High Tibial Osteotomy: A Guide for Orthopedic Surgeons

High Tibial Osteotomy it is not just “cutting of the bone”. We know that is not so simple, so we try to resume 5 important things to take into consideration when you suggest this procedure to a patient.

Not even all the patients can do an High Tibial Osteotomy

This kind of procedure is indicated for active younger patients with pain resulting from instability and malalignment. At least between 40 and 60 years old, not overweight and with pain only on one side of the knee.

Ensure patients symptoms are consistant with the diagnosis. Patellofemoral pain in a varus knee will not be improved by a High Tibial Osteotomy. Despite pain extended for a long time, they still have good knee mobility and arthritis only affects one side of the knee. One of the simply things to test if the patient is a good fit for an osteotomy, test if he is able to fully straighten the knee and bend it at least 90 degrees.

You can ask a patient to wear a leg brace that mimics the knee alignment after an osteotomy. This can help patients to assess whether the osteotomy knee will be beneficial.

This procedure has a long recovery (We’ll talk about it later), so it’s important to commit the patient with a long post-surgical physical therapy regimen and with preparation for the surgery.

How to prepare a patient for a High Tibial Osteotomy?

Some medical preparations are required for this procedure and others are just recommended. We select some of the most important, for you to inform the patient.

1– To improve knee range of motion and build strength before surgery, you must prescribe a physical therapy plan or ask the patient to exercise.

2– There are some restrictions before the surgery. Two weeks before the surgery the patient must:

• Stop taking Aspirin, any type of ibuprofen, and other medications that make it more difficult for blood to clot.
• Stop taking Steroids and other medications that suppress the immune system. Steroids may increase the chance of post-surgical infection.
• Stop smoking (that’s not the easy one), because of the nicotine effects. It slows the healing process and increases the risk of deep vein thrombosis, a potentially deadly blood clot in a deep vein, after surgery.

Verify that the patient is healthy enough for the surgery and anesthesia

As for other surgeries, patients with diabetes or other heart diseases may need medical clearance from a doctor, to validate their medical condition.

It is important to talk with the patient about these recommendations. As we said before, the patient needs to commit with your plan and restrictions before and after the surgery to improve the success rate and to reduce the risks.

When you suggest this procedure to a patient, there’s a question he always makes:

What is the success rate of an High Tibial Osteotomy?

The first thing you need to mention is that the goal of this procedure is to allow them to walk without discomfort, not to allow them to return to sports competition. The success rate of this practice is 91% at 5 years and 80% at 10 years. The benefits typically fade after 8 to 10 years. High Tibial Osteotomy generally is indicated to prolong the time before a knee replacement is necessary.

Besides the success rate of an HTO, there are some risks to take into consideration:

• Injury of the peroneal nerve can occur if the cast, brace or bandages are too constricting, putting the back of the knee under pressure for a long time. Sensory loss is one of the symptoms, but most patients recover without any permanent functional disability.
• During surgery, there’s less than 1% chance of blood vessels injury around the knee.
• Delayed or non-union of the osteotomy site may occur in 2 to 4% of cases. In these cases, another surgery is required to get the bone to heal properly.
• On an HTO, there can be complications involving the muscles, ligaments, and tendons that surround and support the joint.

Every patient needs to be informed about the risks of this procedure, besides the high success rate. There are some risks on every surgery, but with better preparation and with the commitment of the patient, it’s possible to reduce the risks. That’s what we’ll talk about next.

How to reduce the risks of an High Tibial Osteotomy?

Even the less experienced surgeon can lower the chances of complications. In this guide, we already approached some of the ways to reduce post-operative complications.

1- Carefully select the patients for an HTO.

On the first chapter of this article, we talked about that. Some characteristics and procedures to test if this surgery is the best option.

2- Prepare the patients for an HTO.

That’s not so complicated as that. The minor things can help to increase the success and to reduce the recovery time, even before the surgery.

3- Plan an HTO with accurate information.

Nowadays, technology is available to support orthopedic surgeons on the surgery planning process. PeekMed® is a powerful 3D pre-operative planning system for orthopedic surgeons. With this system, you get more visual and accurate information. Using a CT scan or an MRI (that you can easily upload to the system), you know the exact osteotomy location and wedge dimension and perform deformity correction automatically. The planning result is shown in high detail, including measurements and implants, as you can see on the video below.