Volume 6 | Issue 2 | July-December 2021 | Page 46-53 | Ravi T Rudraraju , Jobe Shatrov , Brett A Fritsch
Author: Ravi T Rudraraju , Jobe Shatrov , Brett A Fritsch 
 Department of Orthopaedics, Sydney Orthopaedic Research Institute, Chatswood NSW, Australia.
Address of Correspondence:
Dr. Brett Fritsch,
Orthopaedic Surgeon, Sydney Orthopaedic Research Institute, Chatswood NSW, Australia.
Osteotomies around the knee are done to treat unicompartmental knee osteoarthritis, address instability and to correct the deformity. Careful selection of patient and preoperatively planning the target alignment are the key to achieve optimal results. There are multiple types of osteotomies with varying complication rates for each procedure. Opening wedge high tibial osteotomy (HTO) is the commonly performed osteotomy with an incidence of complications ranging from 1.9% to 55%. Closed wedge HTO has complication rate of around 10 to 34% and higher complication rates (19 to 70%) are reported with distal femoral osteotomy. Complications are broadly classified into general and osteotomy specific complications, and osteotomy specific complications can be further subdivided into failure of effect, complications of the osteotomy itself, and complications of the implant.
This paper presents an overview of the complications of common osteotomies around the knee, predominantly high tibial and distal femoral osteotomy, and the approaches and techniques the surgeon can use to minimise their frequency and severity.
Keywords: High Tibial Osteotomy, Medial Closed Wedge HTO, Lateral Closed Wedge HTO, Distal Femoral Osteotomy, Complications after Osteotomy
1. King A, Wall O. Osteotomies around the knee. Orthop Trauma. 2014 Dec 1;28(6):388–95.
2. Vena G, D’Adamio S, Amendola A. Complications of osteotomies about the knee. Vol. 21, Sports Medicine and Arthroscopy Review. 2013. p. 113–20.
3. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year followup study. Clin Orthop Relat Res. 1999 Oct;(367):18–27.
4. Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini A. High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study. J Knee Surg. 2003 Jan;16(1):21–6.
5. Sun H, Zhou L, Li F, Duan J. Comparison between Closing-Wedge and Opening-Wedge High Tibial Osteotomy in Patients with Medial Knee Osteoarthritis: A Systematic Review and Meta-analysis. J Knee Surg. 2017 Feb 1;30(2):158–65.
6. Edgerton BC, Mariani EM, Morrey BF. Distal femoral varus osteotomy for painful genu valgum. A five-to-11-year follow-up study. Clin Orthop Relat Res. 1993 Mar;(288):263–9.
7. Magyar G, Toksvig-Larsen S, Alkstedt J, Lindstrand A, Nilsson LT, Andersen R, et al. Frequent complications in distal femoral osteotomy: a retrospective 8 year multicenter follow-up. Chir Organi Mov. 1999;84(1):19–26.
8. Ramanathan D, Keudell A Von, Minas T, Gomoll AH. Survivorship and Complications of the Distal Femoral Osteotomy. Vol. 2, Orthopaedic Journal of Sports Medicine. 2014.
9. Luceri F, Tamini J, Ferrua P, Ricci D, Batailler C, Lustig S, et al. Total knee arthroplasty after distal femoral osteotomy: a systematic review and current concepts. SICOT-J. 2020;6:35.
10. Kim YC, Yang J-H, Kim HJ, Tawonsawatruk T, Chang YS, Lee JS, et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. 2018 Mar;30(1):3–16.
11. Cotter EJ, Gowd AK, Bohl DD, Getgood A, Cole BJ, Frank RM. Medical Comorbidities and Functional Dependent Living Are Independent Risk Factors for Short-Term Complications Following Osteotomy Procedures about the Knee. Cartilage. 2020 Oct;11(4):423–30.
12. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118–26.
13. Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg. 2004;124(10):649–53.
14. Bauer T, Hardy P, Lemoine J, Finlayson DF, Tranier S, Lortat-Jacob A. Drop foot after high tibial osteotomy: A prospective study of aetiological factors. Vol. 13, Knee Surgery, Sports Traumatology, Arthroscopy. 2005. p. 23–33.
15. Song EK, Seon JK, Park SJ, Jeong MS, K Seon PJ, Surgeon J Park OS, et al. The complications of high tibial osteotomy CLOSING-VERSUS OPENING-WEDGE METHODS. J Bone Jt Surg [Br]. 2010;92(9):92–1245.
16. Anagnostakos K, Mosser P, Kohn D. Infections after high tibial osteotomy. Vol. 21, Knee Surgery, Sports Traumatology, Arthroscopy. 2013. p. 161–9.
17. Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: A meta-analysis of clinical and radiological outcomes. Vol. 18, Knee. 2011. p. 361–8.
18. Gao L, Madry H, Chugaev D V., Denti M, Frolov A, Burtsev M, et al. Advances in modern osteotomies around the knee: Report on the Association of Sports Traumatology, Arthroscopy, Orthopaedic surgery, Rehabilitation (ASTAOR) Moscow International Osteotomy Congress 2017. Vol. 6, Journal of Experimental Orthopaedics. Springer Berlin Heidelberg; 2019.
19. Parihar M, Singh T, Shah L. How to obtain a non-digital Full-length lower limb Radiographs using regular X-ray plates. Vol. 1, Journal of Orthopaedic Case Reports. 2011. p. 36–8.
20. Vasconcellos David A.and Giffin JR and AA. Avoiding and Managing Complications in Osteotomies of the Knee. In: Meislin Robert J.and Halbrecht J, editor. Complications in Knee and Shoulder Surgery: Management and Treatment Options for the Sports Medicine Orthopedist [Internet]. London: Springer London; 2009. p. 115–32. Available from: https://doi.org/10.1007/978-1-84882-203-0_7
21. Matsushita T, Watanabe S, Araki D, Nagai K, Hoshino Y, Kanzaki N, et al. Differences in preoperative planning for high-tibial osteotomy between the standing and supine positions. Knee Surg Relat Res. 2021 Dec 1;33(1).
22. Marx RG, Grimm P, Lillemoe KA, Robertson CM, Ayeni OR, Lyman S, et al. Reliability of lower extremity alignment measurement using radiographs and PACS. Knee Surgery, Sport Traumatol Arthrosc. 2011 Oct;19(10):1693–8.
23. Yazdanpanah O, Mobarakeh MK, Nakhaei M, Baneshi MR. Comparison of Double and Single Leg Weight-Bearing. 2017;174:174–80.
24. Specogna A V, Birmingham TB, Hunt MA, Jones IC, Jenkyn TR, Fowler PJ, et al. Radiographic measures of knee alignment in patients with varus gonarthrosis: effect of weightbearing status and associations with dynamic joint load. Am J Sports Med. 2007 Jan;35(1):65–70.
25. Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979 Jul;10(3):585–608.
26. Schallberger A, Jacobi M, Wahl P, Maestretti G, Jakob RP. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years. Knee Surg Sports Traumatol Arthrosc. 2011 Jan;19(1):122–7.
27. Bode G, von Heyden J, Pestka J, Schmal H, Salzmann G, Südkamp N, et al. Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015 Jul;23(7):1949–55.
28. Laprade RF, Spiridonov SI, Nystrom LM, Jansson KS. Prospective outcomes of young and middle-aged adults with medial compartment osteoarthritis treated with a proximal tibial opening wedge osteotomy. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2012 Mar;28(3):354–64.
29. De Neve F, Braems B, Holvoet M, De Scheerder M-A, Arnout N, Victor J. Return to sport and work after medial open wedge high tibial osteotomy : a case series. Acta Orthop Belg. 2021 Mar;87(1):117–24.
30. Kuriyama S, Watanabe M, Nakamura S, Nishitani K, Sekiguchi K, Tanaka Y, et al. Classical target coronal alignment in high tibial osteotomy demonstrates validity in terms of knee kinematics and kinetics in a computer model. Knee Surg Sports Traumatol Arthrosc. 2020 May;28(5):1568–78.
31. Noyes FR, Goebel SX, West J. Opening wedge tibial osteotomy: The 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med. 2005 Mar;33(3):378–87.
32. Song SJ, Bae DK. Computer-assisted navigation in high tibial osteotomy. Vol. 8, CiOS Clinics in Orthopedic Surgery. Korean Orthopaedic Association; 2016. p. 349–57.
33. Akamatsu Y, Mitsugi N, Mochida Y, Taki N, Kobayashi H, Takeuchi R, et al. Navigated opening wedge high tibial osteotomy improves intraoperative correction angle compared with conventional method. Knee Surg Sports Traumatol Arthrosc. 2012 Mar;20(3):586–93.
34. Jacquet C, Sharma A, Fabre M, Ehlinger M, Argenson J-N, Parratte S, et al. Patient-specific high-tibial osteotomy’s “cutting-guides” decrease operating time and the number of fluoroscopic images taken after a Brief Learning Curve. Knee Surg Sports Traumatol Arthrosc. 2020 Sep;28(9):2854–62.
35. Munier M, Donnez M, Ollivier M, Flecher X, Chabrand P, Argenson J-N, et al. Can three-dimensional patient-specific cutting guides be used to achieve optimal correction for high tibial osteotomy? Pilot study. Orthop Traumatol Surg Res. 2017 Apr;103(2):245–50.
36. Han SB, Choi JH, Mahajan A, Shin YS. Incidence and Predictors of Lateral Hinge Fractures Following Medial Opening-Wedge High Tibial Osteotomy Using Locking Plate System: Better Performance of Computed Tomography Scans. J Arthroplasty. 2019 May 1;34(5):846–51.
37. Takeuchi R, Ishikawa H, Kumagai K, Yamaguchi Y, Chiba N, Akamatsu Y, et al. Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: A new classification of lateral hinge fracture. Arthrosc – J Arthrosc Relat Surg. 2012 Jan;28(1):85–94.
38. Kang K-T, Koh Y-G, Lee J-A, Lee JJ, Kwon SK. Biomechanical effect of a lateral hinge fracture for a medial opening wedge high tibial osteotomy: finite element study. J Orthop Surg Res. 2020 Feb;15(1):63.
39. Jung G-H, Lee K-H, Wang L. Three-dimensional analysis of lateral cortical hinge in medial open-wedge high tibial osteotomy: A computational simulation study of adult cadavers. J Orthop Surg (Hong Kong). 2020;28(3):2309499020959172.
40. Nakamura R, Komatsu N, Fujita K, Kuroda K, Takahashi M, Omi R, et al. Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy. Bone Jt J. 2017;99(10):1313–31.
41. Ogawa H, Matsumoto K, Akiyama H. The prevention of a lateral hinge fracture as a complication of a medial opening wedge high tibial osteotomy: a case control study. Bone Joint J. 2017 Jul;99-B(7):887–93.
42. Boström A, Amin AK, Macpherson GJ, Pankaj P, Scott CEH. Hinge location and apical drill holes in opening wedge high tibial osteotomy: A finite element analysis. J Orthop Res. 2021 Mar 1;39(3):628–36.
43. Dessyn E, Sharma A, Donnez M, Chabrand P, Ehlinger M, Argenson J-N, et al. Adding a protective K-wire during opening high tibial osteotomy increases lateral hinge resistance to fracture. Knee Surg Sports Traumatol Arthrosc. 2020 Mar;28(3):751–8.
44. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications After Medial Opening Wedge High Tibial Osteotomy. Arthrosc – J Arthrosc Relat Surg. 2009 Jun;25(6):639–46.
45. de Mello Junior WA, Arruda LRP, Coluccini AM, da Silva Nunes RP, Pedro M do AC, de Souza MR, et al. COMPLICATIONS FOLLOWING MEDIAL OPENING WEDGE OSTEOTOMY OF THE KNEE: RETROSPECTIVE STUDY. Rev Bras Ortop. 2011 Jan;46(1):64–8.
46. Pearson RG, Clement RGE, Edwards KL, Scammell BE. Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis. BMJ Open. 2016 Nov;6(11):e010303.
47. Tunggal JAW, Higgins GA, Waddell JP. Complications of closing wedge high tibial osteotomy. Vol. 34, International Orthopaedics. 2010. p. 255–61.
48. Gaasbeek RDA, Welsing RTC, Verdonschot N, Rijnberg WJ, Van Loon CJM, Van Kampen A. Accuracy and initial stability of open- and closed-wedge high tibial osteotomy: A cadaveric RSA study. Knee Surgery, Sport Traumatol Arthrosc. 2005 Nov;13(8):689–94.
49. Hankemeier S, Hufner T, Wang G, Kendoff D, Zeichen J, Zheng G, et al. Navigated open-wedge high tibial osteotomy: Advantages and disadvantages compared to the conventional technique in a cadaver study. Knee Surgery, Sport Traumatol Arthrosc. 2006 Oct;14(10):917–21.
50. Suero EM, Sabbagh Y, Westphal R, Hawi N, Citak M, Wahl FM, et al. Effect of Medial Opening Wedge High Tibial Osteotomy on Intraarticular Knee and Ankle Contact Pressures. 2015;(April):598–604.
51. El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S. Patellar height and posterior tibial slope after open- and closed-wedge high tibial osteotomy: A radiological study on 100 patients. Am J Sports Med. 2010 Feb;38(2):323–9.
52. Erquicia J, Gelber PE, Perelli S, Ibañez F, Ibañez M, Pelfort X, et al. Biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy, radiological and clinical analysis with minimum follow-up of 2 years. J Exp Orthop. 2019 Feb;6(1):10.
53. Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Nakanishi A, Ueoka K. Patellofemoral Osteoarthritis Progression and Alignment Changes after Open-Wedge High Tibial Osteotomy Do Not Affect Clinical Outcomes at Mid-term Follow-up. Arthrosc – J Arthrosc Relat Surg. 2017 Oct 1;33(10):1832–9.
54. Kley K, Bin Abd Razak HR, Khakha RS, Wilson AJ, van Heerwaarden R, Ollivier M. Soft-Tissue Management and Neurovascular Protection During Opening-Wedge High Tibial Osteotomy. Arthrosc Tech. 2021 Feb;10(2):e419–22.
55. Wootton JR, Ashworth MJ, MacLaren CA. Neurological complications of high tibial osteotomy–the fibular osteotomy as a causative factor: a clinical and anatomical study. Ann R Coll Surg Engl. 1995 Jan;77(1):31–4.
56. Woodacre T, Ricketts M, Evans JT, Pavlou G, Schranz P, Hockings M, et al. Complications associated with opening wedge high tibial osteotomy – A review of the literature and of 15 years of experience. Knee. 2016 Mar 1;23(2):276–82.
57. Visser J, Brinkman J-M, Bleys RLAW, Castelein RM, van Heerwaarden RJ. The safety and feasibility of a less invasive distal femur closing wedge osteotomy technique: a cadaveric dissection study of the medial aspect of the distal femur. Knee Surg Sports Traumatol Arthrosc. 2013 Jan;21(1):220–7.
58. van den Bekerom MPJ, Patt TW, Kleinhout MY, van der Vis HM, Albers GHR. Early complications after high tibial osteotomy: a comparison of two techniques. J Knee Surg. 2008 Jan;21(1):68–74.
59. Hartz C, Wischatta R, Klostermeier E, Paetzold M, Gerlach K, Pries F. Plate-related results of opening wedge high tibial osteotomy with a carbon fiber reinforced poly-ether-ether-ketone (CF-PEEK) plate fixation: A retrospective case series of 346 knees. J Orthop Surg Res. 2019 Dec 27;14(1).
60. Roberson TA, Momaya AM, Adams K, Long CD, Tokish JM, Wyland DJ. High Tibial Osteotomy Performed With All-PEEK Implants Demonstrates Similar Outcomes but Less Hardware Removal at Minimum 2-Year Follow-up Compared With Metal Plates. Orthop J Sport Med. 2018 Jan 2;6(3).
61. Lim JBT, Chong HC, Pang HN, Tay KJD, Chia SL, Lo NN, et al. Revision total knee arthroplasty for failed high tibial osteotomy and unicompartmental knee arthroplasty have similar patient-reported outcome measures in a two-year follow-up study. 2017;99(10).
62. Pearse AJ, Hooper GJ, Rothwell AG, Frampton C. Osteotomy and unicompartmental knee arthroplasty converted to total knee arthroplasty: data from the New Zealand Joint Registry. J Arthroplasty. 2012 Dec;27(10):1827–31.
63. Badawy M, Fenstad AM, Indrekvam K, Havelin LI, Furnes O. The risk of revision in total knee arthroplasty is not affected by previous high tibial osteotomy. Acta Orthop. 2015;86(6):734–9.
|How to Cite this article: Rudraraju RT, Shatrov J, Fritsch BA| Osteotomy Complications: Prevention and Cure | Asian Journal of Arthroscopy | July-December 2021; 6(2): 46-53.|