High tibial osteotomy- All you need to know

for exam going post graduates of orthopaeic students.all things that you need to learn about HTO.

1. High tibial osteotomy (hto) By Dr. Ranveer Patel Orthopaedic Surgeon, Shreeji Orthopaedic Care

2. Introduction Prior to development of TKA, HTO was the most common surgical treatment for varus gonarthrosis The surgical technique was primarily a closing wedge or dome osteotomy The prevalence of the HTO has declined because of the success TKR and UKA

3. Introduction Goals of osteotomy include pain relief, functional improvement, and increase the life span of the knee joint With appropriate patient selection, accurate pre-operative planning, modern surgical fixation techniques and rapid rehabilitation, osteotomy around the knee is now an effective biological treatment for degenerative, deformity, knee instability

4. Indications The ideal candidate for a proximal valgus osteotomy is a young, physically active patient with medial compartment osteoarthritis of the knee and varus tibiofemoral alignment The patients have pain on the medial aspect of the knee and radiographic evidence of medial arthrosis demonstrated by less than 4 mm of medial joint space on a standing knee film It is generally agreed that no lateral pain should exist preoperatively R.P.Jakob , MD et al ICL 2015

5. Absolute Contraindications Inflammatory disease Stiffness (90 °- 120°) Severe patellofemoral arthrosis ( ? ) Meniscectomy in the compartment intended for weight bearing Unrealistic patient expectations

6. Relative Contraindications Obesity (BMI > 30 ?) A ge older than 60 years Severe arthrosis in the medial compartment ( Ahlback or Outerbridge grade 3 or higher) Tibiofemoral subluxation Moderate or severe ligamentous instability Smoking

7. Surgical Techniques Lateral closing tibial wedge osteotomy Medial opening tibial wedge osteotomy Dome tibial osteotomy Double-osteotomy

8. Preoperative Planning AP , Lat. , Intercondylar notch views Skyline view of patella in 30 flexion Full-length, weight-bearing hip-knee-ankle radiographes CT-Scan MRI

9. Preoperative Varus The principal considerations include the location, direction, and magnitude of malalignment

10. Preoperative Varus Tibial bone varus angle (TBVA), is the angle between the mechanical axis of the tibia and the epiphyseal axis of the proximal tibia. TBVA is an important prognostic factor (>5 °)

11. Preoperative Varus Age 37/ Female Varus (Mechanical Femorotibial Angle): 11° mLDFA (Mechanical Lateral Distal Femoral Angle): 89° MPTA (Medial Proximal Tibial Angle): 80° CA (Convergence Angle): 2 °

12. Postoperative X-Ray

13. Preoperative Varus

14. Preoperative Varus Age 38 years/ Female Varus (Mechanical Femorotibial Angle): 18° mLDFA (Mechanical Lateral Distal Femoral Angle): 96° MPTA (Medial Proximal Tibial Angle): 85° CA (Convergence Angle): 7 °

15. Postoperative X-Ray

16. Preoperative Varus

17. Preoperative Varus 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 benefit from HTO

18. Postoperative Alignment Undercorrection of varus during a tibial osteotomy is associated with inferior results. The consensus opinion is that correction in the presence of degeneration should be to beyond neutral.

19. Postoperative Alignment Some authors recommend correction to 1-2 ° of mechanical axis valgus. Weight bearing axis slightly lateral to the center of the knee. Some recommend a correction that results in passage of the W-B line through the 62% coordinate of the tibial articular surface

20. Intraoperative Alignment Precise intraoperative measurements of correction are difficult to achieve. The mechanical axis can be estimated intraoperatively using a Bovie cord or an alignment rod. Meticulous preoperative planning. Navigation

21. Postoperative Alignment Mechanical axis valgus is beneficial regarding knee pain outcomes , it also produces a visually obvious alignment. The patient may be dissatisfied with this procedure due to cosmetic.

22. Infection Loss of alignment Nerve and vessel injury Hardware problems Nonunion Persistent or Recurrent pain Complications

23. Persistent Or Recurrent Pain It’s important for patients to understand that a successful result is a substantial reduction in pain, not necessarily the elimination of pain. Studies commonly report a 4-to 5- point improvement on a 0-to 10- point pain scale. A small percentage of patients treated with HTO (4% to 26%) do not have satisfying pain relief.

24. HTO vs. Arthroplasty Valgus HTO is more appropriate for younger patients who accept a slight decrease in their physical activity Medial UKA is appropriate for younger patients obtaining sufficient pain relief but with reduced physical activity

25. Clinical results Studies have reported 10-year survival rates ranging from 74% to 96%. Reports for opening and closing wedge osteotomies have been similar.

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27. Conclusion Realignment osteotomy is a good option in active patients with symptomatic medial compartment osteoarthritis of the knee with varus deformity The key to success after osteotomy is careful patient selection combined with skillful surgical technique Accurate and appropriate pre-operative planning is critical for HTO