Minimally invasive treatments to reduce pain, speed up recovery and improve mobility

Professor Adrian Wilson opened The London Knee Osteotomy Centre as a centre of excellence for this type of surgery. He is joined at the Centre by leading international osteotomy expert, Mr Ronald van Heerwaarden and Mr Raghbir Khakha.

Professor Wilson is one of the founding members of the UK Knee Osteotomy Registry (UKKOR), the first national database dedicated to knee realignment (osteotomy) surgery. The Group has data on the results of over 1,000 procedures, the biggest series of its kind in the world.

Knee osteotomy or knee realignment surgery is carried out on patients experiencing a range of knee conditions, including arthritis and sports-related injuries.

Bow-legged – this can result in damage from arthritis to the inner side of the knee joint. Alignment surgery is known as ‘high tibial osteotomy’ where the top part of the shin bone is realigned. Around 80% of the Centre’s realignment procedures are for bow-legged patients.

Knock-kneed – this can result in damage from arthritis to the outer side of the knee joint. Alignment surgery is known as ‘femoral osteotomy’ where the bottom part of the thigh bone is realigned.

Professor Adrian Wilson has pioneered a minimally invasive technique for osteotomy that enables patients to get back to normal activities as quickly as possible. All the results of surgery are carefully monitored so that the treatment is evidence based. In many cases, the results are comparable to joint replacement surgery.

X-rays will determine the position of the bones in your leg to see the correction required to realign your knee.

If you are bow-legged, surgery involves a wedge being cut into the bone, using precise measurements calculated during a pre-surgery scan. The bone is then pulled slightly apart and fixed into the correct position using a metal plate and pins. The whole leg is realigned during surgery to prevent further damage to the knee.

High tibial knee realignment (osteotomy) surgery is when the tibia, or shinbone, is cut and reshaped to remove pressure from the knee joint. It’s normally used to treat arthritis and to correct a bowlegged deformity that has caused damage to one side of the knee. It can delay – or even avoid the need for – joint replacement surgery.

If you are knock-kneed, surgery involves making cuts into the bone, using precise measurements calculated during a pre-surgery scan. Plates and pins are used to fix the bone into its new position. The whole leg is realigned during surgery to prevent further damage to the knee.

Distal femoral knee realignment (osteotomy) involves changing the shape of the knee joint in order to take the load off the side of the knee affected by arthritis and increase the load on the other side. In some cases, it can delay – or even avoid – the need for joint replacement surgery. It is similar to having a high tibial osteotomy in terms of planning your operation but the cut in the bone is made in the lower end of the femur (thigh bone) to correct a knock-kneed deformity.

The operation is usually carried out by removing a wedge of bone from the inside of the thigh bone.

The gap created is then closed and held rigid with a strong plate and screws. This corrects the alignment of the bones and the closure of the wedge provides much greater stability after surgery.

The two sections of bone that are fixed together will heal completely after surgery to form one bone.

After your operation, you’re likely to stay in hospital for two to three days. You’ll need to use crutches and, in some cases, wear a knee brace for four to six weeks after surgery to protect your knee while the bone is healing.

You’ll be encouraged to begin some exercises straight away as part of your rehabilitation plan; these will help to maintain the range of motion and restore strength in the knee joint. Adrian will be able to advise you about the type of activities you can do after surgery and how to build up your fitness so that you can return to normal levels of exercise as soon as possible. In most cases, you’ll be able to drive again around four to six weeks after surgery.

Most people are able to bear their own weight within 24 hours while full rehabilitation takes between 6-12 weeks. Unless your job is highly active or involves manual labour, you are likely to be able to return to work after six weeks.

Elite sportsmen and women have been able to return to normal following an osteotomy and, having regained their fitness levels, they’ve gone on to compete successfully. This includes one elite triathlon runner who, after having his osteotomy surgery, went on to become the top ranked sportsman in his age group.

In the UK, the vast majority of patients with arthritis are offered knee replacement surgery. For younger patients where the wear and tear is very severe or even where there is significant bone on bone disease (in some cases, down to the bone), the only traditional options would have been to either put up with pain or have steroid injections, which usually provide only temporary benefit.

While knee replacement surgery may be the answer for some people, for others – particularly younger patients, sportsmen and women, and older patients who are very active – removing the knee joint, which also means taking away a great deal of healthy tissue, may not be the best option. Osteotomy can usually significantly delay the need for knee replacement surgery (although patients may need this procedure to treat advanced arthritis later, most commonly 10-15 years later); in some cases, it can avoid the need for knee replacement altogether.

The main advantages of osteotomy over knee replacement include:

• Reduced knee pain without needing to remove/replace your knee joint
• A better range of movement and function
• Faster recovery
• The knee can feel more stable than after knee replacement surgery
• You can return to your normal activities including competitive sport, which isn’t recommended after a knee replacement as it can wear out the artificial joint
• You are not having anything replaced, you keep your own knee

All surgery carries risks. However, we are committed to minimising risk to our patients. Your consultant will discuss the risks of surgery with you beforehand and you’ll have an opportunity to discuss any concerns before you decide to go ahead. It’s important that you fully understand both the risk and benefits of any procedure before you decide whether surgery is right for you.

The risks of surgery vary from procedure to procedure, but can include:

Deep vein thrombosis (DVT) (blood clot in the legs): Pulmonary embolism (blood clot in the lungs). Each patient’s individual risk for blood clots is assessed and precautions taken such as foot pumps for all patients (the pumps encourage good blood flow in your leg veins) and blood thinning medications for high-risk patients. The best, and simplest, way of preventing blood clots is getting up and moving about as soon as possible after surgery.

Bleeding: this is a rare complication, especially after keyhole surgery. The use of a tourniquet and/or surgical drain minimises the risk of bleeding. In a very small number of cases, for patients who have major surgery, such as a total knee replacement, a blood transfusion may be needed.

Infection: this is a rare but serious complication. Steps are taken before, during and after your surgery to minimise the risk of infection. Infection can be superficial (in the wound itself) or deep (around an artificial joint). In most cases, the infection settles down with a course of antibiotics. However, in rare cases, further surgery may be necessary to treat serious infections.

Delayed wound and bone healing: this is more common in smokers, diabetics, very overweight patients and patients on certain medications, such as steroids.

Anaesthetic complications: serious complications are extremely rare. Post-operative nausea, a rare complication, can be well controlled with appropriate medication.

Our specialist knee surgeons work with all the major insurance companies, so you will usually be able to have your knee replacement operation paid for by your private medical insurance.

A physiotherapist can design a regimen that reduces pain and strengthens the key muscles that affect your knees. They can work with you to make sure you’re doing exercises correctly. The physiotherapist may apply ice and heat. They might also try electrical stimulation, ultrasound therapy, or other procedures that can increase blood flow to the skin, helping to reduce pain.

Knee injections of hyaluronic acid lubricate the knee joint and help improve shock absorption. The procedure can reduce pain and improve knee mobility.

Medication, including over-the-counter pain relievers and topical creams with the numbing agent lidocaine or bupivacaine, may help control your knee pain. Your consultant might also recommend a steroid injection to reduce the inflammation in your knee.

The steroids are injected at the site of inflammation. They mimic naturally occurring hormones in your body. Steroid injections usually work to relieve pain within a few days and last several weeks.

Our consultants may suggest arthroscopic surgery to remove bone fragments, pieces of torn meniscus, or damaged cartilage, as well as repair ligaments. An arthroscope is a type of camera that allows your surgeon to view the inside of your joint through a small incision. After making two to four incisions, they use the arthroscope to operate on the inside of your knee.

This technique is much less invasive than traditional surgery. People mostly go home the same day as their surgery. Within a week, you no longer need crutches, and you can drive and resume your daily activities.

Orthopaedic Specialists offers a number of effective and well-researched procedures which are potential alternatives to surgery. They take advantage of cells in the blood or the body and use the natural healing properties in these cells to reduce pain and improve joint function. A number of these cells are taken from the body or the blood, specially prepared and injected into the site of the damaged cartilage, tendons, ligaments, muscle or bone. Patients usually see their symptoms improve in one to two weeks of having the treatment.

These procedures take around an hour and early results suggest an improvement for 75% of suitable patients. These minimally invasive procedures are a possible alternative to having an operation or can be used after surgery to help healing.

A knee brace is an option to delay knee replacement surgery in patients with knee osteoarthritis. Our consultants recommend the Ossur Unloader One knee brace.

A knee brace can reduce pain, give patients greater function of the knee and can reduce the reliance on medication to relieve pain.

The use of a knee brace can be combined with other remedial treatments including weight loss; exercise; injections and physiotherapy. It may also be used to support your knee during recovery from knee osteotomy or other knee surgery.

Osteoarthritis causes the parts of the knee that slide over each other as you move to become damaged which may result in the joint becoming inflamed or sticking, or the bones rubbing together. It is a degenerative disease and you will normally only be considered for knee replacement surgery if it has reached the stage where you are in persistent, disabling pain and other less-invasive treatments, such as painkilling injections or physiotherapy, are failing to provide adequate pain relief. You may need a partial or a total knee replacement, depending how extensively damaged the knee joint is.