Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee.

Abstract

The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the orthopaedic surgeon. Surgical treatment options include high tibial osteotomy (HTO), unicompartmental knee arthroplasty, and total knee arthroplasty.
To examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery.
Case series; Level of evidence, 4.
Four hundred fifty-five consecutive patients underwent lateral closing wedge HTO for medial compartment osteoarthritis between 1990 and 2001. Between 2008 and 2009, patients were contacted via telephone, and assessment included incidence of further surgery, current body mass index (BMI), Oxford Knee Score, and British Orthopaedic Association Patient Satisfaction Scale. Failure was defined as the need for revision HTO or conversion to unicompartmental knee arthroplasty or total knee arthroplasty. Survival analysis was completed using the Kaplan-Meier method.
High tibial osteotomy survival was determined in 413 patients (91%). Of the 397 remaining living patients at the time of final review, 394 (99%) were contacted for follow-up via telephone interview. The probability of survival for HTO at 5, 10, and 15 years was 95%, 79%, and 56%, respectively. Multivariate regression analysis showed that age under 50 years (P = .001), BMI less than 25 (P = .006), and ACL deficiency (P = .03) were associated with better odds of survival. Mean Oxford Knee Score was 40 of 48 (range, 17-48). Overall, 85% of patients were enthusiastic or satisfied, and 84% would undergo HTO again at a mean 12 years of follow-up.
High tibial osteotomy can be effective for periods longer than 15 years; however, results do deteriorate over time. Age less than 50 years, normal BMI, and ACL deficiency were independent factors associated with improved long-term survival of HTO.

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Long-Term Survival of High Tibial
Osteotomy for Medial Compartment
Osteoarthritis of the Knee
Catherine Hui,* MD, FRCS(C), Lucy J. Salmon,* BAppSci (Physio), PhD,
Alison Kok,* BMedSci (Hons), BAppSci (Physio), Heidi A. Williams,* MScMed,
Niels Hockers,* Willem M. van der Tempel,* MD, Rishi Chana,* FRCS (Tr & Orth), and
Leo A. Pinczewski,*yMBBS, FRACS
Investigation performed at North Sydney Orthopaedic & Sports Medicine Centre, Sydney,
Australia
Background: The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the
orthopaedic surgeon. Surgical treatment options include high tibial osteotomy (HTO), unicompartmental knee arthroplasty, and
total knee arthroplasty.
Purpose: To examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery.
Study Design: Case series; Level of evidence, 4.
Methods: Four hundred fifty-five consecutive patients underwent lateral closing wedge HTO for medial compartment osteoarthri-
tis between 1990 and 2001. Between 2008 and 2009, patients were contacted via telephone, and assessment included incidence
of further surgery, current body mass index (BMI), Oxford Knee Score, and British Orthopaedic Association Patient Satisfaction
Scale. Failure was defined as the need for revision HTO or conversion to unicompartmental knee arthroplasty or total knee arthro-
plasty. Survival analysis was completed using the Kaplan-Meier method.
Results: High tibial osteotomy survival was determined in 413 patients (91%). Of the 397 remaining living patients at the time of
final review, 394 (99%) were contacted for follow-up via telephone interview. The probability of survival for HTO at 5, 10, and 15
years was 95%, 79%, and 56%, respectively. Multivariate regression analysis showed that age under 50 years (P = .001), BMI
less than 25 (P = .006), and ACL deficiency (P = .03) were associated with better odds of survival. Mean Oxford Knee Score
was 40 of 48 (range, 17-48). Overall, 85% of patients were enthusiastic or satisfied, and 84% would undergo HTO again at
a mean 12 years of follow-up.
Conclusion: High tibial osteotomy can be effective for periods longer than 15 years; however, results do deteriorate over time. Age
less than 50 years, normal BMI, and ACL deficiency were independent factors associated with improved long-term survival of HTO.
Keywords: high tibial osteotomy; knee, osteoarthritis; survival
Medial compartment osteoarthritis (MCOA) of the knee
leading to varus deformity and subsequent disability is
a common problem.11,26,34During the early stages of osteo-
arthritis (OA), nonsurgical treatment options include
weight loss, low-impact activity, and physiotherapy.45As
the disease progresses to end-stage MCOA, the surgical
treatment options are high tibial osteotomy (HTO), uni-
compartmental knee arthroplasty (UKA), and total knee
arthroplasty (TKA).10,26
Arthroplasty, both UKA and
TKA, is considered a good option for low-demand patients
older than 60 years, with good long-term outcomes
reported.5,10,39However, concern remains regarding the
longevity of these implants in younger patients.5,10,24
When performed successfully, HTO is a joint-preserving
procedure that does not compromise future TKA.5,51It is
a good option for young patients with isolated MCOA and
varus deformity.6,10,24,36,42,47,53The biomechanical principle
of HTO in MCOA is to redistribute the weightbearing forces
from the worn medial compartment across to the lateral
compartment to relieve pain and to slow disease progres-
sion.5,7,10,17,52,54Biopsy and second-look arthroscopic and
open procedures have shown that there is regrowth of fibro-
cartilage in the worn medial compartment with a predilec-
tion for the ulcerated regions of wear in the weightbearing
portion of the medial femoral condyle.8,25,32,33,41
yAddress correspondence to Leo Pinczewski, MBBS, FRACS, North
Sydney Orthopaedic & Sports Medicine Centre, Suite 2, 3 Gillies Street,
Wollstonecraft, NSW 2065, Australia (e-mail: lpinczewski@nsosmc
.com.au).
*North Sydney Orthopaedic & Sports Medicine Centre, Sydney,
Australia.
Presented at the interim meeting of the AOSSM, New Orleans, Loui-
siana, March 2010.
The authors declared that they had no conflicts of interests in their
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 39, No. 1
DOI: 10.1177/0363546510377445
? 2011 The Author(s)
64
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It has been well established that good short- and
medium-term outcomes can be achieved with HTO for
MCOA.27,28Unfortunately, these results have been shown
to deteriorate over time.1,17,29,31,46,52,55Most recent studies
report satisfactory outcomes of approximately 80% at 5
years and 60% at 10 years.5,9,18,31,40,46,50
The purpose of this study was to examine the long-term
survival of lateral closing wedge HTO in a large series of
patients up to 19 years after surgery to determine whether
the results deteriorate over time, to review the complica-
tions, and to determine the factors associated with
improved long-term survival of HTO.
METHODS
Ethical approval for this study was granted by The Univer-
sity of Sydney. The results of 455 consecutive patients
undergoing lateral closing wedge HTO for MCOA between
1990 and 2001 were reviewed. Indication for surgery was
MCOA that was not responsive to nonoperative treatment
with grade IV changes evident clinically or radiographically.
Exclusion criteria included inflammatory arthritis, symp-
tomatic OA of the lateral compartment, previous HTO, flex-
ion contracture greater than 10?, and flexion less than 90?.
The senior author (L.P.) performed all osteotomies. A
modified Coventry16lateral closing wedge HTO was per-
formed with the goal to correct the femoral-tibial align-
ment to 10? valgus. A posterolateral hockey-stick incision
was used following the course of the common peroneal
nerve. The nerve was identified and protected. The proxi-
mal tibiofibular joint was excised, leaving the styloid pro-
cess and its attached structures intact. A transverse
tibial osteotomy was made at the level of the superior tibio-
fibular joint parallel to the joint line and an angular jig was
used to make the second, oblique, osteotomy to a predeter-
mined wedge size. The medial cortex was gently fractured
as the osteotomy was closed. Medial collateral ligament
(MCL) laxity can lead to overcorrection of the osteotomy
and more valgus than intended. Therefore, in cases of
MCL laxity, 2 special considerations were made. First,
MCL laxity is calculated into the wedge size by taking
a smaller size wedge depending on the amount of laxity
present. Second, the proximal osteotomy was intentionally
completed through the medial cortex, and the distal saw
cut was made with the apex of the osteotomy more lateral,
such that a closing lateral osteotomy and an opening
medial osteotomy were achieved, thus restoring the ten-
sion in the MCL (Figure 1). Fixation was achieved with
a Krakow staple (Smith & Nephew, Memphis, Tennessee).
From 1990 to 1996, the method was for the limb to be
immobilized in extension using a long-leg plaster cast.
From 1997, the method was for the limb to be supported
in a range of motion brace, allowing full range of motion,
with pads providing 4-point pressure supporting the valgus
osteotomy for 6 weeks. All patients received 1 preoperative
and postoperative dose of antibiotics for infection prophy-
laxis and warfarin for venous thromboembolism prophylaxis
for 6 weeks with a target international normalized ratio of
1.5-2.0. Patients were toe-touch weightbearing for 2 weeks,
then were partial weightbearing for 2 weeks, and then pro-
gressed to full weightbearing by 6 weeks, with commence-
ment of an activemobilization
physiotherapy program once the brace or plaster was
removed. Clinical examination was performed for union,
and radiographs were obtained if needed.
Between 2008 and 2009, patients were contacted via
telephoneforlong-termfollow-up
included incidence of further surgery, current body mass
index (BMI; weight [kg]/height [m]2), Oxford Knee Score,19
and British Orthopaedic Association Patient Satisfaction
Scale.4For those patients who had proceeded to surgery,
the medical records were reviewed for BMI at time of fail-
ure. Failure was defined as the need for revision HTO or
conversion to UKA or TKA.
The probability of failure was estimated as a function of
time using the Kaplan-Meier survival method with a 95%
confidence interval. Comparisons of survival curves were
made with log-rank tests. Univariate and multivariate
Cox proportional hazards analyses were used to verify the
relationship between survival and each possible associated
factor. These included cause of OA, previous surgery, status
of the ACL, age, BMI at review or failure, gender, and MCL
laxity. Estimation of the hazard ratio was used to evaluate
the association between the risk of failure and contributing
factors. P \ .05 was considered statistically significant.
andstrengthening
assessment.This
RESULTS
From 1990 to 2001, 460 patients underwent lateral closing
wedge HTO for MCOA. Five patients (1%) declined
Figure 1. Preoperative planning of osteotomy cuts with lat-
eralized apex (arrow) and final combined lateral closing and
medial opening wedge osteotomy for patients with medial
collateral ligament laxity.
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participation in the study and were excluded, leaving 455
patients enrolled in the study. Forty-two patients (9%)
were lost to follow-up. High tibial osteotomy survival was
determined in 413 patients (91%). Thirteen patients (3%)
had died of unrelated causes with intact osteotomies, 128
patients (31%) required further knee surgery (104 TKAs,
22 UKAs, and 2 revision HTOs), and 272 patients (66%)
had surviving osteotomies. By 2008 to 2009, 3 patients
were deceased after HTO failure, leaving 397 living
patients remaining. Three hundred ninety-four (99%) of
these patients were contacted for telephone interview.
Three patients that were known to have undergone TKA
were unable to be contacted for subjective review (Figure 2).
There were 326 (79%) men and 87 (21%) women in the
final HTO study. The mean age at the time of osteotomy
was 50 years (range, 24-70 years). There were 208 (50%)
left and 205 (50%) right knees. The mean time to follow-
up was 12 years (range, 1-19 years).
The mean initial femoral-tibial alignment was 0? (stan-
dard deviation [SD], 3.8). Immediately postoperatively, all
limbs were in valgus alignment with a mean femoral-tibial
alignment of 10.3? (SD, 1.9). The mean BMI at the time of
final review or HTO failure was 28.3 (SD, 3.8). The BMI
was categorized according to the definitions of the World
Health Organization for analysis (Table 1).
Complications included 5 pulmonary emboli and 8 deep
vein thromboses that were treated with therapeutic levels
of anticoagulation, 1 nonunion requiring bone grafting,
and 1 postoperative subarachnoid hemorrhage related to
a pre-existing aneurysm that was subsequently clipped.
One patient had a transient peroneal nerve palsy that
was explored and found to be due to a hematoma, which
was evacuated. There were no infections.
Using the Kaplan-Meier survivorship estimate of fail-
ure, the overall probability of survival of HTO was 95%
at 5 years, 79% at 10 years, and 56% at 15 years (Figure 3).
Univariate Analysis
Analysis of the potential risk factors for failure of HTO
using univariate Cox regression analysis showed that post-
traumatic OA (P = .001), any previous surgery (P = .04),
ACL deficiency (P = .001), age less than 50 years (P \
.001), and BMI less than 25 (P = .04) (Figure 4) were fac-
tors associated with longer HTO survival. Univariate anal-
ysis failed to show a significant association between early
failure and gender and MCL laxity (Table 1).
Multivariate Analysis
Factors that were significant (P\.05) on univariate analy-
sis were entered into a multivariate Cox regression analy-
sis. Factors were then eliminated one at a time in a step-
wise fashion, until only the independent significant factors
remained (Table 2). Analysis of the potential risk factors
for failure of HTO using multivariate Cox regression analy-
sis showed that age less than 50 years (P = .001), BMI at
review less than 25 (P = .006), and ACL deficiency (P =
.03) (Table 2, Figure 4) were factors associated with longer
HTO survival.
Subjective Outcomes
The results of patients who were enthusiastic or satisfied
according to the British Orthopaedic Association Patient
Satisfaction Scale and whether the patient would undergo
surgery again are presented in Table 3. Patients who did
not require further surgery were asked to complete the
Oxford Knee Score regarding their HTO (n = 272).
The mean Oxford Knee Score was 40 of 48 (range, 17-
48). There was no difference in Oxford Knee Score
between patients less than 50 and more than 50 years of
age (P = .15).
DISCUSSION
To our knowledge, we report the long-term follow-up of lat-
eral closing wedge HTO in the largest group of patients in
the literature. We found that age less than 50 years, BMI
less than 25, and ACL-deficient knees were independent
factors associated with improved long-term survival of
the osteotomy. Consistent with previous studies, we found
that the results of HTO do deteriorate over time but that
HTO can be effective for longer than 15 years.17,29,31,46,52,55
Figure 2. Participant flow.
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In our study, the overall Kaplan-Meier probability of sur-
vival of HTO was 95% at 5 years, 79% at 10 years, and 56%
at 15 years, which is consistent with previously published
results in the literature. Previous studies have reported
73% to 99% survival at 5 years and 55% to 75% survival
at 10 years.3,9,18,24,34,40,50,53Recently, Akizuki et al3reported
survivorship of HTO to be 99% at 5 years, 98% at 10 years,
and 90% at 15 years. The Japanese authors acknowledged
that their results were significantly better than those of
other countries, but were consistent with another Japanese
study that reported survivorship to be 98% at 5 years, 96%
at 10 years, and 93% at 15 years.34Whether these improved
results compared with studies from Western countries are
aberrant, or possibly related to Japanese body habitus, cul-
ture, and lifestyle requires further study.
Flecher et al,24Holden et al,28and Odenbring et al42
found age less than 50 years to be the only factor associated
with long-term HTO survival. The long rehabilitation after
HTO has been well documented. Younger patients are able
to recover more quickly and more fully from the rigorous
rehabilitation.30These patients also have the greatest chance
for satisfactory long-term function when compared with
those patients who have the operation done at an older age.
Overweight is defined by the World Health Organiza-
tion as BMI greater than 25, and obese is defined as BMI
greater than 30. We report the BMI of the patients at
the time of HTO failure or final review. There was incom-
plete data on BMI at the time of surgery, so it was not
reported. We found that a normal BMI was an indepen-
dent factor associated with improved long-term survival
of HTO. This is consistent with several other studies in
the literature.3,18,24,37In our study, BMI greater than
TABLE 1
Univariate Cox Regression of Potential Risk Factorsa
Survival, y
Factor and CategoryNo. of Patients5 10 15Hazard Ratio 95% CI
P Value
Cause of OA
Posttraumatic
Idiopathic
Previous surgery
Any
Nil
Status of ACL
Deficient
Intact
Age, y
\50
?50
Gender
M
F
BMI at review or failure, kg/m2
\25
?25
\30
?30
MCL laxity, mm
0-3
3-10
227
186
97
92
84
74
67
46
2.01.4-2.8 .001
299
114
95
94
79
80
60
46
1.5 1.0-2.1 .04
90
323
99
94
90
76
74
51
2.6 1.5-4.4 .001
198
215
99
90
94
65
72
41
3.72.5-5.5 .00
326
87
95
95
80
78
57
53
1.2 0.8-1.8.48
63
331
272
122
90
96
96
93
82
79
80
79
76
52
58
54
1.9 1.0-3.4 .04
0.90.62-1.32 .60
279
134
95
94
81
75
57
55
0.70.5-1.1.17
aPosttraumatic, history of ACL injury (with and without reconstruction), meniscectomy performed .5 years prior to high tibial osteotomy,
osteochondritis dissecans, previous lower limb fracture; idiopathic, no history of trauma or arthroscopic surgery performed within 5 years of
high tibial osteotomy. CI, confidence interval; OA, osteoarthritis; BMI, body mass index; MCL, medial collateral ligament.
Figure 3. Kaplan-Meier survivorship analysis for all high tib-
ial osteotomy participants.
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25 seemed to be a critical number when looking at the
effect of BMI on survival of HTO. The strong association
between OA and being overweight or obese has been
well established.14,21,22Early failure of the osteotomy
may be related to the extra weight and larger force per
unit area through the knee.
The improved results observed in ACL-deficient knees
may be related to the osteotomy improving not only the
pain related to MCOA, but also to the HTO improving
the stability of the knee. All HTOs have been shown to
alter the slope of the tibia. Lateral closing wedge osteoto-
mies tend to decrease posterior tibial slope and medial
openingwedge osteotomies
slope.5,10,20Biomechanical studies have shown a linear
increase posterior tibial
relationship between tibial slope and anterior tibial trans-
lation with weightbearing (ie, the greater the tibial slope,
the greater the anterior tibial translation).2,20Therefore,
closing wedge osteotomies improve instability secondary
to ACL incompetency.5,10,20Furthermore, patients with
chronic ACL deficiency have a tendency for posteromedial
tibial wear.38Decreasing the tibial slope decreases the
tibiofemoral contact area and pressure and offloads the
worn posterior tibial plateau.2We have shown that the lat-
eral closing wedge HTO is an effective way to address
symptoms related to both MCOA and anterolateral insta-
bility, if present, in patients with varus alignment and
chronic ACL deficiency.
There was no statistically significant difference in sur-
vival between male and female patients in our study. How-
ever, we acknowledge that there was a selection bias
present as the senior author preferred not to perform
HTO in obese patients, particularly obese female patients,
because of known inferior outcomes in this subset of
patients.11,13,15,16,18,40
Multiple studies have looked at risk factors for early
failure of HTO. These have included age, gender, BMI,
grade of OA, prior surgery, MCL laxity, varus thrust, walk-
ing aids, range of motion, preoperative alignment, and
amount of overcorrection.1,3,5,10,24,40,48,54The results from
these studies have been inconsistent, often contradicting
each other. These inconsistent results reflect the fact
that the origin of OA is multifactorial, with a natural his-
tory of disease progression over time.23The goal of HTO
is to attempt to alter the natural history of the disease
both biomechanicallybyaltering
axis5,7,10,17,54and biologically by inciting the repair of the
worn articular cartilage with fibrocartilage.8,25,32,33,41
What we can draw from these previous studies is that
the ideal patient for HTO is one who is under age 50 years
with isolated MCOA and who wishes to continue partici-
pating in high-level activity.6,10,24,36,47For patients older
than 60 years, TKA is a good, long-lasting treatment for
OA.5,10,39In patients between 50 and 60 years, careful dis-
cussion with the patient to determine their activity level
and goals is needed to determine whether they are better
suited for HTO or arthroplasty.10,12,29
the weightbearing
Figure 4. Kaplan-Meier survivorship analysis for all high tibial osteotomy participants.
TABLE 2
Multivariate Cox Regression of
Significant Risk Factorsa
Risk Factor Category Hazard Ratio 95% CI
P Value
Age, y
\50
?50
\25
?25
3.42.2-5.1 .001
BMI at review or
failure, kg/m2
Status of ACL
2.31.3-4.2.006
Deficient
Intact
2.01.1-3.6 .03
aCI, confidence interval; BMI, body mass index.
TABLE 3
Patient Satisfactiona
OverallSurviving HTO
Further
Surgery
BOA Patient
Satisfaction Scale
Surgery again
85% (335/394) 93% (252/272)68% (83/122)
84% (332/394)91% (247/272)70% (85/122)
aHTO,
Association.
high tibialosteotomy;BOA,BritishOrthopaedic
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Tang and Henderson50reported patient satisfaction of
76%, with 90% of patients stating they would choose the
operation again at an average of 6.5 years after HTO. We
found that 85% of our patients were enthusiastic or satisfied
with the HTO, and 84% of patients would have the same
surgery again when asked at a mean of 12 years after sur-
gery. Many patients perceive HTO as a useful and worth-
while procedure to alleviate pain and improve quality of life.
We have shown that HTO is a successful surgical treat-
ment option for carefully selected patients with severe
MCOA of the knee. Medial UKA is another surgical treat-
ment option often considered in this group of patients. Pre-
vious outcome studies of UKA have shown much higher
survival rates than with HTO.44,49However, these studies
have been in much older patients than those in our study
group (mean age, 50 years) and any comparison would not
be meaningful. Parratte et al43recently published a retro-
spective review of 31 patients (35 knees) with a mean age
of 46 years and a mean BMI of 26. These patients all under-
went medial UKA using a cemented metal-backed prosthe-
sis and had a mean follow-up of 9.7 years. Patients were
allowed unrestricted activity. Survival was 81% at 12 years
and 70% at 16 years. These results are similar to our sur-
vival rates in patients undergoing HTO with age less than
50 years at the 15-year time point (72%); however, survival
of HTO appears to be markedly better at the 10-year mark
(95%) than UKA. The concern regarding UKA in younger
patients remains polyethylene wear. Parratte et al43found
that 19% of their patients required revision, two thirds of
these because of polyethylene wear and aseptic loosening.
Kuster35has previously shown that running and jumping
produce surface loads that exceed the limits of polyethylene
resistance. The benefit of HTO is that the patient is afforded
unrestricted activity without the concerns of polyethylene
wear and the need for further revision surgery.
The greatest strength of this study is the long-term
follow-up of a large group of patients with minimal loss
to follow-up. Further, all osteotomies were performed by
a single surgeon using the same technique. Also, subjective
outcomes were measured using validated outcome scores
and were gathered prospectively via telephone interview.
Limitations of this study are related to its retrospective
nature, especially with incomplete data. However, the
main purpose of our study was to determine the survivor-
ship of lateral closing wedge HTO. The missing data are of
secondary outcomes. To exclude such a large number of
patients when the primary outcome is known (ie, survivor-
ship) but a secondary outcome is unknown has the poten-
tial to introduce selection bias into the study.
The primary outcome in this study is the long-term sur-
vival of lateral closing wedge HTO. We made no attempt to
look at clinical or radiographic outcomes. Although we recog-
nize that the study would be improved with the addition of
the postoperative angle of overcorrection, we do not have
these data. Furthermore, the angle of correction and postop-
erative angle of overcorrection have been studied in previous
studies in the literature, with inconsistent results on what
the exact angles should be. Insall et al29and Holden et al28
have also shown that good clinical outcomes may not be
related to the exact amount of correction. What we can
draw from previous studies is that the limb should be in val-
gus alignment postoperatively without too much overcorrec-
tion that would lead to overload and more rapid deterioration
of the lateral compartment.27In our study, immediate post-
operative alignment was in valgus in all patients. So as to
minimize radiation to patients, 3-foot to 4-foot standing
alignment films were not performed routinely postopera-
tively. It was the practice of the senior author to assess
limb alignment clinically at each subsequent follow-up visit.
If there was any concern, a long-leg alignment film was then
obtained. To avoid too much overcorrection, we carefully
assessed MCL laxity preoperatively and took this into consid-
eration when determining the wedge size.
The management of early degenerative arthritis of the
knee in the young adult presents a challenge to the ortho-
paedic surgeon. Improved long-term survival of HTO is
associated with age less than 50 years, BMI less than 25
kg/m2, and ACL deficiency. We have shown that in appro-
priately selected patients and circumstances, HTO gives
high patient satisfaction and affords patients unrestricted
activity for many years.
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