What is High Tibial Osteotomy (HTO) Surgery?

HTO is a procedure to correct the leg alignment by making a planned bone cut on the tibia. The goal is to shift the load from the damaged area to the healthier area, thereby reducing pain and functional problems.

What techniques are used?

High tibial osteotomy is performed using two main methods: medial opening wedge and lateral closing wedge. The choice of technique is determined by the type and degree of deformity, cartilage status, bone quality, targeted correction amount, and the surgeon’s experience.

Medial Opening Wedge

In the medial opening wedge technique, a controlled gap is created on the inner side of the tibia. The opened space is stabilized with a plate and screws and is supported with bone graft if necessary.

Lateral Closing Wedge

In the lateral closing wedge, a small wedge of bone is removed from the outer side of the tibia, and the line is closed to correct the alignment. Both techniques are chosen based on patient characteristics and the surgeon’s plan.

Who is it suitable for?

This surgery is primarily considered for active patients with medial compartment osteoarthritis and varus alignment. Results are more successful in cases where the knee ligaments are stable and other parts of the joint are not severely affected.

• Knee osteoarthritis predominantly affecting the medial compartment
• Varus (bow-legged) alignment
• Patients with an active lifestyle and the goal of postponing knee replacement

Who is it not suitable for?

HTO may not be the right option for every patient. Alternative treatments may be considered if there is widespread arthritis, significant ligament instability, or uncontrolled systemic diseases. The surgery may be avoided in the following individuals:

• Advanced, widespread knee arthritis
• Active infection, uncontrolled diabetes, heavy smoking
• Advanced obesity, long-standing flexion contracture

What are the benefits?

HTO can reduce pain and increase function. It also has the potential to delay the need for total knee replacement for many years. Other benefits include:

• Relief in daily activities (walking, stairs)
• More effective return to sport and work life
• Possibility of postponing replacement surgery

Are there risks?

Like any surgery, HTO has risks. Your surgeon will share the precautions to minimize risks and your personal risk profile with you. Possible risks include:

• Infection, bleeding, nerve-vessel injury
• Delayed or non-union (non-healing), loss of correction
• Deep vein thrombosis, stiffness (frozen knee)
• Discomfort related to metallic implants (plate-screws)

How is preparation for surgery?

A good preparation process is important for a successful outcome. Lifestyle and medication adjustments may be made after imaging and planning. The preparation phase includes:

• Detailed planning with full-length standing X-rays
• Quitting smoking, adjustment of blood thinners
• Procurement of crutches and cold therapy equipment.

How is the surgery performed?

HTO is usually performed under spinal or general anesthesia. Most patients are mobilized the same day or the next day and start an early movement program. The surgery time is generally between 1–2 hours. Discharge is typically planned within 1–3 days.

How is the recovery?

Recovery after HTO is a step-by-step process involving controlled weight increase and goal-oriented physical therapy. Ice, elevation, and appropriate pain control are applied from the first days to reduce swelling and pain. Knee range of motion is maintained with gentle exercises. Crutches are generally used with partial weight-bearing for 4–6 weeks; if bone healing is sufficient during check-ups, a gradual transition to full weight-bearing is initiated.

Balanced, protein-rich nutrition, adequate hydration, avoidance of smoking, and regular adherence to home exercises support recovery; however, every protocol must be personalized according to individual status and the recommendations of the surgeon and physiotherapist.

High satisfaction rates have been reported with appropriate patient selection. Age, weight, activity level, and co-existing diseases affect long-term results. Satisfactory outcomes extending to 10–15 years and beyond have been reported. Prosthetic surgery is resorted to in the future if necessary.

How does physical therapy support recovery?

The physiotherapy program focuses on quadriceps activation, gaining knee flexion-extension, and correcting the gait pattern in the early stage; hip-core strengthening, balance-proprioception, and closed kinetic chain exercises are added in the mid-stage.

Resistance and repetition numbers are increased according to the patient’s pain, swelling, and muscle strength; exercises are modified, and the team is informed in case of sharp pain, excessive swelling, or redness. Return to low-impact sports (cycling, swimming) is typically planned after 3–6 months; running and pivoting activities are considered after 6–12 months, provided sufficient strength, balance, and pain-free full range of motion are achieved.