Knee Surgery & Rehabilitation
Knock-knees may cause knee pain and limitations, especially as we grow older. The medical term used to describe this problem is valgus and it indicates a malalignment of the lower extremity. Some people are born with knock-knees, but others may develop the problem in just one leg following an injury. The main problem with knock-knees is that osteoarthritis may develop in the outer (lateral) area of the knee, causing pain, swelling, and limitations with recreational sports and eventually, problems with normal activities of daily living. This may be worsened with obesity or overuse of the knee joint, and can become a serious problem if the lateral meniscus (cartilage) is removed.
Osteoarthritis may occur from knock-knees because there is an abnormal amount of stress and pressure placed on the outer portion of the knee joint. A good analogy to this problem is the wearing of a portion of a tire on a car that is out of proper alignment. If the alignment is not fixed, the tire will wear out on one side, shortening its expected lifespan.
Technically, the term osteoarthritis refers to damage to the articular cartilage in the joint. Articular cartilage is a protective layer of tissue located on the ends of bone that come together in the knee, which are the femur (thigh bone), tibial (shin bone), and patella (kneecap). There is a second type of cartilage in the knee called a meniscus. There are 2 menisci in the knee – a medial (inner) and a lateral (outer). Each meniscus is an important tissue that acts as a cushion between the femur and tibia.
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Overall, how advantageous is it to correct knock-knees?
We and many other orthopaedic centers believe it is very advantageous to have an osteotomy for a painful knock-knee condition. Studies have shown that femoral osteotomy buys many years before patients need further surgery such as a partial or total knee replacement. This is particularly helpful in younger patients who wish to remain active and avoid knee replacement for as long as possible. Patients who require a lateral meniscus transplant or articular cartilage restoration procedure need to have the knock-knee malalignment corrected first or the other procedure will most likely fail.
What are the overall success rates of femoral osteotomy?
Overall, we have noted that 70-80% of patients have a significant improvement in their symptoms and knee function. Many can return to recreational sports that allow an active lifestyle for many years after surgery. The majority can do their daily activities without problems. However, we always advise our patients that if there is already arthritis in knee joint that it will progress. About 20% of patients will not have a long-term benefit and may require a partial or total knee replacement.
Who are candidates for femoral osteotomy?
- Patients aged less than 50 with knock knees, lateral side cartilage damage (not down to bone) with lateral side pain with activity
- Patients with knock-knees with a knee ligament injury, before a ligament reconstruction
- Patients with knock-knees before a meniscus transplant or articular cartilage procedure
Why should I see a sports medicine-trained orthopaedic surgeon?
The training of an orthopaedic surgeon involves many years of undergraduate, medical school, and residency education. The specialization of sports medicine involves additional training, usually at an educational center where a fellowship year is completed. This involves advanced training in arthroscopic surgery, required in the treatment of most knee, shoulder, ankle, elbow and sports medicine-related injuries. The sports medicine-trained surgeon also has knowledge of specific rehabilitation and muscle performance issues to safely regain function and return patients to athletics. A sports medicine center combines the disciplines of physicians, physical therapists, athletic trainers, and more to totally heal all aspects of an injury.
Who are not candidates for femoral osteotomy?
- Patients with bone exposed on the lateral side (> 15 mm x 15 mm area)
- Patients who had a prior medial meniscectomy or who have medial cartilage damage
- Patients with painful patella arthrosis
- Patients in whom lateral compartment depression and concavity prevent medial compartment loading
- Patients with poor motivation or unrealistic expectations
- Patients who are obese
- Patients who had a prior joint infection
- Patients who have diabetes, rheumatoid arthritis, autoimmune diseases, malnutrition
- Patients who have no joint space left in the lateral compartment
How soon will I start rehab?
In our clinic, patients begin rehabilitation the day after surgery. It is very important during the first week to control pain and swelling, which may be done with appropriate medications, ice, and elevation of the limb. It is also important to “turn on” the muscles in the leg which may be accomplished with the assistance of modalities (such as electrical muscle stimulation) guided by a physical therapist. The early start of knee motion and muscle strength exercises reduces the risk of complications such as excessive scarring and muscle atrophy. Our rehabilitation program lasts for 6 months, but most of the exercises may be done at home or in a fitness facility.
Click here to see our physical therapy program after distal femoral osteotomy.
What is rate of nonunion that requires subsequent surgery?
In our experience, no further bone grafting or surgery for bone healing problems has been required. We believe this was due to the type of fixation we used to stabilize the fracture site. We do inform patients that there is a 1-5% chance of a delayed union that requires the patient to spend a longer amount of time on crutches.
What are the published results of femoral osteotomy?
Only a few long-term clinical studies have been published on the outcome of distal femoral osteotomy. Four studies followed 136 patients who received a closing wedge femoral osteotomy for 10 years postoperatively. These investigations found the following survival rates (meaning the patients were doing well and had not required total knee replacement): 90%, 87%, 82%, and 64%. To date, 3 studies reported 15-year survival rates after this procedure of 45%, 49%, and 79%.
Two studies provided 7-year survival rates after opening wedge femoral osteotomy in 41 patients of 82-91%. We expect in the near future for more data to be published because this technique has gained favor with many surgeons over the last several years. Considering the fact that this operation’s goal is to buy time and provide pain relief with regular daily activities until total knee replacement is required, the 7 and 10-year survival rates justify its use in correctly indicated patients.