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| INVITED ARTICLE |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 38-41 |
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Controversy of high tibial osteotomy
Tsukasa Teramoto
Department of Traumatology, Fukushima Medical University, Koriyama, Fukushima, Japan
| Date of Submission | 19-Oct-2015 |
| Date of Acceptance | 27-Oct-2015 |
| Date of Web Publication | 5-Nov-2015 |
Correspondence Address:
Tsukasa Teramoto
Department of Traumatology, Fukushima Medical University, Koriyama, Fukushima 963 8563
Japan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2455-3719.168747
The medial compartment osteoarthritis (OA) of knee joint has various surgical options such as high tibial osteotomy (HTO), hemiarthroplasty, and total knee arthroplasty. In the early stages of medial OA, there are no intra-articular deformities. Thus HTO, which is an extra-articular osteotomy, is recommended for the treatment of mild OA, but in moderate and severe medial OA, there are intra-articular deformities. HTO cannot correct these intra-articular deformities. Thus, an intra-articular osteotomy like the Tibial condylar valgus osteotomy (TCVO) is required in cases of moderate to severe medial OA knee. The contact area of the articular surface of the knee joint after TCVO is broader than it is after HTO in cases of moderate/severe OA. TCVO also improves the bony stability, eliminates the lateral thrust and surely corrects the alignment of the lower limb. To conclude, in cases of medial OA knee, the type of deformity must be evaluated and corrected accordingly. Intra-articular deformity must be corrected first. If the correction of varus and the mechanical axis is not enough, then extra-articular deformity must also be corrected, with a simultaneous or subsequent HTO.
Keywords: High tibial osteotomy, knee joint, medial, osteoarthritis, tibial condylar valgus osteotomy
How to cite this article:
Teramoto T. Controversy of high tibial osteotomy. J Limb Lengthen Reconstr 2015;1:38-41 |
| Introduction | |  |
Surgical treatments for medial knee osteoarthritis (medial OA) include high tibial osteotomy (HTO), hemiarthroplasty (Hemi), and total knee arthroplasty (TKA). HTO is typically indicated for the treatment of mild and moderate medial OA. Hemiarthroplasty and TKA are indicated for the treatment of moderate and severe medial OA. HTO osteotomizes the proximal part of the tibia and corrects the varus deformity. After HTO, the force diagram of the knee in patients with medial OA is shifted from the medial side to the lateral side of the knee joint [Figure 1]. Therefore, the load on the medial joint that has the ruptured meniscus and the defect of the cartilage is decreased, and the load on the lateral joint that has the normal lateral meniscus and the normal cartilage is increased after HTO. As a result, the pain in the medial joint is eliminated. | Figure 1: (a) An 67-year-old man with mild medial osteoarthritis knee treated with dome high tibial osteotomy fixed with Charnley external fixator. (b) An 80-year-old female with moderate medial osteoarthritis treated with total knee replacement. (c) A 74-year-old female with most severe medial osteoarthritis treated with sliding osteotomy and total knee replacement
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With increasing degeneration and progression to moderate/severe medial OA, the medial meniscus subluxates medially. In the next stage, the cartilage of the medial joint is worn. Next, the medial femoral condyle is subluxated medially, and then the lateral femoral condyle is detached from the lateral tibial articular surface. As a result, both condyles of the knee in patients with moderate/severe medial OA cannot make contact with the tibial articular surface simultaneously. Patients who are experiencing this will often complain about the lateral thrust of the knee joint while walking. Kettlekamp [1] reports that HTO is not indicated for the teeter knee because of these reasons. Changes of the medial meniscus, cartilage, medial femoral condyle, and lateral femoral condyle of the moderate/severe medial OA knee represent an intra-articular deformity of the knee joint.
However, HTO, which cuts the proximal part of the tibia, is an extra-articular correction. Hence, HTO cannot correct the intra-articular deformity of the knee in patients with moderate/severe medial OA.
| Evaluation of Deformities of the Lower Limbs and the Principles of Deformity Correction | | |
There are two kinds of deformities in the lower limbs: One is intra-articular, and the other is extra-articular. Paley [2] reports the correction methods used by the principles of Center of Rotation of Angulation (CORA). The corrective osteotomy based on CORA is an entirely extra-articular osteotomy and not an intra-articular one. CORA is usually located at the upper metaphysis of the tibia, and the deformity is usually an extra-articular angular varus deformity. Extra-articular deformities can be corrected acutely by osteotomy or by gradual correction based on CORA. For example, HTO can be performed either acutely or gradually with an external fixator or a plate. Intra-articular deformities cannot be corrected by an extra-articular osteotomy; the intra-articular deformity can only be corrected by an intra-articular osteotomy.
The knees of some patients with moderate/severe medial OA have intra-articular deformities, and in some cases have both intra-articular as well as extra-articular deformities. Intra-articular deformities of the medial OA knee include the wear of cartilage and the medial femoral condyle, the medial subluxation of the medial femoral condyle, and the detachment of the lateral femoral condyle from the lateral articular surface of the proximal tibia. HTO (whether a medial opening wedge or lateral closing wedge or a Focal dome) cannot correct these intra-articular deformities because HTO offers only extra-articular correction.
Therefore, our conclusion is that when there are intra-articular deformities and extra-articular deformities of the lower limb, these two deformities must be evaluated and corrected individually. The intra-articular deformity of the knee in patients with moderate/severe medial OA must be corrected first. If this correction does not result in overall restoration of the mechanical axis of the limb, the extra-articular deformity must also be corrected [Figure 2]. | Figure 2: (a) A 66-year-old male with posttraumatic varus deformity of lower limb. (b) Same patient with extra-articular (tibial and fibular varus) deformity. (c) Same patient with intra-articular (varus deformity of knee joint) deformity
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| Problems of High Tibial Osteotomy | | |
There are no intra-articular deformities in the early stages of medial OA; both condyles come into contact with the articular surface of the proximal tibia simultaneously. HTO is the extra-articular osteotomy chosen to correct this. It is recommended for the treatment of mild OA. Moderate/severe medial OA, develops intra-articular deformities. HTO cannot correct these.
Therefore, HTO is not recommended for the treatment of moderate and severe medial OA. This is borne out in our clinical experience where we have experienced some failures of HTO.
One such example was a case with an unstable knee after HTO. The symptoms of this case were not improved at all. These symptoms were due to the appearance of the severe instability of the knee joint after HTO. The instability of the knee joint was not changed after HTO because HTO gave only an extra-articular correction.
Another example was a case with a recurrence of varus deformity after HTO. It was caused by the detachment of the lateral femoral condyle in load after HTO. In this case of moderate/severe OA, the alignment of the lower limb became valgus after HTO, and the load line of the lower limb was shifted to the lateral side of the knee joint. But since the medial joint space did not open after HTO, the lateral femoral condyle was still detached from the lateral articular surface of the tibia after HTO. As a result, the load bearing line shifted to the lateral side of the knee joint, but the contact area of the knee remained on the medial side. The load pressure after HTO was not shared on the lateral articular surface, so the weight bearing forces on the medial joint space were not decreased enough. The recurrence of varus deformity after HTO occurred for these reasons. Our conclusion is that the causes of the failure are the severe instability or noncontact between the lateral femoral condyle and the lateral articular surface of the proximal tibia after HTO [Figure 3] and [Figure 4]. | Figure 3: (a) Contact area in the medial joint space of the knee joint before opening wedge high tibial osteotomy. (b) Contact area in the medial joint space of the knee joint opens after opening wedge high tibial osteotomy
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 | Figure 4: (a) Contact area of the medial joint space of the knee joint before opening wedge high tibial osteotomy. (b) In moderate to severe osteoarthritis knee, medial joint space contact area not opens after high tibial osteotomy
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| Comparison between High Tibial Osteotomy and Tibial Condylar Valgus Osteotomy | | |
In tibial condylar valgus osteotomy (TCVO) [3] the proximal tibia is osteotomized in an L-shaped manner from the intercondylar eminence proximally to the medial side of proximal tibia at approximately 5-7 cm from the joint line. Using a spreader, the osteotomy site was spread until the lateral tibial articular surface makes contact with the lateral femoral condyle, and the medial articular surface of the tibia makes contact with the medial femoral condyle. The tibia is fixed with a contoured plate (locking or nonlocking) and screws. Both femoral condyles make contact with the medial and lateral articular surface of the proximal tibia simultaneously, thus eliminating the alternating contact and teeter effect.
The first difference between TCVO and HTO is the contact area of the articular surface of the knee joint. [4],[5] The contact area of the articular surface of the knee joint after TCVO is broader than it is after HTO in cases of moderate/severe OA. Contact area after HTO is either on the medial side or lateral side of the knee joint. This is because the lateral femoral condyle of the knee detaches from the lateral articular surface of the proximal tibia. The load on the articular surface of the knee joint after TCVO decreases more than it does after HTO because both femoral condyles make contact simultaneously with the medial and lateral articular surface of the proximal tibia. The broader surface area of contact reduces the forces as explained by formula, Pressure = Force/Area.
Furthermore, in the case of the moderate/severe OA, if the medial joint space of the knee joint is not opened after HTO, the lateral femoral condyle does not make contact with the lateral articular surface of the proximal tibia, and the load is dispersed only in the medial surface of the proximal tibia. If the medial joint space of the knee joint is open widely and detached after HTO, the lateral femoral condyle makes contact with the lateral articular surface of the tibia, and the load is dispersed in only the lateral articular surface. The contact area after TCVO is broader than it is after HTO, so the load dispersion of TCVO occurs more than it does after HTO [Figure 5] and [Figure 6]. | Figure 5: (a) Contact area between articular surface before tibial condylar valgus osteotomy. (b) Contact area of the articular surface after tibial condylar valgus osteotomy
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 | Figure 6: (a) Contact area after opening wedge high tibial osteotomy. (b) Contact area after tibial condylar valgus osteotomy
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The second difference between TCVO and HTO is the stability of the knee joint after surgery [5] TCVO is an intra-articular correction, and the shape of the articular surface is changed after TCVO. The bone instability of the joint due to the articular shape is improved after TCVO, and the lateral thrust is eliminated. However, the bony instability of the knee joint does not change after HTO because HTO is the extra-articular osteotomy, and the shape of the articular surface of the knee joint does not change. From the above, after TCVO the stability and dynamic alignment of the lower limbs is also surely corrected.
By contrast, the correction of the alignment of the lower limbs is not certain after HTO because HTO does not improve the instability of the knee joint. If the severe instability of the knee joint remains after HTO, the load line of the lower limb after HTO is unstable. Furthermore, in the case of the moderate/severe OA, if the medial joint space of the knee joint is widely open after HTO, the load line is extremely shifted laterally [Figure 7]. | Figure 7: (a) Varus stress test after high tibial osteotomy. (b) Varus stress test after tibial condylar valgus osteotomy. (c) Valgus stress test after high tibial osteotomy. (d) Valgus stress test after tibial condylar valgus osteotomy
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| Conclusion | | |
There are both intra-articular deformities and extra-articular deformities of the lower limb, and these two deformities must be evaluated and corrected individually. The deformities of both moderate and severe medial OAs are mainly intra-articular deformities, and the intra-articular deformity must be corrected first.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kettlekamp DB, Leach RE, Nasca R. Pitfalls of proximal tibial osteotomy. Clin Orthop 1975;104:232-41.  |
| 2. | Paley D. Principles of Deformity Correction. Berlin, Heidelberg, New York: Springer-Verlag; 2002. |
| 3. | Teramoto T, Nakamura S, Makino Y, Suzuki R. The application of Ilizarov external fixator for tibial condylar valgus osteotomy (TCVO). J JAEFLL 1997;8:77-80. |
| 4. | Teramoto T, Chiba G, Fujita M. Clinical results of tibial condylar valgus osteotomy (TCVO) for severe osteoarthritis of knee. J West Jpn Soc Orthop Traumatol 2000;49:37-41. |
| 5. | Teramoto T, Harada S, Takaki M, Takenaka N, Watanabe Y, Matsushita T, et al. Operative methods of arthroplasty used by intra-articular osteotomy of the knee joint and ankle joint. J JAEFLL 2014;25:169-76. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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