Dr.Pranjal's Blog

Alternatives to Knee Replacement Surgery

Dome Osteotomy To Avoid Joint Replacement

Dome Osteotomy & Kodkanis Dome Stabilizer : A Knee Conserving, Reliable, Safe, Convenient & Cost-effective substitute to knee joint replacement surgery.

Osteoarthritis, or degenerative (wear & tear of joint increases as age advances) joint disease, is one of the oldest and most common types of arthritis (disease of a joint). It is characterized by the breakdown of cartilage (Insulating coating over the ends of bones within the joint) in the joint. Cartilage is the part of the joint that cushions (insulates from the nerve endings and provides a smooth surface for friction free movements of the joint) the ends of bones and its breakdown causes bones to rub against each other, resulting in pain and loss of movement. Most commonly affecting middle-aged and older people, Osteoarthritis can range from very mild to very severe. It affects hands and weight-bearing joints such as knees, hips, feet and the back.

According to the World Health Organization (WHO), around 10% of the world’s population above the age of 60 is estimated to be suffering from this condition. Moreover, an increasing number of young people, some even as young as 30, suffer from osteoarthritis.

In patients suffering from osteoarthritis of the knee, the inner sides of the knee joint gets worn off and the joint space collapses, causing ‘bowing’ (outward bending of the knee) of the knees. This ‘bowing’ leads to increased load on the inner side of the knee causing further wear and tear. In this entire process, the outer side of the knee joint is virtually intact.

The commonly opted solution to such a condition is a replacement of the knee joint, an expensive option as the cost of the artificial joint alone may be Rs. 75,000 onwards + surgical + medical +hospital cost = about Rs 1.5 lacs. Due to financial constraints a large number of patients are unable to go in for this replacement surgery. Moreover, patients lose their natural knee joint and must adjust to an artificial one.

To overcome these problems, an innovative, unique, cost-effective and less invasive (small incision of about 1 inch on front of the knee without ‘added damage’ caused to the knee) solution to deal with this condition is now available.

Dr. Pranjal Kodkani says: “Instead of knee replacement, osteotomy is now available for patients who have not reached the last stages of arthritis. This involves realigning ( straightening the ‘bowed’ knee ) the knee in such a manner that the load on the inner side of the knee is transferred to the outer side of the knee. This is done by cutting the lower bone of the knee in a particular (curved manner & not the previously followed method of removal of a wedge of bone & aligning the knee. This previous method still practised by some require postoperative plastering & immobilisation of the knee which in turn delays mobilisation and does not as good results) manner and then realigning it to make the limb straight. This osteotomy is known as the ‘dome osteotomy’ because of its shape. The surgery does not involve removal of any part of the bone or the joint and so does not shorten the leg.”

Advantages of Dome Osteotomy

Ø The patient is able to retain his original knee joint
Ø The treatment proves very cost-effective, enabling a large number of patients with modest incomes to opt for it.
Ø Allows all activities following surgery including squatting.
Ø Ideal for patients in the early stages of the disease as the original joint is saved.
Ø The surgery is less invasive.
Ø Significant amount of pain relief
Ø Faster mobilisation
Ø No artificial sensation
Ø Reduced risk of complications.
Ø Convenient, lightweight fixator facilitates faster recovery

This method also has several advantages when it comes to the recovery period. No plaster immobilization is required. Earlier, the patient would have to put up with a plaster cast, leading to immobility (since the patient cannot walk independently with a plaster. Also the plaster per se has its own disadvantages) and discomfort.

Large external ring fixators (Large metal rings applied from outside the knee to hold the bone with wires passed thro them) such as the one devised by Ilizarov in Russia allow some mobility however; their cumbersome (numerous wires are passed so the patient needs to take adequate care of all the wires and the entire apparatus to keep it clean and free of potential infection) and bulky nature may cause a certain amount of discomfort for the patient ( and difficult to socialise or even wear ones routine attire). To deal with these problems, a unique fixator, which is compact, lightweight, economical and allows early mobility is also available. It is called the ‘Kodkanis Dome Stabilizer’ (a patented and copyright product).

Before After

The surgery thus retains the original knee of the patient and results in a well-aligned (a knee straight enough so that the weight now is transmitted through the outer side of the knee rather than the inner side which is worn out and painful) leg, with significant pain relief.

Also the patient can squatt after the surgery and return to all their routine activities unlike a joint replacement where squatting which is an important activity in the Indian senario is not permitted following the surgery. Also this surgery does not burn any bridges unlike a joint replacement where a knee once cut off & lost cannot be regained.

Perhaps, the greatest advantage of Dome Osteotomy is the cost factor. The fixator is very economically priced at Rs. 3,500, bringing the total cost of the treatment to around Rs.50,000, as opposed to upto Rs 1.5 – 2 lacs for joint replacement.

With incidence of young arthritics on the rise, the expectations from treatment for painful arthritic knee in this group of population are - relief of pain, rapid functional recovery for return to daily activities with the ability to squatt, not be a dependent for long, long lasting results, with least serious complications & risk of losing ones knee forever, less resurgeries, patient convenience and at an economical rate. Keeping these expectations in mind, osteoarthritis of the knee in this stage would be best treated with dome osteotomy for realignment of the knee fixed with this indigenous fixator designed to meet these requirements.

However this particular osteotomy, which is capable of providing all these advantages, is a more technically demanding procedure unlike the previously performed osteotomies and therefore not performed by all.

Older method of removing a wedge of bone and realigning the knee (High Tibial Osteotomy). Results in shortening because of removal of bone and also at times over or under correction of deformity. Also requires plastering.

‘Dome Osteotomy’ done with a curved cut in the bone & the knee is straightened by rotating the bone within the cut without removing any part of bone. The cut is fixed (stabilized) using ‘Kodkanis Dome Stabilizer’. Here ‘x’ degrees is the degree of abnormal bend in the knee which is straightened.

Advantages Of ‘Kodkanis Dome Stabilizer’ For Dome Osteotomy.

Compact & Light.
Stable fixation of dome osteotomy.
Immediate joint mobilization.
Early full weight bearing.
Early return to Activities of Daily Living.
Ability to alter correction in post-op period without anaesthesia.
No residual implants following treatment.
Better patient compliance.
Surgeon convenience.


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Very Nice Article!!!

hi, Recently I have done such an osteotomy, however I have used a Plaster to immobilize patient. You have shown a fixator, which is similar to Charnley's clamps- any advantage of your clamp over Charnleys? Also did you use any special jig for the cut?

Thanks doctor for such detailed information. I have found very few detailed articles on the web written by Indian doctors. Doctors like you are asset to our Nation. Keep up the good work.

Great work. Keep it up. Should help a lot of our Indians.

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