Classical target coronal alignment in high tibial osteotomy demonstrates validity in terms of knee kinematics and kinetics in a computer model

  • Shinichi KuriyamaEmail author
  • Mutsumi Watanabe
  • Shinichiro Nakamura
  • Kohei Nishitani
  • Kazuya Sekiguchi
  • Yoshihisa Tanaka
  • Hiromu Ito
  • Shuichi Matsuda



The purpose of this study was to determine the ideal coronal alignment under dynamic conditions after open-wedge high tibial osteotomy (OWHTO). It was hypothesised that, although the classical target alignment was based on experimental evidence, it would demonstrate biomechanical validity.


Musculoskeletal computer models were analysed with various degrees of coronal correction in OWHTO during gait and squat, specifically with the mechanical axis passing through points at 40%, 50%, 60%, 62.5%, 70%, and 80% of the tibial plateau from the medial edge, defined as the weight-bearing line percentage (WBL%). The peak load on the lateral tibiofemoral (TF) joint, the medial collateral ligament (MCL), and anterior cruciate ligament (ACL) tensions, and knee kinematics with or without increased posterior tibial slope (PTS) were evaluated.


The classical alignment with WBL62.5% achieved sufficient load on the lateral TF joint and maintained normal knee kinematics after OWHTO. However, over-correction with WBL80% caused an excessive lateral load and non-physiological kinematics. Increased WBL% resulted in increased MCL tension due to lateral femoral movement against the tibia. With WBL80%, abnormal contact between the medial femoral condyle and the medial intercondylar eminence of the tibia occurred at knee extension. The screw-home movement around knee extension and the TF rotational angle during flexion were reduced as WBL% increased. Increased PTS was associated with increased ACL tension and decreased TF rotation angle because of ligamentous imbalance.


The classical target alignment demonstrated validity in OWHTO, and over-correction should be avoided as it negatively impacts clinical outcome.

Level of evidence



Open-wedge high tibial osteotomy (OWHTO) Coronal alignment Posterior tibial slope (PTS) Over-correction Kinematics and kinetics Medial proximal tibial angle (MPTA) 



There was no funding for this study.

Compliance with ethical standards

Conflict of interest

Kuriyama S, Watanabe M, Nakamura S, Nishitani K, Sekiguchi K, Tanaka Y, Ito H, and Matsuda S declare that they have no conflict of interest in association with the present study.

Ethical approval

All procedures were in accordance with the ethical standards of our institutional research committee.

Informed consent

Informed consent was obtained from the single study participant.

Supplementary material

Supplementary material 1 (MOV 260393 kb)


  1. 1.
    Akamatsu Y, Kumagai K, Kobayashi H, Tsuji M, Saito T (2018) Effect of increased coronal inclination of the tibial plateau after opening-wedge high tibial osteotomy. Arthroscopy 34:2158–2169CrossRefPubMedGoogle Scholar
  2. 2.
    Akamatsu Y, Mitsugi N, Mochida Y, Taki N, Kobayashi H, Takeuchi R et al (2012) Navigated opening wedge high tibial osteotomy improves intraoperative correction angle compared with conventional method. Knee Surg Sports Traumatol Arthrosc 20:586–593CrossRefPubMedGoogle Scholar
  3. 3.
    Akamatsu Y, Ohno S, Kobayashi H, Kusayama Y, Kumagai K, Saito T (2017) Coronal subluxation of the proximal tibia relative to the distal femur after opening wedge high tibial osteotomy. Knee 24:70–75CrossRefPubMedGoogle Scholar
  4. 4.
    Bagherifard A, Jabalameli M, Mirzaei A, Khodabandeh A, Abedi M, Yahyazadeh H (2019) Retaining the medial collateral ligament in high tibial medial open-wedge osteotomy mostly results in post-operative intra-articular gap reduction. Knee Surg Sports Traumatol Arthrosc. CrossRefPubMedGoogle Scholar
  5. 5.
    Bode G, von Heyden J, Pestka J, Schmal H, Salzmann G, Sudkamp N et al (2015) Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:1949–1955CrossRefPubMedGoogle Scholar
  6. 6.
    D’Lima DD, Patil S, Steklov N, Chien S, Colwell CW Jr (2007) In vivo knee moments and shear after total knee arthroplasty. J Biomech 40(Suppl 1):S11–S17CrossRefPubMedGoogle Scholar
  7. 7.
    Dugdale T, Noyes F, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264Google Scholar
  8. 8.
    Feucht MJ, Minzlaff P, Saier T, Cotic M, Südkamp NP, Niemeyer P et al (2014) Degree of axis correction in valgus high tibial osteotomy: proposal of an individualised approach. Int Orthop 38:2273–2280CrossRefPubMedGoogle Scholar
  9. 9.
    Fujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin N Am 10:585–608Google Scholar
  10. 10.
    Hamai S, Miura H, Higaki H, Matsuda S, Shimoto T, Sasaki K et al (2008) Kinematic analysis of kneeling in cruciate-retaining and posterior-stabilized total knee arthroplasties. J Orthop Res 26:435–442CrossRefPubMedGoogle Scholar
  11. 11.
    Han JH, Kim HJ, Song JG, Yang JH, Nakamura R, Shah D et al (2015) Locking plate versus non-locking plate in open-wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 25:808–816CrossRefPubMedGoogle Scholar
  12. 12.
    Hatsushika D, Nimura A, Mochizuki T, Yamaguchi K, Muneta T, Akita K (2013) Attachments of separate small bundles of human posterior cruciate ligament: an anatomic study. Knee Surg Sports Traumatol Arthrosc 21:998–1004CrossRefPubMedGoogle Scholar
  13. 13.
    Hohloch L, Kim S, Mehl J, Zwingmann J, Feucht MJ, Eberbach H et al (2018) Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy. Knee Surg Sports Traumatol Arthrosc 26:2766–2773CrossRefPubMedGoogle Scholar
  14. 14.
    Innocenti B, Pianigiani S, Labey L, Victor J, Bellemans J (2011) Contact forces in several TKA designs during squatting: a numerical sensitivity analysis. J Biomech 44:1573–1581CrossRefPubMedGoogle Scholar
  15. 15.
    Jacobi M, Villa V, Reischl N, Demey G, Goy D, Neyret P et al (2015) Factors influencing posterior tibial slope and tibial rotation in opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:2762–2768CrossRefPubMedGoogle Scholar
  16. 16.
    Jo HS, Park JS, Byun JH, Lee YB, Choi YL, Cho SH et al (2018) The effects of different hinge positions on posterior tibial slope in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 26:1851–1858CrossRefPubMedGoogle Scholar
  17. 17.
    Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski MP, Devitt BM, Aroen A et al (2013) Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med 41:2828–2838CrossRefPubMedGoogle Scholar
  18. 18.
    Kim HJ, Park J, Shin JY, Park IH, Park KH, Kyung HS (2018) More accurate correction can be obtained using a three-dimensional printed model in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 26:3452–3458CrossRefPubMedGoogle Scholar
  19. 19.
    Kim SJ, Koh YG, Chun YM, Kim YC, Park YS, Sung CH (2009) Medial opening wedge high-tibial osteotomy using a kinematic navigation system versus a conventional method: a 1-year retrospective, comparative study. Knee Surg Sports Traumatol Arthrosc 17:128–134CrossRefPubMedGoogle Scholar
  20. 20.
    Kuriyama S, Ishikawa M, Furu M, Ito H, Matsuda S (2014) Malrotated tibial component increases medial collateral ligament tension in total knee arthroplasty. J Orthop Res 32:1658–1666CrossRefPubMedGoogle Scholar
  21. 21.
    Kuriyama S, Ishikawa M, Nakamura S, Furu M, Ito H, Matsuda S (2016) No condylar lift-off occurs because of excessive lateral soft tissue laxity in neutrally aligned total knee arthroplasty: a computer simulation study. Knee Surg Sports Traumatol Arthrosc 24:2517–2524CrossRefPubMedGoogle Scholar
  22. 22.
    Kuriyama S, Morimoto N, Shimoto T, Takemoto M, Nakamura S, Nishitani K et al (2019) Clinical efficacy of preoperative 3D planning for reducing surgical errors during open-wedge high tibial osteotomy. J Orthop Res 37:898–907CrossRefPubMedGoogle Scholar
  23. 23.
    LaPrade RF, Bollom TS, Wentorf FA, Wills NJ, Meister K (2005) Mechanical properties of the posterolateral structures of the knee. Am J Sports Med 33:1386–1391CrossRefPubMedGoogle Scholar
  24. 24.
    Lee DK, Wang JH, Won Y, Min YK, Jaiswal S, Lee BH, Kim JY (2019) Preoperative latent medial laxity and correction angle are crucial factors for overcorrection in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. CrossRefPubMedGoogle Scholar
  25. 25.
    Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132–138CrossRefPubMedGoogle Scholar
  26. 26.
    Nakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K et al (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 26:1873–1878CrossRefPubMedGoogle Scholar
  27. 27.
    Nam D, Lin KM, Howell SM, Hull ML (2014) Femoral bone and cartilage wear is predictable at 0° and 90° in the osteoarthritic knee treated with total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:2975–2981CrossRefPubMedGoogle Scholar
  28. 28.
    Park SE, DeFrate LE, Suggs JF, Gill TJ, Rubash HE, Li G (2005) The change in length of the medial and lateral collateral ligaments during in vivo knee flexion. Knee 12:377–382CrossRefPubMedGoogle Scholar
  29. 29.
    Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090CrossRefPubMedGoogle Scholar
  30. 30.
    Rodner CM, Adams DJ, Diaz-Doran V, Tate JP, Santangelo SA, Mazzocca AD et al (2006) Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure. Am J Sports Med 34:1431–1441CrossRefPubMedGoogle Scholar
  31. 31.
    Schallberger A, Jacobi M, Wahl P, Maestretti G, Jakob RP (2011) High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13–21 years. Knee Surg Sports Traumatol Arthrosc 19:122–127CrossRefPubMedGoogle Scholar
  32. 32.
    Seitz AM, Nelitz M, Ignatius A, Dürselen L (2018) Release of the medial collateral ligament is mandatory in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. CrossRefPubMedGoogle Scholar
  33. 33.
    Sharma A, Komistek RD, Ranawat CS, Dennis DA, Mahfouz MR (2007) In vivo contact pressures in total knee arthroplasty. J Arthroplasty 22:404–416CrossRefPubMedGoogle Scholar
  34. 34.
    Smith JO, Wilson AJ, Thomas NP (2013) Osteotomy around the knee: evolution, principles and results. Knee Surg Sports Traumatol Arthrosc 21:3–22CrossRefPubMedGoogle Scholar
  35. 35.
    Sugita T, Amis A (2001) Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 29:466–472CrossRefPubMedGoogle Scholar
  36. 36.
    Takeuchi R, Ishikawa H, Aratake M, Bito H, Saito I, Kumagai K et al (2009) Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy 25:46–53CrossRefPubMedGoogle Scholar
  37. 37.
    Takeuchi R, Ishikawa H, Miyasaka Y, Sasaki Y, Kuniya T, Tsukahara S (2014) A novel closed-wedge high tibial osteotomy procedure to treat osteoarthritis of the knee: hybrid technique and rehabilitation measures. Arthrosc Tech 3:e431–e437CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Tanaka Y, Nakamura S, Kuriyama S, Ito H, Furu M, Komistek RD et al (2016) How exactly can computer simulation predict the kinematics and contact status after TKA? Examination in individualized models. Clin Biomech (Bristol, Avon) 39:65–70CrossRefGoogle Scholar
  39. 39.
    Watanabe M, Kuriyama S, Nakamura S, Tanaka Y, Nishitani K, Furu M et al (2017) Varus femoral and tibial coronal alignments result in different kinematics and kinetics after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25:3459–3466CrossRefPubMedGoogle Scholar
  40. 40.
    Wijdicks CA, Ewart DT, Nuckley DJ, Johansen S, Engebretsen L, Laprade RF (2010) Structural properties of the primary medial knee ligaments. Am J Sports Med 38:1638–1646CrossRefPubMedGoogle Scholar
  41. 41.
    Yan J, Musahl V, Kay J, Khan M, Simunovic N, Ayeni OR (2016) Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc 24:3529–3555CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
  2. 2.Department of Orthopaedic SurgeryYawata Central HospitalKyotoJapan
  3. 3.Department of Orthopaedic SurgeryJapanese Red Cross Society Wakayama Medical CenterWakayamaJapan

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