Simultaneous Correction of Varus Deformity and Posterior Tibial Slope by Modified Hybrid Closed-Wedge High Tibial Osteotomy

Editorial Commentary: When Performing Proximal Tibial Slope Decreasing Osteotomies in Patients Undergoing Primary or Revision Anterior Cruciate Ligament Reconstruction, Surgeons Must Be Cautious to Avoid Overcorrection of the Posterior Tibial Slope: Teeter-Totter Tibial Translation

An excessive or large proximal tibial posterior slope is directly correlated with the risk of knee joint injury. This includes anterior cruciate ligament (ACL) graft reconstruction failure and meniscal tear. Correction of the excessive posterior slope seems prudent in patients whose prior surgical procedures have not succeeded in restoring normal knee stability including anterior tibial translation. Such an approach has been presented through techniques involving tibial osteotomy. By decreasing the tibial slope, there will be a decrease in the rate of ACL graft failure. When one is performing a corrective osteotomy, the correction should be neither too little nor too much. Too little a correction will not sufficiently alter the mechanics, resulting in a limited effect. Too great a change will produce negative static anterior tibial translation. Moreover, recent research has shown that after slope-correcting osteotomy, achieving the target slope occurs in fewer than 50% of cases. Surgeons must be cautious to avoid overcorrection of the posterior tibial slope.

Derotational Hybrid Closed-Wedge High Tibial Osteotomy for Knee Osteoarthritis With Patellar Subluxation Caused by Tibial Torsional Deformity

Patellar subluxation and recurrent dislocation are commonly treated with medial patellofemoral ligament reconstruction, and patients with predisposing factors for these problems often require additional bony realignment procedures. However, these procedures mainly address problems in the axial plane, and patients with medial-compartmental knee osteoarthritis may require further realignment in the coronal plane. In this Technical Note article, we introduce our technique for derotational hybrid closed-wedge high tibial osteotomy. Using this technique, simultaneous 3-dimensional realignment in the axial, coronal, and sagittal planes can be achieved in patients with medial compartmental knee osteoarthritis and patellar subluxation caused by a tibial torsional deformity. The indications for the technique and the preoperative planning assessments involving a static torsional deformity analysis on computed tomography images and a dynamic gait analysis by our walking-on-paper method are presented. This is followed by a detailed description of the surgical procedure, together with consideration of the pearls and pitfalls of the procedure. A video of the surgery performed in a representative case with medial knee osteoarthritis and patellar subluxation in the right knee owing to an outward tibial torsion deformity is also provided.