High Tibial Osteotomy (HTO) with iBalance Implant
High tibial osteotomy — commonly referred to as HTO — is a joint-preservation procedure that corrects varus (bow-legged) alignment of the lower leg to shift weight off the damaged inner compartment of the knee and onto healthier cartilage on the outer side. When a patient has medial compartment arthritis combined with bow-legged alignment, every step sends excessive force through the worn inner side of the joint, accelerating cartilage breakdown and causing progressive pain. By making a precise cut in the upper shinbone and repositioning the bone to restore a more neutral leg axis, HTO redirects that load, relieves pain, and significantly delays or eliminates the need for total knee replacement — often by a decade or more. The iBalance implant system developed by Arthrex has become the gold-standard fixation method for this procedure, anchoring the corrected bone into position with a wedge-shaped implant rather than traditional plates and screws.
Dr. Jonathan Glashow is a board-certified orthopedic surgeon and Clinical Associate Professor of Orthopedic Surgery at NYU Grossman School of Medicine, widely recognized as one of New York City’s top knee specialists. With over 30 years of experience, more than 15,000 orthopedic procedures performed, and published research in the Journal of Bone and Joint Surgery on knee anatomy and function, he brings the precision and joint-preservation focus that HTO procedures demand. High tibial osteotomy requires detailed preoperative planning — full-length standing X-rays, precise angular calculations, and intraoperative verification — to restore the leg’s mechanical axis accurately. As Chief Medical Officer for the New Jersey Devils and Philadelphia 76ers, Dr. Glashow has managed complex knee alignment problems in athletes whose careers depend on preserving their native joint. Named a Castle Connolly Top Doctor every year since 2000, he performs HTO with iBalance at his Upper East Side practice in New York City.
Understanding High Tibial Osteotomy
In high tibial osteotomy, Dr. Glashow makes a precise cut in the upper shinbone (tibia) just below the knee joint and reshapes the bone to correct the alignment of the lower leg. For most HTO procedures, a wedge of space is created on the inner side of the tibia and stabilized with an implant — shifting the leg’s mechanical axis to transfer weight off the damaged inner compartment of the knee onto the healthier outer side. This surgery is most commonly performed on younger, active patients with medial compartment arthritis or bow-legged alignment, who want to preserve their native joint and avoid or delay knee replacement surgery.
The primary goal of osteotomy is to change alignment — decreasing the pain associated with arthritis, improving knee function, and slowing the progression of cartilage breakdown. While HTO does not reverse arthritis or cure the underlying condition, it can significantly reduce pain and extend the functional life of the knee. Tibial osteotomy typically produces substantial pain relief and marked improvement in function for appropriately selected patients, and because it preserves the native joint, patients can return to high-impact and pivoting sports that a knee replacement would not permit.
The iBalance Implant System
The iBalance implant system, developed by Arthrex, represents a significant advancement over the traditional plates and screws used in earlier HTO techniques. Rather than being secured with external hardware, the iBalance device is a wedge-shaped implant that anchors directly into the bone at the osteotomy site, maintaining the corrected alignment while allowing the bone to heal around it. This approach offers several advantages including more precise angular correction, reduced soft tissue disruption, and lower rates of hardware-related discomfort — and it has become the gold-standard fixation method for HTO procedures. Patients receiving the iBalance implant can expect many years of pain relief and durable alignment correction.
Who Is a Candidate for High Tibial Osteotomy?
HTO is most appropriate for younger, active patients who have arthritis confined to the inner (medial) compartment of the knee, bow-legged alignment contributing to the joint damage, and a desire to preserve their native knee rather than undergo total or partial knee replacement. Common reasons patients seek evaluation for HTO include:
- Persistent inner knee pain — ongoing medial joint pain that has not responded to conservative treatment
- Impaired flexibility and range of motion — stiffness that interferes with daily activities
- Reduced knee strength — weakness or instability during weight-bearing activities
- Sports-related functional limitations — pain that restricts participation in athletic activities
- Altered gait — noticeable changes in walking pattern due to alignment or pain
Dr. Glashow evaluates each patient with a comprehensive clinical examination, full-length standing X-rays, MRI, and a detailed review of prior treatments to determine whether HTO is the right approach. Patients with multi-compartment arthritis, significant stiffness, or certain ligament instabilities may be better served by total knee replacement or another procedure, and Dr. Glashow discusses all available options during the consultation.
Schedule an HTO Consultation in New York City
If you have been diagnosed with medial compartment knee arthritis, have bow-legged alignment contributing to knee pain, or have been told you need a knee replacement but want to explore joint-preservation alternatives, Dr. Glashow can evaluate whether HTO with iBalance is right for you. With same-day imaging, comprehensive alignment analysis, and the full range of knee treatment options available, his Upper East Side practice offers the expert evaluation that active patients deserve before committing to a surgical plan. Contact our office to schedule your consultation — we accept out-of-network insurance benefits and offer same-day, after-hours, and weekend appointments.
Frequently Asked Questions About High Tibial Osteotomy
What is the difference between high tibial osteotomy and distal femoral osteotomy?
Both procedures are joint-preservation osteotomies that correct leg alignment and redistribute load within the knee, but they address opposite deformities. High tibial osteotomy corrects varus (bow-legged) alignment by reshaping the shinbone below the knee and is typically used for medial compartment arthritis. Distal femoral osteotomy corrects valgus (knock-kneed) alignment by reshaping the thighbone above the knee and is typically used for lateral compartment arthritis. Dr. Glashow determines which procedure is appropriate based on the direction of malalignment and the location of cartilage damage.
Is HTO better than a knee replacement?
For the right patient, yes — but the two procedures treat different situations. HTO is typically recommended for younger, active patients with arthritis limited to one compartment of the knee who want to preserve their native joint and return to high-impact activities that a knee replacement would not allow. Total knee replacement is generally more appropriate for older patients or those with advanced, multi-compartment arthritis. An osteotomy also preserves the option for a future knee replacement if needed. Dr. Glashow discusses both options during the consultation to help each patient understand which is the best fit for their specific situation.
Does HTO cure knee arthritis?
No. High tibial osteotomy does not cure arthritis or reverse cartilage damage that has already occurred. What HTO does is correct the underlying mechanical cause of the cartilage breakdown — the malalignment that is overloading one side of the joint — which significantly reduces pain, improves function, and slows the progression of further arthritis. For appropriately selected patients, this can extend the functional life of the knee by 10 to 15 years or longer before a knee replacement may eventually be needed.
What does recovery look like after HTO iBalance surgery?
Recovery typically involves a period of protected weight-bearing — usually six to eight weeks on crutches — to allow the bone to heal in its new position. A structured physical therapy program begins shortly after surgery and progresses through range-of-motion recovery, strengthening, and return to activity over several months. Most patients return to daily activities within three to four months and to sports or demanding physical activity between six and nine months after surgery, depending on the extent of correction and individual healing. Dr. Glashow monitors bone healing with follow-up X-rays and adjusts rehabilitation timelines accordingly.
Can I return to sports after HTO surgery?
Yes. One of the significant advantages of osteotomy over knee replacement is that patients can return to high-impact and pivoting sports after recovery — including running, skiing, tennis, and contact sports — which are generally not recommended after a knee replacement. Return-to-sport timing depends on individual healing, the extent of correction, and sport-specific demands. Dr. Glashow works closely with each patient and their physical therapist to develop a safe return-to-activity plan.
Is HTO with iBalance covered by insurance?
High tibial osteotomy is a medically necessary procedure for appropriately selected patients and is covered by most insurance plans. Dr. Glashow’s office accepts out-of-network insurance benefits and works with patients to verify coverage before surgery, including submitting claims on the patient’s behalf and providing surgical quotes through a dedicated surgical coordinator.
