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Surgical anatomy of medial open-wedge high tibial osteotomy: crucial steps and pitfalls

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To give an overview of the basic knowledge of the functional surgical anatomy of the proximal lower leg and the popliteal region relevant to medial high tibial osteotomy (HTO) as key anatomical structures in spatial relation to the popliteal region and the proximal tibiofibular joint are usually not directly visible and thus escape a direct inspection.

Methods

The surgical anatomy of the human proximal lower leg and its relevance for HTO are illustrated with a special emphasis on the individual steps of the operation involving creation of the osteotomy planes and plate fixation.

Results

The posteriorly located popliteal neurovascular bundle, but also lateral structures such as the peroneal nerve, the head of the fibula and the lateral collateral ligament must be protected from the instruments used for osteotomy. Neither positioning the knee joint in flexion, nor the posterior thin muscle layer of the popliteal muscle offers adequate protection of the popliteal neurovascular bundle when performing the osteotomy. Tactile feedback through a loss-of-resistance when the opposite cortex is perforated is only possible when sawing and drilling is performed in a pounding fashion. Kirschner wires with a proximal thread, therefore, always need to be introduced under fluoroscopic control. Due to anatomy of the tibial head, the tibial slope may increase inadvertently.

Conclusions

Enhanced surgical knowledge of anatomical structures that are at a potential risk during the different steps of osteotomy or plate fixation will help to avoid possible injuries.

Level of evidence

Expert opinion, Level V.

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Authors and Affiliations

  1. Center of Experimental Orthopaedics and Osteoarthritis Research, University of Saarland, Kirrberger Strasse 100, Building 37, 66421, Homburg/Saar, Germany

    Henning Madry & Lars Goebel

  2. Department of Orthopaedics Surgery, Saarland University Medical Center, Kirrberger Strasse 100, Building 37-38, 66421, Homburg/Saar, Germany

    Henning Madry & Lars Goebel

  3. Cartilage Net of the Greater Region, 66421, Homburg/Saar, Germany

    Henning Madry, Lars Goebel, Romain Seil & Dietrich Pape

  4. Sports Medicine Research Laboratory, Public Research Centre for Health, Luxembourg, Medical Center Foundation Norbert Metz, 76 Rue d’Eich, 1460, Luxembourg, Luxembourg

    Alexander Hoffmann, Klaus Dück, Torsten Gerich, Romain Seil & Dietrich Pape

  5. Institute of Anatomy and Cell Biology, Saarland University Medical School, Kirrberger Strasse 100, Building 61, 66421, Homburg, Germany

    Thomas Tschernig

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  1. Henning Madry
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Correspondence to Henning Madry.

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The authors declare no competing interests. In particular, the authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to the subject of this article.

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Madry, H., Goebel, L., Hoffmann, A. et al. Surgical anatomy of medial open-wedge high tibial osteotomy: crucial steps and pitfalls. Knee Surg Sports Traumatol Arthrosc 25, 3661–3669 (2017). https://doi.org/10.1007/s00167-016-4181-3

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