Rehabilitation after high tibial osteotomy: weight-bearing, strength and return to activity

Knee osteoarthritis often affects one side of the joint more than the other. An osteotomy realigns the leg so that the load moves towards the healthier side, which the Royal Berkshire leaflet likens to buying time for the knee. The surgeon cuts the bone below the joint and either opens a wedge or removes one, then fixes it with a plate and screws.

Since the bone has been deliberately cut, the plate holds it steady while it knits, and rehabilitation needs to restore movement and strength without disrupting healing. Leicester's booklet adds that swelling can last several months and that the exercises are essential to reduce stiffness.

Leicester says most patients stay overnight and go home with crutches, and may or may not be allowed to bear weight depending on how surgery was done. Royal Berkshire says most go home the day after surgery if pain is controlled, you can get in and out of bed and walk confidently on crutches to the bathroom. Stitches or clips are removed at your GP practice about 10 to 14 days after the operation according to Royal Berkshire, or at 2 weeks according to Leicester.

Physiotherapists teach early range-of-movement exercises and stairs technique before discharge. The Leicester booklet recommends protect, rest, ice, compression and elevation, with the leg straight rather than resting the back of the knee over a pillow, and exercises two to three times a day, 10 repetitions each, starting with pressing the knee down into the bed and bending the knee while seated.

The Robert Jones and Agnes Hunt Orthopaedic Hospital publishes a criteria-based guide for therapists. Phase 1, from day 1, allows weight-bearing as symptoms allow with elbow crutches for comfort, movement as symptoms allow, ice, kneecap mobilisation, stretches, ankle exercises and weight transfer. Phase 2, from week 1, adds static cycling, anti-gravity treadmill, gait re-education, early balance work and hydrotherapy when wounds allow, with an X-ray at 6 weeks.

Phase 3 begins from week 6 if the X-ray is satisfactory, discomfort is minimal, swelling is resolving, you walk without aids and can lift the straight leg without lag. The guide lists benchmarks such as active movement from full extension to at least 100 degrees and single-leg stance reaching at least 80 percent of the other side. From week 8 the guide adds speed work and structured strength and endurance training, with benchmarks including a normal symmetrical walking pattern and active bending to at least 120 degrees.

• Progress depends on meeting criteria, not on the calendar alone.

• The guide is meant to be adapted to each patient and to any special instruction from the surgeon.

• It asks therapists to follow the most conservative guide when another health condition is present.

Royal Berkshire covers the thigh-bone version of the operation in the same leaflet. After a distal femoral osteotomy you are touch-toe weight-bearing for the first 6 weeks and then increase gradually if all goes well, and driving typically resumes 6 to 10 weeks after, once crutches are discarded and you can perform an emergency stop. After a high tibial osteotomy driving is usually not advised for 6 weeks.

Royal Berkshire says that as long as the osteotomy heals and there are no other complications, swimming and gentle cycling or rowing can begin at around 3 months, and it may be 6 to 9 months before vigorous sport is possible. Research it cites indicates that only a few people regain their previous high-level sport, but most can do leisure sport such as walking, hiking, cycling, swimming and tennis. Contact sports and distance running are not recommended, though how the knee feels should also guide you.

Leicester's booklet is more optimistic, saying many younger patients keep an active lifestyle for years and that some return to manual work, running or sport. The two documents are consistent in leaving the final decision to your surgeon and your own knee.

Both leaflets list wound infection, bleeding, blood clots, delayed bone healing or non-union, and the possibility of later plate removal if it irritates. Contact your hospital team or NHS 111 for a hot, red or leaking wound, a high temperature, a hard painful swollen calf, or numbness or colour change in the foot. Chest pain or breathlessness need 999 or A&E.