High Tibial Osteotomy

Pre-Op Assessment

High Tibial Osteotomy

• History
• Age
• Career
• Level of Activity
• PMH
• Expectation

• Examination
• ROM
• Ligamentous Instability
• Compensatory arc of motion
• Hip joint and abductors
• Foot and Ankle
• Leg length discrepancy

• Radiology
• Knee x-ray standing AP
• Full Length
• MRI

Closing Wedge Technique

Varus-producing tibial osteotomy

Presentation

• Surgical Goals
• unload involved joint compartment by correcting tibial malalignment
• maintain the joint line perpendicular to mechanical axis of the leg
• Indications
• valgus knee with lateral compartment degeneration
• deformity should be <12 degrees or else the joint line will become oblique
• Specific Contraindications
• medial compartment arthritis
• loss of medial meniscus
• distal femoral osteotomy better if lateral femoral condyle hypoplasia present

Technique

Mark Kent

BSc (HONS) Physiotherapy

• Symptoms
• pain on medial or lateral side of knee
• Examination
• knee malalignment

• Opening wedge technique
• transverse bone cut made in proximal tibia, and wedged open on medial side
• ORIF of wedge
• advantage of maintaining posterior slope
• avoids proximal tibiofibular joint
• avoids peroneal nerve in anterior compartment

Complications

Objectives

• Patella baja
• refers to a shortened patellar tendon which decreases the distance of the patellar tendon from the inferior joint line
• can be caused by raising tibiofemoral joint line in opening wedge osteotomies
• can be caused by retropatellar scarring and tendon contracture
• can cause bony impingement of patella on tibia
• Peroneal nerve palsy
• more common in lateral opening wedge osteotomy

• Introduction
• Indications and Contraindications
• Anatomy
• Presentation
• Pre-Op Assessment
• Varus-producing tibial osteotomy
• Valgus-proucing tibial osteotomy
• Technique
• Complications
• Suggested Rehab Protocol

High Tibial Osteotomy

• Predominately done for varus deformities
• Less common for valgus deformities

Valgus-producing tibial osteotomy

Opening Wedge Technique

Complications

Anatomy

• Surgical Goals
• unload the involved joint compartment by correcting tibial malalignment
• maintain the joint line perpendicular to mechanical axis of the leg
• Indications
• Varus knee with medial compartment degeneration (more common)
• best results achieved by over correction of the anatomical axis to 8-10 degrees of valgus
• Specific contraindications
• narrow lateral compartment cartilage space with stress radiographs
• loss of lateral meniscus
• lateral tibial subluxation >1cm
• medial compartment bone loss >2-3mm
• varus deformity >10 degrees

• Recurrence of deformity
• 60% failure rate after 3 years when
• failure to overcorrect
• patients are overweight
• Loss of posterior slope
• Compartment Syndrome
• Malunion or nonunion

Introduction

Technique

• Closing wedge technique
• Lateral for Varus (most common)
• Medial for Valgus
• wedge of bone removed from tibia via an anterolateral approach
• ORIF of wedge
• more inherent stability allows for faster rehab and weight bearing
• no required bone grafting

• Angular deformity in the knee leads to abnormal distribution of weight bearing stresses
• can accelerate wear in medial or lateral compartments and lead to degeneration
• HTO commonly combined with cartilage restoration for better mechanical environment and biological repair

• Mechanical axis of lower extremity can be assessed by drawing straight line from center of femoral head to the center of the ankle joint
• line axis should pass just medial to the medial tibial spine

Indications

Suggested Rehab Protocol

Thank You!

Any Questions?

Suggested Rehab Protocol

Contraindications

Suggested Rehab Protocol

• <60, active person in whom TKR would fail due excess wear
• healthy, good vascular status
• not obese
• pain and disability affecting ADL
• only one knee compartment is affected
• compliant patient, will adhere to post op protocol

Suggested Rehab Protocol

Phase 2: 4-6/52

• Weightbearing
• As tolerated on E/Cs ROM Brace unlocked
• ROM Brace: unlocked, may remove to sleep
• ROM: AROM/AAROM/PROM - 0-120 degrees under guidance
• Exercise: as per phase 1, SLR without brace if Pt can maintain extension, static bike

• inflammatory arthritis
• obese patient BMI>35
• flexion contracture >15 degrees
• knee flexion <90 degrees
• procedure will need >20 degrees of correction
• patellofemoral arthritis
• ligament instability
• varus thrust during gait

Phase 4: 3-9/12

• Weightbearing: full with normal gait pattern
• ROM: full and pain free
• Exercise: progress closed chain, treadmill walking, swimming and sports specific activities

Phase 1: 0-4/52

• Weightbearing
• PWB 25%, E/Cs, ROM Brace locked in extension (0-2/52)
• FWB, E/Cs, ROM Brace locked in extension (2-4/52)
• ROM Brace: only removed for PT
• ROM: AROM/AAROM/PROM - 0-90 degrees under guidance
• Exercise: Heel glides, SQ, IRQ, TFA, NWB calf/hamstring stretch, SLR (brace on, locked in extension), resisted ankle PF/DF

Phase 3: 6-12/52

• Weightbearing
• As tolerated, discard E/Cs when able, aim for normal gait pattern
• ROM Brace: discard once SLR with nil lag achieved
• ROM: AROM/AAROM/PROM - aim for full pain free ROM

Exercise: mini squats 0-45 deg, step us, leg press 0-60 deg, closed chain terminal knee extension, toe raises, proprioceptive exercises, balance exercises, hamstring curls, mod reistance on static bike