Vol 44 # 2 June 2012 - Kma.org.kw

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Proximal Tibial Osteotomy in Medial Compartment Osteoarthritis: How High is High?
June 2012
Fig. 5a Fig. 5b Fig. 5c
Fig. 5 a: Focal dome high tibial osteotomy. (b) Anteroposterior radiograph of 62-year-old female patient in the 7 th post-operative year.
(c) Lateral radiographs of the same patient.
reported a new approach for HTO in the treatment of
MCOA in 1994 [22] . This procedure was named “focal
dome osteotomy” because, when seen from above,
it has the shape of a reverse dome distal to the tibial
tuberosity (Fig. 5 a - c).
History of nomenclature of proximal tibial osteotomy
techniques
Various techniques of HTO, performed as treatment
for MCOA of the knee, have different nomenclature. A
few of them are, “proximal tibial osteotomy”, “upper
tibial osteotomy”, “valgus tibial osteotomy”, “tibial
osteotomy” “osteotomies around the knee”, “dome
osteotomy”, “closing or open wedge high tibial
osteotomy” and “focal dome osteotomy”. Osteotomy
for treatment of osteoarthritis of the knee was first
reported in 1958, and Jackson performed osteotomies
distal to the tibial tubercule and named this approach
as “osteotomy through the upper tibia.......” [12] . In
1961, Jackson and Waugh [12] were the first to publish
an article about tibial osteotomies entitled “Tibial
Osteotomy for Osteoarthritis of the Knee” in which
they performed dome tibial osteotomy at the level of
/ or distal to the tibial tuberosity. In their next article
on this subject, published in 1963, the osteotomy level
was still below the tibial tubercle and the article was
entitled “Tibial Osteotomy for Osteoarthritis of the
Knee” [37] . In 1961 Smillie [14] performed the osteotomy
about one centimeter below the articular surface and
the technique was named “upper tibial osteotomy”. In
1962, Wardle [15] published an article entitled “Osteotomy
of the Tibia and Fibula” in which osteotomy was
performed transversely distal to the tibial tubercle. In
the same year, Venemans [38] performed an osteotomy
immediately distal to the tibial tubercle and he
reported it as “Tibial osteotomy for osteoarthritis of
the knee”. Gariepy was the first to use the term “High
Tibial Osteotomy” in 1964 [16] . This osteotomy, which
was performed proximal to the tibial tubercle was
reported in his article “Genu varum treated by high
tibial osteotomy”. He stated that the advantages of
doing a wedge osteotomy at a high level, i.e., above the
insertion of the patellar tendon, are obvious both for
mechanical reasons and for bone healing [30] . Coventry
modified and popularized the technique described by
Gariepy and reported it in his 1965 article “Osteotomy
of the upper portion of the Tibia for Degenerative
Arthritis of the Knee” [17] . Devas [39] in 1969 and Harris
and Kostuik [40] in 1970 performed the osteotomy again
above the tibial tubercle and used the term “high
tibial osteotomy”. However in 1966, Gunn [41] reported
his cases as “high” tibial osteotomy, but in his article
osteotomies were performed at the level of the tibial
tubercle or lower. In fact, as Jackson and Waugh
moved the level of osteotomy from inferior of the
tibial tubercle to superior, they also changed the title
of their article “Tibial Osteotomy for Osteoarthritis of
the Knee” to “High Tibial osteotomy for Osteoarthritis
of the Knee” [13,37,42] . In 1969, Bauer et al [43] preferred
“high rather than shaft osteotomy of the tibia” and
they termed osteotomies performed superior to the
insertion of the patellar tendon as high.
HTO, as defined by Gariepy [16] and popularized
by Coventry [17] is a procedure where the osteotomy is
performed proximal to the attachment of the patellar
tendon. In the following years, as the use of external