High tibial osteotomy

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High tibial osteotomy
Specialty orthopedic

High tibial osteotomy is an orthopaedic surgical procedure which aims to correct a varus deformation with compartmental osteoarthritis. Since the inception of the procedure, advancements to technique, fixation devices, and a better understanding of patient selection has allowed HTO to become more popular in younger, more active patients hoping to combat arthritis. [1] The idea behind the procedure is to realign the weight-bearing line of the knee. By realigning the knee, the force produced from weight-bearing is shifted from the arthritic, medial compartment to the healthy, lateral compartment. This decrease in force or load in the diseased part of the knee joint decreases knee pain and can delay the development or progression of osteoarthritis in the medial compartment. [2]

Contents

Patient selection

The accepted protocol used for patient selection was developed in 2004 by the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine (ISAKOS). According to this protocol, an ideal patient is: [1]

Contraindications specified by ISAKOS are: [1]

Surgical technique

The general surgical technique includes either performing HTO alone or performing HTO in combination with ligament reconstruction. When deciding which treatment avenue to take, one must consider patient demographics, their predominant symptoms, and which ligaments, if any are involved. When ligaments are involved, but the ACL deficiency is chronic and pain is due to arthritis and malalignment, HTO alone should be sufficient. However, if instability is the predominant symptom, in for example an acute ACL deficiency, HTO in combination with ACL reconstruction may be performed to protect the ACL graft that was constructed. [3]

The two most common surgical techniques used in HTO are lateral close wedge osteotomy and medial open wedge osteotomy. [3]

Lateral close wedge osteotomy

Starting at the anterolateral aspect about 1 cm below the joint line of the knee, an L-shaped cut is made to the lateral edge of the tibial tubercle and anterior tibial crest. To expose the bone, the fascia of the anterior compartment is cut near the anterior tibial crest and the anterior tibialis is elevated. Osteotomy starts 15 mm below the joint line, just above the tibial tubercle, and is directed parallel to the joint line, medially. [1]

Some of the advantages of the lateral close wedge method are faster healing with less morbidity, greater potential for healing, and no need for bone grafting, unlike the medial open wedge method. [3]

Medial open wedge osteotomy

The initial cut is made in between the posteromedial border of the tibia and medial aspect of the tibial tubercle. Medial collateral ligament (MCL) is exposed by cutting the sartorius fascia and pulling it medially. MCL is then removed from its insertion medially. Two K-wires are placed towards the lateral cortex, about 4 cm below the joint line. The osteotomy is done below the K-wires and parallel to the joint line. [1]

The advantages of the medial open wedge method include less risk of peroneal nerve injury compared to the lateral close wedge method, no limb shortening, no bone loss, and the use of a single cut with no need to detach muscles. [3]

Methods of fixation

Two main types of fixation plates are used: spacer plates and plate fixators. Spacer plates are lower profile implants that require a smaller incision. The disadvantage of using a spacer plate is the decreased rigidity associated with increased rates of delayed union or nonunion. Because of this, spacer plates require a longer period of staying off the leg that was operated on. Plate fixators give a stronger fixation, allowing for earlier weight-bearing and initiation of therapy. [1] A couple of studies attempted to compare these two methods but found no differences in reliability. [4]

Filling the bone gap

After part of the bone is removed, there is a space that may need to be filled. Some prefer using a graft or bone substitute, which will hopefully increase stability and decrease healing time. Bone can also be taken from the hip of the patient to use as a graft. This has a lower complication rate so is considered in someone who is at risk of the bone not healing, like a smoker or obese patient. [1]

Complications

The most common complications are the same as those occurring for any orthopedic procedure performed on a lower limb. These are:

The complications specific to the HTO are rare and include the failure of the bone to heal, common peroneal nerve palsy, decreased ROM, a low lying knee-cap, and a fracture inside the knee joint. [3]

Related Research Articles

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Posterior cruciate ligament</span> One of four major ligaments of the knee

The posterior cruciate ligament (PCL) is a ligament in each knee of humans and various other animals. It works as a counterpart to the anterior cruciate ligament (ACL). It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the femur.

<span class="mw-page-title-main">Anterior cruciate ligament</span> Type of cruciate ligament in the human knee

The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee. The two ligaments are also called "cruciform" ligaments, as they are arranged in a crossed formation. In the quadruped stifle joint, based on its anatomical position, it is also referred to as the cranial cruciate ligament. The term cruciate translates to cross. This name is fitting because the ACL crosses the posterior cruciate ligament to form an "X". It is composed of strong, fibrous material and assists in controlling excessive motion. This is done by limiting mobility of the joint. The anterior cruciate ligament is one of the four main ligaments of the knee, providing 85% of the restraining force to anterior tibial displacement at 30 and 90° of knee flexion. The ACL is the most injured ligament of the four located in the knee.

<span class="mw-page-title-main">Anterior cruciate ligament reconstruction</span> Surgical process

Anterior cruciate ligament reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after an injury. The torn ligament can either be removed from the knee, or preserved before reconstruction through an arthroscopic procedure. ACL repair is also a surgical option. This involves repairing the ACL by re-attaching it, instead of performing a reconstruction. Theoretical advantages of repair include faster recovery and a lack of donor site morbidity, but randomised controlled trials and long-term data regarding re-rupture rates using contemporary surgical techniques are lacking.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources. It may also be performed for other knee diseases, such as rheumatoid arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation, and is not a reason to perform knee replacement.

A meniscus transplant or meniscal transplant is a transplant of the meniscus of the knee, which separates the thigh bone (femur) from the lower leg bone (tibia). The worn or damaged meniscus is removed and is replaced with a new one from a donor. The meniscus to be transplanted is taken from a cadaver, and, as such, is known as an allograft. Meniscal transplantation is technically difficult, as it must be sized accurately for each person, positioned properly and secured to the tibial plateau. As of 2012, only a few surgeons have significant volume of experience in meniscus transplantation worldwide.

<span class="mw-page-title-main">Medial meniscus</span>

The medial meniscus is a fibrocartilage semicircular band that spans the knee joint medially, located between the medial condyle of the femur and the medial condyle of the tibia. It is also referred to as the internal semilunar fibrocartilage. The medial meniscus has more of a crescent shape while the lateral meniscus is more circular. The anterior aspects of both menisci are connected by the transverse ligament. It is a common site of injury, especially if the knee is twisted.

<span class="mw-page-title-main">Cruciate ligament</span> Type of ligament shaped like an X

Cruciate ligaments are pairs of ligaments arranged like a letter X. They occur in several joints of the body, such as the knee joint, wrist joint and the atlanto-axial joint. In a fashion similar to the cords in a toy Jacob's ladder, the crossed ligaments stabilize the joint while allowing a very large range of motion.

<span class="mw-page-title-main">Anterior cruciate ligament injury</span> Ligament injury near the knee

An anterior cruciate ligament injury occurs when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, an audible cracking sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours. In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.

<span class="mw-page-title-main">Patellar tendon</span> Tendon in the human knee

The patellar tendon is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar ligament as it forms a bone to bone connection when the patella is fully ossified.

<span class="mw-page-title-main">Unhappy triad</span> Medical condition of the knee

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

Tibial Tuberosity Advancement (TTA) is an orthopedic procedure to repair deficient cranial cruciate ligaments in dogs. It has also been used in cats. This procedure was developed by Dr. Slobodan Tepic and Professor Pierre Montavon at the School of Veterinary Medicine, University of Zurich, in Zurich, Switzerland beginning in the late 1990s.

<span class="mw-page-title-main">Meniscus tear</span> Rupturing of the fibrocartilage strips in the knee called menisci

A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they actually may be referring to an injury to a meniscus at the top of one of the tibiae. Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear'. Especially acute injuries can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the joint. The joint will be in pain when in use, but when there is no load, the pain goes away.

<span class="mw-page-title-main">Unicompartmental knee arthroplasty</span>

Unicompartmental knee arthroplasty (UKA) is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacement procedure, particularly in people over 75 years of age. Moreover, UKAs may require a smaller incision, less tissue damage, and faster recovery times.

Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.

<span class="mw-page-title-main">Tibial plateau fracture</span> Medical condition

A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. Symptoms include pain, swelling, and a decreased ability to move the knee. People are generally unable to walk. Complication may include injury to the artery or nerve, arthritis, and compartment syndrome.

<span class="mw-page-title-main">Medial knee injuries</span> Medical condition

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee consists of:

The anterolateral ligament (ALL) is a ligament on the lateral aspect of the human knee, anterior to the fibular collateral ligament.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

References

  1. 1 2 3 4 5 6 7 Sabzevari, Soheil; Ebrahimpour, Adel; Roudi, Mostafa Khalilipour; Kachooei, Amir R. (2016). "High Tibial Osteotomy: A Systematic Review and Current Concept". The Archives of Bone and Joint Surgery. 4 (3): 204–212. ISSN   2345-4644. PMC   4969364 . PMID   27517063.
  2. ↑ Liu, Xiaoyu; Chen, Zhenxian; Gao, Yongchang; Zhang, Jing; Jin, Zhongmin (2019). "High Tibial Osteotomy: Review of Techniques and Biomechanics". Journal of Healthcare Engineering. 2019: 8363128. doi: 10.1155/2019/8363128 . ISSN   2040-2309. PMC   6525872 . PMID   31191853.
  3. 1 2 3 4 5 Wade, Roshan; Shah, Swapneel; Sujith, B. S.; Shah, Kunal; Raj, Aditya; Marathe, Nandan (2020). "High tibial osteotomy in a lax knee: A review of current concepts". Journal of Orthopaedics. 19: 67–71. doi:10.1016/j.jor.2019.10.023. ISSN   0972-978X. PMC   6994797 . PMID   32021040.
  4. ↑ Amendola, Annunziato; Bonasia, Davide Edoardo (2010). "Results of high tibial osteotomy: review of the literature". International Orthopaedics. 34 (2): 155–160. doi:10.1007/s00264-009-0889-8. ISSN   0341-2695. PMC   2899364 . PMID   19838706.
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