1. High Tibial Osteotomy Planning and Indications

2. 45yo female Active lifestyle Not overweight

3. 12 weeks

4. Goals of Treatment – Pain Relief – Maintain or Improve function Stay in the work force Sport

5. Non – Operative Treatment Lifestyle Modification – Weight loss – Low impact – Change occupation – Change sport

6. Non – Operative Treatment Paracetamol NSAIDs – significant reduction in pain compared to placebo – GIT risks Glucosamine / Chondroitin Sulfate – Cochrane review = no definitive clinical benefit vs placebo Steroid Injection – Effective short term Viscosupplementation – Cochrane review no benefit over placebo

7. Non – Operative Treatment Physiotherapy – Relationship / painful treatment – Quads strengthening – Stretching

8. Non – Operative Treatment Bracing and heel wedges – Some effect – Daily use? – 2 years - 25% compliance

9. Operative Treatment Options Needle Lavage – Not significant benefit Arthroscopic Debridement – Reserved for mechanical symptoms

10. Operative Treatment Options UKA – Good patient satisfaction – Physiologic function – Accelerated rehab and recovery time – Discharge day 1-3 – Conversion to TKR improving – Double the revision rate compared to TKR – labour – Bone stock

11. TKR

13. Operative Treatment Options HTO Morrey JBJS 1989 – 34 osteotomies – 7.5 yr fu – 73% satisfactory results Bourne 1999 – 106 Osteotomies – Survivorship 5yrs = 73%, 10yrs = 51% – In patient <50 5yrs = 95%, 10yrs = 80% Hui Am J Sports Med 2010 – 349 osteotomies – Mean fu 12 years (1-19yrs), avg age 50yrs – Survival 5yrs = 95%, 10yrs = 79%, 15yrs = 56% – 10yrs = 21% failure rate (reoperation) Results for conversion HTO to Primary TKR not different to primary OA to TKR Results UKR to TKR slightly better than a TKR to revision TKR

14. Operative Treatment Options HTO downside General risks Non-union Fracture Painful Long rehab Pain not all gone Arthroplasty in the future

15. Lateral Closing Wedge

16. 12 weeks Medial Opening Wedge

17. Indications Genu Varum with medial OA Adult OCD Osteonecrosis PLC instability

18. Appropriate Patient Young patient (<60 relative) Active Motivated for rehabilitation BMI <30 (<1.32x ideal bw)

19. Appropriate Joint Unicompartmental pathology Correlation with XRs Non Inflammatory FFD <15degrees Flexion arc >90 degrees Varus <15 degrees, Valgus <12 degrees

20. Contraindications Smokers Lateral compartment OA or previous injury / menesectomy Inconsistent pain Inflammatory arthritis Obese (BMI >30) FFD >15 degrees

21. Pre – op Planning Correct patient Deformity – Tibial – Femoral – Both Axes – Mechanical – Anatomical Correction desired Implant choice Graft type

22. Pre – op Planning - Deformity Standing Long leg views MRI to check other compartments

23. Pre – op Planning - Deformity mLDFA = 88 o mPTA = 81 o

24. Pre – op Planning - Axis Mechanical Axis Femoral – Tibial – 2 o varus med 75%, lat 25% – 0 o (centre) med 60% lat 40% – 4 o valgus med 50% lat 50% – 6 o valgus med 40% lat 60% Correction angle – Angle of deformity + 4-6 o = 14 o 8o8o mLDFA = 88 o mPTA = 81 o

25. Pre – op Planning – Fujisawa point Simplify 14 degrees 14 o

26. Pre – op Planning – Correction Now we know the angle of correction - ? mm opening First 10mm : 1mm = 1 o correction – Variation in tibial length and metaphyseal width – 14 mm < 14 o C- arm II Navigation

27. Pre – op Planning – Correction Now we know the angle of correction - ? mm opening First 10mm : 1mm = 1 o correction – Variation in tibial length and metaphyseal width – 14 mm < 14 o

28. Fixation Spacer plate Rigid locked plates

29. Bone Graft Opening wedge Structural support Biological healing Scaffold Autograft vs Allograft vs Synthetic substitute No need?

30. Steps 123

32. Summary Correct patient Locate the deformity for correction Axes Correction Implant Graft