Various treatment options for osteoarthritis discussed with special focus on High tibial osteotomy which forms the main stay of definitive treatment for early medial compartment OA knee

1. Management of
Osteoarthritis of knee by
High tibial osteotomy –
An alternative to TKR
Dr.Santhosh Raj B K
Post graduate 1st year
Department of Orthopaedic Surgery
Prof.Dr.Rajarajan unit

2. Osteoarthritis of knee
Osteoarthritis is a chronic degenerative disorder characterised by cartilage loss.
It is extremely prevalent in society and is a major cause of disability.
It is important to treat osteoarthritis effectively using a multidisciplinary approach tailored to the
patient’s needs

3. What Happens in Osteoarthritis?
In healthy joints, cartilage covers the end of each one. It provides a smooth, gliding surface for
joint motion and acts as a cushion between the bones.
In OA, this cartilage breaks down, leading to pain, swelling and problems using the joint.
Changes also occur in the underlying bone. Bony growths called spurs develop on the edges of
the joint.
Bits of bone or cartilage may float loosely in the joint space.
The membrane lining the joint (the synovium) often becomes inflamed, leading to joint swelling.

5. Risk factors
The risk factors for OA can be divided into those that act at the level of individual susceptibility and
those that alter the biomechanical stability of individual joints
Person-level risk factors include increasing age, female sex, joint biomechanics, genetic factors
and adiposity.
The predominant joint-level factors are joint injury, repetitive joint use through occupation or leisure
and joint malalignment.

6. PATHOLOGICAL FINDINGS
Macroscopy
• Osteoarthritic process results in cystic degeneration of the
bone surrounding the joint,
• Loss of cartilage
• Irregular, abnormal bone formation at the edges of the joint

7. Pathological findings
Microscopy
• There is flaking and fibrillation of the articular cartilage
• Destruction of the cartilage microarchitecture with formation of holes within it, as well as
bony cysts

8. CLINICAL FEATURES
Patients are usually over the age of 50
Pain and stiffness in the affected joint, which is exacerbated with activity and relieved
by rest.
Early morning stiffness, if present, is typically less than 30 minutes.
Joint tenderness
Crepitus on movement
Swelling may be due to bony deformity such as osteophyte formation, or due to an
effusion caused by synovial fluid accumulation.
Systemic symptoms are absent, with a normal erythrocyte sedimentation rate.

9. INVESTIGATIONS
Imaging
Plain radiographs
The following changes may be seen on plain radiographs
• Joint space narrowing.
• Osteophytes.
• Bony cysts.
• Subchondral sclerosis.
.

10. Magnetic resonance imaging
Used in assessing
Ligament status
Meniscal tears
It has no place in routine clinical assessment of osteoarthritis, but may be a specific and sensitive
way of quantifying cartilage loss.

12. Investigations
Blood tests
Patients would often have blood tests
• Rheumatoid factor
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein
To rule out other conditions.
However, these tests are not essential as a diagnosis can be made in their absence

13. Kellgren Lawrence classification

14. Management
The aims of management of patients with osteoarthritis are:
• Patient education.
• Pain control.
• Improve function.
• Alter the disease process.
Each management plan should be individualized and patient centred, agreed
on by the patient and doctor in a mutual discussion.

15. Treatement options
Management interventions in osteoarthritis include:
• Education.
• Exercise.
• Weight loss.
• Physiotherapy.
• Assisted weight bearing appliances.
• Drugs.
• Surgery.

16. Surgical options
Surgery is used when medical therapy has reached its limits.
•Arthroscopic debridement and lavage can improve symptoms in degenerative meniscal tears, but
does not halt progression.
•Autologous cartilage transplantation, where grafts of normal cartilage are taken from the edge of
the diseased joint
•Osteotomy in early osteoarthritis helps to relieve symptoms and slow the rate of progression.
•Joint replacement surgery

17. High Tibial Osteotomy
High tibial osteotomy (HTO) is a widely performed procedure to treat medial knee arthrosis
For relatively young patients who require greater knee preservation, a surgical treatment with low
operation trauma and revision rate is needed. Osteotomy around the knee, based on the notion of
“knee preservation,” has been chosen as an alternative surgical treatment. Cutting and realigning
the bones corrects the mechanical line of lower limb force bearing. As such, osteotomy around the
knee retains normal anatomical structure and obtains good functional recovery of the knee joint.

18. Goals
The goals of HTO are twofold:
1) To reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral
compartment in varus knees
2) To delay the need for a knee replacement by slowing or stopping destruction of the medial joint
compartment.

19. Preoperative assessment
Indications
Appropriate patient selection is a key to a successful HTO.
Primary or secondary medial compartment degenerative arthritis is the most common indication for
HTO
The ideal candidate for HTO
• Age 45 to 65 years
• Isolated medial osteoarthritis with a varus deformity
• Good range of motion (ROM)
• Without ligamentous instability

20. Medial compartment OA

21. Preoperative assessment
Contraindications
• Severe joint destruction
• ≥65 years of age
• Advanced patellofemoral arthritis
• <90degree of ROM,
• ≥15degree of flexion contracture,
• Joint instability
• ≥1 cm lateral tibial thrust
• ≥20degree of correction
• Rheumatoid arthritis

24. Radiographic assessment
Multiple views should be obtained for preoperative radiographic assessment
•Bilateral weight-bearing anterior-posterior views in full extension
•Lateral views
•Skyline views
•Lower limb alignment can be assessed from the full length scannogram of the lower extremity that
visualizes the alignment of the hip, knee, and ankle joints.
•Magnetic resonance imaging can be helpful in detecting intraosseous lesions, meniscal tears,
ligamentous lesions, osteochondral defects, osteonecrosis, or subchondral edema

25. Alignment of lower limb

26. Scannogram lower limb

27. Correction angle calculation
Closing wedge HTO
The weight-bearing line is determined by measuring from
the point located at 62.5%(Fujisawa point) of the width of
the tibial plateau to the center of the femoral head and the
center of the ankle. The angle (α) formed at the
intersection of these weight bearing lines represents the
angle of correction. The wedge bone that constitutes the α
angle is to be removed.

28. Correction angle calculation
Opening wedge HTO
The weight-bearing line is determined by measuring from
the point located at 62.5% (Fujisawa point)of the width of
the tibial plateau to the center of the femoral head and the
center of the ankle.
The α angle is calculated and transferred to the osteotomy
site to open the proximal tibia.

29. Open wedge osteotomy

30. Intra operative alignment

31. Cases done in ESIC

35. Thank you