High Tibial Osteotomy and Distal

What Is Knee Osteotomy? (High Tibial Osteotomy and Distal Femoral Osteotomy)

Osteotomy literally means “cutting of the bone.” Knee osteotomy is a procedure in which the shin bone (tibia) or thigh bone (femur) is controlledly cut near the knee joint, then realigned and fixed in place.

The basic principle of this surgery is to shift the weight-bearing axis of the knee. The aim is to take the load off the (damaged) compartment where osteoarthritis and excessive load are present, and transfer it to the healthier compartment. This reduces pressure in the damaged area, relieves pain, and slows further wear of the cartilage.

There are two main types:

1. High Tibial Osteotomy (HTO): Generally performed in patients with osteoarthritis on the inner side of the knee (medial compartment osteoarthritis) accompanied by bow-leg (varus) alignment. The procedure is performed on the upper part of the shin bone (tibia) near the knee joint.
2. Distal Femoral Osteotomy (DFO): Generally performed in patients with osteoarthritis on the outer side of the knee (lateral compartment osteoarthritis) accompanied by knock-knee (valgus) alignment. The procedure is performed on the lower part of the thigh bone (femur) near the knee joint.

Who Is a Suitable Candidate for Knee Osteotomy?

Knee osteotomy is not suitable for every patient with knee osteoarthritis. Ideal candidates for this surgery must meet certain criteria:

• Single-Compartment (Unicompartmental) Osteoarthritis: The osteoarthritis must be predominantly confined to a single compartment of the knee (inner or outer), while the other compartments and the kneecap joint remain relatively healthy.
• Malalignment: The patient’s legs must have a noticeable bow-leg (varus) or knock-knee (valgus) deformity that needs correction. Osteotomy corrects this deformity and thereby changes the load distribution.
• Age and Activity Level: Patients who are generally under 60-65 years old, who lead or wish to lead a more active lifestyle, and who are considered too young for a knee prosthesis are preferred candidates. This surgery may potentially allow for higher activity levels compared to a prosthesis.
• Adequate Range of Motion: There should be no severe restriction of motion (stiffness) in the knee.
• Intact Ligaments: It is important that the main ligaments of the knee (cruciate ligaments, collateral ligaments) are intact.
• Normal Weight: Being overweight or obese can adversely affect the success of the surgery and increase the risk of complications.
• General Health Status: The patient should not have a serious health problem (uncontrolled diabetes, smoking, etc.) that would affect bone healing.
• Motivation: It is important to have the motivation to adapt to the long and patience-demanding postoperative rehabilitation process.

Patients with inflammatory rheumatic diseases (rheumatoid arthritis, etc.), those with advanced osteoarthritis in more than one compartment of the knee, or those with severe ligament insufficiency, are generally not suitable candidates for osteotomy.

What Symptoms Does Osteotomy Target?

Knee osteotomy primarily aims to relieve the following symptoms:

• Activity-Related One-Sided Knee Pain: Pain localized particularly to the compartment with osteoarthritis (inner or outer) that increases with activities such as walking and standing.
• Leg Deformity: A visible bow-leg or knock-knee appearance and the resulting gait disturbances.

The surgery aims both to relieve pain and to correct leg alignment.

Diagnosis and Preoperative Planning Process

The success of osteotomy surgery depends on careful preoperative planning. Prof. Dr. Murat Bozkurt follows these steps in the decision-making and planning process:

• Detailed History and Physical Examination: The patient’s complaints, activity level, and expectations are learned. Leg alignment, range of motion, ligament stability, and the source of pain are carefully assessed.
• Imaging Methods:
  
  • Standing Full-Leg X-Rays (Orthoroentgenogram): This is the most critical imaging study for osteotomy planning. It allows the entire leg, from hip to ankle, to be seen on a single film. Special measurements are taken on this film to precisely determine the leg’s mechanical axis (weight-bearing line) and the degree of deformity. The amount of correction needed during surgery is calculated based on these measurements.
  • Knee X-Rays: Standard anteroposterior, lateral, and special views of the knee joint show in detail which compartments have osteoarthritis and how severe it is.
  • Magnetic Resonance Imaging (MRI): May be requested to obtain detailed information especially about the condition of the cartilage in other compartments, the menisci, and the ligaments.
• Surgical Planning: Using the data obtained, the target location to which the weight-bearing line will be shifted (generally slightly outward for HTO, slightly inward for DFO — e.g., the Fujisawa point) is determined, and the angle of the bone cut and the exact degree of correction are planned to the millimeter.

Knee Osteotomy Surgical Techniques: HTO and DFO

The surgery is performed under general or spinal anesthesia. Arthroscopy (minimally invasive examination of the inside of the joint) is generally performed at the start of the operation to assess and treat any accompanying meniscus or cartilage problems. The osteotomy procedure is then carried out:

High Tibial Osteotomy (HTO) Techniques (For Medial Compartment Osteoarthritis and Bow-Leg):

• Opening Wedge HTO: This is the more commonly preferred method today. The bone is controlledly cut from the inner side of the shin bone, near the knee joint (without breaking the outer cortex). The cut is carefully opened at the planned angle (in a wedge shape), correcting the leg alignment. The resulting gap is typically filled with bone graft (taken from the patient’s own body or from a cadaver) or synthetic bone-substitute materials. The corrected position is fixed with a specially designed, strong plate and screws.
• Closing Wedge HTO: A triangular piece of bone is removed from the outer side of the shin bone at the planned angle. The cut ends of the bone are brought together to achieve correction and are fixed with a plate and screws or other methods. This is less commonly preferred because the risk of peroneal nerve injury is somewhat higher and it can cause shortening of the leg.

Distal Femoral Osteotomy (DFO) Techniques (For Lateral Compartment Osteoarthritis and Knock-Knee):

• The principle is similar to HTO, but the cut is made in the lower part of the thigh bone (femur) near the knee joint.
• It is generally performed as a closing wedge (bone removal) from the inner side of the thigh bone, or as an opening wedge (cutting the bone, opening it, and placing a graft) from the outer side.
• After correction, the bone is again fixed with a plate and screws.

Risks, Benefits, and Recovery Process of Knee Osteotomy

Knee osteotomy is a surgery that provides significant benefits in suitable patients but requires careful evaluation and a long recovery process.

• Benefits:
  
  • Significant reduction in pain in the compartment affected by osteoarthritis.
  • Correction of the leg alignment deformity.
  • Improvement in knee function and increased activity level.
  • Preservation of the patient’s own knee joint.
  • Significantly delaying the need for total knee replacement (a successful osteotomy can provide relief for 10-15 years or longer), or preventing it in some cases.
  • Potentially allowing higher-impact activities (such as running, with the doctor’s approval) compared to prosthetic surgery.
• Risks:
  
  • General Surgical Risks: Infection, deep vein thrombosis (DVT), pulmonary embolism (PE), anesthesia complications.
  • Osteotomy-Specific Risks:
    
    • Nonunion or Delayed Union: The cut bone failing to heal, or healing very slowly. The risk is higher in smokers.
    • Correction Problems: Undercorrection (insufficient) or overcorrection (excessive) relative to the plan.
    • Nerve Injury: The peroneal nerve in particular (which enables lifting the ankle and toes upward) is at risk in closing wedge HTO and sometimes in opening wedge HTO/DFO.
    • Compartment Syndrome: An excessive increase in pressure within the leg muscles (rare but an emergency condition).
    • Fixation Hardware (Plate-Screw) Problems: The plate or screws causing discomfort under the skin (irritation), loosening, or breaking (rare). In case of hardware irritation, it can be removed after the bone has healed (usually after 1-1.5 years).
    • Joint Stiffness: Restricted knee motion resulting from inadequate rehabilitation.
    • Persistent Pain.
    • Future Prosthetic Surgery: A knee replacement surgery that may become necessary in the future after osteotomy can be technically somewhat more difficult than in a knee that has never been operated on.
• Recovery Process:
  
  • Recovery after osteotomy is long and requires patience. The success of the surgery largely depends on adherence to this process.
  • Time is needed for the bone to heal. For this reason, after surgery it is necessary to avoid placing full weight on the leg — using crutches for 6 to 12 weeks and bearing only partial weight. It is very important to strictly follow the amount of weight your doctor allows.
  • Exercises are started early to maintain range of motion and prevent adhesions (a CPM device is sometimes used).
  • Once bone healing is complete, a program of months of intensive physical therapy is carried out to regain muscle strength, balance, and function.
  • Return to normal daily activities may take a few months, while return to more strenuous activities and sports can take 6 to 12 months.

Knee Osteotomy (HTO/DFO) in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Knee osteotomy is an important joint-preserving surgical option offered in Ankara as an alternative to knee replacement, particularly for young and active patients. The success of this surgery relies on correct patient selection, precise surgical planning, and meticulous surgical technique.

Prof. Dr. Murat Bozkurt follows the following approach to knee osteotomy in Ankara:

• Comprehensive Evaluation and Correct Patient Selection: He carefully evaluates, through the patient’s detailed history, physical examination, special X-ray measurements (orthoroentgenogram), and MRI findings, whether the patient is truly a suitable candidate for osteotomy.
• Precise Preoperative Planning: By taking detailed digital or manual measurements on the orthoroentgenogram, he calculates the targeted correction angle and the load-transfer point (e.g., the Fujisawa point) to the millimeter.
• Modern Surgical Techniques: He performs both HTO and DFO surgeries using current, reliable techniques (particularly the opening wedge method and stable plate-and-screw fixation). When needed, he also performs arthroscopic procedures for accompanying problems in the same session.
• Close Follow-Up and Rehabilitation Management: He closely monitors the critical postoperative bone-healing process and rehabilitation program, providing the guidance the patient needs to achieve the best possible outcome.

Prof. Dr. Bozkurt regards osteotomy as a valuable surgical method that relieves pain and increases functional capacity in suitable patients while preserving the natural structure of the knee.

When performed with correct patient selection and meticulous surgical technique, knee osteotomy is a highly effective joint-preserving surgical method for relieving pain and improving function related to knee osteoarthritis. However, it is important to remember that it requires a long postoperative rehabilitation process. If you are considering this treatment option in Ankara, you can consult Prof. Dr. Murat Bozkurt to find out whether it is suitable for you.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.