Minimally-invasive high tibial osteotomy in a trauma patient

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Minimally-invasive high tibial osteotomy with a bone wedge obtained from the tissue bank helped Andrew to rehabilitate rapidly and with very little pain.

Thirty years ago this unfortunate patient fractured his right tibia and fibula and was managed in plaster for six months. The injury left him with some deformity and, although his ankle always felt a bit tight, he did well for many years.

Eight years ago he developed some medial (inner aspect) knee pain and had an arthroscopy under a different surgeon with a good recovery and some benefit, but a year ago he began to develop medial knee pain once more and it made walking difficult, although  he does not have any major issues at rest or at night. At this stage he was referred to me.

reduced joint space on medial side

Pre-operative X-ray, demonstrating how the abnormal forces going though the joint have resulted in the joint line gap closing on the inner side

patient with old healed fracture of the right lower leg

This long-leg weight-bearing X-ray demonstrates the site of the old fracture (unfortunately a bit obscured by the X-ray marker)

The main issue is that he is otherwise fit and active at 51 years of age, still working, and he would like to continue cycling and swimming and, if possible, running.​

On examination, he had varus alignment (bow-leggedness) on the right and a slight flexion deformity at the fracture site. He was tender on the medial (inner) aspect of the knee with an excellent range of motion from 0-130 degrees with a stable knee, no patellofemoral irritability and good hip movements.​

His x-rays and MRI scans showed that there was arthritic joint damage, but that this was mostly confined to the medial 'compartment' of the knee as well as a bit under the kneecap on that same aspect.

Surgery

We decided to go ahead with a high tibial osteotomy, but before this we took a look inside the knee to confirm our original suspicions about the joint surfaces.

arthroscopic photograph showing horizontal cleavage tear of the meniscus and damage to the cartilage of the femur

Arthroscopic view showing the damaged meniscus with a horizontal cleavage tear, and above it the frayed cartilage covering the end of the femur

probing the cartilage defect in the femur with the probe feeling the bare bone

Arthroscopic view of the rounded condyle at the end of the femur, showing how the white cartilage has worn down to expose the underlying bone.

The damage to the joint surfaces was largely confined to the medial side, and it was decided that he would be a very good candidate for osteotomy surgery realign the leg and shift the forces away from the medial side.

An 'opening wedge' high tibial osteotomy was performed, using a small incision and a bone wedge - what is called a minimally-invasive osteotomy. 

post-operative view showing the plated osteotomy from the front

Post-operative view from the front, showing the 'opening wedge' and which is packed with the bone wedge and plated

post-operative view showing the plated osteotomy from the side

The same post-operative view from the side

Before plating, the gap is filled with a bone wedge, and then the plate is screwed into place to hold the altered position of the bones until new bone cells can populate the bone wedge and fill the gap. Using a bone wedge - which we obtain from our tissue bank - tends to result in much less pain than traditional osteotomy. This patient kept a video diary for the first few days to record his pain levels.

Post-op

2018 Update from Andrew

I was recommended to speak to Mr Adrian Fairbank, Consultant Orthopaedic Surgeon at Parkside Hospital, who, on learning I was enquiring about an HTO, in turn referred me to Prof Wilson. I believed that the HTO would involve serious surgery with a fairly long period of recovery, but that I would be mobile within a matter of weeks, and that the new angle of my leg and associated realigned load-bearing should result in walking without the knee pain I had been suffering for a number of years. But probably not going back to playing football or serious running. I also expected to be able to have the plate removed within 12 - 18 months.

My expectations have been met in almost all respects. It was painful, but I was mobile in a matter of weeks. The plate allowed for full weight bearing pretty much as soon as the initial wound had healed. Most crucially, I am no longer in pain when walking, and it's been achieved without having to have a knee replacement. The only noticeable legacy from the operation at the moment is a slight lack of skin sensation on my lower leg adjacent to the operation site. I had the op in October 16, and was walking comfortably, cycling to work etc pretty much from Feb 2017. This year, about 18 months post op I have played gentle tennis, cycled round the North Coast of Scotland for a week (450 miles), walked up Pen Y Fan (900m) in the Brecon Beacons, and in July completed a ride over many of the highest mountain Cols on the Route des Grandes Alps - a total amount of climbing of 58,000 feet (or twice the height of Everest! I'm descending from a 2,000m Col in the photo above). The knee has completed all these strenuous activities without pain. The only slight disappointment has been the speed at which my bone has fully mended, sufficient to allow the plate to be removed. It will actually be closer to two years before the plate is removed. That said, as you can see, this hasn't impacted my new found mobility.

I would advise others in my situation to have the operation, expect it will be painful for the first few weeks while the bone starts to heal, and get active as soon as possible - cycling was great for me, and I believe swimming is good also.

I was in very good hands with Professor Wilson, clearly a leading expert in HTO surgery. I was 52 when I had the operation, having suffered acute right knee pain when walking for a good number of years. I had been told the deterioration in my knee, including a complete lack of cartilage at the weight-bearing point, would probably require a knee replacement, but that I was too young to have this op only once. The consultant suggested instead to consider an HTO to change the weight bearing point in my knee, and I was recommended Professor Wilson. Prior to surgery, I received a very clear briefing of the expectations I should have of the operation itself, the likely recovery process and both the probable and possible outcomes from this surgery (i.e. I had a good grasp of the positives and possible negatives). Everything went very smoothly. Recovery from the surgery was, as expected, pretty painful for a number of weeks, but after a couple of months I was weight bearing, and as my leg strengthened, I was aware when walking that the operation had succeeded in removing the chronic knee pain. I am currently waiting on a time to have the plate removed. 12-18 months after the operation I am now cycling long distances, hill walking and surfing without any knee pain! A big thank you to Professor Wilson, Raghbir Khakha and the whole team.

Andrew

Update 2018

Professor Adrian Wilson

Adrian Wilson


Andrew had an old traumatic deformity of his right leg. He was referred to me by a London knee specialist colleague in July 2016. The abnormal forces in the leg had led to a narrowing of the joint surface within the knee joint on the inner aspect, with deterioration of the shock-absorbing meniscus and  arthritic damage to the joint surface. He had Grade IV medial osteoarthritis in the right knee, with Grade IV wear on the medial facet of the patella.

Improvement was achieved via high tibial osteotomy (HTO), using our 'minimally-invasive' technique with bone grafting.

I feel that he is a great example of how such correction can be accomplished with a rapid recovery and little ongoing pain.


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