Tag Archive for: Knee preservation

Volume 6 | Issue 2 | July-December 2021 | Page 01-02 | Anshu Shekhar, Sachin Tapasvi


Author: Anshu Shekhar [1], Sachin Tapasvi [2]

[1] Sushrut OrthoPlastic Clinic, Raipur, Chhattisgarh, India.
[2] The Orthopaedic Speciality Clinic, Pune, Maharashtra, India.

Address of Correspondence:

Dr. Anshu Shekhar,
Consultant, Sushrut OrthoPlastic Clinic, Raipur, Chhattisgarh, India.
E-mail: dr.anshushekhar@gmail.com


Asian Journal of Arthroscopy completes 5 years of publication with this issue. This feat could only be achieved because of the unflinching support from all our authors, reviewers and above all, the readers. In all our previous issues, we have dealt with specific areas and pathologies which can be treated by arthroscopy. The knee joint has received most attention because it the most common joint to be injured and be treated as well. However, any
talk of knee preservation is incomplete without acknowledging the art and science of osteotomy. This issue is dedicated to discussing the various aspects of a modern knee osteotomy for preserving the knee joint because it is indeed the final frontier.

Osteotomy surgery is a proven method of knee joint preservation by correcting mal-alignment in the coronal and sagittal planes [1]. It has been used to treat knee osteoarthritis by correcting varus or valgus mal-alignment since a very long time and with good results [2]. However, the science and art of osteotomy has evolved significantly over the last decade or so and everything is not so simple about a high tibial osteotomy (HTO) anymore. This has made osteotomy more predictable and safer, while expanding the indications and applications. One major ‘expanded’ indication has been to use osteotomy to treat ligament instabilities of the knee. This has been a force multiplier for ligament surgeons, who can achieve greater success with their soft-tissue reconstruction [3]. Perhaps the most remarkable progress has been made in planning an osteotomy. The use of digital planning techniques and specialized software for defining the deformity and correction has made osteotomy planning more reproducible and accurate [4, 5]. However, clinical examination cannot be given a miss in spite of any sophisticated radiological planning tool. Assessment of the soft-tissue laxity has to be considered in the surgical plan because this is an important cause of over-correction [6].

Medial open wedge high tibial osteotomy (MOWHTO) remains by far the most commonly performed surgery to correct malalignment around the knee for any indication. A close wedge or dome osteotomy are less frequently performed but have their place. Techniques of these surgeries are also evolving, the most important of which are performing a biplanar osteotomy and use of angle-stable locked plates for fixation. Both these provide definite benefits in terms of biology and biomechanics, thus permitting early mobilization and weight bearing [7, 8]. Another simple but remarkable innovation has been use of a K wire as a hinge protection tool. This has reduced the incidence of lateral hinge fractures by increasing the stiffness of hinge by about 880% and allowing early healing of the osteotomy [9, 10]. Even in cases of varus osteoarthritis with severe deformity, the utility of a double-level osteotomy to prevent joint line obliquity and provide good results has been demonstrated [11]. Another area of interest now are sagittal tibial osteotomies, especially the anterior closing wedge to reduce the posterior tibial slope in the setting of repeated failures of anterior cruciate ligament reconstruction [12].

As regards the use of technology for performing osteotomies, navigation has been used for quite some time. Although navigated HTO has yielded better precision and accuracy of alignment correction, it has not translated to better clinical outcomes [13]. The newest technological marvel in osteotomy surgery is the use of patient-specific cutting jigs and implants. This is a promising new avenue with good clinical results reported in the short-term without an increased risk of specific or non-specific complications [14]. In spite of everything, some patients will eventually require a total knee arthroplasty (TKA) for end-stage disease. The long-term survivorship of a TKA after HTO has been reported as 97% with a 3% revision rate for instability [15]. The survival drops to 88% after a distal femoral osteotomy when 6% revisions are due to instability [16]. These numbers are for patients who underwent osteotomies when the philosophy was still not refined. With better osteotomy technique and respect to ligament balancing, the TKA survivorship should also improve in future.

All these issues related to planning, execution and performance of a knee osteotomy have been dealt with in great detail and up to date information in this issue. We do hope that the wealth of knowledge contributed by the stalwarts of osteotomy surgery will be loved and appreciated by all our readers. The bone always wins and anybody willing to preserve a knee joint must have the weapon of osteotomy in their armamentarium.


1. Zampogna B, Vasta S, Papalia R. Patient Evaluation and Indications for Osteotomy Around the Knee. Clin Sports Med. 2019;38(3):305-315. doi:10.1016/j.csm.2019.02.011
2. Peng H, Ou A, Huang X, et al. Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis. Orthop Surg. 2021;13(5):1465-1473. doi:10.1111/os.13021
3. Tischer T, Paul J, Pape D, et al. The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med. 2017;5(3):2325967117697287. doi:10.1177/2325967117697287
4. Elson DW, Petheram TG, Dawson MJ. High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci’s method. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):2041-2048. doi:10.1007/s00167-014-2920-x.
5. Schröter S, Ihle C, Mueller J, Lobenhoffer P, Stöckle U, van Heerwaarden R. Digital planning of high tibial osteotomy. Interrater reliability by using two different software. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):189-196. doi:10.1007/s00167-012-2114-3
6. Park JG, Kim JM, Lee BS, Lee SM, Kwon OJ, Bin SI. Increased preoperative medial and lateral laxity is a predictor of overcorrection in open wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3164-3172. doi:10.1007/s00167-019-05805-8.
7. Pape D, Lorbach O, Schmitz C, et al. Effect of a biplanar osteotomy on primary stability following high tibial osteotomy: a biomechanical cadaver study. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):204-211. doi:10.1007/s00167-009-0929-3
8. Koh, YG., Lee, JA., Lee, HY. et al. Design optimization of high tibial osteotomy plates using finite element analysis for improved biomechanical effect. J Orthop Surg Res 14, 219 (2019). doi.org/10.1186/s13018-019-1269-8.
9. Gulagaci F, Jacquet C, Ehlinger M, et al. A protective hinge wire, intersecting the osteotomy plane, can reduce the occurrence of perioperative hinge fractures in medial opening wedge osteotomy. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3173-3182. doi:10.1007/s00167-019-05806-7
10. Dessyn E, Sharma A, Donnez M, et al. Adding a protective K-wire during opening high tibial osteotomy increases lateral hinge resistance to fracture. Knee Surg Sports Traumatol Arthrosc. 2020;28(3):751-758. doi:10.1007/s00167-019-05404-7
11. Schröter S, Nakayama H, Yoshiya S, Stöckle U, Ateschrang A, Gruhn J. Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line. Arch Orthop Trauma Surg. 2019;139(4):519-527. doi:10.1007/s00402-018-3068-9
12. Vadhera AS, Knapik DM, Gursoy S, et al. Current Concepts in Anterior Tibial Closing Wedge Osteotomies for Anterior Cruciate Ligament Deficient Knees. Curr Rev Musculoskelet Med. 2021;14(6):485-492. doi:10.1007/s12178-021-09729-0
13. Wu ZP, Zhang P, Bai JZ, et al. Comparison of navigated and conventional high tibial osteotomy for the treatment of osteoarthritic knees with varus deformity: A meta-analysis. Int J Surg. 2018;55:211-219. doi:10.1016/j.ijsu.2018.03.024
14. Chaouche S, Jacquet C, Fabre-Aubrespy M, et al. Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort. Int Orthop. 2019;43(12):2757-2765. doi:10.1007/s00264-019-04372-4
15. Chalmers BP, Limberg AK, Tibbo ME, Perry KI, Pagnano MW, Abdel MP. Total Knee Arthroplasty After High Tibial Osteotomy Results in Excellent Long-Term Survivorship and Clinical Outcomes. J Bone Joint Surg Am. 2019;101(11):970-978. doi:10.2106/JBJS.18.01060
16. Chalmers BP, Limberg AK, Athey AG, Perry KI, Pagnano MW, Abdel MP. Total knee arthroplasty after distal femoral osteotomy long-term survivorship and clinical outcomes. Bone Joint J. 2019;101-B(6):660-666. doi:10.1302/0301-620X.101B6.BJJ-2018-1334.R2

How to Cite this article: Shekhar A, Tapasvi S | Osteotomy: The Final Frontier in Knee Preservation | Asian Journal of Arthroscopy | July-December 2021; 6(2): 01-02.

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Volume 6 | Issue 2 | July-December 2021 | Page 08-11 | Hamid Razak, Kristian Kley

Author: Hamid Razak [1, 2], Kristian Kley [3, 4]

[1] SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme 20 College Road, Academia Level 4, Singapore 169865.
[2] Department of Orthopaedic Surgery, Sengkang General Hospital 110 Sengkang East Way, Singapore 544886.
[3] London Osteotomy Centre, Harley Street Specialist Hospital, 18-22 Queen Anne Street, London.
[4] Orthoprofis Hannover, Luisenstraße 10-11, 30159, Hannover, Germany.

Address of Correspondence:
Dr. Hamid Razak,
Department of Orthopaedic Surgery, Sengkang General Hospital 110 Sengkang East Way, Singapore 544886.
E-mail: hamidrazak@gmail.com


High tibial osteotomy (HTO) has been the workhorse joint preserving surgery for medial knee osteoarthritis (KOA) with varus deformity. Its importance as a surgical option has been amplified in recent years due to the greater incidence of KOA in young active patients. HTO procedures produce the best outcomes and the highest predictability when executed according to the pre-ordained surgical plan. Planning for an HTO is a mandatory and critical step. Failure to plan adequately leads to poor outcomes following HTO. Methods of planning can be broadly classified into traditional pen-and-paper planning as well as digital planning with software. Both are acceptable methods with their own merits but their utilization may be influenced by surgeon preferences, accessibility, case load and experience.
keywords: Varus knee osteoarthritis, Knee preservation, High tibial osteotomy, Preoperative planning, Surgical planning


1. Smith JO, Wilson AJ, Thomas NP. Osteotomy around the knee: evolution, principles and results. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):3-22.2. Niinimäki TT, Eskelinen A, Ohtonen P, Junnila M, Leppilahti J. Incidence of osteotomies around the knee for the treatment of knee osteoarthritis: a 22-year population-based study. Int Orthop. 2012;36(7):1399-402.
3. Bayliss LE, Culliford D, Monk AP, Glyn-Jones S, Prieto-Alhambra D, Judge A, et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet. 2017;389(10077):1424-30.
4. El-Azab HM, Morgenstern M, Ahrens P, Schuster T, Imhoff AB, Lorenz SG. Limb alignment after open-wedge high tibial osteotomy and its effect on the clinical outcome. Orthopedics. 2011;34(10):e622-8.
5. Razak H, Micicoi G, Khakha RS, Ehlinger M, Faizan A, LiArno S, et al. Patients with varus knee osteoarthritis undergoing high tibial osteotomy exhibit more femoral varus but similar tibial morphology compared to non-arthritic varus knees. Knee Surg Sports Traumatol Arthrosc. 2021.
6. Engel GM, Lippert FG, 3rd. Valgus tibial osteotomy: avoiding the pitfalls. Clin Orthop Relat Res. 1981(160):137-43.
7. Kettelkamp DB, Wenger DR, Chao EY, Thompson C. Results of proximal tibial osteotomy. The effects of tibiofemoral angle, stance-phase flexion-extension, and medial-plateau force. J Bone Joint Surg Am. 1976;58(7):952-60.
8. Tjörnstrand B, Selvik G, Egund N, Lindstrand A. Roentgen stereophotogrammetry in high tibial osteotomy for gonarthrosis. Arch Orthop Trauma Surg. 1981;99(2):73-81.
9. Majeed H. Litigations in trauma and orthopaedic surgery: analysis and outcomes of medicolegal claims during the last 10 years in the United Kingdom National Health Service. EFORT Open Rev. 2021;6(3):152-9.
10. Al Ghunimat A, Hind J, Abouelela A, Sidhu GAS, Lacon A, Ashwood N. Communication With Patients Before an Operation: Their Preferences on Method of Communication. Cureus. 2020;12(11):e11431-e.
11. Miniaci A, Ballmer FT, Ballmer PM, Jakob RP. Proximal tibial osteotomy. A new fixation device. Clin Orthop Relat Res. 1989(246):250-9.
12. Fick R. Handbuch der Anatomie und Mechanik der Gelenke: T. Spezielle Gelenk-und Muskelmechanik: G. Fischer; 1911.
13. 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;10(3):585-608.
14. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992(274):248-64.
15. Lee SS, Lee HI, Cho ST, Cho JH. Comparison of the outcomes between two different target points after open wedge high tibial osteotomy: The Fujisawa point versus the lateral tibial spine. Knee. 2020;27(3):915-22.
16. 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. Arthroscopy. 2012;28(1):85-94.
17. Jacobi M, Wahl P, Jakob RP. Avoiding intraoperative complications in open-wedge high tibial valgus osteotomy: technical advancement. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):200-3.
18. Han SB, Lee DH, Shetty GM, Chae DJ, Song JG, Nha KW. A “safe zone” in medial open-wedge high tibia osteotomy to prevent lateral cortex fracture. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):90-5.
19. 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 Joint J. 2017;99-b(10):1313-8.
20. Sivertsen EA, Vik J, Meland ASV, Nerhus TK. The Dugdale planning method for high tibial osteotomies underestimates the correction angle compared to the Miniaci method. Knee Surg Sports Traumatol Arthrosc. 2021.
21. Elson DW, Petheram TG, Dawson MJ. High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci’s method. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):2041-8.
22. Yoon SD, Zhang G, Kim HJ, Lee BJ, Kyung HS. Comparison of Cable Method and Miniaci Method Using Picture Archiving and Communication System in Preoperative Planning for Open Wedge High Tibial Osteotomy. Knee Surg Relat Res. 2016;28(4):283-8.

How to Cite this article: Razak H, Kley K | Indications for High Tibial Osteotomy | Asian Journal of Arthroscopy | July-December 2021; 6(2): 08-11.

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