Avoiding and Managing Complications in Osteotomies of the Knee

  • David A. Vasconcellos
  • J. Robert Giffin
  • Annunziato AmendolaEmail author


Osteotomies around the knee are technically demanding surgical procedures requiring careful preoperative planning and precise surgical technique. When procedures do not go as planned, it is important that the surgeon recognizes the problem and/or complication and has an appropriate course of action to rectify the situation. In this chapter, the complications associated with both high tibial osteotomies and distal femoral osteotomies of the knee will be reviewed. Strategies for prevention and management of these complications will be discussed.

High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are both widely accepted treatment options for young, active patients with symptomatic medial or lateral compartment gonarthrosis that is associated with a varus or valgus malaligned lower extremity. Realignment surgery may also performed in conjunction with other surgical procedures aimed at addressing concomitant ligamentous instability, meniscal deficiency, patellar maltracking, and chondral defects. Failure to recognize and/or address an underlying malalignment problem may lead to premature failure of other reconstructive surgical procedures about the knee due to mechanical overload.

In a recent review at the University of Iowa, the overall incidence of major complications following knee osteotomy surgery was 18%. Twenty nine percent of the patients had minor complications. However, it was interesting to note that the complication rate was not statistically different between patients undergoing isolated realignment surgery vs. combined procedures, or with HTO compared with DFO. The most common major complication in this cohort of patients was failure of hardware 5% (Table 7.1).1 Out of 79 cases, there were two cases of intra-articular fracture (2.5%), and failure of proper correction in two cases (2.5%). This complication rate seems to be consistent with other studies published in the literature.


Anterior Cruciate Ligament Total Knee Arthroplasty Anterior Cruciate Ligament Reconstruction High Tibial Osteotomy Tibial Tunnel 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Willey M, Wolf B, Kocaglu B et al (submitted for publication) Complications associated with realignment osteotomy of the knee performed simultaneously with additional reconstructive procedures. University of Iowa Hospitals and Clinics, Iowa City, IAGoogle Scholar
  2. 2.
    Finkelstein J, Gross A, Davis A (1996) Varus osteotomy of the distal part of the femur. A survivorship analysis. J Bone Joint Surg Am 78(9):1348-52Google Scholar
  3. 3.
    Wang J, Hsu C (2005) Distal femoral varus osteotomy for osteoarthritis of the knee. J Bone Joint Surg Am 87(1):127-33CrossRefPubMedGoogle Scholar
  4. 4.
    Hernigou P, Medevielle D, Debeyre J et al (1987) Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69(3):332-54Google Scholar
  5. 5.
    Matthews L, Goldstein S, Malvitz T et al (1988) Proximal tibial osteotomy. Factors that influence the duration of satisfactory function. Clin Orthop Relat Res Apr(229):193-200Google Scholar
  6. 6.
    Marti C, Gautier E, Wachtl S et al (2004) Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 20(4):366-72CrossRefPubMedGoogle Scholar
  7. 7.
    Fowler J, Gie G, Maceachern A (1991) Upper tibial valgus osteotomy using a dynamic external fixator. J Bone Joint Surg Br 73(4):690-1PubMedGoogle Scholar
  8. 8.
    Weale A, Lee A, MacEachern A (2001) High tibial osteotomy using a dynamic axial external fixator. Clin Orthop Relat Res Jan(382):154-67Google Scholar
  9. 9.
    Magyar G, Toksvig-Larsen S, Lindstrand A (1999) Hemicallotasis open-wedge osteotomy for osteoarthritis of the knee. Complications in 308 operations. J Bone Joint Surg Br 81(3):449-51CrossRefPubMedGoogle Scholar
  10. 10.
    Cameron H, Park Y (1997) Total knee replacement after supracondylar femoral osteotomy. Am J Knee Surg 10(2):70-1 discussion 1-2PubMedGoogle Scholar
  11. 11.
    Nelson C, Saleh K, Kassim R et al (2003) Total knee arthroplasty after varus osteotomy of the distal part of the femur. J Bone Joint Surg Am 85(A-6):1062-5PubMedGoogle Scholar
  12. 12.
    Paley D (2002) Principles of Deformity Correction. Springer, BerlinGoogle Scholar
  13. 13.
    Specogna A, Birmingham T, Hunt M et al (2007) Radiographic measures of knee alignment in patients with varus gonarthrosis: effect of weightbearing status and associations with dynamic joint load. Am J Sports Med 35(1):65-70CrossRefPubMedGoogle Scholar
  14. 14.
    Dugdale T, Noyes F, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res Jan(274):248-64Google Scholar
  15. 15.
    Phisitkul P, Wolf B, Amendola A (2006) Role of high tibial and distal femoral osteotomies in the treatment of lateral-posterolateral and medial instabilities of the knee. Sports Med Arthrosc 14(2):96-104CrossRefPubMedGoogle Scholar
  16. 16.
    Hunt M, Fowler P, Birmingham T et al (2006) Foot rotational effects on radiographic measures of lower limb alignment. Can J Surg 49(6):401-6PubMedGoogle Scholar
  17. 17.
    Sabharwal S, Zhao C (2008) Assessment of lower limb alignment: supine fluoroscopy compared with a standing full-length radiograph. J Bone Joint Surg Am 90(1):43-51CrossRefPubMedGoogle Scholar
  18. 18.
    McDermott A, Finklestein J, Farine I et al (1988) Distal femoral varus osteotomy for valgus deformity of the knee. J Bone Joint Surg Am 70(1):110-6PubMedGoogle Scholar
  19. 19.
    Wang J, Hsu C (2006) Distal femoral varus osteotomy for osteoarthritis of the knee. Surgical technique. J Bone Joint Surg Am 88(Suppl 1 Pt 1):100-8CrossRefGoogle Scholar
  20. 20.
    Scuderi G, Windsor R, Insall J (1989) Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am 71(2):245-8PubMedGoogle Scholar
  21. 21.
    Billings A, Scott D, Camargo M et al (2000) High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am 82(1):70-9Google Scholar
  22. 22.
    Westrich G, Peters L, Haas S et al (1998) Patella height after high tibial osteotomy with internal fixation and early motion. Clin Orthop Relat Res Sep(354):169-74Google Scholar
  23. 23.
    Wright J, Heavrin B, Begg M et al (2001) Observations on patellar height following opening wedge proximal tibial osteotomy. Am J Knee Surg 14(3):163-73PubMedGoogle Scholar
  24. 24.
    Noyes F, Mayfield W, Barber-Westin S et al (2006) Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med 34(8):1262-73CrossRefPubMedGoogle Scholar
  25. 25.
    Puddu G, Cipolla M, Cerullo G et al (2007) Osteotomies: the surgical treatment of the valgus knee. Sports Med Arthrosc 15(1):15-22CrossRefPubMedGoogle Scholar
  26. 26.
    Noyes F, Goebel S, West J (2005) Opening wedge tibial osteotomy: the 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med 33(3):378-87CrossRefPubMedGoogle Scholar
  27. 27.
    Amendola A, Panarella L (2005) High tibial osteotomy for the treatment of unicompartmental arthritis of the knee. Orthop Clin North Am 36(4):497-504CrossRefPubMedGoogle Scholar
  28. 28.
    Giffin J, Shannon F (2007) The role of the high tibial osteotomy in the unstable knee. Sports Med Arthrosc 15(1):23-31CrossRefPubMedGoogle Scholar
  29. 29.
    Zaidi S, Cobb A, Bentley G (1995) Danger to the popliteal artery in high tibial osteotomy. J Bone Joint Surg Br 77(3):384-6PubMedGoogle Scholar
  30. 30.
    Smith P, Gelinas J, Kennedy K et al (1999) Popliteal vessels in knee surgery. A magnetic resonance imaging study. Clin Orthop Relat Res Oct(367):158-64Google Scholar
  31. 31.
    McLaren C, Wootton J, Heath P et al (1989) Pes planus after tibial osteotomy. Foot Ankle 9(6):300-3PubMedGoogle Scholar
  32. 32.
    Flierl S, Sabo D, Hornig K et al (1996) Open wedge high tibial osteotomy using fractioned drill osteotomy: a surgical modification that lowers the complication rate. Knee Surg Sports Traumatol Arthrosc 4(3):149-53CrossRefPubMedGoogle Scholar
  33. 33.
    Kirgis A, Albrecht S (1992) Palsy of the deep peroneal nerve after proximal tibial osteotomy. An anatomical study. J Bone Joint Surg Am 74(8):1180-5Google Scholar
  34. 34.
    Coventry M (1987) Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee. J Bone Joint Surg Am 69(1):32-8PubMedGoogle Scholar
  35. 35.
    Clatworthy M, Amendola A (1999) The anterior cruciate ligament and arthritis. Clin Sports Med 18(1):173-98CrossRefPubMedGoogle Scholar
  36. 36.
    Latterman C, Jakob R (1996) High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament deficient knees. Knee Surg Sports Traumatol Arthrosc 4(1):32-8CrossRefGoogle Scholar
  37. 37.
    Noyes F, Barber-Westin S, Hewett T (2000) High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 28(3):282-96PubMedGoogle Scholar
  38. 38.
    Amendola A (2008) What Technical pearls do you have when performing a single-stage ACL reconstruction and high tibial osteotomy? In: Bach BR Jr, Verma NN (eds) Curbside Consultation of the ACL: 49 Clinical Questions. Slack Incorporated, Thorofare, NJ, pp 159-62Google Scholar
  39. 39.
    Aggarwal A, Panarella L, Amendola A (2005) Considerations for osteotomy in the ACL deficient knee. Sports Med Arthrosc Rev 13(2):109-15CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2009

Authors and Affiliations

  • David A. Vasconcellos
    • 1
  • J. Robert Giffin
    • 2
  • Annunziato Amendola
    • 3
    Email author
  1. 1.Department of Orthopedics and RehabilitationUniversity of Iowa Hospitals and ClinicsIowa CityUSA
  2. 2.Department of Orthopedic SurgeryUniversity of Western OntarioLondonCanada
  3. 3.Department of Orthopedics and RehabilitationUniversity of Iowa Hospitals and ClinicsIowa CityUSA

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