Realignment (Osteotomy) Surgery

Overview

Damage or wear to the knee often involves one side of the joint more than the other. In such cases, realigning the knee to place more load on the "better" side of the joint relieves symptoms while preserving function. 

"Osteotomy" literally translates as "cutting the bone". It has a long history of providing lasting relief and predates joint replacement. It has been modernised considerably and the latest techniques use very precise planning computer software to accurately judge the correction and strong plates to allow earlier resumption of weight-bearing. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction 

Osteotomy is an operation to change the alignment of a bone. In the lower limb it is most commonly done for arthritis around the knee where the arthritis involves one half of the joint. It is also done in patients with cartilage, meniscus or  ligament issues where realignment can alleviate symptoms.  The osteotomy is performed by cutting across the bone and either taking a wedge of bone out and closing the gap (which we call “closing wedge osteotomy‟) or opening a gap up (which we call “opening wedge osteotomy‟). In patients who are bow legged due to arthritis involving the medial side of the knee, the osteotomy is usually performed in the tibia and for patients who have a valgus (knock) knee, the osteotomy is usually performed in the femur.

 

Osteotomy to realign the leg has two specific goals: 

  1. a)  To improve the pain associated with wear in one compartment of the knee

  2. b) To protect the native knee and allow a more active lifestyle that would not be possible following knee replacement

Occasionally osteotomy can be performed as part of the treatment of knee ligament instability or in association with surgery to repair articular cartilage or transplant a meniscus. 

 

Hospital 

You are admitted to hospital on the day of surgery. The surgery is most commonly performed under a general anaesthetic. Leg alignment is usually changed by cutting the tibia (shin bone) just below the knee and either opening up the bone to create a wedge or cutting a wedge of bone out. The size of wedge that is opened up or removed determines the eventual alignment and this is ascertained from a combination of pre- operative planning X-rays and computer software then radiographs taken during the surgery.

After the osteotomy has been performed, patients will have a  titanium metal plate and screws inserted to secure the bone in position whilst it heals

After the wound is closed and dressings applied, a brace will be applied. The physiotherapists in hospital will help you with walking safely with crutches prior to discharge. Most patients will go home on the day of surgery or the following morning. 

Progress 

Following discharge from hospital, you will see clinic nurses at the two-week mark to check the wound. Your brace is worn for a further 4—6 weeks for comfort and confidence if helpful. It can be removed if it is found to be uncomfortable. During this period you will be have crutches to assist with walking. Weight bearing (WB) can progress up to full weight bearing once you are able and pain allows. Most patients are unable to weight bear initially as a result of the level of pain. At the 6 weeks check, x rays will be taken to assess bone healing. It is possible to resume a sedentary job 3— 4 weeks after surgery if this can be done with crutches. It is usually 2-3 months before physical work is possible and between 6—12 months before sport can be resumed. 

Results 

Osteotomy surgery usually results in good pain relief and improvement in function. Most patients feel improvement in their knee following osteotomy. A few (5% - 8%) are unimproved and 2% are worse. The improvement seen following tibial osteotomy lasts a variable time depending on how well the patient cares for the knee as well as the degree of damage already done to the knee prior to surgery and the quality of the articular cartilage in the joint. 

 

Complications 

 

Infection
Deep bony infection is rare but if this occurs and is untreated, serious problems follow. Any unexplained fever, wound redness or increasing pain should be reported to Mr Howells 

 

Blood clots
Make sure you carry out your calf pump exercises regularly and drink enough fluids to remain hydrated. Risk factors (e.g.: previous clots, a strong family history) are considered in all patients to determine whether preventative medication is required to prevent clots. You should inform Mr Howells of any such risk factors or concerns that you may have. 

A clot which travels to the lung can be fatal although this is extremely rare. Chest and calf pain can be symptoms of a clot and must be reported immediately. 

 

Bone healing problems
In approximately 2% - 3% of patients the bone may not fully heal or may slip in position whilst healing. This is monitored by X-rays of the bone. Occasionally, revision surgery may be required to promote bone healing. Poor bone healing is much more common in smokers and you should stop smoking two months prior to surgery and not recommence until bone healing is complete. 

 

Nerve and blood vessel damage
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 with Mr Howells 

X Ray image from during knee realignment surgery. Nick Howells Specialist Knee Surgeon Bristol, Bath, Cotswolds