Courtesy: Dr Alan Getgood, Ashok Shyam, Ortho TV

Introduction

The session focuses on practical concepts in knee osteotomy, using real clinical cases to illustrate decision-making.
Osteotomy remains an important procedure for young, active patients with malalignment and compartmental knee pathology.
Revisiting fundamental principles is valuable because:
- These procedures can be technically demanding.
- Proper patient selection and planning significantly influence outcomes.
Many modern surgeons were strongly influenced by earlier pioneers in osteotomy techniques whose contributions helped shape current practices.

Case 1: Active Patient with Medial Compartment Pain

Patient Profile

43-year-old female.
Very active lifestyle; works as a spin class instructor.
Bilateral mild varus limb alignment.
Good quadriceps strength and muscle bulk.
Medial joint line tenderness.

Patient Expectations

Wishes to avoid joint replacement.
Goal is rapid return to high activity level.

Imaging and Alignment

Radiographs show medial compartment degeneration.
Alignment films reveal mild varus deformity.

Key Considerations

Determine whether deformity originates from:
- Tibia
- Femur
Small corrections may be treated with tibial osteotomy, depending on surgeon preference.

Osteotomy Options

Tibial Osteotomy

Advantages:

Corrects alignment across the entire knee flexion arc.
Particularly useful for activities involving flexion such as:
- Cycling
- Skiing
- Horse riding

Femoral Osteotomy

Characteristics:

Primarily affects early knee flexion range.

Leg Length Consideration

Important principle:

Opening wedge osteotomy lengthens the limb.
Closing wedge osteotomy shortens the limb.

Guideline:

If limb is already long – consider closing wedge osteotomy.
If limb is short – consider opening wedge osteotomy.

Ignoring limb length differences can lead to postoperative dissatisfaction.

Role of MRI

Possible indications:

Evaluate for meniscal or chondral pathology.
Assess lateral compartment condition.

However:

In health systems with limited resources, MRI may not be routinely required when radiographs clearly show osteoarthritis.

Treatment Performed

Bilateral high tibial osteotomy
Small correction (~6 mm).
Fixation with locking plate system.

Rehabilitation

Typical protocol:

Initial partial weight bearing.
Gradual progression to full weight bearing.

Outcome example:

Patient resumed teaching spin classes within six weeks.

Osteotomy Gap Management

Bone Grafting Debate

For small corrections (<10 mm):

Many surgeons do not graft.

For larger corrections:

Bone graft or substitute may be used.

Common materials:

Allograft chips
Autograft bone
Bone substitutes

Purpose of grafting:

Fill the osteotomy gap.
Improve stability and reduce bleeding.
Not necessarily required for union in small gaps.

Protecting the Lateral Hinge

Techniques to Prevent Hinge Fracture

Important steps include:

Correct osteotomy placement.
Complete posterior cortex release.
Adequate medial collateral ligament release.
Controlled gradual opening.

Methods Used

Possible strategies:

Hinge K-wire
Lateral hinge screw
Controlled spreading instruments
Stacked osteotomes

Goal:

Achieve controlled plastic deformation rather than sudden fracture.

Patient-Specific Instrumentation (PSI)

Advantages

Accurate preoperative planning.
Reproducible correction.
Reduced reliance on intraoperative navigation.

Current Use

Some surgeons use PSI for all osteotomies, while others reserve it for:

Complex deformities
Small, precise corrections.

Limitations

Accurate placement on bone can be challenging.
Incorrect positioning may lead to errors.

Pain Management in Osteotomy

Typical Analgesia Strategies

Spinal anesthesia
Local anesthetic infiltration
Peripheral nerve blocks
Oral analgesics

Common medications:

Opioids
NSAIDs
Paracetamol

NSAIDs and Bone Healing

Concern:

Animal studies suggest possible delayed bone healing.

Clinical practice varies:

Some surgeons avoid NSAIDs.
Others use them briefly for postoperative pain.

Opioid Considerations

Overprescription has contributed to the opioid crisis in some countries.
Short courses are usually sufficient for osteotomy patients.

Postoperative Weight Bearing

Protocols vary between surgeons:

Examples include:

Partial weight bearing for 4 weeks.
Gradual progression to full weight bearing.

Observation:

Even when unrestricted weight bearing is allowed, patients usually self-limit due to pain.

Case 2: Young Patient with Lateral Compartment Degeneration

Patient Details

29-year-old male.
Previous subtotal lateral meniscectomy.
Persistent lateral knee pain.
Valgus alignment.

Clinical Findings

Mechanical symptoms.
Stable ligaments.
Pain during pivoting movements.

Imaging

Early lateral compartment arthritis.
Valgus malalignment.

Surgical Planning

Traditional assumption:

Lateral OA – distal femoral osteotomy

However:

Detailed deformity analysis may reveal tibial-based deformity.

Key message:

Always perform full alignment analysis rather than relying on assumptions.

Treatment

Closing wedge tibial osteotomy
Demonstrated good outcomes for selected patients.

Case 3: Recurrent ACL Failure with Increased Tibial Slope

Clinical History

Multiple failed ACL reconstructions.
Medial meniscus deficiency.
Lateral meniscus root tear.

Key Findings

Increased posterior tibial slope (~17°).
Increased anterior tibial translation.

Importance of Tibial Slope

Increased posterior slope leads to:

Greater anterior tibial translation
Increased ACL graft stress
Higher risk of reconstruction failure

Surgical Options

Slope-Reducing Osteotomy

Anterior closing wedge osteotomy can:

Reduce posterior tibial slope.
Improve knee stability.

Staged Approach

Stage 1:

Correct tibial slope.

Stage 2:

Revision ACL reconstruction if instability persists.

Case 4: Hyperextension Instability

Problem

Persistent knee hyperextension after ligament reconstruction.
Relatively flat tibial slope.

Treatment Concept

Increase tibial slope using anterior opening wedge osteotomy.

Expected benefits:

Reduce hyperextension.
Improve PCL stability.

Case 5: Severe Varus Knee with Multiligament Injury

Clinical Situation

Traumatic knee dislocation.
ACL, PCL, and posterolateral corner injury.
Significant varus deformity.

Alignment Strategy

If mechanical axis lies outside the knee joint, consider:

Double-level osteotomy
- Tibial correction
- Femoral correction