Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 21, Issue 1, pp 161–169 | Cite as

Infections after high tibial osteotomy

  • Konstantinos Anagnostakos
  • Philipp Mosser
  • Dieter Kohn



High tibial osteotomy is an established method in the treatment for knee osteoarthritis. Infections are a rare but severe complication that might endanger the clinical, radiological and functional outcome and might require several surgical revisions.


A systematic literature review was performed through PubMed until November 2011. Search terms were “HTO” or “(high) tibial osteotomy”, alone or in combination with “infection(s)”, “infected” or “septic”. Only articles focussing on the infection treatment or analysis of risk factors for emergence of infection after high tibial osteotomy were included.


A total of 26 studies could be identified. Seven studies were published before and 19 in or after 2000. One study had a level of evidence II, five level of evidence III and 20 level of evidence IV. Superficial infections were found in 1–9 % and deep infections in 0.5–4.7 % of the cases. Pin tract infections occurred in 2-71 % of the cases. One study reported on a secondary bacterial arthritis in 4.5 % of the cases. An oblique skin incision, non-smokers and a one-day hospitalization were found to be risk factors for infection emergence. Depending on the type of infection, treatment consisted of oral or systemic antibiotic therapy, alone or in combination with surgical revision, debridement and hardware removal. In some cases, antibiotic-loaded cement beads were inserted for local antibiotic therapy.


Infections after high tibial osteotomy are rare. Current data about infection rates, infection localization, risk factors for emergence of infection and treatment options allow not for a generalization of conclusions. A large multi-centre study is required to develop a diagnostic and therapeutic algorithm.

Level of evidence



High tibial osteotomy HTO Infection Medial knee osteoarthritis 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Adili A, Bhandari M, Giffin R, Whately C, Kwok DC (2002) Valgus high tibial osteotomy. Comparison between an Ilizarov and a coventry wedge technique for the treatment of medial compartment osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 10:169–176PubMedCrossRefGoogle Scholar
  2. 2.
    Asik M, Sen C, Kilic B, Goksan SB, Ciftci F, Taser OF (2006) High tibial osteotomy with puddu plate for the treatment of varus gonarthrosis. Knee Surg Sports Traumatol Arthrosc 14:948–954PubMedCrossRefGoogle Scholar
  3. 3.
    Bachhal V, Sankhala SS, Jindal S, Dhillon MS (2011) High tibial osteotomy with a dynamic axial fixator. Precision in achieving alignment. J Bone Joint Surg Br 93-B:897–903CrossRefGoogle Scholar
  4. 4.
    Billings A, Scott DF, Camargo MP, Hofmann AA (2000) High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am 82-A:70–79Google Scholar
  5. 5.
    Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K, Jenkyn TR, Fowler PJ (2009) Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, and patient-related outcomes. Arthritis Rheum 61:648–657PubMedCrossRefGoogle Scholar
  6. 6.
    Brosset T, Pasquier G, Migaud H, Gougeon F (2011) Opening wedge high tibial osteotomy performed without filling the defect but with locking plate fixation (Tomofix™) and early weight-bearing: prospective evaluation of bone union, precision and maintenance of correction in 51 cases. Orthop Traumatol Surg Res 97:705–711PubMedCrossRefGoogle Scholar
  7. 7.
    Brouwer RW, Bierma-Zeinstra SM, van Raaij TM, Verhaar JA (2006) Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomized, controlled study. J Bone Joint Surg Br 88-B:1454–1459CrossRefGoogle Scholar
  8. 8.
    Catagni M, Guerreschi F, Ahmad T, Cattaneo R (1994) Treatment of genu varum in the medial compartment osteoarthritis of the knee using the Ilizarov method. Orthop Clin North Am 25:509–514PubMedGoogle Scholar
  9. 9.
    Chae DJ, Shetty GM, Wang KH, Montalban AS Jr, Kim JI, Nha KW (2011) Early complications of medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation. Knee 18:278–284PubMedCrossRefGoogle Scholar
  10. 10.
    Coventry MB (1987) Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee. J Bone Joint Surg Am 69-A:32–38Google Scholar
  11. 11.
    Efe T, Ahmed G, Heyse TJ, Boudriot U, Timmesfeld N, Fuchs-Winkelmann S, Ishaque B, Lakemeier S, Schofer MD (2011) Closing-wedge high tibial osteotomy: survival and risk factors analysis at long-term follow-up. BMC Musculoskelet Disord 12:46PubMedCrossRefGoogle Scholar
  12. 12.
    El-Assal MA, Khalifa YE, Abdel-Hamid MM, Said HG, Bakr HM (2010) Opening-wedge high tibial osteotomy without bone graft. Knee Surg Sports Traumatol Arthrosc 18:961–966PubMedCrossRefGoogle Scholar
  13. 13.
    Engh GA, Ammeen D (2004) Is an intact anterior cruciate ligament needed in order to have a well-functioning unicondylar knee replacement? Clin Orthop Relat Res 428:170–173PubMedCrossRefGoogle Scholar
  14. 14.
    Fowler J, Gie G, MacEachern A (1991) Upper tibial valgus osteotomy using a dynamic external fixator. J Bone Joint Surg Br 73-B:690–691Google Scholar
  15. 15.
    Geiger F, Schneider U, Lukoschek M, Ewerbeck V (1999) External fixation in proximal tibial osteotomy: a comparison of three methods. Int Orthop 23:160–163PubMedCrossRefGoogle Scholar
  16. 16.
    Gerdhem P, Abdon P, Odenbring S (2002) Hemicallotasis for medial gonarthrosis: a short-term follow-up of 21 patients. Arch Orthop Trauma Surg 122:134–138PubMedCrossRefGoogle Scholar
  17. 17.
    Ha’eri GB, Wiley AM (1980) High tibial osteotomy combined with joint debridement: a long-term study of results. Clin Orthop Relat Res 151:153–159PubMedGoogle Scholar
  18. 18.
    Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G (2005) The high tibial osteotomy, open versus closed wedge, a comparison method in 108 patients. Arch Orthop Trauma Surg 125:638–643PubMedCrossRefGoogle Scholar
  19. 19.
    Ivarsson I, Myrnerts R, Gilquist J (1990) High tibial osteotomy for medial osteoarthritis of the knee. A 5–7 and an 11–13 year follow-up. J Bone Joint Surg Br 72-B:238–244Google Scholar
  20. 20.
    Jackson JP (1958) Osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br 40-B:826Google Scholar
  21. 21.
    Jenny K, Jenny H, Morscher E (1985) Indications, surgical technic and results of transcondylar tibia osteotomy in gonarthrosis. Experiences based on a follow-up study of 783 tibia osteotomies. Orthopäde 14:161–171PubMedGoogle Scholar
  22. 22.
    Jokio PJ, Lindholm TS, Vankka E (1985) Medial and lateral gonarthrosis treated with high tibial osteotomy. Arch Orthop Trauma Surg 104:135–144PubMedCrossRefGoogle Scholar
  23. 23.
    Ju KL, Zurakowski D, Kocher MS (2011) Differentiating between methicillin-resistant and methicillin-sensitive Staphylococcus aureus osteomyelitis in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 93-A:1693–1701CrossRefGoogle Scholar
  24. 24.
    Karatosun V, Demir T, Unver B, Gunal I (2011) A brief report on managing infected nonunion of a high tibial osteotomy in two stages. A case series involving seven knees. J Bone Joint Surg Br 93-B:904–906CrossRefGoogle Scholar
  25. 25.
    Karlsson J (2011) Quit smoking and reduce surgical complications. Knee Surg Sports Traumatol Surg 19:331–332CrossRefGoogle Scholar
  26. 26.
    Koshino T (1982) The treatment of spontaneous osteonecrosis of the knee by high tibial osteotomy with and without bone grafting or drilling of the lesion. J Bone Joint Surg Am 64-A:47–58Google Scholar
  27. 27.
    Kral JG, Dixon JB, Horber FF, Rössner S, Stiles S, Torgerson JS, Sugerman HJ (2005) Flaws in methods of evidence-based medicine may adversely affect public health directives. Surgery 137:279–284PubMedCrossRefGoogle Scholar
  28. 28.
    Lobenhoffer P (1999) Chronic instability after posterior cruciate ligament injury. Tactics, techniques, and results. Unfallchirurg 102:824–838PubMedCrossRefGoogle Scholar
  29. 29.
    Loberhoffer P, Simoni CD, Staubli AE (2002) Opening-wedge high tibial osteotomy with rigid plate fixation. Tech Knee Surg 2:1–11Google Scholar
  30. 30.
    Lobenhoffer P, Agneskirchner J, Zoch W (2004) Open valgus alignment osteotomy of the proximal tibia with fixation by medial plate fixator. Orthopäde 33:152–160CrossRefGoogle Scholar
  31. 31.
    Magyar G, Toksvig-Larsen S, Lindstrand A (1998) Open wedge tibial osteotomy by callus distraction in gonarthrosis: operative technique and early results in 36 patients. Acta Orthop Scand 69:147–151PubMedCrossRefGoogle Scholar
  32. 32.
    Magyar G, Ahl TL, Vibe P, Toksvig-Larsen S, Lindstrand A (1999) open-wedge osteotomy by hemicallotasis or the closed-wedge technique for osteoarthritis of the knee. A randomized study of 50 operations. J Bone Joint Surg Br 81-B:444–448CrossRefGoogle Scholar
  33. 33.
    Meidinger G, Imhoff AB, Paul J, Kirchhoff C, Sauerschnig M, Hinterwimmer S (2011) May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union. Knee Surg Sports Arthrosc Traumatol 19:333–339CrossRefGoogle Scholar
  34. 34.
    Miller BS, Downie B, McDonough EB, Wojtys EM (2009) Complications after medial opening wedge high tibial osteotomy. Arthroscopy 25:639–646PubMedCrossRefGoogle Scholar
  35. 35.
    Miniaci A, Ballmer FT, Ballmer PM, Jakob RP (1989) Proximal tibial osteotomy. A new fixation device. Clin Orthop Relat Res 246:250–259PubMedGoogle Scholar
  36. 36.
    Moller AM, Pedersen T, Villebro N, Munksgaard A (2003) Effect of smoking on early complications after elective orthopedic surgery. J Bone Joint Surg Br 85-B:178–181CrossRefGoogle Scholar
  37. 37.
    Nakamura E, Mizuta H, Kudo S, Takagi K, Sakamoto K (2001) Open-wedge osteotomy of the proximal tibia hemicallotasis. J Bone Joint Surg Br 83-B:1111–1115CrossRefGoogle Scholar
  38. 38.
    Nasell H, Ottoson C, Törnqvist H, Linde J, Ponzer S (2011) The impact of smoking on complications after operatively treated ankle fractures – a follow-up study of 906 patients. J Orthop Trauma 25:748–755PubMedCrossRefGoogle Scholar
  39. 39.
    Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999) Survivorship of the high tibial valgus osteotomy. A 10–22 year follow-up study. Clin Orthop Relat Res 367:18–27PubMedCrossRefGoogle Scholar
  40. 40.
    Reischl N, Wahl P, Jacobi M, Clerc S, Gautier E, Jakob RP (2009) Infections after high tibial open wedge osteotomy: a case control study. Arch Orthop Trauma Surg 129:1483–1487PubMedCrossRefGoogle Scholar
  41. 41.
    Smilanich RP, Bonnet I, Kirkpatrick JR (1995) Contaminated wounds: the effect of initial management on outcome. Am Surg 61:427–430PubMedGoogle Scholar
  42. 42.
    Smith TO, Sexton D, Mitchell P, Hing CB (2011) Opening- or closing-wedged high tibial osteotomy: a meta-analysis of clinical and radiological outcomes. Knee 18:361–368PubMedCrossRefGoogle Scholar
  43. 43.
    Song EK, Seon JK, Park SJ, Jeong MS (2010) The complications of high tibial osteotomy. Closing- versus opening-wedge methods. J Bone Joint Surg Br 92-B:1245–1252CrossRefGoogle Scholar
  44. 44.
    Spahn G (2003) Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg 124:649–653PubMedCrossRefGoogle Scholar
  45. 45.
    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–B62PubMedCrossRefGoogle Scholar
  46. 46.
    Struijs PA, Poolman RW, Bhandari M (2007) Infected nonunions of the long bones. J Orthop Trauma 21:507–511PubMedCrossRefGoogle Scholar
  47. 47.
    Suzuki G, Saito S, Ishii T, Motojima S, Tokuhashi Y, Ryu J (2011) Previous fracture surgery is a major risk factor for infection after toal knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 19:2044Google Scholar
  48. 48.
    Suzuki T, Morgan SJ, Smith WR, Stahel PF, Gillani SA, Hak DJ (2010) Postoperative surgical site infection following acetabular fracture fixation. Injury 41:396–399PubMedCrossRefGoogle Scholar
  49. 49.
    Takahashi T, Wada Y, Tanaka M, Iwagawa M, Ikeuchi M, Hirose D, Yamamoto H (2000) Dome-shaped proximal tibial osteotomy using percutaneous drilling for osteoarthritis of the knee. Arch Orthop Trauma Surg 120:32–37PubMedGoogle Scholar
  50. 50.
    Valkering KP, van de Bekerom MP, Kappelhoff FM, Albers GH (2009) Complications after tomofix medial opening wedge high tibial osteotomy. J Knee Surg 22:218–225PubMedCrossRefGoogle Scholar
  51. 51.
    Van Raaij TM, Bakker W, Reijman M, Verhaar JA (2007) The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study. BMC Musculoskelet Disord 8:74PubMedCrossRefGoogle Scholar
  52. 52.
    Viskontas DG, MacLeod MD, Sanders DW (2006) High tibial osteotomy with use of the Taylor Spatial Frame external fixator for osteoarthritis of the knee. Can J Surg 49:245–250PubMedGoogle Scholar
  53. 53.
    W-Dahl A, Toksvig-Larsen S (2006) Infection prophylaxis: a prospective study in 106 patients operated on by tibial osteotomy using the hemicallotasis technique. Arch Orthop Trauma Surg 126:441–447PubMedCrossRefGoogle Scholar
  54. 54.
    Wildner M, Peters A, Hellich J, Reichelt A (1992) Complications of high tibial osteotomy and internal fixation with staples. Arch Orthop Trauma Surg 111:210–212PubMedCrossRefGoogle Scholar
  55. 55.
    Wilson AP, Livesey SA, Treasure T, Gruneberg RN, Struridge MF (1987) Factors predisposing to wound infection in cardiac surgery: a prospective study of 517 patients. Eur J Cardiothorac Surg 1:158–164PubMedCrossRefGoogle Scholar
  56. 56.
    Ysauda K, Majima T, Tsuchida T, Kaneda K (1992) A ten-year follow-up observation of high tibial osteotomy in medial compartment osteoarthritis. Clin Orthop Relat Res 282:186–195Google Scholar
  57. 57.
    Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351:1645–1654PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Konstantinos Anagnostakos
    • 1
  • Philipp Mosser
    • 1
  • Dieter Kohn
    • 1
  1. 1.Klinik für Orthopädie Und Orthopädische ChirurgieUniversitätsklinikum Des SaarlandesHomburg, SaarGermany

Personalised recommendations