High tibial osteotomy — an alternative to knee replacement for younger patients

For a younger, active patient with arthritis confined to one side of the knee, jumping straight to a knee replacement is not always the best first step. High tibial osteotomy (HTO) is a joint-preserving operation that can relieve pain and buy many years before a replacement is needed — sometimes avoiding it altogether.

The problem it solves

Many people with knee arthritis have it predominantly on the inner (medial) side, often combined with bow-legged (varus) alignment. This alignment concentrates the body's load onto the worn inner compartment, like a tyre wearing unevenly because the wheels are out of alignment. The result is pain on the inner side of the knee, while the rest of the joint may still be in good condition.

What a high tibial osteotomy does

An HTO realigns the leg by making a precise cut in the top of the shin bone (tibia) and changing its angle, which shifts the load away from the worn inner compartment onto the healthier outer compartment. The bone is held in its new position with a plate and screws while it heals. By offloading the damaged area, pain is reduced and the patient's own knee is preserved.

An osteotomy realigns the leg so the load passes through the healthier part of the knee — preserving the natural joint rather than replacing it.

Who is it for?

The ideal candidate is younger and active, with arthritis limited to one compartment, malalignment that is driving the wear, good movement in the knee, and a desire to remain active in ways that a replacement might limit. It is particularly attractive for patients who are considered young for a replacement, because it preserves the option of a replacement later.

How it compares with replacement

The advantage of an osteotomy is that it keeps the patient's own knee, which can allow a higher level of activity, including some that are discouraged after a replacement. The trade-offs are a longer recovery than a replacement, because bone has to heal, and the fact that it does not cure the arthritis — it offloads it and buys time. For the right patient, that time can be many years.

Recovery

Because the operation relies on bone healing, weight-bearing is restricted for a period and the early recovery is more protracted than a joint replacement. Physiotherapy is important throughout. Most patients then return to good function and activity once the bone has healed.

The bottom line

High tibial osteotomy is an important option to consider for younger patients with single-compartment arthritis and malalignment. It will not suit everyone, but for the right candidate it preserves the natural knee and delays the need for replacement. Whether it is appropriate depends on careful assessment of the alignment, the pattern of arthritis, and the patient's goals.