Close Wedge HTO Iran University ( IUMS ) DR Ali Torkaman

HTO Key to success Remain a viable treatment option - careful patient selection - skillful surgical technique

HTO Indications - pain relief for DJD with malalignment ( buying time ) - mechanical axis correction with : , lig reconstruction , cartilage transplantation , meniscal allograft

HTO Contraindication Cautionary factors - inflammatory disorders - significant P/F DJD - body wt by 1/3 time

Close wedge Advantage - sooner wt bearing - no need for graft - decrease tibial slop

Close wedge Disadvantage - more difficult to control tibial slop - violation of prox tib-fib joint - risk of peroneal N injury - alter the shape of prox tibia - shorthening – bone loss

Open wedge Advantage - simpler - avoid tib- fib joint - avoid peroneal N - avoid ant leg compartment

Open wedge Disadvantage - delayed wt bearing - need bone graft - delayed union and non union - increase tib slop - overlengthening - patella baja

Dome osteotomy Varus more than 20 deg less effect on joint line obliquity No length alteration Potential for ant displacement of tib-tuberosity Transverse and sagital correction

Close wedge Recommend for - older patient - patella infra - stage 3-4 DJD - DJD due to ACL tear ( decrease slop )

Technique (close wedge) Incision; -long lateral curvilinear - short oblique (fib-head to tib-tub)

Technique (close wedge) Fibular ost ; removal of inner third of fibula - the best site is junction of M/3 to D/3

Technique (close wedge) Osteotomy site , 2-2.5 cm below joint line , med cortex not be transected

Technique (close wedge) Fixation; , two stepped staples (starter hole distal to the tine for compression) Prefered method ; Less soft tissue dissection No need for removal at subsequent TKA Less problem with conformity

Technique (close wedge) Post op - PWB for the first 6-8 wk then FWB

Complications Peroneal N jnjury Vascular injury - more dissection for plate fixation predispose Ant Tib Artery compromise Compartment syn - suction drainage of Ant compartment is helpful DVT - anticoagulation protocol is the same for TKA

Comparison of closing wedge and opening wedge HTO for med DJD ; a randomized clinical trial with 6 years FU (JBJS Am 2014 ) Duivenvoorden; et al 92 pt ;randomized ; 6 years FU - maintenance of achieved correction , progression of DJD ,pain ,knee function , walking distance and complications are the same -conversion to TKA ( close 20% open 10% )

Opening or closing HTO; a meta-analysis of clinical and radiological outcomes ( knee journal 2011 ) smith ;et al 324 open 318 close No difference in the incidence of infection, DVT, peroneal N palsy, non union ,pain , functional score, complications and conversion to TKA

TKA after HTO ;a systematic review 2007 TomVan Raaij ;et al 456 article ( 9 had criteria )( 4 close ,1 dome ,4 open ) median FU 5 years (3-13 Y ) Result ; osteotomy does not compromise subsequent TKA All studies reported on primary knee design and no revision tibial component Operation time ( 26 min more ) More lat lig release More tib tubercle os No difference in poly thickness,aseptic loosening, deep infection 10 deg less ROM

TKA after HTO; comparison of open and closing wedge osteotomy (international orthopaedic 2013 ) Ricardo Basto Fiho ;et al 141 TKA ( 24 after open , 117 after close ) mean FU 2 years -tourniquet time , exposure, intraoperative complications, X Ray alignment, IKS score are equal in both groups - more med release for open - more lat release for close

- SF 12 , WOMAC ,KSS score ,survivorship at 5 years ( no difference ) TKA after HTO ; no difference between medial and lateral osteotomy approaches( clin ortho relat reserch 2014 ) preston;et al 265 TKA (188 after close & 77 after open ) - SF 12 , WOMAC ,KSS score ,survivorship at 5 years ( no difference )