High Tibial Osteotomy (HTO)

High Tibial Osteotomy, commonly known as HTO, is a knee-preserving surgery that corrects bone alignment around the knee joint. Dr. Divya Ahuja, MS Ortho, a Mumbai-based limb reconstruction and Ilizarov surgery specialist, performs HTO surgery for patients with bow legs and early-stage knee arthritis from across India.

High Tibial Osteotomy (HTO): What is High Tibial Osteotomy?

HTO stands for High Tibial Osteotomy. It is a surgical procedure in which the upper part of the tibia, or shin bone, is carefully cut and realigned to shift body weight away from a damaged or arthritic part of the knee. The same procedure is also referred to as osteotomy surgery, knee realignment surgery, corrective osteotomy, or leg straightening surgery, depending on the terminology a patient or referring doctor uses.

Unlike a knee replacement, HTO does not remove or replace the joint. It preserves the patient’s natural knee while correcting the alignment of the leg. This makes it a preferred option for younger, active patients with varus deformity, commonly known as bow legs, where arthritis is limited to the inner side of the knee. Patients exploring bow leg correction often benefit from HTO when arthritis is also present alongside the deformity.

HTO surgery works best for a specific group of patients.

Ideal candidates usually:

Are under 60 years of age, though fit and active patients above 60 can also be evaluated
Have arthritis or pain limited to one side of the knee, most often the inner (medial) side
Have a bow leg deformity or knee malalignment from injury, infection, or bone disease
Lead an active lifestyle and want to delay or avoid total knee replacement

HTO may not be suitable for patients with arthritis across the whole knee, very limited mobility, advanced age with poor bone quality, or conditions that slow healing. For patients with a knock-kneed, or valgus, deformity instead of bow legs, a similar realignment is performed on the thigh bone. Read more about knock-knee correction for valgus deformities.

There are different ways to perform HTO depending on the patient’s deformity and bone quality.

Opening wedge HTO is the most common technique. A wedge-shaped gap is created in the tibia and filled with a bone graft or a fixation plate, often called a Puddu plate, allowing precise correction of bow legs.

Closing wedge HTO involves removing a wedge of bone and closing the gap to realign the leg. It generally has a shorter healing time but offers less precision for larger corrections.

Dome osteotomy uses a curved bone cut and is reserved for complex or larger deformity corrections.

Dr. Divya Ahuja selects the technique based on the degree of deformity, bone quality, and the patient’s lifestyle goals.

Preparing for HTO Surgery

Good preparation helps lower risks and supports a smoother recovery.

Before HTO surgery, Dr. Divya Ahuja’s team reviews the patient’s X-rays, CT scans, and blood investigations to finalise the surgical plan. Patients should inform the team about all current medications, as some may need to be paused before surgery.

In the days before the procedure, keeping the skin around the knee clean and free from cuts or infection is important. Patients are also asked to fast for a few hours before surgery as advised by the anaesthesia team, and to arrange help at home for the first few weeks, including crutches or a walker.

How is HTO Surgery Performed?

HTO surgery is generally completed in 1.5 to 2 hours under spinal or general anaesthesia.

Before surgery, Dr. Divya Ahuja studies detailed X-rays, CT scans, and digital alignment planning to calculate the exact correction needed.

During the procedure, a controlled cut is made in the upper tibia. The bone is realigned to the planned angle and held in place with a plate, screws, or bone graft to support healing.

After surgery, the bone heals in its corrected position over several weeks while physiotherapy begins early to restore knee movement and strength.

Recovery after HTO surgery is gradual but predictable with proper guidance.

Hospital stay is usually 3 to 5 days. In the first few weeks, patients walk with crutches and partial weight bearing, moving to full weight bearing by around 6 to 8 weeks as the bone heals.

Physiotherapy starts early to restore knee bending and strength. Most patients manage daily activities comfortably within 3 months, while returning to sports or physically demanding work usually takes 6 to 9 months. Total HTO recovery time, including a return to high-impact activity, can extend up to 12 months depending on age, bone quality, and physiotherapy compliance.

If a plate was used for fixation, it can usually stay in place permanently without causing problems. In some cases, if the plate irritates the skin, it can be removed in a short daycare procedure once the bone has fully healed, typically after 12 to 18 months.

HTO has both advantages and risks that patients should weigh carefully.

Benefits of HTO include:

Pain relief by shifting weight to the healthier part of the knee
Improved walking alignment and joint function
Preservation of the natural knee joint, delaying or avoiding total knee replacement
Return to sports, travel, and active routines for most patients

Risks of HTO include infection, blood clots, stiffness, or delayed bone healing at the cut site. Damage to nearby blood vessels or nerves is also possible, though uncommon, with an experienced surgical team. In rare cases, delayed healing can lead to nonunion, where the bone does not heal as expected. Dr. Ahuja’s team has extensive experience managing such complications, including through dedicated nonunion treatment when required.

The main disadvantage compared to knee replacement is a longer recovery period, and some patients may still need a knee replacement years later. Most patients enjoy 8 to 15 years of pain relief before this becomes a consideration.

Cost of HTO and Osteotomy Surgery in India

India remains one of the most affordable destinations for HTO and osteotomy surgery without compromising on the quality of care.

In Mumbai, the typical cost of HTO surgery ranges from Rs 2.5 lakhs to Rs 4.5 lakhs, depending on the hospital, implants used, and the complexity of the deformity. This is broadly in line with osteotomy surgery costs across other Indian cities, though prices vary based on the type of fixation and length of hospital stay.

Costs in the US, UK, and other Western countries are typically 4 to 5 times higher for the same procedure.

The total cost usually includes pre-operative imaging and planning, the surgical procedure, implants, hospital stay, and initial physiotherapy sessions. Most health insurance plans cover HTO when it is medically necessary for arthritis or deformity correction.

Patients from across India, including Pune, Bangalore, Delhi, and Hyderabad, travel to Mumbai for HTO surgery with Dr. Divya Ahuja because of her experience with complex knee and limb deformity cases.

What affects the cost of HTO surgery

The final cost can vary based on a few factors:

Type of HTO performed, as opening wedge HTO with a plate and bone graft is generally priced higher than closing wedge HTO
Implants used, such as a Puddu plate or a locking plate
Pre-operative tests, including X-rays, CT scans, MRI, and blood investigations
Length of hospital stay and the number of post-operative physiotherapy sessions
Recovery aids, such as a knee brace, crutches, or a walker, which are usually billed separately

About the Treating Surgeon

Dr. Divya Ahuja is a Mumbai-based orthopaedic surgeon with an MS in Orthopaedics and over 20 years of experience in bone alignment, deformity correction, and joint preservation surgery.

He has performed over 1,000 successful deformity correction and knee preservation procedures, including HTO, bow leg correction, and knock knee correction. His training in Ilizarov surgery techniques allows him to manage even complex cases where standard fixation alone is not enough.

Dr. Ahuja takes a personalised approach, spending time with each patient to explain the diagnosis, surgical plan, recovery expectations, and long term outcomes. To know more about his qualifications and experience, visit the About Dr. Divya Ahuja, or book an appointment to discuss your treatment options.

How We Work

What qualifications should an HTO surgeon have? Answer: Look for a registered orthopaedic surgeon with State Medical Council or NMR registration and training in knee osteotomy.

Dr. Divya Ahuja, MS Ortho, is a Mumbai-based specialist in HTO, deformity correction, and Ilizarov surgery with over 20 years of experience.

High Tibial Osteotomy (HTO)

High Tibial Osteotomy (HTO): What is High Tibial Osteotomy?

Who Should Consider HTO Surgery?

Types of HTO Surgery

Preparing for HTO Surgery

How is HTO Surgery Performed?

Recovery After HTO Surgery

Benefits and Risks of HTO Surgery

Cost of HTO and Osteotomy Surgery in India

What affects the cost of HTO surgery

About the Treating Surgeon

How We Work

Frequently Asked Questions

What is the full form of HTO?

What is HTO surgery?

Is HTO a major surgery?

How much does HTO or osteotomy surgery cost in India?

What is the recovery time after HTO surgery?

What is the success rate of HTO surgery?

When can I walk after HTO surgery, and when is the plate removed?

What are the pros and cons of HTO?

Which is better, HTO or knee replacement?

What qualifications should an HTO surgeon have? Answer: Look for a registered orthopaedic surgeon with State Medical Council or NMR registration and training in knee osteotomy.

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