Management of OA Knee by HTO

1. Synopsis of thesis
PRINCIPAL INVESTIGATOR
NAME : Dr. SANTHOSH RAJ B K
DESIGNATION : MS POSTGRADUATE IN ORTHOPAEDIC
ADDRESS : ESIC MEDICAL COLLEGE & PGISMR,
K.K NAGAR,
CHENNAI -78.
GUIDE:
NAME : Dr. RAJA RAJAN
DESIGNATION : PROFESSOR AND HEAD,
DEPARTMENT OF ORTHOPAEDIC SURGERY,
ESIC MEDICAL COLLEGE & PGIMSR,
K.K NAGAR,
CHENNAI - 78
CO- GUIDE:
NAME : Dr. Vignesh
DESIGNATION : ASSISTANT PROFESSOR
DEPARTMENT OF ORTHOPAEDIC SURGERY,
ESIC MEDICAL COLLEGE & PGIMSR,
K.K NAGAR,
CHENNAI - 78.
Title :

2. Evaluation of functional outcome and cartilage regeneration for medial compartment osteoarthritis of
knee joint following osteotomies around the knee
Introduction :
With the advent of global ageing, knee osteoarthritis has become one of the major chronic degenerative
diseases seen in orthopedics among middle-aged and elderly patients, which has brought a heavy
burden to the society.1,2 Osteoarthritis often results in loss of articular cartilage, which is critical to the
function of knee joint.3 Knee joints commonly affect one compartment, and it is associated with
malalignment such that a greater load is placed on the affected compartment.4 A correlation has been
shown betweenmalalignment and longitudinal cartilage loss, in both the medial femur and the tibia .5,6
Currently, high tibial osteotomies (HTO) are commonly used internationally to treat varus genicular
combined with unilocular osteoarthritis. Osteotomy can relieve the pressure of the medial compartment
of the knee, alleviate pain, delay the further development of osteoarthritis, and delay the time of total
knee replacement.7,8 High tibial osteotomy alters the weightbearing axis of the lower limb by realigning
the tibia, which changes forces on the articular cartilage within the knee, reducing the load on the
affected compartment.9
Woon-Hwa Jung et al.10 have found that the degenerated cartilage of the medial femoral condyle and
medial tibial plateau could be partially, if not entirely, covered by newly regenerated cartilage at 2 years,
after adequate correction of the varus deformity by a medial opening-wedge high tibial osteotomy
without cartilage regeneration strategies.
Literatures:
1. Giuseffi SA, Replogle WH and Shelton WR. Opening-wedgebhigh tibial osteotomy: review of 100
consecutive cases. Arthroscopy 2015; 31: 2128–2137.
2. Marks R. Knee osteoarthritis and exercise adherence: a review. Curr Aging Sci 2012; 5: 72–83.
3. Barlow T, Downham C and Griffin D. Arthroscopy in knee osteoarthritis: a systematic review of the
literature. Acta Orthop Belg 2015; 81: 1–8
4. Parker DA and Viskontas DG. Osteotomy for the early varus arthritic knee. Sports Med Arthrosc Rev
2007; 15: 3–14.
5. Cicuttini F, WlukA A, Hankin J, et al. Longitudinal study of the relationship between knee angle and
tibiofemoral cartilage volume in subjects with knee osteoarthritis. Rheumatology
(Oxford, England) 2004; 43: 321–324.
6. Parker DA, Beatty KT, Giuffre B, et al. Articular cartilage changes in patients with osteoarthritis after
osteotomy. Am Sports Med 2011; 39: 1039–1045.
7. Lee DH, Ryu KJ, Kim JH, et al. Fixator-assisted technique enables less invasive plate osteosynthesis in
medial opening- wedge high tibial osteotomy: a novel technique. Clin Orthop

3. Relat Res. 2015; 473: 3133–3142.
8. Loia MC, Vanni S, Rosso F, et al. High tibial osteotomy in varus knees: indications and limits. Joints
2016; 4: 98–1
9.o investigate the effect of arthroscopy combined with high tibial osteotomy (HTO) on cartilage
regeneration in patients with knee osteoarthritis.
Jiang Wu, Bin Zhao, Wei Luo, Xiao Chen, Qian Zhao, Fuji Ren, Huifeng Zheng and Jingmin Huang
10.To investigate the effectiveness of high tibial osteotomy (HTO) combined with arthroscopic surgery
to treat medial compartment knee osteoarthritis (KOA) and secondary arthroscopic exploration to
evaluate the outcome of cartilage and meniscus.
Zhong H, Jin Y, Liu X, Yang J, Wu S, Liu Y. [Short-term effectiveness of high tibial osteotomy combined
with arthroscopic surgery for knee varus arthritis and the results of secondary arthroscopic exploration].
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2022 Aug 15;36(8):969-975. Chinese. doi: 10.7507/1002-
1892.202204093. PMID: 35979788; PMCID: PMC9379456.
11 .To analyze the effectiveness of intra-articular MSC injection in patients who underwent HTO in terms
of clinical outcomes, radiological outcomes, and cartilage repair by a meta-analysis of the available
literature
Jin L, Yang G, Men X, Zhang J, Chen Z, Li Z, Li Y, Ma J, Dong J. Intra-articular Injection of Mesenchymal
Stem Cells After High Tibial Osteotomy: A Systematic Review and Meta-analysis. Orthop J Sports Med.
2022 Nov 23;10(11):23259671221133784. doi: 10.1177/23259671221133784. PMID: 36452339; PMCID:
PMC9703558.
12.Osteotomies around the knee -Surgical treatment of osteoarthritis
2021 THE AUTHORS. ORTHOPAEDIC SURGERY PUBLISHED BY CHINESE ORTHOPAEDIC ASSOCIATION AND
JOHN WILEY & SONS AUSTRALIA, LTD
Objectives
1. To assess the functional outcome of patients with osteoarthritis of knee treated by Osteotomy around
the knee

4. 2.To investigate the effect of cartilage regeneration in patients with osteoarthritis of knee treated with
infiltration of PRP injections intra operatively
Process
Patients with medial compartment Osteoarthritis of knee who atttend the Orthopaedic Surgery OPD will
be considered for the
Grading of Osteoarthritis of knee joint will be done based on Kellgren Lawrence classification
After attaining informed consent , based on the inclusion and exclusion criteria , patient selection will be
done and planned for DFO /HTO as a definitive procedure after undergoing meticulous pre operative
assessment as mentioned detailed in the thesis proposal
Preoperative scoring will be assessed based on three scales to assess the functionality of the patient
preoperatively which forms the first objective of the study
1.IKDC subjective knee evaluation form
2.Lysholm knee scoring scale
3.Visual analogue scale
Preoperative imaging includes MRI of the affected knee which helps in visualising the cartilage status of
the patient preoperatively which forms the part of second objective of the study
Surgery
1.We will do a diagnostic arthroscopy of knee joint for the patient which again gives idea about the
cartilage status of the patient preoperatively and depending on the findings, following procedures may
be done which will be decided intra operatively so thay we can give best possible outcome for the
patient
- ACL reconstruction
-Meniscal repair
- Abrasion of cartilages
2.PRP injection will be injected into the damaged cartilage intra operatively

5. 3.Osteotomy around the knee joint either DFO Or HTO will be perfomed based on the inclusion and
exclusion criteria
Post operative protocol
1. Static quadriceps and ankle pumping exercises on the day of surgery
2. Non weight bearing walking for 6 weeks
3. Partial weight bearing 6 to 12 weeks
4. Complete weight bearing after 12 weeks
5. Follow up evaluation at 3 months and 6 months by following means
- Standard plain radiograph to assess the axis correction
-Function outcome assessed by following scales which forms the first objective of the study
1.IKDC subjective knee evaluation form
2.Lysholm knee scoring scale
3.Visual analogue scale
- MRI / relook diagnostic arthroscopy to look for cartilage regeneration which forms the second
objective of the study
Study justification
Osteotomy around the knee ( DFO and HTON) will change the weight bearing axis to relatively
unaffected lateral compartment therefore slowing the disease progression coupled with arthroscopic
abrasion of condyle and infiltration of regenerative medicines like PRP can even halt the degenerative
disease process and nullifies the need for future TKA
Thereby achieving the objective of this study will give more benefits to the patients of ESI and adds
more value to the scientific community
Limitation of the study
Study can't be applied to older population more than 65 years of age

6. Study can't be applied to patients with severe OA knee with Grade 4 Kellgren Lawrence classification
Signature of Principal investigator - Dr. Santhosh Raj B K