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Release of the medial collateral ligament is mandatory in medial open-wedge high tibial osteotomy

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



The purpose of this study was to quantify the effect of clinically relevant open-wedge high tibial osteotomies on medial collateral ligament (MCL) strain and the resultant tibiofemoral contact mechanics during knee extension and 30° knee flexion.


Six human cadaveric knee joints were axially loaded (1 kN) in knee extension and 30° knee flexion. Strains at the anterior and posterior regions of the MCL were determined using strain gauges. Tibiofemoral contact mechanics (contact area, mean and maximum contact pressure) were investigated using pressure-sensitive sensors. Open-wedge osteotomy was performed using biplanar cuts and osteotomy angles of 5° and 10° were maintained using an external fixator. Tests were performed first with intact and then with dissected MCL.


Nonparametric statistical analyses indicated a significant strain increase (p < 0.01) in the anterior and posterior fibres of the MCL with increasing osteotomy angle of up to 8.3% and 6.0%, respectively. Only after releasing the MCL the desired lateralisation of the mechanical axis was achieved, indicating a significant decrease in the maximum contact pressure in knee extension of − 25% (p = 0.028) and 30° knee flexion of − 21% (p = 0.027).


The results of the present biomechanical study suggest, that an open-wedge high tibial osteotomy is most effective in reducing the medial contact pressure when spreading the osteotomy to 10° and concomitantly releasing the MCL. To transfer the results of this biomechanical study to the clinical day-to-day practice, it is necessary to factor in the individual ligamentous laxity of each patient into the treatment options e.g. particularly for patients with distinct knee ligament laxity or medial ligamentary instability, the release of the MCL should be performed with care.

Level of evidence

Controlled laboratory study.

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Contact area mm2


Contact pressure MPa

CPmax :

Maximum (peak) contact pressure MPa

ε ant :

Strain at the anterior part of sMCL %

ε post :

Strain at the posterior part of sMCL %


Medial collateral ligament


Open wedge high tibial osteotomy


Superficial medial collateral ligament


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No funding was required for this study.

Author information

Authors and Affiliations



AMS and MN carried out the in-vitro experiments, and drafted the manuscript. MN prepared all specimen. AMS carried out the statistical analyses. AI participated in the design of the study and helped to interpret the data. LD conceived of the study, and participated in the design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Andreas M. Seitz.

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Conflict of interest

None of the authors declare that they have any conflict of interest related to this work.

Ethical approval

This study was performed with the approval of the institutional review boards of Ulm Universiy.

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Seitz, A.M., Nelitz, M., Ignatius, A. et al. Release of the medial collateral ligament is mandatory in medial open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 27, 2917–2926 (2019).

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