High tibial osteotomy for the treatment of gonarthrosis in

genu varum – closed wedge versus open wedge

Nuno Borralho, Alberto Monteiro
Centro Hospitalar Entre-Douro e Vouga
Serviço de Ortopedia

Introduction
High tibial osteotomy (HTO) was a well established technique in the treatment of
unicompartmental osteoarthritis of the knee.1Later it was almost entirely
abandoned because of the success of total and unicompartmental knee
replacement (TKR and UKR). Compared to replacements, osteotomy was
considered a demanding procedure with an unpredictable outcome and associated
with significant complications.
In the 1990s, in sports medicine, the role of correction of varus malalignment in the
treatment of ligamentous injuries and imbalance of the knee led to a reappreciation
of osteotomy.2 Furthermore, new knowledge led to renewed interest in the
influence of malalignment on the development and symptoms of osteoarthritis.3-5
Recently, better guidelines have been formulated for the selection of candidates for
osteotomy by the International Society of Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine (ISAKOS).6
New techniques for medial-opening-wedge osteotomy7 and specially designed
fixation plates based on the locking-compression-plate (LCP) concept, providing
superior initial stability, are now available.8-12
These factors have led to a revival of interest on HTO.
Among the various techniques available, the closed wedge HTO is still the most
used worldwide, but in the recent years the open wedge HTO is becoming
increasingly popular.13,14
This paper focuses some of the current aspects of HTO and presents the author’s
case series comparing the two techniques.

Indications
The main indication for HTO is the correction of varus malalignment in medial
unicompartmental osteoarthritis of the knee. The aim is to unload the medial
compartment by slightly overcorrecting into valgus, in order to reduce pain, slow
the degenerative process and delay joint replacement.1,15-22
A second indication is the correction of load imbalance in ligamentous instability in
patients with a varus thrust in order to change the axial alignment, thereby
reducing the varus thrust and unloading any ligament reconstruction. A possible
secondary goal in these patients is to change the tibial slope in order to reduce
translational forces and improve the anteroposterior stability of the knee.
Patient selection
There is consensus in current literature that rigorous patient selection is one of the
most important factors in the success of HTO. In 2005 ISAKOS defined the place
of osteotomies and UKR in the management of osteoarthritis of the knee.
For each treatment option ideal patients, possible patients and patients not suited
for surgery were defined (Table I).

Table I. Ideal and possible patients for high tibial osteotomy and patients not suited for the
procedure according to the International Society of Arthroscopy, Knee Surgery and Orthopaedic
6
Sports Medicine

Ideal Possible Not suited

Isolated medial joint line pain Flexion contracture < 15° Bi-compartmental (medial and lateral) OA
Age (yrs) 40 to 60 Previous infection Fixed flexion contracture > 25°
BMI < 30 Age 60 to 70 or < 40 Obese patients
High-demand activity but no running or ACL, PCL or PLC insufficiency Meniscectomy in the compartment to be
jumping loaded by the osteotomy
Malalignment < 15° Moderate patellofemoral arthritis
Metaphyseal varus, i.e. TBVA > 5° Wish to continue all sports
Full range of movement
Normal lateral and patellofemoral
components
IKDC (A) B, C, D/Ahlback I to IV
No cupula
Normal ligament balance
Non-smoker
Some level of pain tolerance

BMI, body mass index; TBVA, tibial bone varus angle; IKDC, International Knee Documentation Committee osteoarthritis classification
ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner
OA, osteoarthritis

Surgical techniques
Classically, the correction is usually performed in the tibia. This is contraindicated
in knee joints that have an oblique joint line, as the subsequent tibial osteotomy
causes an increase in obliquity. This is also true in patients where a distal femoral
deformity causes a varus malalignment of the axis.23 Generally, the principles of
the correction of deformity as formulated by Paley24 should be respected.
A lateral closing-wedge, a medial opening-wedge or a dome-type tibial osteotomy
may be used.17,25 Many studies have shown good short- and mid-term follow-up
results for the various techniques of osteotomy.21,26-30
The lateral closing-wedge HTO, as popularised by Coventry, is still the most
utilised worldwide. However, the opening wedge HTO is becoming increasingly
more popular, especially with the development of new fixation implants – the
locking compression plates (LCP).
The closing-wedge procedure behaves as an optimal controlled fracture, providing
a large contact area between the proximal and distal surfaces of the osteotomy
after the osteotomy closure. This renders bone healing faster and theoretically
results in a less probable loss of the correction achieved. However, several
disadvantages are associated with the closing wedge osteotomy. The exposure
required on the lateral side includes release of the extensor musculature and risks
damage to the common peroneal nerve. This is said to occur in between 3.3% and
11.9% of patients, and indeed electromyography shows damage in up to 27% of
patients.42,43. Furthermore, it requires either a fibular osteotomy or a release of the
proximal tibiofibular joint and removes tibial bone stock causing leg shortening.
Large corrections may cause marked shortening of the leg and a large offset of the
proximal tibia, which may compromise later placement of the tibial component of a
TKR. Two saw cuts are needed, and only malalignment in the frontal plane can be
corrected.
By opposition, the medial opening-wedge technique of HTO is performed through a
small incision and requires minimal soft tissue dissection and muscle release. It
preserves the tibial bone stock avoiding leg shortening, the fibula is left intact, and
there is no need for peroneal nerve dissection. Only one saw cut is required, and
corrections in the frontal plane can be combined with adjustments in the sagittal
plane. It also allows for the intra-operatory adjustment of axial alignment correction.
An additional feature is the possibility of ACL reconstruction through the same
incision. However, this procedure has been less popular in a recent past, mainly
because implants for internal fixation have, until recently, been unable to withstand
the axial and torsion forces in the proximal tibia. Indeed, with the opening wedge
HTO there is a high initial demand on the implant and several implant-related
complications have been reported. This has been overcome with the development
of angle-stable implants, the locking compression plates, which provide a superior
initial stability on the osteotomy. Other disadvantages referred are related to the
absence of a large bone contact area as in the closing wedge technique, such as
the higher risk of pseudarthrosis, eventual need of bone graft and longer period of
non-weight bearing. In the cases where large corrections are performed there is a
potential for limb lengthening, patella baja and increased tibial slope.

Case series
The author’s case series 20
reflects what was exposed 18
above about the closing and 16
opening wedge osteotomy and 14
follows the global tendency
12
towards a shift from closing
10
wedge to opening wedge
8
osteotomy.
6
The chronological evolution of
4
the type of osteotomy
2
performed is shown in chart 1.
0
2000 2001 2002 2003 2004 2005 2006 2007 2008

C los ed wedge O pen wedge

Chart 1 – Closed wedge and open wedge osteotomies:

chronological evolution
Material and methods
Between 2000 and 2008, 73 patients were submitted to a HTO by the same 2
surgeons. 44 patients were females and 29 were males. The average age was 51
years (minimum 27, maximum 73).
The patients selected had isolated medial compartment gonarthrosis, BMI < 30,
epiphyseal varus > 5º and full range of movement.
All patients were evaluated with a radiographical protocol including weight-bearing
anteroposterior (AP) and lateral radiographs and axial views of the patellofemoral
joint as well as whole-leg standing radiographs in order to assess alignment.
The anatomical and mechanical axes are measured. The tibial bone varus angle
(TBVA) is measured and the type of varus is determined, whether it is a true
epipyseal varus with an increased TBVA (>5º) or a varus caused by wearing of the
cartilage of the medial compartment.
In 58 patients the closing wedge technique was used and in 15 patients the
opening wedge.
The opening wedge technique utilised is described. With the patient in decubitus
position, a tourniquet is applied and the lower limb is prepped and drapped. By
protocol, a knee arthroscopy is performed prior to the HTO (fig. 1). It allows
debridement of the degenerate medial compartment and removal of inflammatory
mediators of the synovial fluid, but most important it permits a final and definitive
assessment of the lateral compartment, which in some cases may lead to a
change in surgical intervention44.

The starting position for the HTO is with

the knee flexed to 90°. A fluoroscope is
mandatory, with visualisation possible in
two directions. The medial side of the
proximal tibia is exposed through a small
longitudinal incision (fig. 2).

After division of the subcutaneous

tissue, the medial collateral ligament and
the hamstrings are identified (fig. 3)

Figure 1 – Arthroscopy is performed routinely before HTO

Figure 2 – Longitudinal incision Figure 3 – Identification of MCL and hamstrings

The superficial fibres of the medial collateral ligament are mobilised and a distal
subperiosteal release is performed. The upper border of the hamstrings marks the
starting point of the osteotomy. A Kirschner wire is placed under fluoroscopic
control to mark the saw cut. The lateral aiming point is the upper third of the
proximal tibiofibular joint, 10 mm medial to the lateral cortex (figs 4 and 5). This is
the hinge point of the osteotomy.

Figures 4 and 5 – Guide wire placement

With an oscillating saw placed immediately distal to the guide wire the tibial
osteotomy is performed. In the final part an osteotome is utilised for fine control of
the osteotomy under fluoroscopy. It’s important to cut the tibia distal to the guide
wire to avoid an unwanted proximal misdirection of the tibial osteotomy and an
iatrogenic fracture of the lateral tibial plateau (figs 6 and 7).
Figures 6 and 7 – Tibial osteotomy

The osteotomy is opened gradually using chisels and a specially-calibrated

spreading device (fig. 8). It’s important to open the osteotomy with a wide posterior
basis, in order to avoid augmenting the tibial antero-posterior slope. The normal
tibial AP slope is 10º, and the literature shows that classically the tibial slope
increases after an opening wedge HTO and decreases after a closing wedge
HTO.41 This is related to the geometry of the proximal tibia, which has a pyramidal
configuration with a triangular transverse section and 3 surfaces, antero-medial,
antero-lateral and posterior. In the opening wedge osteotomy, augmenting the
osteotomy gap with an antero-medial basis will lead to an increase in tibial slope.
There is a strong relationship between increased tibial slope and increased anterior
tibial translation40 with possible antero-posterior knee instability. Then the
importance of opening the osteotomy with a posterior or postero-medial basis, to
avoid increasing the tibial slope.

The gap is then measured and compared with the planned length of the base of
the wedge. A final check is done with the cable of the electrocautery projected over
the centres of the hip and ankle,
marking the mechanical axis, under
fluoroscopy (figs. 9 and 10). The current
recommendations for axial alignment
correction in valgus HTO are post-
operative corrections from 8° to 10°
valgus relative to the anatomical axis,
and 3° to 5° valgus relative to the
mechanical axis, 20,21,31-35 which means
a slight valgus hypercorrection (normal
anatomical axis 6º valgus and normal
mechanical axis 1,2º varus).
Figure 8 - Osteotomy opening
Figures 9 and 10 – Mechanical axis checking

Some authors have recently used the

position of the mechanical leg axis
relative to the width of the tibial plateau,
pre- and post-operatively, as a guideline
for the amount of correction needed.36
Their recommendations are based on
the work of Fujisawa et al,19 who
concluded that, for optimal results, the
corrected axis should run through the
lateral 30% to 40% of the tibial plateau.
Based on this clinical work, it is
recommended by many that the post-
operative mechanical axis should run
laterally through the tibial plateau, at
62% of its entire width, measured from
“Fujisawa the medial side (fig. 11).37-39
point” If the desired correction is achieved, a
laminar bone spreader is inserted. It is
essential to obtain full extension during
these measurements.

Figure 11 – Fujisawa point

 The plate is introduced and fixed with
screws using the standard technique
(fig.12).
Usually we do not use bone graft, except
for cases where a large opening wedge
correction is necessary. If the osteotomy
gap is greater than 1.5 cm, we use
autologous bicortical bone graft from the
iliac crest.

Figure 12 – Plate fixation

The patients were evaluated retrospectively, with a mean follow-up of 54 months

(minimum 12 months, maximum 108 months). The following parameters were
determined: age, sex, weight, height, Ahlback gonarthrosis stage for the medial,
lateral and femuro-patelar compartment, gonarthrosis etiology (primary,
secondary), type of implant utilized, axial alignment correction, time to full weight
bearing (weeks), time to consolidation (months), pain (Visual Analogic Scale), knee
range of motion (ROM), functional score KSS, complications.

Results
The following parameters were analyzed: clinical evaluation – pain (VAS), ROM,
time to full weight bearing; functional evaluation – KSS score; radiological
evaluation – axial alignment correction, osteotomy consolidation time.
The average of the results obtained is summarized in table 2.

Closed wedge Open wedge

Pre-op Pos-op Pre-op Pos-op

Pain (VAS) 5.9 3.6 6.3 3.7
ROM 120.5 145.3 118.9 146.4
Axial alignment 6.8 -3.4 5.7 -4.3
Function (KSS score) 70.9 90.5 71.5 91
NWB (weeks) - 6.3 - 9.6
Consolidation (months) - 3.2 - 6.6
Complications
As complications we report in the open wedge group one case of pseudarthrosis
associated with fracture of the lateral tibial plateau (fig. 13) and one case of implant
failure (fig. 14)

Figure 13 – Pseudarthrosis and fracture Figure 14 – Implant failure

of the lateral tibial plateau

In the closed wedge group there were 3 cases of peroneal nerve palsy, all of which
were temporary.
As for osteotomy survival, in the closed wedge group 11 patients (19%) were
submitted to total knee replacement, and in the open wedge group only one (7%)

Discussion
Comparing the closed wedge group and the open wedge group in our case series,
we can say there was a significant and equivalent improvement in pain, knee range
of motion, axial alignment correction and functional score in both groups.
The non-weight bearing time and time to radiological consolidation were longer in
the open wedge group, but with no influence in the final clinical and functional
result.

Conclusions
In a recent past, technical complexity and complications of high tibial osteotomy,
associated to the good results obtained with knee arthroplasty, have led many
surgeons to prefer arthroplasty to osteotomy.
However, new data from investigation on ligamentous knee injuries and the
mechanisms of osteoarthrosis, new surgical techniques and new implants
available, and a refined patient selection, among other factors, caused a revival of
interest on HTO.
Today, there is still a well defined place for HTO. It is a viable treatment option for
a well-defined patient group suffering from osteoarthritis of the medial compartment
with epiphyseal varus and ligamentous imbalance of the knee.
The goal for axial alignment correction is 3º to 5º of mechanical valgus.
Key points in HTO are: patient selection, pre-operatory planning and surgical
technique.
Both closed and open wedge osteotomy give good and equivalent results, but
today we prefer the open wedge technique, as we consider it technically easier,
without the potential hazards of the lateral approach.
Although the closed wedge technique is still classically the most used, presently
there is a shift towards open wedge HTO.

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