Abstract
Valgus-producing high tibial osteotomy (HTO) is a well-accepted treatment modality in active patients with varus malalignment and symptomatic medial unicompartmental osteoarthritis (OA) of the knee. One of the key factors for long-term success of the osteotomy is the achievement of an even distribution of the mechanical load on the knee joint by obtaining an ideal alignment of the lower-extremity mechanical axis. Proper surgical techniques are very important, and lateral closing wedge proximal tibial valgus osteotomy (CWO) is highly effective in achieving the desired overcorrection of 3° to 7° of valgus.
The major steps of CWO are (1) preoperative planning, in which the frontal plane varus knee deformity is assessed on a standard whole-leg radiograph; (2) a transverse anterolateral incision from the tubercle toward the posterior aspect of the proximal part of the fibular head; (3) exposure and snaring of the common peroneal nerve; (4) resection of the anterior aspect of the proximal part of the fibular head; (5) use of a calibrated slotted wedge resection guide to perform the osteotomy proximal to the tuberosity under fluoroscopic guidance; (6) removal of an osseous wedge and closure of the osteotomy site, with the medial opposite cortex acting as a hinge; and (7) fixation of the osteotomy site with two step staples. Complications (e.g., nonunion, deep infection, and peroneal neuropathy) are rare. At follow-up, CWO has been shown to improve knee function and reduce pain. Male patients with early-onset knee OA have an almost ten times lower probability of failure of a CWO than women with more degenerative disease. The survival rate, with knee replacement as the end point, is approximately 75% at ten years following CWO. CWO postpones primary total knee arthroplasty (TKA) for a median of seven years, and there is low-quality evidence that osteotomy does not compromise subsequent knee replacement.
Acknowledgments
Note: The three graphs showing survival rates after CWO in Video 14 (Results) were reproduced, with permission, from: van Raaij TM, Brouwer RW, de Vlieger R, Reijman M, Verhaar JA. Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening-wedge technique. Acta Orthop. 2008 Aug;79(4):508-14.
Footnotes
Published outcomes of this procedure can be found at: Cochrane Database Syst Rev. 2014 Dec 13;12:CD004019, Acta Orthop. 2008 Apr;79(2):230-4, and J Bone Joint Surg Am. 2014 Sep 3;96(17):1425-32.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
References
- 1.Brouwer RW, Raaij van TM, Bierma-Zeinstra SM, Verhagen AP, Jakma TS, Verhaar JA. Osteotomy for treating knee osteoarthritis [review]. Cochrane Database Syst Rev. 2014. December 13;12:CD004019. [DOI] [PubMed] [Google Scholar]
- 2.van Raaij T, Reijman M, Brouwer RW, Jakma TS, Verhaar JN. Survival of closing-wedge high tibial osteotomy: good outcome in men with low-grade osteoarthritis after 10-16 years. Acta Orthop. 2008. April;79(2):230-4. [DOI] [PubMed] [Google Scholar]
- 3.van Raaij TM, Brouwer RW, de Vlieger R, Reijman M, Verhaar JA. Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening-wedge technique. Acta Orthop. 2008. August;79(4):508-14. [DOI] [PubMed] [Google Scholar]
- 4.Huizinga MR, Brouwer RW, van Raaij TM. High tibial osteotomy: closed wedge versus combined wedge osteotomy. BMC Musculoskelet Disord. 2014;15:124 Epub 2014 Apr 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Duivenvoorden T, Brouwer RW, Baan A, Bos PK, Reijman M, Bierma-Zeinstra SM, Verhaar JA. Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: a randomized controlled trial with a six-year follow-up. J Bone Joint Surg Am. 2014. September 3;96(17):1425-32. [DOI] [PubMed] [Google Scholar]
- 6.van Egmond N, van Grinsven S, van Loon CJ, Gaasbeek RD, van Kampen A. Better clinical results after closed- compared to open-wedge high tibial osteotomy in patients with medial knee osteoarthritis and varus leg alignment. Knee Surg Sports Traumatol Arthrosc. Epub 2014 Sep 13. [DOI] [PubMed] [Google Scholar]
- 7.Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of the mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard School of Public Health on behalf of the World Health Organization, and the World Bank; 1996. [Google Scholar]
- 8.Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Rheum Dis Clin North Am. 2008. August;34(3):515-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.W-Dahl A, Robertsson O, Lohmander LS. High tibial osteotomy in Sweden, 1998-2007: a population-based study of the use and rate of revision to knee arthroplasty. Acta Orthop. 2012. June;83(3):244-8. Epub 2012 May 10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Robertsson O, Knutson K, Lewold S, Lidgren L. The Swedish Knee Arthroplasty Register 1975-1997: an update with special emphasis on 41,223 knees operated on in 1988-1997. Acta Orthop Scand. 2001. October;72(5):503-13. [DOI] [PubMed] [Google Scholar]
- 11.van Raaij TM, Brouwer RW, Reijman M, Bierma-Zeinstra SM, Verhaar JA. Conventional knee films hamper accurate knee alignment determination in patients with varus osteoarthritis of the knee. Knee. 2009. March;16(2):109-11. Epub 2008 Nov 18. [DOI] [PubMed] [Google Scholar]
- 12.Myrnerts R. Optimal correction in high tibial osteotomy for varus deformity. Acta Orthop Scand. 1980. August;51(4):689-94. [DOI] [PubMed] [Google Scholar]