Complications with OW HTO: 3 Common Mistakes & How I Avoid Them - - PowerPoint PPT Presentation

Complications with OW HTO: 3 Common Mistakes & How I Avoid Them

Anil Ranawat, MD Hospital for Special Surgery New York, NY

HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. ANIL RANAWAT, MD Disclosure: I DO have a financial relationship with Smith and Nephew, Stryker Mako, Conformis, Elesevier and Arthrex

Renaissance

HTO is experiencing a rebirth akin to the cultural movement beginning in Italy in the late Middle Age encompassing a revival of classical principles and modern ideas

• Philipp Lobenhoffer,

Chairman Knee Expert AO Group

Why I Love OW Osteotomy

• Preserves cruciates
• Concomitant – collateral or

cartilage procedures

• Aid ACL and PCL def.
• No activity restriction
• Can delay need for

arthroplasty

• Arthroplasty is Not always

best option!

What is bad about Osteotomy

• Limited Indications
• Under/Over correction
• Intra-articular Fractures
• Patella Baja/anterior knee pain
• Nonunion, fixation failure
• Immobilization
• Conversion to TKA

Complications with HTO: 3 Common Mistakes & How I Avoid Them 5

Outline: 3 Common Mistakes

• 1. Indications / Pre-operating

Planning

• 2. Surgical Technique

– Correction/Slope – Nonunion/Delayed Union

• 3. Post-operative Care

Complications with HTO: 3 Common Mistakes & How I Avoid Them 6

• 1. Indications / Pre-operative Planning
• Biggest mistake : amount and

location of VARUS

• Assess amount of varus
• >10º not all on tibia
• Location of varus
• > 20% of varus on femur
• Ideal Patient for isolated OW
• <87º of MPT Angle (CORA) and

under <10º deformity

Complications with HTO: 3 Common Mistakes & How I Avoid Them 7

Too much deformity (>10º not all on tibia)

Goal of all Osteotomy = Joint line should be parallel to the floor

Complications with HTO: 3 Common Mistakes & How I Avoid Them 8

Ideal deformity (<10º - all on tibia)

Goal of all Osteotomy = Joint line should be parallel to the floor

Complications with HTO: 3 Common Mistakes & How I Avoid Them 9

• 2. Surgical technique

Complications with HTO: 3 Common Mistakes & How I Avoid Them 10

• Biggest mistake #1:

BAD exposure AND coronal and sagittal correction is based on wedge height in 3 planes

• Slope neutral 1:2 ratio (ant-post)
• Slope reducing 1:3 ratio
• If wedge gap opens too quick –

check for fracture into joint or lateral hinge

• 2. Correct Exposure

Complications with HTO: 3 Common Mistakes & How I Avoid Them 11

• 2. Graduated Osteotomes

Complications with HTO: 3 Common Mistakes & How I Avoid Them 12

• 2. Understand your gap

Complications with HTO: 3 Common Mistakes & How I Avoid Them 13

• 2. If Pin placement is off?

Complications with HTO: 3 Common Mistakes & How I Avoid Them 14

Lateral hinge violation

• No subluxation, but

increased BMI Intra-articular Fracture

• Minimal step-off, ORIF,

then recut or accept

Too Flat and Distal Too Oblique and Proximal

• 2. Surgical technique

Complications with HTO: 3 Common Mistakes & How I Avoid Them 15

• Biggest mistake #2: delayed /

nonunion

• Use rigid fixation
• AO technique
• Over – correct, then compress

= tension band technique

• Use allograft/BMAC
• Progressive Weight-bearing

• 2. Over-correct, then Compression plating

Goal of all OW Osteotomy = COMPRESSION AT OSTEOTOMY SITE

Complications with HTO: 3 Common Mistakes & How I Avoid Them 16

• 3. Post-operative Care
• Biggest mistake :

inappropriate WB and PT

• Early WBAT has shown

increased bone healing

• CPM all patients minimize

baja = better func.

• Medication: Ca/Vit D for all, ?

Bone stimulator, DVT prophylaxis

Complications with HTO: 3 Common Mistakes & How I Avoid Them 17

• 4. Conclusion

3 common mistakes with OW HTO

• 1. Inadequate templating
• Look for CORA
• 2. Improper Surgical technique
• Understand EXPSOURE, gap

height, pin placement and compression technique

• 3. Bad Post-operative Protocol
• <Aggressive WB, CPM and meds

Complications with HTO: 3 Common Mistakes & How I Avoid Them 18

Why I love OW HTO?

• Biomechanically sound
• Maintains high function
• Versatile / Durable
• Bone Preserving
• Reproducible technique with

less complications with improved fixation Should be a tool in armentarium

• f all knee surgeons!

Thank You!