We compared the results ten years after an inverted V-shaped high tibial osteotomy with those of a historical series of conventional closing-wedge osteotomies. The closing-wedge series consisted of 56 knees in 51 patients with a mean follow-up of 11 years (10 to 15). The inverted V-shaped osteotomy was evaluated in 48 knees in 43 patients at a mean follow-up of 14 years (10 to 19). All the patients were scored using the Japanese Orthopaedic Association rating scale for osteoarthritis of the knee and radiological assessment. The pre-operative grade of osteoarthritis was similar in both groups. Post-operatively, the knee function score was graded as satisfactory in 63% (35) of the closing-wedge group but in 89% (43) of the inverted V-shaped osteotomy group. Post-operative radiological examination showed that delayed union and loss of correction occurred more often after a closing-wedge osteotomy than after an inverted V-shaped procedure. Our study suggests that the inverted V-shaped osteotomy may offer more dependable long-term results than traditional closing-wedge osteotomy

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m. 2. ), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis. The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy. Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity

Aims. The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique. Methods. This retrospective study analyzed 121 knees in 101 patients. Patient-reported outcome measures (PROMs) were collected preoperatively and one year postoperatively, and were analyzed according to the surgical technique (opening or closing wedge), postoperative mechanical axis deviation (deviations above and below 10% from the target), and achievement of medial joint opening (∆JLCA > 1°). Radiological parameters, including JLCA, mechanical axis deviation, and the difference in JLCA between preoperative standing and supine radiographs (JLCA. PD. ), an indicator of medial soft-tissue laxity, were measured. Cut-off points for parameters related to achieving medial joint opening were calculated from receiver operating characteristic (ROC) curves. Results. Patients in whom the medial joint opening was achieved had significantly better postoperative PROMs compared with those without medial opening (all p < 0.05). Patients who were outliers with deviation of > 10% from the target mechanical axis deviation had significantly similar PROMs compared with patients with an acceptable axis deviation (all p > 0.05). Medial joint opening was affected by postoperative mechanical axis deviation and JLCA. PD. The influence of JLCA. PD. on postoperative axis deviation was more pronounced in a closing wedge than in an opening wedge HTO. Conclusion. Medial joint opening rather than the mechanical axis deviation determined the clinical outcome in patients who underwent HTO. The JLCA. PD. identified the optimal postoperative axis deviation necessary to achieve medial joint opening. For patients with increased laxity, lowering the target axis deviation is recommended to achieve medial joint opening. The target axis deviation should also differ according to the technique of undergoing HTO. Cite this article: Bone Joint J 2024;106-B(3):240–248

Aims. To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. Methods. We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey. Results. Significant improvements in all clinical outcome categories were found between the preoperative and second-look arthroscopic assessments in both groups (p < 0.001). At the latest follow-up, the mean IKDC and WOMAC scores in the good status group further improved compared with those at the time of second-look arthroscopic surgery (p < 0.001), which was not shown in the poor status group. The mean IKDC (good status, 72.8 (SD 12.5); poor status, 64.7 (SD 12.1); p = 0.002) and mean WOMAC scores (good status, 15.7 (SD 10.8); poor status, 21.8 (SD 13.6); p = 0.004) significantly differed between both groups at the latest follow-up. Moreover, significant correlations were observed between ICRS CRA grades and IKDC scores (negative correlation; p < 0.001) and WOMAC scores (positive correlation; p < 0.001) at the latest follow-up. Good cartilage status was found more frequently in knees with the desired range of 2° to 6° valgus correction than in those with corrections outside this range (p = 0.019). Conclusion. Second-look arthroscopic cartilage status correlated with clinical outcomes after MOHTO at intermediate-term follow-up, despite the relatively small clinical differences between groups. Cite this article: Bone Joint J 2021;103-B(11):1686–1694

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review. Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR

Valgus high tibial osteotomy for osteoarthritis of the medial compartment of the knee can be performed using medial opening- and lateral closing-wedge techniques. The latter have been thought to offer greater initial stability. We measured and compared the stability of opening- and closing-wedge osteotomies fixed by TomoFix plates using radiostereometry in a series of 42 patients in a prospective, randomised clinical trial. There were no differences between the opening- and closing-wedge groups in the time to regain knee function and full weight-bearing. Pain and knee function were significantly improved in both groups without any differences between them. All the osteotomies united within one year. Radiostereometry showed no clinically relevant movement of bone or differences between either group. Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening-wedge technique was more likely to produce the intended correction

Radiographs of 110 patients who had undergone 120 high tibial osteotomies (60 closed-wedge, 60 open-wedge) were assessed for posterior tibial slope before and after operation, and before removal of the hardware. In the closed-wedge group the mean slope was 5.7° (. sd. 3.8) before and 2.4° (. sd. 3.9) immediately after operation, and 2.4° (. sd. 3.4) before removal of the hardware. In the open-wedge group, these values were 5.0° (. sd. 3.7), 7.7° (. sd. 4.3) and 8.1° (. sd. 3.9) respectively, when stabilised with a non-locking plate, and 7.7° (. sd. 3.5), 9.4° (. sd. 4.1) and 9.1° (. sd. 3.8), when stabilised with a locking plate. The reduction in slope (−2.7° (. sd. 4.1)) in the closed-wedge group and the increase (+2.5° (. sd. 3.4), in the open-wedge group was significantly different before and after operation (p = 0.002, p = 0.003). In no group were the changes in slope directly after operation and before removal of the hardware significant (p > 0.05). There was no correlation between the amount of correction in the frontal plane and the post-operative change in slope. Posterior tibial slope decreases after closed-wedge high tibial osteotomy and increases after an open-wedge procedure because of the geometry of the proximal tibia. The changes in the slope are stable over time, emphasising the influence of the operative procedure rather than of the implant

The outcome of high tibial osteotomy (HTO) deteriorates with time, and additional procedures may be required. The aim of this study was to compare the clinical and radiological outcomes between unicompartmental knee replacement (UKR) and total knee replacement (TKR) after HTO as well as after primary UKR. A total of 63 patients (63 knees) were studied retrospectively and divided into three groups: UKR after HTO (group A; n = 22), TKR after HTO (group B; n = 18) and primary UKR (group C; n = 22). The Oxford knee score (OKS), Knee Society score (KSS), hip–knee–ankle angles, mechanical axis and patellar height were evaluated pre- and post-operatively. At a mean of 64 months (19 to 180) post-operatively the mean OKS was 43.8 (33 to 49), 43.3 (30 to 48) and 42.5 (29 to 48) for groups A, B and C, respectively (p = 0.73). The mean KSS knee score was 88.8 (54 to 100), 88.11 (51 to 100) and 85.3 (45 to 100) for groups A, B and C, respectively (p = 0.65), and the mean KSS function score was 85.0 (50 to 100) in group A, 85.8 (20 to 100) in group B and 79.3 (50 to 100) in group C (p = 0.48). Radiologically the results were comparable for all groups except for patellar height, with a higher incidence of patella infra following a previous HTO (p = 0.02). Cite this article: Bone Joint J 2013;95-B:1348–53

The aim of this study was to examine the functional outcome at ten years following lateral closing wedge high tibial osteotomy for medial compartment osteoarthritis of the knee and to define pre-operative predictors of survival and determinants of functional outcome. . 164 consecutive patients underwent high tibial osteotomy between 2000 and 2002. A total of 100 patients (100 knees) met the inclusion criteria and 95 were available for review at ten years. Data were collected prospectively and included patient demographics, surgical details, long leg alignment radiographs, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five years. Overall Kaplan–Meier survival was 87% (95% confidence interval (CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years, respectively. When compared with unrevised patients, those who had been revised had significantly lower mean pre-operative WOMAC Scores (47 (21 to 85) vs 65 (32 to 99), p < 0.001), higher mean age (54 yrs (42 to 61) vs 49 yrs (26 to 66), p = 0.006) and a higher mean BMI (30.2; 25 to 39 vs 27.9; 21 to 36, p = 0.005). Each were found to be risk factors for revision, with hazard ratios of 10.7 (95% CI 4 to 28.6; pre-operative WOMAC < 45), 6.5 (95% CI 2.4 to 17.7; age > 55) and 3.0 (95%CI 1.2 to 7.6; BMI > 30). Survival of patients with pre-operative WOMAC > 45, age < 55 and BMI < 30 was 97% at five and ten years. WOMAC and KSS in surviving patients improved significantly between pre-operative (mean 61; 32 to 99) and five (mean 88; 35 to 100, p = 0.001) and ten years (mean 84; 38 to 100, p = 0.001). Older patients had better functional outcomes overall, despite their higher revision rate. This study has shown that improved survival is associated with age < 55 years, pre-operative WOMAC scores > 45 and, a BMI < 30. In patients over 55 years of age with adequate pre-operative functional scores, survival can be good and functional outcomes can be significantly better than their younger counterparts. We recommend the routine use of pre-operative functional outcome scores to guide decision-making when considering suitability for high tibial osteotomy. Cite this article: Bone Joint J 2014;96-B:1491–7

We carried out a prospective study of 132 patients (159 knees) who underwent closed-wedge high tibial osteotomy for severe medial compartment osteoarthritis between 1988 and 1997. A total of 94 patients (118 knees) was available for review at a mean of 16.4 years (16 to 20). Seven patients (7.4%) (11 knees) required conversion to total knee replacement. Kaplan-Meier survival was 97.6% (95% confidence interval 95.0 to 100) at ten years and 90.4% (95% confidence interval 84.1 to 96.7) at 15 years. Excellent and good results as assessed by the Hospital for Special Surgery knee score were achieved in 87 knees (73.7%). A pre-operative body mass index > 27.5 kg/m. 2. and range of movement < 100° were risk factors predicting early failure. Although our long-term results were satisfactory, strict indications for osteotomy are required if long-term survival is required

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3° or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy

Aims. The aim of this prospective randomised study was to compare the time course of clinical improvement during the first two years following a closing or opening wedge high tibial osteotomy (HTO). It was hypothesised that there would be no differences in clinical outcome between the two techniques. Patients and Methods. Between 2007 and 2013, 70 consecutive patients were randomly allocated to undergo either a closing or opening wedge HTO. All patients had medial compartment osteoarthritis (OA), and were aged between 30 years and 60 years. They were evaluated by independent investigators pre-operatively and at three and six months, and one and two years post-operatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), the Lysholm score, the Tegner activity score, the University of California, Los Angeles (UCLA) activity scale and range of movement (ROM). Results. There were no significant differences at any time between the two techniques for any clinical outcome score (p > 0.05). The mean scores for all the systems, except UCLA and Tegner, significantly improved until six months post-operatively (p < 0.001). For some scores, the improvement continued until one and two years. Conclusion. This prospective randomised study suggests that there are no differences in the time course of the clinical improvement between the closing and opening wedge techniques for HTO during the first two post-operative years. Patients can expect continued improvement in physical function for between six months and one year after HTO regardless of the technique used. Cite this article: Bone Joint J 2017;99-B:1157–66

Aims. We aimed to investigate factors related to the technique of medial opening wedge high tibial osteotomy which might predispose to the development of a lateral hinge fracture. Patients and Methods. A total of 71 patients with 82 osteotomies were included in the study. Their mean age was 62.9 years (37 to 80). The classification of the type of osteotomy was based on whether it extended beyond the fibular head. The level of the osteotomy was classified according to the height of its endpoint. Results. At a mean follow-up of 20 months (6 to 52), a total of 15 lateral hinge fractures (18.3%) were identified. A sufficient osteotomy, in which both anterior and posterior tibial cortices were involved with extension into the lateral aspect of the plateau in relation to an anteroposterior line tangential to the medial edge of the fibular head in the CT axial plane, was seen in 48 knees (71.6%) in those without a lateral hinge fracture and in seven (46.7%) in those with a lateral hinge fracture. An osteotomy which ended above the level of the fibular head was seen in nine (13.4%) of the knees without a lateral hinge fracture and seven (46.7%) of the those with a lateral hinge fracture. There was a significant relationship between the absence of a lateral hinge fracture and both a sufficient osteotomy and one whose endpoint was at the level of the fibular head (p = 0.0451 and p = 0.0214, respectively). Conclusion. A sufficient osteotomy involving both the anterior and posterior cortices, whose endpoint is at the level of the fibular head, should be performed when undertaking a medial opening wedge high tibial osteotomy if a lateral hinge fracture is to be avoided as a complication. Cite this article: Bone Joint J 2017;99-B:887–93

Aims. Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication. Patients and Methods. Consecutive patients undergoing OWHTO were evaluated on coronal multiplanar reconstruction CT images. Hinge positions were divided into five zones in our new classification, by their relationship to the proximal tibiofibular joint (PTFJ). Fractures were classified into types I, II, and III according to the Takeuchi classification. Results. Among 111 patients undergoing OWHTOs, 22 sustained lateral hinge fractures. Of the 89 patients without fractures, 70 had hinges in the zone within the PTFJ and lateral to the medial margin of the PTFJ (zone WL), just above the PTFJ. Among the five zones, the relative risk of unstable fracture was significantly lower in zone WL (relative risk 0.24, confidence interval 0.17 to 0.34). Conclusion. Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site. Cite this article: Bone Joint J 2017;99B10:1313–18

The objective of this study was to validate the efficacy of Takeuchi classification for lateral hinge fractures (LHFs) in open wedge high tibial osteotomy (OWHTO). In all 74 osteoarthritic knees (58 females, 16 males; mean age 62.9 years, standard deviation 7.5, 42 to 77) were treated with OWHTO using a TomoFix plate. The knees were divided into non-fracture (59 knees) and LHF (15 knees) groups, and the LHF group was further divided into Takeuchi types I, II, and III (seven, two, and six knees, respectively). The outcomes were assessed pre-operatively and one year after OWHTO. Pre-operative characteristics (age, gender and body mass index) showed no significant difference between the two groups. The mean Japanese Orthopaedic Association score was significantly improved one year after operation regardless of the presence or absence of LHF (p = 0.0015, p < 0.001, respectively). However, six of seven type I cases had no LHF-related complications; both type II cases had delayed union; and of six type III cases, two had delayed union with correction loss and one had overcorrection. These results suggest that Takeuchi type II and III LHFs are structurally unstable compared with type I. Cite this article: Bone Joint J 2015;97-B:1226–31

Aims. Little is known about the relative outcomes of revision of unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) to total knee arthroplasty (TKA). The aim of this study is to compare the outcomes of revision surgery for the two procedures in terms of complications, re-revision and patient-reported outcome measures (PROMs) at a minimum of two years follow-up. Patients and Methods. This study was a retrospective review of data from an institutional arthroplasty registry for cases performed between 2001 and 2014. A total of 292 patients were identified, of which 217 had a revision of HTO to TKA, and 75 had revision of UKA to TKA. While mean follow-up was longer for the HTO group compared with the UKA group, patient demographics (age, body mass index and Charlson co-morbidity index) and PROMs (Short Form-36, Oxford Knee Score, Knee Society Score, both objective and functional) were similar in the two groups prior to revision surgery. Outcomes included the rate of complications and re-operation, PROMS and patient-reported satisfaction at six months and two years post-operatively. We also compared the duration of surgery and the need for revision implants in the two groups. . Results . At two-year follow-up, both groups of patients had made significant improvement in terms of PROMs compared with pre-operative scores. PROMs and satisfaction rates were similar in the two groups. Complications requiring re-operation were significantly more frequent in the HTO group whilst more revision implants were used in the UKA group, resulting in a longer operative duration. . Conclusion. Revision of HTO and UKA achieve similar post-operative PROMs and satisfaction. Revision of UKA more frequently requires revision components with increased operation duration but fewer complications requiring re-operation compared with revision of HTO. . Cite this article: Bone Joint J 2017;99-B:1329–34

Our aim was to compare the degree of patellar descent and alteration in angle of the inclination of the tibial plateau in lateral closing-wedge and medial opening-wedge high tibial osteotomy (HTO) in 51 consecutive patients with osteoarthritis of the medial compartment and varus malalignment. Patellar height was measured by the Insall-Salvati (IS) and the Blackburne-Peel (BP) ratios. The tibial inclination was determined by the Moore-Harvey (MH) method. Multivariate linear regression analysis was used to determine the influence of the type of HTO (closing vs opening wedge) on the post-operative patellar height or tibial inclination. The intra- and interobserver variability of these methods was determined before operation and at follow-up at one year. After an opening-wedge HTO the patellar height was significantly more decreased (mean post-operative difference: IS = 0.15; 95% confidence interval (CI) 0.06 to 0.23; BP = 0.11; 95% CI 0.05 to 0.18) compared with a closing-wedge HTO. The angle of tibial inclination differed significantly (mean post-operative difference MH = −6.40°; 95% CI −8.74 to −4.02) between the two HTO techniques, increasing after opening-wedge HTO and decreasing after closing-wedge HTO. There was no clinically-relevant difference in the intra- and interobserver variability of measurements of patellar height either before or after HTO

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2°, and the mean mechanical axis following fixation was valgus 3.6°. On the radiographs the mean pre-operative mechanical axis was varus 7.3°, and the mean post-operative mechanical axis was valgus 2.1°. There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3° vs 3.7°, p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO

To assess migration of the tibial component we used roentgen stereophotogrammetric analysis in 40 patients who had had a total knee arthroplasty after failure of a closing wedge osteotomy and compared them with 40 matched patients after primary total knee arthroplasty. We found no difference in migration over time or in the tendency for continuous migration between the two groups. There were no differences in alignment or position of the knee prosthesis or in the clinical outcome. Our findings show that revision of a failed high tibial osteotomy to a total knee arthroplasty is effective

Between 2003 and 2007, 99 knees in 77 patients underwent opening wedge high tibial osteotomy. We evaluated the effect of initial stable fixation combined with an artificial bone substitute on the mid- to long-term outcome after medial opening-wedge high tibial osteotomy (HTO) for medial compartmental osteoarthritis or spontaneous osteonecrosis of the knee in 78 knees in 64 patients available for review at a minimum of five years (mean age 68 years; 49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean Knee Society knee score and function score improved from 49.6 (. sd. 11.4, 26 to 72) and 56.6 (. sd. 15.6, 5 to 100) before surgery to 88.1 (. sd. 12.5, 14 to 100) and 89.4 (. sd. 15.6, 5 to 100) at final follow-up (p <  0.001) respectively. There were no significant differences between patients aged ≥ 70 and < 70 years. The mean standing femorotibial angle was corrected significantly from 181.7° (. sd.  2.7°, 175° to 185°) pre-operatively to 169.7° (. sd. 2.4°, 164° to 175°) at one year’s follow-up (p < 0.001) and 169.6° (. sd. 3.0°, 157° to 179°) at the final follow-up (p = 0.69 vs one year). . Opening-wedge HTO using a stable plate fixation system combined with a bone substitute is a reliable procedure that provides excellent results. Although this treatment might seem challenging for older patients, our results strongly suggest that the results are equally good. Cite this article: Bone Joint J 2014;96-B:339–44