1	Osteotomy for the treatment of knee arthritis Jonathan P. Keeve, MD
2	Osteotomy for Treatment of Knee Arthritis Osteotomies (Osteo ; bone, otomy ; cut) are procedures designed to re-orient or re-align the skeleton to improve function or decrease pain. Patients may have different types of deformities for a variety of reasons including congenital problems (from birth), trauma (accidents, fractures) or degeneration (arthritis). Osteotomies can be a very helpful alternative treatment when joint replacement may be inappropriate.
3	Who is a candidate? Ideally, an osteotomy patient would have: A correctable deformity (bowing or some type of mal-alignment) An active life-style Good knee motion Knee pain that interferes with daily activities
4	Why not total knee replacement? Although knee replacement is an excellent and predictable surgical procedure, many younger and more active patients are unwilling or unable to follow the permanent restrictions: No lifting more than 35 pounds No impact activities (jogging, running, singles tennis, skiing, baseball, basketball, etc.) No kneeling No heavy work activities
5	Total Knee Arthroplasty compared with Tibial Osteotomy
6	Osteotomy for Treatment of Knee Arthritis Osteotomies allow patients to retain their own joint surfaces and are more durable for heavy work or sporting activities. Osteotomies are more suitable for younger and more active patients. Prior to the actual procedure, special radiographs (x-rays) are obtained and skeletal models created on a computer. Osteotomies are then carefully planned, simulating the actual surgical procedure and allowing the surgeon to develop an optimal surgical plan. Any number of surgical alternatives can be visualized and treatment decisions can be made to develop an individual treatment strategy.
7	Osteotomy This is a computer generated drawing of a typical patient with arthritis on the inside of the right (medial) knee. This patients knee stress (mechanical axis) passes through the area of the knee where there is no remaining cartilage. The blue line demonstrates this axis and shows its relationship to the rest of the knee. Ideally, it would be found in the center of the knee (red circle.)
8	Osteotomy for Treatment of Knee Arthritis One common problem that may be treated with an osteotomy is arthritis of the knee. This may occur as a result of prior injuries, surgery or the normal aging process. If the arthritis is confined to one part of the knee, an osteotomy may allow shifting of joint stress to another area of the knee that has a better joint surface. This relieves the stress from the arthritic area and decreases pain. A wedge of bone from the pelvis may be needed to help re-align the joint and a plate and screws are used to hold the bones in position until the osteotomy heals. The result of this re-alignment procedure is durable and allows resumption of many activities that would be inadvisable with a joint replacement.
9	Principle of Osteotomy The following diagram illustrates the principle of corrective osteotomy of the knee. The deviation of the mechanical axis is first shown in the medial (inside) compartment. A wedge of bone is inserted below the medial aspect of the joint and the mechanical axis is shifted to the relatively normal lateral (outside) compartment of the knee. The red arrows demonstrate the shift in the mechanical axis.
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11	Arthroscopy and Osteotomy The first step in the surgical procedure is to perform an arthroscopic evaluation of the joint surfaces This is done to ensure adequate cartilage on the lateral side of the joint and ensure there are no other mechanical problems within the joint A microfracture procedure may be performed to stimulate the regeneration of a smooth surface in the medial compartment
12	K wire guidance A guide pin is placed with x-ray guidance at the level of the osteotomy in the tibia
13	Confirmation of mechanical axis correction The osteotomy is completed with a small saw. The osteotomy site is gradually opened to correct the alignment of the extremity with x-ray guidance
14	Osteotomy Fixation with Plate Bone graft (taken from the pelvis) is then inserted into the osteotomy defect A plate and screws are inserted to hold the osteotomy in the correct position until the bone heals
15	Osteotomy Rehabilitation The rehabilitation from an osteotomy may be slightly longer than from joint replacement, but most patients are able to resume many activities in 10-12 weeks. During the post operative period, patients are encouraged to maintain motion of the knee and anticoagulant (“blood thinners”) are prescribed to prevent blood clots. Only partial weight-bearing is permitted until the osteotomy heals, typically within 6-10 weeks. A hinged knee brace is worn for approximately six weeks.
16	Healed Osteotomy Once healing has occurred, regular activities are permitted including athletics and heavy work The plate can be removed at this time if it causes symptoms of skin irritation (10%)
17	Double Osteotomy In patients with severe deformities, it may be necessary to perform osteotomies at two levels to obtain the desired correction
18	Risks of Osteotomy Risks of the surgery to perform an osteotomy may include, but not be limited to the following: Bleeding Blood clots Infection Non-healing or delayed healing of the osteotomy Pain or numbness at the incision sites Additional operations including conversion to a knee replacement Persistent knee or leg pain Nerve or blood vessel injury Stroke, heart or lung problems Joint stiffness As with any surgical procedure, you should discuss these risks and concerns with your physician
19	Tibial osteotomy An osteotomy may be an excellent choice for an active patient with knee arthritis Although a knee replacement may eventually be necessary, most patients have excellent pain relief for 7-10 years or more.
20	Tibial Osteotomy If you have any additional questions about this procedure, please discuss them with your physician Thank you for viewing this presentation