Saturday, July 18, 2009

High Tibial Osteotomy

There is plenty of information around on total knee replacement but relatively little on the common surgical precursor, the high tibial osteotomy.

Osteotomy is a medical term meaning 'to cut a bone'. High tibial refers to its location, just below the knee joint. So this operation's name pretty well describes what happens. But why cut the bone?

Osteotomies are done to change the alignment of a bone and hence the angle of a joint. If your knee is bow-legged, you are taking all of your weight through the inside half of your knee. This leads to much greater rates of wear and much more pain. A high tibial osteotomy aims to straighten out your leg to evenly share the load between the inside and outside of your knee.

The are two main types of osteotomy for knee osteoarthritis. Opening wedge and closing wedge.

In an opening wedge, a cut is made in the tibia and the two sides are separated. The wedge shaped space is filled with a bone graft.
In a closing wedge, two cuts are made and a wedge shaped piece of bone is removed. The two edges are then brought together creating the desired change angle.
Both types of operation then require the bone to be fixed, usually with a plate and screws.

A high tibial osteotomy does not make the joint unworn so is looking to decrease pain rather than completely relieve it. The operation is seen as a way of delaying a total knee replacement in those considered too young. It is not suitable for everyone so individual cases need to be discussed with your surgeon.


  1. me too, had one an it sure does hurt an suck. next step knee replacement, if i don't treat it with care. it's not my wife that had it...

  2. makes an acl reconstruction seem getting a deep tissue massage.....hurts like hell

  3. I was told 2 months on crutches, 4 months of re-hab, longer to get back to "normal". They made it "same day surgery", sent me home with a pain ball which lasts 48 hours. When that emptied, I went into shock due to the extreme pain and nature of what had been done. Was taken to the hospital by ambulance for a sonar-gram and pain management. Told the next day by my surgeon, you need to get out of here asap as it is the best place to get mercer. 10 weeks of zero weight bearing, 7 months so far and still on crutches. Horrible experience and I wonder if I will ever get to where I was. Worse off now that before surgery. It been a really bad experience and God only knows where this will lead me

  4. Hi Kevin,
    In my experience, it is extremely rare for patients to be given sufficient information about the recovery period following HTO. I tell people it will be a year before they are back to "normal" and ask them to consider the serious impact the surgery will have on their life. Work and family commitments are severely affected.
    The average knee replacement patient will be walking with a cane at 6 weeks. For a HTO you will still be non weight-bearing on crutches at this stage.
    The HTO is an effective operation in the right person but even the perfect patient will be disappointed if they go into the procedure unaware of the arduous recovery.
    Same day surgery for a HTO is rather optimistic as the primary reason for delayed discharge in my experience is poor pain control.

  5. Re-covering from HTO perform in the UK, after 7 weeks now walking without crutches and back to work (on light duties) full weight bearing due to a large T shaped plate controlling the osteotomy.
    Pain was well controlled after the operation, will be having the Left knee done in December.
    So far very happey whith the operation as the original knee pain has gone

    1. I am glad to hear of your more positive experience as all I am reading on here is very negative experiences. Just came from my orthopedic doctor and am leaning in this direction.

    2. Glad to hear a more positive experience.

  6. Glad to hear it Steve, sounds like you had a good run.

    The type of internal fixation used can have a say in the speed of recovery. A Closing wedge osteotomy fixed with a decent sized plate will permit weight bearing relatively early when compared to other versions of the procedure. Sounds like this is what you had done.
    Good luck with the left, hope all goes just as well.

  7. It was a open wedge with about 8 deg of correction, its true that the quality of the surgeon is paramount my surgeon gave me some statistics of his work before we agreed on the procedure.
    He had performed 110 HTO out of which one had problems with the bone damage, one infection and 10% not completely satisfied with the end result.
    I think the outlook and exceptions of the individual will also affect the outcome of the HTO.

    All the best Steve

  8. omg. I am scheduled for an HTO on Nov 17th. All i was told is that i wouldn't be able to drive for 6 weeks. i see now that driving will be the least of my problems!!!! Now having serious second thoughts.....

  9. I am due to have a closed wedge HTO in 5 days. My surgeon says I won't be in a cast & I will be putting weight on it as soon as I can. I have high confidence in his skills. I am a little worried about pain control. They are keeping me for 1 night for that reason. I was told 3-4 months total recovery, is this right? I know there is a huge difference between opened & closed but just wanted someone else's opinion.

    1. Your right. I was completely pain free in 5 months I could walk all day with out any issues. Some pinching aches if I thought about it after long walks.

  10. Casts are rare as complete immobilization of the knee quickly leads to stiffness. Common post-operative protocols use a Range of Motion knee brace to protect the knee from sideways forces while still allowing protected movement.
    Early protected weight bearing sounds like a closing wedge. Hopefully in 3 - 4 months time you will be walking around the house independently and starting to manage longer periods on your knee.

  11. Had an Arthroscopy in june 2010 , made my condition worse, off work and limited walking until last op in oct 2012, HTO Closed wedge, now nearly five months on and feel worse than last op by 75%, nearly 2yrs off work not happy,I still maintain my original problem,pain inside and behind Patella + Knee Cap, which was there before the first operation and still exists today.

  12. HTO causes significant pain and discomfort, but is worth it in the long run (no pun intended). My advice is don't play any sports again, even rec. The consequences of messing up your knee again are huge. Just enjoy the fact you can walk with out pain.

  13. Have had two closing wedge HTO's. First one in '93 has been great. You never fully recover (muscle mass), but after a year I forgot it ever happened. Second one in '99 was not done correctly. The doctor got the leg straight instead of over correcting and placing the weight on the lateral compartment. Partial knee replacement done in '01.

  14. Please comment on how HTO may impact on the quality of TKA done later on. Have been told by one orthopedic surgeon that HTO makes the TKA more difficult.

    1. Hello Gao Rui,
      Once again there is no simple answer to this as it depends on which form of osteootomy is used (opening or closing wedge) and hence the type of internal fixation used. Having said that, as a HTO is used to buy time before a TKR, surgeons are assuming they will eventually need to replace the joint so try and leave as many options open as possible. Surgeons don't like complications and so try and balance future technical considerations with the complexities of the initial HTO proceedure.
      As a joint replacement is generally done many years after a HTO, if necessary, internal metalwork can be removed safely prior to the TKR or at the start of the replacement.

  15. I'm in my 3rd week of recovery of HTO. I researched my doctor a great deal before having the HTO done, even saw the knee replacement doc {top 1% in the US} and he recommended the HTO. I felt very comfortable going into it, did as much research as I could online before hand, asked a ton of questions.

    So far so good. Had it done on a Fri and went home on Sun. PT in home the day after I got home and now 3x per week. I'm still non-weight bearing at this point. For me the pain isn't that bad, It's controlled with Oxycodone but had to go to Vicodin over the weekend due to my doc & his colleagues being out of the office. The first night I woke up to pain at about 3:30 am, but have been ok since. I only had about 2 instances where I had to count down the time until the next dose of pain meds.

    My range of motion was 12 - 30 degrees on the first in-home PT appt. now I'm 2 - 78 degrees. I follow all the instructions given by my doc & physical therapist. I'm hoping to be back to work after this week, making it a total of 3 wks out. {I mostly sit at a desk}. I'll still be in the brace for awhile and can maneuver with the crutches pretty good now {what an arm workout}. I'm very athletic and was before I had the HTO done and I think that helped me tremendously.

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  17. I'm going to enter the discussion with reluctance, because everyone suffering from arthritis has to make the right decision for himself or herself.
    I am too young for a knee replacement, however in 2007 I had a climbing accident which destroyed the meniscus in the medial compartment of my left knee. I had bone on bone, but the lateral compartment was intact.
    My first surgeon tried an arthroscopic repair. It failed utterly. There was nothing left to repair. As a result, while deciding upon my next step, I had to wear a titanium off-loader brace with activity for eight months - used crutches when I removed the brace because my knee was so unstable.
    I'm an RN, my husband is a doctor. We researched all my options carefully and I considered a high tibial osteotomy, even met with a surgeon. After studying the high number of reported poor results and the long-term outcomes, I opted for a uni-compartmental knee replacement, researched surgeons and found exactly the doctor I wanted to do my surgery. I was wait-listed for 6 months but I didn't care. He was the doctor for me.
    The first month post-op was hell, partly because I'm allergic to most pain meds, but I rehabbed extensively and six months after surgery I literally hiked across Costa Rica - from the Caribbean coast to the Pacific coast. A year later I spent 10 days hiking and climbing in the Highlands of Scotland. I'm heading off on a week-long hiking trip in Wales this fall. My gait is absolutely normal. No "knee-walk" for me.
    My limitations? No running for exercise, although I can jog short distances if I need to. I'm not supposed to jump, especially from rock to rock, but I have done it. I've even taken some pretty significant falls-- no problem.
    If I walk too hard and too fast on cement, I do have some pain. No big deal. Don't even need Tylenol.
    I'm hoping the implant will last 15 years and then, if necessary and if possible, I'll get another. My goal was to avoid a total knee and continue with my usual activities. This uni-compartmental knee replacement has been an unqualified success for me.
    I can swim, bike, hike, waterski, cross-country ski. I still play basketball and volleyball.
    Soccer is out as is downhill skiing but that's life.
    A lot of doctors don't offer a uni-compartmental knee replacement. It's not for everyone. It's most successful in patients who are younger, active, have disease in only one compartment, and are not overweight.
    I have zero regrets.