The effect of patient, provider and surgical factors on survivorship of high tibial osteotomy to total knee arthroplasty: a population-based study

  • Amir Khoshbin
  • Ujash ShethEmail author
  • Darrell Ogilvie-Harris
  • Nizar Mahomed
  • Richard Jenkinson
  • Rajiv Gandhi
  • David Wasserstein



The aim of this study was to identify the survivorship of high tibial osteotomy (HTO) to total knee arthroplasty (TKA) on a population level, and identify the patient, provider and surgical factors that influenced eventual TKA.


Administrative records from physician billings and hospital admissions were used to identify all adults in Ontario, Canada, who underwent an HTO from 1994 to 2010. The primary outcome was time to TKA, which was estimated using Kaplan–Meier (KM) survival analysis. A Cox proportional hazards model examined the risk associated with patient factors (age, sex, income and co-morbidity score), provider factors (hospital status, surgeon volume and surgeon year in practice) and surgical factors (concurrent ligament reconstruction or bone grafting; and previous chondral or meniscal surgery).


A total of 2671 patients who underwent HTO met inclusion. The median age was 46 years (interquartile range 39–53 years), and 62 % were male. The KM survivorship of HTO to TKA at 10 years was 0.67 ± 0.01. Older age [HR 1.05 (95 % CI 1.04, 1.06), p < 0.001; 5 % increased risk for each year over age 46], female sex [HR 1.35 (95 % CI 1.17, 1.55), p < 0.001], higher comorbidity score [HR 1.58 (95 % CI 1.12, 2.22), p = 0.009] and a prior history of arthroscopy/meniscectomy [HR 1.24 (95 % CI 1.08, 1.43), p = 0.002] increased the risk of eventual TKA. However, HTO with concurrent ligament reconstruction was associated with lower [HR 0.62 (95 % CI 0.43, 0.88), p = 0.008] risk of eventual TKA.


In this population, two-thirds of patients were able to avoid a TKA for 10 years after HTO. Specific factors such as older age, female sex, higher comorbidity and prior meniscectomy lowered survival rates. An understanding of patient risk factors for conversion to TKA may help guide surgeons in their selection of patients who will benefit most from HTO.

Level of evidence

Retrospective cohort study, III.


High tibial osteotomy Total knee arthroplasty Osteoarthritis Risk factors Survival 



This study was supported by funds from the Arthritis Research Program of the University Health Network. The study was performed at the Institute for Clinical Evaluative Sciences, a non-profit research institute funded by the Ontario Ministry of Health and Long-Term Care.


The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. Parts of this material are based on data and information compiled and provided by the CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author and not necessarily those of CIHI. No endorsement by the Institute for Clinical Evaluative Sciences (ICES) or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred. ICES policies require that small cells (≤6) be suppressed to protect patient confidentiality.

Compliance with ethical standards

Conflict of interest

No authors have signed any agreement with a commercial interest related to this study, which would in any way limit publication of any and all data generated for the study or delay publication for any reason. None of the authors are paid consultants or have any conflicts of interests.

Supplementary material

167_2015_3849_MOESM1_ESM.pdf (55 kb)
Supplementary material 1 (PDF 55 kb)
167_2015_3849_MOESM2_ESM.pdf (64 kb)
Supplementary material 2 (PDF 63 kb)


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Amir Khoshbin
    • 1
  • Ujash Sheth
    • 2
    Email author
  • Darrell Ogilvie-Harris
    • 3
  • Nizar Mahomed
    • 3
    • 5
  • Richard Jenkinson
    • 4
  • Rajiv Gandhi
    • 3
  • David Wasserstein
    • 4
  1. 1.Division of Orthopaedic SurgerySt. Michael’s HospitalTorontoCanada
  2. 2.University Health Network Arthritis ProgramTorontoCanada
  3. 3.University Health Network Arthritis ProgramTorontoCanada
  4. 4.Division of Orthopaedic SurgerySunnybrook Health Sciences CentreTorontoCanada
  5. 5.Institute for Clinical Evaluative SciencesTorontoCanada

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