Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy

  • Ken Kumagai
  • Yasushi Akamatsu
  • Hideo Kobayashi
  • Yoshihiro Kusayama
  • Tomihisa Koshino
  • Tomoyuki Saito



This study documented the healing potential of degenerated articular cartilage after opening-wedge valgus high tibial osteotomy (HTO) in patients with osteoarthritis of the knee. It was hypothesized that regeneration of articular cartilage is affected by several factors, including preoperative cartilage degeneration grade, difference between the medial femoral condyle (MFC) and the medial tibial condyle (MTC), and postoperative knee alignment.


Medial opening-wedge valgus HTO was performed in 131 knees of 100 patients (mean age 66 ± 7.7 years). Initial arthroscopy was performed at the time of HTO, and a second-look arthroscopy was performed at the time of plate removal (20.8 ± 6.5 months after HTO). Status of articular cartilage was assessed according to the ICRS grade. Cartilage regeneration was also evaluated by the presence of newly formed cartilaginous tissue. All subjects were followed up postoperatively at 2 years for assessment of clinical and radiographic outcomes.


The number of subjects in ICRS grade 1/2/3/4 was significantly altered from 0/11/53/67 preoperatively to 14/21/56/40 postoperatively in the MFC (P < 0.05) and 0/12/62/57 preoperatively to 9/24/64/34 postoperatively in the MTC (P < 0.05). Newly formed cartilaginous tissue was found in 71 % of MFCs and 51 % of MTCs. Incidence of cartilage regeneration was significantly higher in lower BMI cases, MFC, preoperatively advanced ICRS grade and overcorrected knees. Age, gender and clinical outcomes did not affect cartilage regeneration.


Cartilage regeneration in degenerated articular cartilage is induced after opening-wedge valgus HTO, which is affected by BMI, the difference between the MFC and MTC, preoperative cartilage degeneration grade, and postoperative limb alignment. Therefore, patient selection by BMI rather than age, and surgical techniques maintaining valgus knee alignment should be considered for cartilage regeneration.

Level of evidence

Level IV, therapeutic case series.


High tibial osteotomy Opening-wedge Knee Cartilage regeneration 


  1. 1.
    Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H (2008) The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br 90:592–596CrossRefPubMedGoogle Scholar
  2. 2.
    Akizuki S, Yasukawa Y, Takizawa T (1997) Does arthroscopic abrasion arthroplasty promote cartilage regeneration in osteoarthritic knees with eburnation? A prospective study of high tibial osteotomy with abrasion arthroplasty versus high tibial osteotomy alone. Arthroscopy 13:9–17CrossRefPubMedGoogle Scholar
  3. 3.
    Bauer GC, Insall J, Koshino T (1969) Tibial osteotomy in gonarthrosis (osteo-arthritis of the knee). J Bone Joint Surg Am 51:1545–1563CrossRefPubMedGoogle 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 82:70–79CrossRefPubMedGoogle Scholar
  5. 5.
    Cooke TD, Sled EA, Scudamore RA (2007) Frontal plane knee alignment: a call for standardized measurement. J Rheumatol 34:1796–1801PubMedGoogle Scholar
  6. 6.
    Coventry MB (1973) Osteotomy about the knee for degenerative and rheumatoid arthritis. J Bone Joint Surg Am 55:23–48CrossRefPubMedGoogle Scholar
  7. 7.
    Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196–201CrossRefPubMedGoogle Scholar
  8. 8.
    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
  9. 9.
    Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987) Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69:332–354CrossRefPubMedGoogle Scholar
  10. 10.
    Hunziker EB, Rosenberg LC (1996) Repair of partial-thickness defects in articular cartilage: cell recruitment from the synovial membrane. J Bone Joint Surg Am 78:721–733CrossRefPubMedGoogle Scholar
  11. 11.
    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14Google Scholar
  12. 12.
    Jung WH, Takeuchi R, Chun CW, Lee JS, Ha JH, Kim JH et al (2014) Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy. Arthroscopy 30:72–79CrossRefPubMedGoogle Scholar
  13. 13.
    Kanamiya T, Naito M, Hara M, Yoshimura I (2002) The influences of biomechanical factors on cartilage regeneration after high tibial osteotomy for knees with medial compartment osteoarthritis: clinical and arthroscopic observations. Arthroscopy 18:725–729CrossRefPubMedGoogle Scholar
  14. 14.
    Koshino T, Morii T, Wada J, Saito H, Ozawa N, Noyori K (1989) High tibial osteotomy with fixation by a blade plate for medial compartment osteoarthritis of the knee. Orthop Clin N Am 20:227–243Google Scholar
  15. 15.
    Koshino T, Tsuchiya K (1979) The effect of high tibial osteotomy on osteoarthritis of the knee. Clinical and histological observations. Int Orthop 3:37–45CrossRefGoogle Scholar
  16. 16.
    Koshino T, Wada S, Ara Y, Saito T (2003) Regeneration of degenerated articular cartilage after high tibial valgus osteotomy for medial compartmental osteoarthritis of the knee. Knee 10:229–236CrossRefPubMedGoogle Scholar
  17. 17.
    Koshino T, Yoshida T, Ara Y, Saito I, Saito T (2004) Fifteen to twenty-eight years’ follow-up results of high tibial valgus osteotomy for osteoarthritic knee. Knee 11:439–444CrossRefPubMedGoogle Scholar
  18. 18.
    Kwon SK, Moon HK, Choi CJ, Park SH, Lee JJ, Kim YC et al (2015) Accelerated degeneration of the discoid lateral meniscus after medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 23:97–103CrossRefPubMedGoogle Scholar
  19. 19.
    Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132–138CrossRefPubMedGoogle Scholar
  20. 20.
    Mankin HJ (1974) The reaction of articular cartilage to injury and osteoarthritis (first of two parts). N Engl J Med 291:1285–1292CrossRefPubMedGoogle Scholar
  21. 21.
    Mankin HJ (1974) The reaction of articular cartilage to injury and osteoarthritis (second of two parts). N Engl J Med 291:1335–1340CrossRefPubMedGoogle Scholar
  22. 22.
    Matsui N, Moriya H, Kitahara H (1979) The use of arthroscopy for follow-up in knee joint surgery. Orthop Clin N Am 10:697–708Google Scholar
  23. 23.
    Matsunaga D, Akizuki S, Takizawa T, Yamazaki I, Kuraishi J (2007) Repair of articular cartilage and clinical outcome after osteotomy with microfracture or abrasion arthroplasty for medial gonarthrosis. Knee 14:465–471CrossRefPubMedGoogle Scholar
  24. 24.
    Odenbring S, Egund N, Lindstrand A, Lohmander LS, Willen H (1992) Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis: an arthroscopic, roentgenographic, and histologic study. Clin Orthop Relat Res 277:210–216Google Scholar
  25. 25.
    Parker DA, Beatty KT, Giuffre B, Scholes CJ, Coolican MR (2011) Articular cartilage changes in patients with osteoarthritis after osteotomy. Am J Sports Med 39:1039–1045CrossRefPubMedGoogle Scholar
  26. 26.
    Saito T, Kumagai K, Akamatsu Y, Kobayashi H, Kusayama Y (2014) Five- to ten-year outcome following medial opening-wedge high tibial osteotomy with rigid plate fixation in combination with an artificial bone substitute. Bone Joint J 96-B:339–344CrossRefPubMedGoogle Scholar
  27. 27.
    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
  28. 28.
    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–B62CrossRefPubMedGoogle Scholar
  29. 29.
    Wakabayashi S, Akizuki S, Takizawa T, Yasukawa Y (2002) A comparison of the healing potential of fibrillated cartilage versus eburnated bone in osteoarthritic knees after high tibial osteotomy: an arthroscopic study with 1-year follow-up. Arthroscopy 18:272–278CrossRefPubMedGoogle Scholar
  30. 30.
    Ziegler R, Goebel L, Seidel R, Cucchiarini M, Pape D, Madry H (2015) Effect of open wedge high tibial osteotomy on the lateral tibiofemoral compartment in sheep. Part III: analysis of the microstructure of the subchondral bone and correlations with the articular cartilage and meniscus. Knee Surg Sports Traumatol Arthrosc 23:2704–2714CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2016

Authors and Affiliations

  • Ken Kumagai
    • 1
  • Yasushi Akamatsu
    • 1
  • Hideo Kobayashi
    • 1
  • Yoshihiro Kusayama
    • 1
  • Tomihisa Koshino
    • 1
  • Tomoyuki Saito
    • 1
  1. 1.Department of Orthopaedic Surgery, Graduate School of MedicineYokohama City University HospitalYokohamaJapan

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