34 / 324
Early degenerative arthritis of the medial
femorotibial joint in middle-aged, physically
active people is still a difficult problem to
solve for the orthopaedic surgeon. One pos-
sible solution is high tibial osteotomy (HTO)
that overcorrects the long leg axis slightly, lea-
ding to force transmission predominantly in
the lateral part of the femorotibial joint
(Holden DL 1988, Coventry MB 1993). In
many patients knee symptoms after HTO will
be reduced but will recur within lifetime
(Odenbring S 1990). It is this group of people
that the present article deals with, because spe-
cific problems have been described if total
knee arthroplasty (TKA) has to be performed
after previous HTO (Windsor RE 1988, Neyret
P 1992). It is suggested to call a HTO “failed”
if the knee causes enough problems after the
osteotomy that conversion to total knee arthro-
plasty is needed. After reviewing the literature
we suggest a classification for knees that need
TKA after HTO.
LITERATURE REVIEW
Several authors have compared the results
after total knee arthroplasty when it was per-
formed as a primary procedure versus the
results when a high tibial osteotomy was done
first (Table 1). But statements in the literature
are contradictory. Whereas some authors do
not see differences between the outcomes,
others do. In particular there are controversies
about the position of the patella. Whereas
Mont MA (1997) found that patella infera is
more common after HTO/TKA, Nizard RS
(1998) came to the very different solution that
this is not true. It seems to be dependent of the
HTO technique if patella height is altered or
not (Brouwer RW 2005). Controversy exists as
well according to the need for lateral retinacu-
lar release if HTO has been the first operation
and TKA had to be performed later. Whereas
Krackow (1990) found an additional need for
lateral retinacular release and release of other
lateral structures in his TKA patients after
HTO, Meding JB (2000) did not see a need for
that. So literature is difficult to interpret, first
because it is contradictory and second becau-
se all the studies available are on evidence
levels 3 or 4.
CLASSIFICATION
One problem with existing data about TKA
after failed HTO is that the word “failed” can
be interpreted differently. The state of the knee
when the surgeon indicates TKAmight be very
33
TOTAL KNEE ARTHROPLASTYAFTER FAILED
HIGH TIBIAL OSTEOTOMY
D. KOHN