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Global varus malalignment increase from double-leg to single-leg stance due to intra-articular changes



Preoperatively planned correction for tibial osteotomy surgery is usually based on weightbearing long-leg Xrays, while the surgery is performed in a supine non-weightbearing position. The purpose of this study was to assess the differences in lower limb alignment in three different weightbearing conditions: supine position, double-leg (DL) stance and single-sleg (SL) stance prior to performing a medial opening wedge high tibial osteotomy (MOWHTO) for varus malalignment. The hypothesis of this study was that progressive limb-loading would lead to an increased preoperative varus deformity.

Material and methods

This retrospective study included 89 patients (96 knees) with isolated medial knee osteoarthritis (Ahlbäck grade I or II) and significant metaphyseal tibial vara (> 6°). The differences between supine position, DL stance and SL stance were analysed for the hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), weight-bearing line ratio (WBL) and joint line convergence angle (JLCA).


From a supine position to DL stance, the HKA angle slightly increased from 175.5° ± 1.1° to 176.3° ± 1.1° and JLCA changed from 2.0° ± 0.3° to 1.8° ± 0.3° without a statistically significant difference. From DL to SL stances, the HKA angle decreased from 176.3° ± 1.1° to 174.4° ± 1.1° (p < 0.05) and the JLCA increased from 1.8° ± 0.3° to 2.6° ± 0.3° (p < 0.05). A significant correlation was found between ΔHKA and ΔJLCA between the DL and the SL stances (R2 = 0.46; p = 0.01).


Varus malalignment increases with weight-bearing loading from double-leg to single-leg stances with an associated JLCA increase. Thus, single-leg stance radiographs may be useful to correct preoperative planning considering patient-specific changes in JLCA.

Level of clinical evidence

III, retrospective comparative study.

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Authors and Affiliations



MO designed the protocol and performed statistical analysis. LB and HF collected the Data. LB wrote the initial draft and perform edition for the different version of the manuscript. GM, RK, ME and MO corrected the different versions of the draft. All the authors approved the submitted version.

Corresponding author

Correspondence to Matthieu Ollivier.

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Conflict of interest

LB, GM, RK have nothing to disclose. MO is educational consultant for Stryker, AO-Recon and Newclip-Technics. ME is educational consultant for Amplitude, Groupe Lépine and Newclip-Technics.

Ethical approval

The local ethics committee approved our study protocol prior to investigation.

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Bardot, LP., Micicoi, G., Favreau, H. et al. Global varus malalignment increase from double-leg to single-leg stance due to intra-articular changes. Knee Surg Sports Traumatol Arthrosc 30, 715–720 (2022).

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  • Knee
  • Osteotomy
  • Weight-bearing
  • Genu varum
  • Weight-bearing radiographs
  • Joint line convergence