Knee Osteotomy (High Tibial Osteotomy / Distal Femoral Osteotomy) in Bristol

Osteotomy is one of the most underused operations in knee surgery. When the problem is alignment – a bow-leg or knock-knee that is grinding one side of the joint into the ground – no amount of physiotherapy, injection, or arthroscopy will fix the underlying mechanics. A knee osteotomy corrects the leg alignment itself, shifting load away from the damaged compartment and onto the healthier side. Done well, it can transform symptoms and delay or avoid knee replacement for years.

Osteotomy is also a powerful tool alongside other procedures. When I reconstruct an ACL or perform a complex meniscal repair or transplant in a malaligned knee, correcting the alignment at the same time is often essential to protect the reconstruction and give it the best chance of lasting.

What is a knee osteotomy?

"Osteotomy" literally means cutting bone. I make a controlled cut in the tibia or femur, realign it to the planned angle, and fix it with a plate and screws. The result is a straighter leg (or a deliberate shift in alignment) that moves weight-bearing away from the worn compartment.

The two main types are:

High Tibial Osteotomy (HTO): correction in the upper shin bone, most commonly used for inner (medial) compartment overload with bow-leg alignment
Distal Femoral Osteotomy (DFO): correction in the lower thigh bone, most commonly used for outer (lateral) compartment overload with knock-knee alignment

Unlike a knee replacement, osteotomy preserves your own joint surfaces and ligaments. It changes the mechanics that are driving the problem.

Why osteotomy matters

I consider osteotomy when symptoms are driven by one-sided overload and the alignment is clearly contributing. The goals are straightforward:

Reduce pain from early-to-moderate compartment arthritis or cartilage wear
Improve walking tolerance and confidence, especially on slopes and stairs
Keep you active – hiking, cycling, gym work, and sometimes sport
Delay or avoid partial or total knee replacement
Protect a cartilage repair, meniscal transplant, or ligament reconstruction by correcting the alignment that would otherwise overload it

Who is suitable (and who is not)

Osteotomy works best when the problem is compartment-focused and the knee still has reasonable movement and stability.

Good candidates typically have:

Pain mainly on one side of the knee (inner or outer)
Imaging showing arthritis or cartilage damage predominantly in one compartment
A clear alignment pattern (bow-leg or knock-knee) contributing to overload
Reasonably preserved knee movement – the joint is not severely stiff
Motivation for a real rehabilitation programme

Other options may be better if:

Arthritis is advanced across multiple compartments
The knee is very stiff or unstable in a way osteotomy alone cannot address
There is widespread inflammatory arthritis affecting the whole joint
A replacement procedure would give a more predictable result

Suitability is not based on age alone. I have done osteotomies on patients in their twenties and their sixties. The decision depends on your knee pattern, your goals, and what will give the most reliable outcome.

How I assess for osteotomy

Getting the alignment correction right starts with precise measurement. I need to understand exactly where the overload is and how much correction is needed.

The key investigations are long-leg alignment X-rays – I request these for every patient I am considering for osteotomy. These standing films show how load passes from hip to ankle and let me plan the correction angle. I also use weight-bearing knee X-rays to assess the arthritis pattern and joint space, and an MRI to check the cartilage, meniscus, and ligaments where this would change the plan. Occasionally, if the main problem is in the kneecap joint, I will request a CT to assess rotational alignment.

The goal is to confirm whether osteotomy is the best option, whether it should be combined with another procedure, or whether a partial or total knee replacement would be more appropriate.

Non-surgical treatment

Before committing to surgery, it is often worth trying:

An offloading brace – this partly simulates what an osteotomy does, and if it helps your symptoms, that is a good sign the surgery will too
Targeted physiotherapy to improve strength, movement control, and load tolerance
Activity modification and low-impact fitness (cycling, swimming, structured walking)
Weight management where relevant
Simple pain relief and anti-inflammatory medication
Injections for symptom control when the pain is flaring

If symptoms remain limiting despite these measures and alignment is clearly a key driver, osteotomy becomes a logical next step – a longer-term mechanical solution rather than repeated symptom management.

Types of osteotomy

The operation shifts load away from the worn side of the knee and onto the healthier side.

High Tibial Osteotomy (HTO)

Used when the inner (medial) side is worn and the leg is bow-legged (varus)
The most common type of knee osteotomy I perform

Distal Femoral Osteotomy (DFO)

Used when the outer (lateral) side is worn and the leg is knock-kneed (valgus)
Less common, but the right operation when the deformity is in the femur

Osteotomy combined with other procedures

This is where osteotomy becomes particularly valuable. If I am reconstructing a ligament, repairing or transplanting a meniscus, or performing a cartilage restoration procedure, and the leg alignment is wrong, then correcting alignment at the same time protects the reconstruction. Without it, the forces that damaged the knee in the first place will continue to overload the repair.

What happens during surgery

The specifics vary depending on the plan, but the basic steps are:

A controlled cut in the tibia (HTO) or femur (DFO)
Correction of alignment to the pre-planned angle
Fixation with a plate and screws
Bone graft or a bone substitute in some cases, depending on the osteotomy type

The aim is a stable correction that allows the bone to heal reliably while you get on with rehabilitation.

Before the operation

You will usually attend a pre-admission assessment. It is important to let the team know about:

Medical conditions (diabetes, heart or lung problems, any history of blood clots)
All medications, especially blood-thinners that may need adjusting before surgery
Any allergies or previous reactions to medications

Please contact me if you develop an infection (cough, cold, urinary infection), feel unwell, or have any broken skin, ulcers, or rashes around the leg before the operation.

Anaesthetic

Your consultant anaesthetist will discuss the safest and most comfortable approach. Most patients have a general anaesthetic, sometimes combined with a spinal anaesthetic or nerve blocks. Local anaesthetic around the surgical area is commonly used to help with pain control during and after the procedure.

After surgery: early recovery

The early focus is on pain control, safe mobility, bone healing, and preventing complications.

Mobilisation and weight-bearing

Most people use crutches initially. How much weight you can put through the leg depends on the stability of the correction and the type of osteotomy. Physiotherapists will help you start walking safely and begin exercises early.

Blood clot prevention

I use a combination of early mobilisation and blood-thinning medication to reduce clot risk, and sometimes compression devices, depending on your individual risk profile.

Length of stay

Hospital stay depends on the procedure and your progress with walking, pain control, and confidence on stairs.

Recovery timeline

Osteotomy recovery is gradual because the bone needs time to heal. Most people notice improvement in stages rather than all at once.

I follow your progress carefully with regular X-rays to confirm the osteotomy is healing as expected.

Typical recovery pattern (guide only)

First 4–6 weeks: swelling control, walking with crutches, restoring movement
6 weeks to 3 months: progressive strengthening, improving walking distance, building confidence on stairs and slopes
3+ months: return to higher-level activities as strength and bone healing allow

Many patients continue to improve for months after surgery as fitness returns and the knee adapts to its new alignment.

Benefits and limitations

Potential benefits

Meaningful pain reduction when symptoms are driven by compartment overload
Improved function and confidence in the knee
Preservation of your own joint surfaces and ligaments
In many cases, delaying partial or total knee replacement by years

Important limitations

Recovery takes significant time because the realigned bone must heal
It does not "cure" arthritis – milder symptoms may continue despite the improved mechanics
Arthritis may still progress over time, and some people eventually need a partial knee replacement or total knee replacement

Risks and complications

Knee osteotomy is a well-established procedure, but as with any operation there are risks:

Infection
Blood clots (DVT / pulmonary embolus)
Delayed bone healing or non-union (slow or incomplete healing of the osteotomy)
Over-correction or under-correction of alignment
Nerve or blood vessel injury (rare)
Hardware irritation – the plate can be noticeable, particularly in slim patients, and sometimes needs removing once the bone has healed
Progression of arthritis in another compartment over time

When to seek urgent advice after surgery

Increasing redness, heat, wound leakage, fever, or feeling unwell
New calf pain or swelling
Chest pain or shortness of breath
A sudden change in leg function, severe pain, or inability to weight-bear

Frequently asked questions

Is osteotomy an alternative to knee replacement?

In the right patient, yes. When wear is mainly on one side and alignment is driving overload, osteotomy can be an excellent knee-preservation option. If arthritis is widespread across the joint, a partial or total knee replacement is usually more predictable.

Will I have metalwork in my leg?

Yes – most osteotomies are held with a plate and screws. Some patients notice the plate, particularly if they are slim. If it causes discomfort after the bone has healed, it can be removed.

How long will the correction last?

That depends on several things: the severity of arthritis at the time of surgery, the accuracy of the correction, your activity level, body weight, and whether the rest of the knee stays healthy. Many people get long-lasting improvement, but some do eventually progress to knee replacement.

When can I drive and return to work?

This depends on which leg was operated on, your comfort, strength, and the type of work you do. Desk-based work may be possible earlier than heavy physical work. You should only drive when you can safely control the vehicle, perform an emergency stop without limitation, and meet insurance requirements.

Can I play sport after osteotomy?

Many people return to low-impact activities like cycling, swimming, and hiking. Higher-impact sport may be possible depending on your knee condition, healing, and goals – but it needs to be planned carefully as part of rehabilitation.

Can I be assessed for knee osteotomy in Bristol?

Yes. I see patients at my Bristol clinics for osteotomy assessment, including long-leg alignment X-rays, bracing trials before surgery, and full rehabilitation planning afterwards.