Double-level osteotomy

Lateral closing wedge distal femoral osteotomy in the femur and medial opening wedge high tibial osteotomy in the tibia.

• High tibial osteotomy (HTO) for most symptomatic varus patients
• Double-level osteotomy for large or complex corrections
• How is a double-level osteotomy performed?
• Forum discussions

High tibial osteotomy (HTO) for most symptomatic varus patients

Most patients who opt for osteotomy correction of a bow-leg (varus) deformity will be offered a simple high tibial osteotomy.

Adequate digital planning on long leg weight-bearing X-rays will usually guide the surgeon as to the amount of correction that can be safely provided by correction in just the one bone.

Quick links

• High tibial osteotomy

• Distal femoral osteotomy

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Double-level osteotomy for large or complex corrections

If correction is likely to be compromised with a single level osteotomy, then the planning can be revised to calculate what corrections would be needed in both tibia and femur simultaneously to provide adequate safe realignment.

The safety concern in correcting just the one bone in a severe alignment problem is because of the size of the opening wedge that would be needed to correct the alignment.  Such a large wedge may lead to the lateral tibial plateau having an abnormal inclination with the articular cartilage being under a severe sheer force.

Also the femur may tend to sublux and strain the joint capsule, making things difficult for any future total knee replacement.

So in these severe cases of bow legs, the surgeon may opt instead for a double-level osteotomy.

Peer-reviewed papers

• Quote from peer-reviewed paper:

  "....Multiple studies published more than 30 years ago advocated against the [double level osteotomy]....[but surgeons]...lacked the detailed preoperative planning associated with [this procedure] today...."

  Citation: Elbardesy H, McLeod A, Ghaith HS, Hakeem S, Housden P. Outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity. A systematic review. SICOT J. 2022;8:7. doi: 10.1051/sicotj/2022009. Epub 2022 Apr 1. PMID: 35363133; PMCID: PMC8973300.

• Quote from peer-reviewed paper:

  "...The main advantage [of double level osteotomy] is to maintain a horizontal joint line and avoid creating secondary anatomic deformities...."

  Citation: Sautet P, Kley K, Khakha R, Ollivier M. Minimally Invasive Double Level Osteotomy in Severe Knee Varus: Pearls and Pitfalls. Arthrosc Tech. 2022 Jun 21;11(6):e1105-e1109. doi: 10.1016/j.eats.2022.02.023. PMID: 35782831; PMCID: PMC9244850.

End of paper

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How is a double-level osteotomy performed?

On the operating table a closing-wedge distal femoral osteotomy is performed first, under X-ray control, using K-wires to define the intended cuts.

A retractor is used to protect protect the nerves and blood vessels in this area. Once the defined bone wedge has been removed and the bony defect fixed closed with a plate and screws, then the opening-wedge high tibial osteotomy is performed. The wedge is held open with spreaders and a donor bone wedge is pushed in to fill the opening, and again the new position is held in place with a plate and screws.

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Forum discussions

• Femoral Osteotomy and Tibial Osteotomy??

  Patients discuss this difficult decision of an osteotomy both above and below the knee.

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