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Faster union rate and better clinical outcomes using autologous bone graft after medial opening wedge high tibial osteotomy



To compare the radiological bone union rate after medial opening wedge high tibial osteotomy (MOW-HTO) and stabilization using a TomoFix™ plate (Synthes, Oberdorf, Switzerland) in three patient groups.


Retrospective analysis of 137 knees that underwent MOW-HTO between January 2014 and January 2017 was using a TomoFix™ plate. Osteotomy gaps were filled with β-tricalcium phosphate (β-TCP) (group A), left unfilled (group B), and subject to autologous bone graft and β-TCP (group C). Radiological bone union using simple radiography was determined by a modified version of the Brosset et al. osteotomy filling index. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and Lysholm score. Statistical analyses using the Chi-square and ANOVA tests were performed between the groups.


The mean time for radiological bone union was 8.3 ± 3.1 months in group A, 7.2 ± 3.2 in group B and 3.4 ± 1.5 in group C (p = 0.001). There was statistically significant faster bone union in Group C. If the opening distance was more than 10 mm, group A united in 8.6 ± 3.6 months, group B in 8.8 ± 3.4, and group C in 3.5 ± 1.7 (p = 0.001). IKDC and Lysholm knee scores improved significantly (p = 0.004 for IKDC and 0.001 for Lysholm knee scores) in group C when compared to groups A and B at sixth month follow-up. At final follow-up, there was no difference in IKDC and Lysholm knee scores. Less delayed union occurred in group C.


MOW-HTO with autologous bone graft and β-TCP had the fastest radiological bone union and best clinical scores at 6 month follow-up.

Level of evidence

Retrospective comparative study, Level III.

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  1. Akiyama T, Okazaki K, Mawatari T, Ikemura S, Nakamura S (2016) Autologous osteophyte grafting for open-wedge high tibial osteotomy. Arthrosc Tech 5(5):e989–e995

    Article  Google Scholar 

  2. Amis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21(1):197–205

    Article  Google Scholar 

  3. Brosset T, Pasquier G, Migaud H, Gougeon F (2011) Opening wedge high tibial osteotomy performed without filling the defect but with locking plate fixation (TomoFix™) and early weight-bearing: prospective evaluation of bone union, precision and maintenance of correction in 51 cases. Orthop Traumatol Surg Res 97(7):705–711

    CAS  Article  Google Scholar 

  4. Chae DJ, Shetty GM, Wang KH, Montalban ASC Jr, Kim JI, Nha KW (2011) Early complications of medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation. Knee 18(4):278–284

    Article  Google Scholar 

  5. 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

  6. Duivenvoorden T, van Diggele P, Reijman M, Bos PK, van Egmond J, Bierma-Zeinstra SM, Verhaar JA (2015) Adverse events and survival after closing- and opening-wedge high tibial osteotomy: a comparative study of 412 patients. Knee Surg Sports Traumatol Arthrosc 25(3):895–901

    Article  Google Scholar 

  7. El-Assal MA, Khalifa YE, Abdel-Hamid MM, Said HG, Bakr HM (2010) Opening-wedge high tibial osteotomy without bone graft. Knee Surg Sports Traumatol Arthrosc 18(7):961–966

    Article  Google Scholar 

  8. Galla M, Lobenhoffer P (2004) High tibial open wedge valgus osteotomy stabilized with the TomoFix™ plate fixator. Oper Orthop Traumatol 16:397–417

    Article  Google Scholar 

  9. Han JH, Kim HJ, Song JG, Yang JH, Bhandare NN, Fernandez AR, Park HJ, Nha KW (2015) Is bone grafting necessary in opening wedge high tibial osteotomy? A meta-analysis of radiological outcomes. Knee Surg Relat Res 27(4):207–220

    Article  Google Scholar 

  10. Hantes ME, Natsaridis P, Koutalos AA, Ono Y, Doxariotis N, Malizos KN (2017) Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up. Knee Surg Sports Traumatol Arthrosc 26(11):3199–3205

    Article  Google Scholar 

  11. Jung WH, Chung WC, Ji-Hoon L, Jae-Hun H, Ji-Hyae K, Jae HJ (2013) Comparative study of medial opening-wedge high tibial osteotomy using 2 different implants. Arthroscopy 29(6): 1063–1071

    Article  Google Scholar 

  12. Kuremsky MA, Schaller TM, Hall CC, Roehr BA, Masonis JL (2010) Comparison of autograft vs allograft in opening-wedge high tibial osteotomy. J Arthroplasty 25(6):951–957

    Article  Google Scholar 

  13. Lee SS, Nha KW, Lee DH (2018) Posterior cortical breakage leads to posterior tibial slope change in lateral hinge fracture following opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc.

    Article  PubMed  Google Scholar 

  14. Lobenhoffer P, Agneskirchner J, Zoch W (2004) Die öffnende valgisierende Osteotomie der proximalen Tibia mit Fixation durch einen medialen Plattenfixateur. Orthopade 33(2):153–160

    CAS  Article  Google Scholar 

  15. Montgomery AA, Graham A, Evans PH, Fahey T (2002) Inter-rater agreement in the scoring of abstracts submitted to a primary care research conference. BMC Health Serv Res 2(1):8

    Article  Google Scholar 

  16. Moyad TF, Minas T (2008) Opening wedge high Tibial osteotomy—a novel technique for harvesting autograft bone. J Knee Surg 21(01):80–84

    Article  Google Scholar 

  17. Nicholas JL, Julian AF, Lachlan MB, Jason W, Anneka KR (2015) Bone grafts and bone substitutes for opening-wedge osteotomies of the knee: a systematic review. Arthroscopy 31(4):720–730

    Article  Google Scholar 

  18. Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP (2006) Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med 34(8):1262–1273

    Article  Google Scholar 

  19. Santic V, Tudor A, Sestan B, Legovic D, Sirola L, Rakovac I (2010) Bone allograft provides bone healing in the medial opening high tibial osteotomy. Int Orthop 34(2):225–229

    Article  Google Scholar 

  20. Slevin O, Ayeni OR, Hinterwimmer S, Tischer T, Feucht MJ, Hirschmann MT (2016) The role of bone void fillers in medial opening wedge high tibial osteotomy: a systematic review. Knee Surg Sports Traumatol Arthrosc 24(11):3584–3598

    Article  Google Scholar 

  21. 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 34:55–62

    Article  Google Scholar 

  22. Takeuchi R, Bito H, Akamatsu Y, Shiraishi T, Morishita S, Koshino T, Saito T (2010) In vitro stability of open wedge high tibial osteotomy with synthetic bone graft. Knee 17(3):217–220

    Article  Google Scholar 

  23. Takeuchi R, Ishikawa H, Aratake M, Bito H, Saito I, Kumagai K, Akamatsu Y, Saito T (2009) Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy 25(1):46–53

    Article  Google Scholar 

  24. Takeuchi R, Woon-Hwa J, Ishikawa H, Yamaguchi Y, Osawa K, Akamatsu Y, Kuroda K (2017) Primary stability of different plate positions and the role of bone substitute in open wedge high tibial osteotomy. Knee 24(6):1299–1306

    Article  Google Scholar 

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The authors would like to thank Prof. Yong Chan Ha and Jian Kang for their advice and expert technical assistance with the statistical analysis.


This study did not receive any funding.

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Authors and Affiliations



Design of study: WHJ and RT. Analysis of data: DHK and RN. Writing of manuscript: RN and DHK. Supervision of study: WHJ and RT. All authors read and approved the final manuscript.

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Correspondence to Woon-Hwa Jung.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Supplementary electronic data: Video of bone graft harvesting from medial femoral condyle (MP4 31760 KB)

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Jung, WH., Takeuchi, R., Kim, DH. et al. Faster union rate and better clinical outcomes using autologous bone graft after medial opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 28, 1380–1387 (2020).

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  • Open wedge high tibial osteotomy
  • Bone union
  • Osteotomy gap
  • Autologous bone grafting
  • Osteoarthritis
  • Knee