Reasons for refusing high tibial osteotomy and the impact of virtual reality-based patient education: a prospective single-centre study.

backgroundHigh tibial osteotomy (HTO) is a well established joint preserving surgical option for young and active patients with medial compartment osteoarthritis. Although clinically effective, the use of this technique remains suboptimal due to a high rate of patient refusal. Understanding the underlying reasons for this reluctance is crucial, as modifiable psychological and informational barriers may be preventing patients from accessing a potentially life-changing procedure.

methodsThis prospective, single-centre study included 235 of 330 patients screened for HTO between January 2020 and December 2024. The study was conducted in three phases. In Phase 1, semi-structured interviews were performed with 125 patients who declined surgery, and thematic analysis was conducted according to age and gender. In Phase 2, a virtual reality (VR)-based educational module was developed based on qualitative findings. In Phase 3, 110 newly recruited patients were randomized into VR (n = 55) and control (n = 55) groups. All participants completed a knowledge test, the Hospital Anxiety and Depression Scale (HADS), and their surgical decision was recorded.

resultsThe 235 patients comprised 30.2% females and 69.8% males, with a mean age of 44.6 years. Female patients most frequently declined surgery due to fear and a preference for non-operative treatments, while male patients cited anesthesia risks and financial concerns. In the VR group, knowledge scores improved by 3.84 points, anxiety decreased by 4.44 points, and surgical acceptance increased to 74.5%, compared to 45.5% in the control group. Knowledge was found to be negatively correlated with anxiety (r = - 0.20) and positively with surgical acceptance (r = + 0.15), while anxiety showed a stronger negative correlation with surgical acceptance (r = - 0.23).

conclusionPatient refusal of HTO is often driven by modifiable factors such as insufficient knowledge, preoperative anxiety, and perceived risks. VR-based education was seen to significantly improve knowledge and acceptance while reducing anxiety, indicating its potential as a powerful tool to enhance informed consent and shared decision-making in orthopaedic surgery. LEVEL OF EVIDENCE: Level II - Single-centre, randomized, controlled trial.