Total Knee Arthroplasty After High Tibial Osteotomy

Jabalameli, Mahmoud

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Jabalameli M. Total Knee Arthroplasty After High Tibial Osteotomy. JROS 2014; 1 (1)
URL: http://jros.iums.ac.ir/article-1-111-en.html

Total Knee Arthroplasty After High Tibial Osteotomy

Mahmoud Jabalameli

Department of Knee Surgery, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

Keywords: Total knee arthroplasty (TKA), high tibial osteotomy (HTO), TKA outcome

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Abstract

© 2014, Shafa Orthopedic Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Isolated medial compartment osteoarthritis of the knee with varus deformity is a common problem in Iran. An acceptable option for young active patients with this problem is high tibial osteotomy (HTO) that yields excellent pain relief and functional improvement. The positive effect of HTO is thought to be based on a redistribution of the body weight from arthritic medial femorotibial compartment towards the opposite unaffected side (1-3). In other words, as said by Sherman and Cabanella (4) “the goals of osteotomy include: to relieve pain, to redistribute weight bearing forces, to improve function and thereby potentially increase the longevity of the native knee joint” (4). It has been well established that good short and medium-term outcomes can be achieved with HTO for medial compartment osteoarthritis of the knee. Unfortunately, these results have been shown to deteriorate over time (5-9).

Various studies have reported satisfactory outcomes of approximately 80% at 5 years and 60% at 10 years after the HTO (9-14). Thus, while a HTO is capable of providing adequate pain relief for a young patient, it is unlikely to provide permanent relief, but nevertheless the need for total knee arthroplasty (TKA) is delayed (14). Some studies have shown inferior results after TKA in patients who had a previous HTO (15, 16), and some others have demonstrated similar results in patients with and without a previous HTO (17-27). This review aims to highlight the current literature findings regarding the problems that can complicate the TKA procedure in patients after HTO. The TKA after a previous HTO is technically challenging and influenced by a number of factors, which will be discussed in details (Table 1).

Table 1. The Factors That Influence the Total Knee Arthroplasty Results After High Tibial Osteotomy

Factors
Prior incisions
Operative exposure
Patella baja
Previous implants
Joint line distortion
Offset tibial shaft
Deficiency of the lateral tibial plateau
Mal:union:
Non:union:

2. Prior Incisions

Unlike the hip joint, the knee could not tolerate multiple parallel or crisscrossing incisions. In the knee, the vascular supply and lymphatic drainage are dominant on the medial side which increases lateral flap vulnerability. The most vulnerable knee is one with a long lateral parapatellar incision and occurs when a surgeon plans a parallel median parapatellar incision for a medial arthrotomy. In these situations, when multiple incisions are present, the most laterally based incision is preferable. Transverse incisions can be safely crossed at 90° angle, although angles lesser than 60° should be avoided. In unclear situations, the “delayed technique” or “sham incision” can be considered.

In the sham incision, the skin incision is performed without using tourniquet, the flaps are elevated, and the medial and lateral skin edges are carefully inspected for active bleeding. If the blood flows insufficiently, the procedure is aborted. In the delayed technique, skin incision is made, the skin flaps are elevated for the arthrotomy, and then the wound is closed. Assuming no occurrence of skin necrosis the TKA is carried out through the same incision 4 to 6 weeks later.

3. Operative Exposure

4. Previous Implants

5. Patella Baja

6. Tibial Implant Alignment

Closing wedge osteotomy may create lateral tibial bone deficiency. Care should be taken to resect the least amount of bone from the tibial plateau. Rarely, tibial wedges or graft may be required. After HTO, the offset of the plateau relative to the tibial shaft may be changed. The tibial anatomical axis may pass the medial of tibial plateau and the tibial component stem may come into contact with the lateral tibial cortex (21). The tibial component may have to be shifted medially and undersized or used with an offset stemmed tibial component (22). Change in the posterior tibial slope can occur after HTO, and one must care to cut the tibia in sagittal plane properly for creation a normal slope.

7. Mal:union:

Mal:union: may be in the varus or valgus plane, one should decide whether the secondary deformity can be corrected through the joint with ligament release or whether the corrective osteotomy is necessary. For elderly patients, correction through the joint by ligament release is usually preferred. A semi-constrained prosthesis may be required. In younger patients, osteotomy in mal:union: site is preferred. This could be performed as a two or one-stage procedure to fix the osteotomy site with a long stem tibial component. Mal:union: may occur in the flexion-extension plane. In anterior bowing of the tibia, fully functional extension can be achieved by allowing hyperextension at the joint surface. In tibial bow extension, hyperextension can be avoided by tightening the extension gap. TKA procedure after an osteotomy in excessive valgus can be challenging due to the following issues (26):

1. A valgus joint line in the knee joint that used to be in varus alignment prior to osteotomy,

2. The lateral plateau bone deficiency,

3. In a failed osteotomy with a valgus tibial joint line, the femur will be externally rotated. Thus, the femoral component will have to be internally rotated to restore flexion gap symmetry with a 90° tibial resection (26). This plan is unprecedented in classic practice.

8. Non:union:

9. Type of Prosthesis

10. Open Wedge HTO

Today, open wedge HTO has been accepted as a good procedure, but in conversion to the TKA following issues may occur:

1. The lateralized incision which can compromise the TKA outcomes,

2. Removal of hardware may be needed using a separate incision, which in turn can cause problems during TKA approach,

3. If commercial bone substitutes are used as a graft during a previous open wedge HTO, the weakness of the osteotomy site may be a serious concern and thus a stem for the tibial tray should be applied.

11. Outcome

12. Conclusion

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Subject: Knee surgery
Received: 2019/09/9 | Published: 2014/02/15

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