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High tibial osteotomy

154 citationsUpdated Sep 2026

Overview

High tibial osteotomy is a standardized, safe, and reliable procedure that provides satisfactory pain relief and functional outcomes for selected patients with high activity demands [1, 6]. It is particularly indicated for physiologically young, active patients with unicompartmental knee disease, specifically those aged less than 55 years who are not obese and have not progressed to severe symptomatic disability [10, 18]. The procedure is preferred for individuals with strenuous occupations or those wishing to continue sports, whereas total knee arthroplasty is generally reserved for patients over sixty years old [28]. Patient age does not restrict the indication for high tibial osteotomy [7]. In appropriately indicated patients, medial opening-wedge high tibial osteotomy is widely accepted to produce good outcomes for symptomatic medial compartment osteoarthrosis [27].

The procedure demonstrates a survival rate of over 96% at 5 years and 85% at 20 years, with union achieved in 93% of cases [2, 11, 13]. While results can remain effective for periods longer than 15 years, they deteriorate over time [3]. Medial opening wedge high tibial osteotomy is a radiologically and clinically rewarding procedure with a high survival rate at 5 and 10 years and a low complication rate in experienced hands [39]. Infections after the procedure are rare [8]. Observational studies suggest that high tibial osteotomy can substantially improve outcome measures important to knee joint structure, function, patient quality of life, and health care systems, although high-level evidence comparing it with alternate treatments is required for stronger recommendations [5].

High tibial osteotomy is the most cost-effective treatment modality in this population [16]. Possible alterations in tibial slope and leg length are considered when choosing the technique [17]. The procedure can be combined with transtibial drilling of tibial and femoral medial compartment cartilage defects without additional incisions [14], and has extended the indication for ligament reconstruction, potentially halting the evolution of arthritis [36]. However, most studies have failed to show improved clinical outcomes in the short term when adding cartilage restoration procedures to high tibial osteotomy [29]. If high tibial osteotomy fails, a subsequent total knee arthroplasty is technically more demanding and may perform less well or be more liable to failure [12, 25]. Nevertheless, a previous high tibial osteotomy was not determinant for having a worse outcome at total knee replacement, even when radiographic differences existed [4], and the clinical outcome of total knee arthroplasty after high tibial osteotomy was almost identical to a matched group that had no prior procedure [25].

Anatomy & Pathophysiology

Biomechanics and Kinematics

High tibial osteotomy corrects deformity to create a more biomechanically stable knee [19]. The position of the loading axis in the frontal plane strongly affects tibiofemoral cartilage pressure distribution [120]. Tibial flexion osteotomy significantly alters cartilage pressure and knee joint kinematics [96]. Kinematic changes resulting from open and closed high tibial osteotomy must be considered when selecting the surgical technique for patients with medial osteoarthritis [46]. Three-dimensional kinematic analysis detects changes due to high tibial osteotomy that standard radiographs do not identify, including changes in the patellofemoral joint [140].

Radiographic analysis demonstrates increased hip-knee-ankle (HKA) angles and percentage of mechanical axis (%MA), along with reduced femorotibial angle (FTA) following medial opening-wedge high tibial osteotomy [124]. In pre-operative varus knees, the mean mechanical axis on single-limb stance is more varus than on double-limb stance, whereas it changes to less valgus in post-operative valgus knees [137]. Both medial opening wedge and lateral closing wedge high tibial osteotomy techniques result in smaller changes in leg length than predicted by mathematical models [152]. The effect of varus-producing distal femoral osteotomy and high tibial osteotomy on compartment pressures and contact area is amplified as the knee flexion angle increases [118].

If the leg is realigned by a medial opening wedge high tibial osteotomy, the proximal tibial fragment rotates in adduction during stance, causing the joint line to slope distally/laterally as the femur is adducted to maintain congruent tibiofemoral contact [194]. It has usually been accepted that a medial–lateral slope up to 10 degrees is acceptable, but there is no real evidence to support that limit [194]. Excessive medial/lateral slope may lead to transverse shearing forces, with the femur tending to 'slide downhill', and sliding may be arrested by impingement of the inner aspect of the femoral intercondylar notch against the tibial spinous process [194]. In knees where the underlying deformity is in the femur, such as after a supracondylar fracture that has healed in misalignment or due to a hypoplastic femoral condyle, the osteotomy should be in the distal femur to obtain a closer approach to a horizontal joint line after realignment [194].

Gait and Functional Outcomes

High tibial osteotomy results in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment [88]. Preoperative gait characteristics, specifically the knee adduction moment, are predictive of postoperative clinical results; patients with lower preoperative adduction moments had substantially better clinical outcomes [92]. Gait adaptations known to reduce knee loading employed pre-high tibial osteotomy were not retained post-high tibial osteotomy [143]. Findings from five-year follow-up of concomitant high tibial osteotomy and ACL reconstruction are consistent with an intended, sustained shift in the mediolateral distribution of knee loads [94].

Patellofemoral Joint

Most patients develop significant patella baja after proximal tibial osteotomy [57]. Factors that may cause patella baja after proximal tibial osteotomy include shortening of the patellar tendon after prolonged immobilization, new bone formation at the site of the osteotomy in the area of the insertion of the patellar tendon, and fibrosis of the patellar tendon [57]. The decrease in the height of the patella has no appreciable effect on the success or failure of the osteotomy or the need for subsequent total joint replacement [57]. However, patella baja is likely to make a subsequent total knee arthroplasty more technically demanding [57].

Kinematic changes correlating with poorer postoperative functional results suggest that in patients with preexisting pathological patellar height, a modification of the classical osteotomy technique should be discussed [95]. Medial open wedge high tibial osteotomy does not relevantly alter patellar kinematics in cadaveric studies, though future clinical studies are needed to prove its effect on anterior knee pain [121]. An open-wedge valgus high tibial osteotomy technique with inverted L-shaped configuration achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope [55]. Both cadaver and clinical studies have reported negative effects of open wedge high tibial osteotomy on the patellofemoral joint, including a decrease in patellar height, increase in contact pressure and degeneration of the patellar and femoral trochlear cartilage [193]. Femoral trochlear cartilage degeneration can improve after treatment by abrasion arthroplasty combined with open wedge high tibial osteotomy [193]. Neither patellar height nor limb alignment affects improvement of femoral trochlear cartilage after open wedge high tibial osteotomy combined with abrasion arthroplasty [193].

Posterior Tibial Slope

One frequently reported problem associated with opening wedge high tibial osteotomy is that posterior tibial slope can be altered [189]. In clinical follow-up studies, an unintended increase in posterior tibial slope of up to a mean of 4.4° has been reported [189]. An incidental increase in posterior tibial slope is generally avoided as it can lead to anterior translation of the tibia relative to the femur, especially if anterior cruciate ligament deficiency is present [189]. The triangular shape of the proximal tibia is a widely discussed theory for posterior tibial slope increase, as the bone’s shape demands a smaller opening of the osteotomy anteriorly than posteriorly if the posterior tibial slope is to remain unchanged [189].

Anterior plate placement may compound the problem of posterior tibial slope increase by more effectively opening the osteotomy anteriorly [189]. If the osteotomy is not performed in the frontal but rather in an oblique plane with the hinge posterolateral, the posterior tibial slope can be increased [189]. An incomplete posterior osteotomy cut and inappropriate release of posterior soft tissues can be responsible for a posterior tibial slope increase, resulting in increased opening anteriority [189]. A specific technique offered the advantage of preserving the posterior tibial slopes postoperatively even in highly deformed knees which necessitated higher degrees of corrections in the mechanical axes [138]. The magnitude of change in posterior tibial slope after open- and closed-wedge high tibial osteotomy was similar and small (approximately 2°), suggesting that both osteotomy techniques may have little effect on the biomechanics of the cruciate ligaments [132]. There was no change in sagittal plane knee moment, including flexion and extension moments, from before to after medial open wedge high tibial osteotomy [134]. Increasing posterior tibial slope in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [93]. For smaller corrections in the coronal plane, more extreme hinge axis positions were necessary to achieve higher magnitudes of posterior tibial slope reduction in medial opening wedge high tibial osteotomy [156].

Rotational Alignment

Derotational high tibial osteotomy corrects lower limb rotational malalignments due to excessive tibial torsion [191]. Excessive external tibial torsion, femoral antetorsion, and varus or valgus may jeopardize the patellofemoral joint function, with an emphasis on rotational imbalance [191]. Deformity in the torsional alignment of the tibia leads to stress on the components of the joint, such as ligaments and cartilage, which can result in recurrent patellar subluxation and contribute to patellar maltracking and subsequently to anterior knee pain [191]. Knees with anterior knee pain display increased tibial external rotation [191]. Excessive rotation may generate medial patellofemoral ligament traction, causing medial pain [191].

Meniscal Pathology

The medial meniscal root plays a crucial role in maintaining the knee joint's biomechanics by preserving hoop tension and evenly distributing load across the medial compartment [188]. Medial meniscus posterior root tears disrupt the mechanism of hoop tension and load distribution, leading to increased contact pressures in the knee and accelerated cartilage degeneration [188]. Medial meniscus posterior root tears increase medial contact pressures and accelerate cartilage degeneration, particularly in varus-aligned knees [188]. Limb realignment surgery (high tibial osteotomy) should be considered earlier in the treatment algorithm for patients with varus alignment and degenerative meniscal tears to address the underlying biomechanical problem [158]. A combined approach of high tibial osteotomy, anterior cruciate ligament reconstruction, and medial meniscus posterior root repair enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment [127]. High tibial osteotomy improves the peak pressures in the medial compartment at all degrees of varus/valgus alignment in the setting of meniscal transplantation [154]. A free-floating medial meniscus implant remains within the medial knee joint gap under challenging dynamic loading situations without indicating any luxation tendencies after simulation of medial open-wedge high tibial osteotomy and notchplasty [112]. When considering the use of a high tibial osteotomy in the setting of ACL deficiency, lateral closing wedge should be considered given its favorable post-operative knee kinematics [149, 153].

Surgical Anatomy and Complications

The peroneal nerve is most at risk with osteotomy of the proximal fibula, where the nerve wraps around the neck of the fibula before dividing into deep and superficial branches [57]. The deep peroneal nerve has a potential risk of injury during open-wedge high tibial osteotomy [192]. A cadaver study demonstrated that at 90 degrees of flexion, the distance between the osteotomy blade and the popliteal artery averaged only 10.6 mm [57]. Popliteal artery injury is rare but devastating [57].

The incidence of lateral hinge fracture in medial opening wedge high tibial osteotomy may be between 20% and 25% [61]. Instability at the site of the osteotomy due to a lateral hinge fracture may cause delayed union, nonunion, and loss of correction requiring further surgery [61]. Lateral hinge fractures are classified as follows: * Type I: Involves an extension of the osteotomy just proximal to or within the tibiofibular joint [61]. * Type II: Reaches the distal aspect of the tibiofibular joint [61]. * Type III: Is an intra-articular fracture of the tibia plateau [61].

Types II and III lateral hinge fractures require careful treatment as they are unstable compared with type I [61]. Inadequate correction and recurrent varus deformity have been reported to occur in 5% to 30% of patients with proximal tibial osteotomy [57]. Recurrence of a varus deformity was the most common complication in Coventry's report of 213 proximal tibial osteotomies [57]. Coventry attributed the recurrence of varus deformity to inadequate correction at the time of surgery and suggested that overcorrection beyond the normal 5 degrees of anatomic valgus decreased the frequency of this complication [57]. Other reported complications of proximal tibial osteotomy include recurrence of deformity, peroneal nerve palsy, nonunion, infection, knee stiffness or instability, intraarticular fracture, deep vein thrombosis, compartment syndrome, patella infra, and osteonecrosis of the proximal fragment [57].

Classification

Lateral Hinge Fracture

Takeuchi: This classification categorizes lateral hinge fractures into three types based on the position of the osteotomy line relative to the proximal tibiofibular joint [61]. Type I involves an extension of the osteotomy just proximal to or within the tibiofibular joint, while Type III is an intra-articular fracture of the tibial plateau [61]. Type I fractures are considered stable, whereas Types II and III are unstable [61]. Type I fractures are further subdivided into subtypes A, B, and C based on anterior, posterior, or both anterior and posterior cortical disruptions [173].

Displacement: Lateral hinge fractures are divided into nondisplaced (≤ 2 mm displacement) and displaced (> 2 mm displacement) categories, with nondisplaced fractures being more common [168]. Zone WL appears to offer the safest position for osteotomy hinge placement when attempting to avoid fracture at the osteotomy site [144]. Posterior tibial slope increased over time following surgery in Type I lateral hinge fractures with posterior cortical involvement (subtype B) compared to those with anterior cortical involvement (subtype A) [173].

Coronal Plane Alignment

Coronal Plane Alignment of the Knee: A modification of this classification uses the measured hip-knee-ankle angle from full-length standing radiographs [142]. Measured hip-knee-ankle angle-based and arithmetic classification methods produced different phenotype assignments before and after medial opening-wedge high tibial osteotomy [142]. Preoperative coronal alignment phenotypes were not consistently associated with postoperative patient-reported outcomes after medial opening-wedge high tibial osteotomy [142].

Clinical Presentation

Indications and Patient Selection

High tibial osteotomy is indicated for appropriately selected patients, particularly those who are physiologically young and active with unicompartmental knee disease [10]. This procedure is an underutilized option that warrants consideration for patients for whom total knee arthroplasty is an imperfect long-term solution [10]. Age does not have to be taken into consideration for the indication of high tibial osteotomy [7]. In sport-related cases, the procedure effectively alleviates symptoms, corrects alignment, improves stability, and preserves meniscal tissue and cartilage [100]. Careful patient selection and evaluation are essential to maximize successful outcomes in these sport-related cases [100].

Specific indications for inverted V-shaped high tibial osteotomy include symptomatic, isolated medial-compartment osteoarthritis knees with varus deformity where the valgus correction angle is calculated to be 15° or more [54]. Candidates for this specific technique include knees with severe varus deformity and osteoarthritis changes classified as stage 3 or 4 on the Kellgren-Lawrence grading scale [54]. Additionally, knees presenting with severe varus deformity, osteoarthritis changes (stage 2), medial meniscal injury, post-traumatic deformity, and spontaneous osteonecrosis of the medial femoral condyle can be candidates for inverted V-shaped high tibial osteotomy [54]. The procedure can also treat severe congenital genu varum deformity associated with Blount disease, Turner syndrome, and rickets [54].

A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates for high tibial osteotomy [22]. Open-wedge high tibial osteotomy provides a satisfactory solution for constitutional high tibia vara with minor morbidity in the short-term follow-up period [49]. Regardless of applying a closed- or open-wedge technique, the procedure should be selected with careful consideration of the osteoarthritic status of the patellofemoral joint and the required correction angle [37]. A knee joint line obliquity greater than 5° or a planned medial proximal tibial angle greater than 94° preferentially indicates a double level osteotomy compared to an isolated opening wedge high tibial osteotomy [104].

Clinical Outcomes and Survival

High tibial osteotomy is a standardized, safe, and reliable procedure when taking care of correct preoperative planning and intraoperative procedure [6]. With a survival rate of over 96% at 5 years, high tibial osteotomy is a reliable treatment option with satisfying clinical outcome [11]. The procedure can be effective for periods longer than 15 years, although results do deteriorate over time [3]. A meta-analysis showed that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months [35].

In sport-related populations, more than 8 of 10 patients returned to sport after high tibial osteotomy [34]. After open-wedge high tibial osteotomy, clinical results showed improvement compared to pre-operative values [32]. Medial opening high tibial osteotomy shows remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity and can effectively relieve knee joint pain with less postoperative complications [44]. Tibial osteotomy can successfully alleviate knee pain in the management of malalignment associated with knee arthrosis in young or active patients [51].

Complications and Risks

The rate of peroneal nerve lesions after high tibial osteotomy is higher than that detected clinically, with electrophysiological means revealing lesions that may be overlooked by mild weakness and hypesthesia [40]. Instability at the osteotomy site may contribute to the high rate of delayed union or nonunion associated with medial opening wedge high tibial osteotomy [47]. Accelerated degeneration of the discoid lateral meniscus can occur after medial opening wedge high tibial osteotomy [109]. The aberrant anterior tibial artery should be respected and can be protected in high tibial osteotomy surgery [108].

Clinical outcome is good with no differences between closing-wedge and opening-wedge high tibial osteotomy, except for more frequent late complications with closing-wedge osteotomy [48]. The difference in post-operative angular deformities of the proximal tibia between closing wedge and opening wedge high tibial osteotomy was considered clinically irrelevant [98]. Patients should be counseled that if high tibial osteotomy fails, a subsequent total knee arthroplasty will be more difficult and may perform less well and/or be more liable to failure [12]. However, a previous high tibial osteotomy does not influence the function or survival of a knee long term [9]. The clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different [20].

Surgical Technique and Accuracy

High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique [24]. Arthroscopic and computer-assisted high tibial osteotomy using standard total knee arthroplasty navigation software provides intraoperative real-time guidance of the degree of correction that is accurate and reliable [21]. This navigation technique represents a useful tool for the surgeon who uncommonly performs high tibial osteotomy [21]. Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high tibial osteotomy [56].

The inverted L-shaped configuration of open-wedge valgus high tibial osteotomy achieves correction of axial malalignment without changing patellar height or posterior tibial slope [55]. A significant rate of tibial overcorrection with an increased joint line obliquity occurred after isolated high tibial osteotomy without considering international consensus [104]. No clinical outcome difference was observed between varus phenotypes after medial opening-wedge high tibial osteotomy at 2 years follow-up [114]. Simultaneous bilateral medial opening wedge high tibial osteotomy can be performed safely and effectively without bone grafting [116].

The clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy [26]. Combined high tibial osteotomy and transtibial drilling of tibial and femoral medial compartment cartilage defect can be performed without additional incisions [14]. Multicompartmental osteochondral allografts of the knee can be treated alongside high tibial osteotomy when malalignment is present [23].

Investigations

Plain radiography: Plain radiographs serve as the appropriate initial imaging studies for most knee conditions, allowing assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [78]. Weight-bearing AP (extension) radiographs assess cartilage loss from the distal femur and tibial plateau [78], while weight-bearing PA (Rosenberg; flexion) radiographs assess cartilage loss from the posterior femur and tibial plateau [78]. Patellofemoral views evaluate patellofemoral alignment (tilt/subluxation), patellar and trochlear morphology, osteochondral injury, and patellofemoral arthritis [78]. A notch view is used to assess posterior femoral cartilage, notch width, and osteophytes [78]. In osteoarthritis, radiographs may identify subchondral sclerosis, joint space narrowing, subchondral cysts (variable), osteophytes (variable), and joint subluxation [78]. Radiographs may also identify subchondral radiolucency in osteochondral defects, which is most common in the medial femoral condyle [78]. Although radiographs can underestimate isolated chondral lesions, they may demonstrate joint space narrowing, osteophytes, sclerosis, and cysts [80]. Long leg alignment views are used to determine the mechanical axis [80]. If the mechanical axis traverses the involved compartment (varus knees with medial compartment lesions or valgus knees with lateral compartment lesions), realignment may need to be considered as an initial procedure or as an adjunct to a cartilage restorative procedure [80].

MRI: MRI may identify the degree of articular cartilage injury (chondrosis, full-thickness cartilage loss), the presence of associated bone marrow edema, and the location (medial condyle, lateral condyle, trochlea, patella; anterior, posterior) [78]. MRI can also be used to evaluate articular cartilage morphology [80].

CT: Three-dimensional CT reconstructions may help with preoperative planning for multiplanar osteotomy for limb malalignment [78]. Axial plane imaging of the knee can help assess the rotational alignment of components of a total knee arthroplasty in cases of patellar maltracking [78].

Bone scan: SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy [70]. Open wedge high tibial osteotomy led to a significant decrease in bone tracer uptake of the medial compartment, which correlated well with knee pain and postoperative mechanical alignment [64].

Other Considerations: Physical examination along with radiographic or advanced imaging findings must be used concomitantly to determine the source of each patient’s symptoms, and to determine appropriate surgical intervention when nonsurgical measures have failed [73]. The authors recommend that possible alterations in tibial slope and leg length are considered when the technique of high tibial osteotomy is to be chosen [17]. The technique of arthroscopic and computer-assisted high tibial osteotomy using standard total knee arthroplasty navigation software provides intraoperative real-time guidance of the degree of correction that is accurate and reliable [21].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physiotherapy, or pharmacological interventions. High tibial osteotomy is indicated for patients who have failed non-operative management or for whom total knee arthroplasty is an imperfect long-term solution [10].

Operative

Indications: High tibial osteotomy is indicated for appropriately selected patients, particularly physiologically young, active patients with unicompartmental knee disease for whom total knee arthroplasty is an imperfect long-term solution [10]. The ideal candidate is a patient younger than 60 years with isolated medial osteoarthritis, good range of motion, and no ligamentous instability [59]. The procedure is reserved for patients with strenuous occupations or those wishing to continue sports, whereas total knee arthroplasty is considered more suitable for patients over sixty years old [28]. Lateral opening wedge high tibial osteotomy is a viable option for patients with lateral knee pain and valgus malalignment requiring small degrees of correction [167]. This procedure remains underutilized but warrants consideration in appropriately selected patients [10].

Surgical Approach / Technique: The open-wedge technique in combination with fixed-angle plates is recommended for high tibial osteotomy [63]. Medial opening wedge high tibial osteotomy is a highly accurate procedure that allows precise frontal alignment correction and prevents alteration of the tibial slope [31]. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence [43]. Proper posterior cortical osteotomy is the key step to preventing increased tibial slope, and a preserved lateral hinge is a prerequisite for successful surgery [81]. Technical modifications improve the safety and reproducibility of the procedure [42]. The goal of modified medial open-wedge high tibial osteotomy is the combined correction of a double varus deformity (mechanical medial proximal tibia angle, joint line convergence angle >2°) and an increased posterior tibial slope >12° [41]. Anterior opening-wedge high tibial osteotomy aims to correct limb sagittal alignment and provide stability to the knee joint [62]. Derotational hybrid closed-wedge high tibial osteotomy involves internal rotation of the distal tibia at the osteotomized site to reduce the tibial tuberosity-trochlear groove distance [171]. Lateral opening wedge high tibial osteotomy involves an oblique skin incision between the anterior portion of the fibular head and the tibial tubercle, followed by a biplanar tibial osteotomy [174]. Anterior open-wedge osteotomy to correct sagittal and coronal malalignment involves a midline incision medial to the tibial tuberosity and detachment of a 7-cm bone block of the tibial tubercle with the attached patellar tendon [178]. An acute oblique osteotomy and suture ligation procedure to shorten the fibula in lateral closing-wedge high tibial osteotomy can be completed within 10 minutes or less [183].

Implant Selection: Implant design strongly influences stability after opening wedge valgus high tibial osteotomy, with short designs being inferior to longer designs [147].

Alignment / Balancing Strategy: If proper alignment is obtained, the procedure provides satisfactory pain relief for a lengthy period with little deterioration after the third year [91]. Open-wedge high tibia osteotomy provides a satisfactory solution for constitutional high tibia vara with minor morbidity in the short-term follow-up period [49]. High tibial osteotomy for unilateral medial knee osteoarthritis unloads the osteoarthritic area, gives pain relief, and may prevent later osteoarthritis if performed for the ideal indications [160]. Both closing wedge and open wedge techniques allow good to excellent functional outcomes, significant pain reduction, and high patient satisfaction while correcting varus limb malalignment and metaphyseal tibial varus in patients with medial compartment osteoarthritis [184].

Pain Management: Intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively [186].

Adjuncts: The described technique for treating osteochondral defects can be used alongside high tibial osteotomy when malalignment is present [23]. A method of transtibial drilling can be combined with high tibial osteotomy without additional incisions [14]. The use of high tibial osteotomy has extended the indication for ligament reconstruction, which, when combined, may ultimately halt the evolution of arthritis and preserve the natural knee joint for a longer period of time [36]. Performing an anatomical double-bundle anterior cruciate ligament reconstruction on knees after valgus high tibia osteotomy may overconstrain the knee and result in high forces in the posterolateral graft, which could predispose it to failure [169]. The surgical technique for slope-reducing high tibial osteotomy and over-the-top anterior cruciate ligament reconstruction involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy [90].

Setting of Care: There is a longer length of stay in hospital in patients who are converted from high tibial osteotomy to total knee arthroplasty compared to primary total knee arthroplasty [182].

Revision: Total knee arthroplasty after high tibial osteotomy seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no high tibial osteotomy previously [25]. The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results [30]. Postoperative knee instability due to posterior cruciate ligament insufficiency contributes to the inferior results of posterior cruciate-retaining prostheses after high tibial osteotomy, making posterior cruciate-substituting total knee arthroplasty suitable for use after high tibial osteotomy [65]. There are no differences in postoperatively patient-reported outcome measures between patients who were converted from high tibial osteotomy to total knee arthroplasty versus primary total knee arthroplasty [182]. There is no difference related to patellar height between patients converted from high tibial osteotomy to total knee arthroplasty and those undergoing primary total knee arthroplasty [182].

Other Considerations: With a 54.1% survival after 18 years, high tibial osteotomy is a useful facility to protract the implantation of a total knee prosthesis [58]. Opening-wedge high tibial osteotomy has a higher rate of adverse events compared to closing-wedge osteotomy, particularly persistent pain at the iliac crest [71]. High tibial osteotomy modifies patellar height depending on the technique employed [84]. Distal high tibial osteotomy allows improved patellofemoral joint preservation but results in increased posterior tibial slope compared to proximal high tibial osteotomy [45]. The presence of preoperative subchondral bone marrow edema may have a negative effect on postoperative pain and subjective outcome after medial open wedge high tibial osteotomy [187]. Patients with non-union following high tibial osteotomy for osteoarthritis of the knee should undergo resection of the pseudarthrosis and transfixation compression as the treatment of choice [136]. The postoperative regimen for lateral closing wedge osteotomies must include 6 months of partial weightbearing, then full weightbearing if radiological consolidation of the fracture is visible [59]. Implant removal after medial opening wedge high tibial osteotomy is a safe procedure that improves symptoms and functional scores, with improved rates of bone healing and no loss of correction after 1 year postoperatively [69]. As there is no significant alteration in tibial slope after high tibial osteotomy performed with the Ilizarov system, complications due to alteration in tibial slope will not be experienced in follow-up or in further total knee prosthesis procedure [145].

Complications

General Complication Rates: Postoperative complication rates after high tibial osteotomy are expected to be in the range of 10% to 15% [139]. In a series of 100 consecutive cases, the rate of complications was low and approximately two-thirds of the knees had a good or excellent clinical result at an average of 8.5 years [204]. A low rate of serious complications (6.5%) requiring unplanned additional surgery was found in a study using the Tomofix locking plate [141]. In a prospective study of 101 operated knee joints, 5 patients died and 6 could not be traced, resulting in a retrieval rate of 94% [38]. In a cohort of young and active patients, 4 major complications (6.7%) with hospital admissions were registered [105]. In the same cohort of young and active patients, 3 minor complications (5.0%) were registered [105]. In a series of 136 knees treated with oblique high tibial osteotomy, there were 11 complications [151]. In a 15-year experience from a single academic institution, three intraoperative complications (1.2%) involving fracture were recorded [164].

Nonunion and Healing: Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies [211]. Nonunions can occur after osteotomy and are more common with opening wedge osteotomies, particularly those with larger corrections [125]. Nonunion, loss of correction, and implant failure are more common in patients managed with opening wedge osteotomies compared with closing wedge osteotomies [125]. In a study of 23 patients with delayed bone healing following high tibial osteotomy, cortical deficiency was present in 14 cases and clear gaps were observed in 9 cases [113]. Union rates and nonunion characteristics of fibular osteotomies differ according to the level of osteotomy, apposition of bone ends, and type of accompanying high tibial osteotomy [60].

Thromboembolism: The overall incidence of early DVT after OWHTO was 44.7%, with thrombi found particularly around the osteotomy site [159]. This study identified a high incidence of DVT following MOWHTO and demonstrated that female sex, diabetes and hyperlipidemia were significant risk factors [199]. Patients undergoing CWHTO are at risk of postoperative VTE [200]. The overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis, suggesting routine chemoprophylaxis may not be necessary in this population [201]. In a series of 136 knees, five patients developed deep vein thrombosis [151]. These findings indicate that considering the possibility of coincidental paradoxical embolism after orthopaedic surgery is important [202].

Nerve and Vascular Injury: Peroneal nerve injury most often is related to fibular osteotomy performed in conjunction with proximal tibial osteotomy [57]. Peroneal nerve complications are found to occur more commonly in closing wedge osteotomies [125]. In a series of 250 high tibial osteotomies, the popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique [163]. In the same series of 250 high tibial osteotomies, a tibial nerve paresis occurred in 1 patient [163]. In the same series of 250 high tibial osteotomies, temporary palsy of the anterior tibialis muscle was documented in 3 patients [163]. In the same series of 250 high tibial osteotomies, palsy of the extensor hallucis longus occurred in 4 patients [163]. The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles [163]. Damage to the popliteal artery or tibial nerve can occur only by placing the Hohman retractor behind the muscles [163]. In a cohort of young and active patients, one case of a common peroneal nerve deficit that resolved spontaneously was registered [105]. In a series of 136 knees, two patients experienced temporary peroneal nerve dysfunction [151]. In a study of medial closing wedge high tibial osteotomy for lateral osteoarthritis, a high rate of transient peroneal nerve palsy was reported in a comparable study of lateral opening osteotomies [161].

Infection: Postoperative complication rates include infection at a rate of 2.9% [139]. In a series of 136 knees, four patients developed superficial wound infection [151]. In a cohort of young and active patients, one case of a deep infection treated with debridement and antibiotic therapy was registered [105]. In the same cohort of young and active patients, 2 cases of superficial surgical wound infections were registered [105]. The use of artificial bone graft and longer anaesthesia duration were identified as risk factors for surgical site infection after high tibial osteotomy [205]. Primary diagnosis of osteonecrosis and younger age were identified as protective factors for surgical site infection after high tibial osteotomy [205]. In a study of medial closing wedge high tibial osteotomy for lateral osteoarthritis, one infection resolved with treatment [161].

Loss of Correction and Deformity Recurrence: Coventry attributed the recurrence to inadequate correction at the time of surgery and suggested that overcorrection beyond the normal 5 degrees of anatomic valgus decreased the frequency of this complication [57]. Postoperative complication rates include loss of correction at a rate of 1.2% [139]. In a cohort of young and active patients, one case of residual varus-valgus instability with subsequent surgery was registered [105].

Patellar Issues: Factors that may cause patella baja include shortening of the patellar tendon after prolonged immobilization, new bone formation at the site of the osteotomy in the area of the insertion of the patellar tendon, and fibrosis of the patellar tendon [57]. Windsor et al. observed that 80% of patients who had a TKA and a previous high tibial osteotomy had patella infera [101]. Scarring and shortening of the patellar ligament often prevents eversion of the patella, and surgical exposure may require specialized exposure techniques during a subsequent TKA [101]. Patella baja was found to be more common after high tibial osteotomy [106].

Hardware and Implant Issues: 21 reoperations (35.0%) were recorded in a cohort of young and active patients, including 20 cases (33.3%) of plate removal for intolerance in patients who underwent medial OW-HTO [105]. Hardware removal was reported for 43 (67.2%) patients in a study of medial closing wedge high tibial osteotomy for lateral osteoarthritis [161]. In a study of 23 patients with delayed bone healing, hardware removal times ranged from 13 to 55 months [113]. In a series of 101 operated knee joints, the plate and the screw were removed easily by a 1–2-cm incision one year after surgery [38].

Other Considerations: Intraoperative fractures of the hinge, either medially or laterally, can impair stability, healing, and potentially disrupt the articular surface [125]. Other potential complications include infection, venous thromboembolic events, and compartment syndrome [125]. In a study of medial closing wedge high tibial osteotomy for lateral osteoarthritis, two intraoperative lateral hinge fractures (2.9%) occurred requiring additional staple fixation [161]. In the same study of medial closing wedge high tibial osteotomy, one case of complex regional pain syndrome was noted [161]. In a cohort study of anterior open wedge high tibial osteotomy for slope correction, a mild extension deficit was observed in three patients [162]. In the same cohort study of anterior open wedge high tibial osteotomy, no cases of infection, loss of correction, implant failure or revision surgery for recurrent instability were recorded [162]. In a cohort of young and active patients, one case of postoperative arterial bleeding treated with embolization was registered [105]. In the same cohort of young and active patients, 1 case of residual stiffness that was managed nonoperatively was registered [105].

Recovery

Rehabilitation protocol: Rehabilitation following medial opening-wedge high tibial osteotomy (MOWHTO) is guided by absolute knee extensor strength rather than limb symmetry, which defines the threshold for progression [126]. In protocols utilizing a medial locked plate system, full weight-bearing walking commences at 6 weeks postoperatively [119]. Surgeons must account for the increase in deviation of the mechanical axis and femorotibial angle after weight-bearing when planning the rehabilitation trajectory [68].

Functional milestones: High tibial osteotomy effectively unloads the knee medial compartment and redistributes internal loads between the medial and lateral compartments during walking and stair tasks [131]. In active patients with medial compartment knee osteoarthritis, the procedure yields favorable clinical results, allowing return to sports and recreational activities similar to preoperative levels [111]. Most patients return to sport at a level equal to or greater than the preoperative level [197]. In young, high-demand populations, 54.5% of knees returned to full duty without restriction, although 36.4% required reoperation [198].

Other Considerations: Large medial opening wedge osteotomies increase gastrocnemius tension, causing transient knee flexion contracture that resolves clinically but highlights soft-tissue adaptation during recovery [123]. Patients may experience progression of patellofemoral osteoarthritis after the procedure [128]. Type I and II lateral hinge fractures managed with a relatively conservative rehabilitation protocol showed no radiologic changes or functional deterioration during midterm followup [119]. Long-term data indicate that HTO is a reliable treatment with a survival rate of over 96% at 5 years [11] and high survival rates at 5 and 10 years in experienced hands [39]. While effective for periods longer than 15 years, results do deteriorate over time [3]. A previous high tibial osteotomy does not influence the function or survival of a knee long term [9], and clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous HTO are not substantially different [20].

Key Evidence

• [L1] High tibial osteotomy offers satisfactory pain relief and functional outcome in selected patients with high activity demand. [1] (10.1186/s12891-020-3177-9)
• [L4] Medial opening high tibial osteotomy achieved union in 93% of cases. [2] (10.1016/j.arthro.2014.04.013)
• [L4] High tibial osteotomy can be effective for periods longer than 15 years; however, results do deteriorate over time. [3] (10.1177/0363546510377445)
• [L3] A previous high tibial osteotomy was not determinant for having a worse outcome at total knee replacement, even when there were radiographic differences. [4] (10.1007/s00264-018-3837-7)
• [L4] Observational studies suggest that high tibial osteotomy can substantially improve outcome measures important to knee joint structure and function, patient quality of life, and health care systems, yet high-level evidence comparing it with alternate treatments is required for stronger recommendations. [5] (10.1016/j.csm.2019.02.001)
• [L5] The high tibial osteotomy procedure is standardized, safe, and reliable when taking care of correct preoperative planning and intraoperative procedure. [6] (10.1016/j.arthro.2018.08.016)
• [L3] As a consequence, the age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy. [7] (10.1007/s00167-012-2016-4)
• [L4] Infections after high tibial osteotomy are rare. [8] (10.1007/s00167-012-2084-5)
• [L4] Our observations suggest a previous high tibial osteotomy does not influence the function or survival of a knee long term. [9] (10.1007/s11999-011-1810-5)
• [L5] High tibial osteotomy is an underutilized procedure that warrants consideration in appropriately selected patients, particularly physiologically young, active patients with unicompartmental knee disease, for whom total knee arthroplasty is an imperfect long-term solution. [10] (10.5435/00124635-201110000-00003)
• [L4] With a survival rate of over 96% at 5 years, high tibial osteotomy seems to be a reliable treatment option with satisfying clinical outcome. [11] (10.1007/s00167-013-2762-y)
• [L3] Patients should be counseled that if high tibial osteotomy fails, a subsequent total knee arthroplasty will be more difficult and may perform less well and/or be more liable to failure. [12] (10.1016/j.arth.2006.01.031)
• [L4] High tibial osteotomy remains an attractive option for young and active patients to delay knee arthroplasty, with a survival rate of 85% at 20 years. [13] (10.1097/01.blo.0000229362.12244.f6)
• [L5] This method can be combined with high tibial osteotomy without additional incisions. [14] (10.1016/j.eats.2025.103533)
• [L5] High tibial osteotomy is preferred in younger, more active patients and has been shown to be the most cost-effective treatment modality in this population. [16] (10.1016/j.csm.2019.02.006)
• [L1] The authors recommend that possible alterations in tibial slope and leg length are considered when the technique of high tibial osteotomy is to be chosen. [17] (10.1007/s00167-015-3817-z)
• [L4] The most suitable candidates for high tibial osteotomy are aged less than 55 years, are not obese, and have not progressed to severe symptomatic disability. [18] (10.1177/03635465231217742)
• [L5] High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee. [19] (10.1177/2325967121s00858)
• [L3] The present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different. [20] (10.2106/00004623-200009000-00005)
• [Paper] The technique provides intraoperative real-time guidance of the degree of correction that is accurate and reliable, representing a useful tool for the surgeon who uncommonly performs high tibial osteotomy. [21] (10.1016/j.eats.2013.01.009)
• [L4] A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates for high tibial osteotomy. [22] (10.1002/ksa.12156)
• [Paper] The authors recommend the described technique for treating osteochondral defects alongside high tibial osteotomy when malalignment is present, but encourage further studies focused on the assessment and validation of the technique. [23] (10.1016/j.eats.2017.07.026)
• [L2] High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique. [24] (10.1007/s00167-011-1785-5)
• [L3] Total knee arthroplasty after high tibial osteotomy seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no high tibial osteotomy previously. [25] (10.1186/1471-2474-8-74)
• [L3] However, the clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy. [26] (10.1186/s12891-019-2607-z)
• [Paper] In appropriately indicated patients, medial opening-wedge high tibial osteotomy is widely accepted to produce good outcomes for younger, active patients with symptomatic medial compartment osteoarthrosis. [27] (10.1016/j.csm.2019.02.003)
• [L3] Total knee arthroplasty is now considered more suitable for patients over sixty years old, while high tibial osteotomy should be reserved for patients with strenuous occupations or those wishing to continue sports. [28] (10.2106/00004623-198466070-00010)
• [L5] Most studies have failed to show improved clinical outcomes in the short term when adding cartilage restoration procedures to high tibial osteotomy, raising questions about whether longer term studies will show improved efficacy. [29] (10.1016/j.arthro.2023.07.002)
• [L4] The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results. [30] (10.1007/s00264-011-1373-9)
• [L4] The reported surgical technique of medial opening wedge high tibial osteotomy is a very accurate procedure that allows an accurate frontal alignment correction and prevents alteration of the tibial slope. [31] (10.1007/s00167-008-0717-5)
• [L4] After open-wedge high tibial osteotomy, clinical results showed improvement compared to pre-operative values. [32] (10.1007/s00167-014-3349-y)
• [L3] More than 8 of 10 patients returned to sport after high tibial osteotomy. [34] (10.1177/0363546519849476)
• [L1] The meta-analysis showed that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months. [35] (10.1007/s00402-003-0545-5)
• [L4] The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction which, when combined, may ultimately halt the evolution of arthritis and preserve their natural knee joint for a longer period of time. [36] (10.1302/2058-5241.1.000001)
• [L3] High tibial osteotomy should be selected with careful consideration of the osteoarthritic status of the patellofemoral joint and required correction angle, regardless of applying a closed- or open-wedge technique. [37] (10.1177/0363546520943872)
• [L3] [38] (10.1007/s00402-002-0446-z)
• [L4] Medial opening wedge high tibial osteotomy (MOWHTO) is a radiologically and clinically rewarding procedure with a high survival rate at 5 and 10 years and a low complication rate in experienced hands. [39] (10.1016/j.jisako.2025.100703)
• [L3] The rate of peroneal nerve lesions after high tibial osteotomy is higher than that detected clinically, with electrophysiological means revealing lesions that may be overlooked by mild weakness and hypesthesia. [40] (10.1007/s001670000138)
• [L5] The goal of the modified medial open-wedge high tibial osteotomy is the combined correction of a double varus deformity (mechanical medial proximal tibia angle ◦, joint line convergence angle >2◦) and an increased posterior tibial slope >12◦. [41] (10.1016/j.eats.2025.103969)
• [L4] The presented technical modifications improve the safety and reproducibility of high tibial osteotomy. [42] (10.1007/s00167-002-0334-7)
• [L4] Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. [43] (10.1177/0363546510388929)
• [L3] Medial opening high tibial osteotomy shows remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity, and it can effectively relief the pain of knee joint with less postoperative complications. [44] (10.1177/2325967120s00543)
• [L3] Distal high tibial osteotomy (DTO) allows improved patellofemoral joint preservation but results in increased posterior tibial slope compared to proximal high tibial osteotomy (PTO). [45] (10.1016/j.arthro.2025.05.017)
• [L5] These kinematic changes should be considered when selecting the surgical technique for patients with medial osteoarthritis. [46] (10.1007/s00167-007-0305-0)
• [L5] Instability at the osteotomy site may contribute to the high rate of delayed union or nonunion associated with medial opening wedge high tibial osteotomy. [47] (10.1177/0363546505275488)
• [L4] The study confirmed that clinical outcome is good with no differences between closing-wedge and opening-wedge high tibial osteotomy, except for more frequent late complications with closing-wedge osteotomy. [48] (10.1016/j.otsr.2017.07.011)
• [L4] Open-wedge high tibia osteotomy provides a satisfactory solution for constitutional high tibia vara with minor morbidity on behalf of the patient in the short-term follow-up period. [49] (10.1007/s00167-010-1148-7)
• [L5] Tibial osteotomy can successfully alleviate knee pain in the management of malalignment associated with knee arthrosis in young or active patients. [51] (10.1016/j.csm.2009.12.005)
• [Paper] [54] (10.1016/j.eats.2018.06.005)
• [Paper] It achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope. [55] (10.1016/j.eats.2017.08.009)
• [L3] [56] (10.1186/s12891-021-04475-3)
• [Paper] With a 54.1% survival after 18 years, high tibial osteotomy is a useful facility to protract the implantation of a total knee prosthesis. [58] (10.1007/s00402-007-0438-0)
• [Paper] [59] (10.1016/j.csm.2019.02.002)
• [L3] Union rates and nonunion characteristics of fibular osteotomies differ according to the level of osteotomy, apposition of bone ends, and type of accompanying high tibial osteotomy. [60] (10.1007/s00402-016-2493-x)
• [L3] [61] (10.1302/0301-620x.99b7.bjj-2016-0927.r1)
• [L5] The surgical technique aims to correct the limb sagittal alignment and provide stability to the knee joint, with the ultimate goal of improving patient outcomes. [62] (10.1016/j.eats.2023.06.007)
• [L3] The authors recommend the open-wedge technique in combination with fixed-angle plates for high tibial osteotomy. [63] (10.1007/s00167-009-1020-9)
• [L3] Open wedge high tibial osteotomy led to a significant decrease in bone tracer uptake of the medial compartment, which correlated well with knee pain and postoperative mechanical alignment. [64] (10.1016/j.arthro.2017.08.123)
• [L3] Postoperative knee instability due to posterior cruciate ligament insufficiency contributes to the inferior results of posterior cruciate-retaining prostheses after high tibial osteotomy, making posterior cruciate-substituting total knee arthroplasty suitable for use after high tibial osteotomy. [65] (10.1007/s00167-009-0790-4)
• [L4] When performing the open wedge high tibial osteotomy, the surgeon should consider the increase in deviation of the mechanical axis and femorotibial angle after weight-bearing. [68] (10.1007/s00167-009-1000-0)
• [L5] Implant removal after medial opening wedge high tibial osteotomy is a safe procedure that improves symptoms and functional scores, with improved rates of bone healing and no loss of correction after 1 year postoperatively. [69] (10.1016/j.arthro.2024.01.010)
• [L2] SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy. [70] (10.1007/s00167-014-3053-y)
• [L3] Opening-wedge high tibial osteotomy has a higher rate of adverse events compared to closing-wedge osteotomy, particularly persistent pain at the iliac crest. [71] (10.1007/s00167-015-3644-2)
• [L5] Proper posterior cortical osteotomy is the key step to preventing increased tibial slope in open-wedge high tibial osteotomy, and a preserved lateral hinge is a prerequisite for successful surgery. [81] (10.1016/j.arthro.2021.03.082)
• [L3] High tibial osteotomy modifies patellar height depending on the technique employed. [84] (10.1007/s002640000173)
• [L3] HTO resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment. [88] (10.1007/s00167-011-1496-y)
• [L5] The surgical technique involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy. [90] (10.1016/j.eats.2022.07.019)
• [L3] Preoperative gait characteristics, specifically the knee adduction moment, are predictive of postoperative clinical results; patients with lower preoperative adduction moments had substantially better clinical outcomes. [92] (10.2106/00004623-198567080-00007)
• [L5] Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. [93] (10.1002/ksa.12577)
• [L3] These findings are consistent with an intended, sustained shift in the mediolateral distribution of knee loads. [94] (10.1177/0363546515591995)
• [L3] These kinematic changes correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed. [95] (10.1177/2325967116s00039)
• [L5] Tibial flexion osteotomy significantly affects cartilage pressure and kinematics of the knee joint. [96] (10.1007/s00402-004-0728-8)
• [L2] The difference in post-operative angular deformities of the proximal tibia between closing wedge and opening wedge high tibial osteotomy was considered clinically irrelevant. [98] (10.1007/s00167-016-4074-5)
• [L5] High Tibial Osteotomy is an effective approach to alleviate symptoms, correct alignment, improve stability, and preserve meniscal tissue and cartilage in sport-related cases, though careful patient selection and evaluation are essential to maximize successful outcomes. [100] (10.1177/2325967124s00386)
• [L4] [101] (10.1007/s00167-004-0572-y)
• [L4] [104] (10.1007/s00167-023-07518-5)
• [L4] [105] (10.1177/03635465251322795)
• [L3] [106] (10.1007/s00402-007-0488-3)
• [L4] [108] (10.1002/ksa.12807)
• [L4] [109] (10.1007/s00167-012-2289-7)
• [L4] High tibial osteotomy for the treatment of medial compartment knee osteoarthritis in the active patient demonstrated favorable clinical results and allowed patients to return to sports and recreational activities similar to the preoperative level. [111] (10.1177/0363546508325666)
• [L5] The non-anchored free-floating device remains within the medial knee joint gap under challenging dynamic loading situations without indicating any luxation tendencies. [112] (10.1186/s40634-023-00576-1)
• [L4] [113] (10.1016/j.injury.2014.04.018)
• [L4] [114] (10.1002/ksa.12099)
• [L4] [116] (10.1186/s12891-024-08022-8)
• [L5] This effect is amplified as the knee flexion angle increases. [118] (10.1177/2325967123s00049)
• [L4] Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a medial locked plate system and relatively conservative rehabilitation protocol with full weight-bearing walking commenced at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm followup. [119] (10.1016/j.arthro.2018.07.022)
• [L5] The position of the loading axis in the frontal plane has a strong effect on the tibiofemoral cartilage pressure distribution of the knee. [120] (10.1016/j.arthro.2007.05.018)
• [L5] Future clinical studies have to prove the effect of MOWHTO on patellar kinematics measured in this experimental setup, especially regarding its influence on anterior knee pain. [121] (10.1007/s00402-020-03578-1)
• [L4] Large medial opening wedge high tibial osteotomy increases gastrocnemius tension, causing transient knee flexion contracture; effects resolve clinically but highlight soft-tissue adaptation in recovery. [123] (10.1016/j.jisako.2026.101146)
• [L4] Radiographic analysis demonstrated increased hip-knee-ankle (HKA) angles and percentage of mechanical axis (%MA), along with reduced femorotibial angle (FTA). [124] (10.1177/23259671261450211)
• [L5] [125] (10.5435/jaaos-d-23-00323)
• [L2] Absolute knee extensor strength, not limb symmetry, predicts outcomes and defines a rehabilitation threshold after medial opening-wedge high tibial osteotomy. [126] (10.1002/ksa.70535)
• [L5] This combined approach enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment, potentially improving long-term outcomes compared with isolated procedures. [127] (10.1002/atn2.70123)
• [L1] Patients appear to have progression of patellofemoral osteoarthritis after medial open-wedge high tibial osteotomy. [128] (10.1016/j.arthro.2021.04.015)
• [L1] High tibial osteotomy effectively unloads the knee medial compartment and redistributes knee internal loads between the medial and lateral compartments during walking and stair tasks. [131] (10.1002/ksa.70348)
• [L1] The magnitude of change after open- and closed-wedge HTO was similar and small (approximately 2°), suggesting that both osteotomy techniques may have little effect on the biomechanics of the cruciate ligaments. [132] (10.1177/0363546515626172)
• [L2] There was no change in sagittal plane knee moment, including flexion and extension moments, from before to after medial open wedge HTO. [134] (10.1186/s12891-019-2472-9)
• [L4] Patients with non-union following high tibial osteotomy for osteoarthritis of the knee should undergo resection of the pseudarthrosis and transfixation compression as the treatment of choice. [136] (10.2106/00004623-197860070-00018)
• [L3] In pre-operative varus knee, the mean mechanical axis on single-limb stance was more varus than on double-limb stance, whereas it changed to less valgus in post-operative valgus knee. [137] (10.1007/s00264-016-3279-z)
• [L4] This technique offered the advantage of preserving the posterior tibial slopes postoperatively even in highly deformed knees which necessitated higher degrees of corrections in the mechanical axes. [138] (10.1177/2325967117s00052)
• [L4] Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). [139] (10.1177/03635465221142868)
• [L3] Three-dimensional kinematic analysis detects changes due to HTO that standard radiographs do not identify, including changes in the PF joint. [140] (10.1016/j.arthro.2013.07.039)
• [L4] A low rate of serious complications (6.5%) requiring unplanned additional surgery was found. [141] (10.1007/s00167-020-06199-8)
• [L3] [142] (10.1016/j.jisako.2026.101204)
• [L2] Gait adaptations known to reduce knee loading employed pre-HTO were not retained post-HTO. [143] (10.1007/s00167-019-05644-7)
• [L3] [144] (10.1302/0301-620x.99b10.bjj-2017-0103.r1)
• [L4] As there is no significant alteration in tibial slope after high tibial osteotomy performed with the Ilizarov system, complications due to alteration in tibial slope will not be experienced in follow-up or in further total knee prosthesis procedure. [145] (10.1007/s00167-006-0151-5)
• [L5] The results show that implant design strongly influences stability after opening wedge valgus high tibial osteotomy, with short designs being inferior to longer designs. [147] (10.1007/s00167-005-0690-1)
• [L5] When considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its favorable post-operative knee kinematics. [149] (10.1177/2325967114s00052)
• [L4] [151] (10.1007/s00167-006-0053-6)
• [L3] Both techniques resulted in smaller changes in leg length than predicted by mathematical models. [152] (10.1177/0363546511410025)
• [L5] When considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its favorable postoperative knee kinematics. [153] (10.1016/j.arthro.2014.04.068)
• [L5] This biomechanical study confirms the hypothesis that an HTO improves the peak pressures in the medial compartment at all degrees of varus/valgus alignment in the setting of meniscal transplantation. [154] (10.1055/s-0031-1275401)
• [L4] For smaller corrections in the coronal plane, more extreme hinge axis positions were necessary to achieve higher magnitudes of posterior tibial slope reduction. [156] (10.1177/23259671221094346)
• [L5] The authors propose that limb realignment surgery (HTO) should be considered earlier in the treatment algorithm for patients with varus alignment and degenerative meniscal tears to address the underlying biomechanical problem. [158] (10.1016/j.csm.2019.02.010)
• [L3] The overall incidence of early DVT after OWHTO was 44.7%, with thrombi found particularly around the osteotomy site. [159] (10.1177/23259671211030883)
• [L5] High tibial osteotomy for unilateral medial knee osteoarthritis unloads the osteoarthritic area, gives pain relief, and may prevent later osteoarthritis if performed for the ideal indications. [160] (10.1016/j.arthro.2019.10.039)
• [L4] [161] (10.1002/ksa.70176)
• [L4] [162] (10.1002/ksa.70522)
• [L4] [163] (10.1007/s001670050114)
• [L4] [164] (10.1177/03635465231183092)
• [L4] Lateral opening wedge high tibial osteotomy is a viable surgical option for patients with lateral knee pain and valgus malalignment requiring small degrees of correction. [167] (10.1007/s00167-012-2070-y)
• [L4] [168] (10.5435/jaaos-d-23-01114)
• [L5] Performing an anatomical double-bundle anterior cruciate ligament reconstruction on knees after valgus high tibia osteotomy may overconstrain the knee and result in high forces in the posterolateral graft, which could predispose it to failure. [169] (10.1177/0363546505283269)
• [L5] [171] (10.1016/j.eats.2023.05.017)
• [L4] [173] (10.1007/s00167-018-4977-4)
• [Paper] [174] (10.1016/j.csm.2019.02.012)
• [L5] [178] (10.1016/j.eats.2024.103032)
• [L3] [182] (10.1016/j.jisako.2025.100931)
• [Paper] [183] (10.1016/j.eats.2020.05.008)
• [L3] Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis. [184] (10.1002/ksa.12026)
• [L1] This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively. [186] (10.1016/j.arthro.2014.04.104)
• [L3] The presence of preoperative subchondral bone marrow edema may have a negative effect on postoperative pain and subjective outcome after medial open wedge high tibial osteotomy. [187] (10.1016/j.arthro.2017.08.121)
• [L1] [188] (10.1016/j.jisako.2025.101035)
• [L5] [189] (10.1007/s00167-014-3100-8)
• [L4] [191] (10.1016/j.jisako.2024.02.015)
• [L4] [192] (10.1007/s00167-019-05445-y)
• [L5] [193] (10.1136/jisakos-2020-000575)
• [L5] [194] (10.1007/s00167-012-2122-3)
• [L4] Most patients return to sport at a level equal to or greater than the preoperative level. [197] (10.2106/jbjs.16.00036)
• [L4] In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. [198] (10.1177/23259671241252410)
• [L3] This study identified a high incidence of DVT following MOWHTO and demonstrated that female sex, diabetes and hyperlipidemia were significant risk factors. [199] (10.1186/s12891-025-08713-w)
• [L2] Patients undergoing CWHTO are at risk of postoperative VTE. [200] (10.1016/j.otsr.2017.07.016)
• [L2] The overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis, suggesting routine chemoprophylaxis may not be necessary in this population. [201] (10.1055/s-0039-1700976)
• [L5] These findings indicate that considering the possibility of coincidental paradoxical embolism after orthopaedic surgery is important. [202] (10.5435/jaaosglobal-d-19-00044)
• [L4] In this series, the rate of complications was low and approximately two-thirds of the knees had a good or excellent clinical result at an average of 8.5 years. [204] (10.2106/00004623-200001000-00009)
• [L3] The study revealed novel risk factors for surgical site infection after high tibial osteotomy, including the use of artificial bone graft and longer anaesthesia duration, while primary diagnosis of osteonecrosis and younger age were identified as protective factors. [205] (10.1007/s00167-020-05943-4)
• [L4] Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. [211] (10.1016/j.arthro.2015.04.097)

See Also

• Total Knee Replacement
• Distal femoral osteotomy
• ACL reconstruction
• Knee osteoarthritis

References

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[100] High Tibial Osteotomy in Sport-Related Cases. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00386

[101] Evaluation of patellar height and measurement methods after valgus high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-004-0572-y

[104] A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07518-5

[105] Kinesiophobia and High-Impact Sport Activity Are Associated With a Reduced Rate of Return to Sport After High Tibial Osteotomy: A Risk Factor Analysis of a Young and Active Population. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251322795

[106] Mid-term results of total knee arthroplasty after high tibial osteotomy. Archives of Orthopaedic and Trauma Surgery. 2007. DOI: 10.1007/s00402-007-0488-3

[108] The aberrant anterior tibial artery should be respected and can be protected in high tibial osteotomy surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12807

[109] Accelerated degeneration of the discoid lateral meniscus after medial opening wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2289-7

[111] Sporting Activity after High Tibial Osteotomy for the Treatment of Medial Compartment Knee Osteoarthritis. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508325666

[112] Free‐floating medial meniscus implant kinematics do not change after simulation of medial open‐wedge high tibial osteotomy and notchplasty. Journal of Experimental Orthopaedics. 2023. DOI: 10.1186/s40634-023-00576-1

[113] Delayed bone healing following high tibial osteotomy related to increased implant stiffness in locked plating. Injury. 2014. DOI: 10.1016/j.injury.2014.04.018

[114] No clinical outcome difference between varus phenotypes after medial opening‐wedge high tibial osteotomy at 2 years follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12099

[116] Simoultaneous bilateral medial opening wedge high tibial osteotomy can be performed safely and effectively without bone grafting: analysis of a monocentric retrospective series. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08022-8

[118] Paper 23: Taking the Load Off: Effect of Varus Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area in Varying Stages of Knee Flexion. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00049

[119] Extra‐articular Lateral Hinge Fracture Does Not Affect the Outcomes in Medial Open‐Wedge High Tibial Osteotomy Using a Locked Plate System. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.022

[120] The Effects of Valgus Medial Opening Wedge High Tibial Osteotomy on Articular Cartilage Pressure of the Knee: A Biomechanical Study. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.05.018

[121] Medial Open Wedge High tibial Osteotomy (MOWHTO) does not relevantly alter patellar kinematics: a cadaveric study. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03578-1

[123] Large Medial Opening Wedge High Tibial Osteotomy Increases Gastrocnemius Tension: A Cadaveric Study with Clinical Correlation to Early Knee Flexion Contracture. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2026.101146

[124] Effects of Medial Opening-Wedge High Tibial Osteotomy on 3-Dimensional Knee Joint Biomechanics and Trunk Posture. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261450211

[125] High Tibial Osteotomy in Knee Reconstruction and Joint Preservation. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00323

[126] Absolute knee extensor strength, not limb symmetry, predicts outcomes and defines a rehabilitation threshold after medial opening‐wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70535

[127] Concurrent High Tibial Osteotomy, Anterior Cruciate Ligament Reconstruction, and Medial Meniscus Posterior Root Repair. Arthroscopy Techniques. 2026. DOI: 10.1002/atn2.70123

[128] Patellofemoral Osteoarthritis Progresses After Medial Open-Wedge High Tibial Osteotomy: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.04.015

[131] High tibial osteotomy leads to medial‐lateral redistribution of knee internal forces during walking and stair ambulation and improves patient‐reported outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70348

[132] Change in Posterior Tibial Slope After Open-Wedge and Closed-Wedge High Tibial Osteotomy. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515626172

[134] Change in adduction moment following medial open wedge high tibial osteotomy: a meta-analysis. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2472-9

[136] Results of surgical treatment for non-union after high tibial osteotomy in osteoarthritis of the knee.. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860070-00018

[137] Discrepancy of alignment in different weight bearing conditions before and after high tibial osteotomy. International Orthopaedics. 2016. DOI: 10.1007/s00264-016-3279-z

[138] Is it possible to avoid posterior tibial slope increase in open-wedge high tibial osteotomy?. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00052

[139] Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221142868

[140] Paper #35: Opening‐Wedge High Tibial Osteotomy Changes 3D Knee Kinematics. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.039

[141] Low rates of serious complications but high rates of hardware removal after high tibial osteotomy with Tomofix locking plate. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06199-8

[142] Preoperative coronal plane alignment of the knee phenotype does not predict patient-reported outcomes after medial opening-wedge high tibial osteotomy. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2026.101204

[143] High tibial osteotomy results in improved frontal plane knee moments, gait patterns and patient-reported outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05644-7

[144] Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b10.bjj-2017-0103.r1

[145] Tibial slope and high tibial osteotomy using the circular external fixator. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0151-5

[147] Primary stability of four different implants for opening wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-005-0690-1

[149] Closing Wedge and Opening Wedge High Tibial Osteotomy in the ACL Deficient Knee: A Comparison of Stability and Alignment. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00052

[151] The oblique high tibial osteotomy technique without bone removal and with rigid blade plate fixation for the treatment of medial osteoarthritis of the varus knee: medium and long‐term results. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0053-6

[152] The Effect of Medial Opening and Lateral Closing High Tibial Osteotomy on Leg Length. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511410025

[153] Comparison of Stability and Slope Neutralization Between Closing Wedge and Opening Wedge High Tibial Osteotomy in the ACL Deficient Knee. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.068

[154] Biomechanical Evaluation of a High Tibial Osteotomy with a Meniscal Transplant. Journal of Knee Surgery. 2011. DOI: 10.1055/s-0031-1275401

[156] Extreme Hinge Axis Positions Are Necessary to Achieve Posterior Tibial Slope Reduction With Small Coronal-Plane Corrections in Medial Opening Wedge High Tibial Osteotomy. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221094346

[158] Degenerative Meniscal Tears and High Tibial Osteotomy. Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2019.02.010

[159] Patterns and Distribution of Deep Vein Thrombosis and Its Effects on Clinical Outcomes After Opening-Wedge High Tibial Osteotomy. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211030883

[160] Editorial Commentary: High Tibial Osteotomy for Varus Knees With Medial Osteoarthritis May Prevent Total Knee Arthroplasty. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2019.10.039

[161] Medial closing wedge high tibial osteotomy for lateral osteoarthritis in valgus knee offers good long‐term outcomes in patients with normal body mass index. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70176

[162] Anterior open wedge high tibial osteotomy for slope correction as a successful method in PCL insufficiency—Radiological and clinical results of a cohort study. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70522

[163] Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study. Knee Surgery, Sports Traumatology, Arthroscopy. 1999. DOI: 10.1007/s001670050114

[164] Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231183092

[167] A case series of lateral opening wedge high tibial osteotomy for valgus malalignment. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2070-y

[168] Intraoperative Complications in Medial Opening Wedge High Tibial Osteotomy. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01114

[169] Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction after Valgus High Tibial Osteotomy. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505283269

[171] Derotational Hybrid Closed‐Wedge High Tibial Osteotomy for Knee Osteoarthritis With Patellar Subluxation Caused by Tibial Torsional Deformity. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.05.017

[173] Posterior cortical breakage leads to posterior tibial slope change in lateral hinge fracture following opening wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4977-4

[174] The Role of Osteotomy in Chronic Valgus Instability and Hyperextension Valgus Thrust (Medial Closing Wedge Distal Femoral Varus Osteotomy and Lateral Opening Wedge High Tibial Osteotomy). Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2019.02.012

[178] Anterior Open‐Wedge Osteotomy to Correct Sagittal and Coronal Malalignment in a Case of Failed High Tibial Osteotomy and Failed Posterior Cruciate Ligament Reconstruction. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103032

[182] Comparable clinical outcomes after conversion total knee arthroplasty following high tibial osteotomy and primary total knee arthroplasty: A matched cohort study. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100931

[183] An Acute Oblique Osteotomy and Suture Ligation Procedure to Shorten the Fibula in Lateral Closing‐Wedge High Tibial Osteotomy. Arthroscopy Techniques. 2020. DOI: 10.1016/j.eats.2020.05.008

[184] Economic evaluation of high tibial osteotomy: Closing wedge is more cost‐effective than open wedge technique when analysing the KOOS‐12 improvement. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12026

[186] Efficacy of Periarticular Multimodal Drug Injection After Medial Opening‐Wedge High Tibial Osteotomy: A Randomized, Controlled Study. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.104

[187] Paper #157: Does Subchondral Bone Marrow Edema Have Effect on Outcome of Medial Open Wedge High Tibial Osteotomy?. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.121

[188] Combined high tibial osteotomy and root repair improves patient-reported outcomes in medial meniscus posterior root tears: A systematic review and meta-analysis. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2025.101035

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[191] Derotational high tibial osteotomy in cases of anterior knee pain and/or patellofemoral instability: a systematic review. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.02.015

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