High tibial osteotomy is an orthopedic knee realignment surgery that includes the alignment of the knee joint. The intention of this procedure is pain reduction, functional improvement of the knee, and the reduction of disability in that particular knee by shifting its weight-bearing part away from the area where damage to the cartilage occurs. This article will provide information in detail about this surgical operation. We hope this will give any person who is presented with the decision whether or not to have an HTO procedure enough information on which to base a decision.
What is high tibial osteotomy operation? This operation anatomically realigns the knee. The primary indications for an HTO include alleviating unicompartmental pain due to osteoarthritis, restoration of functional knee realignment surgery, correction of malalignment with a concomitant ligamentous insufficiency, and/or treatment of a bony deformity that may preclude ligamentous reconstruction. There are obvious differences between HTOs for possible multicompartmental disease, HTOs combined with either cartilage repair or osteochondral transfer procedures, and HTO in the varus knee. The terminology and surgical techniques have changed over time, and it is easily confusing for any patient considering an HTO. Patient education is indeed the key to any successful surgical intervention.
Indications of high tibial osteotomy include young patients with acute knee arthritis and varus deformity. Varus deformity is a condition of the knee where it takes on a deformity that is usually bent inward, bowing the legs and thus increasing pressure upon the medial compartment of the knee. Indication for the performance of HTO is in cases of early or moderate knee arthritis with still-intact cartilage, consisting of 4 to 6 on the Kellgren-Lawrence scale with modification. Patients with such characteristics, when there is varus deformity, are encouraged to undergo HTO in order to gain a new alignment.
High tibial osteotomy guide: A person who receives HTO will get several benefits, including-
Key steps prior to knee realignment surgery are general assessments, informed patient consent, and choosing the most appropriate imaging modalities. Although long-leg radiography was the standard image in nearly all studies and the only available image in the initial projects, CT was reformulated for planning in HTO at a later date to detect individual antecurvation of the tibia. Furthermore, MRI and cone-beam CT images have been indicated, especially when investigating meniscus injuries and improving patient care by analyzing the weight-bearing line or mechanical axis.
Determination of correction based on the high tibial osteotomy guide gives rise to the decision about the surgical procedure, including the different tibial procedures in terms of the osteotomy as well as the direction of the correction. There are different osteotomy techniques available, such as medial-positive osteotomy or oblique osteotomy. With respect to the different angles, the medial-positive osteotomy and valgising the knee can be performed with different techniques.
OWHTO and LCWHTO are the most common osteotomy techniques for extravertebral HTO, but there is no clear evidence showing which method is preferable in elevation with regard to the purpose of the deformity and type of correction. The techniques were performed percutaneously with a drill from the medial or lateral entry point after the osteotomy gap distractor was used. Most often, an OWHTO is stated as a “high osteotomy” and an LCWHTO as a “low osteotomy.” The exposure of distal fixation can be attended by one long skin incision that shares the wrist of the leg and tibia tracking. Most orthopedic surgeons will utilize a tourniquet. OWHTO is the most performed osteotomy in Europe and also in the USA. The flexibility of the technique is due to the variability of its performance. As high tibial osteotomy explained, the operation shall comprise patient evaluation, surgical technique, postoperative management, outcomes, regeneration processes, and finally, the case. The patients in all studies underwent complete clinical assessment, including physical examination and radiographic assessment as a minimum.
Recovery after high tibial osteotomy explained: It is an often slow and sometimes frustrating process. Many patients are non or limited weight-bearing for six weeks, followed by a slow progression toward putting their full weight on their operated leg. The early part of rehabilitation is focused on pain control, swelling management, limits in positioning the leg, and protection of the repair, which is more likely identified as a nonunion. Between six and twelve weeks, most patients are evaluated and given the “green light” to begin progressing their rehabilitation and activity under the care of physical therapy. Many orthopedic surgeons utilize a rehabilitation protocol that is specific for their patient population. With more orthopedic surgeons performing reconstructive procedures, the use of rehabilitation protocols is becoming more standardized. There are no randomized controlled studies to date on different rehabilitation programs and what is the optimal rehabilitation following osteotomy.
Patients who have high tibial osteotomies receive their rehabilitation programs from their surgeon. It is believed that with the various surgical techniques for high tibial osteotomy, the rehabilitation program should be individualized. Resorting to such programs as home-based protocols without the use of physical therapy may enhance a patient’s successful recovery with a high rate of union. Pain can be a complicating issue in the recovery process. It can be managed by prescription medication or over-the-counter pain relief. There are also many programs utilizing physical therapy for guided range of motion exercises and strengthening that have had successes as well. It is important to not forget patients who have undergone the closed wedge or dome; although these patients are weight-bearing, they usually have significant bone pain for months as the bones unite. It is essential for surgeons and patients to have goals and milestones set in the recovery process. There are complications that can occur during this time period that could alter rehabilitation. Significantly fewer complications have been reported following the opening wedge compared with the traditional closing procedures. Any swelling or effusions in the joint usually decreases. Physiotherapy and strength building have had successes as well. It is therefore critical at 12 weeks to begin to establish rehabilitation goals that need to be met for a return to normal activities. During this crucial phase, deformity correction is important.
The performance of a knee realignment surgery has been refined over the years, and surgeons are well aware of the potential risk profile. There are many potential complications associated with a high tibial osteotomy, especially at the standard medial opening site. The most common factors potentially contributing to the complications are patient-specific factors and the quality of the osteotomy displacement, fixation tools, and preoperative planning. The biggest risk occurs when the surgeon stops evaluating the patient after one year without a clinically successful outcome evaluation. Most of the complications could have been found in a few months postoperatively if only more aggressive routine postoperative examinations were performed. The administration of informed consent and a detailed schedule for consequences is essential to clinically successful outcomes.
Complications of the knee realignment surgery include malunion, nonunion, lateral cortical fracture, peroneal nerve palsy, intra-articular complications, and joint penetration with hardware. To avoid complications, removal of hardware must be performed to improve soft tissue balancing and to perform total knee arthroplasty in the following situations: no painful hardware status and no contraindications. Proper patient case selection, a meticulous osteotomy technique, and bone healing enhancement reduce the probability of complications. The most challenging situation, nonunion with knee pain evolution, requires immediate precise examination of the patient’s comorbidities, alcohol and nicotine intake, and technique blunders before planning revision. Careful examination of possible complications is critical to understanding why the patient has not succeeded.
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