Osteotomy

(Realignment Of The Knee)

Osteotomy can relieve pain and delay the progression of arthritis in the knee. It can allow a younger patient to lead a more active lifestyle for many years. Even though many patients will ultimately require a total knee replacement, an osteotomy can be an effective way to buy time until a replacement is required.

Osteotomy literally means “cutting of the bone.” In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then repositioned to relieve pressure on the knee joint.

Knee osteotomy is commonly used to realign your knee if you have arthritis damage on only one side of your knee. The aim is to shift your body weight off the damaged area to the other side of your knee, where the cartilage is still healthy. After removing a wedge of your shinbone from underneath the healthy side of your knee, the shinbone and thighbone can bend away from the damaged cartilage.

A good way to think of this is to imagine the hinges on a door. When the door is shut, the hinges are flush against the wall. As the door swings open, one side of the door remains pressed against the wall as space opens up on the other side. Removing just a small wedge of bone can “swing” your knee open, pressing the healthy tissue together as space opens up between the thighbone and shinbone on the damaged side so that the arthritic surfaces do not rub against each other.

Knee osteotomy is most commonly performed on people who may be considered too young for a total knee replacement. Total knee replacements wear out much more quickly in people younger than 55 than in people older than 70. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years or more.

Why it’s done

Articular cartilage allows the ends of the bones in a healthy knee to move smoothly against each other. Osteoarthritis damages and wears away the cartilage — creating a rough surface.

When the cartilage wears away unevenly, it narrows the space between the femur and tibia, resulting in a bow inward or outward depending on which side of the knee is affected. Removing or adding a wedge of bone in your upper shinbone or lower thighbone can help straighten this bowing, shift your weight to the undamaged part of your knee joint and prolong the life span of your knee joint.

Osteoarthritis can develop when the bones of your knee and leg do not line up properly. This can put extra stress on on either the inner (medial) or outer (lateral) side of your knee. Over time, this extra pressure can wear away the smooth cartilage that protects the bones, causing pain and stiffness in your knee.

Advantages and Disadvantages

Knee osteotomy has three goals:

  • To transfer weight from the arthritic part of the knee to a healthier area
  • To correct poor knee alignment
  • To prolong the life span of the knee joint

By preserving your own knee anatomy, a successful osteotomy may delay the need for a joint replacement for several years. Another advantage is that there are no restrictions on physical activities after an osteotomy – you will be able to comfortably participate in your favorite activities, even high impact exercise.

Osteotomy does have disadvantages. For example, pain relief is not as predictable after osteotomy compared with a partial or total knee replacement. Because you cannot put your weight on your leg after osteotomy, it takes longer to recover from an osteotomy procedure than a partial knee replacement.

In some cases, having had an osteotomy can make later knee replacement surgery more challenging.

The recovery is typically more difficult than a partial knee replacement because of pain and not being able to put weight on the leg.

Because results from total knee replacement and partial knee replacement have been so successful, knee osteotomy has become less common. Nevertheless, it remains an option for some patients.

The Procedure

Most osteotomies for knee arthritis are done on the tibia (shinbone) to correct a bowlegged alignment that is putting too much stress on the inside of the knee.

There are two types of osteotomy – “closing wedge osteotomy” and “opening wedge osteotomy”. For closing wedge osteotomy a wedge of bone is removed from the outside of the tibia, under the healthy side of the knee. When the surgeon closes the wedge, it straightens the leg. This brings the bones on the healthy side of the knee closer together and creates more space between the bones on the damaged, arthritic side. For opening wedge osteotomy cut is made in the tibia, under the worn inner side of the knee. When the surgeon opens up this cut to create a wedge shaped gap, it straightens the leg. Bothe techniques bring the bones on the healthy side of the knee closer together and creates more space between the bones on the damaged, arthritic side.

As a result, the knee can carry weight more evenly, easing pressure on the painful side.

Osteotomies of the thighbone (femur) are done using the same technique. They are usually done to correct a knock-kneed alignment.

Candidates for Knee Osteotomy

Knee osteotomy is most effective for thin, active patients who are 40 to 60 years old. Good candidates have pain on only one side of the knee, and no pain under the kneecap. Knee pain should be brought on mostly by activity, as well as standing for a long period of time.

Candidates should be able to fully straighten the knee and bend it at least 90 degrees.

Patients with rheumatoid arthritis are not good candidates for osteotomy. Your orthopaedic surgeon will help you determine whether a knee osteotomy is suited for you.

Osteotomy FAQs

Most patients can begin physiotherapy around six to eight weeks after surgery. Unlike other surgical treatments for arthritis, osteotomy relies on bone healing before more vigorous, weight bearing exercises in the gym can begin. In the best scenario, people respond to strengthening exercises and stop wearing the brace after the first three to six months of therapy.

Light exercise is one of the most effective ways to relieve arthritis pain by stimulating circulation and strengthening the muscles, ligaments, and tendons around your knee. Strong muscles take pressure off the bones so there is less grinding in the knee joint during activities. In conjunction with a healthy diet, exercise can also help you lose weight, which takes stress off your arthritic knee.

 

In the first few weeks of rehabilitation, your physical therapist usually helps you stretch the muscles in the hamstrings, quadriceps, and calves while flexing and extending your knee to restore a full, pain-free range of motion.

When pain has decreased, physicians generally recommend at least 30 minutes a day of low-impact exercise a day for patients with arthritis. You should try to cut back on activities that put a pounding on your knees, like running and strenuous weight lifting.

Cross-training exercise programs are commonly prescribed when you have arthritis. Depending on your preferences, your workouts may vary each day between cycling, cross-country skiing machines, elliptical training machines, swimming, and other low-impact cardiovascular exercises. Walking is usually better for arthritic knees than running, and many patients prefer swimming in a warm pool, which takes your body weight off your knees and makes movement easier.

Strength training usually focuses on moving light weights through a complete, controlled range of motion. You should generally avoid trying to lift as much as possible with your quadriceps and hamstrings. Your physical therapist typically teaches you to move slowly through the entire movement, like bending and straightening your knee, with enough resistance to work your muscles without stressing the bones in your knee.

Once your physical therapist has taught you a proper exercise program, it is important to find time each day to perform the prescribed exercises.

You will likely feel pain or discomfort for the first week at home after an osteotomy, and you will be given a combination of pain medications as needed. A prescription-strength painkiller is usually prescribed and should be taken as directed on the bottle.

Swelling in your leg usually decreases over a span of three to six months after surgery. There may be some minor bleeding for a few days, but by the time you are released from the hospital, most bleeding should have stopped. If you notice an increase in swelling or bleeding, you should call your physician.

Physicians generally recommend that you avoid putting stress on your knee until the bones have healed. Putting weight on your knee too early may damage the bone surface and prolong healing time.

 

  • Icing your knee for 20 or 30 minutes a few times a day during the first week after an osteotomy will help reduce pain. Ice therapy may need to intermittently continue for a few months if pain bothers you.
  • As much as possible, you should keep your knee elevated above heart level to reduce swelling and pain. It often helps to sleep with pillows under your ankle.
  • Immobilize your knee in the prescribed, hinged knee brace for about six weeks. You may remove the brace for brief periods to perform passive motion exercises with the aid of a physical therapist or a CPM machine. Range of motion exercises are important for healing. Regaining full extension is just as important as bending your knee.
  • Your leg may appear slightly bent after the surgery as it heals into its new alignment.
  • Most patients have to keep the incision dry for seven to ten days. Your physician can recommend a surgical supply store that sells plastic shower bags. Wait until you can stand comfortably for 10 or 15 minutes at a time before you take a shower.
  • Crutches or a cane may be needed for between six and ten weeks, depending on the pain. It is difficult to describe the amount of pain any given patient will experience.
  • Six weeks after surgery, your physician usually gives you a check-up. X-rays can determine how your bones are healing and whether you are ready to begin rehabilitation.

You may have to take between six weeks and six months off from work, depending on how much you rely on your knee to perform your job.

After rehabilitation, preventing osteoarthritis is a process of slowing the progression and spread of the disease. Because patients remain at risk for continued pain in their knees after treatment, it is important they are proactive about managing their conditions.

A fall or torque to the leg during the first two months after surgery may jeopardize the healing of your bones. You should exercise extreme caution during all activities, including walking, until your physician determines that your bones have healed.

Maintaining aerobic cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic knee than occasional, heavy exercise.

When you have arthritis in your knees, it is especially important to avoid suffering any serious knee injuries, like torn ligaments or fractured bones, because arthritis can complicate

knee injury treatment. You should avoid high-impact or repetitive stress sports, like football and distance running, that commonly cause severe knee injuries. Depending on the severity of your arthritis, your physician may also recommend limiting your participation in sports that involve sprinting, twisting, or jumping.

Because osteoarthritis has multiple causes and may be related to genetic factors, no simple prevention tactic will help everyone avoid increased arthritic pain. To prevent the spread of arthritis, physicians generally recommend that you take the following precautions:

  • Avoid anything that makes pain last for over an hour or two.
  • Perform controlled range of motion activities that do not overload the joint.
  • Avoid heavy impact on the knees during every-day and athletic activities.
  • Gently strengthen the muscles in your thigh and lower leg to help protect the bones and cartilage in your knee.

Non-contact activities are a great way to keeping joints and bones healthy and maintain fitness over time. Exercise also helps promote weight loss, which can take stress off your knees.

Please ask questions if you are unsure or need more clarification as it is important that you have enough information to fully weigh up the benefits and risks of surgery.

General risks of surgery include:

  • Allergies to anaesthetic agents, antiseptic solutions, suture materials or dressings
  • Pain and discomfort around the incisions
  • Nausea, typically from the anaesthetic, this usually settles down quickly
  • Bleeding from the incisions
  • Separation of wound edges
  • Slow healing – most likely to occur in smokers and people with diabetes
  • Wound infections
  • Blood Clots (Deep Vein Thrombosis or DVT, Pulmonary Embolism or PE)

What are the risks of osteotomy surgery?

  • Infection. This can be reduced by using antibiotics at the time of surgery and by using ‘clean air’ ventilation in theatre. However, infection still occurs in less than 1 in 100 cases. Deep bony infection is very rare but if this occurs and is untreated, serious problems follow.
  • Blood clots. Deep vein thrombosis (DVT) is a relatively common complication after major lower limb surgery. It is caused by the blood clotting in the veins of the leg in the deep muscles and is associated with pain and swelling of the leg, normally coming on between ten days and six weeks after surgery but occasionally occurring sooner.

Post-operative calf pain, tenderness and swelling are regarded as a serious risk and require immediate investigation and treatment. Normally, this can be done with simple ultrasound scanning and medication. If it occurs at home postoperatively, it needs emergency hospital treatment. It is not a situation to leave to the next clinic appointment.

The risks of deep vein thrombosis are: 1. Long term pain and swelling in the leg (the post-phlebitic syndrome) which may last indefinitely or 2. The clot can move from the leg into the lung, leading to pulmonary embolus. In extreme cases this can be a cause of sudden death, but more often gives rise to chest pain and shortness of breath. Patients who develop a pulmonary embolus don’t always get the typical symptoms of calf swelling first (a silent DVT).

Because of the severe nature of deep vein thrombosis, we go to significant lengths to reduce its incidence by chemical means with drugs, and with pneumatic calf pumps which are used in the pre and post-operative period. We also aim to get patients mobile quickly after the operation.

Patients already on blood thinning medication, such as Warfarin, will be taken off it temporarily so that we can use a more reversible form of treatment during surgery and then the Warfarin can be

restarted a few days after the operation. Unfortunately, despite all of this, it is not always possible to prevent every clot or pulmonary embolus.

  • Poor Bone Healing. In approximately 2 – 3% of patients, the bone may not fully heal or slip in position whilst healing. This is monitored by x-rays of the bone. Occasionally, revision surgery may be required to promote bone healing.
  • Nerve and Blood Vessel Injury. Major nerves and arteries which supply the leg are in the vicinity of the surgery. Although rare, damage to these is possible.
  • Fracture. During or after surgery the bone of the leg can break if it is overloaded so it is important to follow your specific post surgery directions and not put too much force through the leg. Fracture of bones or implants may need further surgery to correct.
  • Nerve and Vessel Injury. Major nerves and arteries which supply the leg are in the vicinity of the surgery. Although rare, damage to these is possible. Other complications include haematoma, superficial infection and knee stiffness. Please feel free to discuss these prior to surgery.

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