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Osteotomies of the Knee

by Amir Jamali, MD

Date last updated 04/29/2017

Osteotomies are the mainstay of the concept of joint preservation surgery. Many of our younger patients are not candidates for joint replacement. Our goal is to provide pain relief and return to activities with their own native joint. Osteotomies are surgeries to realign the bones. They are helpful in cases of localized arthritis or deformities. We use a variety of techniques to make these corrections including combinations of these surgeries with cartilage restoration surgeries and ligament reconstructions.

High Tibial Osteotomy

Osteotomy is defined as “the surgical division or sectioning of bone”.   Osteotomies are commonly used in the treatment of deformities from congenital or traumatic conditions. Osteotomy has also been applied to cases of knee arthritis isolated to one part of the knee with relative sparing of the other parts. In such cases, the alignment of the leg can be changed to shift the weightbearing line from an area of more damaged cartilage to that of healthy cartilage. High tibial osteotomy is aimed at changing the alignment of the knee to unload the medial (inner) aspect of the knee. It has been widely employed over the past 30 years in cases of isolated medial compartment athritis. The osteotomy for this indication is usually performed on the tibia to maintain the joint parallel to the ground. Early osteotomies were associated with a high rate of complications such as wound breakdown, delayed union, nerve injury, and difficulty with conversion to total knee replacement. More recent advances in fixation technology and our understanding of this procedure have led to a lower complication rate. Traditionally, the osteotomy is indicated in very young patients who would like to continue with an active lifestyle and have isolated arthritis of the medial compartment of the knee such as after a meniscectomy. We perform the procedure using a plate on the inner aspect of the tibia and occasionally use bone graft from the patient’s iliac crest or from a bone bank. Patients are kept in the hospital for 1-2 days and are on crutches for about 6 weeks after the surgery.

High Tibial Osteotomy Clinical Case

The patient is a 17 year old male who had a motorbike accident with an upper tibial fracture just below the growth plate. He developed a knock kneed (valgus) deformity which caused him substantial knee pain.

1.This xray at the time of the injury shows the fracture below the growth plate (white arrows)

 

2.Standing alignment radiographs show that he has developed a knock-kneed (valgus) deformity on the right side.

3.Using a specialized computer program, a computerize preoperative plan is created correcting the deformity and providing us with a guide to achieve complete correction of the deformity.

4.Postoperative images showing the use of a titanium plate and a synthetic graft to achieve the desired correction.

 

Distal Femoral Osteotomy

In cases of isolated arthritis on the outer aspect of the knee combined with a knock-knee deformity (genu valgum), one potential treatment option is an osteotomy of the end of the femur. An osteotomy is a surgical procedure where the end of the femur bone is cut and the femur is realigned to eliminate the deformity. This procedure is done to correct deformities as well as to better distribute the joint contact pressures onto the medial (inner) part of the knee. The osteotomy is usually stabilized with a plate. Patients remain on crutches for about 6 to 8 weeks until there is evidence of healing of the osteotomy. The osteotomy is a good alternative to partial knee replacement in the younger and more active age population.

Distal Femoral Osteotomy Clinical Case

The following case describes a 20 year old female with knee pain and a severe knock-knee deformity (genu valgum) of both of her knees. She had not responded to physical therapy or medications.

 

1. This long casette radiograph demonstrates the severe deformity in her femurs that is causing the knock-knee deformity. She elected to undergo a correctional osteotomy of the femur in order to help her pain as well as to decrease the chance of progression of arthritis in the outer part of her knee. The contours of the femur are traced on paper and the correction of the deformity is planned.

2.This final radiograph demonstrates the profound correction of the deformity. The osteotomy takes approximately eight weeks to heal. The patient is kept on crutches throughout this period of time.

 

References

1.            Insall JN. High tibial osteotomy in the treatment of osteoarthritis of the knee. Surg Annu. 1975;7:347-359.

2.            Mallory TH, Dolibois JM. Unicompartment total knee replacement: a 2--4 year review. Clin Orthop Relat Res. Jul-Aug 1978(134):139-143.

3.            Aglietti P, Rinonapoli E, Stringa G, Taviani A. Tibial osteotomy for the varus osteoarthritic knee. Clin Orthop Relat Res. Jun 1983(176):239-251.

4.            Brouwer RW, Jakma TS, Bierma-Zeinstra SM, Verhagen AP, Verhaar J. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2005(1):CD004019.

5.            Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg. Jul 2010;18(7):406-416.

6.            Fu D, Li G, Chen K, Zhao Y, Hua Y, Cai Z. Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis. J Arthroplasty. May 2013;28(5):759-765.

7.            Gardiner A, Richmond JC. Periarticular osteotomies for degenerative joint disease of the knee. Sports Med Arthrosc. Mar 2013;21(1):38-46.

8.            Bonasia DE, Governale G, Spolaore S, Rossi R, Amendola A. High tibial osteotomy. Curr Rev Musculoskelet Med. Dec 2014;7(4):292-301.

9.            Brouwer RW, Huizinga MR, Duivenvoorden T, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. Dec 13 2014;12:CD004019.