Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 4, pp 519–527 | Cite as

Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line

  • S. SchröterEmail author
  • H. Nakayama
  • S. Yoshiya
  • U. Stöckle
  • A. Ateschrang
  • J. Gruhn
Arthroscopy and Sports Medicine



The purpose of the study was to describe the development of the surgical technique of double level osteotomy in patients with severe varus malalignment and to investigate the clinical and radiological outcome. It was hypothesized that good clinical results without a higher complication rate can be achieved by double level osteotomy to normalize joint angles and avoid joint line obliquity even in cases of progressed osteoarthritis.

Materials and methods

Between 2011 and 2014, 33 patients (37 knees) undergoing double level osteotomies (open wedge HTO and closed wedge DFO) were included; of these, 24 patients (28 knees) were available in mean of 18 ± 10 months for the follow-up examination. Indication was symptomatic varus malalignment and medial compartment osteoarthritis. Postoperatively, these patients were assigned to 20 kg partial weight-bearing using two crutches for 6 weeks followed by full weight-bearing. No braces or casts were used. Full weight-bearing long leg anteroposterior radiographs were obtained preoperatively, after 6 weeks and at the time of final follow-up. Mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA) and medial proximal tibia angle (MPTA) were measured. Clinical outcome was evaluated using Lequesne-, Lysholm-, Oxford-, and IKDC-score at the time of follow-up.


The preoperative mTFA of − 11 ± 3° increased to 0 ± 2° at final follow-up. The difference between mTFA-planning and final follow-up was − 2 ± 3° (p < 0.0006). At final follow-up, MPTA and mLDFA were 89.2 ± 2° and 87 ± 2°, respectively. The Lysholm, Oxford, Lequesne, and IKDC scores were 88 ± 13, 44 ± 3, 2 ± 2, and 77 ± 12, respectively.


This study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalises the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis.

Level of evidence

Case series, Level IV.


Double level osteotomy Osteotomy HTO DFO High tibial osteotomy Joint line obliquity 



The gratitude of the authors goes to the participants who have made this study possible. Furthermore, the authors would particularly like to thank the staff of the Radiology Department of the BG Trauma Center Tübingen.


  1. 1.
    Seil R, van Heerwaarden R, Lobenhoffer P, Kohn D (2013) The rapid evolution of knee osteotomies. Knee Surg Sports Traumatol Arthrosc 21(1):1–2. CrossRefGoogle Scholar
  2. 2.
    Lee OS, Ahn S, Ahn JH, Teo SH, Lee YS (2018) Effectiveness of concurrent procedures during high tibial osteotomy for medial compartment osteoarthritis: a systematic review and meta-analysis. Arch Orthop Trauma Surg 138(2):227–236. CrossRefGoogle Scholar
  3. 3.
    Schroter S, Ihle C, Mueller J, Lobenhoffer P, Stockle U, van Heerwaarden R (2013) Digital planning of high tibial osteotomy. Interrater reliability by using two different software. Knee Surg Sports Traumatol Arthrosc 21(1):189–196. CrossRefGoogle Scholar
  4. 4.
    Saragaglia D, Mercier N, Colle PE (2010) Computer-assisted osteotomies for genu varum deformity: which osteotomy for which varus? Int Orthop 34(2):185–190. CrossRefGoogle Scholar
  5. 5.
    Nakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K, Kambara S, Yoshiya S, Higa M (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(6):1873–1878. CrossRefGoogle Scholar
  6. 6.
    Babis GC, An KN, Chao EY, Rand JA, Sim FH (2002) Double level osteotomy of the knee: a method to retain joint-line obliquity. Clinical results. J Bone Joint Surg Am 84-A(8):1380–1388CrossRefGoogle Scholar
  7. 7.
    Saragaglia D, Rubens-Duval B, Chaussard C (2007) [Computer-assisted combined femoral and tibial osteotomy for severe genu varum: early results in 16 patients]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur 93 (4):351–356 (MDOI-RCO-06-2007-93-4-0035-1040-101019-200520006 [pii]) Google Scholar
  8. 8.
    Nakayama H, Iseki T, Kanto R, Kambara S, Kanto M, Yoshiya S, Schröter S (2018) Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity. Knee Surg Sports Traumatol Arthrosc. Google Scholar
  9. 9.
    Benjamin A (1969) Double osteotomy for the painful knee in rheumatoid arthritis and osteoarthritis. J Bone Joint Surg Br 51(4):694–699CrossRefGoogle Scholar
  10. 10.
    Angel JC, Liyanage SP, Griffiths WE (1974) Double osteotomy for the relief of pain in arthritis of the knee. Rheumatol Rehabil 13(3):109–119CrossRefGoogle Scholar
  11. 11.
    Iveson JM, Longton EB, Wright V (1977) Comparative study of tibial (single) and tibiofemoral (double) osteotomy for osteoarthrosis and rheumatoid arthritis. Ann Rheum Dis 36(4):319–326CrossRefGoogle Scholar
  12. 12.
    Schuller HM, van Dijk CN, Fidler MW (1987) Poor results of double osteotomy for the rheumatoid knee. Acta Orthop Scand 58(3):253–255CrossRefGoogle Scholar
  13. 13.
    Niinimaki TT, Eskelinen A, Mann BS, Junnila M, Ohtonen P, Leppilahti J (2012) Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees. J Bone Joint Surg Br 94(11):1517–1521. CrossRefGoogle Scholar
  14. 14.
    Backstein D, Morag G, Hanna S, Safir O, Gross A (2007) Long-term follow-up of distal femoral varus osteotomy of the knee. J Arthroplasty 22(4 Suppl 1):2–6. CrossRefGoogle Scholar
  15. 15.
    Hernigou P, Duffiet P, Julian D, Guissou I, Poignard A, Flouzat-Lachaniette CH (2013) Outcome of total knee arthroplasty after high tibial osteotomy: does malalignment jeopardize the results when using a posterior-stabilized arthroplasty? Hss J 9(2):134–137. CrossRefGoogle Scholar
  16. 16.
    Valenzuela GA, Jacobson NA, Buzas D, Korecki TD, Valenzuela RG, Teitge RA (2013) Unicompartmental knee replacement after high tibial osteotomy: Invalidating a contraindication. Bone Joint J 95-B(10):1348–1353. CrossRefGoogle Scholar
  17. 17.
    Brinkman JM, Freiling D, Lobenhoffer P, Staubli AE, van Heerwaarden RJ (2014) Supracondylar femur osteotomies around the knee. Patient selection, planning, operative techniques, stability of fixation, and bone healing. Orthopade 43(11):988–999. CrossRefGoogle Scholar
  18. 18.
    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–B62CrossRefGoogle Scholar
  19. 19.
    Brinkman JM, Hurschler C, Agneskirchner JD, Freiling D, van Heerwaarden RJ (2011) Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations. Knee Surg Sports Traumatol Arthrosc 19(4):579–587. CrossRefGoogle Scholar
  20. 20.
    Brinkman JM, Hurschler C, Staubli AE, van Heerwaarden RJ (2011) Axial and torsional stability of an improved single-plane and a new bi-plane osteotomy technique for supracondylar femur osteotomies. Knee Surg Sports Traumatol Arthrosc 19(7):1090–1098. CrossRefGoogle Scholar
  21. 21.
    Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer P (2006) Primary stability of four different implants for opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 14(3):291–300CrossRefGoogle Scholar
  22. 22.
    Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A (1994) Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 25(3):425–465Google Scholar
  23. 23.
    Freiling D, van Heerwaarden R, Staubli A, Lobenhoffer P (2010) The medial closed-wedge osteotomy of the distal femur for the treatment of unicompartmental lateral osteoarthritis of the knee. Oper Orthop Traumatol 22(3):317–334. CrossRefGoogle Scholar
  24. 24.
    Visser J, Brinkman JM, Bleys RL, Castelein RM, van Heerwaarden RJ (2013) The safety and feasibility of a less invasive distal femur closing wedge osteotomy technique: a cadaveric dissection study of the medial aspect of the distal femur. Knee Surg Sports Traumatol Arthrosc 21(1):220–227. CrossRefGoogle Scholar
  25. 25.
    Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11(3):132–138CrossRefGoogle Scholar
  26. 26.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502CrossRefGoogle Scholar
  27. 27.
    Saragaglia D, Chedal-Bornu B, Rouchy RC, Rubens-Duval B, Mader R, Pailhe R (2016) Role of computer-assisted surgery in osteotomies around the knee. Knee Surg Sports Traumatol Arthrosc. Google Scholar
  28. 28.
    Terauchi M, Shirakura K, Katayama M, Higuchi H, Takagishi K, Kimura M (2002) Varus inclination of the distal femur and high tibial osteotomy. J Bone Joint Surg Br 84(2):223–226CrossRefGoogle Scholar
  29. 29.
    Hofmann S, Lobenhoffer P, Staubli A, Van Heerwaarden R (2009) Osteotomies of the knee joint in patients with monocompartmental arthritis. Orthopade 38(8):755–769; quiz 770CrossRefGoogle Scholar
  30. 30.
    Pape D, Dueck K, Haag M, Lorbach O, Seil R, Madry H (2013) Wedge volume and osteotomy surface depend on surgical technique for high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21(1):127–133. CrossRefGoogle Scholar
  31. 31.
    Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P (2013) Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc 21(1):170–180. CrossRefGoogle Scholar
  32. 32.
    Schröter S, Gonser CE, Konstantinidis L, Helwig P, Albrecht D (2011) High complication rate after biplanar open wedge high tibial osteotomy stabilized with a new spacer plate (position HTO plate) without bone substitute. Arthrosc J Arthrosc Relat Surg 27(5):644–652CrossRefGoogle Scholar
  33. 33.
    Schroter S, Mueller J, van Heerwaarden R, Lobenhoffer P, Stockle U, Albrecht D (2013) Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Traumatol Arthrosc 21(1):213–219. CrossRefGoogle Scholar
  34. 34.
    Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, Helwig P, Suedkamp NP (2008) Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy 24(7):796–804CrossRefGoogle Scholar
  35. 35.
    Halder A, Kutzner I, Graichen F, Heinlein B, Beier A, Bergmann G (2012) Influence of limb alignment on mediolateral loading in total knee replacement: in vivo measurements in five patients. J Bone Joint Surg Am 94(11):1023–1029. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Traumatology and Reconstructive SurgeryBG Traumacenter TübingenTübingenGermany
  2. 2.Department of Orthopaedic SurgeryHyogo College of MedicineNishinomiyaJapan

Personalised recommendations