A comparative evaluation of clinical outcomes following high tibial osteotomy versus total knee arthroplasty in early elderly patients with advanced knee osteoarthritis

Knee osteoarthritis is a degenerative disease that is progressive in nature and that has great influence on mobility, independence, and quality of life, especially in the elderly population. As many patients are living longer and as more of them have functional needs, there is an increased need to treat advanced knee osteoarthritis surgically. Non-operative management may continue but most patients ultimately lose their functional capacity and suffer chronic pain and thus may need to undergo surgery as a major treatment [1-3].

Knee osteoarthritis is a degenerative disease, which is progressive in nature and has tremendous impact on the mobility, independence and quality of life particularly among the elderly population. Due to the longer life span of many patients and also with the ever-growing number of patients with functional needs, surgical treatment of the advanced knee osteoarthritis is on the rise [4-6]. Non-operative management can be followed but in most cases, patients end up losing their functional status and experiencing chronic pain and therefore might have to undergo surgery as a significant measure [7-9].

The current research was conducted to determine the short-term clinical outcomes of tibial realignment osteotomy compared with knee joint replacement in elderly individuals with advanced degenerative knee disease. This study will offer evidence-based practice that can guide operation decision-making in this group of patients by assessing pain relief, functional improvement, postoperative recovery, and complications within one year

This comparative clinical research was carried out at JINNAH POSTGRADUATE MEDICAL CENTER (JPMC), Karachi within a period of one year, between June 2024 and June 2025. All patients with severe knee osteoarthritis (n=72) were used and separated into two equal groups depending on the type of surgery done on the patients. The research was aimed at comparing postoperative results following tibial realignment osteotomy were compared with those of knee replacement surgery in an early elderly population.

Knee osteoarthritis patients between 55-65 years with symptomatic knee pain that was resistant to conservative treatment were eligible to be included. The presence of advanced osteoarthritis was confirmed through the radiography of normal weight-bearing anteroposterior knee radiograph. Patients whose arthritis was inflammatory, who had undergone knee surgery on that side, had excessive flexion defect, active infection or had severe medical comorbidity that precludes surgery were not included.

Following the assessment of the inclusion criteria and informed consent, patients were divided into two groups, including high tibial osteotomy (HTO group, n = 36) and total knee arthroplasty (TKA group, n = 36). The decision on which procedure to use was made on a clinical assessment, radiographic, age of the patient, functional requirements, and the judgment of the surgeon. All the operations were done by qualified orthopedic surgeons with standardized operations.

Preoperative evaluation involved a thorough history taking and physical examination, and recording of baseline demographic data. The visual analogue scale (VAS) was used to evaluate the pain severity and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to assess the functional status. The knee range of motion was determined by means of a goniometer and general fitness to undergo surgery was determined based on the American Society of Anesthesiologists (ASA) classification.

All patients were subjected to a standard rehabilitation postoperative protocol, which was in line with the kind of surgery done. There was the focus on pain control, early mobilization, and physiotherapy in both groups, and the weight-bearing status was altered based on the operation. In the outpatient department, the patients were monitored frequently and the clinical outcomes were measured after specific intervals and the ultimate evaluation was done after one year of surgery.

The outcome measures involved postoperative pain level, improvement of function, range of motion, duration to bear full weight, length of stay and patient satisfaction. Complications that occurred after the surgery, including infection, slow union, issues with the implants and necessity to perform revision surgery were also noted. Structured proformas were used to collect all data on a prospective basis.

The standard statistical software was used in statistical analysis. Continuous variables were reported in the form of mean +-standard deviation, whereas categorical variables were reported in the form of frequencies and percentages. Appropriate tests that were used are independent t-test and Chi-square test to compare results of the two groups. The p-value used was 0.05 or below which was regarded as statistically significant.

Baseline characteristics were comparable between patients who underwent ‘tibial osteotomy and those treated with knee arthroplasty’ No meaningful differences were observed between the groups with respect to age distribution, sex, body mass index, duration of symptoms, radiographic disease severity, or preoperative anesthetic risk classification. This comparability indicates that the two cohorts were suitably aligned at baseline, allowing postoperative outcomes to be interpreted without major confounding from preoperative variables

Table 1. Demographic and Baseline Characteristics of the Study Population (n = 72)

Both surgical operations led to a substantial clinical improvement at a one year follow-up. Patients with total knee arthroplasty showed more pain relief and functional improvement than high tibial osteotomy patients based on postoperative VAS and WOMAC scores. Nevertheless, there was no significant difference in range of motion after the operation of the two groups.

Table 2. Postoperative Outcome Assessment of Tibial Osteotomy and Knee Arthroplasty After One Year

Both groups had postoperative complications but there was no significant difference in the overall rates. Delayed union was limited to the osteotomy group, while implant-related complications occurred only in patients who underwent ‘knee arthroplasty’. Full weight bearing was earlier in patients undergoing total knee arthroplasty and a slightly higher rate of satisfaction was reported at a one-year follow-up.

Table 3. Postoperative Complications and Functional Recovery

Figure 1. Comparison of mean improvement in WOMAC score comparing tibial realignment osteotomy with knee joint replacement surgeryat one-year follow-up. Patients undergoing total knee arthroplasty demonstrated greater functional improvement compared to those treated with high tibial osteotomy.

The current research compared postoperative results following ‘tibial osteotomy and knee replacement surgery’ during the period of one year follow up. The two procedures led to significant pain reduction and functional placement, which proves the validity of surgical interventions as long as the attempts at conservation have been unsuccessful. Nevertheless, total knee arthroplasty showed better results in pain relieve and functional improve as indicated by the reduced postoperative VAS scores and higher gains in WOMAC scores [10-13].

The higher degree of functional improvement in the total knee arthroplasty patients is in line with the findings reported in the past that joint replacement provides more reliable symptomatic relief in patients with more severe degenerative alterations. Complete correction of deformity, and more comprehensive address to all knee compartments, can potentially optimize a restoration of joint mechanics and stability with total knee arthroplasty. However, in comparison, whereas high tibial osteotomy is preservative of the native joint and postpones arthroplasty, its advantages are less evident with severe osteoarthritis patients [14-16].

Nevertheless, in spite of these disparities, high tibial osteotomy exhibited some benefits which are still clinically applicable. Osteotomy patients spent less time in hospitals and had a marginally better post-operative range of motion, which would be relevant to physically active patients. But only in this group a delay in uniting was seen, which is one of the limitations of osteotomy surgeries known to be so delicate as to be required to select the patient and follow up carefully [17, 18].

The incidence of complications was not significantly different between the two groups, and there were no statistically significant differences in the number of adverse events overall and revision surgery during the study period. Only arthroplasty group experienced implant-related complications, whereas only osteotomy group experienced delayed bone healing which indicated risks of specific procedural reasons rather than surgical safety. The level of patient satisfaction would be more favorable after the total knee arthroplasty probably because of the previous pain relief and the fact that weight bearing was restored quicker [19, 20].

This research indicates that whereas high tibial osteotomy can be used in specific early elderly populations, total knee arthroplasty is more effective than the surgery in terms of giving more stable short-term clinical outcomes to the chosen patients with severe osteoarthritis. The one-year follow-up enabled the evaluation of early findings; in the long term, the results are required to gauge more on the issue of sustainability, survival and loss of functional capabilities with time.

Tibial osteotomy and knee replacement surgery’ both represent viable operative approaches for managing advanced knee disease in the ‘elderly population’ with severe knee osteoarthritis. Total knee arthroplasty offers greater pain relief, faster functional recovery, and higher patient satisfaction at one-year follow-up, while high tibial osteotomy remains a joint-preserving alternative in carefully selected patients. Surgical decision-making should therefore be individualized, taking into account disease severity, patient expectations, and functional demands.

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