Opposite hinge fractures in high tibial osteotomy: a displacement subtype is more critical than a fracture type

  • Anton DorofeevEmail author
  • Alfred Tylla
  • Martin Benco
  • Wolf Drescher
  • Richard Stangl
Original Article • KNEE - FRACTURES



Analysis of the structure of the fractures of opposite hinge (FOH) after angle-stable closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO), and their influence on the development of tibial pseudarthrosis.


187 CW and 94 OWHTOs were analyzed retrospectively. The FOHs in the OWHTO were classified according to Takeuchi, and in the CWHTO—according to the own classification with two types (depending on the direction of FOH). FOHs in both techniques were also subdivided into three subtypes according to displacement (A—non-displaced, B—primarily displaced, C—secondarily displaced). The statistical analysis included correlation analysis and logistic regression.


FOHs were found in 81 (43.3%) CW and 39 (41.2%) OWHTOs. The stable type 1 fractures predominated in OWHTO (76.9 vs. 42%, p < 0.001), the unstable type 2 FOHs prevailed in CWHTO (58 vs. 17.9%, p < 0.001). The tibial pseudarthrosis rate was higher with type 1 (20 vs. 12.9%, n.s.) and subtype A (16.7 vs. 6.8%, p = 0.048) FOHs in OWHTO, and with type 2 (20 vs. 0%, p < 0.001) and subtypes B (25 vs. 0%, p < 0.001) and C (29.4 vs. 25%, n.s.) in CWHTO (without FOHs 0.9% in CW and 1.8% in OWHTO, n.s.). Relevant correlations were detected between the pseudarthrosis rate and fracture type only in CWHTO (ρs = 0.298, p < 0.001, OR 24.87 for type 2) and displacement subtype in both groups (for subtype C: ρs = 0.345, p < 0.001, OR 43.75 and ρs = 0.231, p = 0.02, OR 18.0, respectively).


The unstable FOH types were more common in CWHTO. The displacement subtype was more predictive for the development of tibial pseudarthrosis than the fracture type, especially in OWHTO. The secondarily displaced FOHs (subtype C) represented the highest risk for the occurrence of pseudarthrosis in both techniques.


Osteotomy Classification Hinge fracture CWHTO OWHTO Pseudarthrosis 


Author’s contribution

AD contributed to design and objectives of this study, data collection, statistical analysis and writing. AT is a surgeon and contributed to the data collection and preparing the manuscript. MB contributed to the data collection and radiological evaluation. WD is a senior surgeon and contributed to design of this study and edition of the manuscript. RS is a senior surgeon and contributed to design of this study, statistical analysis and supervision of the study. All authors read and approved the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures were performed with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

In this study, formal informed consent was obtained from all participants.


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Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgerySana Klinikum RummelsbergSchwarzenbruckGermany
  2. 2.Department of OrthopaedicsRWTH University HospitalAachenGermany

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