Increased preoperative medial and lateral laxity is a predictor of overcorrection in open wedge high tibial osteotomy

  • Jun-Gu Park
  • Jong-Min Kim
  • Bum-Sik Lee
  • Sang-Min Lee
  • Oh-Jin Kwon
  • Seong-Il BinEmail author



This study aimed at determining whether overcorrection after open wedge high tibial osteotomy (OWHTO) would be predicted by the magnitude of preoperative medial and lateral coronal soft tissue laxity around the knee joint.


Overall, 68 knees of 62 patients who underwent OWHTO for primary medial osteoarthritis were retrospectively reviewed. The mechanical hip–knee–ankle (HKA) axis, weight-bearing line (WBL) ratio, medial proximal tibial angle (MPTA), joint line obliquity, coronal subluxation, and joint line convergence angle (JLCA) were measured on full-weight-bearing long-standing HKA radiographs preoperatively and at 1 year postoperatively. The varus valgus stress angle was measured on preoperative radiographs. The correction amount due to soft tissue factors was calculated as the difference between the WBL ratio on postoperative 1-year radiographs and that on virtually corrected preoperative radiographs with the same amount of MPTA at 1 year postoperatively. The patients were grouped according to the presence or absence of a ≥ 10% overcorrection of WBL ratio (overcorrection or expected correction). Multiple logistic regression analysis was performed to identify the preoperative risk factors of overcorrection.


The average WBL ratio was corrected from 19.0 ± 13.5% preoperatively to 61.6 ± 9.1% postoperatively (P < 0.001). The average MPTA changed from 85.1 ± 1.7° preoperatively to 93.6 ± 2.6° postoperatively, resulting in an average tibia correction angle of 8.6 ± 3.1°. The average estimated correction from soft tissue factors was 5.8 ± 7.4% of the WBL ratio. Soft tissue correction of the WBL ratio > 10% was confirmed in 17 patients (28%). The preoperative JLCA and valgus stress angle were significantly greater in the overcorrection group than in the expected correction group: 5.0 ± 1.7° vs. 3.4 ± 1.9° (P = 0.003) and 2.4 ± 1.0° vs. 1.3 ± 1.2° (P = 0.002), respectively. Among the radiologic parameters, the presence of both ≥ 4° JLCA and ≥ 1.5° valgus stress angle was the only significant risk factor for overcorrection from soft tissue factors (P = 0.006; odds ratio, 30.2).


The magnitude of both medial and lateral coronal soft tissue laxity was a predictor of overcorrection from soft tissue factors after OWHTO. Overcorrection was more likely to occur in cases with both ≥ 4° JLCA and ≥ 1.5° valgus stress angle.

Level of evidence



Knee High tibial osteotomy Overcorrection Joint line convergence angle Soft tissue laxity 


Compliance with ethical standards

Conflict of interest

Each author certifies that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article.


No funding for this study was required.

Ethical approval

This study was approved by the institutional review board of Asan Medical Center (AMC IRB No. 2018-1225).

Supplementary material

167_2019_5805_MOESM1_ESM.docx (18 kb)
Supplementary file1 (DOCX 17 kb)


  1. 1.
    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(1):70–75CrossRefGoogle Scholar
  2. 2.
    Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H (2008) The long-term outcome of high tibial osteotomy: a 10- to 20-year follow-up. J Bone Jt Surg Br 90(5):592–596CrossRefGoogle Scholar
  3. 3.
    Andriacchi TP (1994) Dynamics of knee malalignment. Orthop Clin N Am 25(3):395–403Google Scholar
  4. 4.
    Bellemans J, Vandenneucker H, Vanlauwe J, Victor J (2010) The influence of coronal plane deformity on mediolateral ligament status: an observational study in varus knees. Knee Surg Sports Traumatol Arthrosc 18(2):152–156CrossRefGoogle Scholar
  5. 5.
    Briem K, Ramsey DK, Newcomb W, Rudolph KS, Snyder-Mackler L (2007) Effects of the amount of valgus correction for medial compartment knee osteoarthritis on clinical outcome, knee kinetics and muscle co-contraction after opening wedge high tibial osteotomy. J Orthop Res 25(3):311–318CrossRefGoogle Scholar
  6. 6.
    El-Azab HM, Morgenstern M, Ahrens P, Schuster T, Imhoff AB, Lorenz SG (2011) Limb alignment after open-wedge high tibial osteotomy and its effect on the clinical outcome. Orthopedics 34(10):e622–628PubMedGoogle Scholar
  7. 7.
    Elson DW, Petheram TG, Dawson MJ (2015) High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci's method. Knee Surg Sports Traumatol Arthrosc 23(7):2041–2048CrossRefGoogle Scholar
  8. 8.
    Feucht MJ, Minzlaff P, Saier T, Cotic M, Sudkamp NP, Niemeyer P, Imhoff AB, Hinterwimmer S (2014) Degree of axis correction in valgus high tibial osteotomy: proposal of an individualised approach. Int Orthop 38(11):2273–2280CrossRefGoogle Scholar
  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(3):585–608Google Scholar
  10. 10.
    Gaasbeek RD, Nicolaas L, Rijnberg WJ, van Loon CJ, van Kampen A (2010) Correction accuracy and collateral laxity in open versus closed wedge high tibial osteotomy A one-year randomised controlled study. Int Orthop 34(2):201–207CrossRefGoogle Scholar
  11. 11.
    Gebhard F, Krettek C, Hufner T, Grutzner PA, Stockle U, Imhoff AB, Lorenz S, Ljungqvist J, Keppler P, Ao C (2011) Reliability of computer-assisted surgery as an intraoperative ruler in navigated high tibial osteotomy. Arch Orthop Trauma Surg 131(3):297–302CrossRefGoogle Scholar
  12. 12.
    Heijens E, Kornherr P, Meister C (2016) The coronal hypomochlion: a tipping point of clinical relevance when planning valgus producing high tibial osteotomies. Bone Jt J 98(5):628–633CrossRefGoogle Scholar
  13. 13.
    Hinman RS, May RL, Crossley KM (2006) Is there an alternative to the full-leg radiograph for determining knee joint alignment in osteoarthritis? Arthritis Rheum 55(2):306–313CrossRefGoogle Scholar
  14. 14.
    Kim YT, Choi JY, Lee JK, Lee YM, Kim JI (2019) Coronal tibiofemoral subluxation is a risk factor for postoperative overcorrection in high tibial osteotomy. Knee 26(4):832–837CrossRefGoogle Scholar
  15. 15.
    Koshino T, Yoshida T, Ara Y, Saito I, Saito T (2004) Fifteen to twenty-eight years' follow-up results of high tibial valgus osteotomy for osteoarthritic knee. Knee 11(6):439–444CrossRefGoogle Scholar
  16. 16.
    Lee DH, Park SC, Park HJ, Han SB (2016) Effect of soft tissue laxity of the knee joint on limb alignment correction in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 24(12):3704–3712CrossRefGoogle Scholar
  17. 17.
    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. CrossRefPubMedGoogle Scholar
  18. 18.
    Madry H, Goebel L, Hoffmann A, Duck K, Gerich T, Seil R, Tschernig T, Pape D (2017) Surgical anatomy of medial open-wedge high tibial osteotomy: crucial steps and pitfalls. Knee Surg Sports Traumatol Arthrosc 25(12):3661–3669CrossRefGoogle Scholar
  19. 19.
    Miller BS, Downie B, McDonough EB, Wojtys EM (2009) Complications after medial opening wedge high tibial osteotomy. Arthroscopy 25(6):639–646CrossRefGoogle Scholar
  20. 20.
    Miniaci A, Ballmer FT, Ballmer PM, Jakob RP (1989) Proximal tibial osteotomy. A new fixation device. Clin Orthop Relat Res 246:250–259Google Scholar
  21. 21.
    Ogawa H, Matsumoto K, Ogawa T, Takeuchi K, Akiyama H (2016) Preoperative varus laxity correlates with overcorrection in medial opening wedge high tibial osteotomy. Arch Orthop Trauma Surg 136(10):1337–1342CrossRefGoogle Scholar
  22. 22.
    Seitz AM, Nelitz M, Ignatius A, Durselen L (2019) Release of the medial collateral ligament is mandatory in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 27(9):2917–2926CrossRefGoogle Scholar
  23. 23.
    So SY, Lee SS, Jung EY, Kim JH, Wang JH (2019) Difference in joint line convergence angle between the supine and standing positions is the most important predictive factor of coronal correction error after medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. CrossRefPubMedGoogle Scholar
  24. 24.
    Staubli AE, De Simoni C, Babst R, Lobenhoffer P (2003) TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia–early results in 92 cases. Injury 34(Suppl 2):B55–62CrossRefGoogle Scholar
  25. 25.
    Valkering KP, van den Bekerom MP, Kappelhoff FM, Albers GH (2009) Complications after tomofix medial opening wedge high tibial osteotomy. J Knee Surg 22(3):218–225CrossRefGoogle Scholar
  26. 26.
    Van den Bempt M, Van Genechten W, Claes T, Claes S (2016) How accurately does high tibial osteotomy correct the mechanical axis of an arthritic varus knee? A systematic review. Knee 23(6):925–935CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopedic Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  2. 2.Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan HospitalPusan National University School of MedicineYangsanRepublic of Korea

Personalised recommendations