Management Plan - Maheshwariben B Bhatt, 43F

Clinical Summary

• Complaint: Bilateral knee pain (L > R) x 10 years, difficulty walking, no trauma
• Examination: Medial joint line tenderness (+), synovitis (+)
• X-ray (Left knee): Mild-to-moderate tricompartmental OA - predominant medial + patellofemoral compartment involvement
• MRI: Complete posterior horn tear of medial meniscus
• Diagnosis: Varus knee OA with medial meniscus posterior root tear (MMPRT)

Advised Management (by Dr. Vaibhav Pate, Orthopaedic Surgeon)

1. High Tibial Osteotomy (HTO)

• Specifically a Closing-Wedge HTO (CWHO) or Opening-Wedge HTO to correct varus malalignment
• Shifts the mechanical axis laterally, offloading the diseased medial compartment
• Indicated in young/active patients (<60 years) with medial compartment OA and varus deformity - this 43-year-old patient fits ideally
• Goal: Joint preservation, delay/avoid total knee replacement

2. Medial Meniscus (Posterior Horn) Root Repair

• Done concurrently with HTO (combined HTO + Meniscal Root Repair = HTO-MRR)
• Arthroscopic repair of the complete posterior horn tear
• Restores the hoop stress function of the meniscus, reduces medial compartment contact pressure
• Rationale: A 2026 systematic review and meta-analysis (Ade-Conde et al., J ISAKOS 2026) showed that combined HTO-MRR significantly improves HSS and IKDC scores versus HTO alone (SMD 0.59 and 0.31 respectively, p<0.05) in degenerative MMPRTs. A 2025 systematic review (Vosoughi et al., KSSTA 2025) also confirmed superior objective outcomes for the combined procedure.

Why This Combination Makes Sense (Rationale)

Perioperative Considerations

• Full-length standing limb alignment X-ray (to calculate correction angle)
• MRI review to confirm repairability of meniscal root
• Optimize BMI, control any metabolic issues
• Anesthesia fitness

• Arthroscopic meniscal root repair first (transosseous or suture anchor technique)
• Then open/arthroscopic HTO with plate fixation
• Target correction: Mechanical axis to 62-66% of tibial plateau width (slight overcorrection into valgus)

• Non-weight bearing x 6 weeks (to protect both HTO healing and meniscal repair)
• Gradual rehabilitation: ROM, quadriceps strengthening
• Weight bearing progressed at 6-8 weeks post X-ray confirmation of healing
• Full recovery: 6-12 months

Long-term Prognosis

• Good functional outcomes expected in young, active patients
• Meniscal healing rate after combined HTO-MRR: ~33% (complete healing), but functional scores improve significantly regardless
• Delays progression to TKR by approximately 10-15 years in appropriately selected patients

Note: The treating surgeon (Dr. Vaibhav Pate, DNB Ortho) has already assessed this patient and advised the combined HTO + Medial Meniscus Repair plan, which is supported by the latest 2025-2026 evidence. The plan is well-aligned with current orthopaedic guidelines for a 43-year-old female with varus knee OA and degenerative MMPRT.