The surgical management of degenerative conditions of the knee joint has gained importance as millennial generations approach their 40s and the percentage of an aging population increases worldwide. HTO benefits (high tibial osteotomy) of the tibia with surgical intervention was first described in 1960. This surgical procedure serves to correct the altered mechanical axis in the knee joint with degenerative osteoarthritis (OA) of the joint (degenerative joint disease). The general and first choice of surgical intervention for the knee joint is a total knee replacement. The present study is designed to observe a comparison of the clinical significance and evidence between the two primary groups of patient participants: HTO vs knee replacement (KR).
Knee problems, particularly in older age groups of the population, are a significant component of mortality, morbidity, disability, resource use, and increased cost. Osteoarthritis (OA) is the leading cause of knee replacement in our society, and the prevalence of this condition is expected to change further with the changes in the intact population (millennial) approaching the 40-year-old category. Tibiofemoral unicompartments are of particular importance in our society. The disease continues to progress, and there is a need to extend our focus on the knee joint at all stages. To continue discussion on additional surgical interventions in this patient population, our objective is the following: to show the difference in quality of life, survival of the putative material, and assessment of management. A case that has been submitted for this topic is discussed in relation to the anteromedial approach.
HTO is a surgical method applied in the treatment of patients with knee osteoarthritis. In high tibial osteotomy, an incision is made and the upper part of the tibia bone of the knee joint is realigned to increase the contact area of the joint, hence decreasing the load per unit area and reducing, consequently, the progress of osteoarthritis. These are performed using arthroscopy to view the knee joint, and using three types of techniques: open wedge and closed wedge, and dome cutting techniques. HTO corrects the malalignment to redistribute excessive shear forces to the non- or less-affected side of the knee joint for patients who are too young and active for total knee replacement surgery. The extent of the duration of symptoms and the amount of arthritis involvement of the knee joint also become a factor in selecting the type of surgery.
Conventional indications have included patients with osteoarthritis of the knee, rheumatoid arthritis, and post-trauma and post-infection knees. The system consists of the removal of the damaged bone and cartilage surfaces and their replacement with metal or plastic components. There are two modes for the surgery to be completed in this type of surgery: cemented and non-cemented prostheses. Several factors should be considered when assessing the progression of HTO vs knee replacement. Currently, due to advances in the surgical treatment of knee osteoarthritis with a TKR, revision total knee prostheses have significantly improved results and can last for longer periods. Postoperative physiotherapy has a significant clinical impact on recovery. The clinic will, therefore, focus on evaluating the comparative effects of high tibial osteotomy and alternatives to knee replacement.
High tibial osteotomy (HTO) is a bone realignment procedure that changes the distribution of forces in the knee by correcting alignment. HTO benefits include preservation of the knee joint anatomy, repair of ligament damage, and pain alleviation in the long term. HTO benefits are recommended option for young patients with mild to moderate osteoarthritis in the medial compartment of the knee and mild valgus malalignment. Knee replacement (KR) is an intensive surgical procedure and is most effective due to its immediate pain relief effects and better post-operative radiographic alignment. The choice between HTO vs knee replacement should be based on individual and disease-specific evaluation. Additionally, preoperative patient expectations for surgery are different for HTO vs knee replacement, and most patients want to experience pain relief, restore function, and increase daily living activities. Therefore, an evidence-based strategy to provide surgical and long-term pain management guidelines for adults with knee joint osteoarthritis should be established.
The incidence is higher after HTO than in primary total joint arthroplasty. However, HTO has a more than five times higher risk of infection than primary total knee arthroplasty, and this infection mainly occurs early. The risk of lateral meniscus detachment and loss during medial meniscus dissociation is still controversial. A retrospective study showed that the overall probability of anterior cruciate ligament injury in the HTO group was 10% to 20%, while it was 80% in the young male group. Therefore, the HTO procedure is not recommended because of the risk of ACL and cartilage damage. The use of fresh or frozen meniscal allografts with high tibial osteotomy may result in loss of meniscal allograft transplants for large defects. The HTO team showed no difference in postoperative complications in studies that assessed the need for arthroplasty among patients with TKA and HTO due to osteoarthritis.
Patient selection is an important point in the decision-making process regarding high tibial osteotomy or arthroplasty. Indications, individual expectations, and social factors should be well known by the orthopedic surgeon. Malalignment with varus deformity is the main indication for high tibial osteotomy. Lateral compartment arthritis with a normal or near-normal function of the knee joint should be present. If there is a misalignment of less than three degrees and the knee joint is stable, the mechanical axis should always pass through the midline of the knee joint. Alternatively, a full-length radiograph may be used to evaluate the standing axis if it concerns the posterior tibial slope, which may be the main cause of the malalignment. In the presence of an elevated varus angle, simultaneous valgus stress radiographs should be examined to predict the progression and identify the patients who may be responsive to a knee realignment vs knee replacement procedure. Diffuse degenerative changes in all three compartments are not a contraindication for high tibial osteotomy. The main absolute contraindication for a high tibial osteotomy is inflammatory arthritis.
The patient’s expectations or the expected activity levels must be known by both the patient and the orthopedic surgeon. Better pain relief should be achieved by high tibial osteotomy at all levels of activity during normal daily activities, heavy or light athletics, and at work alternatives to knee replacement. The patient’s demands and preferences, occupation, marital status, activity level, smoking, and drinking habits should all be considered before surgery, as these factors can prognosticate the outcome. Patients should receive objective preoperative counseling and education on the most likely postoperative outcome. This is to prevent the patient from conceiving the expectation that the preoperative activity level can be achieved after the osteotomy on its own, or alternatively for the patients to expect less than the maximum potential if they also receive tailored advice. The treatment should not negatively influence significant life events of the patients. While performing the surgery for high tibial osteotomy or total knee arthroplasty, clean and full technical competence is the most effective indicator of an excellent outcome. When considering risk factors, bone pathology or osteoporosis, age, and comorbidities may be identified. In particular, elderly patients are dealt with on a less favorable basis, as there is an increased likelihood of complications and a mild to fair functional gain. The decision-making process has been defined by comparative studies that were performed to provide insight for shared decision-making in elderly patients with suboptimal evidence-based indications within current guidelines, but there is a broad literature that can define the patients who have positive indications for the application of these methods. Consequently, for the high tibial osteotomy and total knee arthroplasty controversy, the deciding balance is often an ambiguous choice between interconnected or comparable approaches. Specifically, arthritic varus knees with moderate to high functional demands may not be properly managed. Consequently, further research is required, particularly in relation to patient-centered priorities, to more clearly demarcate preferred high tibial osteotomy and total knee arthroplasty prognosis.
Recovery after high tibial osteotomy explained: It is an often slow and sometimes frustrating process. Many patients are non or limited weight-bearing for six weeks, followed by a slow progression toward putting their full weight on their operated leg. The early part of rehabilitation is focused on pain control, swelling management, limits in positioning the leg, and protection of the repair, which is more likely identified as a nonunion. Between six and twelve weeks, most patients are evaluated and given the “green light” to begin progressing their rehabilitation and activity under the care of physical therapy. Many orthopedic surgeons utilize a rehabilitation protocol that is specific for their patient population. With more orthopedic surgeons performing reconstructive procedures, the use of rehabilitation protocols is becoming more standardized. There are no randomized controlled studies to date on different rehabilitation programs and what is the optimal rehabilitation following osteotomy.
Patients who have high tibial osteotomies receive their rehabilitation programs from their surgeon. It is believed that with the various surgical techniques for high tibial osteotomy, the rehabilitation program should be individualized. Resorting to such programs as home-based protocols without the use of physical therapy may enhance a patient’s successful recovery with a high rate of union. Pain can be a complicating issue in the recovery process. It can be managed by prescription medication or over-the-counter pain relief. There are also many programs utilizing physical therapy for guided range of motion exercises and strengthening that have had successes as well. It is important to not forget patients who have undergone the closed wedge or dome; although these patients are weight-bearing, they usually have significant bone pain for months as the bones unite. It is essential for surgeons and patients to have goals and milestones set in the recovery process. There are complications that can occur during this time period that could alter rehabilitation. Significantly fewer complications have been reported following the opening wedge compared with the traditional closing procedures. Any swelling or effusions in the joint usually decreases. Physiotherapy and strength building have had successes as well. It is therefore critical at 12 weeks to begin to establish rehabilitation goals that need to be met for a return to normal activities. During this crucial phase, deformity correction is important.
The future in knee realignment vs knee replacement procedures highlights the emergence of new techniques and surgical options. Both HTO vs knee replacement can now be offered to patients through a minimally invasive approach. The use of robotics and intelligent instrumentation to visualize and communicate optimal alignment surgeries is at the forefront in aiding the surgeons during knee realignment vs knee replacement procedures. Many studies and research are ongoing to review the use of stem cell therapy in knee realignment surgeries and how the current advancements might benefit these surgeries for quicker healing, better results, and recovery of the patient. The future of stem cell technology will provide a more beneficial understanding of the use of these cells in knee realignment vs knee replacement surgeries for a quicker healing phase and recovery.
The future of implant material development and designs for higher longevity functions and customized designs and patient-specific implants can be the future of these surgeries. Ongoing main research studies include cartilage healing and recovery through conjugate healing techniques and transplant. Ongoing research in knee replacements aims to develop robotic and AI technologies providing visual designs for the correctable alignment of the lower limb for better knee replacement outcomes. Ongoing clinical research into outcomes and the role of dual mobility in young active patients has encouraged the use of dual mobility to further reduce the dislocation risk in high flexion knee replacement designs. This progress in AI, robotics, and patella eversion technique application requires greater training and techniques for surgeons and a knowledgeable understanding of their use in knee surgery, and this knowledge dissemination is of paramount importance in understanding the best knee realignment vs knee replacement techniques to plan for and provide the best outcome. In summary, these future realignment surgeries provide added information where potential progress can occur together with research progress, increasing our knowledge in providing better future personalized outcomes in the long term for our patients.
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