Total Knee Arthroplasty After High Tibial Osteotomy

Educational Objectives As a result of reading this article, physicians should be able to: 1. Delineate the indications for high tibial osteotomy (HTO) and report on its functional results in relation to the conversion to total knee arthroplasty (TKA). 2. Outline the principles and anatomic implications of opening- and closing-wedge HTO. 3. Describe how to undertake soft tissue balance in the knees of patients who previously underwent HTO. 4. Analyze tibial malunions after HTO and their implications for further HTO and TKA. High tibial osteotomy may be indicated in the treatment of varus knee in young, active patients. The preservation of proprioception and native joint and biomechanics is crucial for functional recovery in these patients. However, deterioration of initial good results can occur with time. In such cases, revision with total knee arthroplasty is indicated. However, this is a more surgically demanding option compared with a primary prosthesis. Accurate preoperative planning is mandatory to decrease the risk of intraoperative complications. A precise surgical technique, which is crucial to improving functional outcomes, includes hardware removal, joint exposition, tibial deformities due to previous osteotomy, and managing soft tissue mismatches. Possible technical challenges and surgical solutions exist for each of these aspects. However, several studies report lower functional results compared with primary implants. Thus, patients should be informed before high tibial osteotomy about its failure rate, the difficult surgical aspects of an additional prosthesis, and less satisfactory clinical results. [ Orthopedics. 2014; 37(3):191–198.]