osteotomies: high tibial, distal femoral, and tibial tubercle · an osteotomy performed on the...

American Academy of Orthopaedic Surgeons 47

Malalignment can affect any of the threecompartments of the knee. An osteotomyperformed on the proximal tibia, the dis-tal femur, or the tibial tubercle can alter

the knee’s biomechanical alignment and unload theaffected compartment. Osteotomy can also be very use-ful when done in conjunction with cartilage restorationprocedures. Multiple procedures have been proposed foreach level of osteotomy, with varying degrees of clinicalsuccess. This chapter discusses the indications, surgicaltechniques, and results of opening wedge high tibialosteotomy, opening wedge distal femoral osteotomy, andtibial tubercle osteotomy.

Before a patient can be considered for any of theseosteotomies, a detailed history and physical examina-tion must be performed. The history should determinethe patient’s occupation and activity level, and all pre-vious surgical and nonsurgical interventions. It is impor-tant to note the patient’s body habitus and overallalignment, and any coronal, sagittal, or rotational insta-bility. All arthroscopic and radiographic images obtainedpreviously should be reviewed with the patient. Newradiographs should be obtained, including a Merchantview and weight-bearing AP, lateral, and 45° flexion PAviews. Bilateral weight-bearing long-cassette views alsoshould be obtained to measure the mechanical axis anddegree of correction needed. MRIs are useful when car-tilage or ligament damage is suspected.

High Tibial OsteotomyPatient SelectionHigh tibial osteotomy is indicated for younger patientswith symptomatic, isolated, medial compartment arthri-tis in whom a unicondylar arthroplasty is likely to fail.Patients with osteonecrosis or osteochondral defectswith varus malalignment can benefit from an osteotomyonce their cartilage defects have been addressed.

The procedure is contraindicated in patients with tri-compartmental arthritis, a deformity greater than 15°,a flexion contracture greater than 15°, knee flexion lessthan 90°, medial or lateral tibial subluxation greater than1 cm, excessive bone loss (more than 3 mm), inflamma-tory arthritis, morbid obesity, or any medical comor-bidities that might interfere with bony healing.Patellofemoral arthritis and patient age over 60 years areconsidered relative contraindications.1

Calculating the Degree of CorrectionCoronal PlaneFor medial compartment arthritis, overcorrection to the62% lateral weight-bearing line (roughly two thirds thewidth of the tibial plateau) is usually needed.1 Forunloading cartilage restoration procedures, correctionof the mechanical axis to neutral (center of plateau) issufficient. The point of the desired mechanical axis ismarked on the tibial plateau. A line is drawn from thecenter of the femoral head to the desired point on the

C H A P T E R 5

Osteotomies: High Tibial, Distal Femoral,

and Tibial TubercleAmmar Anbar i , MD

ch05_anbari:Layout 1 8/20/2009 2:12 PM Page 47

plateau. Another line is drawn from the point on theplateau to the center of the tibial plafond. The angleformed by the two lines is the degree of correctionneeded (Figure 1). Generally, 1 mm of opening corre-sponds to 1° of correction.

Sagittal PlaneIncreasing the tibial slope will worsen symptoms inpatients with anterior cruciate ligament (ACL) instabil-ity and improve symptoms in those with posterior cru-ciate ligament (PCL) instability. On the other hand,decreasing the tibial slope will improve symptoms inpatients with ACL instability and worsen symptoms inthose with PCL instability.

Surgical TechniqueAll osteotomy procedures are performed on a radio -lucent table. If iliac crest autograft is planned, the ipsi-lateral pelvis can be prepared and draped as well.Arthroscopy is routinely performed to verify the statusof the articular cartilage and to perform any requiredcartilage restoration procedure.

The tibial osteotomy incision extends along a line thatruns from the distal aspect of the anteromedial arthro-scopic portal distally to the level of the pes. The portionof the line below the joint surface can be used to per-form the actual incision. The incision falls roughlybetween the tibial crest and the posteromedial tibial bor-der. Dissection is made down to the anteromedial tibiaand the sartorius fascia. A transverse cut is made alongthe superior aspect of the hamstring tendons, extend-ing from the posteromedial tibia to the level of the patel-lar tendon. This cut is curved inferiorly along the medialside of the patellar tendon. A sleeve is elevated subpe-riosteally to the posteromedial tibia. Two blunt retrac-tors are put in place, one behind the tibia to protect theneurovascular bundle, and the other under the patellartendon.

We use one of the commercially available openingwedge osteotomy systems to fix our osteotomies. Abreakaway osteotomy guide pin is inserted into the tibiain an inferomedial-to-superolateral direction. The start-ing point is about 3 cm distal to the medial joint line.The tip of the guide pin should end on the lateral cor-tex at least 1 cm distal to the lateral tibial joint line, nearthe tip of the fibular head. Another pin is inserted par-allel to the first, taking into account the proximal slopeof the tibia. The pins are bent and broken at their break-away point and the osteotomy cutting guide is placedover the two pins. An oscillating saw is used to cut thetibia to within 1 cm of the lateral cortex (Figure 2, A).Thin osteotomes are used to complete the osteotomy. Toavoid violating the lateral cortex, the tibial cut shouldbe made—and the osteotomes should be placed—infe-rior to the cutting guide and pins.

The guide pins are removed, and the calibrated wedgesare gently tapped through the medial tibia to distractthe osteotomy (Figure 2, B and C).The markings on theside of the wedges correspond to the size of the open-ing in millimeters. The wedges should be inserted slowlybecause rapid insertion can lead to a lateral fracture.Once the appropriate osteotomy angle is achieved, the

SU R G I C A L MA N A G E M E N T O F ART I C U L A R CA RT I L A G E DE F E C T S I N T H E KN E E

48 American Academy of Orthopaedic Surgeons

AP radiograph demonstrating how to calculate the degree of correc-tion to be achieved in the coronal plane by a high tibial osteotomy.

F I G U R E 1


handle is removed and the wedges are left in place. Ifthe wedges do not open the bone, the wedges areremoved and the osteotomes are used again. If theosteotomy extends to the opposite cortex, it can be fixedby making a small incision over the lateral cortex andinserting two bone staples. If the osteotomy extendsproximally to the tibial plateau, it can be fixed using twopartially threaded AO screws or a periarticular plate.

A plate with the same sized opening is placed in thespace between the two wedges (Figure 2, D). Two 6.5-mm unicortical cancellous screws are used to fix the

plate proximally. The calibrated wedges are removed toallow the osteotomy to close down on the plate. Two4.5-mm bicortical screws are used to fix the plate dis-tally (Figure 2, E).

Allograft or autograft tricortical bone is inserted inthe osteotomy site on both sides of the plate (Figure 2,F). The elevated tissue on the medial side of the tibia isrepaired, and the rest of the incision is closed in layers.A knee brace locked in extension is applied. Anticoag-ulation medication—low-molecular-weight heparin orwarfarin—is prescribed for 4 weeks.

C H A P T E R 5 OS T E O T O M I E S : H I G H T I B I A L , D I S TA L F E M O R A L , A N D T I B I A L TU B E R C L E


F I G U R E 2 High tibial osteotomy. A, Fluoroscopic viewdemonstrating how an oscillating saw is usedto cut the tibia to within 1 cm of the lateral cor-tex. B, Fluoroscopic view shows a calibratedwedge in place. C, Intraoperative photographshows the wedge being tapped in place. D, Intraoperative photograph showing the platebeing placed between two wedges. E, Fluoro-scopic view showing the plate fixed proximallyand distally. F, Intraoperative photograph show-ing tricortical bone graft wedges placed ante-rior and posterior to the plate.


Rehabilitation ProtocolThe principal goals of a rehabilitation program followinga high tibial osteotomy include pain relief and improve-ment in the ability to walk. After any type of osteotomy,bone healing must occur before full weight bearing or vig-orous physical activity can be initiated. A detailed descrip-tion of the rehabilitation protocol prescribed after hightibial osteotomy can be found in Table 1.

Distal Femoral OsteotomyPatient SelectionA distal femoral osteotomy is indicated for patients withvalgus deformity in the knee. The procedure should beperformed with cartilage restoration procedures in thelateral compartment when valgus malalignment coexists.The indications and contraindications for distal femoralosteotomy are similar to those for high tibial osteotomy.

Surgical TechniqueA lateral approach is used to perform a distal femoralosteotomy. The iliotibial band is split along its fibers andthe vastus lateralis is elevated off the femur to exposethe femoral shaft and metaphysis. A breakawayosteotomy guide pin is inserted about 4 cm proximal tothe lateral epicondyle (Figure 3, A). The pin is placedfrom lateral to medial at an oblique angle to end nearthe medial epicondyle. It is important not to make theosteotomy cut too distal because it can violate the



F I G U R E 3 T A B L E 1

Rehabilitation Protocol After High TibialOsteotomy

Phase I (first 4 weeks): Touch-down weight bearing withcrutches is allowed for at least 4 weeks. The knee braceis worn at all times, except during continuous passivemotion machine (CPM) use. The CPM should be usedfor 4 hours a day, with a goal of achieving 90° of flex-ion. Physical therapy includes quadriceps sets, anklepumps, straight-leg raises with the brace locked inextension, and non–weight-bearing calf/hamstringstretches.

Phase II (4 to 6 weeks): Weight bearing is advanced with-out crutches. The brace is unlocked for ambulation andthe CPM is discontinued. Physical therapy continueswith gentle stationary bike use and straight-leg raiseswithout the brace.

Phase III (6 weeks to 3 months): The brace can be dis-continued if the patient is pain free. Mini-squats (0° to45°), leg-presses (0° to 60°), closed-chain terminal kneeextensions, balance activities, and toe raises may bestarted.

Phase IV (3 to 9 months): Progress closed-chain exer-cises as tolerated. Treadmill walking may begin; progressas tolerated by the patient. Return to sports and worktypically occurs around 9 to 12 months.

Distal femoral osteotomy. A, Intraoperative photograph showing theincision and soft tissue dissection. B, Fluorograph showing the platefixed proximally and distally.


trochlea and enter the joint. The osteotomy is performedin a way that is similar to that of a high tibial osteotomy;however, the cut should be made perpendicular to thefemur in the sagittal plane to prevent flexing or extend-ing the femur. An opening wedge instrument set simi-lar to that used for a high tibial osteotomy, but withlonger plates, is available for this procedure.

Once the appropriate angle of correction is achieved,the plate is fixed distally with 6.5-mm unicortical can-cellous screws and proximally with at least three 4.5-mm bicortical screws (Figure 3, B). Bone graft is theninserted. The incision is closed in layers. A drain can beused for 24 hours if needed.

A rehabilitation protocol similar to that used for hightibial osteotomy (see Table 1) should be initiated.

Tibial Tubercle OsteotomyPatient SelectionTibial tubercle osteotomy with medialization is indicatedin symptomatic patients with a tibial–tubercle–to–trochleargroove (TT-TG) distance greater than 20 mm, with orwithout signs of patellar instability.2,3 It can be performedon patients who are also undergoing a medialpatellofemoral ligament (MPFL) repair or reconstructionand lateral release. In general, the patellofemoral compart-ment should exhibit no signs of chondrosis.

Tibial tubercle osteotomy with anteromedializationshould be reserved for patients who have an abnormalTT-TG distance with lateral distal chondrosis or whoare undergoing a cartilage restoration procedure in thepatellofemoral compartment. In patients with Outer-bridge grade I or II lesions, an anteromedialization maybe sufficient. In patients who have grade III or IVlesions, the osteotomy should be combined with a car-tilage procedure.2,3

A tibial tubercle osteotomy is contraindicated inpatients who have a normal TT-TG distance or who havecomplete loss of joint space and advanced diffuse arthri-tis. Medical issues that could interfere with bony heal-ing (smoking, infection, and osteoporosis) also areconsidered contraindications to an osteotomy.

EvaluationChondral defects in the patellofemoral compartment arecommonly seen in knee arthroscopies. These chondral

defects sometimes present with alignment and mechan-ical abnormalities, which also may benefit from a tibialtubercle osteotomy.

Affected patients often describe an insidious onset ofpain. The location of the anterior knee pain should bedocumented. Patients with patellar defects present withpain on the back or sides of the patella, and patients withtrochlear defects often present with posterior knee pain.All previous interventions, both nonsurgical and surgi-cal, also should be documented. The physical examina-tion should include testing for some of the entities oftenseen in patellofemoral pain (excessive femoral antever-sion, knee valgus malalignment, hip abductor weakness,and iliotibial band contracture). Patients should beobserved in a standing position, and the Q angle shouldbe measured. It is important to make sure the patella isnot subluxated when measuring the Q angle because asubluxated patella may falsely decrease the value of theangle. Joint effusion and patellar subluxation, mobility,and tilt should be assessed and compared with that of theopposite knee. An exaggerated J-sign may suggest medial



MRI of a patient about to undergo a tibial tubercle osteotomy, demon-strating how to calculate the TT-TG distance.

F I G U R E 4

ch05_anbari:Layout 1 8/20/2009 2:12 PM 1

retinacular laxity and possibly a tear in the MPFL. Finally,it is important to document limb rotation through thehip and any signs of femoral or tibial malrotation.

In addition to the standard radiographic imagingdescribed earlier, a CT scan should be taken to moreaccurately evaluate patellar subluxation and tilt and todiagnose any trochlear dysplasia. The TT-TG distancecan be determined by superimposing two radiographs,one taken through the patellofemoral articulation andthe second through the tibial tubercle, and measuringthe medial-to-lateral distance from the center of thetrochlear groove to the highest point of the tibial tuber-cle (Figure 4). A TT-TG distance less than 15 mm is con-sidered normal; a distance greater than 20 mm is usuallydeemed abnormal and should be considered for a tib-ial tubercle osteotomy.3 Sagittal and coronal reconstruc-

tions can help diagnose patella alta or patella infera. AnMRI is useful if a cartilage defect is suspected.

Surgical TechniqueIn preparation for surgery, the patient is positionedsupine on a radiolucent table with a gel roll under theipsilateral buttock. A tourniquet is applied and used dur-ing the osteotomy portion of the case; it is deflatedbefore closure to achieve hemostasis.

If the surgeon is not certain of the extent of the dam-age to the cartilage, a quick diagnostic arthroscopy canbe performed. A chondroplasty, microfracture, or lat-eral release also can be performed arthroscopically atthis time. In addition to the standard portals, a proxi-mal portal can be used to examine patellar tracking inthe trochlea. If an MPFL repair or reconstruction is



F I G U R E 5

Intraoperative photographs of a tibial tubercle anteromedialization. A, A patient undergoing both an autologous chondrocyte implantationand anteromedialization of the tibial tubercle. B, The anteromedial-ization osteotomy cutting guide is secured with two drill bits. C, Theosteotomy is fixed with two 4.5-mm screws. The patellar autologouschondrocyte implantation is completed before fixing the osteotomy.


planned, it should be done after the osteotomy is com-pleted. If a cartilage reconstruction procedure isplanned, it should be performed after the osteotomy cutis made but before it is fixed.

A tibial tubercle medialization can be performedthrough a small, 6-cm incision centered on the lateralaspect of the tubercle. The soft tissue of the anterior com-partment is elevated, and the patellar tendon is protected.The osteotomy cut is V-shaped and centered posterior tothe patellar tendon insertion. The cut is 5-cm long andis about 1.5 cm posterior to the tibial crest. Theosteotomy is rotated over the intact hinge on the distaltibial tubercle to the desired location and fixed with two4.5-mm fully threaded cortical screws lagged through thetuberosity to achieve interfragmentary fixation.

A tibial tubercle anteromedialization is performedthrough an approximately 10- to 12-cm incision thatextends at an oblique angle from the anterolateral portalproximally to the tibial crest distally. The incision isextended proximally if a cartilage procedure is performedin the same setting (Figure 5, A). Medial and lateral flapsare raised to expose the proximal medial and lateral tib-ial surfaces. The anterior compartment is elevated sub-periosteally, and both edges of the patellar tendon areopened so that a retractor may be placed under it.

We use a commercially available anteromedializationosteotomy guide system to perform this procedure. A

broad retractor is placed on the posterolateral edge ofthe tibia to protect the neurovascular structures. Theosteotomy cutting guide is placed on the medial side ofthe tibia at an angle. The top of the guide should be atthe level of, and 1.5 cm posterior to, the proximal patel-lar tendon insertion. A 2-mm drill bit is used to securethat end of the guide. The distal end of the guide isangled laterally and should terminate on the distal endof the tubercle near the crest. The end of the guide isalso secured with a drill bit (Figure 5, B). To verify theangle and accuracy of the osteotomy cut, the C-shapedguide is placed through the cutting guide with the tipof the guide pointing to the end of the osteotomy cut.The cut should end on the lateral tibial surface. Thehigher the end points on the lateral tibia, the shallowerthe angle of the anteromedialization.

Once the osteotomy cutting guide is in the desiredposition, an oscillating saw is used to perform theosteotomy cut. The guide is removed, and the distal endof the cut is finished with the saw. The proximal end ofthe cut is performed with an osteotome placed on thelateral tibia to connect the saw cut to the anterior tibia.

The bone is now rotated up the slope to the desiredlocation. The osteotomy is fixed with two 4.5-mm, fullythreaded screws lagged bicortically, and both screws arecountersunk (Figure 5, C and Figure 6). The tourniquetis deflated, and a drain is put into place for 24 hours, ifnecessary. The anterior compartment is reattached, andthe incision is closed in layers. A hinged knee brace isapplied and locked in extension.

Rehabilitation ProtocolThe protocol for rehabilitation following a tibial tuber-cle osteotomy is discussed in Table 2.

Summary and Conclusions

High Tibial and Distal FemoralOsteotomiesClosing wedge high tibial and distal femoral osteo -tomies have produced successful short- and long-termresults.4-6 Recent studies have looked at the efficacy andsuccess of opening wedge osteotomies. Esenkaya andElmali7 performed 58 opening wedge high tibial



F I G U R E 6

Postoperative AP (A) and lateral (B) views showing the fixed antero-medialization osteotomy.


osteotomies in patients with medial compartmentarthrosis. Patient ages ranged from 36 to 66 years andthe average follow-up was 21 months. The Hospital forSpecial Surgery (HSS) score improved from 58 to 89.Lateral tibia plateau fractures were seen in 8.6% ofpatients, and lateral cortex fractures were noted in25.8%. Delayed union occurred in 1.7% of patients.Koshino and associates8 studied the outcomes of 21opening wedge high tibial osteotomies. The meanpatient age was 66.6 years, and the patients were fol-lowed for an average of 78.6 months. Two hydroxyap-atite wedges were placed in each osteotomy site. Themean American Knee Society knee scores and func-tional scores improved from 60.2 and 48.1 to 94.3 and93.1, respectively. No recurrence of varus deformity wasnoted in any patient. Franco and associates1 reviewedthe outcomes of 30 patients who underwent openingwedge high tibial osteotomy and who were followed for

36 to 48 months. The average patient age was 49 years.The authors used International Knee DocumentationCommittee and HSS scoring systems for evaluation. Allpatients improved by at least one category. Using anopening wedge technique, Hernigou and associates9

treated 93 knees with opening wedge high tibialosteotomy. At 5-year follow-up, 90% of the knees hadgood or excellent results. These results deteriorated overtime, with just 45% of the patients having excellent orgood results after 10 years. Finally, Dietrick and Bug-bee10 reported their unpublished results of 18 patientsranging in age from 17 to 58 years who underwentopening wedge distal femoral osteotomy for lateralcompartment arthritis or to unload a cartilage restora-tion reconstruction procedure. Symptoms improved in15 patients, but 3 patients eventually underwent con-version to a total knee arthroplasty.

Tibial Tubercle OsteotomiesShort- and long-term studies of tibial tubercleosteotomies have shown promising, good to excellentresults. Fulkerson and associates11 followed 30 patientswho underwent anteromedialization of the tibial tuber-cle (average follow-up of 35 months) and reported 89%objective and 93% subjective good to excellent results.Similar results were reported in 2000 by Buuck andFulkerson.12 Carney and associates13 published a caseseries of 18 patients who underwent a combination oflateral release, medial reefing, and tibial tubercle medi-alization for patellar instability. The patients were fol-lowed at least 3 years and at 26 years. Seven percent ofthe patients had recurrent instability at both 3 and 26years. Although at 3 years, 73% of the patients reportedgood to excellent results, the results dropped to 54%good to excellent results at 26 years. Tibial tubercleanteromedialization results in patients withpatellofemoral arthritic changes depend on the loca-tion of the arthritis. Pidoriano and associates14 retro-spectively reviewed the outcomes of 36 patients whounderwent tibial tubercle anteromedialization forarthritis. Of patients who had distal or lateral patellarlesions, 87% had good to excellent results, as did 55%of patients who had medial facet lesions. Only 20% ofpatients with proximal or diffuse lesions had good toexcellent results, however. Interestingly, no correlationexisted between the Outerbridge grade of the lesion andthe results.



T A B L E 2

Rehabilitation Protocol for Tibial TubercleOsteotomy

Phase I (first 12 weeks): Touch-down weight bearing isallowed for the first 6 weeks. A radiograph is taken atthat point and, if adequate healing is achieved, weightbearing may progress as tolerated by the patient. Thehinged brace is locked for the first 2 weeks and can beremoved by the patient to perform exercises at home.The patient is allowed immediate full range of motionas tolerated. For the first 6 weeks, the patient worksmainly on quadriceps sets and ankle and knee motion.During weeks 6 to 10, the patient may do straight-legraises and partial wall squats. In weeks 10 to 12, ham-string strengthening is added. The brace should beunlocked during walking by week 6 and discontinuedby week 8.

Phase II (12 to16 weeks): Patients should be bearing fullweight on their affected legs, and they should have fullrange of motion. Treadmill walking can begin, alongwith balance and proprioception exercises.

Phase III (16 to 20 weeks): Closed-chain exercises andlight plyometric exercises are advanced.

Phase IV (20 to 24 weeks): Strengthening exercises con-tinue, progressing to running, single-leg jumping, andloading.


References1. Franco V, Cerullo G, Cipolla M, Gianni E, Puddu G:

Open wedge high tibial osteotomy. Tech Knee Surg2002;1:43-53.

2. Gomoll AH, Minas T, Farr J, Cole BJ: Treatment ofchondral defects in the patellofemoral joint. J KneeSurg 2006;19:285-295.

3. Farr J: Distal realignment for patellofemoral disease, inCole BJ, Sekiya JK (eds): Surgical Techniques of theShoulder, Elbow, and Knee in Sports Medicine, Philadel-phia, PA, Saunders, 2008, pp 755-767.

4. Insall JN, Joseph DM, Msika C: High tibial osteotomyfor varus gonarthrosis: A long-term follow-up study. J Bone Joint Surg Am 1984;66:1040-1048.

5. McDermott AG, Finklestein JA, Farine I, Boynton EL,MacIntosh DL, Gross A: Distal femoral varusosteotomy for valgus deformity of the knee. J BoneJoint Surg Am 1988;70:110-116.

6. Healy WL, Anglen JO, Wasilewski SA, Krackow KA:Distal femoral varus osteotomy. J Bone Joint Surg Am1988;70:102-109.

7. Esenkaya I, Elmali N: Proximal tibia medial open-wedge osteotomy using plates with wedges: Earlyresults in 58 cases. Knee Surg Sports Traumatol Arthrosc2006;14:955-961.

8. Koshino T, Murase T, Saito T: Medial opening-wedge

high tibial osteotomy with use of porous hydroxyap-

atite to treat medial compartment osteoarthritis of the

knee. J Bone Joint Surg Am 2003;85:78-85.

9. Hernigou P, Medevielle D, Debeyre J, Goutallier D:

Proximal tibial osteotomy for osteoarthritis with varus

deformity: A ten to thirteen-year follow-up study.

J Bone Joint Surg Am 1987;69:332-354.

10. Dietrick T, Bugbee W: Distal femoral osteotomy utiliz-

ing a lateral opening-wedge technique. Tech Knee Surg

2005;4:186-192.

11. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik

MA: Anteromedial tibial tubercle transfer without bone

graft. Am J Sports Med 1990;18:490-497.

12. Buuck D, Fulkerson JP: Anteromedialization of the tib-

ial tubercle: A 4- to 12-year follow-up. Op Tech Sports

Med 2000;8:131-137.

13. Carney JR, Mologne TS, Muldoon M, Cox JS: Long

term evaluation of the Roux-Elmslie-Trillat procedure

for patellar instability: A 26-year follow-up. Am J Sports

Med 2005;33:1220-1223.

14. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP:

Correlation of patellar articular lesions with results

from anteromedial tibial tubercle transfer. Am J Sports

Med 1997;25:533-537.




osteotomies: high tibial, distal femoral, and tibial tubercle · an osteotomy performed on the...

Documents