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

June 2012
KUWAIT MEDICAL JOURNAL 92
Review Article
Proximal Tibial Osteotomy in Medial
Compartment Osteoarthritis: How High is High?
Teoman Atici 1 , Cenk Ermutlu 1 , Namık Sahin 2 , Alpaslan Ozturk 2 , Kaya Memisoglu 3
1
Department of Orthopedics and Traumatology, Uludag University Medical Faculty, Bursa, Turkey
2
Department of Orthopedics and Traumatology, Bursa Sevket Yılmaz Research and Training Hospital, Yildirim, Bursa,
Turkey
3
Department of Orthopedics and Traumatology, Kocaeli University Medical Faculty, Izmit, Turkey
Kuwait Medical Journal 2012; 44 (2): 92 - 100
ABSTRACT
Proximal tibial osteotomy (PTO), which can be performed
using various techniques, is a common procedure for the
treatment of medial compartment osteoarthritis of the
knee. Changes in the biomechanics of knee may cause
problems in the long term, depending on the technique
that was performed. Whichever technique is used, the
level at which the osteotomy is performed is a significant
factor in any changes in biomechanics and for potential
problems in future surgery. The relationship between the
techniques applied and the names used throughout its
progression is investigated in this review, which briefly
evaluates the historical improvement of PTO applied
in the treatment of knee osteoarthritis. Denomination
defined by the first practitioners of different osteotomies
that were used in the treatment of knee osteoarthritis and
identified under different names were investigated in the
literature. Compatibilty of technique defined by using the
word “high” and different techniques were evaluated.
The contribution of alteration in surgical techniques
on nomenclature has lead to standard usage with time.
The term “high”, which has been used for longer than
four decades, does not cover all of these techniques.
Nomenclature of osteotomies performed for the treatment
of medial compartment osteoarthritis would therefore be
more appropriate, if it were used in such a way as to define
the actual level of osteotomy. We believe that osteotomies
performed distal to the tibial tubercle must be defined
as ‘upper tibial’ or ‘proximial tibial’ instead of ‘high’, or
related osteotomy level and method must be clearly stated
in each individual case.
KEY WORDS: arthroplasty, osteoarthritis, osteotomy, patella, tibia
INTRODUCTION
Osteotomy is one of the oldest approaches
in orthopedic surgery for correcting lower limb
deformity [1] . Today, the most widely used technique is
high tibial osteotomy (HTO), which is performed with
the aim of reducing deformity caused by the occurrence
of medial compartment osteoarthritis (MCOA) of the
knee, one of the most frequently seen indications for
corrective osteotomy [2] . The aim of HTO in MCOA
of a varus knee is decompression of the degenerated
medial compartment, in order to delay the progress
of cartilage degeneration [3,4] . HTO is a highly effective
procedure for relieving pain, correcting deformity and
improving function in cases of MCOA of the knee, and
can be performed using a variety of techniques that are
associated with varying clinical results [4-11] .
Several different osteotomy techniques have been
described for MCOA with varus deformity [11-22] . Over
the past decade there has been an explosion of interest
in developing modifications of surgical techniques, new
surgical instrumentation, and new fixation devices, as
well as increasing interest in the use of external fixation
devices, and computed tomography-free navigation
systems which aim to improve the accuracy, reliability,
and safety of realignment osteotomy [23] . The three
principal techniques to produce valgus realignment of
the proximal tibial articular surface are lateral closing
wedge osteotomy (Fig. 1 a - c), medial opening wedge
osteotomy (Fig. 2 a - c), and dome osteotomy (Fig. 3). A
dome osteotomy can be performed with convexity on
the superior or inferior surface of the osteotomy level.
The level of osteotomy must be agreed on as well as
the appropriate technique. Osteotomies above, below,
and behind the tubercle have all been previously
described [13,15,19] . The pros and cons of osteotomies
performed proximal or distal to the tibial tuberosity
and of closing-opening wedge versus dome osteotomy
should be considered.
Address correspondence to:
Dr. Teoman Atici, MD, Department of Orthopedics and Traumatology, Uludag University Medical Faculty, Bursa, Turkey. Tel: 00 90 224 2952840,
E-mail: atici2009@gmail.com, teoman@uludag.edu.tr