Knee Osteotomy – the ideal patient
Knee osteotomy can offer a big life improvement to patients with limited joint damage who are tending to pain related to bow-legs or knock-knees.
The most common people that we treat with osteotomy are active individuals in their 40s or early 50s who perhaps have had some form of surgery - maybe a tidy up of their joint surface or their inner meniscus. Even without this, they present to us with pain. And quite frequently they are very, very slightly bowlegged and the pain is on the inner aspect of their knee. If we draw a line from the hip down to the ankle, if the legs are bowed the force is going more through the inside or medial side of the knee (outside of the knee = lateral, inside of the knee = medial).
The patient always says in this typical scenario - "This is where it hurts, on the inside of my knee".
When take a look at the patient, we see the rest of the knee is very healthy. The outer aspect - the lateral compartment - joint surface good, meniscus perfect, patella perfect, the end of the thigh bone where the patella (kneecap) goes up and down – perfect, and the ligaments inside the knee also intact. But the problem is joint surface wear and shock absorber problems that is joint cartilage and meniscus problems, on the inside of the knee. So that’s the most typical scenario, and the vast majority of these patients will benefit significantly by an upper, or high, tibial osteotomy (HTO).
Typically these patients have pain with walking, going up and down stairs, simple activities of day-to-day life that they would like to obviously resolve and get back to being active once more. What we do as part of our process is take a special X-ray that looks at the hip, the knee and the ankle and calculate exactly where the weight-bearing line falls across the knee joint and, using this information, we have a digital software programme that will allow us - to within a millimetre or two - plan exactly where we are going to move that weight bearing axis to.
High Tibial Osteotomy
In the operating room we take a precision sawblade through a tiny 4cm incision we’re able to get to the side of the bone and very, very carefully divide the bone with this saw. Once we’ve done that it’s just a simple question of very gently opening the bone to the amount dictated by the X-ray - it can be very small or it can be very big. Patients with small osteotomies, medium sized osteotomies and very large osteotomies all get very good benefit - we’ve shown that in our data.
So, once we’ve opened the osteotomy, in my new technique which I think is incredibly beneficial to patients we then fill that - it’s not necessary but I think that it’s important - with a wedge of bone that exactly matches the empty space that we’ve created. Then it’s a question of just fixing it with a plate, and the plates are very strong and they go in and they slip in through this small incision and are locked both at the top and at the bottom. The beauty of these plates and the bone wedge and this operation is that you can begin immediate mobilisation. In other words, you can walk on this safely from Day 1. We obviously advise very strongly that patients do very little for the first 2 weeks but take it easy at home with their leg elevated, and by doing that they minimise the amount of swelling and discomfort they get.
Our results have been really superb. We’ve had a really low rate of complication in terms of infection and blood clots. We’ve had no damage to any nerve or vessel in our series of nearly 900 patients across 3 centres: our own, Carlisle with Matt Dawson and his group, and Cardiff with Chris Wilson and his group. So those 3 centres are really doing the bulk of the osteotomy surgery that is going on in the UK at the moment, or certainly a significant proportion. We are collecting our data, following all our patients and very, very pleased with the patient satisfaction both subjectively, in other words ‘how well are you doing?’ and the patients are saying, ‘very well’, and in terms of what we can see in terms of our objective results. So I think osteotomy is a very exciting way of treating this very common problem.
Our goal and our challenge has been to really get out to the public, to physiotherapists and GPs and to the surgical community - the orthopaedic community in general - that knee preservation is paramount, particularly given that people are living so much longer. So for us, the typical patient - 40s or 50s - we make the leg straight with an osteotomy They might come back when they are 60 or 65 with pain again - then they get their partial knee replacement.They might come back when they are 75 or 80 - then they get their total knee replacement.
So we are really going up a step-wise progression towards finally replacing the joint - but doing our best to carry out joint preserving surgery so that we can keep the patient’s own knee for as long as possible.
I’d like you to take a look at UKKOR which is the UK Knee Osteotomy Registry, and I’d also like you to take a look at KNEEguru where I’ve written several articles and there are some very good pieces of information for patients about osteotomy surgery.
Distal Femoral Osteotomy
There is a slightly less common scenario: pain on the outer side of the knee, the lateral side of the knee.
Here we see patients that are quite frequently knock-kneed and we do the complete reverse but the surgery is often done in the thigh bone as opposed to the shin bone, again through really tiny incisions, and we remove a wedge of bone. The wedge is then closed and this realigns the leg. This is called a distal femoral osteotomy.
What's right for you?
So in terms of who’s suitable for an osteotomy, really it’s active patients, and there is no age limit. So, if you are a very active 70 year old, you have a very good outer compartment, the kneecap compartment is fine and all the problems are confined to the inner aspect of your knee, and you tick the boxes in terms of your alignment, we would do an osteotomy to preserve your knee as opposed to replace it.
Now the converse of that is, if you’re sedentary and you’re not an active person - typically 40 or 50 but perhaps older - maybe someone who just wants to play golf, and you have bad arthritis - then we would of course offer you some form of knee replacement, hopefully partial, but if not then a total knee replacement.
For any surgeons interested in the 2016 osteotomy masterclass at Basingstoke, UK....
