Ostéotomie tibiale haute ou prothèse du genou : laquelle vous convient le mieux ?

Patient selection is an important point in the decision-making process regarding high tibial osteotomy or arthroplasty. Indications, individual expectations, and social factors should be well known by the orthopedic surgeon. Malalignment with varus deformity is the main indication for high tibial osteotomy. Lateral compartment arthritis with a normal or near-normal function of the knee joint should be present. If there is a misalignment of less than three degrees and the knee joint is stable, the mechanical axis should always pass through the midline of the knee joint. Alternatively, a full-length radiograph may be used to evaluate the standing axis if it concerns the posterior tibial slope, which may be the main cause of the malalignment. In the presence of an elevated varus angle, simultaneous valgus stress radiographs should be examined to predict the progression and identify the patients who may be responsive to a knee realignment vs knee replacement procedure. Diffuse degenerative changes in all three compartments are not a contraindication for high tibial osteotomy. The main absolute contraindication for a high tibial osteotomy is inflammatory arthritis.

The patient’s expectations or the expected activity levels must be known by both the patient and the orthopedic surgeon. Better pain relief should be achieved by high tibial osteotomy at all levels of activity during normal daily activities, heavy or light athletics, and at work alternatives to knee replacement. The patient’s demands and preferences, occupation, marital status, activity level, smoking, and drinking habits should all be considered before surgery, as these factors can prognosticate the outcome. Patients should receive objective preoperative counseling and education on the most likely postoperative outcome. This is to prevent the patient from conceiving the expectation that the preoperative activity level can be achieved after the osteotomy on its own, or alternatively for the patients to expect less than the maximum potential if they also receive tailored advice. The treatment should not negatively influence significant life events of the patients. While performing the surgery for high tibial osteotomy or total knee arthroplasty, clean and full technical competence is the most effective indicator of an excellent outcome. When considering risk factors, bone pathology or osteoporosis, age, and comorbidities may be identified. In particular, elderly patients are dealt with on a less favorable basis, as there is an increased likelihood of complications and a mild to fair functional gain. The decision-making process has been defined by comparative studies that were performed to provide insight for shared decision-making in elderly patients with suboptimal evidence-based indications within current guidelines, but there is a broad literature that can define the patients who have positive indications for the application of these methods. Consequently, for the high tibial osteotomy and total knee arthroplasty controversy, the deciding balance is often an ambiguous choice between interconnected or comparable approaches. Specifically, arthritic varus knees with moderate to high functional demands may not be properly managed. Consequently, further research is required, particularly in relation to patient-centered priorities, to more clearly demarcate preferred high tibial osteotomy and total knee arthroplasty prognosis.