Inverted V-Shaped High Tibial Osteotomy Decreases the Posterior Tibial Slope More but Shortens the Tibia Less Than Closed-Wedge High Tibial Osteotomy

Editorial Commentary: An Inverted V-Shaped High Tibial Osteotomy Combining a Lateral Closing Wedge and Medial Opening Wedge May Have Advantages

High tibial osteotomy (HTO) is enjoying somewhat of a resurgence as a treatment for medial compartment arthritis with a varus deformity. An inverted V-shaped high tibial osteotomy (IVHTO), which is essentially a combined lateral closing-wedge high tibial osteotomy (CWHTO) and medial opening-wedge high tibial osteotomy (OWHTO), has some theoretical benefits over more conventional techniques. This also has been termed a combined HTO or a hemi-wedge osteotomy. After valgus correction is performed, the osteotomy is fixed with the bone wedge resected from the lateral side being inserted into the medial side. There may be a clinical advantage of an IVHTO over a CWHTO, and retrospective evidence has shown some postoperative radiologic differences between the techniques, but there are some inconsistencies between the studies. Proponents have argued that an IVHTO can correct a severe varus deformity more easily than a CWHTO, and that an IVHTO will not change the posterior tibial slope, the patellar height, or the length of the lower limb because the hinge point is located at the centre of rotation of angulation of the lower limb deformity. However, there may be disadvantages of this technique, including the technical difficulty of performing a precise inverted V-shaped osteotomy and the need to perform a fibular osteotomy, with the associated risk of peroneal nerve injury. Prospective clinical and radiological studies are needed, particularly comparing an IVHTO with an OWHTO, to help decide where the hinge of an HTO should be placed: lateral, medial, or central. My view is that the argument for adopting the IVHTO technique over other techniques is not yet persuasive, particularly as the IVHTO is more technically demanding than an OWHTO, my current preferred technique.