High tibial osteotomy increases patellofemoral pressure if adverted proximal, while open-wedge HTO with distal biplanar osteotomy discharges the patellofemoral joint: different open-wedge high tibial osteotomies compared to an extra-articular unloading device

  • Ferdinand KloosEmail author
  • Christoph Becher
  • Benjamin Fleischer
  • Matthias J. Feucht
  • Lisa Hohloch
  • Norbert Südkamp
  • Philipp Niemeyer
  • Gerrit Bode



Valgus high tibial osteotomy (HTO) and a recently introduced extra-articular absorber have been shown to efficiently unload the medial compartment of the knee. However, only little is known about the influence of these treatment modalities on biomechanics of the patellofemoral joint. The purpose of this study was to investigate and compare the impact of different HTO techniques and implantation of an extra-articular absorber on patellofemoral contact forces.


Fourteen fresh frozen cadaveric knees were tested in a specially designed knee simulator that allowed simulation of isokinetic flexion–extension motions under physiological loading. Mean contact pressure (ACP) and peak contact pressure (PCP) of the patellofemoral joint was measured continuously between 0° and 120° of knee flexion using a pressure sensitive film in the following conditions: native, after biplanar medial open-wedge HTO with 5° and 10° correction angle performing an ascending frontal osteotomy of the tibial tuberosity, and after implantation of an extra-articular absorber system (KineSpring®). Including a second testing cycle with a biplanar medial open-wedge HTO with 5° and 10° correction angle performing descending frontal osteotomy of the tibial tuberosity. Values after each procedure were compared to the corresponding values of the native knee.


Biplanar proximal osteotomy leaded to a significant increase of retropatellar compartment area contact pressure compared to the first untreated test cycle (Δ 0.04 ± 0.01 MPa, p = 0.04). Similar results were observed measuring peak contact pressure (Δ 1.41 ± 0.15 MPa, p = 0.03). With greater correction angle 5°, respectively, 10° peak and contact pressure increased accordingly. In contrast, the biplanar distal osteotomy group showed significant decrease of pressure values (p = 0.004). The extracapsular, extra-articular absorber had no significant influence on pressure levels in the patellofemoral joint.


HTO with a proximal biplanar osteotomy of the tuberositas tibia significantly increased patellofemoral pressure conditions depending on the correction angle. In contrast a distally directed biplanar osteotomy diminished these effects while implantation of an extracapsular, extra-articular absorber had no influence on the patellofemoral compartment at all. Consequently, patients with varus alignment with additional retropatellar chondropathia should be treated with a distally adverted osteotomy to avoid further undesirable pressure elevation in the patellofemoral joint.


Unicompartimental osteoarthritis Unloading Osteotomy Medial compartment Patellofemoral compartment 



Funding was provided by Müller-Fahnenberg Stiftung.


The study was funded by the Müller-Fahnenberg Study of Freiburg University.

Compliance with ethical standards

Conflict of interest

None of the authors has any conflict of interest.

Ethical approval

The ethics committee of Hannover University approved this study (ID 3083-2016).


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of MedicineAlbert-Ludwigs-University of FreiburgFreiburgGermany
  2. 2.Orthopaedic DepartmentHannover Medical SchoolHannoverGermany

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