Curvature of the leg bones doesn’t always require dramatic surgical operations. Often, replacing and repairing the missing shock absorbers makes more sense. (Courtesy photo)

Curvature of the leg bones doesn’t always require dramatic surgical operations. Often, replacing and repairing the missing shock absorbers makes more sense. (Courtesy photo)

Don’t break a leg

Many people are bowlegged. Some are knock-kneed. Only a few are truly straight-legged.

Most of the great runners are bowlegged. The running backs in football are all bowlegged. Many of the football linemen, who must squat and be forceful, are neutral to knock-kneed.

If so many great athletes have these leg angles, why are so many people recommended to have a “corrective” osteotomy: a cutting of the tibia — and occasionally the femur — to change the alignment of their legs?

Because of arthritis — and dogma. Orthopedic surgery students are taught that bad biomechanics will destroy good biology any day of the week. So if a patient complains of knee pain with bowed legs, the recommendation has often been to change the alignment of the legs and distribute more force to the center or the outside of the knee. Or if a patient has injured their weight-bearing surface articular cartilage or lost a portion of their meniscus cartilage, the leg gets cut in half, the foot pushed over to the centerline, a plate and screws are applied and six months of healing begins. Unfortunately, very few top athletes have ever returned to their previous level of play after this “corrective” procedure.

The advocates of osteotomy, which is much more common in Europe than in the U.S., argue that the newer plates and screws, the improved surgical techniques and the updated rehab programs have made this surgical technique safer and better. They state that the results are gratifying, with a reduction of pain. Yet the medical literature still reports a high complication rate. And if an artificial knee replacement is required at a later date, the results are compromised by the osteotomy.

What is the alternative? Almost everyone with pain in one side of the joint or the other has had a cartilage injury; they have either damaged the surface or lost the meniscus or both. My bias is to replace the missing meniscus and repair the damaged cartilage first and see if that is good enough.

It almost always is. The problem is the cartilage loss and arthritis — not the curvature of the bones. While it may be argued that changing the curvature could improve the outcome of the cartilage replacement procedures, this has not been borne out in our experience except when the curvature is extreme (greater than seven degrees from straight). Our long-term data, and the data of other cartilage replacement centers, bear out this conclusion.

But the cartilage loss must be treated promptly. Otherwise, the legs gradually collapse into being more bowed or knock-kneed. The surfaces on both the tibia and the femur wear off, eventually becoming bone-on-bone. At this point, either the joint must be reopened with an osteotomy and the cartilage replaced or a partial knee replacement performed. With the introduction of the surgical robot, this partial resurfacing is now becoming more common.

As with so many problems in medicine, identifying the problem — in this case, cartilage loss — and solving it directly is safer and more effective than treating the symptoms. It’s odd that we keep re-learning the same lesson.

Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.HealthKevin StonelegsorthopedicsSan Francisco

If you find our journalism valuable and relevant, please consider joining our Examiner membership program.
Find out more at www.sfexaminer.com/join/

Just Posted

Nicole Canedo looks at her City-issued Medical Reimbursement Account page on her computer outside her Berkeley apartment on Tuesday, Nov. 24, 2020. Canedo has worked numerous retail jobs in The City and the MRA has helped her with health costs. (Kevin N. Hume/S.F. Examiner)
Millions left sitting in medical reimbursement accounts by city workers

Health officials looking at how to improve access, outreach as untapped funds reach $409M

49ers receiver Deebo Samuel picks up yards in front of the Rams defense after a reception in the 4th quarter at SoFi Stadium in Inglewood Sunday. (Wally Skalij/Los Angeles Times)
Rams can’t stop 49ers’ Deebo Samuel from catching defense off guard

Emmanuel Morgan Los Angeles Times Perhaps the Rams didn’t watch enough film.… Continue reading

Dr. Grant Colfax, director of the San Francisco Department of Public Health. (Kevin N. Hume/S.F. Examiner)
SF moves into purple tier, triggering curfew and business shutdowns

San Francisco moved into the state’s purple COVID-19 tier Saturday, requiring The… Continue reading

Indecline, an art activist collective in San Francisco, transformed a billboard into an editorial with a message blasting immigration policies of Donald Trump’s administration. (Screenshot, Indecline website)
Has immigration fallen off the administration’s radar? Not a chance

Enforced as executive orders, Trump’s hardline policies are proceeding, against will of the people

University of San Francisco head coach Todd Golden coaches his team on defense during a 2019 gameat War Memorial Gymnasium on the campus of the University of San Francisco. (Ryan Gorcey / S.F. Examiner)
Stunner in Bubbleville: USF upsets fourth-ranked Virginia

Less than 48 hours removed from a loss to a feeble UMass… Continue reading

Most Read