High tibial osteotomy for the treatment of unicompartmental arthritis of the knee

Abstract

High tibial valgus osteotomy for varus gonarthrosis is a time-honored procedure in the treatment of medial compartment arthritis of the knee joint. The results of high tibial osteotomies have traditionally been shown in the literature to delay total knee arthroplasty from 5 to 10 years, on average. The ideal patient has classically been an active young person with a varus deformity of less than 10 to 12 degrees with primarily medial compartment arthrosis and uninvolved patellofemoral lateral compartments. Good bone stock is also desirable and, given that the osteotomy is performed through metaphyseal bone, healing has not been a problem with this procedure. The literature reports wide variations in the approach used for the high tibial osteotomy, implants used for fixation of the osteotomy, and ultimate outcome. Certainly, wide variations exist in the ultimate correction and alignment obtained from the osteotomy. This review focuses on the anatomic goals of the osteotomy, as well as recent and more classic reports of the results of this procedure. Osteoarthritis of the knee joint with an overall varus deformity is a common condition affecting a large number of patients. Typically, the patients are middle-to older-aged individuals. It is estimated that anywhere from 1% to 6% of individuals between the ages of 55 and 74 are afflicted with arthritic disease in their knees [1]. Classically, valgus-producing high tibial osteotomy of the knee has been successful in the treatment of isolated medial compartment arthrosis of the knee joint with a varus deformity [2–21]. An active young patient under age 55 with a stable varus deformity of less than 10 to 12 degrees with good bone stock is the ideal candidate for this procedure [7,19]. The operative technique used for the osteotomy, as well as recommendations regarding preoperative planning and preparation, the operative incision, and intraoperative measurements, as well as fixation, have been more variable as reported in the literature [10,13,17,22–29]. The use of intraoperative cutting jigs and stable internal fixation devices can improve the accuracy of the ultimate correction of the femorotibial angle [30–34]. Although the success of total knee arthroplasty in the treatment of the osteoarthritic knee has been well documented in the literature [35–39], the potential for mechanical failure, particularly in young patients, remains a significant concern. With over 250,000 knee arthroplasties performed annually [40], the single most important long-term outcome with total knee arthroplasties remains the longevity of the arthroplasty. The long-term results of total knee arthroplasty in more active younger patients may differ from those obtained in an older, less active patient population [41–43]. With the concerns of potential mechanical failure in younger, more active patients and the potential need for revision arthroplasty, as well as combined procedures including autologous cartilage transplants combined with realignment procedures to correct an overall limb malalignment, the interest in high tibial osteotomies for treatment of osteoarthritis of the knee will undoubtedly increase.