High Tibial Osteotomy

Introduction

A high tibial osteotomy  (HTO) is a surgical procedure that involves cutting the tibia bone to realign it. 

This procedure aims to correct those deformities of the lower limbs, which arise around the knee and to restore or improve the lower limb’s biomechanics.   One of the common applications of osteotomies is to alleviate pain associated with partial joint degeneration and pain.

The main objective is to shift the patient’s body weight away from the damaged area and onto the healthier side of the knee, where the cartilage is still healthy. reducing discomfort and enhancing joint function.

Please find below more detailed information on the high tibial osteotomy procedure, including what to expect before, during, and after the surgery, as well as information on the recovery period.

Indications and Contraindications

Indications for High Tibial Osteotomy:

  • Knee Osteoarthritis: High tibial osteotomy is often recommended for younger patients with knee osteoarthritis, especially when the condition primarily affects one side of the knee (unicompartmental arthritis).
  • Malalignment: When there is varus (bow-legged) or valgus (knock-kneed) malalignment of the knee, high tibial osteotomy can correct the alignment to relieve pain and restore joint function.
  • Active Patients: It can be a suitable option for physically active individuals who want to maintain an active lifestyle and delay the need for total knee replacement.

Contraindications for High Tibial Osteotomy:

  • Advanced Osteoarthritis: In cases of advanced knee osteoarthritis that affects multiple compartments of the knee, high tibial osteotomy may not provide sufficient relief.
  • Inflammatory Arthritis: High tibial osteotomy is generally not recommended for patients with inflammatory arthritis, such as rheumatoid arthritis.
  • Severe Ligament Damage: In an unstable knee, other surgical options may be more appropriate.
  • Unrealistic Expectations: Patients with unrealistic expectations regarding the outcomes of the procedure may not be suitable candidates if their expectations cannot be managed or met.
  • Medical Unfitness: Patients with underlying medical conditions may not be ideal candidates for high tibial osteotomy.
  • Inadequate Bone Stock: Severe bone loss or poor bone quality in the tibia may limit the procedure’s feasibility, as it relies on stable bone structures for successful realignment.

The decision to undergo high tibial osteotomy should be made after a thorough evaluation by a healthcare professional, considering the individual patient’s specific medical history, condition, and overall health.

Benefits and Risks

Benefits of High Tibial Osteotomy Procedure:

  • Pain Relief: High tibial osteotomy can effectively alleviate knee pain and improve joint function, particularly in cases of early to mid-stage osteoarthritis.
  • Joint Preservation: The procedure aims to preserve the natural knee joint.
  • Alignment Correction: High tibial osteotomy can restore a more normal leg alignment.
  • Improved Mobility: Patients often experience improved knee mobility, allowing for a better range of motion and enhanced daily activities.
  • Delay in Total Knee Replacement: By delaying the need for total knee replacement, high tibial osteotomy can extend the functional lifespan of the knee joint.

Risks of High Tibial Osteotomy Procedure:

  • Incomplete Pain Relief: In some cases, the procedure may not provide the desired level of pain relief or functional improvement.
  • Overcorrection or Undercorrection: Achieving the optimal realignment can be challenging, and there is a risk of overcorrection or undercorrection, which can affect joint stability and function.
  • Non-Union or Delayed Healing: The osteotomy site may not heal properly, leading to non-union or delayed union, which may require additional surgery.
  • Infection: As with any surgery, there is a risk of post-operative infection, although it’s generally low when proper aseptic techniques are followed.
  • Hardware Issues: Complications related to the hardware used in the procedure, such as screws or plates, can occur, including migration or irritation.
  • Longer Recovery: The recovery period after high tibial osteotomy is often longer and more demanding than some other knee surgeries.
  • Limited Longevity: The realignment achieved through high tibial osteotomy may not last indefinitely, and some patients may eventually require total knee replacement.

Patients considering high tibial osteotomy should discuss the potential benefits and risks with their healthcare provider. The decision to undergo the procedure should be based on individual medical history, condition, and the expertise of the surgical team.

Surgical Approach

High tibial osteotomy (HTO) is a very specialised orthopaedic procedure. It aims to correct various types of deformities around the knee joint. This is done to improve the longevity of the native knee joint in cases of severe deformity, partial damage of the joint cartilage in the knee or damage of other structures in the knee, for example, medial meniscus. The adjustment is most commonly used to reduce pressure on the damaged or arthritic side of the knee, thereby relieving pain and improving joint function.

HTO is a common procedure in our practice, and we routinely employ a 3D analysis and patient-specific instrumentation in this surgery, to ensure a perfect correction of the knee deformity is obtained.

HTO is a valuable option for a group of patients seeking an improvement in pain and function when the joint damage is not severe enough for considering an artificial joint replacement.

Pre-Surgery Information

Before tibial osteotomy surgery, several procedures and preparations will take place:

  1. Examinations: X-rays will be taken, and in some cases, a CT scan or MRI may be needed to assess the extent of the injury and damage. A pre-operative assessment of the general health will also be conducted.
  2. Skin preparation: The night before and on the morning of the operation, the patient will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  3. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and the patient will need to administer them the evening before the surgery. An instruction leaflet will be given to guide them.
  4. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide patients with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. Patients will be fitted with crutches to take home and practise before the surgery.
  5. Medications: The patient should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, they should discontinue any naturopathic or herbal medications during this period.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

Anaesthesia and Infection Prevention: In the operating room, the patient is administered a general anaesthetic for comfort, and antibiotics are given intravenously to prevent infection.

Procedure Overview:

A 15-20cm incision is made on the outside of the knee where the tibia will be cut. 

We use virtual surgical planning and patient-specific cutting jigs for perfect cuts.

After the bone is cut, it is gradually corrected and secured with a plate. A bone graft (bone harvested from the patient or bone bank) may be added for support.

Final Steps

A final X-ray is taken to confirm the position, correction, and alignment of the limb.

The surgical wound is then closed and dressing is applied.

This surgery typically takes between 60 and 90 minutes.

Post-Surgery Information

Immediate Post-Surgery:

Following tibial osteotomy surgery, patients can expect to spend three to five days in the hospital for recovery.

A physiotherapist will help you with your mobility.

Depending on the surgeon’s decision, some patients may need to use crutches for six to twelve weeks.

Post-surgery physiotherapy will focus on regaining motion in the knee, improving mobility, and strengthening the muscles around the knee joint.

Discharge criteria: Patients will be discharged once they can mobilise safely, have regained appropriate motion in the knee, and have their pain well controlled with medication.

The Recovery Process:

During the first week after surgery, the leg may be swollen, and the knee may feel somewhat stiff. It is normal to require regular pain medication during this period. Patients are advised to diligently perform the prescribed exercises at home to optimise recovery following surgery.

The osteotomy is expected to heal over three months.

Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:

  • 1 week postop: for wound check,
  • 2 weeks postop: for sutures removal.
  • 6 weeks postop: for x-ray assessment of healing progressing,
  • Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.

A consistent commitment to the prescribed physiotherapy exercises significantly influences recovery after tibial osteotomy surgery.

Patients should be aware that the leg may look different after the surgery. Besides a scar, the alignment of the knee may change significantly, typically from a bowed leg to a knocked-knee appearance. The return to manual work generally takes about three to six months, while sedentary or office duties can be performed about two weeks after surgery.

Special Considerations

Factors for success: The success of a tibial osteotomy depends on two crucial factors: the patient’s weight and the accuracy of the angular correction during the surgery. When both factors are ideal, approximately 70% of patients may not require major surgery for the next 10 years.

Potential complications: As with any surgical procedure, there are potential complications associated with osteotomy surgery, including wound problems, infection, delayed or incomplete bone healing, injury to major nerves and blood vessels, compartment syndrome, irritation from metalwork, and fracture into the knee joint. However, the incidence of complications is generally low. Moreover, potential complications following osteotomy surgery are typically lower and more manageable compared to those associated with joint replacement surgery.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000

Call on +61 2 8882 9011

X-ray facilities at all locations | Urgent appointments available if necessary.

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Professor Munjed Al Muderis
Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical lecturer at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.
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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.