High Tibial Osteotomy

A high tibial osteotomy (HTO) is surgery that realigns the top of the shin bone to treat knee arthritis. By changing the angle of the bone, it shifts your weight off the worn side of the knee and onto the healthier side.

It is most often offered to younger, active people with arthritis on just one side of the knee who are not ready for a total knee replacement.

About knee arthritis and malalignment

The knee is a hinge joint formed by the thigh bone (femur), shin bone (tibia), and kneecap. Smooth cartilage caps the bone ends, the meniscus acts as a shock absorber, ligaments keep the joint stable, a lining called the synovium makes lubricating fluid, and muscles bend and straighten the knee. When the bones line up correctly, your weight is shared evenly across the joint.

In osteoarthritis, these tissues gradually wear down, the cartilage and meniscus tear, and the joint becomes inflamed and stiff. If the leg is bowed (bowlegs) or knock-kneed, more of your weight passes through one side of the knee, which wears that side out faster. Age, extra weight, and past injuries all speed this up. Because cartilage and meniscus have little blood supply, they do not heal well once damaged.

Symptoms

Common signs of knee arthritis include:

• A grinding, popping, or clicking feeling in the knee.
• Trouble fully bending or straightening the knee.
• Knee pain, especially with activity.
• Stiffness after sitting or resting.
• Swelling around the joint.

How it is diagnosed

Diagnosis starts with your history and a physical exam, where the doctor checks for tenderness, swelling, warmth, range of motion, and how you walk.

X-rays show cartilage loss, bone spurs, and the alignment of the leg. An MRI or CT scan may be added if more detail is needed.

Blood tests can help rule out other causes such as rheumatoid arthritis, and in some cases fluid is drawn from the joint to check for infection or gout.

When to consider high tibial osteotomy

Non-surgical care comes first: anti-inflammatory medicine, physical therapy, weight management, bracing, and injections such as cortisone or hyaluronic acid. When arthritis is advanced, these may not be enough.

An HTO is considered when the wear is limited to one side of the knee, the knee still bends and straightens well, the ligaments are stable, and the person is generally younger than 60 and not significantly overweight.

It is not suitable for people with inflammatory arthritis like rheumatoid arthritis, or with arthritis behind the kneecap (patellofemoral arthritis).

Types of high tibial osteotomy

There are two main ways to realign the bone, and both are held in place while it heals, usually with a plate and screws (sometimes a cast):

• Lateral closing wedge: a measured wedge of bone is removed from the outer side of the upper shin bone to correct the angle.
• Medial opening wedge: a cut is made on the inner side of the upper shin bone, opened up to the right angle, and the gap is usually filled with a bone graft.

The high tibial osteotomy procedure

Osteotomy literally means cutting bone. In an HTO, the surgeon cuts and reshapes the upper shin bone near the knee to change its angle. In an arthritic knee, most of the wear is in one compartment, the inner or outer side, because a malaligned leg pushes the load through that side.

By realigning the bone, the surgery moves weight off the worn compartment and onto the healthier one, which relieves pressure and can slow the arthritis.

High tibial osteotomy recovery

Recovery takes patience because the cut bone needs time to heal. Putting full weight on the leg is delayed, and you may use crutches for up to 12 weeks, with regular physical therapy to rebuild movement and strength.

Full recovery can take several weeks to months. Most people get good relief, though some still have residual pain afterward.

Risks of high tibial osteotomy

As with any bone surgery, there are risks to weigh:

• Infection or knee stiffness.
• Injury to the nerves that work the foot or the blood vessels supplying the leg.
• The bone failing to heal (non-union), which can need a second surgery, and possible problems at the bone-graft site.
• A small change in leg length, longer or shorter.
• Pain relief that is not always predictable.
• The chance that you still need a total knee replacement later, and that the replacement is more technically difficult after an HTO.

Long-term outlook

By correcting the alignment, an HTO can slow or halt the arthritis on the overloaded side and buy your natural knee more milage and pain free years.

It is not always a permanent answer: many people eventually go on to a total knee replacement, and that operation is more challenging for the surgeon once an osteotomy has been done.

High tibial osteotomy vs total knee replacement

These two operations solve the problem in different ways. An HTO keeps your own knee and realigns the bone, which makes it appealing for younger, active people with arthritis in just one compartment. The trade-offs are a longer recovery, sometimes unpredictable pain relief, and the likelihood of needing a replacement down the road.

A total knee replacement resurfaces the joint with metal and plastic parts. It can be done at any age, allows early rehab (most people bear weight the next day), has strong long-term results, and high satisfaction.

Many surgeons now favor a primary knee replacement over an osteotomy, even in earlier arthritis, when it is the better fit for the patient. The right choice depends on your age, how much of the knee is affected, your alignment, and your goals, and it is a decision to make with your surgeon. You can read more on our total knee replacement page.

Insurance & Cost

High Tibial Osteotomy at Complete Orthopedics is covered by Medicare and most major insurance carriers (Aetna, Anthem BCBS, Cigna, Empire BCBS, UnitedHealthcare), as well as most workers’ compensation and no-fault insurance plans. Your out-of-pocket cost depends on your specific plan, deductible, and the medical necessity criteria that apply to your case.

Call our billing team at (631) 981-2663 before scheduling to verify your coverage and discuss expected out-of-pocket costs. For the full list of carriers we accept and patient billing protections, see our Insurance Information page.