Classical target coronal alignment in high tibial osteotomy demonstrates validity in terms of knee kinematics and kinetics in a computer model

  • 243 Accesses



The purpose of this study was to determine the ideal coronal alignment under dynamic conditions after open-wedge high tibial osteotomy (OWHTO). It was hypothesised that, although the classical target alignment was based on experimental evidence, it would demonstrate biomechanical validity.


Musculoskeletal computer models were analysed with various degrees of coronal correction in OWHTO during gait and squat, specifically with the mechanical axis passing through points at 40%, 50%, 60%, 62.5%, 70%, and 80% of the tibial plateau from the medial edge, defined as the weight-bearing line percentage (WBL%). The peak load on the lateral tibiofemoral (TF) joint, the medial collateral ligament (MCL), and anterior cruciate ligament (ACL) tensions, and knee kinematics with or without increased posterior tibial slope (PTS) were evaluated.


The classical alignment with WBL62.5% achieved sufficient load on the lateral TF joint and maintained normal knee kinematics after OWHTO. However, over-correction with WBL80% caused an excessive lateral load and non-physiological kinematics. Increased WBL% resulted in increased MCL tension due to lateral femoral movement against the tibia. With WBL80%, abnormal contact between the medial femoral condyle and the medial intercondylar eminence of the tibia occurred at knee extension. The screw-home movement around knee extension and the TF rotational angle during flexion were reduced as WBL% increased. Increased PTS was associated with increased ACL tension and decreased TF rotation angle because of ligamentous imbalance.


The classical target alignment demonstrated validity in OWHTO, and over-correction should be avoided as it negatively impacts clinical outcome.

Level of evidence


This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8


  1. 1.

    Akamatsu Y, Kumagai K, Kobayashi H, Tsuji M, Saito T (2018) Effect of increased coronal inclination of the tibial plateau after opening-wedge high tibial osteotomy. Arthroscopy 34:2158–2169

  2. 2.

    Akamatsu Y, Mitsugi N, Mochida Y, Taki N, Kobayashi H, Takeuchi R et al (2012) Navigated opening wedge high tibial osteotomy improves intraoperative correction angle compared with conventional method. Knee Surg Sports Traumatol Arthrosc 20:586–593

  3. 3.

    Akamatsu Y, Ohno S, Kobayashi H, Kusayama Y, Kumagai K, Saito T (2017) Coronal subluxation of the proximal tibia relative to the distal femur after opening wedge high tibial osteotomy. Knee 24:70–75

  4. 4.

    Bagherifard A, Jabalameli M, Mirzaei A, Khodabandeh A, Abedi M, Yahyazadeh H (2019) Retaining the medial collateral ligament in high tibial medial open-wedge osteotomy mostly results in post-operative intra-articular gap reduction. Knee Surg Sports Traumatol Arthrosc.

  5. 5.

    Bode G, von Heyden J, Pestka J, Schmal H, Salzmann G, Sudkamp N et al (2015) Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:1949–1955

  6. 6.

    D’Lima DD, Patil S, Steklov N, Chien S, Colwell CW Jr (2007) In vivo knee moments and shear after total knee arthroplasty. J Biomech 40(Suppl 1):S11–S17

  7. 7.

    Dugdale T, Noyes F, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264

  8. 8.

    Feucht MJ, Minzlaff P, Saier T, Cotic M, Südkamp NP, Niemeyer P et al (2014) Degree of axis correction in valgus high tibial osteotomy: proposal of an individualised approach. Int Orthop 38:2273–2280

  9. 9.

    Fujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin N Am 10:585–608

  10. 10.

    Hamai S, Miura H, Higaki H, Matsuda S, Shimoto T, Sasaki K et al (2008) Kinematic analysis of kneeling in cruciate-retaining and posterior-stabilized total knee arthroplasties. J Orthop Res 26:435–442

  11. 11.

    Han JH, Kim HJ, Song JG, Yang JH, Nakamura R, Shah D et al (2015) Locking plate versus non-locking plate in open-wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 25:808–816

  12. 12.

    Hatsushika D, Nimura A, Mochizuki T, Yamaguchi K, Muneta T, Akita K (2013) Attachments of separate small bundles of human posterior cruciate ligament: an anatomic study. Knee Surg Sports Traumatol Arthrosc 21:998–1004

  13. 13.

    Hohloch L, Kim S, Mehl J, Zwingmann J, Feucht MJ, Eberbach H et al (2018) Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy. Knee Surg Sports Traumatol Arthrosc 26:2766–2773

  14. 14.

    Innocenti B, Pianigiani S, Labey L, Victor J, Bellemans J (2011) Contact forces in several TKA designs during squatting: a numerical sensitivity analysis. J Biomech 44:1573–1581

  15. 15.

    Jacobi M, Villa V, Reischl N, Demey G, Goy D, Neyret P et al (2015) Factors influencing posterior tibial slope and tibial rotation in opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:2762–2768

  16. 16.

    Jo HS, Park JS, Byun JH, Lee YB, Choi YL, Cho SH et al (2018) The effects of different hinge positions on posterior tibial slope in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 26:1851–1858

  17. 17.

    Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski MP, Devitt BM, Aroen A et al (2013) Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med 41:2828–2838

  18. 18.

    Kim HJ, Park J, Shin JY, Park IH, Park KH, Kyung HS (2018) More accurate correction can be obtained using a three-dimensional printed model in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 26:3452–3458

  19. 19.

    Kim SJ, Koh YG, Chun YM, Kim YC, Park YS, Sung CH (2009) Medial opening wedge high-tibial osteotomy using a kinematic navigation system versus a conventional method: a 1-year retrospective, comparative study. Knee Surg Sports Traumatol Arthrosc 17:128–134

  20. 20.

    Kuriyama S, Ishikawa M, Furu M, Ito H, Matsuda S (2014) Malrotated tibial component increases medial collateral ligament tension in total knee arthroplasty. J Orthop Res 32:1658–1666

  21. 21.

    Kuriyama S, Ishikawa M, Nakamura S, Furu M, Ito H, Matsuda S (2016) No condylar lift-off occurs because of excessive lateral soft tissue laxity in neutrally aligned total knee arthroplasty: a computer simulation study. Knee Surg Sports Traumatol Arthrosc 24:2517–2524

  22. 22.

    Kuriyama S, Morimoto N, Shimoto T, Takemoto M, Nakamura S, Nishitani K et al (2019) Clinical efficacy of preoperative 3D planning for reducing surgical errors during open-wedge high tibial osteotomy. J Orthop Res 37:898–907

  23. 23.

    LaPrade RF, Bollom TS, Wentorf FA, Wills NJ, Meister K (2005) Mechanical properties of the posterolateral structures of the knee. Am J Sports Med 33:1386–1391

  24. 24.

    Lee DK, Wang JH, Won Y, Min YK, Jaiswal S, Lee BH, Kim JY (2019) Preoperative latent medial laxity and correction angle are crucial factors for overcorrection in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc.

  25. 25.

    Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132–138

  26. 26.

    Nakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K et al (2018) Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc 26:1873–1878

  27. 27.

    Nam D, Lin KM, Howell SM, Hull ML (2014) Femoral bone and cartilage wear is predictable at 0° and 90° in the osteoarthritic knee treated with total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:2975–2981

  28. 28.

    Park SE, DeFrate LE, Suggs JF, Gill TJ, Rubash HE, Li G (2005) The change in length of the medial and lateral collateral ligaments during in vivo knee flexion. Knee 12:377–382

  29. 29.

    Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090

  30. 30.

    Rodner CM, Adams DJ, Diaz-Doran V, Tate JP, Santangelo SA, Mazzocca AD et al (2006) Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure. Am J Sports Med 34:1431–1441

  31. 31.

    Schallberger A, Jacobi M, Wahl P, Maestretti G, Jakob RP (2011) High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13–21 years. Knee Surg Sports Traumatol Arthrosc 19:122–127

  32. 32.

    Seitz AM, Nelitz M, Ignatius A, Dürselen L (2018) Release of the medial collateral ligament is mandatory in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc.

  33. 33.

    Sharma A, Komistek RD, Ranawat CS, Dennis DA, Mahfouz MR (2007) In vivo contact pressures in total knee arthroplasty. J Arthroplasty 22:404–416

  34. 34.

    Smith JO, Wilson AJ, Thomas NP (2013) Osteotomy around the knee: evolution, principles and results. Knee Surg Sports Traumatol Arthrosc 21:3–22

  35. 35.

    Sugita T, Amis A (2001) Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 29:466–472

  36. 36.

    Takeuchi R, Ishikawa H, Aratake M, Bito H, Saito I, Kumagai K et al (2009) Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy 25:46–53

  37. 37.

    Takeuchi R, Ishikawa H, Miyasaka Y, Sasaki Y, Kuniya T, Tsukahara S (2014) A novel closed-wedge high tibial osteotomy procedure to treat osteoarthritis of the knee: hybrid technique and rehabilitation measures. Arthrosc Tech 3:e431–e437

  38. 38.

    Tanaka Y, Nakamura S, Kuriyama S, Ito H, Furu M, Komistek RD et al (2016) How exactly can computer simulation predict the kinematics and contact status after TKA? Examination in individualized models. Clin Biomech (Bristol, Avon) 39:65–70

  39. 39.

    Watanabe M, Kuriyama S, Nakamura S, Tanaka Y, Nishitani K, Furu M et al (2017) Varus femoral and tibial coronal alignments result in different kinematics and kinetics after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25:3459–3466

  40. 40.

    Wijdicks CA, Ewart DT, Nuckley DJ, Johansen S, Engebretsen L, Laprade RF (2010) Structural properties of the primary medial knee ligaments. Am J Sports Med 38:1638–1646

  41. 41.

    Yan J, Musahl V, Kay J, Khan M, Simunovic N, Ayeni OR (2016) Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc 24:3529–3555

Download references

Author information

Correspondence to Shinichi Kuriyama.

Ethics declarations

Conflict of interest

Kuriyama S, Watanabe M, Nakamura S, Nishitani K, Sekiguchi K, Tanaka Y, Ito H, and Matsuda S declare that they have no conflict of interest in association with the present study.

Ethical approval

All procedures were in accordance with the ethical standards of our institutional research committee.

Informed consent

Informed consent was obtained from the single study participant.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MOV 260393 kb)

Supplementary material 1 (MOV 260393 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kuriyama, S., Watanabe, M., Nakamura, S. et al. Classical target coronal alignment in high tibial osteotomy demonstrates validity in terms of knee kinematics and kinetics in a computer model. Knee Surg Sports Traumatol Arthrosc (2019).

Download citation


  • Open-wedge high tibial osteotomy (OWHTO)
  • Coronal alignment
  • Posterior tibial slope (PTS)
  • Over-correction
  • Kinematics and kinetics
  • Medial proximal tibial angle (MPTA)