A double-level osteotomy involves a high tibial osteotomy and a distal femoral osteotomy in the same procedure in patients who have marked alignment problems.
Page updated January 2024 by Dr Sheila Strover (Clinical Editor)
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 one bone, and so if safety is likely to be compromised, then planning can point to corrections in both upper and lower limb simultaneously to provide adequate safe realignment.
Double-level osteotomy for large or complex corrections
When the bowing is severe, a simple high tibial osteotomy may not be suitable 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.
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.
"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.
"The main advantage 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.