High Tibial Osteotomy (with or without ACL Reconstruction)

A knee replacement is best avoided until approximately 65 years of age, if possible. Although it can dramatically reduce pain from a degenerate joint, once performed it cannot be reversed and patients are advised not to do any running activities thereafter.

For younger patients, this is may be unacceptable, and if a knee replacement is performed in a younger patient, there is a higher likelihood of the need for a further, or “revision” the knee replacement (a difficult operation requiring the removal of further bone).

Often the goal is to delay the need for the knee replacement, with non-opertive measures. However some patients with degeneration limited to one side of their knee may be appropriate candidates for an “osteotomy” procedure. This procedure alters the shape of the leg, in such a manner that the weight bearing load is shared with the side of the knee which is not worn out. This reduces the pain on the damaged side, allows a limited amount of healing on that side, and allows the patient to continue with activities that involve a certain amount of running. However, it can take 6 months or more to make a complete recovery from an osteotomy, and it only delays the need for a knee replacement, rather than preventing it.

However, a significant number of young or middle aged patients are good candidates for this operation.

The operation is performed in a hospital operating theatre with the patient under a general anaesthetic.

X-ray control is used during the surgery to ensure that the correct change in angle is achieve to shift the load from one side of the knee to the other.

The operation requires a relatively long incision to expose the upper end of the leg bone, or tibia, immediately below the knee joint.

Step 1 – a cut (osteotomy) is carefully made across the tibia, this enable the tibia to be altered in shape slightly, without breaking the bone.

Step 2 – The angle is altered under x-ray control to achieve the desired shift in mechanical axis of the knee.

Step 3 – One the desired correction is achieved, this is secured with a very strong metal plate and screws. The gap in the bone is filled with either bone graft and / or a bone substitute material. The gap will eventually fill with new  bone.

The patient is placed in a ROM brace, and is only allowed to touch weight bear on the operated knee until the osteotomy has healed sufficiently. Partial weight bearing can often be started around 2 months post surgery, when a check x-ray has confirmed healing of the osteotomy.

Immediately post-surgery

• You will wake up in the recovery ward with your leg held immobile in a brace
• The wound will be closed with stitches, covered with dressings, and a heavy bandage
• A nurse will administer pain killers as required, to keep you comfortable
• You will be discharged from the recovery ward to an orthopaedic ward, when you have recovered sufficiently from the procedure
• Your surgeon will either see you in recovery, or later on that day, in the ward. At that time your surgeon will explain to you the findings at surgery and the precise procedure performed.
• You will be prescribed pain-killers, antibiotics, and a blood thinner for the duration of your stay in hospital. If you require more pain-killers than you are receiving regularly, please ask a nurse for more.
• Before discharge, the follow up arrangements will be explained to you.
• You will also be given pain killers and/or a script to control your pain a home, as well as any other medication that may be required.

Discharge to first post-operative review

• You will not be able to place any weight through the operated leg until 2 weeks post surgery
• Keep the limb elevated when not mobilizing on crutches, and keep the latter to a minimum for the first 2 weeks. This will help to reduce swelling and control pain.
• Take the medications as prescribed by your anesthetist to control pain
• You will start physiotherapy within a week of surgery, and the physiotherapist will supervise your rehabilitation along the guidelines details in the attached table
• Phone the surgeon’s rooms to make an appointment 10-14 days post surgery. Contact your surgeon earlier if there are problems.

First post-operative review

• You will be reviewed by your surgeon 10-14 days post surgery. He will assess the healing of the incisions and remove the sutures
• He will liaise with your physiotherapist if any alterations in the standard rehabilitation regimen are indicated
• You will be allowed to commence touch weight bearing with the brace locked in full extension, from 2 weeks post surgery onwards. The amount of weight bearing and range of motion will be increased as per the attached table. A second review will be schedule for 8 weeks post surgery.
• An x-ray of the knee will be performed as close to the second review as possible.
• You will continue with physiotherapy and you will be allowed to commence touch weight bearing when 4 weeks post-surgery.

Second post-operative review (8 weeks)

• The surgeon will review you and the x-rays to check healing of the osteotomy site, around 6 weeks post surgery.
• If all is well you will be allowed to bear full weight on the operated side, initially while wearing the brace. You will be weaned off use of the brace when 8 weeks post surgery.

Third post-operative review

• This will be 6 months post surgery
• Again a check x-ray will be performed a few days prior to this appointment. In most cases your bone healing will be well advanced at this stage. If so you may be allowed to slowly introduce some impact activities.

0 – 4 weeks

Weight bearing – The brace is locked for all weight bearing, but for the first 2 weeks NWB only, second 2 weeks TWB only

Brace – Locked in full extension all the time, removed for exercises only

ROM – Non weight bearing, as tolerable, active, remove brace, aim for 0-90dg

Therapeutic exercises – Heel slides 0-90dg, quads setting, calf/h’sting stretches, SLR with brace on, resisted plantar flexion

4 – 8 weeks

Weight bearing – 8 wks open brace for ambulation (PWB only) if good quadriceps control

Brace – Unlocked for exercises, remove for sleeping

ROM – Non weight bearing, as tolerable, active and active assisted, aim for full ROM

Therapeutic exercises – Progress above, remove brace for SLR if no extensor lag, cycle against low resistance if adequate ROM

8 weeks – 3 months

Weight bearing – No restrictions, if pain free. Wean off crutches when gait pattern is normal.

Brace – Wean off brace

ROM – Aim to attain and maintain full ROM

Therapeutic exercises – Step ups and down, squats 0-45dg, leg press 0-60dg, hamstring curls, CKC terminal knee extensions, balance training, increase resistance on bike

3 – 9 months

Weight bearing – Full

Brace – None

ROM – Full and pain free

Therapeutic exercises – Progress CKC exercises, treadmill walking, swimming and cycling

Return to work

Sedentary work may be possible at 2-3 weeks

Non-sedentary work may be 3-6 months depending upon the demands of work and the patient recovery

Return to driving

This is usually possible at 8 weeks, and is dependent upon the patient’s ability to use the foot pedals, and break without any hesitancy or weakness

Removal of the plate

If the plate is causing you symptoms, and/or future surgery is likely to be required, your surgeon may wish to remove the plate and screws at a suitable time. This will not be performed earlier than 18 months post surgery.