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Osteotomy for Knee Pain – A Solution for Active Patients
Patients aged 40-50 often visit Rehasport Clinic, complaining of knee joint pain. When the condition is limited to a single compartment of the knee and coexists with a misalignment of the joint's mechanical axis, a high tibial osteotomy (HTO) may be the appropriate solution. This article focuses on the most common indication: medial compartment osteoarthritis associated with increased varus deformity of the knee.
Osteotomy – Back to Running in Three Months
For many physically active individuals, it may come as a surprise that they previously had no significant problems with this part of their limb, yet they now suffer from pain that prevents normal activity. When conservative treatment—such as intensive rehabilitation and intra-articular injections—fails, a surgical intervention may be necessary.
What is Osteotomy?
Osteotomy literally means "cutting of the bone." It is a controlled incision or cutting of the bone followed by its alignment into the correct position through precise repositioning of fragments, fixation, and controlled healing. To maintain the proper alignment, the fragments are stabilized using a fixation plate, similar to the method used in fracture treatment. The result is the restoration of the proper mechanical axis of the knee joint, thereby offloading the affected compartment. An additional effect is the visible straightening of the limb.
A high tibial osteotomy is a solution for active patients who want to avoid or significantly delay the need for a knee joint replacement. It is targeted at individuals suffering from degenerative and overload-related changes, cartilage and meniscal damage (often after previous meniscectomy), but only within one compartment of the joint.
Types of Osteotomy
Osteotomy is most commonly used for correcting deformities of the lower limb: the tibia (high tibial osteotomy), the femur (distal femoral osteotomy), and the foot bones (including bunion correction). This method is also used to lengthen or shorten limbs. Osteotomy can be performed on any long bone in the upper or lower limbs. Types of osteotomies include:
- Axis correction osteotomies,
- Rotational osteotomies,
- Wedge osteotomies.
The most frequently performed procedures are aimed at correcting deformities related to the misalignment of the bones of the lower limbs.
Osteotomy of the Knee – Excessive Stress on the Joint
Detailed diagnostic imaging, including X-rays and magnetic resonance imaging (MRI), can identify the cause of the symptoms. The patient often suffers from degenerative and overload-related changes in the knee joint. The medial meniscus and articular cartilage are damaged. Studies indicate that these joint components have been subjected to excessive stress and continuous degradation over time due to a misaligned joint axis caused by progressive joint disease. This misalignment results in uneven distribution of forces across the knee, disproportionately affecting, for instance, the medial compartment.
Osteotomy – A Better Solution for Many Patients
It is now well understood that advanced knee osteoarthritis will eventually require total knee replacement. However, knee replacement is a major surgery with greater risks and a potential reduction in future physical activity levels. For patients whose disease does not yet involve the entire joint, an alternative surgical solution may delay or replace the need for joint replacement while maintaining an active lifestyle.
The treatment plan includes arthroscopy to examine the knee joint and correct the knee axis to distribute forces appropriately on the cartilage, particularly offloading damaged joint components. This procedure, called high tibial osteotomy, involves correcting valgus or varus deformity. During arthroscopy, damaged joint components (such as the meniscus or cartilage) are repaired.
Causes of Knee Joint Degradation
Knee replacement surgery for joint degradation is considered a last-resort procedure. When planning this surgery, it is crucial first to address the causes of joint damage. These causes are often related to improper lower limb alignment, such as varus or valgus deformities.
These deformities cause the knee joint to function suboptimally, leading to uneven distribution of forces, overload, and accelerated wear of joint structures. Over time, this results in joint tissue damage, gradual degeneration, and ultimately complete destruction.
Replacing the joint with a prosthesis will not provide the desired results if the underlying causes are not addressed. Persistent uneven force distribution will overload the prosthesis, leading to further complications. This may necessitate revision surgery to replace the prosthesis. To avoid this scenario, it is essential to correct the deformities in the lower limb by performing a knee osteotomy.
Osteotomy – Bone Correction
High tibial osteotomy is performed through a small incision below the knee on the medial side. This allows for safe exposure of the tibia. After precisely calculating the correction angle (based on X-rays), specialized tools are used to partially cut the tibia and make the necessary adjustment. Once the proper alignment is achieved, the bone is fixed with a stabilizing plate (titanium or composite). The entire procedure is monitored intraoperatively with X-ray imaging.
Type of Anesthesia Used During Osteotomy
As with most major orthopedic procedures, the patient consults with an anesthesiologist before surgery. The type of anesthesia is determined individually by the anesthesiologist in consultation with the operating surgeon. High tibial and distal femoral osteotomies are typically performed under spinal anesthesia (which numbs the body from the waist down) or, less commonly, general anesthesia (where the patient is put into a state of controlled unconsciousness).
Contraindications for Knee Osteotomy
Unfortunately, not everyone is eligible for knee osteotomy. Contraindications include:
- Obesity,
- Nicotine addiction,
- Tricompartmental degenerative changes in the knee joint,
- Diabetes.
Candidates must meet several criteria, including maintaining an adequate level of physical activity before surgery. Lack of patient cooperation can lead to complications during rehabilitation.
Rehabilitation After Knee Osteotomy
The rehabilitation and recovery period after a high tibial osteotomy varies individually and often depends on the patient’s overall fitness. For the first 6-8 weeks post-surgery, the operated leg must be offloaded using crutches, and sometimes a knee brace is also recommended. During this time, follow-up visits with X-rays are essential to monitor bone healing.
Rehabilitation can begin as early as the day after surgery. The initial phase focuses on restoring basic movement functions of the operated limb—such as walking with crutches under a physiotherapist's guidance and performing mobility exercises. In later stages, an experienced physiotherapist prepares exercise routines to restore full range of motion and rebuild the muscle strength needed to stabilize the joint. These two aspects are crucial for proper joint healing. After six weeks, crutches can be discarded, and within a few months, the patient can return to full physical activity.
Results of Osteotomy
A correctly performed high tibial osteotomy primarily reduces or eliminates knee joint pain. An additional benefit is a "straighter" limb due to the corrected axis, leading to improved joint mechanics.
Related Articles
Explore other potential causes of knee pain in different parts of the joint.
References:
- OrthoInfo - Osteotomy of the Knee - Contributed and/or Updated by Neil P. Sheth, MD, FAAOS; Paul A. Manner, MD; Jared R.H. Foran, MD - 2022
- National Library of Medicine - Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis - Haining Peng, MS, Aichun Ou, BS, Xiaohong Huang, PhD, Chen Wang, MS, Lei Wang, MS, Tengbo Yu, PhD, Yingze Zhang, PhD, Yi Zhang, PhD - 2021
- Ortho Bullets - High Tibial Osteotomy - David Abbasi - 2023
- High Tibial Osteotomy - Wright, John M. MD; Crockett, Heber C. MD; Slawski, Daniel P. MD; Madsen, Mike W. MD; Windsor, Russell E. MD - Journal of the American Academy of Orthopaedic Surgeons 13(4):p 279-289, July 2005.
