Iatrogenic ischiofemoral impingement due to high tibial osteotomy with overvalgization: a case report

Open wedge high tibial osteotomy is a standard procedure for frontal realignment. It is indicated in varus knee with reduced mechanical medial proximal tibia angle. Overcorrection producing a mechanical medial proximal tibia angle out of the normal range (85-90°) is not recommended because this would lead to unphysiological joint-line orientation. Osteotomies around the knee also influence the adjacent ankle and hip joints. For the hip, it is known that frontal alignment of the leg influences the ischiofemoral space. A decreased ischiofemoral space can lead to painful impingement between the ischial bone and the lesser trochanter.

A 53-year-old German woman presented with severe ischiofemoral impingement symptoms and valgus malalignment of the left leg after open wedge high tibial osteotomy, which was indicated and performed by an orthopedic surgeon with intention to treat medial knee pain due to degenerative arthritis of the medial compartment years after medial meniscectomy. The mechanical medial proximal tibia angle was 100.5°. We performed closed wedge high tibial osteotomy producing a mechanical medial proximal tibia angle of 90.0° and normal joint-line orientation. The hip pain was gone immediately after the surgery, and the patient had no signs of ischiofemoral impingement or hip pain at last follow-up 12 months after closed wedge high tibial osteotomy.

Frontal realignment osteotomy around the knee can create problems at adjacent joints. Overvalgization of the proximal tibia made the patient compensate by hyperadduction of the hip to enable full foot sole contact with the floor. Hyperadduction of the hip decreased the ischiofemoral space, leading to severe impingement. Therefore, meticulous planning of osteotomies is important not to produce unphysiological situations or unwanted negative effects at the level of an adjacent joint.