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Factors Influencing Results Of High Tibial Osteotomy: Review Of Literature

*Nilesh Patil, *Vikram Sapre, +Anshul Chadda, *Vaibhav Bagaria

*RN Cooper Hospital, Mumbai, India
+Mure Memorial Hospital, Nagpur, India

Address for Correspondence

Dr Vaibhav Bagaria,
Flat No 8, C 84, ‘Satyam’, Ramprastha. Ghaziabad, UP 201011,
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High tibial osteotomy is a modality in the management of early unicompartmental osteoarthritis which is based on the principle of redistribution of body weight from the arthritic medial femorotibial compartment to the healthy lateral one. HTO is ideally indicated in young, active patients(<60 yrs), with Unicompartmental involvement whose pain has persisted despite of adequate trial of conservative treatment. This review article focuses on various factors that affect the ultimate outcome  of the procedure over a period of time such as age and weight of the patient, the anatomical alignment achieved, the level of activity and the duration since surgery. Thus proper selection of the patient  can be done based on these factors to achieve optimal results.
Keywords: High tibial osteotomy, surgical implications, osteoarthritis

J.Orthopaedics 2006;3(2)e1

Factors Influencing Results Of High Tibial Osteotomy: Review Of Literature

High tibial osteotomy was accepted as safe and effective technique in treatment  of osteoarthritis of knee after the study conducted by Jackson et al[1,2].  Biomechanical basis behind HTO is that the realignment of varus deformity reduces stress on the medial compartment of knee joint.  The beneficial effect of tibial osteotomy is due to redistribution of body weight from the arthrotic medial femorotibial compartment to healthy lateral compartment . It also reduces pain by reducing intraosseus hypertension found in patients of  osteoarithitis. Results following HTO are assessed on various parameters like knee scoring system ( e.g .Hospital for Special surgery knee scoring method), ability to perform mild to moderate level of activity, recurrence of deformity,cosmesis and patient satisfaction.

Conventionally; HTO involves removal of lateral based wedge from Proximal tibia above the level of tibial tubercle ; achieving Tibiofemoral angle of 5-14degrees followed by either internal fixation or immobilization In a cylinder cast. Most of the studies support utility of HTO in treating osteoartrotic knee, but several controversial issues still exist and more longer follow up studies will be required to clarify such issues. There are various factors that affect the outcome of a high tibial osteotomy surgery and being well conversed with them will help surgeon make an informed decision on which patient to operate.This review article attempts to focus on various parameters that affect outcome in high tibial osteotomy for osteoarthritis after extensive literature review.

Factors affecting results of  HTO

1.     Age of the patient
2.     Weight of the patient
3.     Severity of arthrosis
4.     Surgical implications
5.     Duration since surgery
6.     Amount of correction achieved
7.     Preoperative knee score


Tibial osteotomy is  preferred for young , active patients (60yrs) to total knee  arthroplasty because of potential to allow strenuous activity. Preservation of bone stock and intraarticular structures are major advantages of HTO. Insall etall has reported poor results in patients older than 60 yrs, no matter what degree of correction was achieved[3]. However, some authors have reported favourable results even in patients more than 60 yrs. Macquet etall, in his studies of knee osteotomies has reported better and durable results in younger patients as compared to older age group patients[4] .It seems that deterioration of articular cartilage at the time of surgery is  a chief determinant of results following HTO and hence to obtain good results it should be performed during early osteoarthritic stage that is  in younger patients.


In a critical long term study of 87 cases at Mayo clinic, it was pointed out that if, after one year of procedure / valgus angulation was 8 degrees or more and if patient’s weight was 1.32 times ideal weight or less the likelihood of survival at 5yrs was 95%and after 10yrs was 65%. However when valgus angulation was less than 8 degrees and weight was more than 1.32 times ideal body weight, the survival decreased to 38%at 5yrs and 19% at 10 yrs[5]. Thus patients with more than 30% body weight can have propensity for poor results. Perhaps some more studies will be required to clarify this issue.


There is general consensus that osteotomy provides best results when done early in patients having mild to moderate unicompartmental osteoarthritis[4,6]. Patients having major bone attrition [1 cm],subluxation,patellofemoral arthritis or secondary lateral arthrosis were reported to have poor results.  Odenberg S in a larger series observed an increased risk  of revision of osteotomy in moderate to severe preoperative arthritis. Varus deformity of more than 10 degrees has been associated with poor results [7]


A.   Lateral compartment arthrosis
B.    Flexion range < 90 degrees
C.   Flexion deformity > 15 degrees
D.   Lateral tibial subluxation > 1 cm
E.    > 20 degrees correction required


Most important factor that is related to continued satisfactory function was surgical accuracy and appropriate correction of angular deformity[8]. Various surgical techniques described in literature are 

A.   COVENTRY’ TECHNIQUE- entails making proximal plane of osteotomy at least 2 cm distal to the articular surface of tibia and distal plane of osteotomy depending upon the correction required ; removal of wedge and closing the wedge. The osteotomy is fixed securely with 1-2 staples which are driven anterior to  fibula.

B.    SLOCUM’S TECHNIUE- involves leaving a thin posteromedial lip of bone on the proximal tibial fragment .The required wedge is removed ; osteotomy is closed .Posterior lip overrides proximal end of distal fragment and gives additional stability to osteotomy.

C.   HTO with JIG-HOFFMANN advocated performing osteotomy with jig and rigid fixation with L buttress plate followed by mobilization [ Protocol being immediate CPM and 50% weight bearing ]

D.   MACQUET’ TECHNIQUE- is a barrel vault osteotomy which used special jigs to make dome osteotomy allows for adjustability of correction and more accuracy.

E.    ILIZAROV METHOD – SCHWARTSMAN  described Ilizarov ring external fixator for HTO with the plane of osteotomy being distal to the tibial tuberosity so that adjustments can be made.It provides immediate stability and permits early weight bearing and knee ROM.

As emphasized by Coventry and supported by many authors the osteotomy should be performed above tibial tubercle.  He considered good blood supply of this region, large amount of trabeculae and immediate stability provided by the muscle pull across osteotomy highly desirable[9]

Insalletall, Harris, Kaustik recommended that power saw be avoided  due to the possibility of thermal necrosis and subsequent development of nonunion[4].  Internal fixation in HTO aids in rapid recovery of ROM and number of complications are also significantly less as described by Hoffmann. Cast immobilization has therotical disadvantage of joint stiffness and loss of correction.  On the contrary soft tissue dissection required for internal fixation may impose problems for revision to total knee arthroplasty.


There appears to be striking correlation between duration since surgery and deterioration of results following HTO in the form of decrease in knee scores , increase in knee pain ,recurrence of deformity and need for total knee arthroplast.  [ Survival rates been variable in different series using end point as reccurence of pain or arthroplasty [6,7,10,11,13]

On an average. survival rates were

  • 90- 95% at 1 year
  • 80-85% at 5 yrs
  • 55-65 %at 10 yrs

It has also being observed that unsatisfactory results become apparent early after surgery[ usually within 3 yrs].


The femorotibial angle achieved at the time of complete bone union after HTO is significant factor responsible for long term results of HTO. [FTA of 164-168degrees correlated with good long term results][3] . Overcorrection in HTO has been found to produce good results but overcorrection [ > 15 degrees of valgus] is cosmetically unappealing and may have therotical disadvantage of producing early lateral compartment arthrosis.[12]


The preoperative knee score seems to be principle determinant of post operative level of activity.It has been usually observed that ability to perform strenuous activity [such as ability to walk one mile, walk up and down the stairs] reaches a plateau and then gradually deteriorates with time[8,6]

Table 1: Factors associated with better outcomes  in HTO: 



HTO is an effective modality of management in unicompartmental Osteoarthritis, but proper patient selection and appropriate execution of surgical principles is required to obtain good long term results.  The following table tries to elucidate various factors which seem to influence results in HTO and should be considered by the operating surgeon before  undertaking the procedure. 

Reference : 

  1. Jackson JP, Waugh W (1961) Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br 43:746-751

  2. Jackson JP, Waugh W (1974) The technique and complications of upper tibial osteotomy. J Bone Joint Surg Br 56:236–238

  3. Yasuda K, Majima T, Tsuchida T, Kaneda K (1992) A 10- to 15 year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis. Clin Orthop 282:186-195

  4. Matthews LS, Goldstein SA, Malvitz TA, Katz BP, Kaufer H(1988) Proximal tibial osteotomy. Factors that influence the duration of satisfactory function. Clin Orthop 229:193–200

  5. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196–201.

  6. Vainnionpaa SE, Kines P, Tiusanen P. Tibia osteotomy for osteoarthritis of the knee – 5 –10 yr  follow up study. J Bone Joint Surg. (A) 1981 63 Page 938-946.

  7. Odenbring S, Egund N, Lindstrand A, Lohmander LS, Willen H (1992) Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic and histologic study. Clin Orthop 277:210–216.

  8. Nagel A, Insall JN, Scuderi GR (1996) Proximal tibial osteotomy.  A subjective outcome study. J Bone Joint Surg Am 78:1353–1358.

  9. Coventry MB (1965) Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report.  J Bone Joint Surg Am 47:984–990

  10. Ivarsson I, Myrnerts R, Gillqvist J (1990) High tibial osteotomy for medial osteoarthritis of the knee. J Bone Joint Surg Br 72:238–244

  11. Stuart MJ, Grace JN, Ilstrup DN, Kelly CM, Adams RA, Morrey BF (1990) Late recurrence of varus deformity after proximal tibial osteotomy. Clin Orthop 260:61–65

  12. Petri Virolainen, Hannu T.  High tibial osteotomy for the treatment of osteoarthritis of the knee: A review of the literature and a meta-analysis of follow-up studies. Arch Orthop Trauma Surg (2004) 124 : 258261

  13. Rinapoli E, Mancini GB, Corvaglia A, Musiello S (1998) Tibial osteotomy for varus gonarthrosis. A 10- to 21-year follow up study. Clin Orthop 353:185-193

  14. Insall JN, Joseph DM, Msika C (1984) High tibial osteotomy for varus gonarthrosis: a long-term follow-up study. J Bone Joint Surg Am 66:1040–1048

  15. Coventry MB (1984) Upper tibial osteotomy. Clin Orthop 182: 46–52


This is a peer reviewed paper 

Please cite as : Nilesh Patil: Factors Influencing Results Of High Tibial Osteotomy: Review Of Literature

J.Orthopaedics 2006;3(2)e1





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