What is the clinical-effectiveness and cost-effectiveness of surgery with medial opening wedge high tibial osteotomy (HTO) compared with nonsurgical treatment in the management of osteoarthritis (OA) of the knee in patients younger than 60 years?

Osteoarthritis (OA) is the leading cause of disability worldwide. The knee joint is the most common site
of OA. Nearly 1 in 5 people >45 years in the UK will seek treatment for it. In a healthy knee joint, there
is a smooth lining that covers the ends of the bones. In knee OA, this smooth lining thins, roughens
and is permanently damaged causing joint pain, swelling and stiffness. Patients have a reduced quality
of life as they struggle with daily activities like walking, standing and sleeping and often cannot work
due to the disability. Initial treatment is non-surgical with general advice, painkillers, walking aids,
physiotherapy and occasionally, steroid injections. If the knee is still painful, surgery may be
considered. If patients are >60 years then knee replacement surgery is successful as the diseased part
of the knee is physically removed and replaced with an artificial implant. However, in patients <60
years knee replacement surgery is less successful because the metal/plastic knee implant wears out
much sooner due to higher activity levels in young, working age patients. The artificial joint has to be
replaced again, sometimes several times, and patients have to go through complex, risky repeat
operations. Most patients do not return to work either. In patients<60 years, it is therefore best to delay
knee replacement surgery as long as possible, and other treatments should be considered instead.
Fortunately, there is an option whereby the knee can be realigned without the need for replacing it.
During this surgery called ‘high tibial osteotomy’, the bone is cut just below the knee joint and a small
wedge is opened, to shift the person’s weight away from the damaged part of the knee to a healthy
part of the knee. By ‘unloading’ the damaged part of the knee, the surgery can decrease pain, improve
function and delay the need for knee replacement or avoid it altogether. It may allow many more young
patients to return to work. However, we also do not know if delaying or avoiding knee replacement
surgery in patients <60 years with high tibial osteotomy surgery is any better than non-surgical
treatment alone, as the two options have never been compared.
AIM
We wish to study whether treating a painful, arthritic knee joint in patients younger than 60 years with
joint realignment surgery (called high tibial osteotomy) is better than non-surgical treatment in terms of
pain relief, improved quality of life and ability to return to work.