Minimally-invasive high tibial osteotomy with a bone wedge obtained from the tissue bank helped this man 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.
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
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.
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 view showing the damaged meniscus with a horizontal cleavage tear, and above it the frayed cartilage covering the end of the femur
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 from the front, showing the 'opening wedge' and which is packed with the bone wedge and plated
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.
This patient with an old traumatic deformity of his right leg was referred 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.
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.
For any surgeons interested in the 2016 osteotomy masterclass at Basingstoke, UK....