Tibial Osteotomy (Lower Limb Surgery) in Aizawl

Tibial osteotomy is a surgical removal of a part of your tibial bone. "Tibia" means the shinbone or the lower bone of your leg, and "osteotomy" means bone cutting. The tibial bone is broken and realigned into a better position. The main aim of this procedure is to distribute the forces across the knee and take off the pressure from certain areas of the knee joint. Tibial osteotomy is most often performed if you suffer from knee arthritis (inflammation of the joints) when other treatments, such as physiotherapy and anti-inflammatory medications, fail to provide relief.

Tibial osteotomy is a realignment surgery of the lower limb (lower leg) that involves controlled shinbone (tibia) cutting to decrease the pain associated with arthritis and thereby improve function. It also slows the progression of arthritis and is usually done if you are younger and have an active lifestyle. 

Tibial osteotomy is typically done by making a small cut through part of the tibia, just below your knee, or occasionally the thigh bone (femur), just above your knee. The weight from the more worn-out part of the joint is shifted towards the less worn-out areas.

Tibial osteotomy is recommended to treat the symptoms of osteoarthritis (a most common form of arthritis) that affects the inner part of the knees. 

Osteoarthritis is an inflammation of the joint that causes severe pain, swelling, and knee joint stiffness. As you age and as the pressure on your knees increases due to several activities, arthritis may worsen and cause symptoms like deformed knees and bowed legs. This will, over a period of time, put excess pressure on the cartilage and cause a meniscus tear (a type of tear in the rubbery knee cartilage that cushions the shinbone from the thigh bone). There are four stages of osteoarthritis:

• Stage 1- Early stage, where you begin to lose some of the cartilage.
• Stage 2- Mild or minimal stage where the space between the joints narrows.
• Stage 3- Moderate stage where the cartilage between the joints begins to show wear or degeneration.
• Stage 4- Severe stage where the cartilage is completely lost with less synovial (lubricating) fluid. 

Tibial osteotomy is used to treat osteoarthritis (stages 2 and 3). It restores the alignment and minimizes further degeneration, and reduces the pain. 

It is also recommended for the following knee conditions such as:

• Gonarthrosis- Defined as changes due to articular cartilage damage and abnormal bone formation.
• Osteochondritis dissecans- This is a joint condition in which bone underneath the cartilage dies due to reduced blood supply.
• Osteonecrosis- Death of the bone tissue due to lack of blood supply.
• Posterolateral instability- A condition caused due to sports-related injury when the knee is forcefully twisted.

An important aim of tibial osteotomy is to prevent or delay the need for total knee replacement surgery. 

Preparing before any surgery is important to prepare yourself physically and emotionally. This enhances your success rate and promotes quick recovery with minimal post-op complications.

Medical History

• When you visit your healthcare provider, he/she will record your medical history to evaluate your symptoms and overall health. 
• You must inform your provider about any:
  • Medical conditions, including diabetes (increased blood sugar levels), asthma, lung, heart, or kidney diseases, or other blood disorders.
  • History of allergies, previous surgeries, or injuries.
  • Medications like blood thinners, anti-inflammatory medications, and herbal or vitamin supplements, if being taken.

Diagnostic Tests

• Your provider will recommend the following medical tests to confirm the diagnosis and check your general health
  • Blood tests- To check the levels of your blood components like red blood cells, white blood cells, etc.
  • Urine tests- To check for any infection or condition that may affect bone healing (like diabetes).
  • ECG (electrocardiogram)- To check the activity of your heart.
  • X-ray of your knee- To check for arthritis and evaluate the severity.
  • CT (Computed Tomography) scan- Your surgeon will check your bones and joints to determine the size, angle, and dimension of the bone section to be removed. 

Medical Preparation

• You will be asked to use an exercise bike or indulge in certain exercises to help strengthen your knee muscles and improve the range of motion before the surgery.
• You will be prescribed antiseptic or antimicrobial skin cleansers or soaps a week before the surgery to wash your leg(s) thoroughly to decrease your chances of post-op infection.
• You must avoid sunburn, scrapes, and other problems that may negatively impact the skin around the surgical wound.
• Two weeks before tibial osteotomy, you must:
  • Stop medications like blood thinners, anti-inflammatory drugs, antidepressants, and other herbal supplements. This helps to reduce your risk of bleeding during surgery. 
  • Quit smoking and Alcohol consumption since they delay wound healing. 
• You must fast for 6 to 8 hours before the surgery.

Home Preparation

• This will help you prevent falls or accidents that may negatively impact your recovery.
• Arrange for transportation since you cannot drive for 6 to 8 weeks post-surgery.
• Arrange a room for yourself on the same floor as your living area to avoid climbing up and down the stairs.
• Adjust your bed height to make getting in and out easy.
• Take away any items from your way that may make you trip and fall.
• Install small rails or bars near your toilet seat and showers for support.
• Install a modified toilet seat so it is high enough to sit and get up easily. This puts less pressure on the operated leg.
• Arrange for a comfortable and sturdy chair with support to elevate your leg while seated.
• Ensure to practice walking with crutches and walkers to familiarize yourself before the procedure.
   

Tibial osteotomy is an invasive (involves extensive cuts and bleeding) and an inpatient procedure (requires hospitalization) that aids in correcting the malalignment of the tibia. The procedure is performed by an orthopedic surgeon (a doctor specializing in diseases of bones and joints) and takes 1 to 2 hours.

1. On the day of the surgery, you must sign a consent form. This gives the surgeon permission to perform the surgery.

2. Your vitals (blood pressure, sugar levels, heart rate, pulse, and oxygen level) will be checked by the nurse in charge. 

3. Your nurse in charge will prep you by cleaning the surgical area with an antiseptic solution to remove surface contaminants.

4. Your anesthesiologist will administer general anesthesia (a numbing agent) through an IV (intravenous) line.

5. The surgery can be performed through two techniques, namely:

Closing wedge osteotomy

• Here, your surgeon will make an incision (cut) measuring around 3 to 5 inches in front of the knee, on the lateral (away from the midline) side of the tibia, to remove a small wedge of the bone.
• Your surgeon will manipulate the bones and bring them together to fill the gap created due to bone removal.
• Your surgeon will use plates or screws to bind the bones together while the surgical site heals.
• This is an old technique and is not used frequently.
   

Opening wedge osteotomy

• Here, the surgeon will make a large incision (3 to 5 inches) in front of the knee, just below your kneecap, towards the medial side (towards the midline) of the tibia. This opens a wedge-shaped space in the bone.
• A special bone graft (bone tissue taken from other parts of the body for grafting)will be used to fill the space of the wedge-shaped opening.
• Additional screws and plates will be attached to the bone edges for support during the healing process.

6. The skin incision will be closed using stitches.

7. Your surgeon will then place a protective knee brace that supports holding your knee in the correct position and preventing any injury.

Immediately after a tibial osteotomy, you may experience mild pain, swelling, and discomfort while you will be recovering in PACU (post-anesthesia care unit) for 1 to 2 hours. 

• You are expected to stay in the hospital for 2 to 3 days until you regain the strength to walk around before you are sent home. 
• Your operated leg will be placed in a protective knee brace that will remain for 6 to 8 weeks, depending on your individual situation.
• Your physical therapist will examine you and begin your physiotherapy on the day following the surgery. Initial physical therapy treatment will include ice, electric stimulation, and massage to control pain and swelling.
• During your recovery period, you must use your crutches or a walker to support yourself while walking.
• It is important to stay active to prevent the formation of blood clots.
• Once you are sent home, care should be taken to rest as and when required.
• Your stitches will be removed 10 to 14 days post-tibial osteotomy.
• Physical therapy exercises help strengthen your knee muscles, improve stability and the range of motion. These may include the following:
  • Brisk walking
  • Gently bending (flexion) and straightening (extension) of the knee
  • Heel slides- Lie on your back. Bend your surgical knee by sliding your heel toward your buttocks.
  • Quad sets- Lie on your back with your legs straight. Tighten your thigh muscles pushing your knee down into the bed.
  • Hamstring curls- Lie on your belly on the floor and gently bend your injured knee backward. Bring it closer to your buttocks. Hold for 5 seconds, and then straighten it.
  • Gluteal sets- Lie on your back with your legs straight. Squeeze the buttock together and tighten the buttocks muscles.
• Avoid lifting heavy objects and strenuous physical activities for 6 to 8 weeks. 
• Complete recovery will usually take around 2 to 3 months.

Tibial osteotomy is a safe and effective procedure to correct the misalignment caused due to osteoarthritis with the following benefits.

Benefits

• Lengthens the lifespan of your knees.
• Provides an effective solution for poor knee alignment.
• Helps relieve severe pain and soreness caused due to arthritis, thereby improving your quality of life.
• Delays the need for total knee replacement surgery for several years.
• You will not have many restrictions after the procedure.

Risks

Some of the most common complications of tibial osteotomy are as follows:

• Allergic reactions to anesthesia cause skin rash, hives, itching, dizziness, confusion, and breathing difficulties.
• Thrombophlebitis, is the inflammation of a vein that leads to the formation of blood clots in your legs. This can cause swelling and severe pain.
• Pulmonary embolism is when the blood clot dislodges in the bloodstream and travels to the lungs causing life-threatening complications.
• Infection of the surgical wound.
• Formation of scar tissue in the joint below the knee cap.
• Nonunion of the bones may occur when the bone edges fail to heal.
• Persistent pain several weeks after the surgery.

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