High tibial osteotomy is an effective treatment for knee osteoarthritis The anatomy of our human knee joint determines that the knee normally experiences greater medial forces than lateral ones. Therefore, osteoarthritis of the knee is more likely to occur on the medial side. When the knee joint is internally rotated, the pressure on the medial side of the knee joint increases further and wear and tear increases significantly. According to statistics, the incidence of osteoarthritis in the inversion knee is four times higher than in the normal knee, and once osteoarthritis occurs, it progresses 20 times faster than in the non-inversion knee. The more the knee turns inward, the greater the stress on the inside of the joint, the greater the cartilage wear, the narrower the joint space, and the more the knee becomes turned inward, which creates a vicious cycle that develops until the cartilage wears out and the knee bones wear out, making it difficult for the patient to walk. In the case of patients like Auntie Chen, although the medial cartilage is severely worn, the lateral compartment of the knee has been under relatively little stress and the cartilage is almost intact. So the doctor corrected the inversion of the knee with a high tibial osteotomy and put more force on the lateral joint and less on the medial. This breaks the vicious cycle of medial osteoarthritis progression and allows the arthritis to stop and gradually recover. Arthroplasty does not fully meet the functional needs of the patient In total knee replacement, the cruciate ligament inside the knee joint is removed and replaced with a simple mechanical device. This mechanical device only works after the knee has been flexed to 70 degrees or more. Therefore, until this degree of mobility is reached, the knee joint is basically in a state of cruciate ligament deficiency, with sensory instability, loss of proprioception, and unnatural joint sensation. Also, most patients have problems with limited knee flexion. Therefore, although walking is possible, it is not recommended by many exercise doctors. With more activity, patients are prone to painful swelling and increased wear and tear on the joint. Older people are now becoming more and more active. This has led to a low satisfaction rate and a high rate of future revisions in relatively young elderly patients who have received artificial joint replacements. Therefore, in some countries, such as South Korea and South Africa, new health insurance policies have been introduced where patients under 65 years of age with knee osteoarthritis who undergo joint replacement are not reimbursed by health insurance. This has objectively contributed to the development of knee osteotomies by curbing the trend of expanding the indications for artificial joint replacement. What is the current development of osteotomy in China? It starts with the development of osteotomy in the world. The development of osteotomy in Europe, Japan and Korea is very good, while in the United States is poor. The reason for this is that the United States has almost all of the largest artificial joint companies in the world. Artificial joints are a huge medical industry in the United States. The strength and speed of the promotion of artificial joints can be described as a mountain. This has also deeply influenced the medical environment in China, where artificial joints have developed rapidly in recent years, and many hospitals have set up “joint surgery”, which is actually “joint replacement surgery. In the wave of artificial joints, the voice of osteotomy has been drowned out and reduced to a non-mainstream. Japan and Korea, which belong to the same cultural circle as us, have always adhered to the concept of preserving the patient’s own joints as much as possible, and have become one of the best regions for the development of osteotomy. There is also a group of orthopedic surgeons in China who have always adhered to osteotomies in an effort to prevent the expansion of joint replacements. There are other physicians who, with the massive adoption of joint replacement, have found that joint replacement does not meet the functional needs of their patients and that complications are increasing, prompting them to refocus their attention on osteotomy. At Beijing Jishuitan Hospital, for example, osteotomy cases have increased significantly in recent years. What is the “Joint Preservation Group”? Its acronym is JPEG, and its full name is JointPreservationandOsteotomyExpertGroup – Joint Preservation Surgery and Osteotomy Expert Group. The Joint Preservation and Osteotomy Expert Group is simply called the ‘Joint Preservation Group’. It is an international orthopaedic organization dedicated to the research, development, education, and promotion of periarticular osteotomy, and is affiliated with the AO Foundation, based in Switzerland. Its core team is usually composed of five of the world’s most representative experts in the field, appointed by the AO Technical Committee. The current president is Prof. Lobenhoffer, and the other members are currently from Germany, Japan, the United States and China. My selection shows the importance of China as a large country in the future development of osteotomy, and also shows that the work done in the field of osteotomy in China, especially in the orthopedic department of Jishuitan Hospital, has been recognized worldwide. Recent advances in osteotomy In recent years, osteotomy has been constantly evolving. Taking the high tibial osteotomy for knee osteoarthritis, it can be basically summarized into two levels of development. First, at the technical level, the ‘incomplete osteotomy’ technique with locking plate fixation is currently advocated. This method makes high osteotomy accurate, safe and the patient recovers quickly. New osteotomy tools are coming to market that will make osteotomy more accurate, safer and simpler. The promotion of new techniques and the development of new tools is one of the important tasks of JPEG. The second level is at the conceptual level, where we advocate a stepped surgical protocol for the treatment of osteoarthritis. For a patient who has failed conservative treatment, we cannot see that only joint replacement is available. Rather, depending on the patient’s condition, priority should be given to osteotomy, or unicondylar replacement, and then, if that is not possible, total knee replacement. Because osteotomy preserves the patient’s joint, postoperative function is best; unicondylar replacement preserves all of the patient’s ligaments, function is second best; and total knee replacement sacrifices both the joint and the ligaments, with the lowest functional score. The ladder of postoperative function dictates that our surgical selection should also be ladder-based. We should prioritize the surgical option that preserves the maximum function of the patient’s knee. In other words, we should ‘choose the procedure according to the patient’ and select the most favorable surgical option according to the patient’s specific situation in a stepwise manner; instead of ‘choosing the patient according to the procedure’ and having eyes only for joint replacement, as long as the leg hurts, either replace it or wait for it to be replaced. Obviously the latter is what we are against and we should promote the former! In fact, it is not only China that has the problem of expanded indications for joint replacement; according to a survey by the Oxford University School of Medicine in the United Kingdom, approximately nearly half of all total knee replacements in the United Kingdom and the United States can now be resolved by osteotomy or unicondylar replacement. Therefore promoting the concept of stepped therapy is another important task for JPEG.”