Knee Realignment Surgery (Osteotomy)
Offloading arthritis, improving alignment, and preserving the native knee joint
About Knee Realignment Surgery (Osteotomy)
Knee realignment surgery, also known as an osteotomy, is a procedure designed to change how load is distributed across the knee joint.
When the leg is slightly bowed (varus) or knock-kneed (valgus), increased load is placed on one side of the knee. Over time, this can lead to:
Localised cartilage wear
Pain with walking or standing
Swelling after activity
Early, uneven arthritis
Knee realignment surgery reshapes and repositions the tibia (shinbone) or femur (thighbone) so that weight is shared more evenly across the joint.
What is the aim of knee realignment surgery?
The aims of surgery are to:
Reduce pain
Offload the worn compartment
Improve function
Delay or avoid knee replacement in appropriately selected patients
For younger or more active patients with isolated compartment arthritis or symptomatic malalignment, knee realignment can be an effective joint-preserving option.
Who may benefit from knee realignment surgery?
Knee realignment is not suitable for everyone, and many patients can be managed without surgery. It may be considered if:
Pain is predominantly on one side of the knee (inner or outer)
X-rays show asymmetrical wear, rather than advanced arthritis in all compartments
The leg is noticeably bowed or knock-kneed
Symptoms limit walking, work, or sport despite physiotherapy, weight optimisation, and activity modification
You are too young or too active to proceed directly to knee replacement, but pain is no longer manageable with conservative care
In more advanced or widespread arthritis, knee replacement (including robotic-assisted options) may be more appropriate. This is discussed carefully during consultation.
Types of knee realignment procedures
The procedure performed depends on the pattern of deformity, arthritis, and symptoms.
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Most commonly used for bow-leg (varus) alignment with medial compartment arthritis.
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Often used for knock-knee (valgus) alignment with lateral compartment arthritis.
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In selected patients with patellar maltracking or recurrent dislocation, realignment may involve adjusting the position of the tibial tubercle and soft-tissue balancing. This is sometimes combined with MPFL reconstruction.
The most appropriate procedure is determined by careful assessment of alignment, cartilage wear, ligament stability, and individual goals.
How knee realignment surgery is performed
Pre-operative planning
Standing long-leg X-rays are used to assess alignment and calculate the degree and location of correction
Additional imaging may be used to assess joint surfaces, ligaments, and menisci
The operation
Knee realignment surgery is performed under general anaesthesia and may be combined with a nerve block for post-operative pain control.
The procedure typically involves:
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A controlled cut is made in the tibia or femur at a pre-planned site.
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The bone is gently opened or closed to shift load away from the worn side of the joint.
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A low-profile plate and screws hold the bone in its new position while healing occurs.
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Alignment and stability are checked, and the wound is closed. A brace may be used depending on the procedure.
In some cases, knee arthroscopy is performed at the same time to address associated meniscal or cartilage pathology.
Recovery & Rehabilitation
Recovery after knee realignment is structured and progressive. Exact protocols vary depending on the type of osteotomy and the amount of correction required.
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Usually 1–3 nights
Early mobilisation with physiotherapy
Pain and swelling managed with standard post-operative measures
Adjuncts such as compressive cryotherapy or muscle-stimulation devices may assist early recovery and quadriceps activation
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Partial or protected weight-bearing with crutches (often with a brace, as advised)
Focus on:
Swelling control
Regaining full knee extension and gradual flexion
Quadriceps activation and basic hip/core strength
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Gradual progression of weight-bearing as bone healing allows
Emphasis on restoring a normal walking pattern and improving strength
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Progressive strengthening and balance training
Stationary cycling, pool-based rehabilitation, and low-impact gym exercise
Return to most daily activities
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Gradual return to higher-level activities and selected sports once strength, control, and impact tolerance have recovered
Recovery timelines vary depending on bone healing, baseline fitness, age, and whether additional procedures were performed.
Knee realignment vs knee replacement
Both procedures aim to improve pain and function, but they work in different ways.
Knee realignment (osteotomy):
Preserves native joint surfaces
Alters how load passes through the knee
Often preferred in younger, active patients with one-sided arthritis
Knee replacement:
Resurfaces the joint with metal and plastic components
More appropriate when arthritis is advanced or involves multiple compartments
In some patients, knee realignment can delay the need for knee replacement by many years, but it does not stop the ageing process of the joint. Choosing the right option requires an individualised discussion.
Key points to remember
Knee realignment surgery is a joint-preserving option for selected patients
It is most suitable for one-sided arthritis with malalignment
Careful patient selection and planning are critical
Rehabilitation is essential and progressive
The aim is to improve function and delay knee replacement, not to cure arthritis
Frequently asked questions
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You may be a candidate if you have one-sided knee pain, visible malalignment, and X-ray evidence of asymmetric wear, particularly if non-operative treatment is no longer effective. Assessment includes clinical examination and imaging review.
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Robotic technology is most commonly used for knee replacement rather than osteotomy. Knee realignment relies on detailed pre-operative planning, intra-operative imaging, and established osteotomy techniques to achieve accurate correction.
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As a general guide:
Crutches are required initially
Weight-bearing progresses over 6–12 weeks
Most daily activities resume by 3–4 months
Return to higher-level sport or heavy labour occurs between 6–12 months, depending on healing and strength
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Realignment surgery cannot reverse existing cartilage damage. By shifting load away from the worn compartment, it can reduce pain, slow progression of arthritis, and delay the need for joint replacement in selected patients.
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Some discomfort is expected, particularly in the early weeks. Pain is managed with regional anaesthesia, medication, icing, and elevation. Most patients find pain improves steadily as bone healing progresses and mobility returns.
