J Korean Orthop Assoc.  2018 Aug;53(4):283-292. 10.4055/jkoa.2018.53.4.283.

Osteotomy around the Knee: Indication and Preoperative Planning

• Lim SW
• Ryu SM
• Shon OJ

• KMID: 2419463
• DOI: http://doi.org/10.4055/jkoa.2018.53.4.283

Abstract

Osteotomy around the knee is a widely considered surgical procedure for osteoarthritis with lower extremity malalignment. High tibial osteotomy (HTO) is performed for varus deformity, while distal femur osteotomy (DFO) is performed for valgus deformity. However, if the correction is insufficient, double osteotomy can also be considered. This report included the basic principles and current concepts of patient selection and preoperative planning in osteotomy around the knee.

Keyword

knee joint; osteoarthritis; osteotomy

MeSH Terms

Congenital Abnormalities
Femur
Knee Joint
Knee*
Lower Extremity
Osteoarthritis
Osteotomy*
Patient Selection

Figure

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  Figure 1 (A) Normal axis alignment. (B) Varus axis alignment. (C) Valgus axis alignment.

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  Figure 2 Normal physiologic axes and angles of the lower extremities: The physiologic axes and angles have an abnormal value in the malalignment of the lower extremities. CCDA, centrum column diaphyseal angle; aMPFA, anatomical medial proximal femoral angle; mLPFA, mechanical lateral proximal femoral angle; aLDFA, anatomical lateral distal femoral angle; mLDFA, mechanical lateral distal femoral angle; JLCA, joint line congruency angle; mMPTA, mechanical medial proximal tibial angle; mLDTA, mechanical lateral distal tibial angle; aPDFA, anatomical posterior distal femoral angle; aPPTA, anatomical posterior proximal tibial angle; aADTA, anatomical anterior distal tibial angle.

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  Figure 3 Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension for planning the Miniaci method. Line A represents the planned weight bearing line for the postoperative correction extending from the center of the hip to about 60% to 70% of the tibial plateau width past the ankle. Line B connects the osteotomy hinge point with the center of the ankle. Line C connects the osteotomy hinge point with the arc intersection of Line A. The angle formed by Lines B and C is the planned correction angle.

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  Figure 4 Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension for planning the Dugdale method. Line A is drawn from the center of the femoral head to 62.5% of the tibial width. Line B is drawn from the center of the tibiotalar joint to the 62.5% coordinate. The angle formed by these two lines is the correction angle.

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  Figure 5 Weight bearing scanography. A template was cut through the osteotomy site, and the tibia was rotated until the weight-bearing line passed through the 62% to 65% coordinate.

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  Figure 6 Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension to plan the medial close-wedge distal femoral osteotomy. (A) The present mechanical axis is drawn from A, which is the center of the femoral head, to B, which is the center of the ankle joint. Line B–C is of equal length as Line A–B and passes the knee, just medial to the medial eminence, representing the desired postoperative mechanical axis. (B) The hinge point of the osteotomy D is marked just proximal to the upper border of the lateral condyle and 0.5–1.0 cm within the lateral cortex. The angle of correction (α) is defined by Line A–D between the present femoral head center and the hinge point and Line C–D connecting the new femoral head center position and the hinge point. (C) Correction angle α is projected at the distal femur using two oblique, down-sloping lines of equal length converging at the hinge point. The distance measured between those two lines at the level of the medial cortex represents the osteotomy wedge base length, which is to be removed during surgery.

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  Figure 7 Double level osteotomy. A template was cut through each osteotomy site, and the femur and tibia were rotated until the weight-bearing line passed through the 62% to 65% coordinate (Courtesy of Professor Dr. Seung-Beom Han, Department of Orthopaedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea)

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