Tibial osteotomy – wedge resection

This is a joint-preserving surgery. The procedure is highly beneficial for patients with osteoarthritis on the inner side of the knee. The principle behind the surgery is to shift the weight from the inner side of the knee to the center or outer side of the knee. The idea is that when the tender inner side is relieved of pressure, the pain will subside over time. It is a good alternative to a partial knee replacement (Unikne).

Too few knee patients in Denmark are treated with osteotomy due to tradition and ignorance among practitioners. 

Tibial osteotomy

A tibial osteotomy is also called a wedge procedure, since either a wedge is removed or created/inserted in the upper part of the tibia. A tibial osteotomy can be helpful if you have osteoarthritis or simply damaged cartilage on the inner side of the knee (or outer side). If you are even slightly bow-legged, you will experience increased stress on the inner side of the knee (varus knee). This means that most of your weight is concentrated precisely on the tender spot in the knee. A tibial osteotomy corrects the angle of the knee. This means that the weight is transferred to the center of the knee and/or slightly to the healthy outer side of the knee.

By relieving the damaged cartilage, the pain can slowly disappear and the damaged cartilage can regenerate slightly over time. 

Femur osteotomy – knee wedge surgery

Sometimes the correction is not in the tibia but in the femur (just above the knee). Sometimes the correction needs to be made in both the tibia and femur. I have chosen to write more about femur osteotomy elsewhere and you can read about it here.

Why not just a new knee or half a new knee?

Firstly, a new knee (total knee replacement) is not always a good thing and if it doesn’t turn out well, that’s too bad. Secondly, a knee replacement does not last indefinitely. Next, the level of function is typically higher after a tibial osteotomy, with many returning to running.

How long does wedge surgery last?

A tibial osteotomy typically lasts a minimum of 5 and about 2/3 last more than 20 years. The earlier, the longer. Before surgery, you will need to undergo a special X-ray examination to calculate the exact correction angle needed.  

What is the alternative to a tibial osteotomy?

An alternative to a tibial osteotomy is to use a brace. You then use the splint when you put strain on your knee, i.e. while walking or running. The principle is a spring built into the splint that absorbs the load on the inside of the knee. A wedge in the shoe might help a little bit, but if you’re just a few degrees off the wheel leg (not always visible), it won’t help.

How young should you be?

Many orthopedic surgeons think this surgery is only for middle-aged people, but it can be performed in both young people and up to 80 years old.

Surgery with an Ibalance wedge

During the operation, the tibia is opened on the inside and, using a special, highly advanced guide system, the bone is cut 3/4 across and a plastic wedge is inserted. This corrects exactly the number of degrees that the surgeon has measured in advance. The bone will be approximately ½ cm longer, which is usually not a problem. The plastic wedge is attached with four plastic screws. The plastic material mimics the bone and is left in place and only very rarely needs to be removed. The method is called IBalance, a proven method. The method is very safe and precise and has many advantages compared to using a metal plate.  

Watch animated youtube video here

Surgery Using the Loqteq Splint

For major corrections, the Ibalance wedge isn’t suitable, so I use a more standard splint (Loqteq) instead.

After surgery

After the surgery, you will be in the recovery room. I will come and inform you about the surgery.  

Aches and pains

During the surgery, a local anesthetic will be applied around the knee and you will receive a nerve block. This will keep the pain at bay for the first 14 hours or so.

It’s normal to have pain in the first few weeks and you can reduce this by placing ice wrapped in a towel on the knee. This can be applied for 20 minutes every hour. You will also be given some painkillers and a prescription for additional medication.

After Discharge: Ibalance

A splint will be fitted that allows you to bend your knee. You must wear this splint for 6 weeks; it will protect your leg from breaking until the bone has healed sufficiently. After 2 weeks, you can open the brace when you’re sitting on a sofa. After 4 weeks, you can remove the brace while you’re sleeping and taking a shower. For the first 2 weeks, you may only put 5 kg of weight on your leg, and after those 2 weeks, you may put 20–40 kg of weight on it (if you’re unsure how much that is, press down on a bathroom scale with your leg). After 4 weeks, you may bear your full weight. You should expect your lower leg, including your foot, to be swollen during the first few weeks after surgery. It’s also common to experience bruising and soreness (which can be alleviated with gel).  

To prevent deep vein thrombosis, you should take a preventive pill once a day for 10 days. It is common to take strong pain relievers after surgery, such as morphine. Since morphine often causes constipation, it’s a good idea to prevent it by taking laxatives. Local side effects may include nosebleeds and bruising; if this happens, you should take the pill only every other day. You will likely experience an area about the size of your palm on your leg where sensation is reduced. In rare cases, some patients experience severe pain in the foot during the first 2 weeks.

After Discharge: Loqteq Splint

This method is so stable that you can put weight on your knee right away.

Tibia osteotomy – iBalance

Tibial osteotomy with a splint

The image above shows a wedge procedure performed using a splint and screws. This method is suitable for major corrections.  

Tibial osteotomy in the left knee. Image on the left is before surgery. The image on the right is after surgery. The dark area in the bone in the picture on the right is where the wedge is located and the white is some filling that will eventually be absorbed by the body and turn into bone.  

The image below shows a calf knee on the left and a bowleg on the right. 

The angles are exaggerated here for ease of understanding.

So why choose a tibial osteotomy instead of a knee replacement or unic knee? First of all, a knee replacement is not a new knee, but a combination of metal and plastic to restore the worn cartilage. A knee replacement is a major surgery and it is always better to keep your own knee if possible. The results after tibial osteotomy today seem to be better than before and better compared to having a knee replacement. One benefit is a better average range of motion. Overall, 20% say they are satisfied, 70% are good and 10% are bad at it and need a knee prosthesis.

Unfortunately, there is no tradition of performing these surgeries in Denmark, and that is because surgeons have not been trained to do so. As the saying goes, “If all you have is a hammer, every problem looks like a nail.” I see quite a few patients to whom I recommend a tibial osteotomy, and then they seek a second opinion from an orthopedic surgeon who “only” performs unicompartmental knee replacements. Naturally, these patients are advised against a tibial osteotomy because the surgeon lacks personal experience with these procedures but can offer a unicnee (a partial knee replacement). I certainly respect the patient’s choice, but I believe the patient is shortchanging themselves.

I have been performing these operations for 20 years, and over the years I have improved significantly and think there are really good results with the Ibalance method.

The red lines represent the load line in the knees. It illustrates someone who is bow-legged on both knees.

Wheel bone – Varus knee

The X-ray image above shows a person who is very bow-legged. In the right leg there is a load line. The line shows that loads are significantly on the inside of the knee

Rehabilitation

You will be referred to rehabilitation, which typically starts 14 days after surgery.The training aims to restore mobility in the knee and rebuild the muscles in the leg and restore balance.Your life will be complicated for a period of time and you will have difficulty getting around with crutches, especially in the first 2 weeks, because you do not really support yourself.You can only resume driving when you can drive safely in relation to your leg and this is typically 4 weeks after surgery, although slightly faster for the left leg than for the right leg.12-14 days after surgery, you will need to have the stitches removed by your doctor. You will need an X-ray 4 weeks after the surgery and then you will have a check-up with me to see how the healing looks on the X-ray. There will also be a check-up again 3-4 months after surgery. It is not uncommon for the knee to take many months to settle down after surgery.  

Complications

Rarely, infection can occur and this requires prompt treatment. In very rare cases, the bone does not heal. In both cases, new surgery may be necessary. Having operated on hundreds of patients with these surgeries over the past 20 years, I have seen these complications. Thankfully, I have also seen many patients achieve good results with less pain and significantly higher activity levels.