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Knee replacement / osteotomy

Robert N. was a healthy 53 year old man from North Queensland who presented with a badly worn knee that was constantly painful. He had consulted with a surgeon who assured him he eventually needed a knee replacement. Because he was so young it was recommended that undergoing a tibial osteotomy would delay the necessity for about five years.

Upper tibial osteotomy. (fig a) This involves cutting a wedge shaped section from the tibia bone to try to straighten the leg with the explanation that it will align the knee correctly. Once again the knee is being viewed in two dimensions. The procedure is intended to tip the joint sideways and equal out the joint space and pressure. Working on the knee in isolation is not effective as when walking, any excessive foot roll will change knee alignment. This individual has this misaligned knee because the foot and lower leg has a misalignment. This standing x-ray shows that the (L) knee is collapsing outwards but considering it in three dimensional terms, this joint has also externally rotated (turned out) as indicated because the fibula is well behind the condyle of the tibia rather than attached alongside it.

He wanted to pursue a less invasive options that didn't involve the six months on crutches. He had recently been prescribed hard arch support orthoses by a local podiatrist recommended by the surgeon. He wore the devices for 6 weeks and realized they had made his knee much worse, so he searched for an answer.

I noted that he stood with both knees turned out. He has Pes Cavus (high arch) feet which roll out at the front, the left being worse. His ankles collapse outward and turn out, legs and knees externally rotate. The rotated knees hyperextend (lock back). I examined the podiatrist’s hard arch supports heel posted with angles under the medial heel to tip him out. They could not have been more incorrect increasing the turning of his leg/knee tipping it out sideways putting even more pressure onto the worn medial (inside) aspect. This would have definitely caused more wear to the knee. Also his high arch feet would object to arch support. I made flexible orthotics to realign foot contact to correctly realign the entire leg and achieve correct knee function. He actually needed angles on the outside forefoot (not inside heel) to make him roll in the required degrees.

Surgery based on a two dimensional view of his knee would not have been effective.

More was achieved with the less invasive orthotics treatment. I realigned the entire leg, turning his knee joint to face forward, correctly aligned with equal joint space from side to side. Eliminating wear allows the knee to begin to repair and improve over time.

Three months later feedback from a relative who consulted with me was that “Robert’s knee is fixed”..

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