Overview
Knee osteoarthritis (OA) is one of the most common joint disorders and a significant health burden. The lifelong chance of getting knee OA is estimated to be higher in women than in men. The symptoms include pain, stiffness, and activity limitations.
Non-surgical treatment of knee OA begins with simple pain-relieving medications and lifestyle changes such as activity modification to ease the symptoms and weight loss. If symptoms worsen despite non-operative treatment, surgical options may be considered. High tibial osteotomy (HTO) knee surgery is an alternative to arthroplasty in active patients with isolated compartment OA and malalignment.
HTO knee surgery is a joint-preserving surgical procedure that enables patients to resume high-impact sports and activities without any restrictions. It also prevents or delays the need for arthroplasty in the future.
What exactly is a high tibial osteotomy (HTO) knee surgery or operation?
A high tibial osteotomy is a kind of ‘joint preservation’ surgery in which the shin bone (tibia) is cut to modify the knee alignment. It is used to alleviate osteoarthritis symptoms by removing body weight from arthritis-affected cartilage within the knee and to prevent potential knee replacement surgery. An HTO knee surgery may also be done to treat the instability of the knees in some cases.
Who is the right candidate for HTO knee surgery?
An HTO operation is not advised for all patients suffering from knee osteoarthritis.
People aged 40 to 60 who are not overweight, are moderately active or perform physically demanding work, and have osteoarthritis in only one compartment of the knee (most commonly the inner compartment) benefit the most from HTO knee surgery. These patients have the best chance of getting pain relief and postponing the advancement of knee arthritis and the requirement for potential knee replacement surgery in the future.
The advantages of a high tibial osteotomy (HTO) knee surgery
The HTO operation can help patients who have pain and a restricted range of motion due to arthritis in one part of the knee. When the load on the damaged side of the knee is reduced, the necessity for a total knee replacement procedure is postponed. Pain and stiffness are reduced when the heavy load is decreased. Individuals must meet the following criteria for a high tibial osteotomy:
- The knee has some ligament function around it
- Other knee compartments have minimal arthritis
- A sufficient range of motion
Prior to the HTO operation
Individuals will have an MRI and X-rays of the knee before having to undergo high tibial osteotomy (HTO) knee surgery to determine the structural damage and severity of arthritis. The X-rays allow the doctor to assess the functioning of the knee compartment and estimate where the patient is carrying most of their weight in order to correctly realign the leg for the best outcome. The MRI examines the cartilage in all areas of the knee joint, the meniscus, and the ligaments.
On the day of the surgery, the patient will most likely be admitted to the hospital.
An anaesthesiologist will evaluate the patient prior to the procedure. They will go over the patient’s medical history and the anaesthesia options with them. Anaesthesia could be general or spinal (regional).
Before surgery, the surgeon will also examine the patient and sign the knee with a marker to confirm the surgical site.
High tibial osteotomy (HTO) operation techniques or methods used during the procedure
There are various surgical methods that require osteotomy of the knee i.e., creating a cut on the skin surrounding the knee joint and removing a portion of the upper tibia (the bone located in the shin area).
The two primary approaches used in osteotomy surgery are known as ‘lateral closing wedge osteotomy’ and ‘medial opening wedge osteotomy’. In addition to the osteotomy procedure, a minimally invasive diagnostic technique called knee arthroscopy can also be employed during the surgery to examine the interior of the knee joint using a small camera and evaluate its structures.
Closing wedge osteotomies
Closing wedge osteotomy is a surgical procedure that involves cutting a bone and removing a wedge-shaped piece of bone from below the upper tibial joint to correct bone deformities by changing the angle of the affected bone. The remaining bones are then brought together and secured with pins and metal plates.
Opening wedge osteotomies
The most commonly used and preferred type of surgical method for HTO knee surgery is the opening wedge osteotomy. This surgical procedure involves cutting the tibia (shin bone) and wedging it open. To promote bone healing, the wedge space is sometimes packed with graft material that comes from a bone bank (allograft donor) or the patient’s pelvis (autograft). The bone opening is then stabilised with screws and metal plates.
During the surgery
• A knee osteotomy procedure usually takes somewhere between 1 and 2 hours.
• Starting below the kneecap, the surgeon will create an incision in the front of the knee.
• Guide wires will be used by the surgeons to exactly plan the proper size of the wedge, and using an oscillating saw, they will cut along these guide wires and then either remove or place a bone wedge, according to the method used.
• Screws or a plate will be inserted by the surgeon to retain the bones in position until they heal.
After the HTO knee surgery
Following surgery, the patient will be taken to the recovery room and closely monitored as they recover from anaesthesia. The majority of patients will be admitted to the hospital for 1-2 days.
Following discharge
Pain management: The patient will experience pain, and the surgeon will prescribe pain medications to ease the pain.
Weight-bearing: the surgeon may recommend a knee brace (hinged) for the initial 6-12 weeks after the surgery. Further to that, the need for a brace and the amount of weight a patient can put on their leg will be based on the osteotomy size as well as the type of plate used by the surgeon during the surgery.
Doctor’s appointment: Following surgery, the patient will see the surgeon for regular follow-up appointments. The surgeon will take X-rays to determine whether the osteotomy is healing properly. Then, after the check-up, the surgeon will advise the patient on when it is appropriate to put weight on the leg and when they can begin rehabilitation.
Rehabilitation: During rehabilitation, a physiotherapist will teach patients exercises to help them maintain their knee’s range of motion and restore strength. This is a step-by-step approach, with patients typically going back to high-intensity exercises six months following surgery, based on the surgeon’s recommendations.
Complications of HTO knee surgery
Osteotomies have risks, similar to any other surgical procedure. The surgeon will go over each risk with the patient and take specific precautions to avoid any complications.
Even though the risks are minimal, the following are the most common complications:
• Infection
• Knee joint stiffness
• Blood clots
• Injury to nerves and blood vessels
• Failure of the cut bone to heal
• Fractures
• Metal-ware discomfort and subsequent removal
In some cases, re-surgery may be required, particularly if the osteotomy fails to heal.
How much does a high tibial osteotomy (HTO) surgery cost in India?
The cost of a high tibial osteotomy (HTO) procedure in India can vary depending on several factors. Some of the important points influencing the expenses include:
- Type of surgery
- The location and reputation of the hospital
- The hospital room selected
- The experience of the surgeon
- The patient’s overall health condition
Outcomes post-HTO surgery
Osteotomy is effective in alleviating pain and prolonging the progression of knee arthritis in many patients. It may enable a younger group of patients to maintain an active life for many years. Although many patients will eventually necessitate a knee replacement, an osteotomy may serve as an effective way to postpone the need for one.
