Osteotomy is the primary joint surgery that involves removing a slice of bone to correct alignment, relieve pressure, or realign a joint surface. This procedure is distinct from joint replacement, as it preserves the patient’s natural anatomy while mechanically altering the forces acting upon the joint. By cutting and reshaping the bone—often removing a precise wedge—surgeons can shift weight-bearing loads away from damaged cartilage toward healthier tissue, effectively buying time for younger, active patients who are not yet candidates for total joint arthroplasty Simple as that..
Understanding the Core Concept of Osteotomy
The term osteotomy literally translates to "cutting of the bone.Because of that, " While the definition sounds straightforward, the surgical execution requires meticulous preoperative planning and intraoperative precision. The "slice of bone" removed is typically a calculated wedge—either an opening wedge (where a gap is created and often filled with bone graft) or a closing wedge (where a segment is excised and the bone ends are brought together).
The fundamental goal is realignment. Injury, arthritis, or congenital deformity disrupts this balance, concentrating stress on a specific area and accelerating wear. In a healthy joint, forces are distributed evenly across the articular cartilage. Which means by removing a slice of bone from the tibia, femur, or other skeletal structures, the mechanical axis of the limb is corrected. This redistribution of load alleviates pain, improves function, and slows the progression of degenerative joint disease.
The Most Common Application: High Tibial Osteotomy (HTO)
When patients ask which joint surgery involves removing a slice of bone, the answer most frequently points to High Tibial Osteotomy (HTO) for knee osteoarthritis. This is the gold standard for treating unicompartmental knee arthritis—specifically medial compartment wear associated with varus (bow-legged) deformity.
In a medial opening wedge HTO, the surgeon makes a cut in the upper tibia (shinbone) just below the knee joint. But a precise wedge of bone is effectively "removed" from the lateral cortex conceptually, or more accurately, a wedge is opened on the medial side to correct the angle. Conversely, in a lateral closing wedge HTO, a physical slice of bone is excised from the lateral tibia, and the gap is closed to straighten the leg Simple, but easy to overlook..
Ideal candidates for HTO typically share these characteristics:
- Age under 60 (though biological age matters more than chronological age).
- High activity levels or physically demanding occupations.
- Arthritis confined to a single compartment (usually medial).
- Intact ligaments (specifically the ACL).
- Correctable deformity with good range of motion (generally > 90 degrees flexion, < 10 degrees flexion contracture).
The survival rate of HTO at 10 years often exceeds 80-90%, making it a powerful joint-preserving option. It allows patients to return to high-impact activities—running, skiing, manual labor—that are generally discouraged after total knee replacement Surprisingly effective..
Beyond the Knee: Other Joints Utilizing Bone Removal
While the knee is the most famous site, the principle of removing a slice of bone to realign a joint applies elsewhere in the skeleton Simple, but easy to overlook..
Hip: Periacetabular Osteotomy (PAO) and Femoral Osteotomy
Developmental Dysplasia of the Hip (DDH) leaves the acetabulum (socket) too shallow to cover the femoral head. A Periacetabular Osteotomy (PAO) involves a series of cuts around the acetabulum, freeing the socket fragment so it can be rotated into a position of better coverage. While PAO focuses on rotating a fragment rather than simply removing a wedge, bone wedges are often removed from the pelvis or femur during the procedure to achieve tension-free reduction Practical, not theoretical..
A Femoral Varus/Valgus Osteotomy involves removing a wedge from the proximal femur to alter the neck-shaft angle. This improves femoral head coverage in the socket or corrects coxa valga/varva deformities Easy to understand, harder to ignore..
Foot and Ankle: Correcting Deformity
The foot contains numerous small joints where osteotomies are routine.
- First Metatarsal Osteotomy: The standard correction for hallux valgus (bunions). A distal chevron, scarf, or proximal wedge osteotomy removes or displaces a slice of the metatarsal bone to straighten the great toe.
- Calcaneal Osteotomy: Used for flatfoot (pes planus) or cavovarus deformity. A lateral sliding osteotomy or a closing wedge osteotomy of the heel bone realigns the hindfoot.
- Supramalleolar Osteotomy: Performed on the distal tibia to correct ankle arthritis caused by malalignment (varus or valgus ankle), similar in principle to HTO but at the ankle joint.
Elbow and Shoulder
Though less common, osteotomies around the elbow (distal humerus or proximal ulna) correct post-traumatic malunions causing stiffness or instability. In the shoulder, a glenoid osteotomy or humeral osteotomy may address glenoid dysplasia or humeral head subluxation.
The Surgical Workflow: Precision in Planning and Execution
The success of removing a slice of bone hinges on preoperative planning. Still, g. , the Fujisawa point at 62.Modern surgeons use weight-bearing long-leg alignment radiographs and increasingly 3D CT-based planning software. Also, these tools calculate the exact center of rotation (CORA - Center of Rotation of Angulation) and determine the precise size and location of the bone wedge required to shift the mechanical axis to the target zone (e. 5% lateral on the tibial plateau for HTO) Most people skip this — try not to..
Worth pausing on this one.
Intraoperative Steps Generally Include:
- Exposure: Minimally invasive approaches are standard to preserve soft tissue attachments and blood supply.
- Guide Pin Placement: Under fluoroscopic guidance, pins establish the osteotomy plane.
- The Cut: An oscillating saw removes the predetermined wedge (closing wedge) or creates the opening (opening wedge).
- Correction & Fixation: The bone ends are approximated (closing wedge) or spread apart (opening wedge). Opening wedges often require bone graft (autograft from iliac crest, allograft, or synthetic substitutes) to fill the gap and promote healing.
- Stabilization: Low-profile plates and locking screws provide rigid fixation, allowing early mobilization.
Opening Wedge vs. Closing Wedge: A Critical Distinction
The choice between removing a slice (closing wedge) or creating a gap (opening wedge) involves trade-offs Turns out it matters..
| Feature | Closing Wedge Osteotomy | Opening Wedge Osteotomy |
|---|---|---|
| Bone Removal | Yes, a physical wedge is excised. | |
| Correction Limit | Limited by soft tissue tension. | Maintains or slightly increases limb length. That said, |
| Stability | Inherently stable (bone-on-bone contact). In real terms, | Requires rigid plate fixation; gap needs grafting. |
| Bone Length | Shortens the limb slightly. Even so, | |
| Nerve Risk | Higher risk to common peroneal nerve (fibular head proximity). | Easier to achieve large corrections. |
Currently, the medial opening wedge HTO has largely supplanted the lateral closing wedge in many centers due to easier technical execution, better preservation of the proximal tibiofibular joint, and simpler conversion to total knee replacement if needed later. That said, the closing wedge remains a valid, biomechanically sound option where the surgeon has specific expertise Simple, but easy to overlook..
Recovery, Rehabilitation, and Outcomes
Removing a slice of bone initiates a biological healing cascade identical to a fracture. The rehabilitation protocol balances protection of the fixation with prevention of stiffness It's one of those things that adds up..
- Weeks 0-6: Touch-down weight bearing (TDWB) or partial weight bearing (PWB) with crutches. Focus on quadriceps activation, straight leg raises, and passive/active-assisted range of motion.
- Weeks 6-12: Progressive weight bearing as radiographic healing (
Recovery, Rehabilitation, and Outcomes
Removing a slice of bone initiates a biological healing cascade identical to a fracture. The rehabilitation protocol balances protection of the fixation with prevention of stiffness.
- Weeks 0-6: Touch-down weight bearing (TDWB) or partial weight bearing (PWB) with crutches. Focus on quadriceps activation, straight leg raises, and passive/active-assisted range of motion.
- Weeks 6-12: Progressive weight bearing as radiographic healing (e.g., callus formation, bridging trabeculae) confirms bony union. Physical therapy emphasizes gait training, proprioception, and gradual strengthening.
- Weeks 12-24: Full weight bearing is typically permitted. Advanced strengthening, functional exercises, and low-impact activities (e.g., swimming, cycling) are introduced. Return to high-impact activities or sports is delayed until 6–12 months post-surgery, contingent on radiographic and clinical stability.
Outcomes and Considerations
HTO is highly effective for carefully selected patients, particularly those with unicompartmental knee osteoarthritis, preserved joint mobility, and a history of activity-related pain. Studies report 70–90% survivorship at 10–15 years, with significant pain relief and improved function. That said, patient selection is critical—older, less active individuals or those with severe deformity may benefit more from primary knee arthroplasty.
Conclusion
High tibial osteotomy remains a cornerstone in managing unicompartmental knee osteoarthritis, offering a joint-preserving alternative to arthroplasty. Modern techniques, particularly medial opening wedge HTO, prioritize precision, stability, and patient safety while enabling earlier mobilization and rehabilitation. So success hinges on meticulous preoperative planning, appropriate surgical execution, and adherence to a structured recovery program. While not without risks, HTO can significantly delay or even eliminate the need for knee replacement, restoring function and quality of life in active patients. As orthopedic practices evolve, this procedure continues to bridge the gap between conservative care and joint replacement, underscoring the importance of individualized treatment strategies in musculoskeletal medicine.
