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Closing vs. Opening Wedge High Tibial Osteotomy for Osteoarthritis of the Knee

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The debate over whether to perform a closing or an opening wedge high tibial osteotomy for medial compartment osteoarthritis of the knee in a young active individual is presented.

Viewpoint 1: John F. Rudan, MD, FRCSC

Closing Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis

High tibial osteotomy is an effective treatment for mild to moderate medial compartment osteoarthritis of the knee in physiologically young and active people. Good to excellent clinical results are reported in more than 90% of patients over 10 years.1

The major pitfalls associated with failures are most frequently related to two factors. Firstly, overextending the indications for surgery to patients with severe medial compartment plus or minus severe symptomatic patello-femoral disease is associated with earlier clinical failure. The second causal factor of failure is due to over- or under-correction of femoral-tibial alignment. The most common problem is an anatomic axis correction to less than seven degrees of valgus or over-correction of the anatomic axis with alignment greater than 12 degrees of valgus.


Planning appropriate correction is important. Three foot standing X-rays are essential with a ruler to determine magnification error. Be aware that approximately 4 degrees of additional correction, beyond the correction calculated from the removal of bone, occurs in patients with a femoral shaft-transcondylar angle of greater than 10 degrees of valgus. As a result, these patients are prone to excessive valgus over-correction.2

Through a midline anterior skin incision, I expose the proximal tibia laterally, reflecting the anterior compartment muscles to expose the proximal tibial-fibular joint. Care is taken not to dissect below the inferior capsule. This protects the peroneal nerve. Using the image intensifier, I place guide pins parallel to the tibial articular surface at least 1 cm from the articular surface. From my calculations, I measure the absolute distance of the lateral cortex to be removed for the desired angle of correction. Measurement of the distance is calculated from the standing X-rays with compensation for magnification.

A second K-wire is inserted using the image intensifier control so as to mark the desired lateral cortical bone resection. The lower K-wire is placed such that the osteotomy will be above the tibial tubercle. Resection using an oscicllating saw is performed between the K-wires. Care is taken to cut the distal and proximal planes parallel to each other in the sagittal plane to prevent loss of posterior slope tibia of the tibia.

The osteotomy is completed by osteoclasis. The correction is reviewed under image intensification. Should the osteotomy open medially, a staple is placed medially maintain closure of the osteotomy. Two staples are placed laterally, and images are used to check that the staples do not penetrate the knee joint.

No casting is needed. Full range of motion and weight-bearing are tolerated and are started immediately postoperatively. Recently, we have been performing the osteotomy using computer-assisted techniques to improve osteotomy accuracy. Results using this technology have shown a statistically significant improvement in angular corrections.


  1. Rudan JF, Simurda MA, 1991. "Valgus high tibial osteotomy. A long-term follow-up study." Clin Orthop Relat Res (268): 157-60
  2. Rudan J, Harrison M, Simurda MA, 1999. "Optimizing femorotibial alignment in high tibial osteotomy." Can J Surg 42 (5): 366-70

Viewpoint 2: Peter J. Fowler, MD, FRCSC

Opening Wedge High Tibial Osteotomy

Osteotomy about the knee is a good, time-tested procedure for knee pain and/or disability related to arthrosis with malalignment.1-4 Deficiency of the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL), meniscal status, and severity of malalignment affect articular cartilage wear patterns differently. For example, in medial compartment arthrosis with an intact ACL, tibial degeneration is generally mid and anterior, while in ACL deficiency, it is more posterior.

It is important to tailor individual osteotomies to correctly deal with underlying pathology. A factor that has not historically been given consideration in planning or carrying out high tibial osteotomy (HTO) is sagittal alignment. A recent study by Giffin et al5 demonstrated that increasing the posterior tibial slope causes an anterior shift in the tibial resting position that is accentuated under axial loads. The authors suggest that increasing tibial slope may benefit a PCL deficient knee but aggravate an ACL-deficient knee.


Consequently, alterations in tibial slope should be avoided in specific situations but planned in others. In opening wedge HTO, the above-mentioned pathologies can be adequately addressed with a single cut. Additionally, the proximal tibio-fibular joint, the peroneal nerve and anterior compartment of the leg are remote from the surgical site. Most problems associated with violating these are avoided. Also, achieving smaller corrections of 5 mm or less is technically easier.

Preoperative planning is based on a radiographic evaluation of the extent of arthrosis and lower extremity alignment on bilateral weight-bearing anteroposterior views in extension, bilateral weight-bearing posteroanterior tunnel views in 30 degrees of flexion, and lateral and skyline views. True lateral views, ie, with the medial and lateral femoral condyles overlying, are necessary for assessment of the wear pattern and for accurate measurement of the posterior tibial slope angle. We use the Noyes method on hip-to-ankle views to estimate the amount of correction required.6

Fixation is with four-hole Puddu tapered wedge plates (Arthrex Inc.; Naples, Fla.). The taper allows better control of the posterior tibial slope. Alternative fixation methods include other plate and screw systems, bone grafting alone and external fixators. Helpful to the procedure is a mobile low-dose ionizing radiation fluoroscope.

Technical Points

Optimal Guide Pin Placement. The pin is drilled from approximately 4 cm below the medial joint line and, using the tip of the fibular head as reference, advanced across the superior aspect of the tibial tubercle to 1 cm below the lateral joint line. This is repeated as often as necessary to attain the best possible pin placement. Note that the orientation of the guide pin will be oblique and, that while greater obliquity increases the risk of fracture into the lateral compartment, it will, on the other hand, give the osteotomy increased depth.

Creating the Osteotomy. Osteotomizing the tibia parallel to the posterior tibial slope and below the guide pin should avert intra-articular fracture. We use a small oscillating saw to perforate the medial tibial cortex, and complete the osteotomy with thin, flexible osteotomes. Continuous or frequent imaging verifies that the osteotome is not misdirected nor the lateral cortex violated. Stop 1 cm short of the lateral cortex.

Opening the Osteotomy. Confirming that the anterior and posterior cortices are osteotomized prior to opening the osteotomy is another precaution taken to avoid intra-articular fractures. Distract the osteotomy slowly to the pre-planned correction using a calibrated wedge. Evaluate alignment using an external guide aligning the centre of the hip with the centre of the ankle.

Assessment of Posterior Tibial Slope. To maintain the tibial slope, the osteotomy distraction anteriorly should be that at the posteromedial border. A single limb of the calibrated wedge inserted posteromedially is helpful.

Plate Fixation. The plate is secured with 6.5 cancellous screws proximally and 4.5 cortical screws distally. Fluoroscopic evaluation will prevent intra-articular screw placement.

Bone Grafting. Allograft, autograft or, occasionally, bone substitutes are used in corrections greater than 7.5 mm.

Medial Collateral Ligament. If this becomes too taut, it is fenestrated and allowed to slide.

Weight bearing. Depending on the amount of correction and the stability of the construct, weight-bearing progresses from partial to full protected (with crutches) over 12 weeks – at which time there is, in most cases, complete union.

(Note: Technical Points section based on Fowler PJ, Tan JL, Brown GA: Medial opening wedge high tibial osteotomy: How I do it. Operative Techniques in Sports Medicine. 8(1):32-38, 2000.)


  1. Coventry MB, Ilstrup DM, Wallrichs SL, 1993. "Proximal tibial osteotomy. A critical long-term study of eighty-seven cases." J Bone Joint Surg Am 75 (2): 196-201
  2. Ivarsson I, Myrnerts R, Gillquist J, 1990. "High tibial osteotomy for medial osteoarthritis of the knee. A 5 to 7 and 11 year follow-up." J Bone Joint Surg Br 72 (2): 238-44
  3. Rudan JF, Simurda MA, 1991. "Valgus high tibial osteotomy. A long-term follow-up study." Clin Orthop Relat Res (268): 157-60
  4. Yasuda K, Majima T, Tsuchida T, Kaneda K, 1992. "A ten- to 15-year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis." Clin Orthop Relat Res (282): 186-95
  5. Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD, 2004. "Effects of increasing tibial slope on the biomechanics of the knee." Am J Sports Med 32 (2): 376-82
  6. Dugdale TW, Noyes FR, Styer D, 1992. "Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length." Clin Orthop Relat Res (274): 248-64


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