High Tibial Osteotomy Surgery in Delhi, India

High Tibial Osteotomy is a surgical procedure to correct a knee condition called varus or valgus alignment, which occurs when the knee joint is not aligned correctly. Varus alignment occurs when the knee joint is angled inward, and valgus alignment occurs when the knee joint is angled outward. These misalignments can lead to arthritis, pain, and instability in the knee. The surgery involves cutting and repositioning the tibia (shin bone) to correct the alignment of the knee joint.

The tibia is cut above the ankle and moved to align the knee joint properly. It is then held with screws, plates or nails. This procedure can be done on one or both knees. The surgery is usually considered when the symptoms affect the patient's quality of life and ability to perform daily activities.

Types

Several different types of high tibial osteotomy are performed to correct varus or valgus alignment of the knee joint:

• Open-wedge HTO: This surgery involves making a larger incision on the knee and cutting a wedge-shaped piece of bone from the tibia. It allows the surgeon to reposition the tibia and correct the alignment of the knee joint. The cut bone is then held with plates, screws, nails, etc.
• Closed-wedge HTO: This involves making a smaller incision on the knee and cutting a wedge-shaped piece of bone from the tibia. The cut bone is then repositioned and held with plates, screws or nails without removal. This surgery is usually done to correct a milder degree of misalignment.
• Medial Opening Wedge Osteotomy (MOWO): This type of surgery is similar to open-wedge HTO, but the cut is done on the inside of the knee, the medial side.
• Lateral Closing Wedge Osteotomy (LCWO): This type of surgery is similar to closed-wedge HTO, but the cut is done on the outside of the knee, the lateral side.
• Distal Femoral Osteotomy (DFO): This type of surgery is performed on the thigh bone (femur) rather than the shin bone (tibia) to correct the alignment of the knee joint.

Why is a High Tibial Osteotomy Needed?

High Tibial Osteotomy (HTO) may be needed for several reasons, including:

• Varus or Valgus Alignment: HTO can correct the knee joint's misalignments and improve the knee joint's alignment.
• Osteoarthritis: A degenerative condition that affects the knee joint. When the knee is not aligned correctly, the weight-bearing forces are not distributed evenly, leading to excessive wear and tear on one side of the joint. This can lead to arthritis, which can cause pain and limit the patient's ability to perform daily activities. HTO can redistribute the weight-bearing forces across the joint and slow the progression of arthritis.
• Knee Instability: Patients with knee instability may benefit from HTO as it helps improve the alignment of the knee and reduce the risk of a knee injury.
• Post-traumatic Arthritis: Patients who have suffered a knee injury and have developed post-traumatic arthritis may benefit from HTO as it can improve the alignment of the knee joint and slow down the advancement of arthritis.
• Knee Pain: Patients with knee pain caused by misalignment of the knee joint may benefit from HTO as it can correct the alignment of the knee joint and thus reduce pain.

High tibial osteotomy is typically recommended as a last resort after exhausting non-surgical treatment options.

Indications

The primary indication for HTO is to correct varus malalignment in the knee's medial unicompartmental osteoarthritis (OA).

Some of the common indications for HTO are:

• Isolated joint line tenderness
• Metaphyseal varus (tibial bone varus angle, TBVA >5°)
• Malalignment <15°
• Full range of motion (ROM)
• Moderate activity level and high-demand lifestyle
• BMI <30
• Near-normal lateral and patellofemoral compartments
• Pain tolerance
• Asymptomatic lateral and patellofemoral compartments
• Constitutional varus morphotype
• No abnormal ligamentous laxity
• No limb length discrepancy
• No ankle deformity
• No alterations in gait pattern, especially varus thrust.

On the other hand, some of the common contraindications for HTO are:

• Patients older than 65 years
• Severe OA of the medial compartment (Ahlback grade III or higher)
• Tricompartmental OA
• Relevant patellofemoral OA
• ROM <120° (flexion less than 90° and a flexion contracture greater than 10°)
• Joint instability and ≥1 cm lateral tibial thrust
• ≥20° of malalignment
• Axial deformity correctable by physical examination and assessed on stress radiographs
• Diagnosed inflammatory arthritis
• A large area of exposed bone on the tibial and femoral articular surface (>15 cm × 15 mm)
• Heavy smokers.

Who is Not an Ideal Candidate for High Tibial Osteotomy?

High Tibial Osteotomy isn't suited for everyone. Some examples of who may not be an ideal candidate for High Tibial Osteotomy include the following:

• Patients with Severe Osteoporosis: Osteoporosis is a condition that weakens the bones, making them more prone to fractures. Patients with severe osteoporosis may not be good candidates for HTO as the weakened bones may not withstand the surgery's stress.
• Patients with Rheumatoid Arthritis: An autoimmune condition called rheumatoid arthritis produces inflammation in the joints.
• Patients with rheumatoid arthritis need to take special precautions for the surgery as the inflammation may make the surgery more complex and the healing process more prolonged.
• Patients with Severe Knee Joint Degeneration: Advanced knee joint degeneration, such as severe arthritis, may not be suitable for High Tibial Osteotomy.
• Pregnant Patients: Pregnancy may make the surgery more complex and the healing process more prolonged.
• Patients with a History of Bleeding Disorders: Patients with bleeding disorders or who are taking blood-thinning medications may not be good candidates for HTO as they are at increased risk of bleeding during surgery.

Preparation for High Tibial Osteotomy Surgery

• Medical Evaluation: Patients will undergo a thorough medical evaluation, ensuring they are healthy enough to undergo surgery. This may include blood tests, electrocardiograms, and chest X-rays.
• Preoperative Instructions: The patient will be given specific instructions on preparing for surgery, including fasting instructions, medication guidelines, and what to expect on the day of the surgery.
• Anaesthesia: The kind of anaesthesia used depends on the patient's medical history, the surgeon's preference, and the extent of the procedure.
• Marking the Tibia: The surgeon will mark the tibia to indicate where the osteotomy will be performed.
• Sterilization: The surgical site will be cleaned and sterilized to minimize the risk of infection.

High Tibial Osteotomy Surgery Procedure

• Incision: The surgeon will start by making an incision on the front of the knee to expose the tibia bone. The size and location of the incision vary depending on the surgeon's preference and the patient's anatomy.
• Osteotomy: Using a specialized saw or other cutting instruments, the surgeon will carefully make cuts in the tibia bone according to the pre-marked guidelines. The cuts are typically made in a wedge shape, with the wedge's apex pointing towards the knee's lateral side. The size of the wedge will vary depending on the degree of correction needed, which is determined based on preoperative planning and assessment of the patient's alignment.
• Alignment Correction: After the osteotomy cuts have been made, the surgeon will carefully manipulate the tibia bone to correct the desired alignment. This may involve closing the wedge to correct varus malalignment or opening the wedge to correct a valgus malalignment. The surgeon may use a metal plate or other hardware to hold the bone in place while it heals. The type and placement of the hardware will depend on the surgeon's preference and the patient's anatomy.
• Wound Closure: The surgeon will close the incision using sutures or staples once the alignment has been corrected. Sterile dressings may be applied to the wound to promote healing.
• Postoperative Care: After the surgery, the patient will be monitored in the recovery room and then transferred to a hospital room. Pain medication will be administered to relieve discomfort, and the knee may be elevated and wrapped with a compression bandage to reduce swelling. Physical therapy will typically begin within a few days of surgery to promote healing and restore strength and mobility to the knee joint. The patient will be instructed on weight-bearing restrictions, activity modification, and other postoperative care instructions to facilitate healing.

It is essential to note that the exact procedure varies depending on the patient's specific needs and the surgeon's preferences.

Complications of High Tibial Osteotomy:

Some common complications that can occur after HTO include:

• Infection: Any surgical procedure carries a disease risk. An infection may occur at the surgical site or in the wound. It can cause redness, swelling, and a fever.
• Bleeding: HTO is a relatively bloodless procedure, but there is a risk of bleeding. If a patient has significant bleeding, it can cause blood clots, pain and swelling.
• Nerve Injury: There may be a risk of injury to the nerves around the knee joint. This injury can cause numbness or itch in the foot or ankle.
• Stiffness: After the surgery, the knee joint may be stiff and may take some time to regain full range of motion.
• Loss of Function: In rare cases, patients may not regain entire knee joint function after surgery.
• Nonunion: In some cases, the bone may not heal properly and require revision surgery.
• Hardware Failure: There is a risk of the screws or plates used to hold the bone in place breaking or coming loose.
• Malalignment: The bone may not be repositioned correctly during surgery, leading to continued pain and poor outcomes.

It's worth noting that most patients who undergo high tibial osteotomy do not experience complications; if complications occur, they are often minor and treatable.

Care After High Tibial Osteotomy Surgery

The care may vary depending on the type of procedure and the individual's case. Still, some general guidelines include the following:

• Rest and Elevation: After the surgery, it is essential to rest and elevate the affected leg to reduce swelling and promote healing.
• Physical Therapy: Physical therapy is essential for recovery. The therapist helps the patient to regain strength and range of motion in the knee.
• Weight Bearing: The patient may need crutches or a walker during the initial recovery period and is instructed when to bear weight on the affected leg.
• Medication: The patient may be prescribed pain medication to help manage pain or discomfort.
• Follow-up Appointments: The patient may need to attend follow-up appointments with their surgeon to monitor their progress and address any concerns.
• Bracing: The patient may need to wear a brace to support the knee joint during the healing process.
• Stress on the Knee: The patient must avoid activities that stress the knee, like running, jumping, or high-impact sports, until the surgeon advises otherwise.

It's essential to follow the orthopaedic surgeon's instructions, keep follow-up appointments, and be patient during recovery.

Outlook

High tibial osteotomy can be an effective treatment option for patients with medial compartment osteoarthritis or other conditions that cause an overload of the medial side of the knee joint.

With the proper patient selection, surgical technique, and postoperative rehabilitation, patients can expect to see improvements in knee pain, function, and quality of life.

If you observe similar symptoms, then do not take it lightly. And please visit our knee osteotomy doctors at Max Hospital.

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