Minimally-invasive high-tibial osteotomy – a surgeon’s own choice

Why would a busy 56 year old sports surgeon, previously fit and active, but now struggling with knee arthritis, decide to have a high tibial osteotomy at the other end of the world rather than choosing a straightforward knee replacement at home?

Dr Mark Ferguson researched his options, and decided to fly from Johannesburg in South Africa to the UK the week before Christmas 2016 to have the procedure to realign the long bones of his knee, with the objective of altering the forces going through the damaged side.

He had watched knee surgeon Professor Adrian Wilson’s presentations on a minimally-invasive osteotomy technique with a precision bone wedge. The combination of the low surgical insult and the strong plate used to fix the cut bones into the new position, means that patients are allowed to walk immediately and take full weight through the operated leg. Dr Ferguson was already struggling to walk, and felt that this would be his best option to relieve his knee pain, delay the inevitability of a knee replacement and get him back to work quickly.

The history
The history revealed that Mark had had a left-sided high tibial osteotomy back in 2007 and had benefited greatly from this, despite residual evidence of a minor and asymptomatic deep vein thrombosis in the lower leg.
His right knee, too, had been troublesome for a number of years, leading to an arthroscopy with medial cartilage reshaping in 1998, and a further arthroscopy and meniscal surgery in 2005. It was now his major problem, and he was able to get around a golf course but at a very slow rate, and limping heavily.
Mark was experiencing little problem with swelling, and had no instability and no night pain.

On examination he was found to have a varus alignment on the right knee and was in slight valgus on the previously osteotomised left knee. There was a moderate effusion on the right, but no particular tenderness and a full range of motion. The cruciate and collateral ligaments were intact. There was a fair amount of laxity medially because of the deficiency that he has due to his meniscal and chondral pathology.

Imaging & Pre-op Plan
The patient was planned for a medial opening wedge high tibial osteotomy with a 7mm correction.

Osteotomy pre-op planning

Pre-operative long leg films showing the computerised calculation of the planned opening wedge.

Intra-operative fluoroscopic image
to show the extent of the opening wedge

The procedure went well, and after 2 nights he was discharged, having reported to his surgeon that after the operation he experienced no pain other than minor discomfort.

Post-operative AP and Lateral X-rays

He continued to do really well, soon being able to bend to 90 degrees and pain free. He was back at work as an orthopaedic surgeon at 6 weeks following the procedure.

High Tibial Osteotomy (HTO)

High tibial osteotomy (HTO) is a procedure to realign the long bones of the leg and alter the fores going through the joint surfaces.

Testimonial from Mark Ferguson
“Having been involved in a busy sports practice for the last 22 years, a lot of those professional and recreational athletes I treated then are now starting to present with early degenerative problems of their knees. I now found myself in a similar position.
“This posed a treatment problem as unfortunately in South Africa we seem to have followed the USA trend of stretching the indications to do artificial joint replacements in patients in their 5th and 6th decades. Although the procedure of osteotomy around the knee to correct abnormal alignment and unload degenerative cartilage damage has been around for a long time the concept of its use for “joint preservation” is a simple change in philosophy employed by Prof Wilson. Traditionally it has been difficult to convince a patient to undergo an osteotomy as it was a painful operation with a lengthy postoperative morbidity and variable outcomes. Patients were often more inclined to opt for a more permanent knee replacement and worry about any consequences as they arose. As a relatively active sportsman I wanted an alternative to the knee replacement option.
“Professor Wilson at the Candover Clinic, using advanced digital software to accurately plan the procedure, has however developed a minimally invasive technique using precision instruments. In association with his anesthesiology team this has resulted in a relative painless preservation operation with a quicker recovery, improved outcomes and the possible avoidance of future surgery. So in my research to find an internationally acclaimed Centre of Excellence that specialises in joint preservation my choice of Prof Wilson and his team at the Candover Clinic was a simple one ensuring an early return to my work and confident in his expectations for my knee.”

On Alter G (gravity-reducing treadmill)

On Alter G

Walking at 3 weeks, pain free

On an exercise bike 2-3 weeks post-op

Walking pain free

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