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High tibial osteotomy

170 citationsUpdated Sep 2026

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Overview

High tibial osteotomy is a standardized, safe, and reliable procedure that provides satisfactory pain relief and functional outcomes for selected patients with high activity demands [1, 6]. It is an underutilized intervention that warrants consideration in appropriately selected patients, particularly those who are physiologically young and active with unicompartmental knee disease, for whom total knee arthroplasty is an imperfect long-term solution [10]. The procedure is preferred in younger, more active patients and has been shown to be the most cost-effective treatment modality in this population [16]. While total knee arthroplasty is now considered more suitable for patients over sixty years old, high tibial osteotomy should be reserved for patients with strenuous occupations or those wishing to continue sports [28]. The most suitable candidates are aged less than 55 years, are not obese, and have not progressed to severe symptomatic disability [18]. Notably, the age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy [7].

Medial opening-wedge high tibial osteotomy is widely accepted to produce good outcomes for younger, active patients with symptomatic medial compartment osteoarthrosis [27]. It 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]. The procedure offers a survival rate of over 96% at 5 years [11] and remains an attractive option to delay knee arthroplasty, with a survival rate of 85% at 20 years [13]. Medial opening high tibial osteotomy achieved union in 93% of cases [2], and infections after the procedure are rare [8]. Although results deteriorate over time, the procedure can be effective for periods longer than 15 years [3]. 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 [5].

Possible alterations in tibial slope and leg length are considered when the technique of high tibial osteotomy is to be chosen [17]. Transtibial drilling of tibial and femoral medial compartment cartilage defect can be combined with high tibial osteotomy without additional incisions [14], although most studies have failed to show improved clinical outcomes in the short term when adding cartilage restoration procedures [29]. 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]. 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]. Total knee arthroplasty after high tibial osteotomy seems to be technically more demanding than a primary knee arthroplasty [25], yet the clinical outcome was almost identical to a matched group that had no high tibial osteotomy previously [25]. A previous high tibial osteotomy was not determinant for having a worse outcome at total knee replacement, even when there were radiographic differences [4]. High-level evidence comparing high tibial osteotomy with alternate treatments is required for stronger recommendations [5].

Anatomy & Pathophysiology

Biomechanics and Kinematics

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

In a native knee with intact cruciate ligaments, increasing posterior tibial slope affects 6 degrees of freedom knee kinematics and decreases resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [93]. 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 have little effect on the biomechanics of the cruciate ligaments [132]. There is no change in sagittal plane knee moment, including flexion and extension moments, from before to after medial open wedge high tibial osteotomy [134].

Radiographic analysis demonstrates increased hip-knee-ankle (HKA) angles and percentage of mechanical axis (%MA), along with reduced femorotibial angle (FTA), following medial opening-wedge high tibial osteotomy [124]. In pre-operative varus knees, the mean mechanical axis on single-limb stance is more varus than on double-limb stance, whereas it changes to less valgus in post-operative valgus knees [137]. Both medial opening wedge and lateral closing wedge high tibial osteotomy techniques result in smaller changes in leg length than predicted by mathematical models [152]. The effect of varus-producing distal femoral osteotomy and high tibial osteotomy on compartment pressures and contact area is amplified as the knee flexion angle increases [118]. In the setting of meniscal transplantation, high tibial osteotomy improves peak pressures in the medial compartment at all degrees of varus/valgus alignment [154]. 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 [112].

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

Patellofemoral Joint and Posterior Tibial Slope

Open-wedge valgus high tibial osteotomy with an inverted L-shaped configuration achieves correction of axial malalignment without changing patellar height or posterior tibial slope [55]. Most patients develop significant patella baja after proximal tibial osteotomy [57]. Factors that may cause patella baja include shortening of the patellar tendon after prolonged immobilization, new bone formation at the site of the osteotomy in the area of the insertion of the patellar tendon, and fibrosis of the patellar tendon [57]. The decrease in the height of the patella has no appreciable effect on the success or failure of the osteotomy or the need for subsequent total joint replacement [57]. However, patella baja is likely to make a subsequent total knee arthroplasty more technically demanding [57]. Kinematic changes correlating with poorer postoperative functional results suggest that in patients with preexisting pathological patellar height, a modification of the classical osteotomy technique should be discussed [95]. Medial open wedge high tibial osteotomy does not relevantly alter patellar kinematics in cadaveric studies, though future clinical studies are needed to prove its effect on anterior knee pain [121].

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]. The triangular shape of the proximal tibia is a widely discussed theory for posterior tibial slope increase, as the bone’s shape demands a smaller opening of the osteotomy anteriorly than posteriorly if the posterior tibial slope is to remain unchanged [189]. Anterior plate placement may compound posterior tibial slope increase by more effectively opening the osteotomy anteriorly [189]. If the osteotomy is not performed in the frontal but rather in an oblique plane with the hinge posterolateral, the posterior tibial slope can be increased [189]. An incomplete posterior osteotomy cut and inappropriate release of posterior soft tissues can be responsible for a posterior tibial slope increase, resulting in increased opening anteriority [189]. A specific technique offers the advantage of preserving the posterior tibial slopes postoperatively even in highly deformed knees which necessitated higher degrees of corrections in the mechanical axes [138]. For smaller corrections in the coronal plane, more extreme hinge axis positions were necessary to achieve higher magnitudes of posterior tibial slope reduction in medial opening wedge high tibial osteotomy [156].

Complications and Surgical Risks

Other reported complications of proximal tibial osteotomy include recurrence of deformity (loss of correction), peroneal nerve palsy, nonunion, infection, knee stiffness or instability, intraarticular fracture, deep vein thrombosis, compartment syndrome, patella infra, and osteonecrosis of the proximal fragment [57]. Inadequate correction and recurrent varus deformity have been reported to occur in 5% to 30% of patients with proximal tibial osteotomy [57]. Recurrence of a varus deformity was the most common complication in Coventry's report of 213 proximal tibial osteotomies [57]. Coventry attributed the recurrence of varus deformity to inadequate correction at the time of surgery and suggested that overcorrection beyond the normal 5 degrees of anatomic valgus decreased the frequency of this complication [57].

Peroneal nerve injury most often is related to fibular osteotomy performed in conjunction with proximal tibial osteotomy [57]. The peroneal nerve is most at risk with osteotomy of the proximal fibula, where the nerve wraps around the neck of the fibula before dividing into deep and superficial branches [57]. Deep peroneal nerve has a potential risk of injury during open-wedge high tibial osteotomy [192]. Popliteal artery injury is rare but devastating [57]. A cadaver study demonstrated that at 90 degrees of flexion, the distance between the osteotomy blade and the popliteal artery averaged only 10.6 mm [57]. The authors of the cadaver study recommended keeping something substantial between the proximal tibia and the popliteal artery especially when using an oscillating power saw [57].

Medial opening wedge high tibial osteotomy has particular complications including lateral hinge fracture of the proximal tibia, increase in posterior tibial slope, and errors of correction [61]. The incidence of lateral hinge fracture may be between 20% and 25% [61]. Instability at the site of the osteotomy due to a lateral hinge fracture may cause delayed union, nonunion, and loss of correction requiring further surgery [61]. Takeuchi et al described three types of lateral hinge fracture: * Type I: Fracture involves an extension of the osteotomy and is just proximal to or within the tibiofibular joint [61]. * Type II: Fracture reaches the distal aspect of the tibiofibular joint [61]. * Type III: Intra-articular fracture of the tibia plateau [61].

Types II and III lateral hinge fractures require careful treatment as they are unstable compared with type I [61]. A lateral hinge fracture is usually associated with an increased opening distance of the osteotomy [61].

Indications and Patient Selection

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, with the ultimate goal of improving patient outcomes [62]. Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust [103]. Limb-length difference adjustment and matching mechanical axes achieved high levels of pain relief and knee function despite a remaining physiological varus deformity in dome-shaped osteotomy for revision of failed closing-wedge high tibial osteotomy [130]. While high tibial osteotomy is effective for active patients with medial compartment osteoarthritis, maximizing success requires understanding the vital biomechanics of the procedure [135]. 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 [150]. Limb realignment surgery (high tibial osteotomy) should be considered earlier in the treatment algorithm for patients with varus alignment and degenerative meniscal tears to address the underlying biomechanical problem [158].

Derotational high tibial osteotomy corrects lower limb rotational malalignments due to excessive tibial torsion [191]. Derotational high tibial osteotomy, with or without concomitant surgical procedures, resulted in significant improvements in the clinical and functional scores, surpassing the minimal clinically important difference [191]. Excessive external tibial torsion, femoral antetorsion, and varus or valgus may jeopardize the patellofemoral joint function, with an emphasis on rotational imbalance [191]. Deformity in the torsional alignment of the tibia leads to stress on the components of the joint, such as ligaments and cartilage, which can result in recurrent patellar subluxation and contribute to patellar maltracking and subsequently to anterior knee pain [191]. Knees with anterior knee pain display increased tibial external rotation [191]. Excessive rotation may generate medial patellofemoral ligament (MPFL) traction, causing medial pain [191]. 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 [191].

Femoral trochlear cartilage degeneration can improve after treatment by abrasion arthroplasty combined with open wedge high tibial osteotomy [193]. Neither patellar height nor limb alignment affects improvement of femoral trochlear cartilage after open wedge high tibial osteotomy combined with abrasion arthroplasty [193]. Both cadaver and clinical studies have reported negative effects of open wedge high tibial osteotomy on the patellofemoral joint, including a decrease in patellar height, increase in contact pressure and degeneration of the patellar and femoral trochlear cartilage [193]. Some researchers recommend performing closed wedge high tibial osteotomy on patients with cartilage degeneration in the patellofemoral joint [193]. Open wedge high tibial osteotomy lacks some of the disadvantages associated with closed wedge high tibial osteotomy, such as fibular osteotomy, compartment syndrome and difficulty in ensuring precise control of deformity correction [193].

When considering the use of a high tibial osteotomy in the setting of ACL deficiency, lateral closing wedge should be considered given its favorable post-operative knee kinematics [149, 153]. The 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, potentially improving long-term outcomes compared with isolated procedures [127]. Medial meniscus posterior root tears increase medial contact pressures and accelerate cartilage degeneration, particularly in varus-aligned knees [188]. High tibial osteotomy is a commonly used joint-preserving procedure for varus knees with medial compartment overload [188]. 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 [188]. The combined procedure of high tibial osteotomy and meniscal root repair demonstrated satisfactory rates of complete meniscal healing among available studies [188]. A root repair alone does not correct underlying varus malalignment, which is a key risk factor for joint degeneration [188].

Evidence of improvement in knee functions following intra-articular injection of mesenchymal stem cells after high tibial osteotomy remains limited [133]. Intra-articular injection of orthobiologics in patients undergoing high tibial osteotomy for knee osteoarthritis is safe and effective [196]. These findings suggest that knee joint distraction may be an alternative therapy for medial compartmental OA with a limited mechanical leg malalignment [148]. Correcting severe varus deformities with extensive medial soft tissue release largely did not alter knee kinematics or clinical outcome scores compared to those with minimal soft tissue release in the context of posterior-stabilized total knee arthroplasty [122].

Classification

Indications and Patient Selection: High tibial osteotomy is indicated for appropriately selected patients, particularly physiologically young, active individuals with unicompartmental knee disease [10]. The procedure treats symptomatic varus deformity of the knee [15] and is specifically indicated for medial compartment osteoarthritis [53], varus gonarthrosis [38], and spontaneous osteonecrosis of the femoral condyle [33]. Indications include medial compartment Kellgren–Lawrence grade I to IV osteoarthritis with persistent pain after at least three months of conservative treatment, a deformity centre around the proximal tibia, less than 10° of flexion contracture, and physical activity [172]. It is also indicated for medial compartment osteoarthritis with preoperative medial meniscal extrusion [67], asymptomatic mild lateral or patellofemoral degeneration [170], and Kellgren–Lawrence grade 3 or 4 radiographic severity [175].

Deformity and Alignment Criteria: A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates [22]. Indications include medial compartment osteoarthritis where the deformity centre is in the proximal tibia, as defined by measured hip-knee-ankle angle classifications [142], and a preoperative coronal plane alignment phenotype, as these phenotypes do not consistently predict patient-reported outcomes [142]. The procedure is indicated for varus deformity greater than or equal to 10° in 14.6% of cases [50] and medial compartment osteoarthritis with a preoperative HKA angle higher than or equal to 178° in 12.3% of cases [50]. For spontaneous osteonecrosis, indications include a preoperative femorotibial angle resulting in a postoperative femorotibial angle ranging from 164 to 173 degrees (7 to 16 degrees of valgus angulation) for optimal clinical results [33].

Etiology and Activity Levels: High tibial osteotomy is indicated for knee osteoarthritis, which was the primary etiology in 84% of open-wedge and 86% of closing-wedge procedures in a multicenter study [50]. Secondary indications include osteoarthritis secondary to ligament instability, posttraumatic osteoarthritis, osteonecrosis, and osteochondritis [50]. The procedure is indicated for medial compartment osteoarthritis with a preoperative Tegner activity level of 2, 3, or 4 [38]. In specific cohorts, indications included a preoperative Tegner activity level of 2 in 30 knees, 3 in 8 knees, and 4 in 6 knees [166].

Demographic and Anthropometric Parameters: Indications span a preoperative age range of 19–79 years [38] and another cohort range of 44–72 years [166]. Anthropometric indications include a preoperative body mass index range of 20.6–34.4 and a body weight range of 46–73 kg [166].

Other Considerations: 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]. High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee in the context of ACL reconstruction [19]. Indications include medial compartment osteoarthritis with Ahlbäck classification stage II or III [50], where 75.2% of knees in a multicenter cohort were classified stage II or III [50]. Preoperative assessments include a Japanese Orthopaedic Association (JOA) knee score evaluation [166], radiographic arthritic changes graded by Holden et al. classification [166], Mikulicz’s mechanical axis measurement [166], femorotibial angle (FTA) measurement [166], and opening wedge gap calculation [172].

Preoperative patellofemoral joint status requires careful consideration of the required correction angle [37]. Preoperative tibial slope is measured on lateral X-rays of the knee before surgery [50] and may be altered by the procedure [17]. Closed wedge high tibial osteotomy significantly decreases preoperative tibial slope [66], whereas the reported surgical technique of medial opening wedge high tibial osteotomy prevents alteration of the preoperative tibial slope [31]. In subtype B lateral hinge fractures, preoperative tibial slope increases over time following surgery [173]. If preoperative tibial slope is increased, it results in correction loss in the frontal plane after medial open-wedge high tibial osteotomy [165].

In a multicenter study analyzing 302 knees (210 open-wedge and 92 closed-wedge) from a cohort of 321 osteotomies (205 males and 116 females), where 19 files (5.9%) could not be used, preoperative tibial slope was comparable between open-wedge and closed-wedge groups [50]. The closed-wedge procedures had statistically higher preoperative tibial slope values [50]. The open-wedge group had statistically significant higher values in age and body mass index [50]. The distribution of preoperative HKA angles was comparable between the two groups [50], as were the etiologies [50]. The four centers performing both techniques preferred the open-wedge procedure, which was preferred in cases of substantial deformity most often greater than 8° varus [50].

Clinical Presentation

High tibial osteotomy is an underutilized procedure that warrants consideration in appropriately selected patients [10]. It serves as a valid treatment for medial symptomatic knee osteoarthritis associated with extrarticular varus malalignment [116] and is an effective approach to alleviate symptoms, correct alignment, improve stability, and preserve meniscal tissue and cartilage in sport-related cases [100]. The procedure is indicated for knees with severe varus deformity with osteoarthritis changes (stage 2), medial meniscal injury, post-traumatic deformity, and spontaneous osteonecrosis of the medial femoral condyle [54]. Additionally, it provides a satisfactory solution for constitutional high tibia vara with minor morbidity in the short-term follow-up period [49].

Indications and Patient Selection

The primary indication for inverted V-shaped high tibial osteotomy is symptomatic, isolated medial-compartment osteoarthritis knees with varus deformity, where the calculated valgus correction angle is 15° or more [54]. This technique is also useful for treating severe congenital genu varum deformity associated with Blount disease, Turner syndrome, and rickets [54]. Medial opening high tibial osteotomy demonstrates remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity [44]. Tibial osteotomy successfully alleviates knee pain in the management of malalignment associated with knee arthrosis in young or active patients [51].

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]. Patients must be diagnosed as being greater than 18 years of age with radiographic evidence of isolated medial knee joint osteoarthritis who have failed conservative measures and are ready to accept osteotomy [99]. Exclusion criteria include multicompartmental arthritis, a history of inflammatory arthritis, or a history of prior surgery (aside from ligamentous repair) of the knee joint, distal femur, or proximal tibia [99].

Bilateral and Special Considerations

Since varus is mostly a constitutional deformity, many patients present with bilateral medial knee osteoarthritis [116]. Staged procedures may leave the patient with a painful contralateral side, a subtle leg length discrepancy, and alignment differences between legs that may impair rehabilitation [116]. Simultaneous bilateral medial opening wedge osteotomy (SBHTO) has been described as a potential solution to accelerate recovery and avoid a second surgery in patients with bilateral symptomatic medial osteoarthritis [116]. Simoultaneous bilateral medial opening wedge high tibial osteotomy can be performed safely and effectively without bone grafting [116].

For knees with spontaneous osteonecrosis of the femoral condyle, high tibial osteotomy to correct a varus or valgus deformity was performed on thirty-seven knees (thirty-six patients) [33]. Preoperative pain was relieved and walking ability was improved in thirty-five knees [33]. Clinical results, as rated by a knee score, were better in those knees with osteonecrosis of the medial femoral condyle and a postoperative femorotibial angle (as measured on a standing roentgenogram) ranging from 164 to 173 degrees (7 to 16 degrees of valgus angulation) [33]. Postoperatively, the necrotic lesion disappeared in thirteen and improved in seventeen knees [33]. Roentgenographic improvement was greater in those knees in which tibial osteotomy was performed concomitantly with bone-grafting or drilling [33]. Postoperative arthrotomy in eight knees showed that the necrotic lesion was covered with a white layer of fibrocartilage in three of the four knees that had had osteotomy more than one and one-half years previously [33].

Surgical Planning and Alignment

The consensus suggests that a knee joint line obliquity (JLO) greater than 5° or a planned medial proximal tibial angle (MPTA) > 94° preferentially indicates a double level osteotomy (DLO) compared to an isolated opening wedge high tibial osteotomy (OWHTO) [104]. A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus [104]. This study aimed to analyze the corrections performed on a cohort of isolated opening wedge high tibial osteotomies (OWHTOs) prior to the recent ESSKA recommendations, with a focus on the impact of knee joint line obliquity (JLO) and medial proximal tibial angle (MPTA) on the choice of osteotomy procedure [104].

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]. It achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope [55]. The difference in post-operative angular deformities of the proximal tibia between closing wedge and opening wedge high tibial osteotomy was considered clinically irrelevant [98]. The study confirmed that clinical outcome is good with no differences between closing-wedge and opening-wedge high tibial osteotomy, except for more frequent late complications with closing-wedge osteotomy [48].

Adjunctive Procedures

This method can be combined with high tibial osteotomy without additional incisions [14]. The authors recommend the described technique for treating osteochondral defects alongside high tibial osteotomy when malalignment is present, but encourage further studies focused on the assessment and validation of the technique [23]. However, the clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy [26]. There is no limit to the type of internal fixation or prosthesis used in the osteotomy [110].

Outcomes and Complications

High tibial osteotomy can be effective for periods longer than 15 years; however, results do deteriorate over time [3]. 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]. The meta-analysis showed that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months [35]. More than 8 of 10 patients returned to sport after high tibial osteotomy [34]. After open-wedge high tibial osteotomy, clinical results showed improvement compared to pre-operative values [32].

No clinical outcome difference between varus phenotypes after medial opening‐wedge high tibial osteotomy at 2 years follow‐up was observed [114]. Our observations suggest a previous high tibial osteotomy does not influence the function or survival of a knee long term [9]. The present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different [20]. 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].

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

Technical Accuracy

High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique [24]. The technique provides intraoperative real-time guidance of the degree of correction that is accurate and reliable, representing a useful tool for the surgeon who uncommonly performs high tibial osteotomy [21]. Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy [56]. With the introduction of locking plates, providing more stable fixation, medial opening wedge high tibial osteotomy (OWHTO) technique has gained popularity because is less technically demanding and allows a fine regulation of the correction, without risks for peroneal nerve injury [116]. Many surgeons still use bone grafting in their HTO routine with a consistent increase of costs and potential harm to the patient [116]. Autologous bone grafting is related to donor site morbidity, and synthetic grafts are expensive and often associated with infection, bone collapse and nonunion [116].

Investigations

Physical examination and radiographic or advanced imaging findings must be used concomitantly to determine the source of symptoms and appropriate surgical intervention when nonsurgical measures have failed [73].

Plain radiography: Plain radiographs are appropriate initial imaging studies for most knee conditions because they allow the assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [78]. Weight-bearing AP (extension) radiographs are used to assess cartilage loss from the distal femur and tibial plateau [78]. Weight-bearing PA (Rosenberg; flexion) radiographs are used to assess cartilage loss from the posterior femur and tibial plateau [78]. Patellofemoral views are used to assess patellofemoral alignment (tilt/subluxation), patellar and trochlear morphology, osteochondral injury, and patellofemoral arthritis [78]. A notch view is used to assess posterior femoral cartilage, notch width, and osteophytes [78]. Long leg alignment views are used to determine the mechanical axis [80]. If the mechanical axis traverses the involved compartment (varus knees with medial compartment lesions or valgus knees with lateral compartment lesions), realignment may need to be considered as an initial procedure or as an adjunct to a cartilage restorative procedure [80]. Radiographs can underestimate isolated chondral lesions but may demonstrate joint space narrowing, osteophytes, sclerosis, and cysts [80]. The ability to detect subtle narrowing or an isolated chondral defect on the flexion surface may be improved with a semiflexed PA view [80].

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

CT: Three-dimensional CT reconstructions may help with preoperative planning for multiplanar osteotomy for limb malalignment [78].

Bone scan: SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy [70].

Other Considerations: Electrophysiological studies reveal peroneal nerve lesions that may be overlooked by mild weakness and hypesthesia, with a rate of lesions higher than that detected clinically [40].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacological interventions. High tibial osteotomy is indicated for patients 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 [10]. The ideal candidate is a patient under 60 years of age with isolated medial osteoarthritis, good range of motion, and no ligamentous instability [59]. The procedure is reserved for patients with strenuous occupations or those wishing to continue sports, whereas total knee arthroplasty is considered more suitable for patients over sixty years old [28]. Inverted V-shaped high tibial osteotomy is indicated for symptomatic, isolated medial-compartment osteoarthritis with varus deformity where the calculated valgus correction angle is 15° or more [54]. This specific technique can also treat severe congenital genu varum deformity associated with Blount disease, Turner syndrome, and rickets [54]. 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].

Surgical Approach / Technique: The open-wedge technique in combination with fixed-angle plates is recommended for high tibial osteotomy [63]. The reported surgical technique for medial opening wedge high tibial osteotomy allows accurate frontal alignment correction and prevents alteration of the tibial slope [31]. Proper posterior cortical osteotomy is the key step to preventing increased tibial slope, and a preserved lateral hinge is a prerequisite for successful surgery [81]. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence [43]. Technical modifications to valgus high tibial osteotomy improve the safety and reproducibility of the procedure [42]. Distal high tibial osteotomy allows improved patellofemoral joint preservation but results in increased posterior tibial slope compared to proximal high tibial osteotomy [45]. High tibial osteotomy performed with the Ilizarov system does not significantly alter tibial slope [145]. The goal of modified medial open-wedge high tibial osteotomy is the combined correction of a double varus deformity and an increased posterior tibial slope greater than 12° [41]. Anterior opening-wedge high tibial osteotomy aims to correct limb sagittal alignment and provide stability to the knee joint in the setting of genu recurvatum [62]. Derotational hybrid closed-wedge high tibial osteotomy is used to correct tibial torsional deformity causing patellar subluxation [171]. Lateral closing wedge osteotomies are an effective treatment of unicompartmental arthrosis or deformities [59]. In lateral closing wedge osteotomy, the weightbearing line should pass through the lateral 30% to 40% of the tibial plateau [59]. An acute oblique osteotomy and suture ligation procedure can shorten the fibula in lateral closing-wedge high tibial osteotomy [183]. This fibular osteotomy and ligation procedure can be completed within 10 minutes or less, and bone union at the fibular osteotomy site can be obtained within 4 months in nearly 100% of patients [183]. Three-dimensional patient specific instrumentation and cutting guides are used for medial closing wedge high tibial osteotomy to correct valgus malalignment [157]. The surgical technique for lateral opening wedge high tibial osteotomy involves an oblique skin incision between the anterior portion of the fibular head and the tibial tubercle [174]. In this procedure, the patellar tendon is secured by a blunt Hohmann retractor to protect neurovascular structures before guide pin insertion [174]. Anterior open-wedge osteotomy can be used to correct sagittal and coronal malalignment after a failed high tibial osteotomy and failed posterior cruciate ligament reconstruction [178]. The surgical technique for anterior open-wedge osteotomy involves a midline incision just medial to the tibial tuberosity starting from the level of the inferior pole of the patella to 8 cm distal to the tibial tuberosity [178]. During this procedure, a 7-cm bone block of the tibial tubercle is detached along with the attached patellar tendon as a single unit [178]. Slope-reducing high tibial osteotomy involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy [90]. High tibial osteotomy modifies patellar height depending on the technique employed [84].

Adjuncts: High tibial osteotomy with a navigator is more accurate and reproducible in the correction of the deformity compared to the standard technique [24]. Arthroscopic and computer-assisted high tibial osteotomy using standard total knee arthroplasty navigation software provides intraoperative real-time guidance of the degree of correction that is accurate and reliable [21].

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

Other Considerations: Combined high tibial osteotomy and transtibial drilling of tibial and femoral medial compartment cartilage defect can be performed without additional incisions [14]. Multicompartmental osteochondral allografts can be treated alongside high tibial osteotomy when malalignment is present [23]. High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee in conjunction with ACL reconstruction [19]. The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction, which may ultimately halt the evolution of arthritis and preserve the natural knee joint for a longer period of time [36]. Performing an anatomical double-bundle anterior cruciate ligament reconstruction on knees after valgus high tibia osteotomy may overconstrain the knee and result in high forces in the posterolateral graft, which could predispose it to failure [169].

Complications and Adverse Events: Opening-wedge high tibial osteotomy has a higher rate of adverse events compared to closing-wedge osteotomy, particularly persistent pain at the iliac crest [71]. Patients with non-union following high tibial osteotomy for osteoarthritis of the knee should undergo resection of the pseudarthrosis and transfixation compression as the treatment of choice [136].

Hardware Management: Implant removal after medial opening wedge high tibial osteotomy is a safe procedure that improves symptoms and functional scores, with improved rates of bone healing and no loss of correction after 1 year postoperatively [69].

Conversion to Total Knee 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 [20]. Total knee arthroplasty after high tibial osteotomy seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no high tibial osteotomy previously [25]. The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results [30]. Postoperative knee instability due to posterior cruciate ligament insufficiency contributes to the inferior results of posterior cruciate-retaining prostheses after high tibial osteotomy, making posterior cruciate-substituting total knee arthroplasty suitable for use after high tibial osteotomy [65]. There are no differences in postoperatively patient-reported outcome measures between patients who were converted from high tibial osteotomy to total knee arthroplasty versus primary total knee arthroplasty [182]. There is a longer length of stay in hospital in the patients who are converted from high tibial osteotomy to total knee arthroplasty compared to primary total knee arthroplasty [182]. There is no difference related to patellar height between patients converted from high tibial osteotomy to total knee arthroplasty and those undergoing primary total knee arthroplasty [182]. The hardware from previous high tibial osteotomy was retained if it did not cause symptoms and was not located where it would impede placement of the prosthesis during conversion total knee arthroplasty [177]. If necessary, a pin was placed in the tibial tubercle to further protect the patellar tendon from avulsion during conversion total knee arthroplasty after high tibial osteotomy [177].

Outcomes and Survival: With a 54.1% survival after 18 years, high tibial osteotomy is a useful facility to protract the implantation of a total knee prosthesis [58]. Medial opening high tibial osteotomy shows remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity, and it can effectively relieve the pain of knee joint with less postoperative complications [44]. If proper alignment is obtained, the procedure provides satisfactory pain relief for a lengthy period with little deterioration after the third year [91]. Open wedge high tibial osteotomy led to a significant decrease in bone tracer uptake of the medial compartment, which correlated well with knee pain and postoperative mechanical alignment [64]. High tibial osteotomy for unilateral medial knee osteoarthritis unloads the osteoarthritic area, gives pain relief, and may prevent later osteoarthritis if performed for the ideal indications [160]. Both closing wedge and open wedge techniques allowed to achieve good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis [184]. The presence of preoperative subchondral bone marrow edema may have a negative effect on postoperative pain and subjective outcome after medial open wedge high tibial osteotomy [187]. The clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy [26].

Complications

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

Nonunion and Healing: Nonunion is a reported complication occurring in 1.9% of cases [139]. Nonunions can occur after osteotomy and are more common with opening wedge osteotomies, particularly those with larger corrections [125]. Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies [211]. Delayed bone healing following high tibial osteotomy is related to increased implant stiffness in locked plating [113]. Union rates and nonunion characteristics of fibular osteotomies differ according to the level of osteotomy, apposition of bone ends, and type of accompanying high tibial osteotomy [60].

Loss of Correction and Recurrence: Loss of correction is a reported complication occurring in 1.2% of cases [139]. Loss of correction is more common in patients managed with opening wedge osteotomies compared with closing wedge osteotomies [125].

Nerve and Vascular Injury: Peroneal nerve injury is most often related to fibular osteotomy performed in conjunction with proximal tibial osteotomy [57]. Peroneal nerve complications are found to occur more commonly in closing wedge osteotomies [125]. In a cohort of young and active patients, one case of a common peroneal nerve deficit was registered that resolved spontaneously [105]. In a series of 136 knees treated with oblique high tibial osteotomy, 2 patients experienced temporary peroneal nerve dysfunction [151]. The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles [163]. Damage to the popliteal artery or tibial nerve can occur only by placing the Hohman retractor behind the muscles [163]. At 90 degrees of flexion, the distance between the osteotomy blade and the popliteal artery averaged only 10.6 mm [57]. In 250 high tibial osteotomies, the popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique [163]. In 250 high tibial osteotomies, a tibial nerve paresis occurred in 1 patient [163]. In 250 high tibial osteotomies, temporary palsy of the anterior tibialis muscle was documented in 3 patients [163]. In 250 high tibial osteotomies, palsy of the extensor hallucis longus occurred in 4 patients [163].

Infection: Infection is a reported complication occurring in 2.9% of cases [139]. In a cohort of young and active patients, one case of a deep infection was treated with debridement and antibiotic therapy [105]. In a cohort of young and active patients, 2 cases of superficial surgical wound infections were registered [105]. In a series of 136 knees treated with oblique high tibial osteotomy, 4 patients experienced superficial wound infection [151]. The use of artificial bone graft and longer anaesthesia duration are risk factors for surgical site infection after high tibial osteotomy [205]. Primary diagnosis of osteonecrosis and younger age were identified as protective factors against surgical site infection after high tibial osteotomy [205].

Thromboembolic Events: Deep vein thrombosis is a reported complication of proximal tibial osteotomy [57]. Venous thromboembolic events are potential complications of high tibial osteotomy [125]. The overall incidence of early DVT after opening-wedge high tibial osteotomy was 44.7%, with thrombi found particularly around the osteotomy site [159]. Female sex, diabetes, and hyperlipidemia are significant risk factors for DVT following medial opening-wedge high tibial osteotomy [199]. Patients undergoing closing-wedge high tibial osteotomy are at risk of postoperative VTE [200]. The overall incidence of VTE following medial open-wedge high tibial osteotomy was low in Asian patients even without chemoprophylaxis [201]. In a series of 136 knees treated with oblique high tibial osteotomy, 5 patients experienced deep vein thrombosis [151].

Patellar and Mechanical Complications: 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 [57]. Intraoperative fractures of the hinge, either medially or laterally, can impair stability, healing, and potentially disrupt the articular surface [125]. In a cohort of young and active patients, one case of residual varus-valgus instability was registered with subsequent surgery [105]. In a cohort of young and active patients, one case of residual stiffness was managed nonoperatively [105].

Hardware and Reoperation: Hardware removal was reported for 43 (67.2%) patients in a series of medial closing wedge high tibial osteotomies [161]. In a cohort of young and active patients, 21 reoperations (35.0%) were recorded [105]. In a cohort of young and active patients, 20 cases (33.3%) of plate removal for intolerance were recorded in patients who underwent medial opening-wedge high tibial osteotomy [105]. In a cohort of young and active patients, 1 case of arthroscopic surgery for osteophyte removal was recorded [105]. Clinical outcome is good with no differences between closing-wedge and opening-wedge high tibial osteotomy, except for more frequent late complications with closing-wedge osteotomy [48]. Implant failure is more common in patients managed with opening wedge osteotomies compared with closing wedge osteotomies [125].

Recovery

Light activity (weeks): Evidence does not specify a distinct timeline for desk work or driving. However, in patients with Type I and II lateral hinge fractures treated with a medial locked plate system and a relatively conservative rehabilitation protocol, full weight-bearing walking commenced at 6 weeks postoperatively [119].

Full activity (months): Most patients return to sport at a level equal to or greater than the preoperative level [197]. High tibial osteotomy for medial compartment knee osteoarthritis in active patients allows return to sports and recreational activities similar to the preoperative level [111]. In a young, high-demand population, 54.5% of knees returned to full duty without restriction, although 36.4% required reoperation [198].

Rehabilitation protocol: Absolute knee extensor strength, rather than limb symmetry, predicts outcomes and defines the rehabilitation threshold after medial opening-wedge high tibial osteotomy [126]. Large medial opening wedge procedures increase gastrocnemius tension, causing transient knee flexion contracture; these effects resolve clinically but highlight soft-tissue adaptation during recovery [123]. For Type I and II lateral hinge fractures, a relatively conservative protocol involving full weight-bearing walking at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm followup [119].

Functional milestones: High tibial osteotomy effectively unloads the knee medial compartment and redistributes knee internal loads between the medial and lateral compartments during walking and stair tasks [131]. 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 [185].

Other Considerations: Age does not have to be taken into consideration for the indication of high tibial osteotomy [7]. Patients appear to have progression of patellofemoral osteoarthritis after medial open-wedge high tibial osteotomy [128]. When performing the open wedge high tibial osteotomy, the surgeon should consider the increase in deviation of the mechanical axis and femorotibial angle after weight-bearing [68]. Most studies have failed to show improved clinical outcomes in the short term when adding cartilage restoration procedures to high tibial osteotomy, raising questions about whether longer term studies will show improved efficacy [29].

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)
• [L5] High tibial osteotomy can be utilized for deformity correction to create a more biomechanically stable knee. [19] (10.1177/2325967121s00858)
• [L3] The present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different. [20] (10.2106/00004623-200009000-00005)
• [Paper] The technique provides intraoperative real-time guidance of the degree of correction that is accurate and reliable, representing a useful tool for the surgeon who uncommonly performs high tibial osteotomy. [21] (10.1016/j.eats.2013.01.009)
• [L4] A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates for high tibial osteotomy. [22] (10.1002/ksa.12156)
• [Paper] The authors recommend the described technique for treating osteochondral defects alongside high tibial osteotomy when malalignment is present, but encourage further studies focused on the assessment and validation of the technique. [23] (10.1016/j.eats.2017.07.026)
• [L2] High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique. [24] (10.1007/s00167-011-1785-5)
• [L3] Total knee arthroplasty after high tibial osteotomy seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no high tibial osteotomy previously. [25] (10.1186/1471-2474-8-74)
• [L3] However, the clinical and radiologic outcome could not be improved by microfracture in the open wedge high tibial osteotomy. [26] (10.1186/s12891-019-2607-z)
• [Paper] In appropriately indicated patients, medial opening-wedge high tibial osteotomy is widely accepted to produce good outcomes for younger, active patients with symptomatic medial compartment osteoarthrosis. [27] (10.1016/j.csm.2019.02.003)
• [L3] Total knee arthroplasty is now considered more suitable for patients over sixty years old, while high tibial osteotomy should be reserved for patients with strenuous occupations or those wishing to continue sports. [28] (10.2106/00004623-198466070-00010)
• [L5] Most studies have failed to show improved clinical outcomes in the short term when adding cartilage restoration procedures to high tibial osteotomy, raising questions about whether longer term studies will show improved efficacy. [29] (10.1016/j.arthro.2023.07.002)
• [L4] The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results. [30] (10.1007/s00264-011-1373-9)
• [L4] The reported surgical technique of medial opening wedge high tibial osteotomy is a very accurate procedure that allows an accurate frontal alignment correction and prevents alteration of the tibial slope. [31] (10.1007/s00167-008-0717-5)
• [L4] After open-wedge high tibial osteotomy, clinical results showed improvement compared to pre-operative values. [32] (10.1007/s00167-014-3349-y)
• [L4] [33] (10.2106/00004623-198264010-00008)
• [L3] More than 8 of 10 patients returned to sport after high tibial osteotomy. [34] (10.1177/0363546519849476)
• [L1] The meta-analysis showed that high tibial osteotomy has an averaged probability of a good result in 60.3% of patients even after 100 months. [35] (10.1007/s00402-003-0545-5)
• [L4] The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction which, when combined, may ultimately halt the evolution of arthritis and preserve their natural knee joint for a longer period of time. [36] (10.1302/2058-5241.1.000001)
• [L3] High tibial osteotomy should be selected with careful consideration of the osteoarthritic status of the patellofemoral joint and required correction angle, regardless of applying a closed- or open-wedge technique. [37] (10.1177/0363546520943872)
• [L3] [38] (10.1007/s00402-002-0446-z)
• [L4] Medial opening wedge high tibial osteotomy (MOWHTO) is a radiologically and clinically rewarding procedure with a high survival rate at 5 and 10 years and a low complication rate in experienced hands. [39] (10.1016/j.jisako.2025.100703)
• [L3] The rate of peroneal nerve lesions after high tibial osteotomy is higher than that detected clinically, with electrophysiological means revealing lesions that may be overlooked by mild weakness and hypesthesia. [40] (10.1007/s001670000138)
• [L5] The goal of the modified medial open-wedge high tibial osteotomy is the combined correction of a double varus deformity (mechanical medial proximal tibia angle ◦, joint line convergence angle >2◦) and an increased posterior tibial slope >12◦. [41] (10.1016/j.eats.2025.103969)
• [L4] The presented technical modifications improve the safety and reproducibility of high tibial osteotomy. [42] (10.1007/s00167-002-0334-7)
• [L4] Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. [43] (10.1177/0363546510388929)
• [L3] Medial opening high tibial osteotomy shows remarkable therapeutic effect for patients with knee osteoarthritis associated with varus tibial deformity, and it can effectively relief the pain of knee joint with less postoperative complications. [44] (10.1177/2325967120s00543)
• [L3] Distal high tibial osteotomy (DTO) allows improved patellofemoral joint preservation but results in increased posterior tibial slope compared to proximal high tibial osteotomy (PTO). [45] (10.1016/j.arthro.2025.05.017)
• [L5] These kinematic changes should be considered when selecting the surgical technique for patients with medial osteoarthritis. [46] (10.1007/s00167-007-0305-0)
• [L5] Instability at the osteotomy site may contribute to the high rate of delayed union or nonunion associated with medial opening wedge high tibial osteotomy. [47] (10.1177/0363546505275488)
• [L4] The study confirmed that clinical outcome is good with no differences between closing-wedge and opening-wedge high tibial osteotomy, except for more frequent late complications with closing-wedge osteotomy. [48] (10.1016/j.otsr.2017.07.011)
• [L4] Open-wedge high tibia osteotomy provides a satisfactory solution for constitutional high tibia vara with minor morbidity on behalf of the patient in the short-term follow-up period. [49] (10.1007/s00167-010-1148-7)
• [L3] [50] (10.1016/j.otsr.2011.08.013)
• [L5] Tibial osteotomy can successfully alleviate knee pain in the management of malalignment associated with knee arthrosis in young or active patients. [51] (10.1016/j.csm.2009.12.005)
• [L1] [53] (10.1302/0301-620x.99b9.bjj-2017-0062.r1)
• [Paper] [54] (10.1016/j.eats.2018.06.005)
• [Paper] It achieves a correction of the axial malalignment without changing patellar height or posterior tibial slope. [55] (10.1016/j.eats.2017.08.009)
• [L3] [56] (10.1186/s12891-021-04475-3)
• [Paper] With a 54.1% survival after 18 years, high tibial osteotomy is a useful facility to protract the implantation of a total knee prosthesis. [58] (10.1007/s00402-007-0438-0)
• [Paper] [59] (10.1016/j.csm.2019.02.002)
• [L3] Union rates and nonunion characteristics of fibular osteotomies differ according to the level of osteotomy, apposition of bone ends, and type of accompanying high tibial osteotomy. [60] (10.1007/s00402-016-2493-x)
• [L3] [61] (10.1302/0301-620x.99b7.bjj-2016-0927.r1)
• [L5] The surgical technique aims to correct the limb sagittal alignment and provide stability to the knee joint, with the ultimate goal of improving patient outcomes. [62] (10.1016/j.eats.2023.06.007)
• [L3] The authors recommend the open-wedge technique in combination with fixed-angle plates for high tibial osteotomy. [63] (10.1007/s00167-009-1020-9)
• [L3] Open wedge high tibial osteotomy led to a significant decrease in bone tracer uptake of the medial compartment, which correlated well with knee pain and postoperative mechanical alignment. [64] (10.1016/j.arthro.2017.08.123)
• [L3] Postoperative knee instability due to posterior cruciate ligament insufficiency contributes to the inferior results of posterior cruciate-retaining prostheses after high tibial osteotomy, making posterior cruciate-substituting total knee arthroplasty suitable for use after high tibial osteotomy. [65] (10.1007/s00167-009-0790-4)
• [L4] A closed wedge high tibial osteotomy significantly decreases the posterior tibial slope. [66] (10.1007/s00167-005-0700-3)
• [L3] [67] (10.2106/jbjs.21.00456)
• [L4] When performing the open wedge high tibial osteotomy, the surgeon should consider the increase in deviation of the mechanical axis and femorotibial angle after weight-bearing. [68] (10.1007/s00167-009-1000-0)
• [L5] Implant removal after medial opening wedge high tibial osteotomy is a safe procedure that improves symptoms and functional scores, with improved rates of bone healing and no loss of correction after 1 year postoperatively. [69] (10.1016/j.arthro.2024.01.010)
• [L2] SPECT/CT could be used for assessment of adequate correction and healing after high tibial osteotomy. [70] (10.1007/s00167-014-3053-y)
• [L3] Opening-wedge high tibial osteotomy has a higher rate of adverse events compared to closing-wedge osteotomy, particularly persistent pain at the iliac crest. [71] (10.1007/s00167-015-3644-2)
• [L5] Proper posterior cortical osteotomy is the key step to preventing increased tibial slope in open-wedge high tibial osteotomy, and a preserved lateral hinge is a prerequisite for successful surgery. [81] (10.1016/j.arthro.2021.03.082)
• [L3] High tibial osteotomy modifies patellar height depending on the technique employed. [84] (10.1007/s002640000173)
• [L3] HTO resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment. [88] (10.1007/s00167-011-1496-y)
• [L5] The surgical technique involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy. [90] (10.1016/j.eats.2022.07.019)
• [L3] Preoperative gait characteristics, specifically the knee adduction moment, are predictive of postoperative clinical results; patients with lower preoperative adduction moments had substantially better clinical outcomes. [92] (10.2106/00004623-198567080-00007)
• [L5] Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. [93] (10.1002/ksa.12577)
• [L3] These findings are consistent with an intended, sustained shift in the mediolateral distribution of knee loads. [94] (10.1177/0363546515591995)
• [L3] These kinematic changes correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed. [95] (10.1177/2325967116s00039)
• [L5] Tibial flexion osteotomy significantly affects cartilage pressure and kinematics of the knee joint. [96] (10.1007/s00402-004-0728-8)
• [L2] The difference in post-operative angular deformities of the proximal tibia between closing wedge and opening wedge high tibial osteotomy was considered clinically irrelevant. [98] (10.1007/s00167-016-4074-5)
• [L1] [99] (10.1186/s13018-022-03299-8)
• [L5] High Tibial Osteotomy is an effective approach to alleviate symptoms, correct alignment, improve stability, and preserve meniscal tissue and cartilage in sport-related cases, though careful patient selection and evaluation are essential to maximize successful outcomes. [100] (10.1177/2325967124s00386)
• [L4] Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust. [103] (10.1177/0363546503258907)
• [L4] [104] (10.1007/s00167-023-07518-5)
• [L4] [105] (10.1177/03635465251322795)
• [L4] [108] (10.1002/ksa.12807)
• [L4] [109] (10.1007/s00167-012-2289-7)
• [L1] [110] (10.1186/s13018-022-03231-0)
• [L4] High tibial osteotomy for the treatment of medial compartment knee osteoarthritis in the active patient demonstrated favorable clinical results and allowed patients to return to sports and recreational activities similar to the preoperative level. [111] (10.1177/0363546508325666)
• [L5] The non-anchored free-floating device remains within the medial knee joint gap under challenging dynamic loading situations without indicating any luxation tendencies. [112] (10.1186/s40634-023-00576-1)
• [L4] [113] (10.1016/j.injury.2014.04.018)
• [L4] [114] (10.1002/ksa.12099)
• [L4] [116] (10.1186/s12891-024-08022-8)
• [L5] This effect is amplified as the knee flexion angle increases. [118] (10.1177/2325967123s00049)
• [L4] Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a medial locked plate system and relatively conservative rehabilitation protocol with full weight-bearing walking commenced at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm followup. [119] (10.1016/j.arthro.2018.07.022)
• [L5] The position of the loading axis in the frontal plane has a strong effect on the tibiofemoral cartilage pressure distribution of the knee. [120] (10.1016/j.arthro.2007.05.018)
• [L5] Future clinical studies have to prove the effect of MOWHTO on patellar kinematics measured in this experimental setup, especially regarding its influence on anterior knee pain. [121] (10.1007/s00402-020-03578-1)
• [L2] Correcting severe varus deformities with extensive medial soft tissue release largely did not alter knee kinematics or clinical outcome scores compared to those with minimal soft tissue release. [122] (10.1016/j.arth.2019.02.026)
• [L4] Large medial opening wedge high tibial osteotomy increases gastrocnemius tension, causing transient knee flexion contracture; effects resolve clinically but highlight soft-tissue adaptation in recovery. [123] (10.1016/j.jisako.2026.101146)
• [L4] Radiographic analysis demonstrated increased hip-knee-ankle (HKA) angles and percentage of mechanical axis (%MA), along with reduced femorotibial angle (FTA). [124] (10.1177/23259671261450211)
• [L5] [125] (10.5435/jaaos-d-23-00323)
• [L2] Absolute knee extensor strength, not limb symmetry, predicts outcomes and defines a rehabilitation threshold after medial opening-wedge high tibial osteotomy. [126] (10.1002/ksa.70535)
• [L5] This combined approach enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment, potentially improving long-term outcomes compared with isolated procedures. [127] (10.1002/atn2.70123)
• [L1] Patients appear to have progression of patellofemoral osteoarthritis after medial open-wedge high tibial osteotomy. [128] (10.1016/j.arthro.2021.04.015)
• [L4] Limb-length difference adjustment and matching mechanical axes achieved high levels of pain relief and knee function despite a remaining physiological varus deformity. [130] (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. [131] (10.1002/ksa.70348)
• [L1] The magnitude of change after open- and closed-wedge HTO was similar and small (approximately 2°), suggesting that both osteotomy techniques may have little effect on the biomechanics of the cruciate ligaments. [132] (10.1177/0363546515626172)
• [L1] However, evidence of improvement in knee functions remains limited. [133] (10.1177/23259671221133784)
• [L2] There was no change in sagittal plane knee moment, including flexion and extension moments, from before to after medial open wedge HTO. [134] (10.1186/s12891-019-2472-9)
• [L4] 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. [135] (10.1155/2019/8363128)
• [L4] Patients with non-union following high tibial osteotomy for osteoarthritis of the knee should undergo resection of the pseudarthrosis and transfixation compression as the treatment of choice. [136] (10.2106/00004623-197860070-00018)
• [L3] In pre-operative varus knee, the mean mechanical axis on single-limb stance was more varus than on double-limb stance, whereas it changed to less valgus in post-operative valgus knee. [137] (10.1007/s00264-016-3279-z)
• [L4] This technique offered the advantage of preserving the posterior tibial slopes postoperatively even in highly deformed knees which necessitated higher degrees of corrections in the mechanical axes. [138] (10.1177/2325967117s00052)
• [L4] Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). [139] (10.1177/03635465221142868)
• [L3] Three-dimensional kinematic analysis detects changes due to HTO that standard radiographs do not identify, including changes in the PF joint. [140] (10.1016/j.arthro.2013.07.039)
• [L4] A low rate of serious complications (6.5%) requiring unplanned additional surgery was found. [141] (10.1007/s00167-020-06199-8)
• [L3] [142] (10.1016/j.jisako.2026.101204)
• [L2] Gait adaptations known to reduce knee loading employed pre-HTO were not retained post-HTO. [143] (10.1007/s00167-019-05644-7)
• [L4] As there is no significant alteration in tibial slope after high tibial osteotomy performed with the Ilizarov system, complications due to alteration in tibial slope will not be experienced in follow-up or in further total knee prosthesis procedure. [145] (10.1007/s00167-006-0151-5)
• [L5] The results show that implant design strongly influences stability after opening wedge valgus high tibial osteotomy, with short designs being inferior to longer designs. [147] (10.1007/s00167-005-0690-1)
• [L1] These findings suggest that knee joint distraction may be an alternative therapy for medial compartmental OA with a limited mechanical leg malalignment. [148] (10.1007/s00167-016-4131-0)
• [L5] When considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its favorable post-operative knee kinematics. [149] (10.1177/2325967114s00052)
• [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. [150] (10.1016/j.arthro.2023.08.009)
• [L4] [151] (10.1007/s00167-006-0053-6)
• [L3] Both techniques resulted in smaller changes in leg length than predicted by mathematical models. [152] (10.1177/0363546511410025)
• [L5] When considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its favorable postoperative knee kinematics. [153] (10.1016/j.arthro.2014.04.068)
• [L5] This biomechanical study confirms the hypothesis that an HTO improves the peak pressures in the medial compartment at all degrees of varus/valgus alignment in the setting of meniscal transplantation. [154] (10.1055/s-0031-1275401)
• [L4] For smaller corrections in the coronal plane, more extreme hinge axis positions were necessary to achieve higher magnitudes of posterior tibial slope reduction. [156] (10.1177/23259671221094346)
• [L5] [157] (10.1016/j.eats.2021.08.030)
• [L5] The authors propose that limb realignment surgery (HTO) should be considered earlier in the treatment algorithm for patients with varus alignment and degenerative meniscal tears to address the underlying biomechanical problem. [158] (10.1016/j.csm.2019.02.010)
• [L3] The overall incidence of early DVT after OWHTO was 44.7%, with thrombi found particularly around the osteotomy site. [159] (10.1177/23259671211030883)
• [L5] High tibial osteotomy for unilateral medial knee osteoarthritis unloads the osteoarthritic area, gives pain relief, and may prevent later osteoarthritis if performed for the ideal indications. [160] (10.1016/j.arthro.2019.10.039)
• [L4] [161] (10.1002/ksa.70176)
• [L4] [163] (10.1007/s001670050114)
• [L3] [165] (10.1007/s00167-011-1610-1)
• [L4] [166] (10.1007/s00167-006-0077-y)
• [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)
• [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)
• [L3] [170] (10.1177/2325967120927481)
• [L5] [171] (10.1016/j.eats.2023.05.017)
• [L3] [172] (10.1302/0301-620x.97b9.34949)
• [L4] [173] (10.1007/s00167-018-4977-4)
• [Paper] [174] (10.1016/j.csm.2019.02.012)
• [L4] [175] (10.1186/s12891-026-09779-w)
• [L3] [177] (10.1007/s00167-014-3259-z)
• [L5] [178] (10.1016/j.eats.2024.103032)
• [L3] [182] (10.1016/j.jisako.2025.100931)
• [Paper] [183] (10.1016/j.eats.2020.05.008)
• [L3] Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis. [184] (10.1002/ksa.12026)
• [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. [185] (10.1016/j.arthro.2013.10.008)
• [L1] This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively. [186] (10.1016/j.arthro.2014.04.104)
• [L3] The presence of preoperative subchondral bone marrow edema may have a negative effect on postoperative pain and subjective outcome after medial open wedge high tibial osteotomy. [187] (10.1016/j.arthro.2017.08.121)
• [L1] [188] (10.1016/j.jisako.2025.101035)
• [L5] [189] (10.1007/s00167-014-3100-8)
• [L4] [191] (10.1016/j.jisako.2024.02.015)
• [L4] [192] (10.1007/s00167-019-05445-y)
• [L5] [193] (10.1136/jisakos-2020-000575)
• [L1] [196] (10.1186/s40634-021-00387-2)
• [L4] Most patients return to sport at a level equal to or greater than the preoperative level. [197] (10.2106/jbjs.16.00036)
• [L4] In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. [198] (10.1177/23259671241252410)
• [L3] This study identified a high incidence of DVT following MOWHTO and demonstrated that female sex, diabetes and hyperlipidemia were significant risk factors. [199] (10.1186/s12891-025-08713-w)
• [L2] Patients undergoing CWHTO are at risk of postoperative VTE. [200] (10.1016/j.otsr.2017.07.016)
• [L2] The overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis, suggesting routine chemoprophylaxis may not be necessary in this population. [201] (10.1055/s-0039-1700976)
• [L4] In this series, the rate of complications was low and approximately two-thirds of the knees had a good or excellent clinical result at an average of 8.5 years. [204] (10.2106/00004623-200001000-00009)
• [L3] The study revealed novel risk factors for surgical site infection after high tibial osteotomy, including the use of artificial bone graft and longer anaesthesia duration, while primary diagnosis of osteonecrosis and younger age were identified as protective factors. [205] (10.1007/s00167-020-05943-4)
• [L4] Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. [211] (10.1016/j.arthro.2015.04.097)

See Also

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

References

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

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

[110] Distal tibial tubercle osteotomy can lessen change in patellar height post medial opening wedge high tibial osteotomy? A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03231-0

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

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

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

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

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

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

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

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

[130] Dome-Shaped Osteotomy for Revision of Failed Closing-Wedge High Tibial Osteotomy. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119857047

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

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

[133] Intra-articular Injection of Mesenchymal Stem Cells After High Tibial Osteotomy: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221133784

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

[135] High Tibial Osteotomy: Review of Techniques and Biomechanics. Journal of Healthcare Engineering. 2019. DOI: 10.1155/2019/8363128

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

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

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

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

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

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

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

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

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

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

[148] Knee joint distraction compared with high tibial osteotomy: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4131-0

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

[150] Editorial Commentary: High Tibial Osteotomy and Distal Femoral Osteotomy Address Biologics and Biomechanics. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.08.009

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

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

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

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

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

[157] 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

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

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

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

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

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

[165] Increase in posterior tibial slope would result in correction loss in frontal plane after medial open‐wedge high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1610-1

[166] High tibial osteotomy that does not cause recurrence of varus deformity for medial gonarthrosis. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0077-y

[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

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

[170] Are There Harmful Effects of Preoperative Mild Lateral or Patellofemoral Degeneration on the Outcomes of Open Wedge High Tibial Osteotomy for Medial Compartmental Osteoarthritis?. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120927481

[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

[172] 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

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

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

[175] Hybrid closed wedge high tibial osteotomy is associated with short-term arthroscopic changes in the patellofemoral joint. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09779-w

[177] 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

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

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

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

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

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

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

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

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

[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

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

[192] 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

[193] 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

[196] Intra‐articular injection of orthobiologics in patients undergoing high tibial osteotomy for knee osteoarthritis is safe and effective – a systematic review. Journal of Experimental Orthopaedics. 2021. DOI: 10.1186/s40634-021-00387-2

[197] Return to Work and Sport Following High Tibial Osteotomy. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.16.00036

[198] 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

[199] 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

[200] 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

[201] 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] High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200001000-00009

[205] 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

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