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An osteotomy is a procedure that can repair joints damaged by osteoarthritis or other deformities. This could include hip dysplasia, X-legs or O-legs. When non-operative procedures fail to alleviate knee pain, an osteotomy can be an alternative to a full knee replacement. A high tibial osteotomy is generally performed when only one side of the knee is damaged, with part of the tibia removed to realign the knee and a metal plate sometimes used for stability.
Damage to the knee
Even the simple process of walking can cause intense forces to travel through your leg. The meniscus - cartilage - in the knee helps to ease the impact of these forces on your femur (thighbone) and tibia (shinbone). Articular cartilage forms a protective covering at the end of the bones. Osteoarthritis can cause the cartilage to wear away, which exposes the bone and prevents the knee from moving smoothly. Malalignment can also damage the tissue in the knee, as you will become unbalanced and one side of the joint will experience more pressure than the other.
Depending on which part of the cartilage wears away, you could experience varus (bowleg) or valgus (knock knee) deformities that change the axis of the knee. When you walk, this increases the weight and pressure on the damaged area; in turn, this can change the bone in addition to causing pain.
Damage from osteoarthritis or knee malalignment is associated more with older people; however, it can be caused by injury, infection or other conditions found in the young. This is why an osteotomy, which preserves part of the joint, can be the preferred form of osteoarthritis knee surgery rather than a full or partial knee replacement. It will enable the patient to maintain more knee function for longer, which means they can live a more active life.
Before the procedure
You will need to be assessed to ensure an osteotomy is the appropriate procedure. A high tibial osteotomy is not recommended if you have arthritis in other joints, stiff knees, inflammatory joint disease, anterior knee pain or significant knee deformities. Being a smoker can also reduce the effectiveness of tibial osteotomy, as can conditions including diabetes and various heart problems.
An exercise regime may be recommended before you have the procedure to help you to obtain the best possible physical condition. This will also assist your post-operative recovery through improved muscle control and strength. The exercise will be lighter activities, such as cycling and rowing.
Before you can have surgery, an X-ray will be taken of your leg. Computer software will be used to help plan your osteotomy. This will enable the surgeon to decide on the type and extent of the procedure that will be necessary.
Surgery cannot be carried out until you have given your full and informed consent.
About the procedure
Tibial osteotomies are usually carried out under a general anaesthetic, the process for which will be explained to you by an anaesthetist on the morning of your surgery. You may also be given antibiotics to guard against infection. The surgeon may perform an arthroscopy - keyhole surgery examining inside the joint - first to ensure your suitability for an osteotomy.
Once the anaesthetic is working, the surgeon will wrap a tourniquet around your leg to make sure bleeding is minimised during the procedure. A small incision will be made below the knee, next to the tibia or femur, so that accumulated blood in the wound can be drained. With the help of an X-ray, the surgeon will use a saw to remove part of the bone, with the newly-created fracture realigned and stabilised using pins and a metal plate.
There are two types of procedure that come under the heading tibial osteotomy:
Closing wedge osteotomy
Two cuts are used to remove a wedge of bone. If you have a bowleg, this will be from the tibia; if you have knock-knees, it will be from the femur. The gap left by the wedge will be brought back together and either stapled or held by a plate and pins.
Opening wedge osteotomy
Again, the bone will be cut, but this time the wedge is formed by creating it at an angle. The plate and screws are then added for stability. In the case of larger corrections, a bone graft may be needed using bone from the hip, chips of bone that have been sterilised, or a synthetic piece of calcium-based material.
The procedure will take between one and two hours. When the surgery is over, the original incision can be closed with clips or stitches, which can be removed 10 to 14 days later. A dressing may also be applied. When the recovery period is over, you should be able to carry your weight more comfortably as the result of the increased space for the knee to move.
Why is osteotomy used?
Osteotomies are often recommended when you have a bowed leg. Whilst it will not completely heal the knee, it will alleviate pain and prevent further harm. It does this by stopping your weight from being carried on the damaged inner part of the knee, which can cause impaired movement and lasting pain. Your weight will instead be shifted to healthier tissue. The impact of a tibial osteotomy can last for eight to ten years, which means it can delay the need for knee replacement surgery, although not rule it out in the future. This makes it particularly popular with younger patients.
Advantages of osteotomy
There are several benefits to tibial osteotomy that can make it the preferred procedure for dealing with osteoarthritis and malalignment in the knee:
- Can delay the need for more serious knee replacement surgery.
- The risk of infection is low.
- It allows you to remain active for a longer period.
It will be a day or two after your surgery before you can leave the hospital. During the first 24 hours, you will be given antibiotics through an intravenous drip. You may be given a brace or cast for your leg. Elevation of the limb can help to reduce swelling, and you should always ask the healthcare team if you need more pain relief. Any movement should be supervised by a physiotherapist, who will help you to learn how to use crutches and give you some gentle exercises to assist in your recovery. The crutches will probably be needed for several weeks.
Exercises aim to help you regain the range of motion in your leg, including being able to bend and flex it fully. As you recover further, you will be given exercises to improve your strength. The physiotherapist may give you a leaflet or guide to take home. You will not be able to drive for at least six weeks, so you will need to arrange transport home from the hospital.
It will be around two weeks from your discharge before you need to return for a follow-up appointment and the removal of your stitches. During this time, you should continue to elevate your leg and use ice packs to alleviate the swelling. You should also keep using pain relief when necessary. You will not be discharged until you can move relatively comfortably on crutches, including getting out of bed and being able to travel to the bathroom and back. If you have any problems before your follow-up appointment, it is important to speak to your GP or return to the clinic as soon as possible.
Six weeks after your surgery, you will have another follow-up appointment during which an X-ray will be taken. This will assess whether your bones are healing properly. Another X-ray will be taken at three months. During this time, you will continue to work with the physiotherapist to improve your strength and endurance, with exercises becoming more challenging as you improve. Complete recovery can take up to a year.
Particularly sporty patients may have trouble returning to their normal levels of activity. Gentle, low-impact sports such as swimming, light cycling and rowing may be resumed after about three months. Hiking and tennis may also be possible, but more stressful and high-endurance activities, such as long-distance running or contact sports, are not recommended.
Risks of osteotomy
All surgery comes with some risks. These include the dangers associated with a general anaesthetic, which should be discussed by your anaesthetist, and general symptoms resulting from surgery, such as tenderness, stiffness, swelling and bruising.
Risks specific to an osteotomy include:
- Post-operative bleeding - if this leads to haematoma (collected blood), it may need draining
- A 10cm scar curving along your leg
- A keloid scar, which is painful, large and reddened, can occur during the healing process. This is more common in people of Afro-Caribbean descent
- A small (almost unnoticeable) difference in the length of your legs. One may be shorter than the other
- Knee pain
- Blood vessel damage can lead to loss of circulation, which can potentially require more surgery
- Nerve damage can cause a change in the feeling or sensation in your knee
- Infection is still possible and could lead to further surgical procedures to clean the wound and potentially remove plates or pins
- Metal plates and pins may also need to be removed if they become irritating or painful
Less common risks include blood clots, a failure of the bone to reunite, fractures in the bone, and compartment syndrome.