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Joint line obliquity was maintained after double-level osteotomy, but was increased after open-wedge high tibial osteotomy

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



To compare the radiographic, clinical, and arthroscopic outcomes of varus osteoarthritic knees treated with an open-wedge high tibial osteotomy (OWHTO) alone or with a double-level osteotomy (DLO). It was hypothesized that treatment with DLO would maintain the joint line obliquity (JLO) and acquire better arthroscopic and clinical outcomes after surgery than OWHTO alone.


Knees with predicted medial proximal tibial angle (MPTA) > 95° were treated with OWHTO alone or with DLO. Preoperatively, age, body mass index, and hip-knee-ankle angle (HKA) differed between the two groups. Therefore, after adjustment for those factors, 34 knees with OWHTO alone and 34 knees with DLO were compared. On whole-leg radiographs for a single leg, HKA, weightbearing line (WBL) ratio, lateral distal femoral angle (LDFA), MPTA, and JLO were measured before and 2 years after surgery. Clinical outcomes were evaluated by the Knee Society Score (KSS) knee, KSS function, Lysholm, and Knee injury and Osteoarthritis Outcome Score (KOOS) scores before and 2 years after surgery. Arthroscopic findings were obtained before and 1 year after surgery. Various factors were compared between the two groups.


JLO increased significantly from 1.4° to 6.3° in the OWHTO group (p < 0.001) and changed from 1.0° to 1.3° in the DLO group (n.s.). Postoperative MPTA and JLO in the OWHTO group were significantly higher than those in the DLO group (both p < 0.001). There were no significant differences in the KSS knee, KSS function, and KOOS scores between the two groups. Postoperative Lysholm score in the DLO group was higher than that in the OWHTO group (p < 0.025). Femoral and tibial cartilage regeneration in the medial condyles and deterioration in the lateral condyles did not differ between the two groups on second-look arthroscopy.


JLO was not significantly changed after surgery in the DLO group. DLO enabled the acquisition of physiological JLO compared with OWHTO alone.

Level of evidence

Retrospective comparative study, Level III.

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Availability of data and material

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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The authors thank Alison Sherwin, PhD, from Edanz Group for editing a draft of this manuscript. The authors deeply appreciate the surgical instructions of Prof. Steffen Schröter in the BG Trauma Center Tübingen for 6 months.


No funding was obtained for this study.

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YA study design, data collection, interpretation of the data, and writing of the paper. SN data collection. MT, HK, and SM interpretation of the data.

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Correspondence to Yasushi Akamatsu.

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Ethical approval for the study was obtained from the Institutional Review Board of Yokohama City University Hospital (B120906024).

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Akamatsu, Y., Nejima, S., Tsuji, M. et al. Joint line obliquity was maintained after double-level osteotomy, but was increased after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 30, 688–697 (2022).

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