1. Close Wedge HTO
Iran University ( IUMS )
DR Ali Torkaman

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

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

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

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

6. 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

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

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

9. 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

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

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

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

14. Technique (close wedge)
Osteotomy site
, cm below joint line
, med cortex not be transected

16. 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

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

19. 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

21. 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% )

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

25. 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

27. 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

29. - 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 )