Authors

Prof Leo Pinczewski MBBS, FRACS

Dr Keran Sundaraj MBBS, MSc (Trauma), FRACS, FAOA

A painful osteoarthritic knee in a middle-aged recreational patient is one of the most challenging problems to manage. Initially, all patients should be treated conservatively; however, patients consider surgical treatment when the pain worsens as the osteoarthritis progresses. There are two main types of osteoarthritis in the middle-aged - post-traumatic and non-traumatic. Post-traumatic osteoarthritis occurs in patients who have had a previous knee injury as a young adult and may have had their meniscus or part of it removed surgically. Non-traumatic osteoarthritis occurs in patients who have not had a previous knee injury and in whom the osteoarthritis is strongly genetically determined. Such patients often report a family history of early osteoarthritis.

Signs and Symptoms

The predominant symptoms of osteoarthritis of the knee are pain, swelling, stiffness and a decreased activity level. The pain generally worsens with activities and improves with rest. Commonly, wasting of the thigh muscle occurs. This, in turn, may increase pain and may also cause symptoms of giving way. Symptoms such as locking and catching may also be present. 

Treatment Options

An osteoarthritic knee in a young patient is a complex problem to manage. Only certain patients will respond well to osteotomy; therefore, Dr Sundaraj will carefully consider whether you are a likely successful candidate. Some patients can be successfully managed with conservative means, but for the middle-aged patient, this may lead to early joint replacement as an osteotomy is most successful when performed during the early stages of osteoarthritis

Osteotomy

Osteotomy is an appropriate surgical option in selected cases of arthritis affecting one side of the knee only. The purpose of osteotomy is to transfer the load to an uninvolved joint surface. Osteotomy is most commonly performed for patients where the weight-bearing surfaces of the knee joint become worn away on one side. The affected side of the joint is no longer smooth and free running, and this leads to stiffness and pain. In this situation, high tibial osteotomy (HTO) is performed.

It should be stressed that this surgery is designed to allow patients to walk without discomfort, not to return them to sporting activities. If adequate correction is achieved, the success rate of high tibial osteotomy at this practice is 91% at the 5 years and 80% at 10 years. Those patients who fail to achieve such long-term relief usually obtain at least a few years of relief and are then eligible for joint replacement. Osteotomy is strongly recommended for a middle-aged patient with osteoarthritis. If the patient is nearing the age of 60, it is worth considering continuing with conservatives measures for as long as possible so that when complete deterioration of the joint has occurred, joint replacement may be performed.

What is involved for you as the patient  

 After your surgery: When you wake after surgery, you will be in the recovery ward. From here, you will be transferred back to your ward. You will find your leg placed in a brace when you wake. This will stay on for the next 6 weeks. You will be given regular pain relief by the nursing staff in the form of an injection or tablet as required. A physiotherapist will visit you in the afternoon of your surgery, or the following day. They will show you some exercises for your leg and get you up for a walk. You will begin walking with crutches or a walking frame and will need to avoid putting full weight through your operated leg. Once you can mobilise and care for yourself safely, you will be discharged from the hospital, usually 5 to 7 days following your surgery. 

After your hospital stay: You will receive instructions from the nursing staff before being discharged from the hospital. It is usual to be reviewed at 2 weeks after surgery to remove the dressings and check your brace. The brace will be on for a further 4 weeks at which time it will be removed at the 6-week review appointment. At 3-4 weeks after surgery, you may begin to take partial weight bear through your operated leg, as pain allows. You will remain on Warfarin (a blood thinner to prevent blood clots), and have regular blood tests for 6 weeks following surgery. Dr Sundaraj will review you at 6 and 12 weeks following surgery.

Potential Complications Related To Surgery: 

• Pneumonia: After any general anaesthetic, there is always a risk of developing a chest infection. This risk can be minimised by early mobilisation and performing deep breathing exercises after surgery. If you have any history of respiratory problems, you should inform the staff at the hospital.

• Deep vein thrombosis and pulmonary embolus: A combination of surgery, immobilisation of the limb, smoking and the oral contraceptive pill or hormonal replacement therapy multiply to increase the risk of a blood clot. Any past history of blood clots should be brought to the surgeon's attention before your operation. The oral contraceptive pill, hormonal replacement therapy and smoking should cease one week before surgery to minimise the risk.

• Excessive bleeding resulting in a haematoma is known to occur with patients taking aspirin or anti-inflammatory drugs- such as Voltaren, Naprosyn or Indocid. They should be stopped at least one week before surgery.

• Surgery is carried out under strict germ-free conditions in an operating theatre. Antibiotics are administered intravenously at the time of your surgery. Any allergy to any known antibiotics should be brought to the attention of your surgeon or anaesthetist. Despite these measures, following surgery, there is a less than 3% chance of developing an infection. Most commonly, these are superficial wound infections that resolve with a course of antibiotics. More severe infections may require further hospitalisation and treatment.

Potential Complications Specifically Related To Your High Tibial Osteotomy: 

• Neuromuscular Injury - Injury to the peroneal nerve can occur in patients following high tibial osteotomy. This may result in sensory loss or muscle impairment, for example, a foot drop. Most patients recover without any permanent functional disability.

• Injury to the blood vessels around the knee during surgery is a rare complication (less than 1%).

• Delayed or non-union of the osteotomy site may occur in 2 to 4% of cases.

• Other potential problems include postoperative stiffness, pain, wound problems and infection.

As with all operations, if at any stage anything seems amiss, it is better to call for advice rather than wait and worry. A fever, redness or swelling around the line of the wound or an unexplained increase in pain should all be brought to the surgeon's attention. You can contact Dr Sundaraj by telephoning his staff during business hours or the Mater Hospital after hours. For any questions, please do not hesitate to contact our staff (02) 9437 5999 For after-hour assistance contact Mater Hospital (02) 9900 7300 Further information is available on our website