Previous High Tibial Osteotomy



Previous High Tibial Osteotomy


Brian P. Chalmers

Tad M. Mabry



Key Concepts



  • Total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is made challenging by prior skin incisions, patella baja, retained hardware, altered tibial anatomy, and altered knee kinematics.


  • Careful planning of the incision must be done to avoid necrosis between prior incisions while also facilitating exposure and allowing selective hardware removal.


  • In knees with patella baja or stiffness, a stepwise approach to surgical exposure is important to have in mind before surgery.


  • Painful hardware should be removed; otherwise, partial in situ removal of only the hardware that impedes implant placement is preferred.


  • Lateral tibial bone loss and distortion of proximal tibial anatomy causing an offset tibial canal after closing wedge HTO requires preoperative planning of the tibial cut and implant placement; the use of custom implants or corrective osteotomy may be necessary in severe deformities.


  • Altered knee joint kinematics requires attention and appropriate ligament balancing to achieve symmetric gaps; the use of a posterior-stabilized implant is recommended to facilitate this.


Sterile Instruments and Implants


Basic Knee Instruments



  • Cemented knee implant system (surgeon’s choice); a prior HTO is a relative contraindication for a cementless TKA implant design; furthermore, even if not the surgeon’s routine, strongly consider a posterior-stabilized implant; constrained and stemmed options should be available.


  • Implant-specific screwdrivers, extraction devices, metal-cutting burr for hardware removal.


Surgical Approaches



  • Careful assessment of previous skin incisions and planning of the operative skin incision is paramount for successful wound healing. Avoid far lateral incisions.


  • Because many prior HTOs are laterally based closing-wedge osteotomies, make a slightly more medial skin incision to leave a skin bridge of at least 6 cm between previous lateral incisions; in prior medially based osteotomies, the old medial incision is typically acceptable.


  • Cross transverse incisions perpendicularly, and for S-shaped or inverted L-shaped incisions, the vertical limb of the incision can be extended proximally.


  • For stiff knees or knees with patella baja (Figure 56.1), a stepwise approach is necessary to achieve adequate surgical exposure:



    • Extended medial parapatellar arthrotomy


    • Free the medial and lateral gutters of scar tissue


    • Quadriceps snip if necessary


    • Tibial tubercle osteotomy rarely needed but utilized if necessary in the most severe cases







Figure 56.1 ▪ A lateral radiograph of a patient status post high tibial osteotomy with retained step-staple hardware. Note both patella baja and the posterior translation of the proximal tibia.


Preoperative Planning

Dec 14, 2019 | Posted by in ORTHOPEDIC | Comments Off on Previous High Tibial Osteotomy

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