Younger and more active patients who have isolated arthritis on one side of their knee may be candidates for an osteotomy. An osteotomy refers to cutting of either the tibia (shin) or femur (thigh) bone and securing the two ends at a different angle. This effectively changes the force distribution across the knee joint. For example in patients with isolated arthritis on the medial side (inside) of the knee, an osteotomy can be performed on the tibia and opened up on the inside thereby taking some of the load off the worn portion of the knee.
The potential advantages to this are that you maintain your own joint and thus your knee will feel normal afterwards i.e unlike a joint that has been replaced. Potentially you will also be able to get back to more sporting activities than would be recommended following a knee replacement. However it must be stressed that this is not an easy option and requires a period of at least 6 weeks on crutches followed by a lengthy rehabilitation. In reality, many patients with this procedure are not successful in getting back to full on competitive sports and it is important to be realistic in this regard. Also as you still have your own joint, you still have the option of a joint replacement in the future. In many ways it is an operation that can be looked at as a delaying tactic that will hopefully allow you to hold off on a joint replacement for another 8 – 10 years.
It is very important to note that an osteotomy will change the shape of your leg. If for example you are slightly bow-legged beforehand you can expect to be a little knock-kneed afterwards.
Overall, results vary considerably between studies but approximately 90% will last 5 years. The results at 10 years are much more variable and range from 40 to 80% success. It is however very important that you look at it as an operation that can potentially "buy you a few years" until a joint replacement may be more suitable for you.
As with any procedure, there is always a risk of infection and of developing a blood clot (DVT or pulmonary embolism). During the surgery, it is possible that the osteotomy can extend up to the joint and create an intra-articular fracture. In addition, there is a risk that the osteotomy may not heal (non-union) and this can require further surgery. There is also a risk to the blood vessels and nerves around the knee but every effort is made to protect these at the time of surgery. Compartment syndrome is a build-up of excess pressure in the muscular compartments in the calf due to bleeding/swelling in them. This can require emergency surgery to release them. Stiffness can also develop after the surgery. There is a risk that the arthritis in the knee can progress with time and that you will potentially require a knee replacement in the future. Finally, an osteotomy can be somewhat less predictable in terms of the amount of pain relief that you get from it.
Not everyone is suitable for an osteotomy. The ideal candidate is usually very active, between 35 and 50 with isolated arthritis on one side of their knee. The knee should bend to at least 90 degrees and fully straighten out. It is not recommended in people who smoke due to the increased risk that the ostoetomy will not heal. It is also not recommended in patients with inflammatory arthritis due to the risk that the rest of the joint can become involved in future.
An osteotomy is generally performed under a general anaesthetic i.e you are fully put to sleep for it. Obviously this is a decision between you and the anaesthetist and if for some reason you would prefer a spinal anaesthetic or have any other concerns, you can discuss it with them beforehand.
The osteotomy is usually secured with a plate and screws after the correction is made. On the tibial side, the plate and screws will usually have to be removed at a later date when the bone has healed as the plate can be somewhat prominent just in under the skin.
For a high tibial osteotomy, the scar will be an oblique line across the inside of the leg a few centimetres below the kneecap. For a distal femoral osteotomy, the scar will run down the outside of the leg just above the knee.
The bulky wool & crepe bandage can be removed 24 hours after surgery. The dressing underneath can remain in place for several days & only if it leaks blood will the nurse change it. As a general rule, the less the wound is interfered with, the better. It is fine to shower but avoid getting too much water directly on the dressings. The paper stitches can remain in place for 2 weeks. At this point, you can shower without the dressing on & the paper stitches will peel off easily when wet.
At the end of the procedure, some local anaesthetic is injected around the incision. You can expect some discomfort afterwards but this can be minimised with a combination of simple analgesia such as paracetamol, an anti-inflammatory & a stronger morphine-like tablet or injection (depending on patient tolerances / allergies). If you are in severe pain, call the nursing staff as it is important to ensure that you have not developed a compartment syndrome as well as get you some more analgesia.
Normally you will need to protect the leg with crutches for up to 6 weeks after your surgery. Depending on the operation, you may be able to put more weight through the leg earlier than this but you will be instructed in this regard prior to discharge.
When patients return home, they often forget to continue using ice packs. These when combined with a few minutes elevation can really help reduce pain & swelling. Try to adopt the motto “work hard, rest hard”, by performing your exercises regularly as directed by the physiotherapist but then getting the leg up on a couple of pillows with an icepack. A frozen bag of peas wrapped in a towel works fine.
You will normally be reviewed approximately 2 weeks after your surgery to ensure that the wound has healed. A further review and check x-ray will take place 6 weeks after your surgery. Obviously if you develop any problems in the interim, please contact us and you can be reviewed sooner.
This depends on the type of job that you have but as a guide, office based workers will require about 6 weeks off work whereas manual workers will need about 3 months off.
Ultimately it may be possible to return to most sports as you still have your own joint. However it is important that you are realistic as well; many patients do not manage to get back to the same sporting level that they were at prior to their knee trouble.
🏊🏼 You can slowly return to swimming after 3 weeks as long as the wound has fully healed.
🚴🏻 You can start back on a stationary bicycle with the seat raised at 2 weeks.
🏃🏻You will only be able to start light jogging on a treadmill after approximately 3 months.
You can expect it to take roughly 6 months before you can get back to participating in most sports.
This is usually not recommended for 6 weeks after your surgery. If it is your left leg, you may be able to drive a little sooner, at around 4 weeks.
You should seek advice if the pain dramatically worsens after discharge. The risk of developing compartment syndrome is highest in the first 24 hours after surgery but any severe pain will need to be assessed to be sure. Also call if the knee becomes a lot more swollen or you get a large amount of bleeding. Any symptoms such as calf swelling or tenderness or simply feeling unwell or shortness of breath should also be assessed.
Compiled October 2015
Review date: March 2016
Review date: March 2016