Reviewed by Dr Vishal Pai
A realignment osteotomy changes the alignment of the leg to take load off the worn side of an arthritic knee. This page covers who it suits, what the operation involves, recovery, results and risks.
At a Glance
- A realignment osteotomy is a cut in the shin bone (tibia) or thighbone (femur) that changes the alignment of the leg, so less force passes through the worn side of the knee.
- It is usually considered for younger, active people with arthritis on one side of the knee.
- Treatment starts with physiotherapy, load management and weight management. Surgery is considered when symptoms persist.
- You use crutches for 6 weeks, and the bone takes 3 to 6 months to heal.
- An osteotomy does not cure arthritis, but in carefully selected people it can relieve pain for several years.
What is a realignment osteotomy?
A realignment osteotomy of the knee involves making a saw cut in the bone to allow the alignment in the bone to change. This is usually performed in the context of arthritis affecting one side of the knee where the alignment of the knee is such that more force passes through that side. Occasionally, osteotomies are performed to help with the knee’s stability or offload the site of a cartilage regeneration or ligament reconstruction procedure.
Varus alignment, often called bow legs, shifts load onto the inner (medial) compartment of the knee. Valgus alignment, or knock knees, concentrates force on the outer (lateral) compartment. A high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) moves load away from the damaged compartment. Read more about knee alignment and arthritis.
Who might need a realignment osteotomy?
Treatment starts with reducing the load on the joint through targeted physiotherapy, walking-pattern retraining, activity changes and weight management where needed. People who engage fully in rehabilitation often notice a worthwhile improvement in symptoms. Injections can provide short-term relief, but they do not cure arthritis.
Physiotherapy, orthotics and activity changes can help manage symptoms and load, but they do not straighten the bones or correct fixed bony malalignment.
For younger people with arthritis in one compartment and malalignment, a realignment osteotomy is often the joint-preserving option Dr Vishal Pai considers first. It suits younger, active people with arthritis on the inner side of the knee and bow-legged alignment. Careful assessment of alignment, arthritis severity and the rest of the knee is needed. A standing full-length X-ray (a long-leg alignment view) is the most reliable way to assess alignment. Read more about early knee arthritis in active younger people.
What is involved in realignment osteotomy surgery?
The steps involved in realignment osteotomy surgery include:
1. Pre-operative planning
X-rays and CT scans are organised to determine the degree of correction required with the osteotomy. This data is analysed, and a custom-made jig is prepared for the osteotomy surgery.
2. Bone cuts made (osteotomy)
The custom-made jig is applied to the bone (tibia or femur). A saw is used to cut through the bone for which the osteotomy is planned.
3. Change in the bone alignment
Opening wedge osteotomy: This involves opening the gap where the osteotomy has been made to change the alignment (as shown in the diagram).
Closing wedge osteotomy: This involves removing a wedge of bone at the osteotomy site to change the alignment.
4. Fixation of the osteotomy
A metallic plate with screws is used to hold the bone in its new position. In opening wedge osteotomy, a bone graft is sometimes packed at the osteotomy site to fill the gap. This is usually performed if a significant correction is required.
How long does it take to recover from a realignment osteotomy?
Recovery from an osteotomy is more demanding than many people expect. Physiotherapy starts after your first post-operative visit. Avoid resting with a pillow under your knee. Swelling can last 3 to 6 months. As a rough guide:
- Next dayYou will usually go home the day after surgery, once a check X-ray has been taken.
- 2 weeksYour wound is checked at your first follow-up appointment.
- 3 to 4 weeksMost people with an office-based job are able to return to work.
- 6 weeksYou can stop using crutches. You may also return to driving.
- 8 weeksA follow-up X-ray is taken. By this stage, Dr Vishal Pai expects your knee to straighten fully and to bend beyond 90 degrees.
- 8 to 10 weeksPeople in physically demanding jobs can usually return to work.
- 4 monthsA further X-ray is taken. By now, Dr Vishal Pai expects your knee to have close to its full range of movement, and the osteotomy to be almost completely healed.
- 8 monthsA final X-ray is taken to confirm that the bone has fully healed.
What results can you expect?
An osteotomy shifts your body weight away from the worn part of the knee. It does not cure the arthritis or regrow cartilage. In carefully selected people, it usually relieves much of the pain from arthritis, and the relief can last for several years.
About 86 in 100 people have not needed a knee replacement 10 years after an opening wedge high tibial osteotomy. [1] The chance of needing one rises with time, to about 1 in 3 by 15 years. [2]
Most people return to sport and work, usually within a year, and most get back to the same or a higher level of sport. [3] These figures are averages, not one surgeon’s results.
What are the risks and complications?
Every operation carries risks, and Dr Vishal Pai goes through them with you before you decide. The main risks of a realignment osteotomy are:
- Deep infection, in about 1 in 200 people
- Bleeding into the knee, which occasionally needs a return to theatre to wash it out
- Blood clots in the leg
- Irritation from the plate, which can be removed once the bone has healed, usually not before 1 year
- The bone not healing (non-union), in about 2 in 100 people, which may need further surgery with a bone graft [4]
- Stiffness, which occasionally needs a manipulation under anaesthetic if the knee is not bending or straightening by 6 to 8 weeks
Rarely, the bone cracks into the knee joint during surgery, or the artery, vein or nerve near the knee is injured. A nerve injury can cause foot drop (weakness lifting the foot). The arthritis can also progress, and some people later need a knee replacement. You will receive a written information sheet with the full list of risks.
Where does Dr Vishal Pai consult and operate?
Dr Vishal Pai consults at Sandringham Orthopaedic Specialists, Suite 1, 60 Bay Road, Sandringham. He performs osteotomies at Calvary Holmesglen Private Hospital, 490 South Road, Moorabbin, and The Avenue Hospital, 40 The Avenue, Windsor. Patients come from across Bayside, Glen Eira and the Mornington Peninsula, and some travel from regional Victoria.
References
Show all 6 referencesHide references
- Ge YZ et al. 2026. Long-term survivorship after medial open-wedge high tibial osteotomy: a systematic review and single-arm meta-analysis with regional subgroup analysis. Knee Surgery, Sports Traumatology, Arthroscopy.
- Pinto C et al. 2026. No differences between medial opening and lateral closing wedge high tibial osteotomies to correct coronal alignment or cumulative rates of conversion to knee arthroplasty: a systematic review with meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy.
- Ekhtiari S et al. 2016. Return to work and sport following high tibial osteotomy: a systematic review. The Journal of Bone and Joint Surgery (American Volume).
- Loke R et al. 2025. Conversion to total knee arthroplasty after high tibial osteotomy: a systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine.
- Sun XD et al. 2020. A meta-analysis of total knee arthroplasty following high tibial osteotomy versus primary total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery.
- Lee J et al. 2024. Clinical and functional outcomes of TKA after HTO or UKA: a New Zealand Joint Registry study. Archives of Orthopaedic and Trauma Surgery.
Frequently asked questions
Are there limitations on my activity after an osteotomy?
Most people return to sport and work once they have recovered, usually within a year. [3] The osteotomy is designed to allow you to remain as active as possible.
Do I need to wear a brace on return to activity?
No, a brace is not required for activity after an osteotomy has healed.
How long will I use crutches after an osteotomy?
Crutches are used for 6 weeks after an osteotomy, and you can put some weight on your leg during this time. They are designed to offload some force away from the osteotomy site in order to make your rehabilitation in the early stages more comfortable.
Will I need my osteotomy plate removed?
Having your plate removed is not a necessity but is recommended.
The plates used to hold the osteotomy are rigid and thick as they are designed to withstand the force of your body weight. Sometimes the plate can be prominent and people can feel the plate under their incision. In these situations, removal of the plate can help with these symptoms.
In the future, you may need more surgery to your knee such as a knee replacement. The presence of a plate can make this more difficult. Removing a plate several years after surgery can be more challenging as there may be bony ingrowth and overgrowth.
Plate removal is usually performed 9-12 months after your initial surgery, once the osteotomy site has completely healed, and is a day case.
Will my leg look different after osteotomy surgery?
Performing an osteotomy will change the alignment at the knee joint and therefore the appearance of the affected limb. The operated knee will look straighter after the operation.
Will an osteotomy make a knee replacement in the future more difficult?
A later knee replacement is still possible, although it needs careful planning. There are certain technical considerations that need to be taken into account, such as removal of the plate and the scarring in the knee caused by the osteotomy.
Function after a knee replacement that follows an osteotomy is similar to a knee replacement in a knee that has not had one. The operation takes longer, and the risk of infection and of the knee replacement needing revision later is somewhat higher. [5] [6]
When should I seek help after surgery?
Contact Dr Vishal Pai’s rooms or your GP, or go to your nearest emergency department, if you notice:
- Increasing swelling, redness or warmth around the wound
- A temperature above 38°C for 12 hours or more
- Drainage from the wound after 72 hours
- Pain or swelling in your calf
Call 000 if you have chest pain or shortness of breath.
Next step
Talk through your options
If you are weighing up a realignment osteotomy, Dr Vishal Pai can examine your knee, review your scans and explain all your options, including treatment without surgery.