This booklet aims to improve your understanding of high tibial osteotomysurgeryandtherehabilitationafterwards.

Osteoarthritiscanaffectanyjointinthebodybutismorecommoninjointsinthelowerlimbweight-bearingjoints,eghipandknee.

Ajointisformedwheretwobonesmeet.Theendsofthebones,whichformthejoint,arecoveredinarticularcartilage.Thisprovidesasmooth,slipperyandlowfrictionsurfacethatalsocushionsthejoint.Healthycartilageabsorbsstressandallowsthebonestoglideacrosseachothersmoothly.

Theword arthritismeans joint inflammation. Also known as ‘degeneration’ or‘wearandtear’arthritis,osteoarthritisisthemostcommontypeofarthritisanddevelopsoveralongperiodoftime.It affects the articular cartilage,which can start towear away. Sometimes thisaffectsonesideofthekneejointmorethantheother.

PatientInformationAndRehabilitationGuidelinesFollowingHighTibialOsteotomySurgery

Anatomy

Osteoarthritis

This isanoperation,whichaims tochange theweightbearing forces thatpassthroughtheknee.Ifyouhaveosteoarthritis(wearandtear)anditonlyaffectsonesideoftheknee,itmaybeappropriatetohaveaHTO.The operation is aimed at younger patients to avoid/delay total kneereplacement.Thisisbecausetotalkneereplacementdoesrestrictactivitylevelsandhavingoneatayoungagemeansitismorelikelytowearout.

Painisusuallythecommoncomplaint.Thisoperationaimstoreduceorgetridofthe pain. It has a success rate of 70-90%. Other benefits include improvedlifestyleanddelaytofullkneereplacement.

Alternativestosurgeryinclude:

§ Conservative measures, these include painkillers anti-inflammatories,usingawalkingstick.

§ Kinespringimplantation:theinsertionofashockabsorberundertheskinbutoutsidethekneejoint.

§ A unicompartmental (or partial) knee replacement. This replaces theosteoarthriticsideofthejointandreplacesitwithmetalandplastic.Thisisstillakneereplacement,itdoesnotallowyoutoreturntohighimpactactivities (e.g. running). In younger patients it is likely towear out andrequirerevision.

§ Totalkneereplacement.Thisremainsanoptionbutinyoungerpatientsittooislikelytowearoutandrequirerevision.Italsowillnotletyoureturntohighimpactactivities.

TheProcedure

Whatishightibialosteotomy(HTO)?

Benefitsofsurgery

AlternativestoHTOsurgery

Theshinbone(tibia)iscut.Apieceofboneistakenfromthefrontofthepelvisandthisbonegraftisplacedintothecutmadeintheshin.Ametalplate(theAOTomofixplate)isusedtoholdthecuttibiaandbonegraftinplace.Thekneecanchange position so that instead of the leg being straight it can look knockedkneed.Thisisnormal.

Complicationsdooccur.Someareminorandsomerequirefurthersurgery.Itisimportant you understand this before proceeding with surgery. Examplesinclude:Complication Recordedin

literatureProfessorMcNicholas’cases

Anaestheticrisks(discussedwithyouranaesthetist)

Notrecorded

Notrecorded

Delayedbonehealing 4% 4%

Fractureintothekneejoint

4% Notrecorded

Superficialinfection 3.4-7.1% 7%Deepinfectionintothejoint

4%

Notrecorded

Complications

Theprocedure

Kneestiffness 14% Notrecorded

Deepveinthrombosis(clotinthecalf) 4% Notrecorded

Pulmonaryembolism(clotinthelung) 1-2% 7%Compartmentsyndrome

0-0.02%

Notrecorded

Temporarynerveinjury 2-25% 7%

Permanentnerveinjury 4.7-14% Notrecorded

ReflexSympatheticDystrophy(abnormalpainreaction)

0.4% Notrecorded

Furthersurgerytoknee

33%at10years54%at15years

Notrecorded

Conversiontototalkneereplacement

15%at5years47%at10years

21%at3years

Donorsiteproblems

20%

7%

Ifyousmoke,youneedtostopbeforetheoperationascontinuingtosmokecouldcausethebonenottohealandincreaserisksofchest infectionandclots inthelegortothelung.Youmaybegivenaninjectionofbloodthinnertoreducetheriskofclotproblems.Any surgical intervention can theoretically result in mortality (death), it isextremelyrareforthistohappenforthisprocedurebutrecentlegalrulingshavemandatedthisbementioned.

Anassessmentof your fitness toundergo surgery includingadetailedmedicalhistory, height, weight, blood pressure and pulse will be performed beforesurgery.Bloodtestsandahearttrace(ECG)mayalsobeneeded.

You are asked not to drink or eat anything for at least 6 hours before youroperation.You will be seen by Professor McNicholas and your Anaesthetist before youroperation.In the anaesthetic room, youwill have aneedleput into your armandwill beplacedonananaestheticmachine.Surgeryusuallytakesaround1hour.

Pre-operativeAssessment

TheDayoftheOperation

Youwillwake-upinthetheatrerecoveryroom.Onreturntothewardyouwillhavethefollowing:

§ Dressings–woolandcrepebandageonthekneeandasplint§ Dripsanddrains–theremaybesmalltubesinthebackofyourhand.You

mightalsohaveatubeintoyourbladder(catheter).§ Analgesia– thismaybeoralmedicationorpatient controlled analgesia

(PCA),whichlookssimilartoadrip.

You can be discharged from hospital if progressing well, managingexercises,andsafeonthestairs.

Thewoundistobekeptdryuntilhealedandthedressingisnottobedisturbedunlesssoiledandacleanoneapplied.Regulariceapplication(10-15minsevery1-2hours).Youwillbegivenpainrelievingmedicationstotakehomewithyou,pleasetakethese asprescribed topreventpain frombuildingup to a level that is hard tocontrol.Physiotherapy appointment arranged. Expect bruising in the thigh and lowerleg.Rememberyourscarishighlysusceptibletothesun,anduseofahigherfactorsunblockisadvised.

Returntoworkwilldependgreatlyonthejobthatyoudo(desk-basedjobs2-4weeks;manualjobs6-12weeks;jobsrequiringladdersetc.3-4months).Returntodrivingat6weeksformanualgearedcarsandautomaticcarsifitistherightlegthathasbeenoperatedon.Ifitistheleftlegthathasbeenoperatedon,youmaydriveanautomaticcaroncethewoundsarehealedat2weeks.You should notify your insurance company of the procedure that has beenundertakentoensurethatyourcoverisvalid.Forfurtherinformationfollowthisweblink:https://www.gov.uk/driving-medical-conditionsFlying is not permitted for 8weeks following surgery due to a higher risk ofdevelopingabloodclot.Forfurtherinformationfollowtheweblinkbelow:http://www.nhs.uk/chq/Pages/2615.aspx?C%20ategoryID=69

DischargeInstructions

GeneralAdvice

Youwillbeseenat2weeks,3,6,12weeksand3,6,9,12months,2,5,10yearsannuallyafterthat.

6-12weeks

Anx-raywillbeusedtocheckiftheboneishealing.Ifnot,weightbearingmayneedtoberestrictedbutthisisveryunusual.

12weeks+

Another x-ray is used to see whether the bone is fully healed. If it lookssatisfactorythecrutchesarenolongerneeded.

Ifthebonehealingisveryslowaspecialmachinecanbeusedtostimulatebonegrowth.Thisisdonearound3-4monthsaftertheoperation.

0-6weeksUsingaplatecalledanA.O.Tomofix,youwillhaveasplintonthefirstdayuntilyoucanstraightlegraise,thennosplintwouldbeneeded.Youmayweightbearastoleratedandmovementofthekneeisallowed.Youwillprobablyneedelbowcrutchesfor6-12weeks.Thefollowingexercisesneedtobecarriedout4timesaday.1. Bend and straighten your ankles briskly. Repeat 10times.

2. Lying on your back or sitting with legsstraight. Pull your toes up towards you andpush your knee down firmly against the bed.Hold5seconds.Repeat10times.

Follow-up

Rehabilitation(Physiotherapy)Programme

3.Sittingwithbacksupported.Placearolledtowelunder your knee. Pull your toes up towards you,straightenyourkneeandpushitdownagainstthetowel.Hold5seconds.Repeat10times.

4. Sitting on a chair or bed with the leg to be exercisedsupported as shown. Use a rolled towel under the heel ifsitting on a bed. Let your knee straighten in this position.Hold5seconds.Repeat10times.

5.Sitonachair.Pullyourtoestowardsyou,tightenyourthighmuscle and straighten your knee. Hold 5 seconds. Repeat 10times.

6.Sittingonthebedplaceasockonyourfoot.Placeaslipperyboard/trayunderyour footandabandaround it.Bendyourknee as far as possible. Gently pull the band to bend a littlemore.Hold5seconds.Repeat10times.

7.Lyingonyoursidesupportingyourselfonyourelbow.Rolltophipslightlyforward,usetoparmtosupportyourself in front.Keepingtoplegstraightlift it up towards the ceiling. Make sure the legstays in line with your body and toes pointforwards.Repeat20times.

VTEisacollectivetermfortwoconditions:

§ DVT (deepveinthrombosis)–thisisabloodclotmostcommonlyfoundinadeepveinthatblockstheflowofblood.

§ PE(pulmonaryembolism)–apotentialfatalcomplicationwhereabloodclotbreaksfreeandtravelstothelungs.

Whilstyouarelessmobile,especiallyduringthefirstfewweeksfollowingyourprocedure,theriskofVTEishigherbecauseofyourimmobility.

VTE(bloodclots)

ProfessorMcNicholasmayprescribeyouadailyinjectionofClexanetohelpthinyourbloodand these should last approximately14days. If this isneeded, youwillbeshownhowtoinjectthisdrugyourself.Symptoms:

§ Swelling – youwill have some swelling due to your surgery but if youhaveanyconcernspleasecallforadvice

§ Pain–anynewpainwewanttoknowabout§ Calftenderness§ Heatandrednesscomparedwiththeotherleg§ Shortnessofbreath§ Chestpainwhenbreathingin

ThingsyoucandotopreventVTE

§ Movearoundasmuchaspossible.Besensiblethough,shortandregularmovementisbest

§ Drinkplentyofwatertokeepyourselfhydrated§ Westronglyadviseyounot to smoke– thiswillhavebeendiscussed in

preopbutwecanalsoreferyoutooursmokingcessationteamwithintheHospital.

§ Move your ankle around asmuch as possible to keep your calfmusclepumping

Smallpreventativemeasurescanhaveahugeimpactonyourrecovery.Writtenby: MsAHatcher,OrthopaedicPhysiotherapistSpecialist

MrRichardNorris,OrthopaedicPhysiotherapistSpecialistProfessorMJMcNicholas,ConsultantOrthopaedicSurgeon

Editedby: MissFRashid,OrthopaedicRegistrarDatelastreviewed: April2016