High Tibial Osteotomy

When knee discomfort becomes intense, interferes with daily activities, or exhibits symptoms like swelling, tenderness, or redness, consulting a physician is crucial.

At Complete Orthopedics, our team of knee specialists focuses on addressing knee pain through both non-surgical and surgical interventions. We evaluate your symptoms, diagnose the issue, and tailor a treatment plan suited to your needs.

Situated in New York City and Long Island, with surgical privileges in six hospitals, we offer advanced knee surgery and orthopedic care. To schedule an appointment with one of our orthopedic surgeons, you can conveniently book online or contact us by phone.

Explore the common causes of knee discomfort, available treatments, and circumstances where surgical intervention proves beneficial.

Overview

High Tibial Osteotomy (HTO) is a surgical procedure aimed at treating knee osteoarthritis by realigning the knee joint and redistributing weight-bearing load. It’s particularly beneficial for younger, active individuals with localized knee arthritis who are not yet ready for a total knee replacement (TKR). Let’s delve into the symptoms, diagnosis, procedure, treatment, and recovery associated with HTO.

A joint is formed when two bones meet. Knee is a large weight bearing hinge joint formed by the thigh bone, kneecap and shin bone. The various structures forming the joint are:

• Cartilage: Articular cartilage is a glistening white smooth tissue covering the ends of bones where it articulates with other bone and form a joint. It is toughened yet flexible enough to cushion the gliding of the bones forming a joint thereby reducing friction and acting as a shock absorber.
• Meniscus: They are pads of tissue between the joint dampening the impact. Both the meniscus and cartilage have a very limited blood supply therefore limiting any healing if subjected to damage.
• Ligament:  These are tough tissues connecting one bone to another. Ligaments prevent slipping one bone over the other, maintaining stability.
• Synovium: A thin tissue lines the inside of the joint secreting a watery thin, sticky, clear lubrication called synovial fluid. Just like machine oil it helps in smooth movement of the joint.
• Bones and Muscles: End of the thigh bone(femur) and upper part of the shin bone(tibia) with muscles attached to them help to bend or straighten the knee joint. A proper alignment between both is necessary to perform the movements.

 

Alignment of the Knee

In a normal individual the thigh bone and shin bone are aligned so the weight is transmitted equally among the inner and the outer side of the joint. Any malalignment or mismatch leads to excessive weight being placed on one side of the knee. With repetitive loading parts of the cartilage and meniscus get torn on the side placed under undue force. Bow legs or knock knees are examples of malalignment.

Osteoarthritis 

With growing age the tissues forming the knee joint, including the bones, articular cartilage, tendons, ligaments, meniscus and muscles degenerate. The changes culminate into tears of the meniscus and cartilage leading to loss of smooth gliding of the joint. The joint(especially the synovium) becomes inflamed.  

Risk factors and causes: Degenerative OA also called wear and tear arthritis, it is common in middle aged to elderly individuals. Age and obesity are common risk factors but a malaligned knee such as knock knees or bow legs can lead to early osteoarthritis. Injuries to the structures forming the knee joint lead to early OA.

 

Symptoms:

• Grinding/popping/clicking sensation in the knee.
• Inability to fully bend or straighten the knee.
• Knee Pain, especially with activity.
• Stiffness after periods of inactivity
• Swelling around the joint.

 

Diagnosis 

Osteoarthritis (OA) diagnosis typically involves a combination of medical history, physical examination, imaging tests, and sometimes laboratory tests. Here’s an overview of the process:

Medical History: The doctor will begin by asking about your symptoms, including the location and severity of pain, stiffness, swelling, and any limitations in movement. They’ll also inquire about your medical history, including any previous injuries or conditions that may contribute to joint problems.

Physical Examination: During the physical exam, the doctor will inspect and palpate the affected joints for tenderness, swelling, warmth, and range of motion. They may also assess your gait and posture to look for any signs of joint dysfunction.

Imaging Tests: Imaging tests can help confirm the diagnosis and assess the extent of joint damage. Common imaging modalities include:

X-rays: X-rays can reveal joint damage, such as loss of cartilage, bone spurs, and joint deformities characteristic of OA.

Magnetic Resonance Imaging (MRI): MRI scans provide detailed images of soft tissues like cartilage, ligaments, and tendons. They can help detect early signs of OA and assess the severity of joint damage.

Computed Tomography (CT) Scan: CT scans may be used to provide more detailed images of bone structures and detect bone abnormalities in cases where standard X-rays are inconclusive.

Laboratory Tests: While there’s no specific blood test for diagnosing OA, blood tests may be ordered to rule out other conditions that can cause joint pain and inflammation, such as rheumatoid arthritis. Blood tests can also help assess overall health and check for markers of inflammation.

Joint Aspiration (Arthrocentesis): In some cases, joint aspiration may be performed to analyze the synovial fluid (fluid within the joint) for signs of inflammation, infection, or crystals (as in gout).

Diagnostic Criteria: The American College of Rheumatology (ACR) provides diagnostic criteria for OA, which include a combination of symptoms, physical examination findings, and imaging results. However, it’s important to note that these criteria are primarily used for research purposes and may not always align with clinical practice.

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Procedure 

Osteotomy in Osteoarthritis

It is a surgical procedure literally meaning cutting of bone. When performed near the upper end of the shin bone either on outer side or inner side is known as high tibial(shin bone) osteotomy.

Goals & Principles: Two compartments are mainly affected in OA of the knee joint, the outer or the inner compartment. In a malaligned knee the body weight force is transferred mainly through one compartment leading to excessive wear and tear. So the goal of HTO is to reshape and relieve the pressure of the damaged side.

Ideal candidates:

• Patients younger than 60 years of age.
• Knee joint movements are not restricted i.e can fully bend or straighten the knee.
• One compartment involvement either the inner or outer side.
• Normal knee ligaments which balance the knee.
• Patient who are not obese or having inflammatory diseases like rheumatoid arthritis.

Types and procedure:

• Lateral Closing Wedge: A predetermined wedge of bone is removed from the upper part of the shin bone to correct the alignment. Different methods such as casts or plate and screws may be used to fix the cut ends together.
• Medial Opening Wedge: Here a cut is made on the inner side of the upper shin bone. The cut is opened up and usually filled with a bone graft. Again it may be fixed with a plate and screws.

Post Surgery: Weight bearing is delayed and patient walks on crutches as long as 12 weeks with regular physical therapy.

Advantages: The anatomy of the knee is maintained. With corrected alignment the degenerative process of osteoarthritis halts or slows down. Younger age group of patients with limited single compartment involvement are to benefit more.

Disadvantages: Various complications may arise post surgery

• Full recovery is usually prolonged to many weeks or months.
• Pain relief at times is not predictable and many patients complain of residual pain.
• Postoperative complications such as infection and stiffness may occur.
• A potential damage to the nerves which make the foot work or the blood vessels supplying blood to the leg.
• Majority of patients opting for HTO end up having a total knee replacement in the coming years. Although the surgical technique for Total Knee Replacement becomes much more challenging after HTO.
• HTO requires cutting of the bone. The cutting site sometimes fail to heal and a second surgery is then needed to heal it. Moreover, when a bone graft from a person’s own body is used to fill in the gap of cutting, there could be potential complications of bone graft site.
• There could be problems of leg lengthening or leg shortening after the surgery.
• In case there is evidence of kneecap arthritis(patellofemoral arthritis) HTO cannot be performed in such cases.

 

Total Knee replacement 

Knee replacement surgeries have revolutionized the treatment of osteoarthritis. The joint ends are replaced or resurfaced with metal and plastic parts. The prosthetic parts recreate the joint movements.

The tibial post on the polyethylene insert allows femoral rollback during bending of the knee. The post along with the femoral cam reduplicates the function of the posterior cruciate ligament.

The prosthetic parts include metallic (cobalt chromium) femoral and tibial components and a highly cross linked polyethylene bearing insert. The femoral component fits in the lower end of the thigh bone on the cuts made during surgery. The tibial components sits on top the upper end of the shin bone. Both the metal components are fixed to the respective bones using bone cement.

Excellent stability is achieved as the parts reduplicate the function of ligaments and meniscus. Alignment of the joint line is created as it was before the disease process.

Advantages

• Can be performed even in individuals more than 60 years of age.
• Early rehabilitation as most patients start to bear weight the very next day
• Excellent survival of the implant even in second decade of surgery.
• Pain relief is complete and the patient satisfaction rates are very high.
• Most patients carry on their daily activities without feeling any difference from the native knee.
• Revisions are being carried out without any complications.

A primary total knee arthroplasty is emerging as a better option than high tibial osteotomy even in stages of early Osteoarthritis. The success rate of surgery and patient satisfaction rates are unparalleled.

 

Recovery 

After the procedure, you’ll likely spend a few days in the hospital for observation and pain management. You’ll be given pain medications to help manage any discomfort, as well as instructions on how to care for your incision and perform exercises to promote healing.

Most people are able to bear weight on their leg shortly after surgery, although you may need to use crutches or a walker for support. Physical therapy will be an important part of your recovery process, helping you regain strength, flexibility, and range of motion in your knee joint.

It’s important to follow your doctor’s instructions carefully during the recovery period to ensure the best possible outcome. This may include attending follow-up appointments, taking medications as prescribed, and participating in physical therapy as recommended.