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Medial opening wedge high tibial osteotomy: more than ten years of experience with Puddu plate technique supports its indication

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To describe the short-term and long-term results of patients who underwent a medial opening wedge high tibial osteotomy (MOW-HTO) for unicompartmental medial knee joint osteoarthritis.


A retrospective review was conducted of patients with MOW-HTO using a Puddu plate®, with more than ten year follow-up. The degree of correction, initial chondral damage, number of meniscal lesions, preoperative and 1-year postoperative functional scale scores (IKDC and Lysholm), and arthroplasty conversion rates at the ten year follow-up were registered. We assumed early indication when patients underwent the operation before they were 40 years old and delayed ≥ 40. Functional outcomes were analyzed by adjusting for pre-operative values. Fisher’s exact test was used to study the association between the arthroplasty conversion rates and the timing of indication.


Fifty-five patients were included, 37 of whom were male (67%). Twenty-nine patients had early indications for surgery (53%). All patients completed ten year follow-up. All patients improved IKDC (p < 0.01) and Lysholm (p < 0.01) scores compared to their presurgical scores at the one year post-operative evaluation. We had six minor complications, none requiring revision surgery. We had three conversions to arthroplasty, all in the late indication group, not statistically significant different. Linear regression showed that early indication was associated with a higher IKDC score when adjusting for the Outerbridge chondral damage score, the number of meniscal lesions, and sex (p < 0.01).


All patients improved functional scores one year after surgery. Early indication (i.e., younger than 40 years of age) was independently associated with better functional outcomes than late indication at one year follow-up.

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  1. White PH, Waterman M (2012) Making osteoarthritis a public health priority. AJN, Am J Nurs 112:S20–S25

    Article  Google Scholar 

  2. Farr Ii J, Miller LE, Block JE (2013) Quality of life in patients with knee osteoarthritis: a commentary on nonsurgical and surgical treatments. Open Orthop J 7:619–624

    Article  Google Scholar 

  3. Eitner A, Hofmann GO, Schaible H-G (2017) Mechanisms of osteoarthritic pain. Studies in humans and experimental models. Front Mol Neurosci 10:349

    Article  Google Scholar 

  4. Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP (2009) Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee 16:473–478

    Article  Google Scholar 

  5. Cao Z, Mai X, Wang J, Feng E, Huang Y (2018) Unicompartmental knee arthroplasty vs high tibial osteotomy for knee osteoarthritis: a systematic review and meta-analysis. J Arthroplast 33:952–959

    Article  Google Scholar 

  6. Santoso MB, Wu L (2017) Unicompartmental knee arthroplasty, is it superior to high tibial osteotomy in treating unicompartmental osteoarthritis? A meta analysis and systemic review. J Orthop Surg Res 12:50

    Article  Google Scholar 

  7. Jackson JP, Waugh W (1961) Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br 43-B:746–751

    Article  CAS  Google Scholar 

  8. Coventry, Mb (1965) Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report. J Bone Joint Surg Am 47:984–990

    Article  Google Scholar 

  9. Dowd GSE, Somayaji HS, Uthukuri M (2006) High tibial osteotomy for medial compartment osteoarthritis. Knee 13:87–92

    Article  CAS  Google Scholar 

  10. Atrey A, Morison Z, Tosounidis T, Tunggal J, Waddell JP (2012) Complications of closing wedge high tibial osteotomies for unicompartmental osteoarthritis of the knee. Bone Joint Res 1:205–209

    Article  CAS  Google Scholar 

  11. Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987) Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year followup study. J Bone Joint Surg Am 69:332–354

    Article  CAS  Google Scholar 

  12. Puddu G, Cipolla M, Cerullo G, Franco V, Giannì E (2007) Osteotomies: the surgical treatment of the Valgus knee. Sports Med Arthrosc 15:15–22

    Article  Google Scholar 

  13. Puddu G, Cipolla M, Cerullo G, Franco V, Giannì E (2010) Which osteotomy for a valgus knee? Int Orthop 34:239–247

    Article  Google Scholar 

  14. Woodacre T, Ricketts M, Evans JT, Pavlou G, Schranz P, Hockings M, Toms A (2016) Complications associated with opening wedge high tibial osteotomy — a review of the literature and of 15years of experience. Knee 23:276–282

    Article  CAS  Google Scholar 

  15. Han S-B, Lee J-H, Kim S-G, Cui C-G, Suh D-W, Lee S-Y, Jang K-M (2018) Patient-reported outcomes correlate with functional scores after opening wedge high tibial osteotomy: a clinical study. Int Orthop 42:1067–1074

    Article  Google Scholar 

  16. Ekeland A, Nerhus TK, Dimmen S, Thornes E, Heir S (2017) Good functional results following high tibial opening-wedge osteotomy of knees with medial osteoarthritis. Knee 24:380–389

    Article  Google Scholar 

  17. Sherman C, Cabanela ME (2010) Closing wedge osteotomy of the tibia and the femur in the treatment of gonarthrosis. Int Orthop 34:173–184

    Article  Google Scholar 

  18. Higgins LD, Taylor MK, Park D, Ghodadra N, Marchant M, Pietrobon R, Cook C (2007) International knee documentation committee: reliability and validity of the international knee documentation committee (IKDC) subjective knee form. Jt Bone Spine 74:594–599

    Article  Google Scholar 

  19. Smith HJ, Richardson JB, Tennant A (2009) Modification and validation of the Lysholm knee scale to assess articular cartilage damage. Osteoarthr Cartil 17:53–58

    Article  CAS  Google Scholar 

  20. OUTERBRIDGE RE (1961) The etiology of chondromalacia patellae. J Bone Joint Surg Br 43–B:752–757

  21. Outerbridge RE, Dunlop JA The problem of chondromalacia patellae. Clin Orthop Relat Res:177–196

  22. Myrnerts R (1980) High tibial osteotomy with overcorrection of varus malalignment in medial gonarthrosis. Acta Orthop Scand 51:557–560

    Article  CAS  Google Scholar 

  23. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 75:196–201

    Article  CAS  Google Scholar 

  24. Martay JL, Palmer AJ, Bangerter NK, Clare S, Monk AP, Brown CP, Price AJ (2018) A preliminary modeling investigation into the safe correction zone for high tibial osteotomy. Knee 25:286–295

    Article  Google Scholar 

  25. Galia CR, Macedo CA, Rosito R, de Mello TM, Camargo LMAQ, Moreira LF (2008) In vitro and in vivo evaluation of lyophilized bovine bone biocompatibility. Clinics (Sao Paulo) 63:801–806

    Article  Google Scholar 

  26. Tunggal JAW, Higgins GA, Waddell JP (2010) Complications of closing wedge high tibial osteotomy. Int Orthop 34:255–261

    Article  Google Scholar 

  27. Ferner F, Lutter C, Dickschas J, Strecker W (2019) Medial open wedge vs. lateral closed wedge high tibial osteotomy - indications based on the findings of patellar height, leg length, torsional correction and clinical outcome in one hundred cases. Int Orthop 43:1379–1386

    Article  Google Scholar 

  28. Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP (2006) Opening wedge high Tibial osteotomy. Am J Sports Med 34:1262–1273

    Article  Google Scholar 

  29. Dexel J, Fritzsche H, Beyer F, Harman MK, Lützner J (2017) Open-wedge high tibial osteotomy: incidence of lateral cortex fractures and influence of fixation device on osteotomy healing. Knee Surgery, Sport Traumatol Arthrosc 25:832–837

    Article  Google Scholar 

  30. Chahla J, Dean CS, Mitchell JJ, Moatshe G, Serra Cruz R, LaPrade RF (2016) Medial opening wedge proximal Tibial osteotomy. Arthrosc Tech 5:e919–e928

    Article  Google Scholar 

  31. Brandt KD, Radin EL, Dieppe PA, van de Putte L (2006) Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis 65:1261–1264

    Article  CAS  Google Scholar 

  32. Tan AL, Toumi H, Benjamin M, Grainger AJ, Tanner SF, Emery P, McGonagle D (2006) Combined high-resolution magnetic resonance imaging and histological examination to explore the role of ligaments and tendons in the phenotypic expression of early hand osteoarthritis. Ann Rheum Dis 65:1267–1272

    Article  CAS  Google Scholar 

  33. Barker T, Rogers VE, Henriksen VT, Dixon BM, Momberger NG, Rasmussen GL, Trawick RH (2019) Muscular-based and patient-reported outcomes differentially associate with circulating superoxide dismutases and cytokines in knee osteoarthritis. Cytokine 115:45–49

    Article  CAS  Google Scholar 

  34. Radin, EL, Paul, IL, Rose, RM: Role of mechanical factors in pathogenesis of primary osteoarthritis. Lancet (London, England) 1972;1:519–522

  35. Burr DB, Radin EL (2003) Microfractures and microcracks in subchondral bone: are they relevant to osteoarthrosis? Rheum Dis Clin N Am 29:675–685

    Article  Google Scholar 

  36. Yu D, Xu J, Liu F, Wang X, Mao Y, Zhu Z Subchondral bone changes and the impacts on joint pain and articular cartilage degeneration in osteoarthritis. Clin Exp Rheumatol 34:929–934

  37. Lee JH, Fitzgerald JB, DiMicco MA, Cheng DM, Flannery CR, Sandy JD, Plaas AH, Grodzinsky AJ (2009) Co-culture of mechanically injured cartilage with joint capsule tissue alters chondrocyte expression patterns and increases ADAMTS5 production. Arch Biochem Biophys 489:118–126

    Article  CAS  Google Scholar 

  38. Choi J-A, Gold GE (2011) MR imaging of articular cartilage physiology. Magn Reson Imaging Clin N Am 19:249–282

    Article  Google Scholar 

  39. Briem K, Ramsey DK, Newcomb W, Rudolph KS, Snyder-Mackler L (2007) Effects of the amount of valgus correction for medial compartment knee osteoarthritis on clinical outcome, knee kinetics and muscle co-contraction after opening wedge high tibial osteotomy. J Orthop Res 25:311–318

    Article  Google Scholar 

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Correspondence to Sebastián Irarrázaval.

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One of the authors (Orrego M) is consultant for Arthrex®. The other authors do not have financial disclosures and/or conflicts of interest.

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Orrego, M., Besa, P., Orrego, F. et al. Medial opening wedge high tibial osteotomy: more than ten years of experience with Puddu plate technique supports its indication. International Orthopaedics (SICOT) 44, 2021–2026 (2020).

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