High tibial osteotomy with modern PEEK implants is safe and leads to lower hardware removal rates when compared to conventional metal fixation: a multi-center comparison study



Various implant materials have been used in medial, opening-wedge high tibial osteotomy (HTO) including traditional metal and modern polyetheretherketone (PEEK) implants. The purpose of this study was to compare metal and PEEK implants and determine safety, varus deformity correction, as well as short- to mid-term hardware removal and arthroplasty rates.


HTO performed with metal and PEEK implants were reviewed between 2000 and 2015 at two institutions with a minimum of 2 years follow-up. Postoperative complications, radiographic measures, and osteotomy union were compared between groups using Kruskal–Wallis and Fisher’s exact testing. Survival free of hardware removal and arthroplasty was compared between groups using Kaplan–Meier testing. Risk factors for HTO conversion to arthroplasty were examined using Cox proportional hazards regression.


Ninety-five HTOs were performed in 90 patients (59 M, 31 F) using 50 metal and 45 PEEK implants. Mean follow-up was 4.2 years (range 2.0–16.5). Two metal and two PEEK HTO patients experienced nonunions, resulting in revision HTO at a mean of 1.0 years postoperatively (range 0.4–1.4 years). Both implant groups demonstrated similar, significant improvements in coronal deformity, with mean angulation improving from 6.0° and 5.4° varus preoperatively to 1.1° and 1.0° valgus postoperatively for the metal (p < 0.01) and PEEK groups (p < 0.01), respectively. 2- and 5-year hardware removal-free survival was 94% and 94% for PEEK, which was significantly superior to 80% and 73% observed for metal (p = 0.02). 2- and 5-year arthroplasty-free survival was similar for the metal (98% and 94%) and PEEK groups (100% and 78%) (n.s.). HTO performed for focal cartilage defects was observed to demonstrate decreased arthroplasty risk (HR 0.36, p = 0.03) when compared to HTO performed for osteoarthritis.


Both metal and PEEK implants were found to be effective in obtaining and maintaining coronal varus deformity correction, with 88% overall arthroplasty-free survival at 5 years. Metal fixation demonstrated a higher rate of hardware removal while HTO performed for medial compartment osteoarthritis predicted conversation to arthroplasty.

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Proximal tibial osteotomy


High tibial osteotomy




Insall Salvatti Ratio


Caton-Deschamps Index


Weight-bearing line


  1. 1.

    Amendola A, Bonasia DE (2010) Results of high tibial osteotomy: review of the literature. Int Orthop 34:155–160

    Article  PubMed  Google Scholar 

  2. 2.

    Amendola A, Fowler PJ, Litchfield R, Kirkley S, Clatworthy M (2004) Opening wedge high tibial osteotomy using a novel technique: early results and complications. J Knee Surg 17:164–169

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    American College of Surgeons National Surgical Quality Improvement Program. ACS NSQIP Surgical Risk Calculator. https://riskcalculator.facs.org/RiskCalculator/. Accessed 04/23/2018

  4. 4.

    Amis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21:197–205

    Article  PubMed  Google Scholar 

  5. 5.

    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 14:948–954

    Article  PubMed  Google Scholar 

  6. 6.

    Blackman AJ, Krych AJ, Engasser WM, Levy BA, Stuart MJ (2015) Does proximal tibial osteotomy with a novel osteotomy system obtain coronal plane correction without affecting tibial slope and patellar height? Knee Surg Sports Traumatol Arthrosc 23:3487–3493

    Article  PubMed  Google 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 randomised, controlled study. J Bone Joint Surg Br 88:1454–1459

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Brouwer RW, Raaij TM, Bierma-Zeinstra SM, Verhagen AP, Jakma TS, Verhaar JA (2007) Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD004019.pub3Cd004019

    Article  PubMed  Google Scholar 

  9. 9.

    Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H (1982) Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot 68:317–325

    CAS  PubMed  Google Scholar 

  10. 10.

    Cotic M, Vogt S, Hinterwimmer S, Feucht MJ, Slotta-Huspenina J, Schuster T et al (2015) A matched-pair comparison of two different locking plates for valgus-producing medial open-wedge high tibial osteotomy: peek-carbon composite plate versus titanium plate. Knee Surg Sports Traumatol Arthrosc 23:2032–2040

    Article  PubMed  Google Scholar 

  11. 11.

    Debeyre J, Patte D (1962) Value of corrective osteotomies in the treatment of certain knee diseases with axial deviation. Rev Rhum Mal Osteoar 29:722–729

    CAS  Google Scholar 

  12. 12.

    Dugdale TW, Noyes FR, Styer D (1992) Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res 274:248–264

    Google Scholar 

  13. 13.

    Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160

    Article  PubMed  Google Scholar 

  14. 14.

    Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Gaasbeek RDA, Nicolaas L, Rijnberg WJ, van Loon CJM, van Kampen A (2010) Correction accuracy and collateral laxity in open versus closed wedge high tibial osteotomy. A one-year randomised controlled study. Int Orthop 34:201–207

    Article  PubMed  Google Scholar 

  16. 16.

    Getgood A, Collins B, Slynarski K, Kurowska E, Parker D, Engebretsen L et al (2013) Short-term safety and efficacy of a novel high tibial osteotomy system: a case controlled study. Knee Surg Sports Traumatol Arthrosc 21:260–269

    Article  PubMed  Google Scholar 

  17. 17.

    Heary RF, Parvathreddy N, Sampath S, Agarwal N (2017) Elastic modulus in the selection of interbody implants. J Spine Surg 3:163–167

    Article  PubMed Central  PubMed  Google Scholar 

  18. 18.

    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 69:332–354

    Article  CAS  PubMed  Google Scholar 

  19. 19.

    Hernigou P, Roussignol X, Flouzat-Lachaniette CH, Filippini P, Guissou I, Poignard A (2010) Opening wedge tibial osteotomy for large varus deformity with Ceraver(TM) resorbable beta tricalcium phosphate wedges. Int Orthop 34:191–199

    Article  PubMed  Google Scholar 

  20. 20.

    Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    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 23:2762–2768

    Article  PubMed  Google Scholar 

  22. 22.

    Kesmezacar H, Erginer R, Ogut T, Seyahi A, Babacan M, Tenekecioglu Y (2005) Evaluation of patellar height and measurement methods after valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 13:539–544

    Article  PubMed  Google Scholar 

  23. 23.

    LaPrade RF, Oro FB, Ziegler CG, Wijdicks CA, Walsh MP (2010) Patellar height and tibial slope after opening-wedge proximal tibial osteotomy: a prospective study. Am J Sports Med 38:160–170

    Article  PubMed  Google Scholar 

  24. 24.

    Moore TM, Harvey JP (1974) Roentgenographic measurement of tibial-plateau depression due to fracture. J Bone Joint Surg Am 56:155–160

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Roberson TA, Momaya AM, Adams K, Long CD, Tokish JM, Wyland DJ (2018) High tibial osteotomy performed with All-PEEK implants demonstrates similar outcomes but less hardware removal at minimum 2-year follow-up compared with metal plates. Orthop J Sports Med 6:232

    Article  Google Scholar 

  26. 26.

    Wang JH, Bae JH, Lim HC, Shon WY, Kim CW, Cho JW (2009) Medial open wedge high tibial osteotomy: the effect of the cortical hinge on posterior tibial slope. Am J Sports Med 37:2411–2418

    Article  PubMed  Google Scholar 

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Corresponding author

Correspondence to Aaron J. Krych.

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Conflict of interest

Mario Hevesi has received consulting fees from Moximed. Jeffrey A. Macalena serves as a board or committee member of AAOS, AOSSM, and the Mid-America Orthopaedic Society. He receives research or other financial support from Arthrex, Vericel, and the Musculoskeletal Transplant Foundation. Isabella T. Wu and Christopher L. Camp declare no conflicts of interest. Bruce A. Levy received consulting fees from Arthrex, CONMED Linvatec, and Smith & Nephew; he receives research support from Biomet, Smith & Nephew, and Stryker and serves on the Editorial or Governing board for Clinical Orthopaedics and Related Research, Journal of Knee Surgery, Knee Surgery, Sports Traumatology, Arthroscopy, and Orthopedics Today. Elizabeth A. Arendt received consulting fees from Smith & Nephew and serves on the Editorial or Governing board for AJSM, British Journal of Sports Medicine, International Society of Arthroscopy, Knee Surgery, Orthopaedic Sports Medicine, and Knee Surgery, Sports Traumatology, Arthroscopy. Michael J. Stuart received consulting fees from Arthrex and research support from Stryker. He serves on the Editorial or Governing board for AJSM. Aaron J. Krych received consulting fees from Arthrex, JRF Ortho, and Vericel and research support from Aesculap/B. Braun, Arthrex, Arthritis Foundation, Ceterix, and Histogenics. He serves on the Editorial or Governing board for AJSM, the International Cartilage Repair Society, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, Minnesota Orthopedic Society, and Musculoskeletal Transplantation Foundation.

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The study was performed following and in accordance with Institutional Review Board (IRB) approval.

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Hevesi, M., Macalena, J.A., Wu, I.T. et al. High tibial osteotomy with modern PEEK implants is safe and leads to lower hardware removal rates when compared to conventional metal fixation: a multi-center comparison study. Knee Surg Sports Traumatol Arthrosc 27, 1280–1290 (2019). https://doi.org/10.1007/s00167-018-5329-0

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  • High tibial osteotomy
  • High tibial osteotomy
  • Knee
  • Preservation
  • Cartilage
  • Varus