Alternate type of surgery may prevent knee replacement

An under-used type of knee surgery – a procedure called a high tibial osteotomy – may reduce the need for total knee replacement, according to new research from Western University.

Knee illustration by Rob Potter, Western Communications

By Crystal Mackay, Western University February 1, 2021

“High tibial osteotomy is a knee surgery (usually) aimed at younger patients in the earlier stages of knee osteoarthritis. One of its goals is to prevent or delay the need for knee replacement,” said coauthor Trevor Birmingham PhD, professor and Canada Research Chair in Musculoskeletal Rehabilitation in the Faculty of Health Sciences at Western. “In some ways, it’s like performing a front-end alignment on your car to stop asymmetric wear on your tires and increase their longevity.”

Knee osteoarthritis, occurring when the protective tissue surrounding a joint wears away, is a common cause of pain and disability and puts tremendous burden on health care systems. The alignment procedure Birminghams’ team studied fixes the mechanics of the knee so that the joint doesn’t wear out as quickly.

In Canada, rates of total knee replacement are high and increasing, while rates of high tibial osteotomy are low and decreasing. One reason for this is the perception that high tibial osteotomy is not warranted if the joint is going to be replaced soon afterwards. The study’s findings, published in CMAJ (Canadian Medical Association Journal), contradict this perception.

Of patients in this study getting high tibial osteotomy in London, Ontario (643 knees in 556 patients), 95 per cent did not need a total knee replacement within five years; 79 per cent did not get a total knee replacement within 10 years. Even in patients traditionally not considered ideal candidates for high tibial osteotomy (e.g., women and patients with later-stage disease), about 70 per cent did not get a knee replacement within 10 years.

The procedure is particularly suitable for people who are younger, have less severe joint damage and who may be more physically active. “Those patients especially contribute to the burden of knee osteoarthritis,” said Codie Primeau, the study’s lead author. “There is a treatment gap between exhausting nonoperative treatments and appropriateness for joint replacement, resulting in many years of pain, lost productivity and associated costs.”

“Given these findings, high tibial osteotomy may be underused in Canada and could be performed more often to delay or prevent the need for total knee replacement,” said coauthor Dr. Robert Giffin, professor of surgery at Western’s Schulich School of Medicine & Dentistry.

Source Western University


Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors, Primeau CA, Birmingham TB, Leitch KM, Willits KR, Litchfield RB, Fowler PJ, Marsh JD, Chesworth BM, Dixon SN, Bryant DM, Giffin JR. CMAJ. 2021 Feb 1;193(5):E158-E166. doi: 10.1503/cmaj.200934.  Full text

  Further reading

Degenerative Meniscal Tears and High Tibial Osteotomy: Do Current Treatment Algorithms Need to Be Realigned? Primeau CA, Birmingham TB, Leitch KM, Appleton CT, Giffin JR. Clin Sports Med. 2019 Jul;38(3):471-482. doi: 10.1016/j.csm.2019.02.010.

Improved Methods to Measure Outcomes After High Tibial Osteotomy, Lorbergs AL, Birmingham TB, Primeau CA, Atkinson HF, Marriott KA, Giffin JR. Clin Sports Med. 2019 Jul;38(3):317-329. doi: 10.1016/j.csm.2019.02.001.

Survival of total knee arthroplasty after high tibial osteotomy versus primary total knee arthroplasty: A meta-analysis. Seo SS, Nha KW, Kim TY, Shin YS. Medicine (Baltimore). 2019 Jul;98(30):e16609. doi: 10.1097/MD.0000000000016609. Full text

Gait biomechanics after combined HTO-ACL reconstruction versus HTO alone: A matched cohort study, Marriott K, Birmingham TB, Pinto R, Primeau C, Bryant D, Degen R, Giffin JR. J Orthop Res. 2019 Jan;37(1):124-130. doi: 10.1002/jor.24157. Epub 2018 Oct 29. PMID: 30303555.

Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy, Keenan OJF, Clement ND, Nutton R, Keating JF. Knee. 2019 Jan;26(1):207-212. doi: 10.1016/j.knee.2018.11.008. Epub 2018 Nov 22. PMID: 30473375.

High tibial osteotomy in the ACL-deficient knee with medial compartment osteoarthritis, Herman BV, Giffin JR. J Orthop Traumatol. 2016 Sep;17(3):277-85. doi: 10.1007/s10195-016-0413-z. Epub 2016 Jun 29. Full text

Total knee replacement following high tibial osteotomy versus total knee replacement without high tibial osteotomy: a systematic review and meta analysis, Ramappa M, Anand S, Jennings A. Arch Orthop Trauma Surg. 2013 Nov;133(11):1587-93. doi: 10.1007/s00402-013-1838-y

Also see
No pain, no gain for knee osteoarthritis Western University
Does surgery for rupture of the anterior cruciate ligament improve outcomes? The BMJ Opinion

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