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High tibial osteotomy

152 citationsUpdated Oct 2026

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Overview¶

High tibial osteotomy is a standardized, safe, and reliable procedure that offers satisfactory pain relief and functional outcomes in selected patients with high activity demand [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 over total knee arthroplasty for patients with strenuous occupations or those wishing to continue sports, as it serves as a cost-effective modality to delay arthroplasty in this population [16, 29]. Patient age does not restrict the indication for high tibial osteotomy [7].

Clinically, medial opening-wedge high tibial osteotomy is widely accepted to produce good outcomes for younger, active patients with symptomatic medial compartment osteoarthrosis [28]. The procedure demonstrates a survival rate of over 96% at 5 years and 85% at 20 years, with union achieved in 93% of cases [11, 13, 2]. While results can remain effective for periods longer than 15 years, they deteriorate over time [3]. Observational studies suggest that high tibial osteotomy substantially improves outcome measures important to knee joint structure and function, patient quality of life, and health care systems [5]. However, high-level evidence comparing high tibial osteotomy with alternate treatments is required for stronger recommendations [5].

Complications are rare, with infections occurring infrequently [8]. When high tibial osteotomy fails, a subsequent total knee arthroplasty becomes technically more demanding and may perform less well or be more liable to failure [12, 26]. Nevertheless, the clinical outcome of total knee arthroplasty after high tibial osteotomy is almost identical to that of a matched group without prior osteotomy, and a previous high tibial osteotomy is not determinant for worse outcomes at total knee replacement even when radiographic differences exist [26, 4]. The procedure may also be combined with transtibial drilling of cartilage defects without additional incisions [14], and its use can extend the indication for ligament reconstruction to potentially halt the evolution of arthritis [36]. Most studies have failed to show improved short-term clinical outcomes when adding cartilage restoration procedures to high tibial osteotomy [30].

Anatomy & Pathophysiology¶

Biomechanics and Kinematics¶

High tibial osteotomy addresses both mechanical correction and the modulation of the inflammatory environment within the joint [65]. The position of the loading axis in the frontal plane exerts a strong effect on tibiofemoral cartilage pressure distribution [125], while tibial flexion osteotomy significantly affects cartilage pressure and knee joint kinematics [94]. In pre-operative varus knees, the mean mechanical axis on single-limb stance is more varus than on double-limb stance, whereas this axis changes to less valgus in post-operative valgus knees [141]. The effect of high tibial osteotomy on compartment pressures and contact area is amplified as the knee flexion angle increases [122].

Radiographic analysis following medial opening wedge high tibial osteotomy demonstrates increased hip-knee-ankle angles and percentage of mechanical axis, along with a reduced femorotibial angle [128]. Three-dimensional kinematic analysis detects changes due to high tibial osteotomy that standard radiographs do not identify, including alterations in the patellofemoral joint [144]. Regarding sagittal plane mechanics, there is no change in knee moment, including flexion and extension moments, from before to after medial open wedge high tibial osteotomy [138]. The magnitude of change in posterior tibial slope after open- and closed-wedge high tibial osteotomy is similar and small (approximately 2°), suggesting that both techniques may have little effect on the biomechanics of the cruciate ligaments [136]. Conversely, increasing posterior tibial slope in a native knee with intact cruciate ligaments affects 6 DOF knee kinematics and decreases resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [91]. Minor valgus realignment of the proximal tibia does not significantly alter the biomechanics of the ankle [98].

Gait and Functional Outcomes¶

High tibial osteotomy results in the normalisation of several dynamic knee function parameters, such as walking speed, knee flexion, and external knee flexion moment [86]. 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 [90]. Findings from concomitant high tibial osteotomy and ACL reconstruction are consistent with an intended, sustained shift in the mediolateral distribution of knee loads [92]. Gait adaptations known to reduce knee loading employed pre-high tibial osteotomy were not retained post-high tibial osteotomy [149]. There was neither any association between change in knee alignment and change in KOOS pain over time in patients surgically treated for medial knee osteoarthritis by high tibial osteotomy [51].

Patellofemoral Joint and Soft Tissue Effects¶

Most patients develop significant patella baja after proximal tibial osteotomy [55]. 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 [55]. While 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 [55], patella baja is likely to make a subsequent total knee arthroplasty more technically demanding [55]. Kinematic changes in patellar height 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 [93]. Medial open wedge high tibial osteotomy does not relevantly alter patellar kinematics in a cadaveric study setup [126].

Cadaveric findings demonstrate that gastrocnemius recession improved knee extension and ankle dorsiflexion, supporting a biomechanical explanation for transient clinical effects of large medial opening wedge high tibial osteotomy [111]. Femoral trochlear cartilage degeneration can improve after treatment by abrasion arthroplasty combined with open wedge high tibial osteotomy [194]. Neither patellar height nor limb alignment affects improvement of femoral trochlear cartilage after open wedge high tibial osteotomy combined with abrasion arthroplasty [194]. The non-anchored 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 [118].

Deformity Correction and Alignment¶

High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee [20]. Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust [104]. The surgical technique for anterior opening-wedge high tibial osteotomy in the setting of genu recurvatum aims to correct the limb sagittal alignment and provide stability to the knee joint [60]. Limb-length difference adjustment and matching mechanical axes achieved high levels of pain relief and knee function despite a remaining physiological varus deformity in revision dome-shaped osteotomy [133]. Both medial opening wedge and lateral closing wedge high tibial osteotomy techniques resulted in smaller changes in leg length than predicted by mathematical models [157].

The inverted L-shaped configuration of open-wedge valgus high tibial osteotomy achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope [145]. A specific technique for open-wedge high tibial osteotomy 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 [142]. Inadequate correction and recurrent varus deformity have been reported to occur in 5% to 30% of patients with proximal tibial osteotomy [55]. Recurrence of a varus deformity was the most common complication in Coventry's report of 213 proximal tibial osteotomies [55]. 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 [55].

Complications and Anatomical Risks¶

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 [55]. Peroneal nerve injury most often is related to fibular osteotomy performed in conjunction with proximal tibial osteotomy [55]. 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 [55]. Deep peroneal nerve has a potential risk of injury during open-wedge high tibial osteotomy [193]. Popliteal artery injury is rare but devastating [55]. 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 [55].

The incidence of lateral hinge fracture in medial opening wedge high tibial osteotomy may be between 20% and 25% [59]. 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 [59]. Takeuchi et al. described three types of lateral hinge fracture: * Type I: Involves an extension of the osteotomy just proximal to or within the tibiofibular joint [59]. * Type II: Reaches the distal aspect of the tibiofibular joint [59]. * Type III: Is an intra-articular fracture of the tibia plateau [59].

Types II and III lateral hinge fractures require careful treatment as they are unstable compared with type I [59]. One frequently reported problem associated with opening wedge high tibial osteotomy is that posterior tibial slope can be altered, with an unintended increase of up to a mean of 4.4° reported in clinical follow-up studies [189]. 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 responsible for the 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].

Indications and Patient Selection¶

These kinematic changes should be considered when selecting the surgical technique for patients with medial osteoarthritis [46]. Patients with the varus morphotype may be better served with an osteotomy to unload the already overloaded medial compartment [55]. If the underlying cause is significant malalignment, then osteotomy may be preferred [55]. Unicompartamental arthroplasty may be best suited for true medial compartment arthritis [55]. If the problem is an undiagnosed early inflammatory arthritis, then the best choice may be a total knee arthroplasty [55]. The 10-year survival rate for high tibial osteotomy was 60% [55]. The 10-year survival rate for medial compartment arthroplasty reported by Pandit et al. was 91% [55]. A meta-analysis by Fu et al. of clinical outcomes after high tibial osteotomy and medial compartment arthroplasty showed better knee function in the arthroplasty group but no difference in knee score [55]. While high tibial osteotomy is effective for active patients with medial compartment osteoarthritis, maximizing success requires understanding the vital biomechanics of the procedure [139].

When considering the use of an HTO in the setting of ACL deficiency, lateral closing wedge should be considered given its favorable post-operative knee kinematics [155, 158]. This 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 [130]. Medial meniscus posterior root tears increase medial contact pressures and accelerate cartilage degeneration, particularly in varus-aligned knees [187]. High tibial osteotomy is a commonly used joint-preserving procedure for varus knees with medial compartment overload [187]. The combined procedure of high tibial osteotomy and meniscal root repair yields superior patient-reported outcomes compared to osteotomy alone and consistently results in clinically meaningful functional improvement [187]. The combined procedure of high tibial osteotomy and meniscal root repair demonstrated satisfactory rates of complete meniscal healing among available studies [187].

Patellofemoral instability and anterior knee pain are multifactorial conditions that result from an interplay of multiple risk factors, including anatomical abnormalities, soft tissue deficiencies, and joint malalignment [188]. Excessive external tibial torsion, femoral antetorsion, and varus or valgus may jeopardize the patellofemoral joint function, with an emphasis on rotational imbalance [188]. 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 [188]. Knees with anterior knee pain display increased tibial external rotation [188]. Excessive rotation may generate medial patellofemoral ligament traction, causing medial pain [188]. In most cases, the anterior knee pain in the patient with torsional abnormalities is combined with patellar maltracking and patellofemoral instability, but can also appear as isolated without patellofemoral instability [188]. Some of the surgeries that aimed the realignment of the extensor mechanism failed because the torsional irregularity was left untreated [188].

Classification¶

Indications: High tibial osteotomy is indicated for appropriately selected patients, particularly physiologically young, active patients with unicompartmental knee disease [10]. It is specifically indicated for symptomatic varus deformity of the knee [15]. 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 [23]. The procedure is indicated when a patient has medial compartment Kellgren–Lawrence grade I to IV osteoarthritis, persistent pain after at least three months of conservative treatment, a location of the centre of the deformity around the proximal tibia, less than 10° of flexion contracture, and is physically active [173]. Additional indications include spontaneous osteonecrosis of the femoral condyle [34], deformity correction to create a more biomechanically stable knee in the context of ACL reconstruction [20], and osteochondral defects when malalignment is present [24].

Surgical Goals: 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].

Takeuchi Classification: The Takeuchi classification describes three types of lateral hinge fracture. Type I involves an extension of the osteotomy just proximal to or within the tibiofibular joint and is considered stable [59]. Type II reaches the distal aspect of the tibiofibular joint and is unstable [59]. Type III is an intra-articular fracture of the tibia plateau and is unstable [59].

Displacement Classification: Lateral hinge fractures can be divided into nondisplaced (≤ 2 mm displacement) and displaced (> 2 mm displacement) fractures, with nondisplaced fractures being more common than displaced ones [168].

Other Considerations: Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site [150]. Preoperative coronal alignment phenotypes were not consistently associated with postoperative patient-reported outcomes after medial opening-wedge high tibial osteotomy [147].

Clinical Presentation¶

High tibial osteotomy is an established treatment option for unilateral knee osteoarthritis [109] and is used in the management of symptomatic varus deformity of the knee [15]. It serves as an effective approach to alleviate symptoms, correct alignment, improve stability, and preserve meniscal tissue and cartilage in sport-related cases [100]. The procedure is particularly indicated for constitutional high tibia vara, providing a satisfactory solution with minor short-term morbidity [48]. Medial opening high tibial osteotomy demonstrates remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity [45]. In young or active patients, tibial osteotomy successfully alleviates knee pain in the management of malalignment associated with knee arthrosis [50]. Although high tibial osteotomy is an underutilized procedure, it warrants consideration in appropriately selected patients [10].

Patient Selection and Indications¶

Age does not have to be taken into consideration for the indication of high tibial osteotomy [7]. However, careful patient selection and evaluation are essential to maximize successful outcomes [100]. Selection requires careful consideration of the osteoarthritic status of the patellofemoral joint and the required correction angle, regardless of whether a closed- or open-wedge technique is applied [37]. High tibial osteotomy is recommended for treating osteochondral defects alongside the procedure when malalignment is present [24]. The procedure can be combined with transtibial drilling of tibial and femoral medial compartment cartilage defect without additional incisions [14].

Clinical Outcomes and Longevity¶

High tibial osteotomy is a reliable treatment option with satisfying clinical outcomes, demonstrating a survival rate of over 96% at 5 years [11]. Clinical results show improvement compared to pre-operative values after open-wedge high tibial osteotomy [33]. More than 8 of 10 patients return to sport after the procedure [35]. While high tibial osteotomy can be effective for periods longer than 15 years, results do deteriorate over time [3]. A meta-analysis indicates that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months [27]. There was neither any association between change in knee alignment and change in KOOS pain over time [51]. Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy [33].

Specific Pathologies and Adjunctive Procedures¶

High tibial osteotomy has been performed on thirty-seven knees with spontaneous osteonecrosis of the femoral condyle, with preoperative pain relieved and walking ability improved in thirty-five knees [34]. The clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy [19].

Complications and Surgical 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]. The reported incidence of lateral hinge fractures after open wedge high tibial osteotomy ranges from 10 to 30% [101]. The distance from the tibial osteotomy point to the medial edge of the tibia was an independent risk factor for types II and III lateral hinge fractures [101].

Impact on Subsequent Arthroplasty¶

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 [21]. However, 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].

Investigations¶

Plain radiography: Physical examination must be used concomitantly with radiographic or advanced imaging findings to determine the source of symptoms and appropriate surgical intervention when nonsurgical measures have failed [71]. Plain radiographs serve as appropriate initial imaging studies for most knee conditions, allowing assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [76]. Weight-bearing AP (extension) radiographs assess cartilage loss from the distal femur and tibial plateau [76], while weight-bearing PA (Rosenberg; flexion) radiographs assess cartilage loss from the posterior femur and tibial plateau [76]. Patellofemoral views evaluate patellofemoral alignment (tilt/subluxation), patellar and trochlear morphology, osteochondral injury, and patellofemoral arthritis [76]. A notch view is used to assess posterior femoral cartilage, notch width, and osteophytes [76]. In osteoarthritis, radiographs may identify subchondral sclerosis, joint space narrowing, subchondral cysts (variable), osteophytes (variable), and joint subluxation [76]. Although radiographs can underestimate isolated chondral lesions, they may demonstrate joint space narrowing, osteophytes, sclerosis, and cysts [78]. Long leg alignment views determine the mechanical axis [78]. 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 [78]. Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs [184].

MRI: MRI can be used to evaluate articular cartilage morphology [78]. It 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) [76].

CT: Three-dimensional CT reconstructions may help with preoperative planning for multiplanar osteotomy for limb malalignment [76].

Bone scan: SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy [69]. 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 [62].

Other Considerations: 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]. 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 [67]. 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 [22]. High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique [25].

Treatment¶

Non-Operative¶

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions. High tibial osteotomy is indicated for patients who have failed nonoperative 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 [57]. 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 [29]. 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]. For young patients with knee pain, malalignment, and cartilage disorders, osteotomy addresses both mechanical correction and the modulation of the inflammatory environment [65]. In unilateral medial knee osteoarthritis, the procedure unloads the osteoarthritic area, provides pain relief, and may prevent later osteoarthritis if performed for ideal indications [162].

Surgical Approach / Technique: The open-wedge technique in combination with fixed-angle plates is recommended for high tibial osteotomy [61]. Arthroscopic and computer-assisted techniques using standard total knee arthroplasty navigation software provide accurate and reliable intraoperative real-time guidance of the degree of correction [22]. Medial opening wedge high tibial osteotomy is a highly accurate procedure that allows precise frontal alignment correction and prevents alteration of the tibial slope [32]. 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 [44]. Proper posterior cortical osteotomy is the key step to preventing increased tibial slope, and a preserved lateral hinge is a prerequisite for successful surgery [79]. Technical modifications improve the safety and reproducibility of the procedure [43]. The weightbearing line should pass through the lateral 30% to 40% of the tibial plateau, and preoperative planning is mandatory to achieve this result [57].

Specific technical variations include the derotational hybrid closed-wedge high tibial osteotomy, which involves an anterior approach to the proximal tibia, tibial tubercle osteotomy, and anterior closing-wedge osteotomy [88]. Lateral opening wedge high tibial osteotomy involves an oblique skin incision between the anterior portion of the fibular head and the tibial tubercle, elevation of the tibialis anterior, and biplanar tibial osteotomy [174]. Inverted V-shaped high tibial osteotomy involves a biplanar osteotomy in the coronal and sagittal planes, with a coronal ascending osteotomy parallel to the anterior surface of the tibial tubercle leaving the tibial tubercle intact with a width of 10 mm [180]. Anterior open-wedge osteotomy to correct sagittal and coronal malalignment involves a midline incision just medial to the tibial tuberosity and detachment of a 7-cm bone block of the tibial tubercle along with the attached patellar tendon as a single unit [176]. Lateral closing wedge high tibial osteotomy involves an oblique skin incision, elevation of the tibialis anterior, and biplanar tibial osteotomy performed with an oscillating saw and osteotome under fluoroscopic guidance [174]. Medial closing wedge distal femoral varus osteotomy involves a medial skin incision and subvastus approach [174].

For derotational hybrid closed-wedge high tibial osteotomy, the technique involves segmental resection of the fibula at its midportion, approximately 15 mm in length [171], and a tibial skin incision beginning 1 cm proximal to the fibular head, running through Gerdy’s tubercle, and passing 1 cm lateral to the tibial anterior margin [171]. Open-wedge high tibial osteotomy involves an oblique incomplete osteotomy cut starting approximately 4 cm below the joint line and passing cephalad to the superior aspect of the tibial tuberosity, aimed at a point 2 cm below the joint line to create a 1-cm lateral cortical hinge [177]. Medial closing wedge high tibial osteotomy to correct valgus malalignment involves a vertical 10-cm incision over the anteromedial cortex of the tibial surface, starting approximately 1 cm distal to the joint line [160]. High tibial osteotomy with ACL reconstruction involves an anterior approach to the proximal tibia [20]. The acute oblique osteotomy and suture ligation procedure for fibular shortening in lateral closing-wedge high tibial osteotomy can be completed within 10 minutes or less and does not need any additional cost for special fixation devices except a thread for ligation [181]. This method can be combined with high tibial osteotomy without additional incisions [14]. The described technique for treating osteochondral defects alongside high tibial osteotomy when malalignment is present is recommended, though further studies focused on assessment and validation are encouraged [24].

Implant Selection: Implant design strongly influences stability after opening wedge valgus high tibial osteotomy, with short designs being inferior to longer designs [153].

Alignment / Balancing Strategy: 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]. The surgical technique for anterior opening-wedge high tibial osteotomy aims to correct the limb sagittal alignment and provide stability to the knee joint, with the ultimate goal of improving patient outcomes [60].

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 [185].

Adjuncts: SPECT/CT can be used for assessment of adequate correction and healing in symptomatic patients with varus aligned knees [69].

Revision: Posterior cruciate-substituting total knee arthroplasty is suitable for use after high tibial osteotomy [63]. Conversion total knee arthroplasty following high tibial osteotomy involves managing existing hardware and soft tissue adhesions [179]. The surgical approach for cruciate retaining versus posterior stabilized total knee arthroplasty after previous high tibial osteotomy is determined by the previous incision, with the skin cut made through the old healed wound [175].

Other Considerations: The postoperative regimen must include 6 months of partial weightbearing, then full weightbearing if radiological consolidation of the fracture is visible [57]. Bone union at the fibular osteotomy site using the acute oblique osteotomy and suture ligation procedure can be obtained within 4 months in nearly 100% of the patients [181]. 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 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 [186]. High tibial osteotomy modifies patellar height depending on the technique employed [82]. 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 [151]. Locking plate removal after medial opening wedge high tibial osteotomy is a safe procedure that improves symptoms and functional scores [68]. The surgical technique for high tibial osteotomy and medial meniscus transplant is preferred in younger, more active patients [16]. The surgical technique for high tibial osteotomy in young adults with constitutional tibia vara provides a satisfactory solution with minor morbidity [48]. The surgical technique for rehabilitation following high tibial osteotomy can successfully alleviate knee pain in the management of malalignment associated with knee arthrosis in young or active patients [50]. The surgical technique for long-term outcome after high tibial osteotomy is a useful facility to protract the implantation of a total knee prosthesis [56]. The surgical technique for lateral closing wedge high tibial osteotomy for medial compartment arthrosis or overload is an effective treatment of unicompartmental arthrosis or deformities [57]. The surgical technique for accuracy of high tibial osteotomy recommends the open-wedge technique in combination with fixed-angle plates [61]. The surgical technique for comparison of patellofemoral geometry between opening wedge and hybrid high tibial osteotomy led to a significant decrease in bone tracer uptake of the medial compartment [62]. The surgical technique for total knee arthroplasty following failed high tibial osteotomy makes posterior cruciate-substituting total knee arthroplasty suitable for use after high tibial osteotomy [63]. The surgical technique for high tibial osteotomy and distal femoral osteotomy addresses biologics and biomechanics [65]. The surgical technique for effect of high tibial osteotomy on joint loading in symptomatic patients with varus aligned knees allows SPECT/CT to be used for assessment of adequate correction and healing [69]. The surgical technique for surgical anatomy of medial open-wedge high tibial osteotomy involves crucial steps and pitfalls [70]. The surgical technique for tibial slope and high tibial osteotomy using the circular external fixator results in no significant alteration in tibial slope [151]. The surgical technique for primary stability of four different implants for opening wedge high tibial osteotomy shows that implant design strongly influences stability, with short designs being inferior to longer designs [153]. The surgical technique for three-dimensional patient specific instrumentation and cutting guide for medial closing wedge high tibial osteotomy involves a vertical 10-cm incision over the anteromedial cortex of the tibial surface [160]. The surgical technique for high tibial osteotomy for varus knees with medial osteoarthritis may prevent total knee arthroplasty [162]. The surgical technique for a case series of lateral opening wedge high tibial osteotomy for valgus malalignment is a viable surgical option for patients with lateral knee pain and valgus malalignment requiring small degrees of correction [167]. The surgical technique for anatomical double-bundle anterior cruciate ligament reconstruction after valgus high tibial 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 derotational hybrid closed-wedge high tibial osteotomy for knee osteoarthritis with patellar subluxation caused by tibial torsional deformity involves an anterior approach to the proximal tibia [171]. The surgical technique for the role of osteotomy in chronic valgus instability and hyperextension valgus thrust involves two easy stepwise procedures that can be performed using standard AO instruments and special anatomic osteotomy locking plates [174]. The surgical technique for cruciate retaining versus posterior stabilized total knee arthroplasty after previous high tibial osteotomy involves a surgical approach determined by the previous incision with skin cut made through the old healed wound [175]. The surgical technique for anterior open-wedge osteotomy to correct sagittal and coronal malalignment in a case of failed high tibial osteotomy and failed posterior cruciate ligament reconstruction involves a midline incision just medial to the tibial tuberosity [176]. The surgical technique for open-wedge high tibial osteotomy involves a technical trick to avoid loss of reduction of the opposite cortex [177]. The surgical technique for comparable clinical outcomes after conversion total knee arthroplasty following high tibial osteotomy and primary total knee arthroplasty involves managing existing hardware and soft tissue adhesions [179]. The surgical technique for inverted V-shaped high tibial osteotomy for medial osteoarthritic knees with severe varus deformity involves a biplanar osteotomy in the coronal and sagittal planes [180]. The surgical technique for an acute oblique osteotomy and suture ligation procedure to shorten the fibula in lateral closing-wedge high tibial osteotomy involves a 4-cm longitudinal skin incision at the mid-lateral side of the leg [181]. The surgical technique for economic evaluation of high tibial osteotomy shows that both closing wedge and open wedge techniques allowed to achieve good to excellent functional outcomes [182]. The surgical technique for efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy involves intraoperative periarticular multimodal drug injections [185]. The surgical technique for does subchondral bone marrow edema have effect on outcome of medial open wedge high tibial osteotomy involves assessment of preoperative subchondral bone marrow edema [186].

Complications¶

General Complication Rates: Postoperative complication rates for high tibial osteotomy range from 10% to 15% [143]. Reported complications after medial opening wedge high tibial osteotomy reach 41.2%, with 24.7% classified as major [148]. In contrast, a low rate of serious complications (6.5%) requiring unplanned additional surgery was observed in patients treated with the Tomofix locking plate [146]. In a series of 100 consecutive cases using a calibrated osteotomy guide, rigid internal fixation, and early motion, the complication rate was low [207]. Among young and active patients, 4 major complications (6.7%) required hospital admission, while 3 minor complications (5.0%) were registered [107].

Nonunion and Healing: Nonunion occurs in 1.9% of high tibial osteotomy cases [143]. Uncomplicated osteotomy union was achieved in 93% of medial opening-wedge high tibial osteotomies [213]. Nonunions are more common with opening wedge osteotomies, particularly those involving larger corrections [129]. Fibular nonunion was observed in 15 cases (13.8%) following closed-wedge high tibial osteotomy [117]. This occurrence was statistically related to preoperative BMI, reduced obliquity of the osteotomy plane, and reduced fragment contact between osteotomy surfaces [117]. When the fibular osteotomy angle exceeded 50 degrees, fibular nonunion was not observed [117]. Union rates and nonunion characteristics of fibular osteotomies vary according to the level of osteotomy, apposition of bone ends, and the type of accompanying high tibial osteotomy [58]. Delayed bone healing following high tibial osteotomy has been associated with increased implant stiffness in locked plating [119].

Loss of Correction and Recurrence: Loss of correction occurs in 1.2% of high tibial osteotomy cases [143]. Coventry attributed the recurrence of varus deformity to inadequate correction at the time of surgery [55]. Overcorrection beyond the normal 5 degrees of anatomic valgus decreased the frequency of recurrent varus deformity [55]. Loss of correction is more common in patients managed with opening wedge osteotomies compared with closing wedge osteotomies [129].

Nerve and Vascular Injury: Peroneal nerve injury is most often related to fibular osteotomy performed in conjunction with proximal tibial osteotomy [55]. At 90 degrees of flexion, the distance between the osteotomy blade and the popliteal artery averaged only 10.6 mm [55]. Peroneal nerve complications occur more commonly in closing wedge osteotomies [129]. Three knees (2.7%) had nerve lesions following closed-wedge high tibial osteotomy, two of which resolved spontaneously [117]. One patient experienced permanent hypoesthesia of the dorsal and plantar aspects of the foot following a nerve lesion after closed-wedge high tibial osteotomy [117]. One case of a common peroneal nerve deficit that resolved spontaneously was registered in a cohort of young and active patients [107]. Two patients experienced temporary peroneal nerve dysfunction in a series of 136 knees treated with oblique high tibial osteotomy [156].

Infection: Infection occurs in 2.9% of high tibial osteotomy cases [143]. One case of a deep infection treated with debridement and antibiotic therapy was registered in a cohort of young and active patients [107]. Two cases of superficial surgical wound infections were registered in the same cohort [107]. Four patients experienced superficial wound infection in a series of 136 knees treated with oblique high tibial osteotomy [156]. The use of artificial bone graft and longer anaesthesia duration are risk factors for surgical site infection after high tibial osteotomy [208]. Primary diagnosis of osteonecrosis and younger age were identified as protective factors against surgical site infection after high tibial osteotomy [208].

Thromboembolic Events: Deep vein thrombosis is a reported complication of proximal tibial osteotomy [55]. The overall incidence of early deep vein thrombosis after opening-wedge high tibial osteotomy was 44.7% [161]. Thrombi were found particularly around the osteotomy site in patients with early deep vein thrombosis after opening-wedge high tibial osteotomy [161]. Female sex, diabetes, and hyperlipidemia are significant risk factors for deep vein thrombosis following medial opening-wedge high tibial osteotomy [201]. Patients undergoing closed-wedge high tibial osteotomy are at risk of postoperative venous thromboembolism [202]. The overall incidence of venous thromboembolism following medial open-wedge high tibial osteotomy was low in Asian patients even without chemoprophylaxis [203]. Five patients experienced deep vein thrombosis in a series of 136 knees treated with oblique high tibial osteotomy [156]. Paradoxical embolization of the bilateral subclavian arteries has been reported after high tibial osteotomy [204].

Hardware and Implant Issues: Implant failure occurs in 8.2% of medial opening wedge high tibial osteotomy cases [148]. Distal locking screw breakage occurs in 4.7% of these cases, while proximal locking screw breakage occurs in 3.5% [148]. Implant failure is more common in patients managed with opening wedge osteotomies compared with closing wedge osteotomies [129]. Twenty cases (33.3%) of plate removal for intolerance were recorded in patients who underwent medial opening-wedge high tibial osteotomy [107]. Hardware removal was reported for 43 (67.2%) patients in a series of medial closing wedge high tibial osteotomies [163].

Intraoperative and Structural Complications: Intraoperative fractures of the hinge, either medially or laterally, can impair stability, healing, and potentially disrupt the articular surface [129]. Intraoperative lateral hinge fracture (type II or III) occurs in 5.9% of medial opening wedge high tibial osteotomy cases [148]. Lateral hinge fractures are the leading cause of construct instability, displacement, non-union, and varus recurrence after medial opening wedge high tibial osteotomy [148]. Two intraoperative lateral hinge fractures (2.9%) requiring additional staple fixation were reported in a series of medial closing wedge high tibial osteotomies [163]. One case of residual varus-valgus instability with subsequent surgery was registered in a cohort of young and active patients [107].

Other Considerations: Knee stiffness or instability, intraarticular fracture, compartment syndrome, osteonecrosis of the proximal fragment, and patella infra are reported complications of proximal tibial osteotomy [55]. Factors causing 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 [55]. One case of residual stiffness that was managed nonoperatively was registered in a cohort of young and active patients [107]. One case of complex regional pain syndrome was noted in a series of medial closing wedge high tibial osteotomies [163]. A mild extension deficit was observed in three patients undergoing anterior open wedge high tibial osteotomy for slope correction [164].

Recovery¶

Light activity (weeks): Full weight-bearing walking commences at 6 weeks postoperatively in protocols utilizing a medial locked plate system and relatively conservative rehabilitation [123].

Rehabilitation protocol: A relatively conservative rehabilitation protocol is employed when using a medial locked plate system, characterized by the initiation of full weight-bearing walking at 6 weeks postoperatively [123].

Functional milestones: High tibial osteotomy substantially improves outcome measures important to knee joint structure and function, patient quality of life, and health care systems [5]. In active patients with medial compartment knee osteoarthritis, the procedure demonstrates favorable clinical results and allows return to sports and recreational activities similar to the preoperative level [116]. Most patients return to sport at a level equal to or greater than the preoperative level [199]. In a young, high-demand population, 54.5% of knees returned to full duty without restriction, despite 36.4% of knees requiring reoperation [200]. Biomechanically, the procedure effectively unloads the knee medial compartment and redistributes knee internal loads between the medial and lateral compartments during walking and stair tasks [134].

Other Considerations: Long-term survival data indicate that various high tibial osteotomy techniques show high survivorship, although the medial opening-wedge technique carries specific risks regarding tibial slope and patellar height [192]. Regarding bony healing and complications, Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a medial locked plate system showed no radiologic changes or functional deterioration during midterm followup [123]. 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 [68]. Patients appear to have progression of patellofemoral osteoarthritis after medial open-wedge high tibial osteotomy [131].

Cartilage regeneration and adjunctive procedures present mixed evidence. Degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by newly regenerated cartilage at 2 years after adequate correction of varus deformity by medial opening-wedge high tibial osteotomy without cartilage regeneration strategies [183]. However, 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 [30]. Simultaneous use of bone marrow aspirate concentrate with open wedge high tibial osteotomy for early stage medial compartment arthrosis may relieve pain at the early period and improve patient compliance to rehabilitation [135].

Regarding the impact on subsequent total knee arthroplasty, observations suggest that a previous high tibial osteotomy does not influence the function or survival of a knee long term [9]. Clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different [21]. 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 [26].

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)
[L4] This review discusses the indications, techniques, and outcomes for high tibial osteotomies used in the treatment of symptomatic varus deformity of the knee. [15] (10.5435/jaaosglobal-d-21-00141)
[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)
[L3] However, the clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy. [19] (10.1186/s12891-019-2607-z)
[L5] High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee. [20] (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. [21] (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. [22] (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. [23] (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. [24] (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. [25] (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. [26] (10.1186/1471-2474-8-74)
[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. [27] (10.1007/s00402-003-0545-5)
[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. [28] (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. [29] (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. [30] (10.1016/j.arthro.2023.07.002)
[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. [32] (10.1007/s00167-008-0717-5)
[L4] After open-wedge high tibial osteotomy, clinical results showed improvement compared to pre-operative values. [33] (10.1007/s00167-014-3349-y)
[L4] [34] (10.2106/00004623-198264010-00008)
[L3] More than 8 of 10 patients returned to sport after high tibial osteotomy. [35] (10.1177/0363546519849476)
[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)
[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. [43] (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. [44] (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. [45] (10.1177/2325967120s00543)
[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] 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. [48] (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. [50] (10.1016/j.csm.2009.12.005)
[L3] There was neither any association between change in knee alignment and change in KOOS pain over time. [51] (10.1186/1471-2474-10-154)
[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. [56] (10.1007/s00402-007-0438-0)
[Paper] [57] (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. [58] (10.1007/s00402-016-2493-x)
[L3] [59] (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. [60] (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. [61] (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. [62] (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. [63] (10.1007/s00167-009-0790-4)
[L5] Osteotomy is a critical part of comprehensive treatment of young patients with knee pain, malalignment, and cartilage disorders, as it addresses both mechanical correction and the modulation of the inflammatory environment in the joint. [65] (10.1016/j.arthro.2023.08.009)
[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. [67] (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. [68] (10.1016/j.arthro.2024.01.010)
[L2] SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy. [69] (10.1007/s00167-014-3053-y)
[L5] [70] (10.1007/s00167-016-4181-3)
[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. [79] (10.1016/j.arthro.2021.03.082)
[L3] High tibial osteotomy modifies patellar height depending on the technique employed. [82] (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. [86] (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. [88] (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. [90] (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. [91] (10.1002/ksa.12577)
[L3] These findings are consistent with an intended, sustained shift in the mediolateral distribution of knee loads. [92] (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. [93] (10.1177/2325967116s00039)
[L5] Tibial flexion osteotomy significantly affects cartilage pressure and kinematics of the knee joint. [94] (10.1007/s00402-004-0728-8)
[L5] Minor valgus realignment of the proximal tibia does not significantly alter the biomechanics of the ankle. [98] (10.1002/jor.22793)
[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)
[L3] [101] (10.1016/j.arth.2024.11.003)
[L4] Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust. [104] (10.1177/0363546503258907)
[L4] [107] (10.1177/03635465251322795)
[L3] [109] (10.1007/s00402-020-03476-6)
[L3] Cadaveric findings demonstrate that gastrocnemius recession improved knee extension and ankle dorsiflexion, supporting a biomechanical explanation for this transient clinical effect. [111] (10.1016/j.jisako.2026.101146)
[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. [116] (10.1177/0363546508325666)
[L4] [117] (10.1016/j.otsr.2012.09.010)
[L5] The non-anchored free-floating device remains within the medial knee joint gap under challenging dynamic loading situations without indicating any luxation tendencies. [118] (10.1186/s40634-023-00576-1)
[L4] [119] (10.1016/j.injury.2014.04.018)
[L5] This effect is amplified as the knee flexion angle increases. [122] (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. [123] (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. [125] (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. [126] (10.1007/s00402-020-03578-1)
[L4] Radiographic analysis demonstrated increased hip-knee-ankle (HKA) angles and percentage of mechanical axis (%MA), along with reduced femorotibial angle (FTA). [128] (10.1177/23259671261450211)
[L5] [129] (10.5435/jaaos-d-23-00323)
[L5] This combined approach enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment, potentially improving long-term outcomes compared with isolated procedures. [130] (10.1002/atn2.70123)
[L1] Patients appear to have progression of patellofemoral osteoarthritis after medial open-wedge high tibial osteotomy. [131] (10.1016/j.arthro.2021.04.015)
[L4] Limb-length difference adjustment and matching mechanical axes achieved high levels of pain relief and knee function despite a remaining physiological varus deformity. [133] (10.1177/2325967119857047)
[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. [134] (10.1002/ksa.70348)
[L3] Simultaneous use of BMAC with open wedge high tibial osteotomy for early stage medial compartment arthrosis may relieve pain at the early period and improve patient compliance to rehabilitation. [135] (10.1177/2325967121s00191)
[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. [136] (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. [138] (10.1186/s12891-019-2472-9)
[L4] The review highlights that while HTO is effective for active patients with medial compartment osteoarthritis, maximizing success requires understanding the vital biomechanics of the procedure. [139] (10.1155/2019/8363128)
[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. [141] (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. [142] (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%). [143] (10.1177/03635465221142868)
[L4] Three-dimensional kinematic analysis detects changes due to HTO that standard radiographs do not identify, including changes in the PF joint. [144] (10.1016/j.arthro.2013.07.039)
[Paper] It achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope. [145] (10.1016/j.eats.2017.08.009)
[L4] A low rate of serious complications (6.5%) requiring unplanned additional surgery was found. [146] (10.1007/s00167-020-06199-8)
[L3] [147] (10.1016/j.jisako.2026.101204)
[L5] [148] (10.1530/eor-22-0103)
[L2] Gait adaptations known to reduce knee loading employed pre-HTO were not retained post-HTO. [149] (10.1007/s00167-019-05644-7)
[L3] [150] (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. [151] (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. [153] (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. [155] (10.1177/2325967114s00052)
[L4] [156] (10.1007/s00167-006-0053-6)
[L3] Both techniques resulted in smaller changes in leg length than predicted by mathematical models. [157] (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. [158] (10.1016/j.arthro.2014.04.068)
[L5] [160] (10.1016/j.eats.2021.08.030)
[L3] The overall incidence of early DVT after OWHTO was 44.7%, with thrombi found particularly around the osteotomy site. [161] (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. [162] (10.1016/j.arthro.2019.10.039)
[L4] [163] (10.1002/ksa.70176)
[L4] [164] (10.1002/ksa.70522)
[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)
[L3] [173] (10.1302/0301-620x.97b9.34949)
[Paper] [174] (10.1016/j.csm.2019.02.012)
[L3] [175] (10.1007/s00167-014-3259-z)
[L5] [176] (10.1016/j.eats.2024.103032)
[L4] [177] (10.1007/s00167-003-0480-6)
[L3] [179] (10.1016/j.jisako.2025.100931)
[Paper] [180] (10.1016/j.eats.2018.06.005)
[Paper] [181] (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. [182] (10.1002/ksa.12026)
[L4] Degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by newly regenerated cartilage at 2 years after adequate correction of varus deformity by medial opening-wedge high tibial osteotomy without cartilage regeneration strategies. [183] (10.1016/j.arthro.2013.10.008)
[L3] Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs. [184] (10.1186/s12891-022-05526-z)
[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. [185] (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. [186] (10.1016/j.arthro.2017.08.121)
[L1] [187] (10.1016/j.jisako.2025.101035)
[L4] [188] (10.1016/j.jisako.2024.02.015)
[L5] [189] (10.1007/s00167-014-3100-8)
[L5] Various high tibial osteotomy techniques show high survivorship, but the medial opening-wedge technique carries risks regarding tibial slope and patellar height. [192] (10.1016/j.arthro.2025.05.004)
[L4] [193] (10.1007/s00167-019-05445-y)
[L5] [194] (10.1136/jisakos-2020-000575)
[L4] Most patients return to sport at a level equal to or greater than the preoperative level. [199] (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. [200] (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. [201] (10.1186/s12891-025-08713-w)
[L2] Patients undergoing CWHTO are at risk of postoperative VTE. [202] (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. [203] (10.1055/s-0039-1700976)
[L5] These findings indicate that considering the possibility of coincidental paradoxical embolism after orthopaedic surgery is important. [204] (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. [207] (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. [208] (10.1007/s00167-020-05943-4)
[L4] Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. [213] (10.1016/j.arthro.2015.04.097)

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

[145] Open‐Wedge Valgus High Tibial Osteotomy Technique With Inverted L‐Shaped Configuration. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2017.08.009

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[147] 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

[148] Lateral hinge fracture in medial opening wedge high tibial osteotomy: a narrative review. EFORT Open Reviews. 2023. DOI: 10.1530/eor-22-0103

[149] 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

[150] 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

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[155] 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

[156] 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

[157] 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

[158] 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

[160] Three‐Dimensional Patient Specific Instrumentation and Cutting Guide for Medial Closing Wedge High Tibial Osteotomy to Correct Valgus Malalignment. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.08.030

[161] 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

[162] 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

[163] 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

[164] 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

[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] The validity of the classification for lateral hinge fractures in open wedge high tibial osteotomy. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b9.34949

[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

[175] Cruciate retaining versus posterior stabilized total knee arthroplasty after previous high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3259-z

[176] 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

[177] Open‐wedge high tibial osteotomy: a technical trick to avoid loss of reduction of the opposite cortex. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-003-0480-6

[179] 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

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[181] 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

[182] 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

[183] Second‐Look Arthroscopic Assessment of Cartilage Regeneration After Medial Opening‐Wedge High Tibial Osteotomy. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.10.008

[184] Effect of bone morphology of the tibia plateau on joint line convergence angle in medial open wedge high tibial osteotomy. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05526-z

[185] 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

[186] 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

[187] 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

[188] 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

[189] Factors influencing posterior tibial slope and tibial rotation in opening wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3100-8

[192] Editorial Commentary: Various High Tibial Osteotomy Techniques Show High Survivorship, Medial Opening‐Wedge Technique Has Risks, and Patient‐Specific Instrumentation Shows Promise. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.05.004

[193] Deep peroneal nerve has a potential risk of injury during open-wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05445-y

[194] Abrasion arthroplasty promotes improvement of degenerated femoral trochlear cartilage after medial open wedge high tibial osteotomy. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000575

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[200] Return to Duty in Military Servicemembers After High Tibial Osteotomy Not Associated With Preoperative Radiographic Parameters : A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241252410

[201] Incidence of deep venous thrombosis following medial opening-wedge high tibial osteotomy for varus knee osteoarthritis: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08713-w

[202] Edoxaban is effective in reducing the incidence of asymptomatic phlebographic events following closed-wedge high tibial osteotomy. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.07.016

[203] Do We Need Chemoprophylaxis to Prevent Venous Thromboembolism following Medial Open-Wedge High Tibial Osteotomy?. The Journal of Knee Surgery. 2020. DOI: 10.1055/s-0039-1700976

[204] Paradoxical Embolization of the Bilateral Subclavian Arteries After High Tibial Osteotomy. JAAOS: Global Research and Reviews. 2019. DOI: 10.5435/jaaosglobal-d-19-00044

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[208] Type of bone graft and primary diagnosis were associated with nosocomial surgical site infection after high tibial osteotomy: analysis of a national database. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05943-4

[213] Opening‐Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.04.097

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