199 Closing wedge 54 110 / 89 9.6 Arthroplasty 84% survivorship at (2011) with AO plate (27-72) (1-18) 9.6 years, 68% at 15 years Hui et al8 413 Closing wedge 50 326/87 12 Revision HTO 79% 10-year sur- (2011) with staple and (24-70) (1-19) or arthro- vivorship; 85% cast or brace plasty satisﬁ ed with procedure Saragaglia 124/110 Opening wedge 53.2 74/36 10.4 Arthroplasty 89% survivorship at et al45 with Biosorb (32-74) (8-14) 5 years, 74% at 10 (2011) wedge (SBM years Corp) and plate Schal l- 54 Opening wedge 40 37/17 16.5 (13-21) Arthroplasty 92% survivorship berger with plate and (15-69) at 10 years;71% et al41 bone graft and after 15 years; (2011) closing wedge no differences with plate between opening and closing wedge procedures

HTO = high tibial osteotomy, TCP = tricalcium phosphate

been classifi ed by Takeuchi et al.50 Type wedge osteotomy with staple fi xation Tibial Plateau Fracture I is a fracture that reaches just proximal and postoperative casting. Stiffness is Tibial plateau fractures have been re- to or within the tibiofi bular joint. A type best avoided by beginning early motion. ported in as many as 11% of patients II fracture reaches the distal portion of Usually early, unlimited active range of after opening wedge HTO and are com- the proximal tibiofi bular joint. Type III motion is allowed and encouraged. mon after closing wedge HTO.49 The is a lateral plateau fracture. key to avoiding fracture is to complete Deep Vein Thrombosis and the osteotomy so only a very thin lat- Stiffness Pulmonary Embolism eral hinge remains. However, complete Stiffness is uncommon if preoperative Some form of prophylaxis is indicated propagation of the osteotomy can lead to motion is satisfactory. Stiffness is a more after extensive procedures about the instability. Lateral hinge fractures have common complication after a closing knee. Aspirin (100 mg/d) for up to

14 days or mechanical methods are a prior HTO appears to increase the 3. Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr: Factors infl uencing long- most commonly used in the Unit- technical diffi culties of performing term results in high tibial osteotomy. ed States. Portable foot compression TKA.53,54,56,57 Opinion has varied on Clin Orthop Relat Res 1991;272:192-198. units are available and usually covered whether opening or closing wedge 4. Lee DC, Byun SJ: High tibial by insurance for use in the home for HTO is associated with poorer results osteotomy. Knee Surg Relat Res the fi rst week after surgery. If not cov- after TKA. Recent studies have not 2012;24(2):61-69. ered by insurance, they can usually be found any differences in the outcome 5. Parker DA, Viskontas DG: Osteot- rented at low cost. In Europe, low-mo- of TKA after the two procedures.58,59 omy for the early varus arthritic knee. Sports Med Arthrosc 2007;15(1):3-14. lecular-weight heparin administered 6. Akizuki S, Shibakawa A, Takizawa by injection or orally is often used for HTO Versus Arthroplasty T, Yamazaki I, Horiuchi H: The prophylaxis. The choice between HTO and unicom- long-term outcome of high tibial oste- partmental knee arthroplasty or TKA otomy: A ten- to 20-year follow-up. J Bone Joint Surg Br 2008;90(5):592-596. Clinical Results is often controversial and may depend A review of the literature shows that on both surgeon training and patient 7. Coventry MB, Ilstrup DM, Wall- richs SL: Proximal tibial oste- HTO produces excellent intermediate- preferences or perceptions. In general, otomy: A critical long-term study of and long-term survivorship (with con- a frank discussion regarding the pros eighty-seven cases. J Bone Joint Surg Am version to arthroplasty as the end point) and cons of each procedure is advised. 1993;75(2):196-201. and allows patients to resume manual In many instances, consultation with 8. Hui C, Salmon LJ, Kok A, et al: labor and active lifestyles.7,8,41-45 In 1993, another physician (particularly if the Long-term survival of high tibial osteotomy for medial compartment 7 Coventry et al reported a 65% survival treating surgeon performs either HTO osteoarthritis of the knee. Am J Sports rate at 10 years in a subpopulation of or arthroplasty but not both) can be Med 2011;39(1):64-70. patients whose preoperative weight helpful in educating the patient preop- 9. Floerkemeier S, Staubli AE, Schroeter was 1.32 times ideal weight or less and eratively so that an informed decision S, Goldhahn S, Lobenhoffer P: Does obesity and nicotine abuse infl uence whose postoperative valgus angulation can be made. the outcome and complication rate was 8° or more at 1 year after surgery. after open-wedge high tibial oste- Since that time, studies have reported Summary otomy? A retrospective evaluation of fi ve hundred and thirty three patients. 10-year survival rates ranging from 74% Properly performed HTO is a safe and Int Orthop 2014;38(1):55-60. to 96%8,41-45 (Table 1). Koshino et al42 effective procedure in appropriately se- 10. Giagounidis EM, Sell S: High followed 75 knees for 15 to 28 years af- lected patients. These procedures are tibial osteotomy: Factors infl u- ter osteotomy and found that 94% could particularly valuable in avoiding TKA encing the duration of satisfactory walk more than 1 km without pain. In in young patients in whom TKA often function. Arch Orthop Trauma Surg 1999;119(7-8):445-449. 2011, Hui et al8 reported that 85% of the results in poor outcomes and implant patients were satisfi ed with their HTO survivorship and in whom a failed 11. Song EK, Seon JK, Park SJ, Jeong MS: The complications of high tibial procedure. Reports for opening and TKA may be diffi cult to salvage. Os- osteotomy: Closing- versus open- closing wedge osteotomies have been teotomy can usually sustain function in ing-wedge methods. J Bone Joint Surg Br similar, with a study by Schallberger et younger and more active patients until 2010;92(9):1245-1252. al41 reporting no differences between a more appropriate age is reached for 12. Meidinger G, Imhoff AB, Paul J, Kirchhoff C, Sauerschnig M, the two techniques in terms of survi- arthroplasty. Hinterwimmer S: May smokers and vorship and symptom relief. overweight patients be treated with References a medial open-wedge HTO? Risk factors for non-union. Knee Surg Sports Results of TKA after HTO 1. Coventry MB: Osteotomy about the Traumatol Arthrosc 2011;19(3):333-339. If HTO fails to halt the progression knee for degenerative and rheuma- toid arthritis. J Bone Joint Surg Am 13. Spahn G, Kirschbaum S, Kahl E: of osteoarthritis, TKA is usually indi- 1973;55(1):23-48. Factors that infl uence high tibial cated. In general, TKA after an opening osteotomy results in patients with 2. Maquet P: Valgus osteotomy for medial gonarthritis: A score to predict wedge HTO has outcomes as good as osteoarthritis of the knee. Clin Orthop the results. Osteoarthritis Cartilage TKA without prior HTO;51-56 however, Relat Res 1976;120:143-148. 2006;14(2):190-195.

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