A simpler surgical alternative is available called-- a HIGH TIBIAL OSTEOTOMY--this is ideally suited for the middle aged and can give very good pain relief for 10 to 15 years.

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My Doctor and relatives ask me to walk a lot to get exercise. But I get severe pain on walking and can hardly walk a few steps. What to do?

Walking as an exercise will only worsen your pain. Any activity which causes an impact on the knee---such as walking or exercising on a Treadmill worsen the knee pain. What is needed is non-impact exercise which strengthens the muscles. The best exercises are--using a Stationary or Exercise Bicycle( with the seat raised higher) as well as walking in the shallow end of a Swimming pool. This is probably the best exercise that can be done . You need not swim but only have to walk in the shallow end--from front to back; from back to front and side to side.

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My relatives and some doctors tell me that there is no alternative to Joint Replacement surgery.

Joint Replacement surgery is ideal for those who are older than 70 years of age. For those who are younger than 70, another type of surgery known as Repair surgery which is a HIGH TIBIAL OSTEOTOMY can be done. If done by an expert, using very good instruments you can expect a very good result in terms of relief of pain for 10 to 15 years.

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My doctor tells me the only way I can reduce the pain is by reducing my weight. I hardly eat anything and yet cannot reduce my weight. I am 60 years of age.

It is very difficult to reduce weight at this age. It is better to concentrate on reducing the loading of the knee joint. This can be done by avoiding squatting, sitting on the floor, avoiding climbing up and down the stairs. By using high quality footwear both in the home and outside; significant amount of relief from weight bearing pressure is achieved. By exercising in the swimming pool or on a stationary bicycle, there is no load borne by the knees..

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My local doctor tells me that knee repair surgery is unreliable and cannot be done.

Knee Repair surgery is a highly intricate operation involving accurate deformity correction around the knee. It essentially consists of an operation to correct the bony deformity and properly align the knee joint. The key requirement is accuracy.

In the decades past this surgery was performed using rather rudimentary tools such as Plaster of Paris casts and simple thin staples to hold the bone ends together. This lead to many problems like loss of position of bone ends and a delay in the healing of the bony osteotomy. This lead to improper and inadequate correction and hence unreliable pain relief.

Since the last 17 years we have been practising this operation using highly advanced and accurate tools like the Ilizarov External fixator, the software controlled Taylor's Spatial Frame Fixator, Swiss locked plating as well as Japanese dual plating systems. These allow us a highly accurate correction of the deformity as well as proper fixation of the osteotomy.

We also have developed a method of thorough analysis of the deformity as well as Simulation of the surgery by special software. Happily,the poor results of yesteryears are all forgotten now due to these advances. Osteotomy surgery can now be a reliable first choice of treatment for patients in the age group of 40 to 65 years needing surgery for osteoarthritis of the knee joint.

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How long does the effect of the osteotomy last?

A properly done surgery will give pain relief from 10 to 15 years. THis is also subject to the stage at which the surgery is done. When done in an early stage, the pain relief is almost 95% and will last long. When surgery is delayed, pain relief may be less and could come slowly.

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I see some patients wearing rings around their legs. Does it hurt and how long do they have to be kept.

The rings are a part of the External Fixator assembly. This is inserted during surgery and is retained for the time that the bone is healing. Typical duration of the fixator wearing is about 3 to 3½ months. The fixator is a sophisticated assembly and when properly applied and cared for will not be painful. It has great advantages like allowing walking and unlimited ambulation. Most people are able to resume light work, either in the house and kitchen or in the workplace within about 3 weeks. Many doctors are able to start seeing patient and perform minor surgeries within 3 to 4 weeks. Entrepreneurs are able to work on the factory shop floor for several hours within 3 to 4 weeks. Hence this is actually very patient-friendly.

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Why should Total Knee Replacement be done only after 65 to 70 years of age?

A total Knee Replacement arthroplasty removes the cartilage of the knee and substitutes it with a metal and plastic joint surface. The nerves in the joint are removed as well. The joint is grouted in place with bone cement. Done at this later age, the bones are softer and the muscles are weaker and hence the new joint can work for significant periods of time. If the surgery is done at an earlier age, it is likely that it will not be able to last more than 5 years at a time. Any repeat surgeries are more difficult and expensive. Hence it is far better to try and repair the joint at ages lesser than 65 years and reserve the replacement surgery to be done at a later age.

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Till what age can a repair surgery like HIGH TIBIAL OSTEOTOMY be done?

High Tibial Osteotomy when done properly and by an experienced surgeon gives a reliable relief from pain for about 10 to 15 years. While deciding about age limits, we should understand the difference between Chronologcal and Physioogical age. i.e. a person may be 75 years of age but be very healthy and active and hence behave like a 65 year old. Hence for someone in good health and high demands of the knee, a repair surgery like High Tibial Osteotomy can be done on an average till 65 to 70 years of age and as an upper limit till about 75 years if the person is very active.

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When should a High Tibial Osteotomy be never considered as a choice?

When all compartments of the knee joint are involved and worn out; the High Tibial Osteotomy cannot be done. It is necessary that the Lateral Compartment of the Knee Joint should have healthy cartilage. This will allow the medial( inner) compartment to be unloaded and give good pain relief. Any recent history of infection in the knee is also a contra-indication ( a strict no) to perfrming this kind of surgery.

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What are the advantages of performing a High Tibial Osteotomy with the Ilizarov fixator?

The Ilizarov fixator has several advantages in this surgery: *it allows accurate correction of the varus deformity *it allows correction of the deformity even after surgery--on observing gait after the operation as well. *the knee joints and ankle joints remain free * the incisions are very small and hence risk of infection in elderly people with diabetes etc is very less * The ability to give compression ensures that all osteotomies unite early and reliably.

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What is the average cost of a High Tibial Osteotomy?

in general, it costs only about 35% of the costs of a Total Knee Replacement but givesalmost 100% of the same benefits.

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what are the possible complications of a Knee Replacement surgery?

The most catastrophic complication of a knee replacement surgery is infection. The prosthesis has to be removed and a surgery for cleaning the infection needs to be done. Heavy antibiotics are needed which are very expensive. A repeat surgery for re-implantation will turn out to be very expensive. It is also likely that the only solution is fusion of the knee. This way the knee never moves again. Loosening of the prosthesis is likely to take place within a few years if it is done at an early age. This is more likely if there is even a minor mal-alignment. Again the solution is to go for a repeat surgery.

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Is osteotomy more painful than Knee Replacement?

Both surgeries take approximately the same time to become relatively painless--about 3 to 4 weeks. There is not much difference in the amount of pain. Many patients enjoy a high level of comfort with the Ilizarov external fixators during treatment.

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My doctor says I have arthritis under the knee cap as well and this cannot be repaired with the High Tibial Osteotomy

Arthritis under the knee cap is known as Patello-Femoral Arthritis. There are very effective ways of dealing with this problem along with High TIbial Osteotomy. The simplest is the performance of a Patello-Femoral Release which is combined with the osteotomy. This can easily be done along with the use of the Ilizarov or TSF fixator as well as with the Dual or Locked Plating procedures. This will give relief from the pain of the Patello-Femoral as well as the Medial Compartment arthritis

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My Doctor says that if you perform the Osteotomy now, a Knee Replacement cannot be performed later.

In the modern design of the Osteotomy as it is being practised in our institution; the operation is performed at a lower level. It will not interfere in any way in case a replacement is needed in the future. But our results tell us that our patients are getting good pain relief from Osteotomy for 10 to 15 years and hence the chance of needing a Replacement are less anyway.

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If this Operation is so good, why is this Operation not popular and how come not many surgeons advise about it?

Firstly, this operation with the newer tools has been designed only since the last 16 to 17 years. Since the major component of the surgery is the accurate performance of the deformity around the knee; it stands to reason that it can be best performed by surgeons who are trained well in Deformity correction.

Since the results depend on very accurately correcting the deformity, the ability to correct deformities accurately within one or two Degrees of accuracy is a skill not developed in suegeons in general. Hence this operation is performed only by those few who have great expertise as well as a special fondness for this procedure.

Secondly there is no Industry backing for this procedure as no sale of an expensive prosthesis is involved and hence there is no marketing juggernaut to promote this procedure.

However, the fact remains that this opertion is an ideal procedure for those suffering from knee pain , who are aged between 40 and 65 years of age, who have a medial compartment arthritis, have high physical demands from the knee, and have a significant deformity around the knee. THis is borne out by Orthopedic Literature from all over the world.

The procedure also costs significantly lesser than a Total Knee Replacement and is affordable for most middle class Indians, even those who are not covered by insurance.

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