This patient suffered a tibial plateau fracture. Although her alignment issues were subtle, the impact upon her life was major. Osteotomy offered her a tangible solution.
When you are considering an osteotomy procedure in a patient, you have to pay attention to each of these facets:
People with complex leg alignment problems fall into a category where the only way their chronic pain can be managed is psychologically - drugs used over a long time eventually just don’t help - so you’ve got to deal with the patient’s depression. They have lost their life really, and often go into a real decline because they have to stop working and stop being part of society. It’s a terrible situation to find yourself in.
Louise was one of those people where we really had to try and do something for her because she was getting towards the edge of her tolerance, and she was beginning to get quite depressed about it. And the difficult thing is that once you get into that psychological chronic scenario, these sorts of treatments - the physical treatments - become much more difficult because there is a sensitisation of the body. A patient with chronic pain situation does not respond in the same way that a non-chronic pain patient would, so it is much better to intervene earlier rather than later.
Because Louise’s tibial plateau was so minimally displaced, I think 99% of surgeons would have just said “Look, that would be very, very difficult to improve, you’ve got to live with it”. Because our team does so much osteotomy it’s a very easy decision for us to make - osteotomy is an operation that I personally perform several times a week - whereas for a surgeon that maybe does it once or twice a year it’s a really big thing, or if they never do osteotomies than they wouldn’t even consider it. So the minute I saw Louise in the clinic and looked at her long leg X-rays I was immediately thinking about osteotomy, but had we met a year earlier I would still have said osteotomy - I wouldn’t have tried lots of other things. I would have allowed her to recover from her fracture, and if we’d seen her at 6 months saying, “Look, my knee’s really not great” she’d have been listed for the procedure.
When we do an open wedge osteotomy, as in her case, we tend put a bone wedge in. We don’t take that from the patient, we use human donated bone. In our hospital we have a system where, when patients have hip replacements, we save their femoral heads at the top of the hip bone – the ball, so to speak. The bone is obviously harvested in an ultra-clean environment, and then it’s processed and we then have it as an amazing resource. We can fashion it so when we create a wedge in the patient’s bone during the osteotomy, and open the wedge up, then we can take a matching wedge of the harvested bone and put it in the space like a cork in a bottle.
The small incision together with the bone wedge ‘cork-in-the-bottle’, gives some immediate stability to the bone, and then the plate goes over the top to make it all really secure. With that, and with the GameReady cryo-therapy, at least half my patients say to me, “I haven’t experienced any pain”, and a lot of them add “not even a paracetamol” - which is amazing! Now 25% of patients will still say that the procedure was pretty uncomfortable, and then 25% will be like Louise and say “this is really uncomfortable and it’s taken me 2 or 3 months to just get over it to a point where I’m functioning again, and I’ve been in a lot of pain in those 12 weeks”, but it the numbers were the other way around before we used our current techniques. In those days 75% of people were like Louise, and occasionally we would get away with someone saying it didn’t hurt too much. So the new technique has made it much more reproducible as an operation that patients can bounce back from quickly, but it is still a big operation and Louise has experienced that and she’s through it now.
The great thing with having that strong plate is that it allows immediate mobilisation - so you can really work with the physiotherapist. You don’t waste away in a plaster or some form of a brace for 6 or 8 weeks - you just get going with things.Now I take these plates out after osteotomy. I do a lot of osteotomy and I’ve had to take some plates out from other people’s work where the plate had been in for years and I’ve had great difficulty doing that. To take a plate out that has only been in a year or so takes 15 minutes and they can go home the next day and there’s no drama. The screw heads are often cold-welded onto the screws, and as the plate ages the screw heads come off, and then you have to use special excavation equipment to get the screw out. Sometimes you’re lucky and the screws come out easy, but sometimes it’s really hard and it becomes a very difficult operation and causes discomfort because you have got to go excavating to get them out.
Every single person, or virtually everyone, says it feels a lot better once the plate has been removed. This is interesting because a lot of people think they feel very, very good and then you take the plate out and you ask that question and they are amazed that there is again improvement.
Ok, it’s a second operation, and actually because we get a little bit caught up in the consultation it’s something that perhaps people don’t even realise or we don’t discuss properly and tell them explicitly that we will be taking this plate out, because you don’t need to. It comes as a bit of surprise when you say, “well, we will be taking the plate out”, and the patient opens their eyes wide and says “What - another operation?”. They have been through quite a lot with the osteotomy and the thought of having another operation is obviously quite upsetting and worrying and all the rest of it, but it is a very small operation. They go home the same day or the next day.
Obviously I am a real believer in osteotomy, and I am one of the people in Europe rooting for osteotomy now. We’ve got a really exciting group that I’m part of within the organisation of ESSKA, we are going to be running a fellowship programme through ESSKA here, training European surgeons coming into Basingstoke, and will be presenting our data. We keep a very close eye on all of the patients and everyone signs up to being in a long-term follow-up database, and our results are very encouraging.
In the UK we run two courses every year – one in Newcastle, which is coming up in June for the second time, and for the last 8 years I’ve run one in Basingstoke with a great group of UK and European surgeons. We get between 70 and 100 surgeons coming through, mainly consultants, and we train them up. More and more of those surgeons are now going to get on their own learning curve, and are doing osteotomy surgery, so we are seeing a national increase year on year of delegates with that course. But when we compare the UK with what goes on in say, Germany - where they’re doing 10,000 osteotomies a year - we are only doing 1000. I think as we continue to push the education, as we do more and more of this type of work with patients to actually promote osteotomy I think you’ll find that osteotomy will grow and grow in the UK and offer help to a great many patients.
The injury caused the one half of the tibial plateau to crack and tilt.